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Mousa AY, Bates MC, Broce M, Bozzay J, Morcos R, AbuRahma AF. Issues related to renal artery angioplasty and stenting. Vascular 2017. [DOI: 10.1177/1708538116677654 10.5414/cn109239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Renal artery stenosis may play a significant role in the pathogenesis of secondary hypertension, renal dysfunction, and flash pulmonary edema. Currently correction of renal arterial inflow stenosis is reserved for resistant hypertension patients who have failed maximal medical therapy, have worsening renal function and/or unexplained proximal congestive failure. With the recent advances in minimally invasive percutaneous stent placement techniques, open surgical revascularization has been largely replaced by renal artery stenting. The potential benefit of revascularization seemed intuitive; however, the initial enthusiasm and rise in the number of percutaneous interventions have been tempered by many subsequent negative randomized clinical trials that failed to prove the proposed benefits of the percutaneous intervention. The negative randomized trial results have fallen under scrutiny due to trial design concerns and inconsistent outcomes of these studies compared to pivotal trials undertaken under US Food and Drug Administration scrutiny. Treatment of atherosclerotic renal artery occlusive disease has become one of the most debatable topics in the field of vascular disease. The results from recent randomized clinical trials of renal artery stenting have basically limited the utilization of the procedure in many centers, but not every clinical scenario was covered in those trials. There are potential areas for improvement focusing mainly on procedural details and patient selection with respect to catheter based treatment of atherosclerotic renal artery stenosis. We believe, limiting patient selection, enrollment criteria and outcomes measured functioned to reduce the benefit of renal artery stenosis stenting by not enrolling patients likely to benefit. Future studies incorporating potential procedural improvements and that include patients more likely to benefit from renal stenting than were included in ASTRAL and CORAL are needed to more carefully examine specific patient subgroups so that “the baby is not thrown out with the bath water.” We also discuss several other concerns related to renal artery stenting which include diagnostic, procedure, indication, and reimbursement issues.
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Affiliation(s)
- Albeir Y Mousa
- Department of Surgery, Robert C. Byrd Health Sciences Center/West Virginia University, Charleston Area Medical Center, Vascular Center of Excellence, Charleston, WV, USA
| | - Mark C Bates
- Department of Surgery, Robert C. Byrd Health Sciences Center/West Virginia University, Charleston Area Medical Center, Vascular Center of Excellence, Charleston, WV, USA
| | - Mike Broce
- Center for Health Services and Outcomes Research, Charleston Area Medical Center Health Education and Research Institute, Charleston, WV, USA
| | - Joseph Bozzay
- Department of Surgery, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Ramez Morcos
- Florida Atlantic University, Charles E. Schmidt College of Medicine, Internal Medicine Department, Boca Raton, FL, USA
| | - Ali F AbuRahma
- Department of Surgery, Robert C. Byrd Health Sciences Center/West Virginia University, Charleston Area Medical Center, Vascular Center of Excellence, Charleston, WV, USA
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Mousa AY, Bates MC, Broce M, Bozzay J, Morcos R, AbuRahma AF. Issues related to renal artery angioplasty and stenting. Vascular 2017; 25:618-628. [PMID: 28782453 DOI: 10.1177/1708538116677654] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Renal artery stenosis may play a significant role in the pathogenesis of secondary hypertension, renal dysfunction, and flash pulmonary edema. Currently correction of renal arterial inflow stenosis is reserved for resistant hypertension patients who have failed maximal medical therapy, have worsening renal function and/or unexplained proximal congestive failure. With the recent advances in minimally invasive percutaneous stent placement techniques, open surgical revascularization has been largely replaced by renal artery stenting. The potential benefit of revascularization seemed intuitive; however, the initial enthusiasm and rise in the number of percutaneous interventions have been tempered by many subsequent negative randomized clinical trials that failed to prove the proposed benefits of the percutaneous intervention. The negative randomized trial results have fallen under scrutiny due to trial design concerns and inconsistent outcomes of these studies compared to pivotal trials undertaken under US Food and Drug Administration scrutiny. Treatment of atherosclerotic renal artery occlusive disease has become one of the most debatable topics in the field of vascular disease. The results from recent randomized clinical trials of renal artery stenting have basically limited the utilization of the procedure in many centers, but not every clinical scenario was covered in those trials. There are potential areas for improvement focusing mainly on procedural details and patient selection with respect to catheter based treatment of atherosclerotic renal artery stenosis. We believe, limiting patient selection, enrollment criteria and outcomes measured functioned to reduce the benefit of renal artery stenosis stenting by not enrolling patients likely to benefit. Future studies incorporating potential procedural improvements and that include patients more likely to benefit from renal stenting than were included in ASTRAL and CORAL are needed to more carefully examine specific patient subgroups so that "the baby is not thrown out with the bath water." We also discuss several other concerns related to renal artery stenting which include diagnostic, procedure, indication, and reimbursement issues.
