Percutaneous transluminal angioplasty for renovascular hypertension in children

Percutaneous transluminal angioplasty (PTA) has been developed over the past 8 years as an alternative to reconstructive surgery for renovascular hypertension. We report three cases and review the use of PTA in children with renal artery stenosis. At least 37 cases of PTA have been reported in patients whose ages ranged from 1.3 to 17 years (mean 10 years). Of these, 10 had fibromuscular dysplasia; 13 unspecified unilateral renal artery stenosis; 4 bilateral stenosis; 4 neurofibromatosis; 4 renal transplant; 1 atherosclerosis; and 1 postsurgical stenosis. Nine of 10 patients with fibromuscular dysplasia were cured and 3 of 4 with renal transplant arterial stenosis were cured or improved. There were 11 failures of PTA, including all 4 patients with neurofibromatosis and 1 with transplant arterial stenosis. We conclude that PTA is the treatment of choice for children with hypertension due to fibromuscular dysplasia and should be attempted for stenosis of the transplanted renal artery. Other lesions resulting in renal artery stenosis may not be as amenable to dilation and should be considered on an individual basis.R. L. Chevalier is an Established Investigator of the American Heart Association     

Can intrarenal duplex waveform analysis predict successful renal artery revascularizaion?

Purpose: No currently available noninvasive test can preoperatively predict a successful outcome to renal revascularization. Resistance measurements from the renal parenchyma obtained with duplex sonography reflect the magnitude of intraparenchymal disease, and patients with extensive intrarenal disease may respond less favorably to revascularization. To address this question, we reviewed our (primarily) operative experience in patients undergoing renal artery revascularization, and compared the blood pressure (BP) and renal function response with resistance measurements obtained from the kidney both before and after revascularization. Methods: During a 56-month period, 31 consecutive renal artery revascularizations (25 surgical and 6 percutaneous angioplasties) were performed in 23 patients (21 atherosclerotic, 2 fibromuscular dysplasia). Duplex sonography was performed in each patient before and after revascularization, and parenchymal diastolic/systolic (d/s) ratios were calculated. BP and renal function response to intervention were compared with measurements of intrarenal flow patterns before and after revascularization. Results: Mean parenchymal peak systolic velocity was significantly higher after repair in all patients (pre-repair: 19.5 ± 1.3, postrepair: 27.2 ± 1.7; P<.0001). Despite this, there were no statistical differences between preoperative and postoperative parenchymal d/s ratios. A favorable (cured or improved) BP response was seen in 81% (17 of 21) of revascularizations performed for hypertension. Among these successes, parenchymal d/s ratios were in the normal range (ie, ≥0.30) both before and after repair (mean pre-repair: 0.34 ± 0.03, mean postrepair: 0.31 ± 0.03; not significant). In 4 patients in which BP failed to improve after intervention, the d/s ratio was abnormal before surgery (<0.3), and remained so after revascularization (mean preoperative d/s ratio: 0.18 ± 0.04, mean postoperative d/s ratio: 0.11 ± 0.04; P = .003). Mean preoperative parenchymal d/s ratios were significantly higher in all patients with a successful BP response when compared with failures (P = .048). Similarly, among patients with single artery repairs, mean preoperative d/s ratios approached significance in successes vs. failures (success: 0.40 ± 0.03, failure: 0.21 ± 0.03; P = .054). A decrease in serum creatinine greater than or equal to 20% was seen in 8 of 18 patients (44%) with ischemic nephropathy. These patients also had normal d/s ratios preoperatively (mean 0.39 ± 0.04), whereas the 10 patients who failed to improve had significantly lower ratios (mean 0.24 ± 0.03; P = .041). Kidney length did not correlate with d/s ratio. Conclusion: Although we do not believe that duplex sonographic measurement of intrarenal flow patterns alone is an accurate means of assessing main renal artery occlusive disease, the resistive indices seem to reflect the magnitude of intraparenchymal disease, and thus may provide important prognostic information for patients undergoing surgical revascularization. Our data suggest that a preoperative d/s ratio below 0.3 correlates with clinical failure relative to BP and renal function responses. (J Vasc Surg 1998;28:471-81.)     

