Percutaneous transluminal angioplasty in renal transplant arterial stenosis for relief of hypertension

Percutaneous transluminal angioplasty alone versus stent placement for the treatment of transplant renal artery stenosis

PURPOSE

The purposes of this retrospective study were to assess the efficacy of endovascular techniques for the treatment of transplant renal artery stenosis (TRAS) by analyzing technical and clinical success and to compare the results of percutaneous transluminal angioplasty (PTA) alone to those of stenting.

MATERIALS AND METHODS

A retrospective analysis was conducted on 31 patients who underwent endovascular treatment for TRAS between January 2012 and December 2017. There were 23 men and 8 women with a mean age of 60.5±14 (SD) years (range: 24-81 years). Ten patients (10/31; 32%; 8 men, 2 women; median age, 63 years) were treated with PTA alone and 21/31 (68%; 15 men, 6 women; median age, 65 years) with metallic stent placement. Several variables including serum creatinine level, glomerular filtration rate, arterial blood pressure value, antihypertensive medication obtained before and after treatment were compared. Technical success was assessed for each procedure. Clinical success was defined as a 15% drop in serum creatinine level, a decrease greater than 15% in mean blood pressure values or a decrease greater than 10% in mean blood pressure values with a reduction in the number of antihypertensive drugs needed for hypertension control.

RESULTS

Technical success was obtained in all patients [31/31; 100%; 95% confidence interval (CI): 89-100%] and clinical success in 27/31 patients (87%; 95%CI: 71-95%). Four patients (4/31; 13%; 95%CI: 5-29%) underwent repeat endovascular intervention. Mean serum creatinine level and mean arterial blood pressure values were significantly lower after treatment (177.4 and 93.8μmol/l, respectively) compared to before treatment (319.4 and 106.7μmol/l, respectively) in the stent group but not in the group treated with PTA alone (P=0.0012 and P=0.002, respectively).

CONCLUSION

The endovascular approach is safe and effective in the management of TRAS and stenting, depending on the morphology of the stenosis, should be the treatment of choice when possible.

Treatment of renovascular hypertension with percutaneous transluminal angioplasty: experience in Spain

PURPOSE

The clinical results of percutaneous transluminal angioplasty (PTA) were evaluated in patients with renovascular hypertension, and the effect of PTA on blood pressure and renal function was determined.

PATIENTS AND METHODS

Between February 1982 and December 1990, 93 hypertensive patients underwent 123 renal artery PTA procedures. Mean patient age was 43.4 years (range, 12-78 years). Average baseline blood pressure was 162/111 mm Hg (range, 140-230/95-150 mm Hg). The cause of renovascular hypertension, as determined with angiography, was atherosclerosis in 37 patients, fibromuscular dysplasia in 27, and mixed disease in one; 28 patients had renal transplant arterial stenosis.

RESULTS

In patients with atherosclerotic renal vascular disease or fibromuscular renal artery stenosis, systolic and diastolic blood pressure decreased significantly (P < .001) at 96 months after PTA. In patients with renal transplant arterial stenosis, blood pressure also decreased significantly (P < .001) at 12 months after PTA. Technical success was achieved in 78% of patients with atherosclerosis, 92% of patients with fibromuscular dysplasia, and 76% of patients with renal transplants. Complications were seen in 4.8% and were related to renal failure and vessel dissection.

CONCLUSION

PTA is the therapy of choice in patients with renovascular hypertension due to fibromuscular dysplasia. Patients with atherosclerotic renal artery stenosis or stenosis of a renal artery in a transplanted kidney should be selected according to the anatomy of the lesion and clinical patient characteristics.

Percutaneous transluminal renal angioplasty: initial results and long-term follow-up in 202 patients

Percutaneous transluminal renal angioplasty was performed in 202 patients with 250 stenoses. The procedure was successful in 201 of 250 (83%). Results were better for postostial atherosclerotic lesions (94%), fibromuscular lesions (83%), and transplant kidneys (71%) than for ostial atherosclerotic lesions (29%). Of all the patients, 61% had reduced blood pressures following the procedure, with cure (diastolic blood pressure less than or equal to 90 mm Hg) in 31% of the patients. Cure rate with a mean follow-up of 25.8 +/- 19.4 months was 21% in bilateral atheromatous lesions, 30% in unilateral atheromatosis, 65% in unilateral fibromuscular disease, and 40% in bilateral fibromuscular dysplasia. Of the transplanted patients, 60% were cured. Complications occurred in 23 (11%) of the patients. Recurrence of stenoses occurred in 16 lesions (8%), 80% within the first year after the procedure.

