The Appropriateness of Renal Angioplasty. The ANPARIA Software: A Multidisciplinary Expert Panel Approach

Percutaneous transluminal renal angioplasty (PTRA) is an invasive technique that is costly and involves the risk of complications and renal failure. The ability of PTRA to reduce the administration of antihypertensive drugs has been demonstrated. A potentially greater benefit, which nevertheless remains to be proven, is the deferral of the need for chronic dialysis. The aim of the study (ANPARIA) was to assess the appropriateness of PTRA to impact on the evolution of renal function. A standardized expert panel method was used to assess the appropriateness of medical treatment alone or medical treatment with revascularization in various clinical situations. The choice of revascularization by either PTRA or surgery was examined for each clinical situation. Analysis was based on a detailed literature review and on systematically elicited expert opinion, which were obtained during a two-round modified Delphi process. The study provides detailed responses on the appropriateness of PTRA for 1848 distinct clinical scenarios. Depending on the major clinical presentation, appropriateness of revascularization varied from 32% to 75% for individual scenarios (overal 48%). Uncertainty as to revascularization was 41% overall. When revascularization was appropriate, PTRA was favored over surgery in 94% of the scenarios, except in certain cases of aortic atheroma where sugery was the preferred choice. Kidney size >7 cm, absence of coexisting disease, acute renal failure, a high degree of stenosis (≥70%), and absence of multiple arteries were identified as predictive variables of favorable appropriateness ratings. Situations such as cardiac failure with pulmonary edema or acute thrombosis of the renal artery were defined as indications for PTRA. This study identified clinical situations in which PTRA or surgery are appropriate for renal artery disease. We built a decision tree which can be used via Internet: the ANPARIA software (/). In numerous clinical situations uncertainty remains as to whether PTRA prevents deterioration of renal function.     

Percutaneous transluminal renal angioplasty versus renovascular surgery: statistical, medical and economical considerations

Retro- and prospective comparative studies in patients with renal artery stenosis demonstrate that technical results and blood pressure improvement after renovascular surgery or percutaneous transluminal renal angioplasty (PTRA) are strictly comparable. The lesser invasive character of PTRA together with its lower complication rate and the lower cost explain why PTRA is the method of choice in the treatment of renal artery stenosis, with less restrictive selection criteria than used for surgery.     

肾动脉内支架置入术治疗肾性高血压

报告了肾动脉狭窄采用Ｐａｌｍａｚ支架留置的程序，并报告了典型病例和十三个半月的追踪结果。结合文献复习讨论了肾动脉内支架留置的适应证和禁忌证及作者的初步体会。肾动脉内支架留置后的长期开通需要进一步追踪观察。     

Percutaneous angioplasty for atherosclerotic renal artery disease: Effect on renal function in azotemic patients

Purpose We studied the effect of percutaneous transluminal renal angioplasty (PTRA) on renal function in azotemic patients with atherosclerotic renal artery stenosis.Methods The results of PTRA were analyzed retrospectively in 40 patients. There were 61 stenoses, 54 of which received balloon angioplasty; 7 had stent placement during the initial procedure, 6 for recurrent stenosis 6–18 months after PTRA.Results Technical success was achieved in 95% of cases. The complication rate was 15%, compared to 6% in nonazotemic patients. Mean creatinine rose from 1.9 ± 0.15 mg/dl (mean ± SEM) to 2.4 ± 0.17 mg/dl during the year before PTRA, stabilizing at 2.5 ± 0.57 mg/ dl for 1 year after PTRA. PTRA was clinically successful in 60% of patients; 40% showed further deterioration of renal function. Clinical failure was associated with residual renal artery stenosis and presence of intermittent claudication.Conclusion We conclude that PTRA helps salvage renal function in patients with azotemia and atherosclerotic renal artery stenosis.     

Percutaneous transluminal angioplasty of the renal artery

Percutaneous transluminal renal angioplasty (PTRA) has been employed in 70 renal arteries, utilizing the balloon angioplasty technique described by Grüntzig for peripheral vessels. The procedure has been employed both in patients with normal renal function and in selected patients with decreased renal function. The complication rate has been low (5.7%), and no patient has required operative intervention as a result of a complication sustained during PTRA. The early results of PTRA compare favorably to those achieved through operative revascularization. An assessment of the duration of PTRA's effects must however, await the results of long-term follow-up.     

