Atheroemboli during renal artery angioplasty: An ex vivo study

Hiramoto, Jade S.; Hansen, Kimberley J.; Pan, Xian Mang; Edwards, Matthew S.; Sawhney, Rajiv; Rapp, Joseph H.

doi:10.1016/j.jvs.2005.02.042

Cited by 75 publications

(59 citation statements)

References 42 publications

(44 reference statements)

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…However, a cumulative review of the available literature on PTRA for ostial RA stenosis in patients with ischemic nephropathy (i.e., serum creatinine у1.8 mg/dL) demonstrated that only 22% had improved renal function, with the renal function of 78% of patients either unchanged (66%) or worse (22%). 22 Although the apparent differences in renal function response after open operative repair and PTRA may reflect differences in patient selection, recent ex vivo data from PTRA in RA endarterectomy specimens suggest that significant atheroemboli are released during the procedure. 22 When 31 transaortic RA endarterectomy specimens that had been collected during open operations were submitted to ex vivo PTRA, the average number of atheroembolic debris that exceeded 100 in diameter was 350.…”

Section: Discussionmentioning

confidence: 99%

“…22 Although the apparent differences in renal function response after open operative repair and PTRA may reflect differences in patient selection, recent ex vivo data from PTRA in RA endarterectomy specimens suggest that significant atheroemboli are released during the procedure. 22 When 31 transaortic RA endarterectomy specimens that had been collected during open operations were submitted to ex vivo PTRA, the average number of atheroembolic debris that exceeded 100 in diameter was 350. Of greater importance, with PTRA, on average, more than 3 million atheroembolic particles were less than 100 m in diameter.…”

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Open operative management of dialysis‐dependent ischemic nephropathy

Piercy¹,

Mostafavi²,

Craven³

et al. 2007

Dialysis & Transplantation

Self Cite

View full text Add to dashboard Cite

OBJECTIVEThis retrospective review examines open operative management of dialysis‐dependent ischemic nephropathy among consecutive hypertensive adults.METHODSFrom February 1987 through July 2005, 820 patients underwent open operative repair of 1220 kidneys at our center. A subgroup of 45 hypertensive patients (19 women, 26 men; mean age, 68 ± 9 years; mean BP, 205 ± 29/99 ± 20) considered permanently dialysis‐dependent prior to renal artery (RA) repair forms the basis of this report. Estimated glomerular filtration rate (EGFR) was determined from serial serum creatinine measures 14 weeks before and after RA repair. The mean rate of change of EGFR was estimated before and after RA repair using linear regression analysis. Analysis of kidney status and change in EGFR was performed. The relationship between renal function response after an operation and survival was determined by the product‐limit method.RESULTSRenal artery repairs to 73 kidneys included RA bypass (44 repairs: 22 saphenous vein repairs and 22 prosthetic grafts), RA endarterectomy (25 repairs; 13 transrenal and 12 transaortic), and RA reimplantation (4 repairs). Thirty‐five patients had bilateral procedures, including 4 procedures to solitary kidneys. Eighteen patients had combined aortic repair (13 AAA, 5 aortic occlusions). Of 28 RA occlusions, 25 were repaired. Three nephrectomies were performed for unreconstructable RA to a nonfunctioning kidney. After RA repair, 2 patients died (4.4%) within 30 days of operation or in‐hospital. Twenty‐nine of 43 (67%) surgical survivors stopped being dialysis dependent. Among patients removed from dialysis, postoperative EGFR ranged from 10.0 to 91.1 mL/min/1.73 m2 (mean: 41.7 ± 18.6 mL/min/1.73 m2). Four patients initially removed from dialysis progressed to eventual dialysisdependence on follow‐up. Removal from dialysis was associated with a more rapid decline in preoperative EGFR (mean slope per week loge EGFR: −0.1489 ± 0.0180 off dialysis; −0.0748 ± 0.0236 on dialysis; p = .01); however, EGFR did not differ statistically after unilateral or bilateral RA procedures (mean: 25.8 ± 7.7 mL/min/1.73 m2 unilateral versus 44.6 ± 3.8 mL/min/1.73 m2 bilateral; p = .06). On follow‐up, improved survival was observed for patients removed from dialysis compared with patients who remained dialysis dependent (p = 0.003).CONCLUSIONOpen operative management of dialysis‐dependent ischemic nephropathy can remove selected patients from dialysis. Beneficial renal function response was associated with a rapid decline in preoperative renal function. Compared with that of patients who remained dialysis dependent, the survival of patients who could cease dialysis after the operation was was improved.

