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Critical analysis of renal duplex ultrasound parameters in detecting significant renal artery stenosis. J Vasc Surg 2012; 56:1052-9, 1060.e1; discussion 1059-60. [DOI: 10.1016/j.jvs.2012.03.036] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2012] [Revised: 03/09/2012] [Accepted: 03/10/2012] [Indexed: 11/24/2022]
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Pearce JD, Craven TE, Edwards MS, Corriere MA, Crutchley TA, Fleming SH, Hansen KJ. Associations between renal duplex parameters and adverse cardiovascular events in the elderly: a prospective cohort study. Am J Kidney Dis 2010; 55:281-90. [PMID: 20116688 DOI: 10.1053/j.ajkd.2009.10.044] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2009] [Accepted: 10/08/2009] [Indexed: 11/11/2022]
Abstract
BACKGROUND Atherosclerotic renovascular disease is associated with an increased risk of cardiovascular disease (CVD) events. This study examines associations between Doppler-derived parameters from the renal artery and renal parenchyma and all-cause mortality and fatal and nonfatal CVD events in a cohort of elderly Americans. STUDY DESIGN Cohort study. SETTING A subset of participants from the Cardiovascular Health Study (CHS). Through an ancillary study, 870 (70% recruitment) Forsyth County, NC, CHS participants consented to undergo renal duplex sonography to define the prevalence of renovascular disease in the elderly, resulting in 726 (36% men; mean age, 77 years) technically adequate complete studies included in this investigation. PREDICTOR Renal duplex sonography-derived Doppler signals from the main renal arteries and renal parenchyma. Spectral analysis from Doppler-shifted frequencies and angle of insonation were used to estimate renal artery peak systolic and end diastolic velocity (both in meters per second). Color Doppler was used to identify the corticomedullary junction. Using a 3-mm Doppler sample, the parenchymal peak systolic and end diastolic frequency shift (both in kilohertz) were obtained. Resistive index was calculated as (1 - [end diastolic frequency shift/peak systolic frequency shift]) using Doppler samples from the hilar arteries of the left or right kidney with the higher main renal artery peak systolic velocity. OUTCOMES & MEASUREMENTS Proportional hazard regression analysis was used to determine associations between renal duplex sonography-derived Doppler signals and CVD events and all-cause mortality adjusted for accepted cardiovascular risk factors. Index CVD outcomes were defined as coronary events (angina, myocardial infarction, and coronary artery bypass grafting/percutaneous coronary intervention), cerebrovascular events (stroke or transient ischemic attack), and any CVD event (angina, congestive heart failure, myocardial infarction, stroke, transient ischemic attack, and coronary artery bypass grafting [CABG]/percutaneous transluminal coronary intervention [PTCI]). RESULTS During follow-up, 221 deaths (31%), 229 CVD events (32%), 122 coronary events (17%), and 92 cerebrovascular events (13%) were observed. Renal duplex sonography-derived Doppler signals from the renal parenchyma were associated independently with all-cause mortality and CVD outcomes. In particular, increased parenchymal end diastolic frequency shift was associated significantly with any CVD event (HR, 0.73; 95% CI, 0.62-0.87; P < 0.001). Marginally significant associations were observed between increases in parenchymal end diastolic frequency shift and decreased risk of death (HR, 0.86; 95% CI, 0.73-1.00; P = 0.06) and decreased risk of cerebrovascular events (HR, 0.78; 95% CI, 0.61-1.01; P = 0.06). Parenchymal end diastolic frequency shift was not significantly predictive of coronary events (HR, 0.84; 95% CI, 0.67-1.06; P = 0.1). LIMITATIONS CHS participants showed a "healthy cohort" effect that may underestimate the rate of CVD events in the general population. CONCLUSION Renal duplex sonographic Doppler signals from the renal parenchyma showed significant associations with subsequent CVD events after controlling for other significant risk factors. In particular, a standard deviation increase in parenchymal end diastolic frequency shift was associated with 27% risk reduction in any CVD event.