经皮肾动脉腔内成形术治疗肾血管性高血压

目的：评价经皮穿刺肾动脉腔内成形术（PTRA）对肾血管性高血压的治疗效果。方法：1983年3月至1996年12月，对21例肾血管性高血压的24支狭窄肾动脉（双侧者3例）施行了PTPA治疗。根据术中狭窄部位动脉压差改变及临床血压变化对其疗效进行了评价。结果：从21例进行了PTRA的24支狭窄肾动脉中，18支（75%）立刻获得技术成功。后经随访的12例病人中，3年疗效；治愈9例（75%），改善2例（16.7%），无效1例（8.3%）；5年疗效：治愈7例（58.3%），改善2例（16.7%），无效3例（25%）。结论：PTRA对肾血管性高血压的治疗是一种简便，安全，且有较好远期疗效的方法。     

重新认识肾动脉狭窄的发生与发展,规范肾动脉狭窄的介入治疗

回顾肾动脉狭窄(RAS)的流行病学及临床特点,对肾动脉腔内血管成形和支架术(PTRA/S)的适应证、禁忌证、并发症、操作技术等作一评述.虽然国内外已将(PTRA/S)作为RAS的首选治疗,但国内相关临床研究有待加强.     

Percutaneous transluminal renal angioplasty and renal function

Renal function was studied before and after percutaneous transluminal renal angioplasty (PTRA) in 79 patients. In a prospective study of 28 patients with unilateral renal artery stenosis, renal function was similar during angiotensin-converting enzyme (ACE) inhibition and after PTRA. In 37 patients with bilateral renal artery stenoses, 9 patients with solitary kidneys and renal artery stenoses and 5 patients with transplant renal artery stenoses, there was no statistical difference in the renal function before and after PTRA. Of the 79 patients studied, 50 had normal renal function before PTRA. In 5 of these renal function decreased, requiring temporary hemodialysis in 1. Of 29 patients with impairment of renal function due to renal artery stenosis, improvement was noted in 14, stabilization of renal function in 11, and decrease of renal function in 4. It is concluded that PTRA is a safe technique that can make life-long drug treatment unnecessary in antihypertensive patients. It can restore or stabilize renal function in renal insufficiency caused by renal artery stenosis. It has to be kept in mind that contrast medium toxicity and cholesterol embolization can induce severe renal insufficiency after PTRA.     

Outpatient percutaneous transluminal renal artery angioplasty: a Canadian experience

PURPOSE: The authors performed a retrospective study of their experience and complication rate while performing outpatient percutaneous transluminal renal artery angioplasty (PTRA) during a 5-year period. MATERIALS AND METHODS: From July 1992 to July 1997, 87 PTRAs were performed. Of these, 62 PTRA procedures were performed on 53 outpatients. In total, 66 arteries were dilated in 62 PTRA sessions using standard, established techniques. During the same period, only 25 PTRAs were performed on inpatients. Angioplasties were performed on those patients with demonstrated renal artery stenosis and poorly controlled hypertension and/or renal failure. Patients chosen for PTRA were picked by a team that included a vascular surgeon, a nephrologist, and a radiologist. Patients who were deemed suitable for an outpatient procedure were recommended by a nephrologist. Radiological input was sought at that time. Specific guidelines were used to select these patients who were otherwise healthy, well-orientated, and able to respond to an emergency situation. None of the subjects had significant risk factors. All were accompanied by an adult for the first 24 hours and all lived no more than an hour's travel time from a hospital. All were stable on discharge and were seen within 24 hours by a nephrologist. RESULTS: The technical success rate, defined as a residual stenosis on imaging of less than 30% and/or by a pressure gradient of less than 10 mm Hg across the stenosis, was 85%. The early complication rate was 5.6%, including two patients who developed a localized hematoma. In all, four patients were admitted to the hospital rather than being discharged to home after an average of 4.2 hours of observation. The late complication rate was 3% and involved two patients. One patient, who reported pain after balloon deflation, was readmitted 6 hours after discharge with hypotension, and a diagnosis of renal artery rupture was confirmed with computed tomography. Another patient developed peripheral atheroemboli 20 days after the procedure. CONCLUSION: Outpatient PTRA can be performed on selected patients. In this study, late complications occurred in only 3% of patients. Early complications were readily recognized in 5.6% of patients, and these patients were admitted for observation after the procedure.     

