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Homorodean C, Ober MC, Spinu M, Olinic M, Tataru DA, Onea HL, Achim A, Lazar LF, Homorodean R, Deak B, Olinic DM. Outcomes after stenting of renal artery stenosis in patients with high-risk clinical features. Egypt Heart J 2024; 76:4. [PMID: 38236490 PMCID: PMC10796309 DOI: 10.1186/s43044-024-00435-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 01/11/2024] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND In patients with renal artery stenosis, revascularization was seen as a mean to improve outcomes, but large studies failed to show significant benefit in general population. However, data on benefits of renal artery stenting in patients with high-risk features, such as rapidly declining renal function and cardiac destabilization syndromes, are limited, as they were excluded from trials. In this descriptive study, we aimed to evaluate short- and long-term outcomes in high-risk patients with renal artery stenosis, treated by angioplasty and stenting. We have retrospectively interrogated our local databases for renal artery percutaneous interventions; patients at high-risk (rapidly declining renal function; stable chronic renal failure and bilateral renal artery disease; severe hypertensive crisis) were selected for the current analysis. RESULTS Of 30 patients undergoing renal artery stenting, 18 patients were deemed "high-risk." On short term, good in-hospital control of hypertension and cardiac stabilization were obtained in all patients. Renal function improved significantly only in patients admitted with rapidly declining renal function, with significant creatinine level fall from median 3.98 mg/dL to 2.02 mg/dL, p = 0.023. However, for the whole group, creatinine change was non-significant (- 0.12 mg/dL, p = NS). On the long term, five patients (27.8%) ended-up on chronic hemodialysis and six patients died (33.3%) after a median of 20 months. No death occurred during the first year after the procedure. CONCLUSIONS Percutaneous procedures are feasible and safe in patients with high-risk renal artery stenosis, especially in those with rapidly declining renal function, probably saving some of them from the immediate need for renal replacement therapy, but long-term results are negatively influenced by the precarious general and cardio-vascular status of these patients and by the pre-existing significant renal parenchymal disease, non-related to the renal artery stenosis.
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Affiliation(s)
- Calin Homorodean
- Medical Clinic No. 1, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Cluj, Romania
- Cluj County Emergency Clinical Hospital, 3-5, Clinicilor Street, 400006, Cluj-Napoca, Cluj, Romania
| | - Mihai Claudiu Ober
- Cluj County Emergency Clinical Hospital, 3-5, Clinicilor Street, 400006, Cluj-Napoca, Cluj, Romania.
| | - Mihail Spinu
- Medical Clinic No. 1, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Cluj, Romania
- Cluj County Emergency Clinical Hospital, 3-5, Clinicilor Street, 400006, Cluj-Napoca, Cluj, Romania
| | - Maria Olinic
- Medical Clinic No. 1, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Cluj, Romania
- Cluj County Emergency Clinical Hospital, 3-5, Clinicilor Street, 400006, Cluj-Napoca, Cluj, Romania
| | - Dan-Alexandru Tataru
- Medical Clinic No. 1, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Cluj, Romania
- Cluj County Emergency Clinical Hospital, 3-5, Clinicilor Street, 400006, Cluj-Napoca, Cluj, Romania
| | - Horea Laurentiu Onea
- Medical Clinic No. 1, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Cluj, Romania
| | - Alexandru Achim
- Medical Clinic No. 1, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Cluj, Romania
| | - Leontin Florin Lazar
- Medical Clinic No. 1, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Cluj, Romania
| | - Romana Homorodean
- Cluj County Emergency Clinical Hospital, 3-5, Clinicilor Street, 400006, Cluj-Napoca, Cluj, Romania
| | - Balasz Deak
- Medical Clinic No. 1, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Cluj, Romania
| | - Dan Mircea Olinic
- Medical Clinic No. 1, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Cluj, Romania
- Cluj County Emergency Clinical Hospital, 3-5, Clinicilor Street, 400006, Cluj-Napoca, Cluj, Romania
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Karanikola E, Karaolanis G, Galyfos G, Barbaressos E, Palla V, Filis K. Endovascular Management of Atherosclerotic Renal Artery Stenosis: Post-Cardiovascular Outcomes in Renal Atherosclerotic Lesions Era Winner or False Alarm? Vasc Specialist Int 2017; 33:1-15. [PMID: 28377906 PMCID: PMC5374954 DOI: 10.5758/vsi.2017.33.1.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 01/10/2017] [Accepted: 01/10/2017] [Indexed: 12/25/2022] Open
Abstract
Renal artery stenosis (RAS) is frequently associated with severe comorbidities such as reduced renal perfusion, hypertension, and end-stage renal failure. In approximately 90% of patients, renal artery atherosclerosis is the main cause for RAS, and it is associated with an increased risk for fatal and non-fatal cardiovascular and renal complications. Endovascular management of atherosclerotic RAS (ARAS) has been recently evaluated by several randomized controlled trials that failed to demonstrate benefit of stenting. Furthermore, the Cardiovascular Outcomes in Renal Atherosclerotic Lesions study did not demonstrate any benefit over the revascularization approach. In this review, we summarized the available data from retrospective, prospective and randomized trials on ARAS to provide clinicians with sufficient data in order to produce useful conclusions for everyday clinical practice.