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Affiliation(s)
- Jeffrey D Pearce
- Division of Surgical Sciences, Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston-Salem, NC 27157-1095, USA
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Morais Filho DD, Thomazinho F, Motta F, Perozin IS, Sardinha WE, Silvestre JMDS, Palma O, Oliveira RGD. Análise espectral segmentar no seguimento de pacientes revascularizados. J Vasc Bras 2009. [DOI: 10.1590/s1677-54492009000200004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
CONTEXTO: Pacientes tratados por revascularização arterial (enxertos e angioplastias) nos membros inferiores acometidos por doença arterial oclusiva periférica foram seguidos por até 2 anos pós-tratamento usando ultrassom vascular (análise espectral segmentar, AES). OBJETIVO: Demonstrar que a AES pode ser utilizada no seguimento dos pacientes tratados por doença arterial oclusiva periférica. MÉTODOS: As medidas de AES realizadas foram: velocidade sistólica de pico, índice de pulsatilidade e forma da onda de velocidade de fluxo. Essas foram comparadas em cada paciente no pré e pós-tratamento (com intervalos de 3 meses) para diagnóstico de perviedade. RESULTADOS: Medidas realizadas no pós-operatório nas artérias imediatamente distais aos segmentos tratados mostraram aumento consistente de velocidade sistólica de pico e índice de pulsatilidade com mudanças na forma da onda de velocidade de fluxo de unifásica para bi ou trifásica. A velocidade sistólica de pico e o índice de pulsatilidade aumentaram respectivamente em 92,26 e 98,2% (tratamentos no segmento aorto-ilíaco), em 112,83 e 62,39% (tratamentos no segmento fêmoro-poplíteo) e em 149,08 e 28,8% (tratamentos no segmento poplíteo-tibial). Tais mudanças nos padrões de velocidade de fluxo ocorreram em todos os pacientes e permaneceram quase inalteradas enquanto os tratamentos estivessem pérvios. Quando ocorria falência nos tratamentos (oclusões ou estenoses hemodinamicamente significantes), os parâmetros caíam a níveis similares aos de antes do tratamento. Se a falência do tratamento era corrigida por nova revascularização (enxerto ou angioplastia), os parâmetros de AES voltavam a se comportar como após o tratamento inicial. CONCLUSÃO: A AES pode ser usada no seguimento dos pacientes com revascularização dos membros devido a doença arterial oclusiva periférica, demonstrando tanto a perviedade quanto a falência do tratamento.
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Crutchley TA, Pearce JD, Craven TE, Stafford JM, Edwards MS, Hansen KJ. Clinical utility of the resistive index in atherosclerotic renovascular disease. J Vasc Surg 2008; 49:148-55, 155.e1-3; discussion 155. [PMID: 18951751 DOI: 10.1016/j.jvs.2008.08.008] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2008] [Revised: 07/27/2008] [Accepted: 08/03/2008] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This retrospective study examines the relationship between the renal resistive index (RI) and blood pressure and renal function response after open and percutaneous intervention for atherosclerotic renovascular disease (AS-RVD). METHODS From March 1997 to December 2005, 86 patients (46 women, 40 men; mean age, 68 +/- 10 years) underwent renal duplex sonography (RDS), including main renal artery and hilar vessel Doppler interrogation, before treatment of AS-RVD. Of these, 56 patients had open operative repair, and 30 had percutaneous intervention. The RI (1-[EDV/PSV]) was calculated from the kidney with the highest peak systolic velocity (PSV). Hypertension response was graded from preprocedural and postprocedural blood pressure measurements and medication requirements. Renal function response was graded by a >or=20% change in estimated glomerular filtration rate (eGFR) calculated from the serum creatinine concentration. RESULTS Comorbid conditions, baseline blood pressure, and preoperative renal function were not significantly different between open and percutaneous groups. Baseline characteristics that differed between the percutaneous vs open group were higher mean age (71 +/- 11 years vs 67 +/- 9 years; P = .05), kidney length (11.3 +/- 1.3 