Percutaneous transluminal angioplasty of renal artery fibromuscular dysplasia: mid-term results.

OBJECTIVE: To evaluate mid-term imaging, clinical follow-up, and restenosis rates from patients that had undergone percutaneous transluminal renal artery angioplasty (PTRA) for symptomatic renal artery fibromuscular dysplasia (FMD). MATERIALS AND METHODS: Between March 1999 and July 2006, 16 consecutive renal artery FMD patients underwent PTRA for poorly controlled hypertension. The patients were enrolled into this retrospective study after receiving 19 primary and four secondary PTRAs in 19 renal artery segments. Follow-up monitoring of blood pressure, use of antihypertensive medication, and the serum creatinine level after PTRA were assessed at 1, 3, 6, 9, 12 months, and each following year. The degree of restenosis was evaluated with computed tomographic angiography (CTA) after PTRA at 6, 12 months, and every year if possible. Technical and clinical success rates for the treatment of FMD, and restenosis rates for the renal artery were evaluated. RESULTS: The technical success rate for primary PTRA was 79% (15/19) and the complication rate was 16% (3/19). Hypertension improved in 80% (12/15) of the patients after four weeks follow-up, and was finally cured or improved in 93% (14/15) during the mean follow-up period of 23.6 months. There was a cumulative 22% (4/18) restenosis rate during the follow-up period. All of the patients were treated with a second PTRA without complications and all of the patients were cured of hypertension after the second PTRA. CONCLUSION: Percutaneous transluminal renal artery angioplasty for clinically symptomatic renal FMD is technically and clinically successful and safe to perform. For all patients with restenosis, there was a good response after undergoing a second PTRA.     

Percutaneous transluminal renal angioplasty in children and adolescents

Percutaneous transluminal renal angioplasty (PTRA) was performed in 12 children and adolescents with renal artery stenosis. Patients were divided into three groups: those with a short stenosis in the middle or distal part of the renal artery (n = 5), those with a short stenosis at or near the origin of the renal artery (n = 3), and those with a long stenosis at or near the origin (n = 4). The patients in the first group responded to PTRA. Those in the second group had a poor clinical response, and dilation was unsuccessful in the patients in the third group, who remained hypertensive. The location and length of the renal artery stenosis and its underlying cause appear to be important in determining the results of PTRA.     

Stent placement in ostial and nonostial atherosclerotic renal arterial stenoses: a prospective follow-up study

PURPOSE: To compare the results of balloon percutaneous transluminal renal angioplasty (PTRA) and stent placement in atherosclerotic ostial, proximal, and isolated truncal stenoses. MATERIALS AND METHODS: Between January 1994 and April 1998 the authors prospectively followed up 163 consecutive patients with 200 atherosclerotic renal arterial lesions after primary PTRA or primary stent placement. Duplex ultrasonography was performed 1 day and 3, 6, and 12 months later. RESULTS: The primary 12-month PTRA patency rates were 34% (21 of 33 atherosclerotic lesions) for ostial stenoses, 65% (20 of 60) for proximal stenoses, and 83% (five of 30) for truncal stenoses (chi(2) value, 15.63; P <.001). The corresponding stent patency rates were 80% (four of 21), 72% (nine of 34), and 66% (five of nine), respectively (chi(2) value, 4.11; not significant). Significant stent-related reduction in risk of restenosis was limited to the ostial stenoses (P =.002). CONCLUSION: Renal arterial stent placement considerably improves patency in ostial stenoses, but compared with the technically successful PTRA, it does not significantly improve primary patency in proximal and isolated truncal renal arterial stenoses.     

Cutting balloon angioplasty in children with resistant renal artery stenosis

Children with systemic hypertension resulting from a renovascular stenosis commonly have fibromuscular dysplasia and respond to percutaneous transluminal renal angioplasty (PTRA). There is a subset of children, however, with conditions that appear to be resistant to PTRA (eg, syndromic renal artery stenosis and arteritis). These patients are often treated surgically. The development of the cutting balloon may provide a minimally invasive alternative to surgery in these individuals. Associated adverse events may include recurrent stenosis, arterial occlusion with renal loss, and arterial rupture with extravasation and pseudoaneurysm formation. Some of these adverse events can be successfully treated with percutaneous interventional techniques. The authors present four cases of cutting balloon angioplasty performed at two large metropolitan children's hospitals in children with resistant renal artery stenosis.     

