Short- and long-term outcomes of percutaneous transluminal angioplasty/stenting of renal fibromuscular dysplasia over a ten-year period.

The purpose of this study was to evaluate short and long-term outcomes of percutaneous transluminal intervention in patients with symptomatic renal artery stenosis due to fibromuscular dysplasia (RAFMD) and/or the combination of RAFMD with aorto-ostial atherosclerotic disease. A retrospective analysis of all patients with renal artery RAFMD who underwent transcatheter therapy between January 1999 and December 2009 was performed. Blood pressure (BP) measurement, number of BP medications, and hypertension defined by a systolic BP >140 ± diastolic BP >90 were recorded. Renal function was defined by estimated glomerular filtration rate (eGFR). Restenosis was defined by stenosis >60% and was determined by renal artery duplex and/or angiography. Freedom from event (restenosis, renal failure, or recurrent hypertension) was performed using life table analysis. Forty-three procedures were performed on 35 patients with RAFMD. Thirty-two patients (91%) were women, with mean age of 61.9 years old. Technical success was 100% with adjunctive stent placement required in the FMD segment for dissection in 1 patient (2.3%) and in the non-FMD aorto-ostial atherosclerotic lesion in 4 patients (9.3%). Short-term outcomes: the majority (69%) had an immediate clinical benefit for hypertension, 6% were cured without BP medications, and 63% improved with less than or equal to preoperative BP medications. Postintervention, 17% remained at moderately reduced renal function (<60), whereas the percent above >60 mL/minute eGFR increased significantly (from 51% to 69%; P = .002). For the entire cohort, renal function (mean eGFR) significantly increased from 71.9 mL/minute + 5.8 to 80.8 mL/minute + 5.2 (P = .007). Long-term outcomes: freedom from recurrent or worsening hypertension (>140 systolic blood pressure [SBP] and >90 diastolic blood pressure [DBP]) was (93%, 75%, and 41%) and freedom from reduced renal function (eGFR <30 mL/minute) was (100%, 95%, and 64%) at 1, 5, and 8 years, respectively. Patients with reduced baseline renal function (<60 mL/minute) and combined atherosclerotic disease were more likely to experience long-term reduced renal function (eGFR <30 mL/minute; P = .003). Primary and assisted primary patency was (95%, 71%, and 50%) and (100%, 100%, and 100%) at 1, 5, and 9 years, respectively. Renal angioplasty is a safe and durable modality for treating RAFMD with favorable short and long-term clinical outcomes. Patients with combined atherosclerotic disease and FMD were older and were more likely to have declining renal function over time. Early intervention may be imperative to achieve possible cure of hypertension.

Mousa AY ，Campbell JE ，Stone PA ，Broce M ，Bates MC ，AbuRahma AF ... -  《-》

Clinical characteristics and treatment of renal artery fibromuscular dysplasia with percutaneous transluminal angioplasty: a long-term follow-up study.

Yang YK ，Zhang Y ，Meng X ，Yang KQ ，Jiang XJ ，Wu HY ，Zhang HM ，Song L ，Wang LP ，Gao LG ，Zhou XL ... -  《-》

Ten-year experience with renal artery in-stent stenosis.

