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      Enhanced Flow Velocity after Stenting of Renal Arteries Is Associated with Decreased Renal Function

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          Background: Atherosclerotic renal artery stenosis (RAS) is frequently treated by angioplasty and stent placement. Duplex sonography is an established noninvasive technique for patient follow-up. There is lack of evidence that routine monitoring of asymptomatic patients with stable blood pressure is needed. Methods: Renal duplex sonography was performed in 64 patients who had received percutaneous angioplasty and stenting of an atherosclerotic RAS. Duplex sonographic diagnosis was made by a combination of direct flow measurement in the renal artery and evaluation of intrarenal resistive indices. Renal function was determined by serum creatinine and calculated glomerular filtration rate (GFR). Results: With a mean follow-up of 28 months after angioplasty, a flow velocity of >2.0 m/s was detected within the stented arteries in 11/64 patients. While the initial blood pressure and GFR as well as the influence of angioplasty on these parameters were not different, the decrease in renal function over time was significantly higher in patients with flow enhancement (annual GFR decrease, 8.0 ml/min vs. 0.8 ml/min; p < 0.05). Conclusion: Follow-up duplex sonography in patients after renal artery stenting detected an unexpectedly high rate of in-stent restenosis associated with enhanced loss of renal function. Routine duplex sonographic follow-up may detect patients at risk of more rapidly declining renal function.

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          Most cited references 13

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          The renal arterial resistance index and renal allograft survival.

          Most renal transplants fail because of chronic allograft nephropathy or because the recipient dies, but no reliable factor predicting long-term outcome has been identified. We tested whether a renal arterial resistance index of less than 80 was predictive of long-term allograft survival. The renal segmental arterial resistance index (the percentage reduction of the end-diastolic flow as compared with the systolic flow) was measured by Doppler ultrasonography in 601 patients at least three months after transplantation between August 1997 and November 1998. All patients were followed for three or more years. The combined end point was a decrease of 50 percent or more in the creatinine clearance rate, allograft failure (indicated by the need for dialysis), or death. A total of 122 patients (20 percent) had a resistance index of 80 or higher. Eighty-four of these patients (69 percent) had a decrease of 50 percent or more in creatinine clearance, as compared with 56 of the 479 patients with a resistance index of less than 80 (12 percent); 57 patients with a higher resistance index (47 percent) required dialysis, as compared with 43 patients with a lower resistance index (9 percent); and 36 patients with a higher resistance index (30 percent) died, as compared with 33 patients with a lower resistance index (7 percent) (P<0.001 for all comparisons). A total of 107 patients with a higher resistance index (88 percent) reached the combined end point, as compared with 83 of those with a lower resistance index (17 percent, P<0.001). The multivariate relative risk of graft loss among patients with a higher resistance index was 9.1 (95 percent confidence interval, 6.6 to 12.7). Proteinuria (protein excretion, 1 g per day or more), symptomatic cytomegalovirus infection, and a creatinine clearance rate of less than 30 ml per minute per 1.73 m2 of body-surface area after transplantation also increased the risk. A renal arterial resistance index of 80 or higher measured at least three months after transplantation is associated with poor subsequent allograft performance and death. Copyright 2003 Massachusetts Medical Society
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            Arterial stenting and balloon angioplasty in ostial atherosclerotic renovascular disease: a randomised trial.

            Percutaneous transluminal angioplasty (PTA) for ostial atherosclerotic renal-artery stenosis has poor results. Angioplasty with stent placement (PTAS) may be more effective. We undertook a randomised prospective study to compare PTA with PTAS in patients with ostial atherosclerotic renal-artery stenosis. Patients with ostial atherosclerotic renal-artery stenosis were assigned to receive PTA or PTAS. Secondary PTAS was allowed if PTA failed immediately or during 6 months' follow-up. Analysis was by intention to treat. 42 patients were assigned PTA and 43 were assigned PTAS, but one patient in the PTAS group was excluded from the study. Primary success rate (<50% residual stenosis) of PTA was 57% (24 patients) compared with 88% (37 patients) for PTAS (difference between groups 31% [95% CI 12-50]). Complications were similar. At 6 months, the primary patency rate was 29% (12 patients) for PTA, and 75% (30 patients) for PTAS (46% [24-68]). Restenosis after a successful primary procedure occurred in 48% of patients for PTA and 14% for PTAS (34% [11-58]). 12 patients underwent secondary stenting for primary or late failure of PTA within the follow-up period: success was similar to that of primary PTAS. Evaluation based on intention to treat showed no difference in clinical results at six months for PTA or PTAS. PTAS is a better technique than PTA to achieve vessel patency in ostial atherosclerotic renal-artery stenosis. Primary PTAS and primary PTA plus PTAS as rescue therapy have similar outcomes. However, the burden of reintervention after PTA outweighs the potential saving in stents, so primary PTAS is a better approach to use.
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              Treatment of ostial renal-artery stenoses with vascular endoprostheses after unsuccessful balloon angioplasty.

              Percutaneous transluminal renal angioplasty is a safe and effective treatment for nonostial stenoses of the renal arteries, but it has proved to be disappointing for ostial stenoses. Therefore, we prospectively studied the use of intravascular stents for the treatment of critical ostial stenoses after unsuccessful balloon angioplasty. Stainless-steel endoprostheses were placed across 74 renal-artery stenoses located within 5 mm of the aortic lumen in 68 patients with hypertension. Twenty patients had mild or severe renal dysfunction. The indications for stent placement were elastic recoil (63 arteries) or dissection (1 artery) of the vessel after angioplasty, or restenosis after initially successful balloon angioplasty (10 arteries). Patients were followed for a mean of 27 months with measurements of blood pressure and serum creatinine, duplex sonography, and intraarterial angiography. Initial technical success was achieved in all patients. Minor complications (local hematomas) occurred in only three patients; there were no major complications. Eighty-four percent of the patients were free of primary occlusion 60 months after the procedure. Restenosis of more than 50 percent of the vessel diameter occurred in 8 of 74 arteries (11 percent). Reintervention resulted in a secondary patency rate of 92 percent. Long-term normalization of blood pressure was achieved in 11 patients (16 percent). Serum creatinine levels did not change significantly after successful stent implantation in patients with previously impaired renal function. Accurate placement of renal-artery stents is technically feasible without major complications. The favorable early and long-term results suggest that primary stent placement is an effective treatment for renal-artery stenosis involving the ostium.

                Author and article information

                Nephron Clin Pract
                Nephron Clinical Practice
                S. Karger AG
                January 2007
                11 December 2006
                : 105
                : 2
                : c84-c89
                aMedical Department IV, and bDepartment of Diagnostic Radiology, University of the Saarland, Homburg/Saar, and cDepartment of Diagnostic Radiology, University Erlangen-Nürnberg, Erlangen, Germany
                97866 Nephron Clin Pract 2007;105:c84–c89
                © 2007 S. Karger AG, Basel

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                Figures: 2, Tables: 4, References: 20, Pages: 1
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