THE VALUE OF TECHNETIUM-99M RENOGRAPHY FOR THE DETECTION OF RENAL ARTERY STENOSIS IN PATIENTS WITH AORTIC AND LOWER LIMB VASCULAR DISEASE

The results of technetium renography were compared with arteriography to determine whether this is a satisfactory screening test for renal artery stenosis (RAS). Sixty-three patients were studied before aortic surgery. All were investigated by aortography and isotope renography. These tests were assessed blind and all arteriograms were graded by a single independent radiologist. Renal artery stenosis was detected by arteriography in 34 (54%) patients. Twenty-three (37%) had mild (< 50%) stenosis, seven (11%) had moderate (50–80%) stenosis and four (6%) had severe (> 80%) stenosis. Of these 34 patients, only 6 (18%) were correctly diagnosed by isotope renography. None of the four with severe stenosis were identified. Isotope renography resulted in six true positives, six false positives, 23 true negatives and 28 false negatives. It was concluded that isotope renography did not fulfil the criteria for a screening test for the detection of RAS and appeared to be of no value in those patients undergoing aortic surgery in whom arteriography was not indicated.     

Investigation and diagnosis of hypertrophic pyloric stenosis

Forty-nine infants who underwent investigation or surgery for hypertrophic pyloric stenosis (HPS) over a 30-month period were reviewed. Significant weight loss was present in 18 infants, of whom 16 had HPS. A test feed was performed in 46 infants with 1 of 27 false positive and 6 of 29 false negatives. An ultrasound examination was performed in 34 infants with 4 of 23 false positives and 1 of 11 false negatives. It is recommended that if the test feed is positive then surgery should be performed, otherwise an ultrasound examination can be used as a screening test but a positive result should be confirmed by other means before surgery.     

Computed tomography in the evaluation of the aorta in patients sustaining blunt chest trauma

Computed tomography is used with increasing frequency to evaluate blunt chest trauma. Since traumatic aortic rupture (TAR) is a rapidly lethal condition, unnecessary CT scanning may not be justified. To determine the accuracy of chest CT scanning for TAR, we reviewed 17 patients who underwent both chest CT scanning and aortography. Five patients had TAR by aortography. CT scanning yielded three true positives and two false negatives. In 12 patients with a negative aortogram, CT scanning recorded four false positives and eight true negatives. The specificity was 23% and the sensitivity was 83% compared with aortography. The overall accuracy for CT scanning was 53%. From these data we conclude that in the presence of an unstable patient or where there is a strong clinical suspicion of TAR the patient should proceed directly to aortography.     

Detection of Occult Renovascular Disease in Unexplained Chronic Kidney Disease

Atherosclerotic renal artery stenosis (RAS) is a recognized cause of renal impairment. RAS is often overlooked in unexplained chronic kidney disease (CKD). A retrospective analysis of renal angiograms was performed to determine the prevalence of occult renovascular disease in 64 (M:F, 46:18; ages 21–81 years [median 60 years]) patients with unexplained CKD. Twelve patients had diabetes mellitus (type II: 11) and 43 were smokers. Median serum creatinine was 5.2 mg/dl (range 1.5–10.6 mg/dl). Group A included patients with unexplained CKD and with no risk factors for RAS and Group B had patients with increased risk for RAS. A narrowing of the renal vessel, main artery or branch, by >50% on renal arteriography was used as diagnostic criteria for RAS. 31/64 patients had positive angiographic findings. Thirteen patients had unilateral RAS, 9 had bilateral RAS, 5 had unilateral stenosis with occlusion on the opposite side, 3 had unilateral occlusion and 1 had a solitary kidney with RAS. 19/34 (54%) in Group A and 12/30 (40%) in Group B had a positive renal angiogram. In 10 patients with a rise in serum creatinine on recent introduction of ACE inhibition, 2 had evidence of RAS on renal arteriography. Eleven patients underwent angioplasty and 2 reconstructive surgeries. In 4 patients, blood pressure control improved and anti-hypertensive drug requirements were reduced, whilst renal replacement therapy was postponed in 4, by 2–24 months. In 18 patients, the lesions were not amenable to angioplasty or reconstructive surgery. Four patients did not benefit in any form with intervention. Occult atheromatous renal vascular disease is a common, not readily predictable and potentially correctable etiology of unexplained CKD.     