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Affiliation(s)
- Evridiki Karanikola
- Division of Vascular Surgery, 1st Department of Propaedeutic Surgery, University of Athens Medical School, Hippocration General Hospital, Athens, Greece
| | - Georgios Karaolanis
- Vascular Surgery Unit, 1st Department of Surgery, University of Athens Medical School, Laikon General Hospital, Athens, Greece
| | - George Galyfos
- Division of Vascular Surgery, 1st Department of Propaedeutic Surgery, University of Athens Medical School, Hippocration General Hospital, Athens, Greece
| | - Emmanuel Barbaressos
- Division of Vascular Surgery, 1st Department of Propaedeutic Surgery, University of Athens Medical School, Hippocration General Hospital, Athens, Greece
| | - Viktoria Palla
- Vascular Surgery Unit, 1st Department of Surgery, University of Athens Medical School, Laikon General Hospital, Athens, Greece
| | - Konstantinos Filis
- Division of Vascular Surgery, 1st Department of Propaedeutic Surgery, University of Athens Medical School, Hippocration General Hospital, Athens, Greece
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3
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Daloul R, Morrison AR. Approach to atherosclerotic renovascular disease: 2016. Clin Kidney J 2016; 9:713-21. [PMID: 27679718 PMCID: PMC5036906 DOI: 10.1093/ckj/sfw079] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 07/20/2016] [Indexed: 12/20/2022] Open
Abstract
The management of atherosclerotic renal artery stenosis in patients with hypertension or impaired renal function remains a clinical dilemma. The current general consensus, supported by the results of the Angioplasty and Stenting for Renal Atherosclerotic Lesions and Cardiovascular Outcomes for Renal Artery Lesions trials, argues strongly against endovascular intervention in favor of optimal medical management. We discuss the limitations and implications of the contemporary clinical trials and present our approach and formulate clear recommendations to help with the management of patients with atherosclerotic narrowing of the renal artery.
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Affiliation(s)
- Reem Daloul
- Renal Division, Department of Internal Medicine , Washington University School of Medicine , 660 South Euclid, Box 8126, St Louis, MO 63110 , USA
| | - Aubrey R Morrison
- Renal Division, Department of Internal Medicine , Washington University School of Medicine , 660 South Euclid, Box 8126, St Louis, MO 63110 , USA
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Caielli P, Frigo AC, Pengo MF, Rossitto G, Maiolino G, Seccia TM, Calò LA, Miotto D, Rossi GP. Treatment of atherosclerotic renovascular hypertension: review of observational studies and a meta-analysis of randomized clinical trials. Nephrol Dial Transplant 2015; 30:541-553. [DOI: 10.1093/ndt/gfu072] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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5
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Textor SC, Misra S, Oderich GS. Percutaneous revascularization for ischemic nephropathy: the past, present, and future. Kidney Int 2012; 83:28-40. [PMID: 23151953 PMCID: PMC3532568 DOI: 10.1038/ki.2012.363] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Occlusion of the renal arteries can threaten the viability of the kidney when severe, in addition to accelerating hypertension and circulatory congestion. Renal artery stenting procedures have evolved from a treatment mainly for renovascular hypertension to a maneuver capable of recovering threatened renal function in patients with “ischemic nephropathy” and improving management of congestive heart failure. Improved catheter design and techniques have reduced, but not eliminated hazards associated with renovascular stenting. Expanded use of endovascular stent grafts to treat abdominal aortic aneurysms has introduced a new indication for renal artery stenting to protect the renal circulation when grafts cross the origins of the renal arteries. Although controversial, prospective randomized trials to evaluate the added benefit of revascularization to current medical therapy for atherosclerotic renal artery stenosis until now have failed to identify major benefits regarding either renal function or blood pressure control. These studies have been limited by selection bias and have been harshly criticized. While studies of tissue oxygenation using blood oxygen level dependent (BOLD) MR establish that kidneys can adapt to reduced blood flow to some degree, more severe occlusive disease leads to cortical hypoxia associated with microvascular rarefication, inflammatory injury and fibrosis. Current research is directed toward identifying pathways of irreversible kidney injury due to vascular occlusion and to increase the potential for renal repair after restoring renal artery patency. The role of nephrologists likely will focus upon recognizing the limits of renal adaptation to vascular disease and identifying kidneys truly at risk for ischemic injury at a time point when renal revascularization can still be of benefit to recovering kidney function.