Fibromuscular dysplasia of the renal artery: Management and outcome

Renovascular hypertension may be caused by atherosclerotic disease or less commonly by fibromuscular dysplasia (FMD) of the renal arteries. Fibromuscular dysplasia is the commonest cause of renal artery stenosis in the younger age group and affects women predominantly. A review of our clinical database identified all patients with renovascular hypertension. All relevant clinical, biochemical and radiological findings on those with FMD were noted. The outcome of percutaneous transluminal renal angioplasty (PTRA) or reconstructive surgery was evaluated. Eight out of 62 (13%) patients with hypertension secondary to renovascular disease had FMD (all female; bilateral in four; mean age at diagnosis 37.6 years; age range 12–70 years). The mean duration of hypertension before the diagnosis of FMD was 3.3 years (range 3 months–10 years). A renal artery bruit was detected in five, hypertensive retinopathy in three and one had mild renal insufficiency. Twelve PTRAs were attempted on 10 stenotic lesions in six women. This cured the hypertension in three, while the other three have required less antihypertensive therapy. Percutaneous transluminal renal angioplasty was complicated by a trivial renal artery dissection in one, and a small upper pole infarction in another. One patient required a repeat PTRA. The other two women presented before the availability of PTRA and had successful reconstructive surgery. Fibromuscular dysplasia was the cause of hypertension in eight out of 62 (13%) patients with renovascular hypertension. Percutaneous transluminal renal angioplasty has shown encouraging results with a low complication rate. If technically feasible, PTRA should be attempted on all patients with FMD of the renal artery.     

Fibromuscular dysplasia of the renal artery: Management and outcome

SUMMARY: Renovascular hypertension may be caused by atherosclerotic disease or less commonly by fibromuscular dysplasia (FMD) of the renal arteries. Fibromuscular dysplasia is the commonest cause of renal artery stenosis in the younger age group and affects women predominantly. A review of our clinical database identified all patients with renovascular hypertension. All relevant clinical, biochemical and radiological findings on those with FMD were noted. the outcome of percutaneous transluminal renal angioplasty (PTRA) or reconstructive surgery was evaluated. Eight out of 62 (13%) patients with hypertension secondary to renovascular disease had FMD (all female; bilateral in four; mean age at diagnosis 37.6 years; age range 12–70 years). the mean duration of hypertension before the diagnosis of FMD was 3.3 years (range 3 months-10 years). A renal artery bruit was detected in five, hypertensive retinopathy in three and one had mild renal insufficiency. Twelve PTRAs were attempted on 10 stenotic lesions in six women. This cured the hypertension in three, while the other three have required less antihypertensive therapy. Percutaneous transluminal renal angioplasty was complicated by a trivial renal artery dissection in one, and a small upper pole infarction in another. One patient required a repeat PTRA. the other two women presented before the availability of PTRA and had successful reconstructive surgery. Fibromuscular dysplasia was the cause of hypertension in eight out of 62 (13%) patients with renovascular hypertension. Percutaneous transluminal renal angioplasty has shown encouraging results with a low complication rate. If technically feasible, PTRA should be attempted on all patients with FMD of the renal artery.     

Percutaneous transluminal revascularization for renal artery stenosis: Veterans Affairs Puget Sound Health Care System experience.