cm vs 10.7 +/- 1.2 cm; P = .02), proportion of patients with RI >or=0.8 (50% vs 21%; P = .01), and proportion of bilateral AS-RVD (37% vs 80%; P < .01). After controlling for preintervention blood pressure and extent of repair, postoperative eGFR differed significantly for RI <0.8 or >or=0.8 when all patients (P = .003) and percutaneous intervention (P = .008) were considered. Specifically, eGFR declined from preprocedure to postprocedure in the patients with RI >or=0.8 after percutaneous repair and in the group analyzed as a whole. Neither systolic nor diastolic pressure after intervention demonstrated an association with RI. Considering all patients and both groups, multivariable proportional hazards regression models demonstrated that RI was predictive of all-cause mortality. RI was the most powerful predictor of death during follow-up (hazard ratio, 6.7; 95% confidence interval, 2.6-17.2; P < .001). CONCLUSION After intervention for AS-RVD, RI was associated with renal function, but not blood pressure response. A strong, independent relationship between RI and mortality was observed for all patients and both treatment groups.
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Affiliation(s)
- Teresa A Crutchley
- Division of Surgical Sciences, Section on Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
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Abstract
Renal artery disease is the most common cause of potentially curable secondary hypertension, with atherosclerosis as the major cause of renal artery stenosis. Fibromuscular dysplasia is a less common cause of renal artery stenosis and is most frequently observed in premenopausal women. Renal artery stenosis is likely to be underappreciated and is more common in patients with other vascular disease (e.g., coronary or peripheral arterial disease). The diagnosis of renal artery stenosis requires a high clinical index of suspicion as well as an appropriate imaging strategy, with currently effective diagnostic modalities including magnetic resonance imaging, computed tomography and renal artery duplex ultrasonography. The current treatment of choice for atherosclerotic renal artery stenosis is balloon angioplasty and secondary stenting, whereas angioplasty alone is the treatment for renal artery stenosis secondary to fibromuscular dysplasia. Expected outcomes following revascularization include improved blood pressure control and possibly renal preservation. Ongoing studies will hopefully identify patient characteristics that will achieve the most benefit from percutaneous revascularization as well as the impact of percutaneous revascularization with drug-eluting stents and embolic protection devices.
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Affiliation(s)
- Robert S Dieter
- Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.
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Slovut DP, Lookstein R, Bacharach JM, Olin JW. Correlation between noninvasive and endovascular Doppler in patients with atherosclerotic renal artery stenosis: A pilot study. Catheter Cardiovasc Interv 2006; 67:426-33. [PMID: 16502400 DOI: 10.1002/ccd.20627] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Considerable interest exists in using endovascular techniques for assessing the renal circulation. The vasomotor response of the renal circulation in patients with hypertension and severe atherosclerotic renal artery stenosis was evaluated. Sixteen patients (5 men and 11 women) with a mean age of 73.2+/-7.1 years (range, 59-82 years) underwent noninvasive renal duplex ultrasonography and endovascular flow wire evaluation. The flow wire was positioned in the main renal artery distal to the stenosis and used to examine the reactivity of the renal circulation in response to intra-arterial papaverine before and after percutaneous revascularization. Resistive index was computed as (MPV - EDV)/MPV, where MPV is the maximum peak velocity and EDV is the end-diastolic velocity. Renal flow reserve was defined as the ratio of peak hyperemic response to baseline flow. Intervention was technically successful in 18/18 arteries. Heart rate (69+/-11 vs. 65+/-10 