0.5 Tesla cine-magnetic resonance angiography is a poor screening test for atheromatous renal artery stenosis in chronic renal failure

SUMMARY: A prospective comparative study of 0.5 Tesla cine-magnetic resonance arteriography (MRA) versus standard arteriography (SA) was performed in 42 patients with clinical suspicion of atheromatous renal artery stenosis (ARAS), all of whom had chronic renal failure (average creatinine for 42 patients was 269.2±103.4 μmol/L). MRA was performed on a Philips 0.5 Tesla T5 release III, (London, UK) using T1 gradient echo cine, and 3D phase contrast. SA was performed as an aortic flush, with or without selective renal studies, via the femoral artery. Intravenous digital subtraction angiography was performed (instead of a flush procedure) in two patients with severe femoral atheroma. One radiologist reported the MRA's, another reported the SA's; both were blinded to the results of other scans. MRA correctly identified the number of renal arteries in 31 of the 42 patients (75%); accessory arteries could not be visualized. Using SA as the gold standard', MRA had a sensitivity of 90% and a specificity of 54%, with regard to detection of significant (>50%) ARAS lesions. MRA had a negative predictive value of 70%, and a positive predictive value of 82%. MRA was well tolerated by all patients, oral sedation being needed for just three. We conclude that 0.5 Tesla MRA has only limited usefulness as a non-invasive screening test for ARAS, demonstrating fair sensitivity, comparable to other screening methods, in the context of significant renal impairment. However, specificity was poor, due to seven false positives. Improving the signal to noise ratio by using signal-enhancing media, or using a more powerful magnet, are likely to yield more accurate information.     

Feasibility of whole-body MRI for detecting metastatic myxoid liposarcoma: a case series

No feasible method currently exists to evaluate systemic metastasis in patients with myxoid liposarcoma. The purpose of this study was to determine the feasibility of performing whole-body magnetic resonance imaging (MRI) to detect metastatic myxoid liposarcoma. From June 2008 to May 2010, all patients who were newly diagnosed with myxoid liposarcomas at our institution underwent whole-body MRI along with other conventional imaging methods. We divided the whole body into 38 sections (7 soft tissue sections and 31 bone tissue sections). In total, there were 570 regions (105 soft tissue regions and 465 bony regions) in 15 patients (10 men and 5 women) who underwent whole-body MRI.Of 105 soft tissue regions, there were 4 true positives, 3 false positives, 1 false negative, and 97 true positives. Of 465 bone tissue regions, there were 11 true positives, 5 false positives, 2 false negatives, and 447 true negatives. In soft tissue, whole-body MRI for the detection of metastatic lesion showed a sensitivity of 80%, a specificity of 97.0%, a positive predictive value of 57.1%, and a negative predictive value of 99.0%. In bone tissue, whole-body MRI had a sensitivity of 84.6%, a specificity of 98.9%, a positive predictive value of 68.8%, and a negative predictive value of 99.6%.Whole-body MRI is feasible and effective for detecting bone and soft tissue metastasis in patients with myxoid liposarcoma.     

Detection of unsuspected renal artery stenoses in patients with abdominal aortic aneurysms: Refined indications for preoperative aortography

Renal artery stenoses (RASs) that are unsuspected on clinical grounds are common in patients with peripheral vascular disease. These lesions may be missed in patients with abdominal aortic aneurysms (AAAs) who undergo arteriography based on selective clinical indications alone. We reviewed 98 consecutive patients with AAAs to determine how often selective arteriography would fail to diagnose unsuspected RAS. The location and degree of RASs were noted on preoperative arteriograms, which were routinely obtained in all patients considered for AAA repair during the study period. Medical records were studied to determine the presence of selective clinical indications for preoperative arteriography (moderate to severe hypertension or renal insufficiency). Twenty-four patients had a significant (50% diameter loss) RAS, and 10 patients had a severe (75% diameter loss) RAS or renal artery occlusion. Patients with significant RAS had a higher incidence of hypertension (p=0.035) and renal insufficiency (p=0.018). All 10 patients with severe RASs required at least two antihypertensive medications to control their hypertension compared with 22 of 88 patients who did not have a severe RAS (p<0.001). Forty-three patients had an indication for arteriography according to selection criteria (renal insufficiency, moderate or severe hypertension, or both). No severe RASs were found in patients who did not meet the selection criteria for arteriography. Using arteriography based on the presence of hypertension requiring two or more medications for control will detect the vast majority of severe, unsuspected RASs in AAA patients.     

Emergency center arteriography.