PURPOSE: The safety and efficacy of percutaneous transluminal intervention for renal artery stenosis is improving. This study evaluates the immediate and long-term anatomic and functional outcomes of percutaneous transluminal angioplasty and stenting for atherosclerotic renal artery stenosis in a Veterans Affairs population. METHODS: We performed a retrospective analysis of records from patients who underwent renal artery angioplasty with or without stenting at the Veterans Affairs Puget Sound Health Care System between January 1990 and June 1999. Indications for intervention included hypertension (78%) and rising serum creatinine (78%). Seventy-six patients (74 men, average age of 67 years, range 42-83 years) underwent 88 attempted interventions. Seventy-two percent of contralateral kidneys had significant disease (47% had a >60% stenosis; 16% were nonfunctioning or absent). RESULTS: Of the 88 planned interventions, 86 were successfully performed with placement of 46 stents (52%). Technical success (defined by <30% residual stenosis) was achieved in 78 vessels (89%). The procedure-related complication rate was 5%. Patient mortality by life table analysis was 49% at 5 years. Assisted primary patency rate at 5 years was 100%. Primary and secondary restenosis rates were 37% +/- 8% and 31% +/- 8% at 5 years, respectively. Sixty-eight percent of patients treated for hypertension demonstrated clinical benefit (improved or cured hypertension). This clinical benefit was maintained in 52% of the patients at 5 years, as measured by life table analysis. Serum creatinine was lowered or maintained in 88% of the patients, but this clinical benefit was only maintained in 25% of patients at 5 years. CONCLUSIONS: Transluminal intervention for clinically symptomatic atherosclerotic renal artery stenosis is technically successful and safe. There are excellent assisted-patency and low restenosis rates. There is immediate clinical benefit for most patients, as evidenced by improved control of hypertension and preservation of renal function. However, within 5 years the benefit is not maintained for either hypertension (50%) or renal function (20%). Therefore, although technically successful, functional outcomes after endoluminal intervention are not maintained in the long term.     

A preliminary study of the role of duplex scanning in defining the adequacy of treatment of patients with renal artery fibromuscular dysplasia.

Renal artery fibromuscular dysplasia is a well-known cause of hypertension whose presence is confirmed by its typical arteriographic appearance. The functional significance of these lesions is often difficult to determine, particularly when both renal arteries are involved. Duplex scanning has been shown to be accurate for the detection of renal artery stenosis and estimation of the degree of narrowing. To test whether duplex scanning results after intervention correlate with clinical outcome, we reviewed the studies on nine patients with renal artery fibromuscular dysplasia who had been treated by either angioplasty or surgery. A total of 18 arteries were treated. Fourteen of the 18 treatments were successful as measured by a reduction in blood pressure and antihypertensive drugs. In four instances treatment was unsuccessful. For those patients who had clinical improvement, the hemodynamic parameters from the renal artery also improved. In the patients for whom treatment failed, the velocities recorded from the site of narrowing did not improve after intervention. Thus it appears that duplex scanning along with the clinical results may be used to document the basis for failing to improve after treatment be it angioplasty or operation.     

Experience with percutaneous transluminal angioplasty for renal artery stenosis at the Cleveland Clinic

From April 1979 to June 1985 percutaneous transluminal angioplasty was attempted in 68 patients at our clinic to treat renovascular hypertension and/or to preserve renal function. The etiology of renal artery disease was atherosclerosis in 55 patients, fibrous dysplasia in 6, renal transplant arterial stenosis in 5 and postoperative saphenous vein graft stenosis in 2. A successful clinical outcome, defined as a decrease in blood pressure and/or improvement in renal function, was achieved in 12 patients (26.1 per cent) with atherosclerotic renal artery disease, 3 (75 per cent) with fibrous dysplasia, 2 (100 per cent) with saphenous vein graft stenosis and all 5 with transplant renal arterial stenosis (100 per cent). Improved results were observed in patients with nonostial atherosclerotic lesions compared to ostial lesions. There were 23 complications (33.8 per cent) after percutaneous transluminal angioplasty and all but 1 occurred with atherosclerosis. Of these complications 13 (19 per cent) were considered major. Since the beginning of 1983, however, only 3 complications occurred among 32 procedures (9.4 per cent) and only 1 of these was of major significance. When technically feasible, percutaneous transluminal angioplasty can provide effective treatment for selected patients with renal artery stenosis.     

Cure and improvement of renovascular hypertension after percutaneous transluminal angioplasty of renal artery stenosis

In the present study we report our long-term experience in 82 patients with renovascular hypertension (48 with atherosclerotic stenosis, 34 with fibromuscular dysplasia) who were followed up for a mean observation period of 23.6 months after percutaneous transluminal angioplasty (PTA) of renal artery stenosis. Our results show a highly significant decrease in mean systolic and diastolic blood pressure. Cure rates were slightly higher in patients with fibromuscular dysplasia (41% cured, 47% improved) than in those with atherosclerosis (23% cured, 54% improved). Kidney function significantly improved in patients with cure, remained stable in those with improvement and worsened in cases classified as unimproved. These results document the good long-term effect of PTA on blood pressure and kidney function in patients with renal artery stenosis.     