beats/min; P=NS) and systolic blood pressure (168+/-19 vs. 163+/-24 mm Hg; P=NS) remained constant following injection of intrarenal papaverine, while diastolic blood pressure decreased (77+/-13 vs. 65+/-11 mm Hg; P<0.006). Papaverine injection resulted in significant increases in average peak velocity (APV; 148% of baseline; P=0.0003), MPV (146% of baseline; P=0.001), and EDV (161% of baseline; P=0.0026), but had no effect on the endovascular resistive index (0.81+/-0.12 vs. 0.84+/-0.08; P=NS). Renal artery stenting produced no effect on APV or EDV, but a small increase in MPV (123% of baseline; P<0.05). In contrast, renal stenting resulted in a significant increase in the endovascular resistive index (0.77+/-012 vs. 0.84+/-0.08; P=0.003), pulsatility index (1.84+/-0.61 vs. 2.23+/-0.70; P<0.014), and renal flow reserve (1.49+/-0.44 vs. 1.86+/-0.73; P<0.0071). A correlation was found between the noninvasive and endovascular measures diastolic/systolic ratio (r=0.73; P<0.0009) and resistive index (r=0.63; P<0.0053). Patients with atherosclerotic renal artery stenosis have preserved vasomotor response to papaverine, as well as marked increases in renal flow and resistive index following successful renal artery stenting. Endovascular flow wire measurements are safe, easy to perform, and correlate well with noninvasive Doppler measurements.
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Affiliation(s)
- David P Slovut
- Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai School of Medicine, New York, New York 10029, and Department of Cardiology, Avera Heart Hospital of South Dakota, Sioux Falls, USA
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García-Criado A, Gilabert R, Nicolau C, Real MI, Muntañá X, Blasco J, Ganau S, Brú C. Value of Doppler sonography for predicting clinical outcome after renal artery revascularization in atherosclerotic renal artery stenosis. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2005; 24:1641-7. [PMID: 16301720 DOI: 10.7863/jum.2005.24.12.1641] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
OBJECTIVE The purpose of this study was to prospectively evaluate the usefulness of Doppler sonography for predicting blood pressure and renal function improvement after percutaneous renal angioplasty in patients with unilateral atherosclerotic renal artery stenosis. METHODS Thirty-six patients with successfully revascularized unilateral atherosclerotic renal artery stenosis were included. Patients were evaluated by Doppler sonography before treatment, with the resistive index (RI) and acceleration being measured in both kidneys. Blood pressure, number of antihypertensive drugs, and serum creatinine concentration were assessed before treatment and thereafter during a 23 +/- 15-month (mean +/- SD) period. RESULTS In 20 of the 36 patients (55%), the RI was less than 0.80 before revascularization. After treatment, blood pressure improved in 17 (85%) of those 20 patients and improved in 8 (50%) of 16 patients with an RI of greater than 0.80 (P < .05). Twenty-five patients had renal insufficiency pretreatment, and 11 (44%) had a baseline RI of less than 0.80. Improvement in renal function after angioplasty was shown in 5 (45%) of these 11 patients and in 4 (28.5%) of 14 in the group with high RI (P > .05, not significant). On analysis of acceleration, blood pressure improved in 9 (69%) of 13 patients with acceleration of greater than 3 m/s(2) and in 16 (69.5%) of 23 with acceleration of less than 3 m/s(2) (P > .05). In patients with renal insufficiency, 5 (50%) of 10 cases with normal baseline acceleration and 4 (27%) of 15 with low acceleration showed improvement in renal function (P > .05). CONCLUSIONS An elevated RI should not exclude patients from a revascularization procedure because, although renal RI does correlate with blood pressure response to revascularization, it is not a useful parameter in predicting renal function outcome. Acceleration has no prognostic value.
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Affiliation(s)
- Angeles García-Criado
- Department of Radiology, Hospital Clinic of Barcelona, Villarroel 170, 08036, Barcelona, Spain.