show abstract

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Open operative management of dialysis‐dependent ischemic nephropathy

Piercy¹,

Mostafavi²,

Craven³

et al. 2007

Dialysis & Transplantation

Self Cite

View full text Add to dashboard Cite

show abstract

“…70 The in vitro work of Hiramoto et al 71 leaves little doubt that atheroemboli are also a common accompaniment of PRI. Multiple trials and registries describing the performance of the several EPD confirm the high frequency of embolic material that can be recovered during PRI.…”

Section: Atheroembolizationmentioning

confidence: 99%

Optimizing Outcomes for Renal Artery Intervention

White

2010

Circ: Cardiovascular Interventions

View full text Add to dashboard Cite

he 3 clinical syndromes related to atherosclerotic renal artery stenosis (RAS) are (1) renovascular hypertension; (2) ischemic nephropathy; and (3) cardiac disturbance syndromes (ie, sudden-onset pulmonary edema, refractory heart failure, or unstable angina). Clinical improvement after treatment of RAS will depend on the efficacy of reperfusion and the safety of the procedure. Controversy exists among experts regarding the most appropriate utilization of percutaneous renal intervention (PRI) as the treatment for significant RAS. [1][2][3][4] Despite the acknowledged uncertainty in this area, clinicians must make treatment decisions for patients who are considered potential candidates for revascularization of atherosclerotic RAS.Procedural efficacy is defined by both technical and clinical end points. Technical success occurs when stent deployment results in anatomic and physiological relief of the obstruction to renal blood flow. Progressive equipment and device evolution (including down-sizing from the peripheral vascular 0.035-in systems to the coronary 0.014-in systems and new renal guiding catheter shapes) and advanced balloon-expandable stent designs (many are off-label devices Food and Drug Administration-approved for other anatomic regions) have led to excellent technical success rates for PRI in the hands of skilled operators (Table 1). [5][6][7][8][9][10][11] A key principle is that clinical benefit from PRI will result from correcting renal hypoperfusion caused by significant RAS. Published meta-analyses suggest that a high PRI technical success rate (Ͼ95%) is accompanied by surprisingly modest and inconsistent clinical improvement. 12,13 The discordance between the high technical success and the inconsistent clinical response to revascularization suggests that (1) successful PRI procedures were performed on nonobstructive RAS (not causing symptomatic renal hypoperfusion); or (2) that the clinical syndrome being treated was not caused by renal hypoperfusion. Improvement in discriminating ischemia-producing RAS lesions from nonischemiaproducing lesions would be expected to increase the clinical response rate of PRI.The purpose of this article is to review recent developments that may help to guide the clinical practice of PRI by improving case selection of significant RAS and to optimize procedural techniques aimed at improving safety for patients undergoing catheter-based therapy of renovascular disease. Procedural Efficacy HypertensionThe current American Heart Association/American College of Cardiology guideline indications for PRI in hypertensive patients with hemodynamically significant RAS and a viable kidney (linear length Ͼ7 cm), includes (1) accelerated hypertension; (2) refractory hypertension (failure of 3 appropriate drugs, 1 of which should be a diuretic 14 ); (3) hypertension with a small kidney; or (4) hypertension with intolerance to medications (class IIa, level of evidence B). 15 By convention, a hemodynamically significant lesion requires demonstration of a Ն70% RAS by visual estimati...

show abstract

“…Renal stenting has been reported to result in the peri-procedural loss of renal function in some patients [32][33][34][35][36][37]. There are multiple factors that might be responsible for this reported periprocedural loss of renal function but the most likely being distal embolization.…”

Section: Role Of Distal Embolization and Embolic Protection Devices Dmentioning

confidence: 99%