Rotura de la arteria renal en un posoperatorio complicado de angioplastia por estenosis renal Translated title: Renal artery rupture during complicated recovery from angioplasty to treat renal stenosis

The prevalence of atherosclerotic renal artery stenosis (RAS) is more common than was previously thought, particularly in patients with known coronary, cerebrovascular, or peripheral vascular atherosclerosis. Clinical subsets in which RAS is more common include patients with uncontrolled hypertension, renal insufficiency, and/or sudden onset ("flash") pulmonary edema. Renal artery atherosclerosis progresses over time and is associated with loss of renal function regardless of medical therapy. Patients with symptomatic (hypertension, renal insufficiency, or flash pulmonary edema) and hemodynamically significant RAS are potential candidates for revascularization. The current standard of care is stent placement for aorto-ostial atherosclerotic lesions. Procedure success rates are very high (> or =95%), with infrequent major complication rates. Five-year primary patency rates are 80% to 85%, and secondary patency rates exceed 90%. The key element in managing patients with RAS is selecting those most likely to benefit, that is, those with blood pressure control, preservation or improvement of renal function, and control of flash pulmonary edema from renal revascularization. This article will highlight the anatomical features, physiologic parameters, and biomarkers that may be helpful in optimally selecting patients for renal artery revascularization.

Endovascular therapy for symptomatic atherosclerotic renal artery stenosis (ARAS) is considered effective. This study evaluates the factors that impact long term anatomic and functional outcomes of endovascular therapy of ARAS in patients with a solitary functioning kidney. We performed a retrospective analysis of records from patients who underwent endovascular intervention for ARAS and identified patients with a solitary functioning kidney (absent or nonfunctioning contralateral kidney) and patients with contralateral normal kidney (for comparison) between January 1990 and January 2008. Indications for intervention in the solitary functioning kidney were poorly controlled hypertension (diastolic blood pressure [BP] >90 mm Hg on >3 antihypertensive medications) and/or elevated creatinine (Cr >/=1.5 mg/dL). Clinical benefit was defined as freedom from composite recurrent symptoms (recurrent hypertension or renal-related morbidity-increase in persistent creatinine >20% of baseline, progression to hemodialysis, and death from renal-related causes), anatomic patency and patient survival were measured. A total of 242 patients (56% male, average age 69 years, range, 45-90) underwent angioplasty (23%) or primary stenting (77%) of a single renal artery with a normal contralateral renal vessel and kidney and 73 patients (58% male, average age 70 years, range, 52-89) underwent angioplasty (37%) or primary stenting (63%) for a solitary functioning kidney. There were no significant differences in mortality or morbidity between the groups. There was a significant difference in the long-term survival with 55 +/- 8% patients with a normal contralateral kidney vs 27 +/- 7% patients with a solitary functioning kidney alive at 10 years. Clinical benefit was 67 +/- 6% and 67 +/- 4% at 5 years and 63 +/- 8% and 62 +/- 4% at 10 years for solitary functioning kidney and normal contralateral groups, respectively. Using proportional hazard analysis, the predictors of long-term clinical benefit were ipsilateral kidney size (>9 cm), no immediate deterioration in function, and an estimated Glomerular Filtration Rate (eGFR) >30 mL/min/1.73m(2). Neither control of diabetes nor the administration of statins was shown to influence outcomes in the solitary functioning kidney. Intervention in patients with a solitary functioning kidney is a safe procedure and improves or stabilizes renal function in 82% of patients. Clinical benefit is dictated by preoperative GFR, renal size, and the occurrence of acute functional injury after the procedure.

From January 1993 to May 1996, 108 patients (64 men, 44 women; mean age, 72 years; age range, 37 to 87 years) underwent 125 percutaneous transluminal angioplasties and stent implantations primarily for atherosclerotic lesions of the renal artery. Sixty-four patients underwent treatment for renovascular hypertension (two antihypertensive medications or more), 32 patients underwent treatment for a combination of hypertension and renal failure (serum creatinine level >/=1.6 mg/dL), and a small group of six patients (5%) without hypertension or diminished renal function underwent treatment to prevent the progression to renal artery occlusion and kidney loss. Thirty-three patients (31%) had renovascular hypertension that was classified as severe on three or more medications, 31 patients (29%) had renovascular hypertension that was classified as moderate on two medications, and 38 patients (35%) had renovascular hypertension that was classified in the mild group on a single antihypertensive agent. Stenotic lesions were located at the ostium of the renal artery in 82 cases (65%) and were ostial-adjacent (<5 mm from renal ostium) in the other 43 cases (34%). A total of 125 stents were deployed in 125 arteries (procedural success 97.6%). Renovascular hypertension either was cured or was improved in 73 patients (68%), with 14 patients (13%) considered cured (normotensive on no medications). The conditions of 29 patients (27%) were unchanged, and 6 patients (5%) had worsening hypertension after surgery. We were unable to demonstrate a statistically significant improvement in serum creatinine levels after renal artery balloon angioplasty/stenting. Complications occurred in a total of nine cases (7.2%), six of which were related to technical problems. One patient had worsening renal insufficiency caused by contrast agent, and another patient had a perinephric hematoma develop that necessitated evacuation. There were four postoperative deaths (30-day mortality). Two of these deaths were caused by postoperative myocardial infarction. The other two patients had progressive renal failure develop that necessitated dialysis. These patients later died of the disease process despite supportive care. Follow-up renal artery duplex scan studies and angiograms were available on 96 patients (76%). The mean peak systolic renal/aortic ratio on duplex scanning was 2.2. Life-table analysis yielded a 74% primary patency rate and an 85% secondary patency rate at 36 months. This retrospective analysis showed the effectiveness of combining percutaneous transluminal angioplasty with stent deployment for significant renal artery stenosis to treat renovascular hypertension.