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

Abstract

Percutaneous transluminal angioplasty (PTA) has received widespread publicity 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 complicated 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.

Clinical predictors of improved long-term blood pressure control after successful stenting of hypertensive patients with obstructive renal artery atherosclerosis

“…The technical success of ostial lesions using balloon angioplasty is frequently unsatisfactory, ranging from only 30% to 60%, resulting in poor clinical blood pressure response [26,27]. These poor results have led to the general consensus that patients with ostial disease are poor angioplasty candidates and should be considered for surgical revascularization [28]. We were able to restore patency after stent placement in all ostial lesions, achieving similar peak-to-peak transstent gradients irrespective of lesion location.…”

Treatment of Ostial Renal-Artery Stenoses with Vascular Endoprostheses after Unsuccessful Balloon Angioplasty

“…[14][15][16] Therefore, this type of renovascular disease is commonly treated by primary surgical intervention. 13,17 To overcome the problem of elastic recoil after angioplasty, recent reports recommend different types of intravascular stents for the treatment of nonostial renal-artery stenoses. [18][19][20][21][22][23][24][25] Few data are available on the use of intravascular stents for the critical ostial lesions.…”

Reversal of acute renal failure by kidney revascularisation

“…The acute occlusion may be secondary to thrombus apposition on an irregular plaque, intra-plaque haemorrhage (sudden progression of the stenosis) 12 or iatrogenic trauma after balloon angioplasty (plaque dissection). 19 Other possible causes are surgically induced hypotension 12,14 that creates low flow across the stenosis and favours in situ thrombosis, typically in an immediate postoperative setting characterised by a thrombogenic state or acute intrarenal hypotension with decreased renal blood flow due to angiotensin converting-enzyme inhibitors. 20,21 Extensive aortic thrombosis is another rare cause of acute bilateral renal artery occlusion.…”

“…2,7 In such cases there is a contributary irreversible nephro-sclerotic parenchymal damage secondary to longstanding hypertension or to microembolic disease. Percutaneous transluminal angioplasty has little role in the salvage of ischaemic kidneys, because of its bad results in cases of total occlusion or severe ostial stenosis 2,15,19 and its inherent risk of contrast-induced nephropathy. However Pattison et al 10 obtained remarkable results (10 of 13 patients with acute renal failure could be weaned off dialysis after angioplasty).…”