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Affiliation(s)
- Stephen C Textor
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN 55905, USA.
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Margey R, Hynes BG, Moran D, Kiernan TJ, Jaff MR. Atherosclerotic renal artery stenosis and renal artery stenting: an evolving therapeutic option. Expert Rev Cardiovasc Ther 2011; 9:1347-60. [PMID: 21985547 DOI: 10.1586/erc.11.143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Atherosclerotic renal artery stenosis is a common clinical problem for which the optimal therapeutic strategy remains to be defined. However, renal artery stenting procedures have significantly increased as one approach to treat this clinical problem. Despite improvements in device design and technical performance of the procedure, the benefits and results of randomized clinical trials of renal artery stenting as a therapy remain confusing. Understanding the epidemiology, pathophysiology and natural history of renal artery stenosis are central to improving the outcomes of renal artery stenting. Developing both noninvasive and invasive predictive tools to better identify which patient will respond to renal revascularization will also be beneficial. In this article, we will present an overview of atherosclerotic renal artery disease. The results of renal artery stenting will be discussed and from this, the available noninvasive and invasive tools available to assess the clinical and hemodynamic significance of renal artery stenosis will be presented.
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Affiliation(s)
- Ronan Margey
- Section of Vascular Medicine, Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
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7
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Kiernan TJ, Yan BP, Jaff MR. Renal artery revascularization: collaborative approaches for specialists. Adv Chronic Kidney Dis 2008; 15:363-9. [PMID: 18805382 DOI: 10.1053/j.ackd.2008.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Endovascular revascularization for atherosclerotic renal artery stenosis (RAS) is the revascularization strategy of choice for patients with hemodynamically and clinically significant renal artery stenosis. Surgical revascularization is reserved for failed endovascular therapy or concomitant abdominal aortic surgery. Endovascular renal artery stenting is associated with excellent technical success, low complication rates, and acceptable long-term patency. This technique has been proven to be beneficial for preserving kidney function and stabilizing or improving blood pressure control in selected patients. Nevertheless, deterioration in kidney function after the procedure in 10% to 20% of cases may limit the immediate benefits of this technique. Atheroembolism appears to play an important role in the cause of kidney dysfunction after renal revascularization. Renal revascularization with a distal embolic protection device is a promising strategy in reducing the risk of atheroembolism and deterioration in kidney function.
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8
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Holden A, Hill A, Jaff MR, Pilmore H. Renal artery stent revascularization with embolic protection in patients with ischemic nephropathy. Kidney Int 2006; 70:948-55. [PMID: 16837918 DOI: 10.1038/sj.ki.5001671] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
A prospective analysis of renal artery stent revascularization with distal embolic protection in a high-risk patient population with ischemic nephropathy is presented. A total of 63 patients (median age 70.2 years, range 54-86 years) had significant atherosclerotic stenosis of 83 renal arteries documented on pre-procedural imaging. All patients had baseline chronic renal insufficiency with a documented deterioration in renal function in the 6 months before revascularization. The endovascular technique used in all patients involved primary passage of an embolic filter into the distal main renal artery followed by primary stent deployment with a balloon expandable stainless steel stent. The filter baskets were recaptured and contents submitted for pathological analysis. At 6 months post-intervention, 97% of patients demonstrated stabilization or improvement in renal function. Only 3% of patients had an inexorable decline in renal function, unchanged by the intervention. After a mean follow up of 16.0 months (6-27), 94% of patients demonstrated stabilization or improvement in renal function. One patient suffered an acute post-procedural deterioration in renal function. In total, 60% of the filter baskets contained embolic material. This study confirms the technical feasibility of renal artery stent deployment with adjuvant embolic protection. The excellent results for renal preservation at 6 months post-intervention also suggest that a distal embolic protection device may improve the impact of percutaneous renal revascularization on progressive deterioration in renal function. The postulated mechanism is through the prevention of atheromatous embolization and the embolic yield from the distal filters supports this hypothesis. Patients most likely to receive the greatest benefit are those with mild baseline chronic renal insufficiency and a recent decline in renal function.