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Pearce JD, Edwards MS, Craven TE, English WP, Mondi MM, Reavis SW, Hansen KJ. Renal duplex parameters, blood pressure, and renal function in elderly people. Am J Kidney Dis 2005; 45:842-50. [PMID: 15861349 DOI: 10.1053/j.ajkd.2005.01.028] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Changes in renal artery and renal parenchyma perfusion are believed to correlate with severity of hypertension and worsened renal function, but population-based studies of these associations are not available. This study examines relationships between parameters derived from renal duplex sonography (RDS), blood pressure (BP), and excretory renal function in a population-based cohort of elderly Americans. METHODS Through an ancillary study to the Cardiovascular Health Study, 758 participants (37% men; mean age, 77 years) underwent RDS in which flow velocities and frequency shifts were determined from spectral analysis of Doppler-shifted signals obtained from the renal artery and parenchyma. Associations of these duplex parameters with BP and inverse serum creatinine were examined by using multivariate regression techniques. RESULTS Main renal artery peak systolic flow velocity (PSV) showed independent associations with BP, with an SD increase in PSV (0.53 m/s) associated with a 3.3-mm Hg increase in systolic BP (SBP) and a 2.4-mm Hg decrease in diastolic BP (DBP). An SD decrease in end-diastolic frequency shift (EDF; 131 kHz) was associated with a 6.0-mm Hg increase in SBP, a 4.2-mm Hg decrease in DBP, and a significant 3.7% decrease in inverse serum creatinine. CONCLUSION Increases in renal artery PSV and decreases in parenchymal EDF are associated with increased SBP and decreased DBP. Moreover, decreased parenchymal EDF showed significant associations with impaired excretory renal function. These results suggest that renal duplex parameters are associated with renal parenchymal changes caused by hypertension and progressive renal dysfunction in elderly people.
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Affiliation(s)
- Jeffrey D Pearce
- Division of Surgical Sciences, Section on Vascular Surgery, Wake Forest University School of Medicine, Winston-Salem, NC 27157-1095, USA
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Bolduc JP, Oliva VL, Therasse E, Giroux MF, Bouchard L, Perreault P, Cliché A, Soulez G. Diagnosis and treatment of renovascular hypertension: a cost-benefit analysis. AJR Am J Roentgenol 2005; 184:931-7. [PMID: 15728620 DOI: 10.2214/ajr.184.3.01840931] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE We sought to evaluate and compare the relative cost-benefit of Doppler sonography, MR angiography, and captopril-enhanced renal scintigraphy as techniques for predicting a patient's clinical response to renal angioplasty. MATERIALS AND METHODS Estimations of positive and negative predictive values of baseline and captopril-enhanced renal scintigraphy and Doppler sonography examinations for predicting a favorable outcome after renal angioplasty were based on a previously published prospective study involving 74 patients who underwent this treatment. For gadolinium-enhanced MR angiography, predictive values were calculated from a subpopulation of 57 of these 74 subjects. The value of different combined strategies with these techniques for predicting clinical success after angioplasty was evaluated in this population. The costs of investigation and treatment per improved patient were calculated for each imaging technique and for combined strategies in a hypothetic 1,000-patient population with a 30% prevalence of renal artery stenosis, relying on the diagnostic performance reported in the literature for each technique in detecting renal artery stenosis. RESULTS The costs for each improved patient were $12,579 for patients selected on the basis of a positive finding on Doppler sonography (false-negative results = 12/1,000) and $10,149 for patients selected with criteria combining a positive finding on Doppler sonography with a bilateral resistive index of less than 0.75 (false-negative results = 32/1,000). Patient selection based on a positive finding on MR angiography cost $18,119 (false-negative results = 0), whereas the cost of patient selection based on a positive finding on renal scintigraphy was $12,939 (false-negative results = 29/1,000). CONCLUSION Doppler sonography is more cost-efficient but less sensitive than MR angiography for identifying patients with renovascular hypertension. MR angiography should be favored in hypertensive patients who are resistant to medical therapy to avoid false-negative examinations.