From 1983 through 1989, 1,882 emergency center arteriograms were performed on 1,802 patients suspected of having peripheral vascular injuries. The most common indication for emergency center arteriography (ECA) was the proximity of an injury to a major vascular structure. This was the only indication in 1,712 injured extremities (91%). There were 1,510 true negative arteriograms, 294 true positives, 7 false negatives, and 14 false positives. Accordingly, the sensitivity was 95.5% and the specificity was 97.7%. The remaining 57 arteriograms were either equivocal or technically inadequate. Further evaluation of these patients uncovered an additional 11 vascular injuries. Operative intervention was required for 196 (64.3%) injuries detected by emergency arteriography. The remaining 109 injuries were considered minor and were not repaired. No complications developed in 91 patients (88%) with minor vascular injuries who were available for a mean follow-up duration of 12 months. One thousand forty-eight patients (69.4%) with negative arteriograms were followed for a mean of 18 months, and no vascular complications were noted. Emergency center arteriography is a rapid, accurate, and cost-effective technique. It is of particular value in detecting the presence of occult arterial injuries when proximity of a major vascular structure is the sole indication for arteriography. When formal arteriographic support is either unavailable or time consuming, ECA is recommended.     

Quantitative residual cortical activity measurement: appropriate test for diagnosis of renal artery stenosis?

OBJECTIVES: To evaluate the diagnostic validity of quantitative measurement of residual cortical activity (RCA) in renal artery stenosis (RAS). METHODS: In 45 patients with a high clinical likelihood of renovascular hypertension (RVH) and unimpaired renal function, dynamic imaging was performed after an intravenous bolus injection of 148 MBq (99m)Tc MAG3 for both baseline renoscintigraphy and captopril renography following oral application of 50 mg captopril. RCA was measured according to the Sfakianakis method: RCA = cortical counts at 20 min/counts at peak x100%. An increase in RCA of >/=5% from baseline was considered indicative of RAS. After renography, all patients underwent selective transfemoral angiography with the digital subtraction technique. A luminal reduction of >/=50% was considered as proof of RAS. RESULTS: The number of kidneys that had a change of >/=5% in RCA values was 12 (27.2%) in normal kidneys, 7 (58.3%) in the patients with bilateral RAS, 14 (82.3%) in the patients with unilateral RAS, and 21 (72.4%) in overall kidneys with RAS. The positive test ratio in pathologic groups was significantly higher than normal (p < 0.05). The sensitivity and specificity of the RCA test were 72.4 and 72.7%, respectively; the positive and negative predictive values were 63.6 and 80%, respectively. CONCLUSION: Quantitative measurements of RCA can be used as a diagnostic parameter of renal artery stenosis and may contribute of the diagnostic accuracy of visual interpretation and other renographic diagnostic criteria.     

Renovascular hypertension. Prospective diagnostic yield in a random access population

Over a five-year period, 104 patients with diastolic hypertension were clinically evaluated and studied by arteriography, differential renal function studies, and radioisotopic renography. Based on either a positive differential renal function study and/or response to surgery, the incidence of renovascular hypertension was determined to be 6 per cent. Of the entire group studied, 15 per cent ($\text{16}\text{104}$) of patients were found to have renal artery stenosis by arteriography. Eight of these patients had normal differential function studies and were excluded from the renovascular group. In the group with a final diagnosis of essential hypertension (87), 22 patients met roentgen criteria for chronic pyelonephritis. All 6 patients with renovascular hypertension had abnormal renograms; 5 of 8 patients with renal artery stenosis and normal differential function studies had abnormal renograms. However, there was an incidence of 15 per cent false positive renograms. Differential renal function studies were carried out on 75 patients, utilizing a modification of the Stamey technique. Of the 6 patients with renovascular hypertension, 2 had negative results on tests by Stamey's criteria; 2 had negative findings on tests by Rapoport's criteria; and there was 1 negative result on a test utilizing PAH (para-aminohippuric acid) excretion ratios as criteria.     

Functional testing: ACEI renography

Angiotensin-converting enzyme inhibition (ACEI) renography is the only imaging examination that tests directly for the presence of renovascular hypertension (RVH); other imaging examinations test only for the presence of renal artery stenosis (RAS). Consensus panels have recommended that ACEI renograms be interpreted as low, intermediate, or high probability for RVH. ACEI renography is highly accurate in patients with normal renal function and suspected RVH. In this patient population, the sensitivity and specificity of ACEI renography for RAS are approximately 90%; as an initial approach, angiography is not cost effective. Data from 10 studies evaluating cure or improvement in blood pressure in 291 patients undergoing revascularization showed the mean positive predictive value of ACEI renography to be 92%. When azotemic patients present with suspected RVH, as many as 50% of patients may have an intermediate probability ACEI renogram and the sensitivity of detecting RVH falls to approximately 80% even when intermediate and high probability tests are combined.     