Percutaneous transluminal renal angioplasty in atheroma with renal failure: long-term outcomes in 99 patients

The aim of this study was to evaluate renal function changes after percutaneous transluminal renal artery angioplasty (PTRA) done to treat atheromatous renal artery stenosis with renal failure. Between 1990 and 1995, PTRA was performed in 99 renal failure patients (creatinine clearance less than 80 ml/min) with atheromatous stenosis of one or more native renal arteries. Indications for PTRA were chronic renal failure with poorly controlled hypertension (group A, 67 patients) or rapidly deteriorating renal function (group B, 32 patients). Renal function changes after PTRA were evaluated based on the percentages of patients with improved, stabilized, and worsened serum creatinine and creatinine clearance values, and on mean differences between final and baseline creatinine clearances. At the end of follow-up (19+/-10 months), group A had a significantly smaller creatinine clearance gain (42.9 ml/min before PTA to 44.5 ml/min after PTA, D=1.6 ml/min, in group A, vs 24.1-28.4 ml/min, D=4.3, in group B, p=0.03), and a significantly smaller percentage of improved patients (36 vs 62%) than group B. Most stenoses in group B either were bilateral or occurred on a solitary kidney ( p=0.001). Percutaneous transluminal renal artery angioplasty combined with aggressive medical treatment may be useful in maintaining or improving renal function, particularly in patients with a recent, sharp deterioration in renal function.     

Technical and Clinical Results After Percutaneous Angioplasty in Nonmedial Fibromuscular Dysplasia: Outcome After Endovascular Management of Unifocal Renal Artery Stenoses in 30 Patients

Although percutaneous transluminal renal angioplasty (PTRA) is associated with excellent results in medial fibromuscular dysplasia (FMD), the clinical and technical outcome in the less common nonmedial subtype of FMD is not clearly known. Angiographic PTRA results and clinical follow-up were documented, to report technical and clinical results in 30 patients with unifocal, nonmedial dysplastic stenoses. Balloon angioplasty was technically successful in only 65% of the lesions. Additional stenting, performed after PTRA failure in six patients, increased the initial technical success rate to 82%. Stenting was used in another lesion after restenosis, and long-term patency was achieved in only three of the seven stented lesions. Frequent restenoses and unusual complications were observed during follow-up. Stent fracture occurred in two cases. Overall, long-term clinical and technical successes were sustained in 70 and 76%, respectively. We conclude that nonmedial, unifocal renal artery dysplastic stenoses do not share the excellent prognosis of the medial type and that stenting should be avoided. Therefore, surgery should be considered in lesions remaining unresponsive to balloon dilatation, after a second PTRA attempt.     

Noninvasive measurement of renal blood flow with technetium-99m-DTPA in the evaluation of patients with suspected renovascular hypertension

If a hypertensive patient with renal artery stenosis (RAS) is to benefit from percutaneous transluminal renal angioplasty (PTRA) in terms of a sustained improvement in blood pressure control, one may postulate a demonstrable reduction in renal blood flow (RBF) to that kidney, reversible by PTRA. In a population of 32 hypertensive patients, RAS was present in 23 of 62 kidneys. Eleven of the 32 patients underwent renal revascularization, of whom 6 showed improvement in blood pressure control at 6 mo, i.e., had renovascular hypertension (RVH). There was no correlation between RBF and angiographic appearances of the renal artery. Furthermore, there was no significant difference between RBF in the stenosed kidneys of the patients with RVH compared with the stenosed kidneys of patients without RVH. Individual kidney RBF was 22% (s.d. 11) higher 1-3 wk after PTRA but the increase did not correlate with clinical outcome. Angiotensin converting enzyme (ACE) inhibition increased RBF by 25% (s.d. 25) of baseline flow before PTRA but the increase did not correlate with clinical outcome. Measurement of RBF is of limited value for the prediction of the long-term blood pressure response following PTRA.     

Complications of percutaneous transluminal renal angioplasty--case report]

Complications of percutaneous transluminal renal angioplasty (PTRA) most frequently occur on dilated artery, and rarely on peripheral punctured artery. In the study was presented 24-year old female patient in whom the painful tumor developed five days after PTRA at the spot of axillary artery punction. Tumor caused the lesion of brachial plexus by the compression, which was the reason for urgent surgery.     