Donors with renal artery stenosis: fit to donate

Kidney donation from hypertensive donors is now an accepted norm in live related kidney transplantation. The use of hypertensive donors with renal artery stenosis due to atherosclerosis and fibromuscular dysplasia is still debated. The prime concern is about the deleterious effect of hypertension on the donor and the risk of recurrence of such lesions in the solitary kidney. Even as the response of atherosclerotic renal artery stenosis to revascularisation is unpredictable, there is an improvement in blood pressure following revascularisation of kidneys with fibro-muscular dysplasia. The first use of such kidney donors was reported in 1984 and, since then, there have been a few reports of successful use of kidneys from donors with renal artery stenosis. We report here two interesting cases of successful transplantation of kidneys from live related kidney donors with hypertension due to renal artery stenosis who became normotensive with good graft function in the recipient. We conclude that moderately hypertensive donors with renal artery stenosis are fit to donate.     

Imaging modalities for renal artery stenosis in suspected renovascular hypertension: prospective intraindividual comparison of color Doppler US, CT angiography, GD-enhanced MR angiography, and digital substraction angiography

The aim of the study was to evaluate the diagnostic accuracy of Color Doppler US, CT Angiography (CTA), and GD-enhanced MR Angiography (MRA) compared with digital subtraction angiography (DSA) for the detection of renal artery stenosis in patients with clinically suspected renovascular hypertension. Fifty-eight patients with suspected renovascular hypertension were enrolled in the study. All patients underwent Color Doppler US, CTA and GD-enhanced MRA. DSA was the gold standard method for the number of renal arteries, existence and degree of stenosis, or evidence of fibromuscular dysplasia. DSA depicted 132 renal arteries, 16 stenoses, and 4 arteries with fibromuscular dysplasia. Color Doppler US failed to detect 1 main and 14 polar arteries. CTA depicted all main renal arteries and 7/16 polar arteries, but failed to detect stenosis in two accessory vessels. Likewise, MRA did not detect stenotic accessory renal arteries, depicted 9/16 polar renal arteries, but missed two main renal arteries. All methods depicted the four main renal arteries with fibromuscular dysplasia. The overall sensitivity, specificity, and positive and negative predictive accuracy were 75%, 89.6%, 60% and 94.6%, respectively, for color Doppler US; 94%, 93%, 71%, and 99%, respectively, for CTA; and 90%, 94.1%, 75%, and 98%, respectively, for GD-enhanced MRA. CTA and GD-enhanced MRA have comparable and satisfactory results with respect to the negative predictive accuracy of the suspected renal artery stenosis. The concept of an imaging algorithm including US as screening test when appropriate and CTA or MRA as the second step-procedure is suggested. Therefore, DSA may be reserved for cases with major discrepancies or therapeutic interventions.     

Imaging Modalities for Renal Artery Stenosis in Suspected Renovascular Hypertension: Prospective Intraindividual Comparison of Color Doppler US,CT Angiography,GD-Enhanced MR Angiography,and Digital Substraction Angiography

The aim of the study was to evaluate the diagnostic accuracy of Color Doppler US, CT Angiography (CTA), and GD-enhanced MR Angiography (MRA) compared with digital subtraction angiography (DSA) for the detection of renal artery stenosis in patients with clinically suspected renovascular hypertension. Fifty-eight patients with suspected renovascular hypertension were enrolled in the study. All patients underwent Color Doppler US, CTA and GD-enhanced MRA. DSA was the gold standard method for the number of renal arteries, existence and degree of stenosis, or evidence of fibromuscular dysplasia. DSA depicted 132 renal arteries, 16 stenoses, and 4 arteries with fibromuscular dysplasia. Color Doppler US failed to detect 1 main and 14 polar arteries. CTA depicted all main renal arteries and 7/16 polar arteries, but failed to detect stenosis in two accessory vessels. Likewise, MRA did not detect stenotic accessory renal arteries, depicted 9/16 polar renal arteries, but missed two main renal arteries. All methods depicted the four main renal arteries with fibromuscular dysplasia. The overall sensitivity, specificity, and positive and negative predictive accuracy were 75%, 89.6%, 60% and 94.6%, respectively, for color Doppler US; 94%, 93%, 71%, and 99%, respectively, for CTA; and 90%, 94.1%, 75%, and 98%, respectively, for GD-enhanced MRA. CTA and GD-enhanced MRA have comparable and satisfactory results with respect to the negative predictive accuracy of the suspected renal artery stenosis. The concept of an imaging algorithm including US as screening test when appropriate and CTA or MRA as the second step-procedure is suggested. Therefore, DSA may be reserved for cases with major discrepancies or therapeutic interventions.     

