Prediction of Hypertension Improvement After Stenting of Renal Artery Stenosis

Leesar, Massoud A.; Varma, Jai; Shapira, Adam; Fahsah, Ibrahim; Raza, Seyed T.; Elghoul, Ziad; Leonard, Anthony; Meganathan, Karthikeyan; Ikram, Sohail

doi:10.1016/j.jacc.2009.03.031

Cited by 128 publications

(6 citation statements)

References 28 publications

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“…In addition, none of the patients with a targeted arterial stenosis < 75% showed any benefit on revascularization in the present study. These results are consistent with the finding that a RAS greater than 70%–80% is necessary to activate intra-renal RAS [23], although identification of haemodynamic significance by anatomical stenotic severity is limited [11,27–29].…”

Section: Discussionsupporting

confidence: 89%

Effects of percutaneous angioplasty on kidney function and blood pressure in patients with atherosclerotic renal artery stenosis

Kim

Jeon

et al. 2019

Kidney Res Clin Pract.

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Background Previous randomized controlled trials of revascularization for atherosclerotic renal artery stenosis (ARAS) were not successful. We investigated the effects of percutaneous transluminal angioplasty with stent insertion (PTA/S) on kidney function and blood pressure (BP) control in patients with ARAS. Methods From 2000 to 2017, 47 subjects who underwent PTA/S for ARAS were identified. A high-risk group was defined, composed of patients having one or more of the following clinical presentations: pulmonary edema, refractory hypertension, and rapid deterioration of kidney function. Subjects who met the criteria of ‘kidney function improvement’ or ‘hypertension improvement’ after PTA/S were classified as responders. Results Twenty-one (44.7%) subjects were classified into the high-risk group. Two subjects (8.0%) in the low-risk group (n = 25) and 5 subjects (27.8%) in the high-risk group (n = 18) showed improvement in kidney function after PTA/S ( P = 0.110). In patients with rapid decline of kidney function, estimated glomerular filtration rate improved from 28 (interquartile range [IQR], 10–45) mL/min/1.73 m 2 to 41 (IQR, 16–67) mL/min/1.73 m 2 at 4 months after PTA/S, although the difference was not significant ( P = 0.084). Regarding BP control, 9 (36.0%) and 14 (77.8%) subjects showed improvement after PTA/S in the low- (n = 25) and high-risk (n = 18) groups, respectively ( P = 0.007). In patients with refractory hypertension, the systolic BP dropped from 157 (IQR, 150–164) mmHg to 140 (IQR, 131–148) mmHg at 4 months after PTA/S ( P = 0.005). Twenty-five subjects were defined as responders and comprised a significant proportion of the high-risk group ( P = 0.004). Conclusion PTA/S might improve BP control and kidney function in patients with ARAS presenting with high-risk clinical features. The optimal application of PTA/S should be based on individual assessment of the clinical significance of renal artery stenosis.

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Section: Discussionsupporting

confidence: 89%

Effects of percutaneous angioplasty on kidney function and blood pressure in patients with atherosclerotic renal artery stenosis

Kim

Jeon

et al. 2019

Kidney Res Clin Pract.

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“…This hypothesis is supported by the fact that pulse pressure, a surrogate marker of large artery stiffness [36], and albuminuria, considered a marker of widespread vascular damage [37] in the hypertensive population, are among the parameters associated with worse BP outcome. Recently Leeser and collegues demonstrated that evaluation of translesional pressure gradients allows a satisfying BP improvement prediction [38]. Thus it is conceivable that also local factors such as the entity of the stenosis, play a major role in BP response to revascularization.…”

Section: Discussionmentioning

confidence: 99%

Predictive role of renal resistive index for clinical outcome after revascularization in hypertensive patients with atherosclerotic renal artery stenosis: a monocentric observational study