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Affiliation(s)
- Jean Philippe Bolduc
- Department of Radiology, CHUM-Notre-Dame Hospital, 1560 Sherbrooke East, Montreal, Quebec, Canada
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Soulez G, Therasse E, Qanadli SD, Froment D, Léveillé M, Nicolet V, Turpin S, Giroux MF, Guertin MC, Oliva VL. Prediction of clinical response after renal angioplasty: respective value of renal Doppler sonography and scintigraphy. AJR Am J Roentgenol 2003; 181:1029-35. [PMID: 14500224 DOI: 10.2214/ajr.181.4.1811029] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The goal of our study was to compare Doppler sonography and renal scintigraphy as tools for predicting the therapeutic response in patients after undergoing renal angioplasty. SUBJECTS AND METHODS. Seventy-four hypertensive patients underwent clinical examination, Doppler sonography, and renal scintigraphy before and after receiving captopril in preparation for renal revascularization. The patients were evaluated for the status of hypertension 3 months after the procedure. The predictive values of the findings of clinical examination, Doppler sonography, renal scintigraphy, and angiography were assessed. RESULTS For prediction of a favorable therapeutic outcome, abnormal results from renal scintigraphy before and after captopril administration had a sensitivity of 58% and specificity of 57%. Findings of Doppler sonography had a sensitivity of 68% and specificity of 50% before captopril administration and a sensitivity of 81% and specificity of 32% after captopril administration. Significant predictors of a cure or reduction of hypertension after revascularization were low unilateral (p = 0.014) and bilateral resistive (p = 0.016) indexes on Doppler sonography before (p = 0.009) and after (p = 0.028) captopril administration. On multivariate analysis, the best predictors were a unilateral resistive index of less than 0.65 (odds ratio [OR] = 3.7) after captopril administration and a kidney longer than 93 mm (OR = 7.8). The two best combined criteria to predict the favorable therapeutic outcome were a bilateral resistive index of less than 0.75 before captopril administration combined with a unilateral resistive index of less than 0.70 after captopril administration (sensitivity, 76%; specificity, 58%) or a bilateral resistive index of less than 0.75 before captopril administration and a kidney measuring longer than 90 mm (sensitivity, 81%; specificity, 50%). CONCLUSION Measurements of kidney length and unilateral and bilateral resistive indexes before and after captopril administration were useful in predicting the outcome after renal angioplasty. Renal scintigraphy had no significant predictive value.
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Affiliation(s)
- Gilles Soulez
- Department of Radiology, CHUM-Notre-Dame Hospital, 1560 Sherbrooke Street E., Montreal, Quebec H2L 4M1, Canada.
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Cirugía sin arteriografía de los troncos viscerales. ANGIOLOGIA 2003. [DOI: 10.1016/s0003-3170(03)74821-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Cherr GS, Hansen KJ, Craven TE, Edwards MS, Ligush J, Levy PJ, Freedman BI, Dean RH. Surgical management of atherosclerotic renovascular disease. J Vasc Surg 2002; 35:236-45. [PMID: 11854720 DOI: 10.1067/mva.2002.120376] [Citation(s) in RCA: 98] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This review describes the clinical outcome of surgical intervention for atherosclerotic renovascular disease in 500 consecutive patients with hypertension. METHODS From January 1987 to December 1999, 626 patients underwent operative renal artery (RA) repair at our center. A subgroup of 500 patients (254 women and 246 men; mean age, 65 plus minus 9 years) with hypertension (mean blood pressure, 200 plus minus 35/104 plus minus 21 mm Hg) and atherosclerotic RA disease forms the basis of this report. Hypertension response was determined from preoperative and postoperative blood pressure measurements and medication requirements. Change in renal function was determined with estimated glomerular filtration rates (EGFRs) calculated from serum creatinine levels. Proportional hazards regression models were used for the examination of associations between selected preoperative parameters, blood