Bilateral renal artery stenosis and renovascular hypertension

Experience with the diagnostic evaluation and operative management of 38 hypertensive patients having bilateral renal revascularization is presented. Twenty-four patients had atherosclerotic occlusions and 14 had fibromuscular dysplasia. Renal vein renin assays (RVRA) and/or split renal function studies (SRFS) were performed in 37 of the 38 patients before operation. Although RVRA was negative in 29 percent and SRFS negative in 31 percent, 24 of 26 patients (92 percent) having both tests done had at least one positive study. Twenty-one patients had simultaneous bilateral repairs and 12 had staged bilateral reconstructions. The incidence of technical failures in these two groups was 21 and 9 percent, respectively. Excluding three uncorrected technical failures and two patients with recurrent branch renal artery lesions, 90 percent of patients with atherosclerosis and all patients with fibromuscular dysplasia had a favorable blood pressure response to operation. This study supports the use of both RVRA and SRFS in the diagnostic evaluation of hypertensive patients with renal artery stenosis. If these functional tests lateralize to one side, repair of that side only is recommended. If the functional studies do not lateralize, operation is suggested only when hypertension is severe and is not controlled readily with medications. In this circumstance reconstruction of the side that appears to be diseased most severely is recommended. Contralateral repair is undertaken only when hypertension persists and when repeat functional studies lateralize to the unoperated side.     

Interventional radiology in the treatment of renal artery stenosis.

Percutaneous transluminal renal angioplasty (PTRA) alone or in combination with stent implantation, is increasingly used as an alternative technique to surgical revascularization for treatment of renal artery stenosis (RAS) wich may cause hypertension or jeopardize renal function. Herein we report the results obtained with 305 PTRAs performed in 242 hypertensive patients, 144 of whom had atherosclerotic RAS, 69 fibromuscolar dysplasia, 15 Ras in transplanted kidneys, 6 restenosis in surgically revascularized kidneys, 4 Takayasu arteritis and 4 neurofibromatosis. Stents were implanted in 68 cases, mostly in atherosclerotic stenoses. The technical success was achieved in 261 arteries (85.6%), with 33 failures (10.8%) and 11 (3.6%) procedures not completed for anatomical reasons. PTRA related complications were observed in 23 cases (7.5%), but no fatalities occurred. An overall benefit on blood pressure control was observed in 41% of patients with atherosclerotic RAS and in 68% of those with fibromuscolar dysplasia. It appears that independently from the ethiology PTRA is technically effective in correcting RAS; yet the position of PTRA with respect to that of medical or surgical treatment needs to be better delineated through randomized, controlled studies aimed at comparing the clinical efficacies of these different approaches.     

Diagnosis and therapy of atheromatous renal artery stenosis

Atheromatous renal artery stenosis (ARAS), a lesion of systemic atherosclerotic disease, is the leading cause of stenotic lesions in the renal artery, followed by fibromuscular dysplasia, a primary abnormality of the renal artery. As a result of several clinical trails, which failed to show an additional benefit of renal revascularization to medical therapy in ARAS, the treatment of ARAS has shifted, and renal revascularization is less commonly performed for ARAS. However, it is recognized that renal revascularization benefits some patients with ARAS. Advances in imaging modalities would allow more frequent detection of ARAS in a society with a growing elderly population, a group with an increased prevalence of systemic atherosclerotic disease. Therefore, it is imperative to identify the patients with ARAS who could benefit from renal revascularization. This review presents a strategy for the treatment of ARAS based on the results of our analysis.     

Treatment of renal artery fibromuscular dysplasia with balloon angioplasty: a prospective follow-up study.

