Atheroembolism during percutaneous renal artery revascularization
Presented at the Annual Meeting of the Southern Association for Vascular Surgery, Rio Del Mar Hotel and Spa, Puerto Rico, Jan 17-20, 2007.
Received 15 January 2006; accepted 16 March 2007.
Introduction
Atheroembolization during renal artery angioplasty and stenting (RA-PTAS) has been postulated as a cause for the inferior renal function results observed when compared with those with surgical revascularization. To further characterize procedure-associated atheroembolism, we analyzed recovered atheroembolic debris and clinical data from patients undergoing RA-PTAS with distal embolic protection (DEP).
Methods
RA-PTAS procedures were performed with DEP using a commercially available temporary balloon occlusion and aspiration catheter system between July 2005 and December 2006. Following RA-PTAS but prior to deflation of the distal occlusion balloon, the static column of blood proximal to the balloon was aspirated and submitted for embolic particle analysis. Angiograms, demographics, and laboratory data were reviewed. Glomerular filtration rate (eGFR) was estimated before RA-PTAS and at 4 to 8 weeks postintervention using the abbreviated Modification of Diet in Renal Disease formula. Associations between clinical factors, captured particle counts, and changes in renal function were examined using univariate techniques and multiple linear regression.
Results
Twenty-eight RA-PTAS procedures were performed with DEP. Mean total number of embolic particles counted per procedure was 2033 ± 1553 for particles 20-60 μm and 265 ± 132 for particles >60 μm. Significant positive associations with quantity of captured particles 20 to 60 μm were observed for African American race (P = .002), predilation (P = .005), and stent diameter (P < .001); a significant negative association was observed for preoperative aspirin use (P =.016). Quantity of captured particles >60 μm was positively associated with ratio of stent to renal artery diameter (P =.009). Change in eGFR was positively associated with preoperative aspirin use (P = .006) and preoperative eGFR (P < .001), while a negative association was observed for captured particle counts >60 μm (P = .015).
Conclusion
These results demonstrate the liberation of thousands of atheroembolic particles during RA-PTAS. Clinical, anatomic, and device-related factors may be predictive of procedural embolization, and increasing captured particle counts >60 μm were associated with inferior renal function results. Further investigation is warranted to establish relationships between atheroembolism, end organ functional impairment, and clinical responses.
aDivision of Surgical Sciences, Section on Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
bDepartment of Biostatistical Sciences at the Wake Forest University School of Medicine, Winston-Salem, NC
cVeterans Affairs Medical Center and Department of Surgery, Division of Vascular Surgery, at the University of California, San Francisco, Calif.
Correspondence: Matthew S. Edwards, MD, FACS, Wake Forest University School of Medicine, General Surgery, Medical Center Boulevard, Winston-Salem, NC 27157-1095.
Dr Edwards is supported by the American Vascular Association and Lifeline Foundation Research Career Development Award and Grant 1K23HL083981-01 from the National Heart, Lung, and Blood Institute of the National Institutes of Health.
ABSTRACT