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Affiliation(s)
- Albeir Y Mousa
- 1 Department of Surgery, Robert C. Byrd Health Sciences Center/West Virginia University, Charleston Area Medical Center, Vascular Center of Excellence, Charleston, WV, USA
| | - Mark C Bates
- 1 Department of Surgery, Robert C. Byrd Health Sciences Center/West Virginia University, Charleston Area Medical Center, Vascular Center of Excellence, Charleston, WV, USA
| | - Mike Broce
- 2 Center for Health Services and Outcomes Research, Charleston Area Medical Center Health Education and Research Institute, Charleston, WV, USA
| | - Joseph Bozzay
- 3 Department of Surgery, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Ramez Morcos
- 4 Florida Atlantic University, Charles E. Schmidt College of Medicine, Internal Medicine Department, Boca Raton, FL, USA
| | - Ali F AbuRahma
- 1 Department of Surgery, Robert C. Byrd Health Sciences Center/West Virginia University, Charleston Area Medical Center, Vascular Center of Excellence, Charleston, WV, USA
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Campbell JE, Stone PA, Bates MC. Technical discussion of diagnostic angiography and intervention of atherosclerotic renal artery stenosis. Semin Vasc Surg 2014; 26:150-60. [PMID: 25220320 DOI: 10.1053/j.semvascsurg.2014.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Renal artery stenting remains an important adjuvant treatment for true-resistant hypertension, although recent disappointing randomized trials highlight the importance of careful patient selection. Safe and successful renal interventions begin with critical core knowledge regarding renal artery anatomy and understanding the often hostile nature of the parent vessel (pararenal aorta). Armed with fundamental knowledge about anatomy and renal ostial disease pathology, it becomes easier to understand the advantages of less traumatic access techniques and how low-profile contemporary flexible stents have enhanced outcomes. In addition to suggested techniques based on detailed understanding of the vessel architecture and pathology, we will review the current available US Food and Drug Administration-approved balloon-expandable on-label renal stents and discuss the role of intravascular ultrasound for definition of lesion severity, stent sizing, and stent apposition. The durability of renal stenting will also be discussed, as will the velocity criteria for duplex surveillance. Lastly, the current empirical data related to renal embolic protection is provided, along with insight into technical issues in this domain.
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Affiliation(s)
- John E Campbell
- Department of Surgery, West Virginia University Division of Vascular and Endovascular Surgery, Vascular Center of Excellence, Charleston Area Medical Center, 3100 MacCorkle Avenue SE, Charleston, West Virginia 25304.
| | - Patrick A Stone
- Department of Surgery, West Virginia University Division of Vascular and Endovascular Surgery, Vascular Center of Excellence, Charleston Area Medical Center, 3100 MacCorkle Avenue SE, Charleston, West Virginia 25304
| | - Mark C Bates
- Department of Surgery, West Virginia University Division of Vascular and Endovascular Surgery, Vascular Center of Excellence, Charleston Area Medical Center, 3100 MacCorkle Avenue SE, Charleston, West Virginia 25304
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AbuRahma AF, Yacoub M. Renal imaging: duplex ultrasound, computed tomography angiography, magnetic resonance angiography, and angiography. Semin Vasc Surg 2013; 26:134-43. [DOI: 10.1053/j.semvascsurg.2014.06.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Nanjundappa A, Bates MC. Clinical strategy for treating renal artery stenosis and contemporary tactics for renal artery stenting. Interv Cardiol 2012. [DOI: 10.2217/ica.12.41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Mousa AY, Campbell JE, Stone PA, Broce M, Bates MC, AbuRahma AF. Short- and long-term outcomes of percutaneous transluminal angioplasty/stenting of renal fibromuscular dysplasia over a ten-year period. J Vasc Surg 2012; 55:421-7. [DOI: 10.1016/j.jvs.2011.09.006] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2011] [Revised: 08/31/2011] [Accepted: 09/01/2011] [Indexed: 11/29/2022]
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Turba UC, Uflacker R, Bozlar U, Hagspiel KD. Normal renal arterial anatomy assessed by multidetector CT angiography: are there differences between men and women? Clin Anat 2009; 22:236-42. [PMID: 19172661 DOI: 10.1002/ca.20748] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The purpose of this study was to determine renal arterial anatomy and gender differences in adults without renovascular disease using multidetector computed tomography angiography (MDCTA). MDCTA datasets of 399 patients were retrospectively reviewed. Measurements of the aortorenal diameters, the angulation of the renal ostia and pedicles as well as the distance between the origins of the renal arteries were measured. Differences in measurements between genders were tested for statistical significance using analysis of variance (ANOVA) and Pearson's Chi-Square tests. A total of 798 renal arteries were available for analysis in 207 female (mean age = 52.91 years) and 192 male patients (mean age = 53.04 years). Female patients were found to have smaller aortae (at the level of the right renal ostium) and bilateral renal arteries than males (mean aortic diameter M/F = 18.33/15.89 mm, mean right renal artery ostial diameter M/F = 5.06/4.59 mm, mean left ostial renal diameter M/F = 5.14/4.66 mm) (p < .001). There was no statistical significance for the renal ostia level in relation to the vertebrae and the majority of renal arteries originated at the L1 and L2 levels. The longitudinal distance between right and left renal artery ostia ranged from 0 to 32 mm (mean = 4,6 mm, median = 5mm). The mean anteroposterior orientation of the right renal ostia was M/F = 29.45 degrees/28.20 degrees , and M/F = -7.96 degrees/-11.14 degrees for left renal artery ostia. The mean anteroposterior orientation of the right renal pedicle was M/F = 41.37 degrees/44.34 degrees and M/F = 42.31 degrees/43.95 degrees for the left pedicle. There are some differences in normal renal arterial anatomy between genders. Normal renal arterial information is useful not only for planning and performing of endovascular and laparoscopic urologic procedures, but also for medical device development.
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Affiliation(s)
- Ulku Cenk Turba
- Department of Radiology, University of Virginia, Health System Foundation, Charlottesville, Virginia 22908, USA.
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