The value of pre-operative aspiration in the diagnosis of an infected prosthetic knee: a retrospective study and review of literature

The purpose of this study was to compare the results of cultures of preoperative aspiration samples with those of swabs taken intra-operatively. The records of 70 revision arthroplasties of the knee from 69 patients, 49 females and 20 males, were reviewed. The mean age of the patients at time of revision arthroplasty was 67 years (range: 34 to 89). Sixty-eight knees from 67 patients were included. There were 32 true positives, 17 true negatives, 6 false positives and 13 false negatives. This led to a specificity, sensitivity and accuracy of 57%, 84% and 72%, respectively. Based on these findings, pre-operative aspiration has a positive predictive value of 71% and a negative predictive value of 74%. When the aspiration sample yields a positive culture, the chances are high that the prosthetic knee is infected. When aspiration is negative, infection cannot be ruled out. Our study suggests that, in such cases, a coagulase negative Staphylococcus (CNS) infection has to be considered.     

Arrhythmogenic risk of pulmonary artery catheterisation in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation

Many clinicians consider severe aortic stenosis to be a contraindication to pulmonary artery catheterisation, except during open heart surgery with cardiopulmonary bypass. This is due to the perceived high risk of arrhythmia, although the true incidence of ventricular tachycardia and fibrillation remains unclear. We conducted a retrospective study to estimate the incidence of severe arrhythmias during pulmonary artery catheterisation in 380 patients with severe aortic stenosis scheduled for transcatheter aortic valve implantation. Ventricular fibrillation was seen in only one patient (0.26%), and this was successfully terminated by external defibrillation. No episodes of ventricular tachycardia were recorded and there were also no arrhythmias during removal of the catheter. We have therefore concluded that pulmonary artery catheterisation in patients with severe aortic stenosis is not associated with a high incidence of ventricular fibrillation or tachycardia, allowing pulmonary artery pressure monitoring to be performed relatively safely in such patients.     

The clinical utility of carotid duplex scanning

We retrospectively compared the results of duplex scanning (DS) with contrast angiography (CAN) in the evaluation of 119 patients whose 238 carotid arteries were evaluated by both methods within a four-week period. The results of all patients were then categorized by two different definitions of severity of stenosis. Category A classified 1-29% stenosis as mild, 30-69% stenosis as moderate, and 70-99% diameter reduction as severe stenosis. Category B defined mild stenosis as 1-19% lumen diameter reduction, moderate as 20-49% stenosis, and severe as 50-99% stenosis. The findings by each classification were compared in 60 patients with hemispheric symptoms and in 59 patients with nonspecific symptoms. CAN was our "gold standard", and exhibited greater sensitivity, specificity, accuracy, and predictive values than DS. Carotid arteries with 70% stenosis were identified by DS with greater specificity, accuracy, and predictive values than were arteries with 50% stenoses. Only the sensitivity was comparable in categorizations A and B (80% and 83%). All parameters of measurement were superior in patients with hemispheric symptoms. DS alone cannot substitute for CAN in selecting patients for carotid endarterectomy because its error rate exceeded acceptable rates of complications for carotid artery surgery. The false positive rate of DS was 4%. DS failed to diagnose 7 of 19 carotid artery occlusions, 9 of 11 ulcerated plaques, 7 of 119 instances of aortic arch disease, and 13 cases of severe intracranial artery stenosis.     

Detection of significant renal artery stenosis with color Doppler sonography: combining extrarenal and intrarenal approaches to minimize technical failure