OBJECTIVES: to assess restenosis rates and blood pressure response after percutaneous transluminal renal angioplasty (PTRA) in patients treated for fibromuscular dysplastic renal artery stenosis. METHODS: a prospective 12-month follow-up study of 27 patients with 31 treated renal artery stenosis. Follow-up assessment included colour-coded duplex sonography (CCD) of renal arteries, monitoring of blood pressure, antihypertensive medication, and creatinine measurements before discharge and at 3, 6, and 12 months. Primary end point was defined as a haemodynamically significant restenosis >60% assessed by CCD. RESULTS: there was a cumulative 23% restenosis rate at 12 months. Arterial hypertension was cured or improved in 93% of patients immediately after the intervention and remained cured/improved in 74% of patients at 12 months of follow-up. Renal failure present in five patients before PTRA stabilised or improved in all patients. CONCLUSION: although restenosis rate after PTRA in fibromuscular dysplasia is as high as in non-ostial atherosclerotic lesions, there remains a considerable higher therapeutic effect. Profound pressure response and recurrent arterial hypertension with restenosis support the high probability of a renovascular origin of arterial hypertension in this young and otherwise healthy population compared to patients with atherosclerotic renal artery lesions.     

Epidemiology and clinical presentation

Renovascular disease appears to be increasing in prevalence, particularly in older subjects with atherosclerotic disease elsewhere. Its clinical manifestations and presentation are changing because of rapid advances in medical therapy and other comorbid events. Although fibromuscular dysplasia and other diseases affecting the renal artery can produce the syndrome of renovascular hypertension, atherosclerotic renal artery stenosis is the most common clinical entity. It can produce a spectrum of manifestations, ranging from asymptomatic ("incidental"), identified during angiographic evaluation of other conditions, to progressive hypertension to accelerated cardiovascular disease with pulmonary edema and advanced renal failure. With the widespread application of drugs which block the renin-angiotensin system, including angiotensin-converting enzyme inhibitors and angiotensin antagonists, many cases of renovascular hypertension remain unsuspected and never produce adverse effects. Clinicians need to be alert to the potential for disease progression, with the potential for total renal artery occlusion and/or loss of viable renal tissue. Selection of patients for renal revascularization depends on individual balance of risks and benefits regarding the likely outcomes regarding both improvements in blood pressure control and preservation of renal function.     

Long-term outcome after surgical kidney revascularization for fibromuscular dysplasia and atherosclerotic renal artery stenosis

PURPOSE: At a time of minimally invasive surgery in urology, the role of surgical kidney revascularization in the management of renal artery disease has changed during the last decade. Our experience with surgical kidney revascularization, and the long-term clinical outcomes of fibromuscular dysplasia (FMD) and atherosclerotic renal artery stenosis are reviewed. MATERIALS AND METHODS: The study group comprised 140 patients with renovascular hypertension, 72 with FMD and 68 with atherosclerotic renal artery disease, who underwent surgical revascularization between 1982 and 1999. The indications for surgical revascularization were the treatment of hypertension and the preservation of renal function in 17 patients with renal artery occlusion, 55 with ostial stenosis, 52 with branch stenosis, 6 with bilateral artery stenosis, 7 with solitary kidney renal artery stenosis and 3 with solitary kidney renal artery occlusion. RESULTS: Postoperative blood pressure and renal function were monitored for 1 to 17 years (mean 11.3). Long-term blood pressure control was observed in 93% of patients with FMD and in 71% of those with atherosclerosis. Improvement or stabilization of renal function was observed in 92% of patients with FMD and in 68% of those with atherosclerosis. The preoperative estimated glomerular filtration rate compared to postoperative was significantly increased in both groups. CONCLUSIONS: Surgical kidney revascularization is effective in secondary hypertension with a high long-term efficacy in the normalization of blood pressure and in the preservation of renal function, especially in patients with a solitary or 1 functional kidney.     