[Duplex sonography in the diagnosis of renal artery stenoses following allogenic kidney transplantation]

Posttransplant renal artery stenosis (TRAS) as a cause of secondary hypertension is reported with an incidence of 1 to 10%. Early diagnosis of TRAS should be made by non-nephrotoxic and non-invasive means to lower the risk of hypertension. One to 66 months after kidney transplantation 335 patients underwent Duplex-scanning, 38 of cases for clinical tentative diagnosis of TRAS. Parameters for clinical diagnosis of TRAS were diastolic hypertension greater than 100 mm Hg with resistance to therapy (A), an abdominal bruit over the transplant (B), disturbance of renal function (serum-creatinine greater than 2 mg/dl) (C). Admission to study followed the parameter-combination A + B. A + C, B + C. Rejection crisis was excluded in 18/38 cases by fine needle biopsy, cyclosporine over-dosage was negative in 38/38 cases, 20/38 cases had normal renal function. Duplex-/Doppler-ultrasound criteria for TRAS were systolic peak velocity greater than 100 cm/s-1 and broadening of the diastolic frequency spectra with a smooth decline in diastole to an elevated diastolic level. In 32/38 cases (84.2%, n = 38) diagnosis of TRAS was made by duplex-scanning, angiography confirmed the result in 30/32 cases (93.75%, n = 32); sensitivity was 88.2% with a specificity of 66.6%. Duplex-scanning as a primary diagnostic means for TRAS seems a promising method compared to e.g. radionuclide imaging or angiography. Duplex-scanning is a non-nephrotoxic and non-invasive procedure repeatable at any time with only few preliminary conditions.(ABSTRACT TRUNCATED AT 250 WORDS)

Angioplasty of renal transplant artery stenosis in children

Systemic hypertension after renal transplantation in children is frequent, occurring in 85% of the cases and may be the cause of severe neurologic complications. This can be due to multiple factors such as: rejection, recurrence of initial disease, steroid, etc. ... Among those factors, renal transplant artery stenosis (RTAS) must be identified as it may be cured by angioplasty. We report our experience in 18 children who had undergone angioplasty for RTAS. Angioplasty was performed under general anesthesia with 3F, 4F or 5F balloon catheters. Angioplasty was successful in 14 cases (77%) immediately (10 cases), progressively (2 cases) or after a successfully redilated recurrence (2 cases). Two of the 4 failures were due to technical problems, a successful surgical treatment was then performed. The 2 others failures were explained by a severe transplant rejection. The complications were rare: 1 femoral artery thrombosis and spasms of the intra renal arteries but without repercussion on the renal function. In our experience, angioplasty seems to be the treatment of choice in RTAS in children. However the indications must be carefully established taking in account other possible causes of hypertension in such patients.

Duplex Doppler sonography for renal artery stenosis in the post-transplant pediatric patient

Of 60 renal transplant patients who underwent 134 duplex Doppler sonograms, 38 had normal frequency shift profiles and 8 showed only minimal disturbances, within normal post-transplantation limits. Fourteen patients had hypertension and showed a very abnormal profile. In 3 of the 14 the hypertension was controllable medically, and the remaining 11 underwent angiography. Duplex Doppler sonography showed gross turbulence (spectral broadening, bidirectional flow) and high frequency shift confirmed on angiography to represent 50 to 75% main renal artery stenosis in 8 of these 11, and major renal intrahilar vessel stenosis in 2. In the remaining patient, no Doppler signal was found and 95% stenosis was present. In 1 patient with intrahilar stenosis, arterial signals detected in the renal veins indicated the presence of a post-biopsy arteriovenous fistula. One patient with main renal artery stenosis also had a fistula, which was masked by a 70% stenosis. All patients with angiographically proven renal artery stenosis had a distinctive abnormality of the Doppler arterial flow pattern.

Unusual transplant renal angioplasty complication: case report

We report an avulsion of a transplant upper pole renal artery following apparently successful percutaneous transluminal angioplasty (PTA) of a stenosis involving main, upper, and lower pole renal arteries. We believe that the use of a high pressure balloon was the causative factor. If the branches at the bifurcation cannot be protected and if the stenoses fail to resolve under moderate balloon insufflation pressures (less than 5-6 atmospheres), consideration should be given to surgical revascularization.