BACKGROUND: Renal artery disease can cause both hypertension and renal failure, and color Doppler sonography (CDS) may be a good screening method to detect it. Presently reported techniques of Doppler sonography have either a high rate of technical failure (4-42%), or low sensitivity and specificity, or detect only stenoses greater than 70%, or exclude patients with renal failure from analysis. In previous studies Doppler detection of renal artery stenosis (RAS) was based either on increased intrastenotic velocity or on the detection of post-stenotic Doppler phenomena. In the present prospective study these two approaches were combined to detect RAS (> or = 50% diameter reduction) in 226 consecutive patients (144 with normal and 82 with impaired renal function). METHODS: Stenosis of 50% or more was diagnosed if the maximal systolic velocity in the main renal artery was more than 180 cm/sec and velocity in the distal renal artery less than one quarter of the maximum velocity. When these velocities could not be determined a diagnosis of RAS was made when the acceleration time in intrarenal segmental arteries exceeded 70 msec. All patients subsequently underwent arteriography as the gold standard for the detection of RAS. RESULTS: With this combined approach, the technical failure rate of CDS was 0% in both patients with normal and those with impaired renal function. The mean time required for the Doppler investigation was 17 minutes. The sensitivity and specificity for detection of a significant stenosis in a given vessel (including accessory arteries), as compared to angiography, were 96.7% and 98.0%. CONCLUSION: Color Doppler sonography, evaluating both main renal and intrarenal arteries is an ideal screening method for detection of RAS of 50% or more because it allows accurate and rapid detection of stenosis in all patients, irrespective of renal function.     

Angiographic characteristics of renal arterial disease over the spectrum of coronary artery disease

BACKGROUND/AIM: The angiographic characteristics of renal artery stenoses (RAS) in patients with coronary artery disease (CAD) have not been yet fully investigated. We sought to evaluate the angiographic characteristics of RAS in patients with CAD. METHODS: The medical records of consecutive patients who underwent coronary angiography in a single public institution over a 12-month period were evaluated. The patients who underwent coincident diagnostic renal angiography to evaluate renal vessels on the basis of clinical criteria and who had at least one-vessel CAD were analyzed. Moderate (50-70%) to severe (70-100%) arterial stenoses were noted as significant angiographic findings. The types of stenosis (ostial, true renal, mixed) and presence and location of calcium were recorded. RESULTS: Angiographically significant RAS were reported in 40 (19.5%) of 205 consecutive patients (mean age 67.1 +/- 12.8 years, mean serum creatinine concentration 2.1 +/- 0.5 mg/dl, mean glomerular filtration rate 52 +/- 13 ml/min) for a total of 55 lesions. The RAS severity was moderate in 30.9% (17/55), severe in 69.1% (38/55), ostial in 27.2% (15/55), true renal in 10.9% (6/55), and mixed in 61.8% (34/55) of the patients. The mean lesion length was 16 +/- 1.8 mm. Patients with > or = 3-vessel CAD had a statistically significantly higher prevalence of mixed calcified RAS (18/24, 75%). Logistic regression analyses revealed > or = 3-vessel CAD (odds ratio 9.917, p = 0.002), age > 65 years (odds ratio 3.817, p = 0.036), and > or = 3 risk factors (odds ratio 2.8, p = 0.048) as independent predictors of RAS. CONCLUSION: RAS in multivessel CAD patients seems to have a peculiar angiographic pattern, such as a higher prevalence of mixed calcified lesions and poststenotic enlargement, that should be taken in account when dealing with RAS.     

Screening for carotid artery stenosis and renal artery stenosis in patients undergoing tunneled cuffed hemodialysis catheter placement

In this study, we noted the common risk factors with atherosclerosis and chronic renal disease. We, therefore, hypothesized that the placement of a dialysis catheter would be a useful marker in identifying populations at increased risk of vascular disease (carotid, renal, and aortic). To further explore this issue, we examined the results of duplex scanning of the carotid arteries and aortorenal arteries in patients undergoing dialysis catheter placement. Over 49 months, each of the 123 patients who underwent permanent tunneled dialysis catheter placement received a carotid duplex study. Twelve patients (9.8%) had ≥ 60% stenosis and 8 patients (6.5%) had 70% to 99% stenosis. Furthermore, 109 patients who underwent a aortorenal artery duplex study were also analyzed. The study population demonstrated a prevalence rate of 3.7% for abdominal aorta aneurysm (AAA) and 4.6% for renal artery stenosis (RAS). Based upon these data, we suggest performing routine carotid duplex scans in patients who will also receive dialysis catheter placement. However, the data did not support routine screening of AAA or RAS.     

