Treatment of In-Stent Restenosis in Patients with Renal Artery Stenosis

Research progress of drug eluting balloon in arterial circulatory system

The arterial circulatory system diseases are common in clinical practice, and their treatment options have been of great interest due to their high morbidity and mortality. Drug-eluting balloons, as a new type of endovascular interventional treatment option, can avoid the long-term implantation of metal stents and is a new type of angioplasty without stents, so drug-eluting balloons have better therapeutic effects in some arterial circulatory diseases and have been initially used in clinical practice. In this review, we first describe the development, process, and mechanism of drug-eluting balloons. Then we summarize the current studies on the application of drug-eluting balloons in coronary artery lesions, in-stent restenosis, and peripheral vascular disease. As well as the technical difficulties and complications in the application of drug-eluting balloons and possible management options, in order to provide ideas and help for future in-depth studies and provide new strategies for the treatment of more arterial system diseases.

What we have learned from in-vitro studies of the chimney endovascular technique for treatment of complex abdominal aortic aneurysms: A systematic review

BACKGROUND

A considerable number of patients with abdominal aortic aneurysms (AAA) is not eligible for standard endovascular repair. These complex cases require alternative surgical approaches including the readily available chimney graft endovascular aneurysm repair (Ch-EVAR) or sealing (Ch-EVAS). The optimal configuration for Ch-EVAR or Ch-EVAS is important for success but not yet known.

OBJECTIVE

The aim of the present study was to analyze current data of the outcomes of in-vitro chimney graft treatment in complex AAA.

METHODS

A systematic review following PRISMA guidelines was conducted including studies reporting on gutter size, main graft compression, and chimney graft compression in in-vitro configurations.

RESULTS

The search resulted in 285 articles. 11 studies considering 219 individual tests could be included. Gutter size was comparable between Ch-EVAR and Ch-EVAS configurations. In Ch-EVAR set-ups, the deployed BECG were Advanta V12, VIABAHN®, and BeGraft. One type of SECG was used: VIABAHN®. The four types of main grafts (MG) deployed were: Endurant™ I/II; EXCLUDER Conformable AAA Endoprosthesis and AAA Endoprosthesis, and AFX™ Endovascular AAA Delivery System. In the EVAS-configurations, the Nellix® EVAS system was deployed. In general, SECG presented smaller gutters with higher chimney graft compression. 30% main grafts oversizing seems to give the smallest gutters without high risk of infolding of MG. Oversizing, EndoAnchors, and secondary endobag filling (in Ch-EVAS) reduced gutter sizes. CG ballooning during the entire polymer injection in Ch-EVAS prevented CG compression.

CONCLUSION

In-vitro investigations provide insight in optimal Ch-EVAR and Ch-EVAS configurations for simulated complex AAA repair. The findings above might aid physicians in their planning to potential CG set-ups and can be used in future research to refine the most optimal configuration for chimney graft technique in complex AAA.

Endovascular treatments of atherosclerotic renovascular disease: a narrative review and literature search

In recent years, endovascular treatments have become more common in patients with renal artery stenosis and aneurysm. Although the treatment algorithms are not universally accepted, endovascular therapy can be readily utilized for the appropriate indications in the context of surgical treatment for renovascular diseases. The most important factor to consider is that the correct indication is applied for such treatment. Although the applied procedures are believed to have minimal risk, any complications that occur may result in major problems. Moreover, the pathology that is being treated (e.g., hypertension, high serum creatinine concentration, or low glomerular filtration rate) must be well defined. As stent and balloon technologies continue to be developed, more positive results are expected in the coming years. In the present study, we reviewed the endovascular treatment algorithms for atherosclerotic renovascular disease and performed a narrative review of the current literature.

Case report: Recurrence of hypertension after renal artery angioplasty due to the progression of focal renal fibromuscular dysplasia

Whether fibromuscular dysplasia (FMD) is a progressive disease, remains unclear. We reported a case of focal renal artery FMD that slowly progressed to a branching artery over a few years after the angioplasty without in-stent restenosis, which reconfirms that focal FMD is progressive and that such progression may be segmental. Stenting may be an option for young, risk factor-free patients with focal FMD.

Value of contrast-enhanced ultrasound for diagnosis and follow-up of renal artery stenosis in patients with chronic kidney disease

OBJECTIVE

To evaluate whether contrast-enhanced ultrasound (CEUS) is an accurate, non-nephrotoxic diagnostic method and follow-up tool for use in patients with chronic kidney disease (CKD) and renal artery stenosis (RAS).

METHODS

In this prospective and monocentric study, we compared the sensitivity and specificity of CEUS for the diagnosis of RAS in CKD patients, using digital subtraction angiography (DSA) or computed tomographic angiography (CTA) as the gold standard methods. Further, the value of CEUS for distinguishing restenosis from other diseases was assessed. The ultrasound physicians conducted the examinations and served as the CEUS report readers who were blinded to the DSA or CTA results.

