We attempted percutaneous transluminal renal angioplasty in 89 patients with hypertension and renal-artery stenosis (including 51 with atheromatous and 31 with fibromuscular stenoses) who were then followed for an average of 16 months (range, 4 to 40). Angioplasty was technically successful in 87 per cent of the fibromuscular stenoses and in 57 per cent of the unilateral atheromatous stenoses but in only 10 per cent of the bilateral atheromatous stenoses. After successful angioplasty, blood pressure was reduced to normal or improved in 93 per cent of the patients with fibromuscular dysplasia and in 84 per cent of the patients with atheromatous disease. Angiographic follow-up at an average of 21.8 months in 15 patients showed persistent relief of the stenoses and a 12 per cent average increase in kidney size. Renal angioplasty is effective for long-term control of hypertension in patients with renal-artery stenosis due to fibromuscular dysplasia or unilateral non-ostial atheroma.
Distal embolization occurred in 14 of 339 (4%) attempted percutaneous transluminal angioplasty (PTA) procedures, including five of 225 stenoses (2.2%) and nine of the 81 occlusions (11%) that were crossed successfully in 114 attempts (8%). Transcatheter embolectomy by aspiration through a nontapered large-bore catheter was technically successful in five of six attempts (83%), and was combined with successful PTA in three of five patients. In two patients in whom the clinical result of PTA was considered unsatisfactory, successful transcatheter embolectomy permitted an uncomplicated surgical by-pass procedure to be performed. If clinically significant embolization occurs during PTA, this procedure can be attempted prior to surgical embolectomy as an alternative to local fibrinolytic therapy.
When assessing a coronary artery bypass graft, the patency rate is virtually the sole criterion of success. However, this fails to identify grafts which are patent by incompletely reperfuse the diseased vessel. Angiograms of 82 patients with 172 bypassed coronary arteries confirmed patency in 126 (73%); however, in 30 reperfusion was incomplete though the graft was patent, making the rate of complete reperfusion only 56% (96/172). Causes included localized narrowings in the region of the anastomosis [9], significant narrowing along the graft [6], pre-existing additional stenoses in the native vessel, remote from the anastomosis and the lesion [7], stenoses not present preoperatively but seen postoperatively in the native vessel, remote from the anastomosis and original lesion [6], and separate obstructions of unbypassed branches [2]. While incomplete reperfusion is often unavoidable and is certainly preferable to total occlusion, evaluation based purely on patency rates is misleading, since it overlooks the fact that a significant proportion of patent grafts will not totally reperfuse the diseased vessel.
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