Combined thrombolytic therapy and percutaneous transluminal angioplasty for treatment of complex arterial graft thrombosis--a case report

Combined catheter-directed thrombolytic therapy followed by percutaneous transluminal angioplasty (PTA) was successfully performed for the treatment of a thrombosed complex mesenteric artery bypass graft resulting from an anastomotic stenosis. Restenosis of the graft due to neointimal hyperplasia was subsequently treated by PTA, with resultant long-term patency. This approach is an attractive alternative to surgical thrombectomy and graft revision, especially in patients who are poor surgical risks owing to concurrent medical problems.

Digital intravenous subtraction angiography in the evaluation of reconstructed renal arteries

Digital intravenous subtraction angiography (DISA) was used to evaluate 28 patients who had undergone renal artery reconstruction either as part of a renal transplant procedure or for treatment of renovascular hypertension. Satisfactory visualization of the renal artery was obtained in 26 cases, and the clinical questions were adequately answered in these cases. The findings included a variety of possible outcomes and demonstrate the adequacy of DISA as a means of evaluating the results of renal artery surgery. Technical and anatomic factors affecting the quality of the examination are discussed. The cases also illustrate the critical importance of thorough familiarity with the surgical procedures in general and of mutual discussion between surgeon and radiologist in optimizing the DISA examination in a given patient.

Percutaneous transluminal angioplasty in transplant renal artery stenosis: experience and review of the literature

Percutaneous transluminal angioplasty (PTA) was performed in five instances of renal transplant artery stenosis (RTAS) in four patients. Hypertension was present in all cases and improved after angioplasty together with reduction in medicine requirements. Abnormal renal function in four instances also improved after PTA. This reflects the current literature in which 76 of 90 patients were successfully treated by PTA (follow-up to 24 months), with two cases of recurrent stenosis, no mortality, and only a single case of graft loss. Vascular surgical repair succeeded in 130 to 180 patients, but graft loss occurred in 20 cases and recurrent stenosis in 11. Mortality was reported in five cases. Our review of the literature and experience suggests that PTA may be preferred in the treatment of RTAS.

Interventional radiologic procedures in the management of the renal transplant patient

Interventional radiologic procedures have become an important adjunct to the management of the renal transplant patient. Numerous problems can be dealt with, and in our experience these have included the diagnosis and treatment of ureteric obstruction, dilatation of renal artery stenoses, drainage of abscesses, hematomas and lymphoceles, management of complications of pancreatitis and treatment of bleeding due to fistulas and pseudoaneurysms.

The transplanted kidney. Diagnostic and interventional radiology

Following kidney allotransplantation a great number of complications threaten the patient and his graft, e.g. acute tubular necrosis, acute and chronic rejection, urologic and vascular complications and complications due to the immunosuppressive treatment. During the last decade a number of technical developments in radionuclide, ultrasonographic and radiographic imaging and intervention has significantly improved the possibility of early recognition and handling of such complications. Knowledge of the capability and limitations of the various techniques is of vital importance for their rational use. The aim of this review article is to give a short description of the various imaging modalities, the rational monitoring of the posttransplant patient, and possible handling of complications by the aid of imaging techniques.

Gruentzig balloon catheter dilation for acquired bronchial stenosis in an infant

A long stricture of the left main bronchus, which was resistant to the traditional methods of treatment, developed in a 992-gm twin who was ventilated for 114 days. The patient had two bronchial dilations with the Gruentzig balloon catheter placed under fluoroscopic control and inflated to 6 atm of pressure. The treatment was well tolerated by the patient, and one year after the Gruentzig balloon dilation she had a normal chest roentgenogram. Gruentzig balloon catheter dilation is a new technique for repairing bronchial stenosis in infancy without major intrathoracic surgical intervention.

Percutaneous transluminal angioplasty. The radiologist's contribution to the treatment of vascular disease

Percutaneous transluminal angioplasty is a nonsurgical treatment for vascular disease. It is relatively safe and economical and may be an alternative, or an adjunct, to surgery, or may be helpful where no surgical alternative exists. Percutaneous transluminal angioplasty is applicable to nearly every system, except the carotid bifurcation plaque.

Embolization and angioplasty to relieve malignant hypertension and azotemia in a renal transplant patient

The case of a 23-year-old patient with malignant hypertension following a renal transplant illustrates the successful treatment of the hypertension with embolization of the native kidneys. Azotemia followed and was successfully treated with percutaneous transluminal angioplasty of high-grade stenosis at the anastomotic site of the allograft. Malignant hypertension redeveloped with the recanalization of the embolized native kidneys. This was successfully treated with contrast ablation.