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Affiliation(s)
- A Holden
- Department of Radiology, Auckland City Hospital, Park Road, Grafton, Auckland, New Zealand.
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Nolan BW, Schermerhorn ML, Powell RJ, Rowell E, Fillinger MF, Rzucidlo EM, Wyers MC, Whittaker D, Zwolak RM, Walsh DB, Cronenwett JL. Restenosis in gold-coated renal artery stents. J Vasc Surg 2005; 42:40-6. [PMID: 16012450 DOI: 10.1016/j.jvs.2005.03.038] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Gold coating improves stent visibility under fluoroscopy. This is particularly valuable for precise stent placement during renal artery stenting (RAS). There is conflicting evidence regarding restenosis with gold-coated stents. To evaluate the effect of gold coating on restenosis after renal stenting, we reviewed the results of all patients undergoing RAS in our practice. METHODS A retrospective cohort study of all patients undergoing RAS between June 2000 and September 2003 was performed. During this time, both gold-coated and stainless steel stents were used. Restenosis (>60% diameter) was determined by serial follow-up duplex exams (peak systolic velocity >180 cm/s and renal-aortic ratio >3.5). Restenosis rates were determined by using the Kaplan-Meier life-table method. Variables potentially affecting restenosis were evaluated with the log-rank test and Cox proportional hazards modeling. RESULTS RAS was performed in 97 arteries (78 patients). Gold-coated (NIRoyal) stents were placed in 59 arteries (48 patients). Stainless steel stents (Corinthian, Genesis, and Herculink) were placed in 38 arteries (34 patients). Patient demographics, indication for treatment, technical success, and complications did not differ between gold and stainless steel stent groups. Mean follow-up was 15 months for gold-coated stents and 18 months for stainless steel stents (NS). By life-table method, 1-year and 2-year freedom from restenosis rates were 84% and 78% in arteries treated with stainless steel stents versus 69% and 39% in those treated with gold-coated stents (P = .012, log-rank test). By multivariate analysis, only the use of gold-coated stents (P = .018; hazard ratio [HR], 3.3; 95% confidence interval [CI], 1.2 to 8.7) and bilateral disease (P = .046; HR, 2.3; 95% CI, 1.02 to 5.2) predicted restenosis. Stent diameter, patient demographics, and indication for RAS had no effect on restenosis by univariate analysis. According to American Heart Association criteria, 87% of patients in the stainless steel group had improved blood pressure at 1 year, compared with 77% in the gold-coated stent group (Kaplan-Meier; P = .042, log-rank test). There were no significant differences in the effect of RAS on serum creatinine levels between the two groups. CONCLUSION Gold-coated renal stents had a substantially higher rate of restenosis than stainless steel stents in our series. These findings have led us to abandon the use of gold-coated stents for RAS. Patients who have received gold-coated stents for the treatment of atherosclerotic renal artery stenosis should be followed closely for evidence of restenosis.
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Affiliation(s)
- Brian W Nolan
- Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, NH 03756, USA.