pressure and renal function response, and eventual dialysis-dependence or death. RESULTS Two hundred three patients underwent unilateral RA procedures, 297 underwent bilateral RA procedures, and 205 patients underwent combined renal and aortic reconstruction. After surgery, there were 23 deaths (4.6%) in the hospital or within 30 days of surgery. Significant and independent predictors of perioperative death included advanced age (P <.0001; hazard ratio [HR], 3.23; 95% confidence interval [CI], 1.85 to 5.70) and clinical congestive heart failure (P =.013; HR, 3.05; 95% CI, 1.26 to 7.34). Among the patients who survived surgery, hypertension was considered cured in 12%, improved in 73%, and unchanged in 15%. For the entire group, renal function increased significantly after operation (preoperative versus postoperative mean EGFR, 41.1 plus minus 23.9 versus 48.2 plus minus 25.5 mL/min/m(2); P <.0001). For individual patients, with a 20% or more change in EGFR considered significant, 43% had improved renal function (including 28 patients who were removed from dialysis-dependence), 47% had unchanged function, and 10% had worsened function. Preoperative renal insufficiency (P <.001; HR, 2.35; 95% CI, 1.86 to 2.98), diabetes mellitus (P =.007; HR, 2.14; 95% CI, 1.15 to 3.97), prior stroke (P =.042; HR, 1.50; 95% CI, 1.02 to 2.22), and severe aortic occlusive disease (P =.003; HR, 1.69; 95% CI, 1.19 to 2.31) showed significant and independent associations with death or dialysis during the follow-up examination period. After operation, blood pressure cured (P =.014; HR, 0.52; 95% CI, 0.30 to 0.88) and improved renal function (P =.011; HR, 0.40; 95% CI, 0.19 to 0.81) showed significant and independent associations with improved dialysis-free survival rate. All categories of function response and time to death or dialysis showed significant interactions with preoperative EGFR. CONCLUSION The surgical correction of atherosclerotic renovascular disease resulted in blood pressure benefit and retrieval of renal function in selected patients with hypertension. The patients with cured hypertension or improved EGFR after operation showed increased dialysis-free survival as compared with other patients who underwent surgery.
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Affiliation(s)
- Gregory S Cherr
- Division of Surgical Sciences, Section on Vascular Surgery, Department of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC 27157-195, USA
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Affiliation(s)
- SD Sarkar
- Department of Radiology, Long Island Jewish Medical Center, New Hyde Park, New York
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Hetzel GR, Hollenbeck M, Voiculescu A, Malms J, Cohnen M, Willers R, Mödder U, Grabensee B. Effect of acute intravenous ace-inhibition on the intrarenal doppler flow characteristics in hypertensive patients with and without unilateral renal artery stenosis. Clin Exp Hypertens 2000; 22:571-81. [PMID: 10972162 DOI: 10.1081/ceh-100100092] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Assessment of intrarenal doppler signals is of particular importance in screening for renal artery stenosis. We studied the effect of acute ACE-inhibition (1,25 mg enalaprilate i.v.) on intrarenal resistive indices in 10 hypertensive patients with unilateral renal artery stenosis versus 10 patients with essential hypertension. Any changes limited to poststenotic vessels could possibly improve the diagnostic value of duplex sonography. After ACE-inhibition a significant fall of the intrarenal Resistive Index occurred in both patient groups. In cases of unilateral renal artery stenosis we saw a tendency to an increased side difference of the Resistive Index due to a greater fall on the poststenotic side. Therefore a clear advantage of duplex scanning after acute ACE-inhibition due to a limited effect of enalaprilate on poststenotic vessels was not found. The results suggest that the vascular resistance and not only the degree of renal artery stenosis is of significance for the characteristics of the doppler signal.
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Affiliation(s)
- G R Hetzel
- Department of Nephrology and Rheumatology, Heinrich Heine University, Düsseldorf, Germany
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