Renal vein renin analysis: Limitations of its use in predicting benefit from percutaneous angioplasty

Two hundred forty-four consecutive patients (mean age 61 years), including 123 who had technically valid renal vein renin (RVR) analysis and 121 without RVR data, underwent technically successful percutaneous renal artery angioplasty (PTRA). They were retrospectively examined to evaluate the utility of RVR analysis in identifying renal hypertension (RVH), predicting benefit from PTRA, and determining if the lack of knowledge of renin levels significantly affected clinical outcome after PTRA. Abnormal RVR values were associated with clinical benefit after PTRA in 62 of 93 patients (67% sensitivity, 20% specificity, 72% positive predictive value). Clinical improvement following PTRA occurred in 31 of 37 patients with normal pre-PTRA RVR values (16% negative predictive value). RVR analysis correctly identified 86 of 117 patients with renovascular hypertension (74% sensitivity, 16% negative predictive value). Improved blood pressure (BP) control occurred in 72% with abnormal RVR analysis and 66% of the 121 patients without RVR data (p>0.1). We conclude that the very low negative predictive value significantly limited the use of RVR analysis in this elderly (mean age 60 years) patient population with a high incidence of mild renal functional impairment (mean serum creatinine 1.4 mg/dl) and bilateral renal artery stenosis (38%). The lack of pre-PTRA renin data did not significantly affect clinical outcome. If RVR data were relied upon as the exclusive selection criterion in patients of this type, many would be prevented from having the benefit of cure or improvement by PTRA.     

Renal Artery Stenting in Patients with a Solitary Functioning Kidney

Purpose: To retrospectively evaluate the results of renal artery stenting in patients with renovascular disease and a solitary functioning kidney. Methods: Palmaz stents were placed in 16 patients with a solitary functioning kidney, renal artery stenosis, hypertension and renal failure. Stenoses were evaluated with color Doppler ultrasound, MR angiography and digital subtraction angiography (DSA). Indications for stenting were: recoil after percutaneous transluminal renal angioplasty (PTRA) (63%), arterial dissection after PTRA (13%) and primary stenting (25%). Immediate results were evaluated by DSA. On follow-up (6-36 months), patients underwent periodical evaluation of clinical conditions (blood pressure and serum creatinine level) and stent patency, by means of color Doppler ultrasound. Results: Stent placement was successful in all patients (100%). Cumulative primary patency rate was: 100% at 1 day, 93.75% at 6 months, 81.25% at 12 months and 75% at 24 months. A significant reduction in diastolic blood pressure occurred (mean ± SD 104 ± 6 vs 92 ± 3; p < 0.05); renal function improved or stabilized in over 80% of patients. However, there was no significant difference in the creatinine values before and after treatment (mean ± SD 200 ± 142 mmol/l vs 197 ± 182 mmol/l; p > 0.05). Conclusion: Renal artery stenting, both after PTRA and as primary stenting, represents a safe procedure, able to preserve renal function in patients with a solitary functioning kidney.     

Percutaneous transluminal renal angioplasty: indication for renovascular hypertension associated with renal atrophy

The results of clinical studies indicate that percutaneous transluminal renal angioplasty (PTRA) is an effective means for treating renovascular hypertension resulting from renal artery stenosis. However, the indications for the patients with renal failure or renal atrophy are not established on a firm ground. We attempted PTRAs of ten kidneys in nine patients with hypertension associated with renal atrophy. They were followed for an average of 8 months by the methods including blood pressure, angiography or DSA, blood chemistry, and RI-renogram. We also evaluated enlargement of the renal size on an angiogram or on a plain film at DSA. Angiographic follow-up showed persistent relief of the stenosis in all cases. After PTRA, blood pressure reduced to normal or improved in two thirds of the patients for the follow-up period. In the study of three patients with excellent results for blood pressure, two patients showed the renal length to be increased by 1.0 cm or more, and one patient by 0.5 cm. In the same group, RI-renogram also showed good response. These data indicate that PTRA could improve total perfusion on the affected kidneys. On the other hand, in three patients with no change in blood pressure, there was poor response in both the renal size and the data of RI-renograms. We suggest that the irreversible changes might have occurred in these kidneys. It was difficult to predict cure group from no change group before PTRA.