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10
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Nolan BW, Schermerhorn ML, Rowell E, Powell RJ, Fillinger MF, Rzucidlo EM, Wyers MC, Zwolak RM, Walsh DB, Cronenwett JL. Outcomes of renal artery angioplasty and stenting using low-profile systems. J Vasc Surg 2005; 41:46-52. [PMID: 15696043 DOI: 10.1016/j.jvs.2004.10.027] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Renal artery percutaneous transluminal angioplasty (RPTA) and stenting (RAS) are accepted therapies for selected patients with renovascular hypertension and chronic renal insufficiency. We evaluated the outcomes and complications of RAS performed by vascular surgeons at our institution with modern low-profile systems. METHOD We retrospectively analyzed all RPTA and RAS procedures attempted with the use of low-profile systems from June 2000 to September 2003. Eighty-two patients (96 arteries) with atherosclerotic renal artery stenosis were treated. Indication for treatment was hypertension in 44 (54%) and chronic renal insufficiency in 38 (46%). Technical success, complication rates, clinical success for control of hypertension or renal insufficiency, restenosis, and survival were reviewed with a mean follow-up of 1 year. RESULTS Ninety-three arteries were treated with stents, three with RPTA only. Primary technical success was 95%, with 98% overall technical success. Major complications occurred in 6.1% and minor complications in 1.2%. Hypertension was improved in 81% at 1 year. Renal function was improved in 23%, stable in 53%, and worse in 24% at 1 year. Restenosis was seen by routine duplex surveillance in 25% at 1 year. Restenosis associated with clinical deterioration and confirmed by angiogram was seen in 10%. The overall 3-year survival was 83%. CONCLUSION RPTA/RAS can be performed with low-profile systems with excellent technical success, low complication rates, and clinical outcomes that compare favorably with prior reports.
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Affiliation(s)
- Brian W Nolan
- Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756, USA.
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Sivamurthy N, Surowiec SM, Culakova E, Rhodes JM, Lee D, Sternbach Y, Waldman DL, Green RM, Davies MG. Divergent outcomes after percutaneous therapy for symptomatic renal artery stenosis. J Vasc Surg 2004; 39:565-74. [PMID: 14981450 DOI: 10.1016/j.jvs.2003.09.024] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Percutaneous intervention for symptomatic renal artery atherosclerosis is rapidly replacing surgery in many centers. This study evaluated the anatomic and functional outcomes of endovascular therapy for atherosclerotic renal artery stenosis on a combined vascular surgery and interventional radiology service at an academic medical center. METHODS This was a retrospective analysis of patients who underwent renal artery angioplasty with or without stenting between January 1990 and June 2002. Indications included hypertension (86%) and rising serum creatinine concentration (55%). One hundred forty-six patients (80 women; average age, 71 years [range, 44-89 years]) underwent 183 attempted interventions (64 to treat bilateral stenosis). Forty-five percent of patients had significant bilateral disease: 27% had greater than 50% bilateral stenosis, and the remainder had nonfunctioning, absent, or occluded vessels. RESULTS Of 183 planned interventions, technical success (<30% residual stenosis) was achieved in 179 vessels (98%) with placement of 137 stents (75%). Thirty-day mortality was 0.7%. The major morbidity rate was 4%, and the procedure-related complication rate was 18%. Five-year cumulative patient mortality was 25%. Primary patency, assisted primary patency, and recurrent stenosis rates were 82% +/- 9%, 100% +/- 0%, and 30% +/- 7%, respectively, at 5 years. Within 3 months of the procedure, 52% of patients who received treatment of hypertension demonstrated clinical benefit (hypertension improved or cured), which was maintained in 68% of patients at 5 years. Serum creatinine concentration was lowered or stabilized in 87% of patients within 3 months of the procedure, but this benefit, including freedom from dialysis, was maintained in only 45% of patients at 5 years. CONCLUSIONS Endovascular intervention for symptomatic atherosclerotic renal artery stenosis is technically successful. There were excellent patency and low recurrent stenosis rates. There is immediate clinical benefit for most patients, but divergent long-term functional outcomes. Endovascular interventions modestly enhance the care of the patient with hypertension, but poorly preserve long-term renal function in the patient with chronic renal impairment.
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Affiliation(s)
- Nayan Sivamurthy
- Center for Vascular Disease, Department of Surgery, Division of Vascular Surgery, University of Richester, NY 14642, USA
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12
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Abstract
We have detailed several of the urological manifestations of vascular disease. With the aging of the North American population, urologists will encounter the urological complications of vascular disease with ever-increasing frequency.
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Affiliation(s)
- Aaron J Milbank
- The Urological Institute, Cleveland Clinic Foundation, Desk A110, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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Rundback JH, Weintraub JL. Renal vascular interventions. Semin Roentgenol 2002; 37:312-26. [PMID: 12455129 DOI: 10.1016/s0037-198x(02)80008-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- John H Rundback
- New York Presbyterian Hospital, College of Physicians and Surgeons of Columbia University, New York, NY, USA
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