Failed percutaneous transluminal renal angioplasty: Experience with lesions requiring operative intervention

Abstract

Percutaneous transluminal angioplasty (PTA) has received widespread pubficity as a safe, simple, and successful alternative to operation for the management of renal artery stenoses and renovascular hypertension (RVH). Although, in our institution, the primary management of RVH remains operative revascularization, with more than 750 such procedures having been done, we have had the opportunity to manage a spectrum of PTA failures in nine patients during the last 5 years. These include (1) acute dissection of atherosclerotic lesions and occlusion of the distal renal artery requiring emergency operation; (2) unilateral perforation and bilateral thrombosis of fibrodysplastic branch renal artery lesions requiring staged ex vivo reconstruction; (3) cholesterol embolization and recurrence to total occlusion of orificial atherosclerotic lesions with loss of excretory renal function; (4) chronic dissection from repeated "temporarily successful" PTAs of medial fibrodysplastic lesions; and (5) rapid recurrence and acceleration of hypertension in a 17-year-old girl with congenital renal artery stenoses. In each instance operation was compfieated by an intense perivascular inflammatory response from the previous PTA and required a more complex reconstruction than would have been needed originally. These sequelae argue for moderating enthusiasm for the use of PTA and for limiting its routine use to nonorificial atherosclerotic lesions and fibrodysplastic lesions restricted to the main renal artery. Orificial atherosclerotic lesions, branch fibrodysplastic lesions, and congenital stenoses have a high probability of failure, complications, or both when treated by PTA and should be considered for primary operative intervention.

Surgery after failed percutaneous renal artery angioplasty

“…Since this initial report, three additional groups have described the surgical management of 75 patients after F-PTRA. Dean et al 7 described perivascular inflammation in each of nine cases. The complexity of reconstruction was considered to be affected by F-PTRA in five of 12 procedures.…”

“…Early surgical reports that describe significant perivascular inflammation and fibrosis after F-PTRA contrast with reports from the same time period that attribute minimal perivascular changes to F-PTRA. [6][7][8][9] Consequently, we have reviewed our experiences with secondary surgical intervention after F-PTRA in 51 patients (32 with atherosclerosis, 19 with fibromuscular dysplasia [FMD]) who underwent treatment at our institution during the past 11.5 years. Specific areas of interest included the influence of F-PTRA on the methods of secondary surgical repair, blood pressure and excretory renal function response to operation, and follow-up dialysis-free survival rates.…”

Infected renal artery pseudoaneurysm and mycotic aortic aneurysm after percutaneous transluminal renal artery angioplasty and stent placement in a patient with a solitary kidney

“…[6][7][8][9] The procedure has application for carefully selected atherosclerotic lesions and medial fibrodysplasia involving the main renal artery. 10 More recently, reports of successful percutaneous management of renal artery occlusions 11 and ostial lesions with renal artery stents have appeared in the literature. 12 Complications related to metallic stenting after angioplasty in the renovascular bed have been reported, but they usually involve atheroembolism, occlusion, hemorrhage, or deployment difficulties.…”

Successful management of a resistant renal artery stenosis in a child using a 4 mm cutting balloon catheter

“…The technical results of PTRA in adults range from 47% to 90% [1,8,10,24,25]. Ostial arteriosclerotic stenosis show disappointing success rates from 24% to 35%.…”