Use of surgeon-performed office ultrasound and parathyroid fine needle aspiration for complex parathyroid localization

BACKGROUND: This study investigates the utility of ultrasound guided parathyroid fine needle aspiration (FNA) as a localizing technique in patients with hyperparathyroidism (HPT) undergoing re-operative neck surgery or with unusually appearing or ectopically located glands. METHODS: Selected patients with HPT underwent surgeon-performed FNA with ultrasound guidance. Aspirate contents were sent for cytology and parathyroid hormone (PTH) levels. All patients subsequently underwent parathyroid exploration. RESULTS: 54 patients underwent 57 ultrasound guided parathyroid biopsies. Indications for FNA included prior parathyroid (n = 29), thyroid (n = 11), or other neck surgery (n = 2), or unusual parathyroid appearance or location (n = 12). A true positive was defined as a site where the PTH aspirate was >40 pg/mL and a hypercellular gland was removed at surgery. Based on this, there were 44 true positives, 10 true negatives, and 3 false negatives; there were no false positives. The median PTH level in positive aspirates was 11,665 pg/mL. Cytology was primarily helpful in excluding other diagnoses. CONCLUSION: Ultrasound guided FNA is a highly specific localization test for parathyroid tumors. This procedure can be successfully performed by surgeons in the office setting and is extremely valuable for directing parathyroid exploration in challenging cases. We recommend incorporating ultrasound and FNA as a pre-operative localization strategy for selected patients with HPT.     

Débridement-valvotomy for aortic stenosis in adults: A follow-up of 76 patients

Seventy-six adults who had débridement-valvotomy for severe aortic stenosis are reviewed. Of these, 61 had isolated aortic valve stenosis and 15 had multivalvar disease. Twenty-six patients (34%) died at or subsequent to surgery. Thirty-eight of the 40 survivors with isolated aortic valve disease have been followed up for between 21 and 70 (mean 46) months after surgery, and detailed evidence as to the state of the aortic valve was obtained in 34 of these either by left heart catheterization or at operation. Only one result was completely acceptable. The great majority of patients were found to have redeveloped important aortic stenosis, and in many this was already sufficiently severe to warrant further surgery. The initial degree of valve calcification seemed to have little bearing on the final result except in the multivalve group. Other series are reviewed. The operation has become increasingly unpopular, but reports continue to suggest that it may still have a place. Our results suggest that the procedure should be discarded.     

A single-center experience treating renal malperfusion after aortic dissection with central aortic fenestration and renal artery stenting

OBJECTIVE: Patients with aortic dissection were studied to define (1) anatomic and physiologic derangements in renal artery blood flow, (2) differences in clinically suspected renal malperfusion and true functional malperfusion, and (3) variations in endovascular interventions for the treatment of renal malperfusion. METHODS: The cohort comprised 165 patients (mean age, 58 years) with dissections who were thought to have malperfusion sufficient to require arteriography. They were treated from 1996 to 2004 for acute (n = 115) or chronic (n = 50) aortic dissections (75 had type A, 90 had type B lesions). All patients had suspected peripheral vascular malperfusion (ie, cerebral, spinal, mesenteric, renal, or lower extremity vascular beds). Renal malperfusion was suspected in 88 patients secondary to worsening hypertension (n = 34), evolving renal insufficiency (n = 37), computed tomography evidence of impaired renal blood flow (n = 13), or a combination of factors (n = 4). Patients underwent angiographic and intravascular ultrasound studies. Renal malperfusion was confirmed with a systolic gradient between the aortic root and renal hilum (average, 44 mm Hg). RESULTS: Right renal arteries arose exclusively from the true lumen in 115 patients (70%), the false lumen in 11 (7%), and both lumens in 37 (23%). Left renal arteries arose exclusively from the true lumen in 69 patients (42%), the false lumen in 32 (20%), and both lumens in 62 (38%). Angiographic confirmation of malperfusion existed in 59 patients (67%) of the 88 suspected of such, and in 31 patients (39%) of the 79 with suspected malperfusion of nonrenal tissues. Of the 90 patients with confirmed renal malperfusion, 71 underwent endovascular therapy, including isolated renal artery stenting (n = 31), as well as proximal aortic fenestration with or without aortic stenting (n = 24), or both renal and aortic intervention (n = 16). Residual pressure gradients averaged 8.1 mm Hg after these interventions. Five procedure-related complications (7%) occurred. The periprocedural postintervention mortality rate was 21% (n = 15), including multisystem organ failure (n = 7), false lumen rupture (n = 3), reperfusion injury (n = 2), cerebral ischemia (n = 1), cardiac arrest (n = 1), and unknown (n = 1). CONCLUSIONS: Percutaneous aortic fenestration and renal artery stenting are both technically feasible and associated with an acceptable complication rate. Most patients respond well symptomatically, obviating the need for immediate surgical relief of renal artery obstruction and allowing for renal malperfusion recovery.