Atherosclerotic renal artery stenosis (RAS) is the most common cause of secondary hypertension. Renal stenting has become the treatment of choice for RAS in most centers. Primary patency of RAS is well defined, but limited data are available on outcomes of secondary interventions for treatment of in-stent restenosis. This was a retrospective analysis of a 10-year experience with renal artery stenting in patients presenting with recurrent symptomatic stenosis. End points included freedom from tertiary procedures, change in baseline renal function by ≥20% measured by estimated glomerular filtration rate (eGFR), patency confirmed by duplex imaging, long-term hypertension response, freedom from hemodialysis, and survival. We reviewed 948 patients with 1150 treated renal arteries. Of these, 107 patients (122 renal stents) returned with symptomatic in-stent restenosis and required reintervention (target vessel revascularization [TVR] rate, 10.6%): 97% had recurrent or worsening hypertension, and 67% had worsening renal function. There were 69 women (64%) and 38 men (35%) with an average age of 68.9 years. Mean follow-up was 35.5 months (range, 1.0-104.7 months) for patency and 37.7 months (range, 0.03-100.9 months) for renal function (creatinine). Secondary interventions included 27 percutaneous transluminal angioplasties (PTAs), 10 PTAs with cutting balloon, 77 repeat renal artery stenting, and 8 placements of drug-eluting stents (DES). Twenty-five of the 122 arteries (20%) required tertiary interventions in 23 patients, a significantly higher TVR rate vs de novo interventions (11%; P = .003). Freedom from tertiary interventions at 60 months was similar among treatment groups undergoing PTA (66%), cutting balloon (100%), stent (80%), and DES (75%; P = .348). Seventeen (16%) had an increase of >20%, 50 (47%) had a decrease of >20%, and 30 (28%) had no change in renal function. Ultimately 25 (23%) remained or progressed to renal failure (eGFR < 30%), and 8 required hemodialysis. The survival rate was 73% at 5 years. Mean follow-up for long-term hypertension response was 3.2 years, with 56% improved, 28% with no improvement or deterioration, 16% without long-term data available, and no patients cured. Secondary interventions for renal in-stent restenosis had higher TVR vs de novo renal stents in this large series (21% vs 11%; P = .003). Definitive recommendations on the best secondary treatment strategy cannot be made because a medical treatment control group was not available for comparison.

Stone PA ，Campbell JE ，Aburahma AF ，Hamdan M ，Broce M ，Nanjundappa A ，Bates MC ... -  《-》

Predictors of long-term beneficial effects on blood pressure after percutaneous transluminal renal angioplasty in atherosclerotic renal artery stenosis.

Alhadad A ，Mattiasson I ，Ivancev K ，Lindblad B ，Gottsäter A ... -  《-》

Significant reduction in systolic blood pressure following renal artery stenting in patients with uncontrolled hypertension: results from the HERCULES trial.

Atherosclerotic renal artery stenosis (ARAS) causes hypertension (HTN) and threatens renal function (RF). The HERCULES Trial is a prospective, multicenter trial of renal stenting in patients with uncontrolled HTN and ARAS evaluating the safety and effectiveness of the RX Herculink Elite Renal Stent System (Abbott Vascular, Santa Clara, CA). A total of 202 patients (241 total lesions; 78 bilateral lesions) were enrolled between August 2007 and October 2009. The primary endpoint was 9-month binary restenosis determined by duplex ultrasound and/or angiography. Secondary endpoints included changes in blood pressure, antihypertensive medications, and RF between baseline and 9 months. Brain natriuretic peptide (BNP) was measured at baseline, 24 hr and 30 days postprocedure. Mean systolic blood pressure (SBP) at baseline was 162 mm Hg. Nearly 70% of patients were receiving three or more antihypertensive medications (mean 3.4 medications per patient). Baseline serum creatinine was 1.2 ± 0.4 and 61.5% of subjects had estimated glomerular filtration <60. The restenosis rate was 10.5% at 9 months. The study device, procedure, and clinical success rates were 96.0, 99.2, and 98.0%, respectively. Freedom from major adverse events was 94.8%. At 9 months, the mean SBP significantly decreased (mean 145, paired t test P < 0.0001) after stenting with no change in medications. There was no correlation between SBP reduction and baseline BNP or BNP reduction. HERCULES demonstrates clinically and statistically significant SBP reduction in patients with uncontrolled HTN, low in-stent restenosis, and complication rates. This study highlights that when appropriate patients are selected for renal artery stenting, impressive reductions in blood pressure may be anticipated. Although the magnitude of absolute reduction in SBP was related to baseline SBP, elevated baseline BNP levels were not predictive of reduction in SBP. Further studies for predictors of clinical response following percutaneous renal revascularization are needed.

Jaff MR ，Bates M ，Sullivan T ，Popma J ，Gao X ，Zaugg M ，Verta P ，HERCULES Investigators ... -  《-》