Current status of percutaneous transluminal angioplasty

With the development of a dilating balloon catheter that permits percutaneous treatment of many arterial stenoses and some occlusions, a definite advance in the therapy of peripheral vascular disease has been made. It is still too early to be certain what ultimate position this means of therapy will take in the overall treatment of vascular disease, as its use is still being extended and long-term results are not yet clearly known. When compared with surgical therapy, however, it has some striking advantages, although the durability of its effect appears to be less. Despite the fact that more time and experience are needed before its ultimate position is established, we believe that the evidence to date warrants inclusion of this form of therapy in the armamentarium of every major vascular center.

Lasting improvement of renovascular hypertension by transluminal dilatation of atherosclerotic and nonatherosclerotic renal artery stenoses. A follow-up study

Sixteen consecutive patients with renovascular hypertension were treated by transluminal dilatation and observed during 6 - 39 months (mean 21.8 months). Poststenotic renal artery pressure increased (p less than 0.001) and the renal arteries were patent on angiograms taken immediately after dilatation. In 13 patients, angiography was repeated 2 - 9 months later; at that time the selective renal vein renin ratio had decreased (p less than 0.001). At the end of the follow-up, blood pressure was improved or normal in 14 cases. One of the eight patients with atherosclerosis was normotensive without treatment, compared with five of six patients with fibromuscular dysplasia (p less than 0.05). The results in two cases with vasculitis are uncertain. The four patients with relapses, one after intimal catheter dissection, were treated successfully by redilatation. Thus, renovascular hypertension can be improved by transluminal dilatation in patients with atherosclerosis and in patients with fibromuscular dysplasia with lasting success and a low morbidity rate.

Percutaneous transluminal dilatation: the treatment of choice for renal artery stenosis causing hypertension

During the last 3 yr a large number of patients with renal artery stenosis have undergone attempted treatment of their stenosis by the technique termed percutaneous transluminal angioplasty or dilatation (PTD) using the balloon tipped catheter developed by Gruntiz. A number of publications have documented that this technique is reasonably safe and effective in renal artery lesions due to fibromuscular disease (FMD), atherosclerosis (AS), or prior surgery such as renal artery bypass or transplantation. Although initially many of the patients that were treated were felt to be poor surgical risks, many patients have now been treated who were excellent candidates for renal artery bypass. The cumulative experience argues that PTD should be the first treatment tried in any patient with significant renal artery stenosis causing hypertension. It should be noted that the cumulative experience is not based on any controlled trial and therefore may well be biased. Nevertheless, I will present this argument based on the published data and our own experience at Indiana University. This argument pertains to any patient with incomplete renal artery occlusion who has a functionally significant stenosis (determined by renal vein renin sampling) and who is a good surgical candidate. Those patients who are at high risk for major surgery will obviously be best treated by PTD or medical management. The argument has four major points: safety, effectiveness, cost analysis, and availability.

Dilatation of experimental renal artery stenosis by balloon catheter

An experimental model has been developed in the pig in order to evaluate the effect of percutaneous transluminal angioplasty on fibrous renal artery stenosis. Stenoses were induced by bilateral subtotal ligation with chromic catgut. Six weeks following ligation unilateral transluminal dilatation was performed in 9 pigs using Grüntzig balloon catheters. In only one case a serious complication occurred with rupture of the renal artery. Seven pigs with dilated stenoses were re-examined by angiography 8 to 10 weeks after dilatation. In 6 cases the stenoses were practically completely eliminated while in one cases a re-stenosis developed. Microscopy of the dilated arteries revealed several small and large ruptures of th internal elastic membrane.

Percutaneous transluminal dilatation of transplant renal artery stenosis

Percutaneous transluminal angioplasty has been applied to the treatment of transplant renal artery stenosis in 3 patients, 2 with severe hypertension resistant to medical therapy, and one with graft dysfunction related to the presence of the stenosis in the early post-transplant period. The clinical courses of the patients before and after angioplasty are illustrated and the usefulness of the technique in this difficult situation stressed.

Renal artery blood flow assessed by video dilution technique before and after percutaneous transluminal angioplasty

Successful percutaneous transluminal angioplasty was performed in 3 cases of renal artery stenosis where the effect upon renal blood flow was quantified by video dilution technique. This technique adds important information to pressure gradients and renin assays obtained during the dilatation procedure.