RESULTS

Patients with RAS (n = 60) were enrolled. Average patient age was 64.4 ± 18.0 years and median estimated glomerular filtration rate was 66.1 mL/min/1.73 m². CEUS was used to image 94 stenotic renal arteries and DSA- or CTA-verified stenosis was present in 96 renal arteries. The kappa value for CEUS was 0.776 (P < 0.001), with an accuracy of 92.5%, a sensitivity of 94.7%, and a specificity of 84.0%. The accuracy of CEUS was the same for the diagnosis of the CKD3b-5 group as for the CKD1-3a group (100% vs. 87.5%, P = 0.148). There was no difference in CEUS accuracy for the diagnosis of Takayasu RAS compared with atherosclerotic RAS (95.8% vs. 91.7%, P = 0.795). Twenty-nine CEUS examinations were performed to follow in-stent restenosis or progression of RAS, with a median follow-up time of 5.0 months (range 1.0-20.0). Two cases of in-stent restenosis in patients suffering from deteriorating kidney function and recurrent hypertension were examined by CEUS.

CONCLUSION

CEUS examination is a credible alternative for diagnosing moderate and severe RAS in patients with CKD, and is a reliable tool for follow-up surveillance after renal artery revascularization treatment. It shouldn't be thought as a color-coded duplex ultrasonography rescue in these patients.

Intravascular Lithotripsy and Dual Drug-Coated Balloons for the Treatment of Severely Calcific Renal In-Stent Restenosis: All Is Fair in War

Optimal treatment of renal artery "in-stent restenosis" (ISR) is still debated; drug eluting stents (DES), drug coated balloons (DCB) and scoring balloons have all been used, with mixed long term results. The shockwave lithotripsy for the treatment of heavily calcified atherosclerotic plaques has proven to be an effective tool and preliminary data support its use in case of underexpanded stents. Here we present the case of a 60 year old male with a known significant atherosclerotic renal artery stenosis and refractory hypertension who already underwent bilateral renal angioplasty with bare metal stents (BMS) in 2011 and angioplasty with DCB in 2012 for right renal artery ISR. In May 2020 he presented with worsening hypertension and CT scan showed total occlusion of the right with critical ISR of the left renal artery. Because of the high calcium burden he underwent balloon lithotripsy for plaque modification and subsequent renal angioplasty with sirolimus and paclitaxel DCB, with a good angiographic result. This is the first case of recurrent renal ISR successfully treated with Shockwave IVL and double-drug DCB therapy.

Restenosis Rates After Drug-Eluting Stent Treatment for Stenotic Small-Diameter Renal Arteries

PURPOSE

To determine primary rates in small-diameter renal arteries, including complex bifurcation lesions, treated with drug-eluting stents (DES) in patients with atherosclerotic renal artery stenosis.

MATERIALS AND METHODS

This is a retrospective single-institution study. A total of 37 patients with 39 stented renal arteries were included. Patient and procedural data were obtained from the electronic medical record. Survival free from restenosis was estimated using the Kaplan-Meier method with patients stratified into two groups based on renal artery diameters (≤ 3.5 mm or > 3.5 mm). Univariate Cox proportional models were used to estimate hazard ratios associated with clinical and angiographic variables.

RESULTS

Average renal artery diameter at time of treatment was 3.4 mm ± 0.4 mm. The median survival free from restenosis was 992 days, with 11 out of 37 (29.7%) developing an in-stent restenosis. Renal arteries < 3.5 mm in diameter had similar patency rates as renal arteries > 3.5 mm (P = 0.33). The 1-, 2-, and 5-year patency rates were 71%, 63%, and 38%, respectively. History of stroke was the only comorbidity to portend a significantly greater rate of restenosis (hazard ratio 3.77; 95%CI, 1.05-13.6; P = 0.04). Medications did not statistically alter the risk of restenosis.

CONCLUSION

Revascularization of renal arteries with DES achieved similar primary patency rates irrespective of renal artery diameter. Stent configuration was not associated with time to renal replacement therapy or all-cause mortality.

LEVEL OF EVIDENCE

Level 3, Cohort Study.

Complex interventions of abdominal aorta and its branches in children with Takayasu arteritis: Clinical experience from a tertiary care center in north-west India

AIM

To report our experience on complex percutaneous interventions of the abdominal aorta and its branches in six children with Takayasu arteritis (TA).

METHODS

A review of records of children with TA, who underwent percutaneous interventions of the abdominal aorta and its major branches.

RESULTS

In this analysis, we included six children with TA who underwent intervention of the abdominal aorta and its major branches. The endovascular interventions were performed mostly for treatment-resistant renovascular hypertension and mesentery artery ischemia. Mean age (±SD) at time of intervention was 10.6 ± 2.5 years (four boys and two girls). Percutaneous interventions included stenting of abdominal aorta (n = 2), renal arteries (n = 4), mesenteric arteries (n = 2), repeat stenting for renal artery in-stent restenosis (n = 1), and renal autotransplantation (n = 4). All 13 interventions were successful and enabled us to obtain good control of blood pressure.

CONCLUSION

We hereby report six children with TA who were successfully managed with complex percutaneous interventions of the abdominal aorta and its major branches. Balloon dilatation and stent placement constitutes the mainstay of management of TA with stenosis of the large vessels.

Renal autotransplantation for the management of renal artery in-stent restenosis in an adult patient with Takayasu arteritis

Renovascular hypertension is a common clinical presentation in Takayasu arteritis (TA), when the renal arteries are involved. Although most of the patients respond to optimal antihypertensive drug therapy, certain patients with TA require percutaneous or surgical renal artery revascularisation to manage renovascular hypertension. We, hereby, present a 45-year-old woman, who had resistant hypertension secondary to in-stent restenosis (ISR) of renal artery stent in a single functioning kidney. She had successful renal autotransplantation following a failed endovascular attempt to treat ISR. Endovascular and surgical interventions related to renal artery stenosis in TA are discussed in the article.