Divergent outcomes after percutaneous therapy for symptomatic renal artery stenosis

OBJECTIVE: Percutaneous intervention for symptomatic renal artery atherosclerosis is rapidly replacing surgery in many centers. This study evaluated the anatomic and functional outcomes of endovascular therapy for atherosclerotic renal artery stenosis on a combined vascular surgery and interventional radiology service at an academic medical center. METHODS: This was a retrospective analysis of patients who underwent renal artery angioplasty with or without stenting between January 1990 and June 2002. Indications included hypertension (86%) and rising serum creatinine concentration (55%). One hundred forty-six patients (80 women; average age, 71 years [range, 44-89 years]) underwent 183 attempted interventions (64 to treat bilateral stenosis). Forty-five percent of patients had significant bilateral disease: 27% had greater than 50% bilateral stenosis, and the remainder had nonfunctioning, absent, or occluded vessels. RESULTS: Of 183 planned interventions, technical success (<30% residual stenosis) was achieved in 179 vessels (98%) with placement of 137 stents (75%). Thirty-day mortality was 0.7%. The major morbidity rate was 4%, and the procedure-related complication rate was 18%. Five-year cumulative patient mortality was 25%. Primary patency, assisted primary patency, and recurrent stenosis rates were 82% +/- 9%, 100% +/- 0%, and 30% +/- 7%, respectively, at 5 years. Within 3 months of the procedure, 52% of patients who received treatment of hypertension demonstrated clinical benefit (hypertension improved or cured), which was maintained in 68% of patients at 5 years. Serum creatinine concentration was lowered or stabilized in 87% of patients within 3 months of the procedure, but this benefit, including freedom from dialysis, was maintained in only 45% of patients at 5 years. CONCLUSIONS: Endovascular intervention for symptomatic atherosclerotic renal artery stenosis is technically successful. There were excellent patency and low recurrent stenosis rates. There is immediate clinical benefit for most patients, but divergent long-term functional outcomes. Endovascular interventions modestly enhance the care of the patient with hypertension, but poorly preserve long-term renal function in the patient with chronic renal impairment.     

Surgical renal artery reconstruction after percutaneous transluminal angioplasty

Percutaneous transluminal renal angioplasty (PTRA) is a controversial treatment for renal artery stenosis. This article discusses whether or not a prior attempt at PTRA compromises a subsequent elective or emergent surgical revascularization. Thirteen patients had surgical renal artery reconstruction after one or more PTRAs. Eight of the patients were treated because of atherosclerotic renal artery disease whereas five had a form of fibromuscular dysplasia. Five patients had renal artery injury directly related to the angioplasty. Four of these kidneys were saved. Eight patients were treated from 6 to 920 days after PTRA because of recurrent stenosis or occlusion of the renal artery. Only one of these kidneys was lost, an attempt at revascularization of a small kidney that failed to resume function. A prior attempt at PTRA did not compromise the ability of subsequent surgical revascularization to ameliorate hypertension. We conclude that surgical renal revascularization is not made less likely to succeed by a previous attempt at PTRA; even if the renal artery is thrombosed or perforated during the procedure, a reasonable chance of renal salvage is obtained by immediate surgical revascularization.     

Percutaneous Therapy for Renal Artery Fibromuscular Dysplasia

Fibromuscular dysplasia (FMD) accounts for 10% of cases of renal artery stenosis. This study evaluates the anatomic and functional outcomes of endovascular therapy for symptomatic renal artery FMD at an academic medical center. A retrospective analysis of records from patients who underwent percutaneous transluminal renal artery angioplasty (PTRA) found 14 patients (all female) who underwent 19 interventions on 18 renal artery segments. Significant cardiovascular comorbidities were few in this patient population. The PTRA technical success rate was 95%. There were no periprocedural mortalities. Primary patency rates were 81%, 69%, 69%, and 69% at 2, 4, 6, and 8 years. Assisted primary patency rates were 87%, 87%, 87%, and 87% at 2, 4, 6, and 8 years. The restenosis rate was 25% at 8 years. Clinical benefit (improved or cured hypertension) was seen in 79% of patients overall; 65% of patients maintained this benefit at 8 years by life-table analysis. Percutaneous endovascular intervention for clinically symptomatic FMD of the renal arteries is technically successful, safe, and durable. Most patients demonstrate immediate clinical benefit and retain durable functional outcomes. Presented at the Thirteenth Annual Winter Meeting of the Peripheral Vascular Surgery Society, Snowmass, CO, January 31-February 2, 2003.