Bruno

Daghini

Versari

et al. 2014

Cardiovasc Ultrasound

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BackgroundThe present study evaluated the predictive value of renal resistive index (RI) for renal function and blood pressure (BP) outcome in hypertensive patients with unilateral atherosclerotic renal artery stenosis submitted to successful revascularization.MethodsIn 158 hypertensive patients with atherosclerotic renal artery stenosis RI was acquired. Twelve months after revascularization, they were classified on the basis of renal function and BP outcome as benefit (BP < 140/90 mmHg or diastolic BP reduction > 15 mmHg with the same of reduced drugs; decrease in glomerular filtration rate > 20%), or failure.ResultsRegarding renal function outcome, RI in the stenotic and in the contralateral kidney were significantly higher in patients with failure (n = 20) than in those with benefit (0.72 ± 0.11 vs 0.61 ± 0.11 and 0.76 ± 0.08 vs 0.66 ± 0.09, p < 0.05). Among different cutpoints generated, RI in the contralateral kidney >0.73 provided the largest area under the curve (0.77), and the highest sensitivity (80%) and specificity (72%). In the multivariate logistic regression analysis, RI in the contralateral kidney >0.73 was an independent predictor of a failure in renal function outcome.Regarding BP outcome, patients with no benefit from revascularization (n = 60) had similar RI in the stenotic and contralateral kidney (p = ns), but presented higher pulse pressure, albuminuria and hypertension duration in comparison to patients with improved BP control.ConclusionsRI in the contralateral kidney is an independent predictor of renal function outcome after successful revascularization in hypertensive patients with unilateral atherosclerotic renal artery stenosis, whereas it is not able to predict blood pressure outcome.

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“…Intrarenal papaverine is commonly used for eliciting maximal renal hyperemia. Although renal FFR threshold still remains controversial regarding the clinical benefit of revascularization in a patient with renovascular hypertension [ 8 , 9 ], Leesar MA et al showed that a hyperemic systolic gradient ≥21 mmHg is the predictor of hypertension improvement after stenting of renal artery stenosis [ 10 ]. Kapoor N et al suggested that a hyperemic systolic gradient ≥21 mmHg or a renal FFR of 0.90 can be considered a hemodynamically significant stenosis, and resting systolic gradient would underestimate the significance of stenosis [ 11 ].…”

Section: Discussionmentioning

confidence: 99%

Endovascular treatment of transplant renal artery stenosis based on hemodynamic assessment using a pressure wire: a case report

Kadoya

Zen

Matoba

2018

BMC Cardiovasc Disord

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BackgroundTransplant renal artery stenosis (TRAS) is a serious complication after renal transplantation, leading to hypertension, deterioration in renal function, and/or graft loss. The incidence of TRAS reportedly varies from 1 to 23%, depending on its definition or diagnostic tools. The hemodynamic definition or therapeutic indication of TRAS is unclear.Case presentationA 66-year-old man with a history of diabetes, chronic kidney disease, and angina presented with a 2-week history of dyspnea and leg edema. He had undergone living-donor kidney transplantation for end-stage renal disease secondary to diabetic nephropathy 7 years earlier. He developed acute deterioration in renal function after the administration of an angiotensin II receptor blocker and required emergency hospitalization owing to acute congestive heart failure with pulmonary edema. A vasodilator and loop diuretics were administered following his admission, and the patient’s symptoms resolved quickly. Further investigation, including magnetic resonance angiography and ultrasonography, revealed severe stenosis of the transplant renal artery. Renal arteriography and pressure gradient measurement using a 0.014-inch pressure wire were performed. The systolic pressure gradient was 40 mmHg, and the resting Pd/Pa ratio (ratio of mean distal to lesion and mean proximal pressures) was 0.90 without hyperemia. Hemodynamically significant stenosis was suspected. Intravascular ultrasonography revealed vessel shrinkage in the stenotic area, suggestive of the end-to-end anastomosis site. Pre-dilation using a 4-mm balloon, implantation of a 6-mm self-expandable stent, and post-dilatation using a 5-mm balloon were performed. Although the moderate stenosis persisted angiographically, the systolic pressure gradient dropped to 20 mmHg with the mean systolic pressure ratio increased to 0.95, which was considered an acceptable result. One month after the procedure, the patient’s renal function and blood pressure control had significantly improved.ConclusionsHemodynamic assessment using a pressure wire is useful in determining the appropriate therapeutic indication and endpoint of endovascular treatment of TRAS.

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Prediction of Hypertension Improvement After Stenting of Renal Artery Stenosis

Abstract: An HSG >or=21 mm Hg provided the highest accuracy in predicting hypertension improvement after stenting of RAS, suggesting that an HSG >or=21 mm Hg is indicative of significant RAS.

Cited by 128 publications

References 28 publications

Effects of percutaneous angioplasty on kidney function and blood pressure in patients with atherosclerotic renal artery stenosis

Effects of percutaneous angioplasty on kidney function and blood pressure in patients with atherosclerotic renal artery stenosis

Predictive role of renal resistive index for clinical outcome after revascularization in hypertensive patients with atherosclerotic renal artery stenosis: a monocentric observational study

Endovascular treatment of transplant renal artery stenosis based on hemodynamic assessment using a pressure wire: a case report

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