Endovascular management of atherosclerotic renovascular disease: Early results following primary intervention
Presented at the Thirty-second Annual Meeting of the Southern Association for Vascular Surgery, Naples, Fla, Jan 18, 2008.
Received 16 January 2008; accepted 16 April 2008.
Objective
This retrospective review examines periprocedural morbidity and early functional responses to primary renal artery angioplasty and stenting (RA-PTAS) for patients with atherosclerotic renovascular disease (RVD).
Methods
Consecutive patients undergoing primary RA-PTAS for hemodynamically significant atherosclerotic RVD with hypertension and/or ischemic nephropathy were identified from a prospectively maintained registry. Hypertension responses were determined based on pre- and post-intervention blood pressure measurements and medication requirements. Estimated glomerular filtration rate (eGFR) was used to determine renal function responses. Both hypertension and renal function responses were assessed at least three weeks after RA-PTAS. Stepwise multivariable regression analysis was used to examine associations between blood pressure and renal function responses to RA-PTAS and select clinical variables.
Results
One-hundred ten primary RA-PTAS were performed on 99 patients with atherosclerotic RVD with a mean angiographic diameter-reducing stenosis of 79.2 ± 12.9%. All patients had hypertension (mean of 3.4 ± 1.3 antihypertensive agents). Mean pre-intervention eGFR was 49.9 ± 22.7 mL/min/1.73 m2, and 74 patients had a pre-intervention eGFR < 60 mL/min/1.73 m2. The technical success rate for RA-PTAS was 94.5%. The periprocedural complication rate was 5.5%; there were no periprocedural deaths. Statistically significant decreases in mean systolic blood pressure (161.3 ± 25.2 vs. 148.5 ± 25.2 post-intervention, P < .0001), diastolic blood pressure (78.6 ± 13.3 versus 72.5 ± 13.5 post-intervention, P < .0001), and number of antihypertensive agents (3.3 ± 1.2 versus 3.1± 1.3 post-intervention, P = .009) were observed. Assessed categorically, hypertension response to RA-PTAS was cured in 1.1%, improved in 20.5%, and unchanged in 78.4%. Categorical eGFR response to RA-PTAS was improved in 27.7%, unchanged in 65.1%, and worsened in 7.2%. Multivariable stepwise regression revealed associations between pre- and post-intervention systolic blood pressure (P < .0001), diastolic blood pressure (P < .0001), and eGFR (P < .0001), as well as a trend toward improved diastolic blood pressure response among patients managed with staged bilateral intervention (P = .0589).
Conclusion
Primary RA-PTAS for atherosclerotic RVD was associated with low peri-procedural morbidity and mortality but only modest early improvements in blood pressure and renal function. Results from ongoing prospective trials are needed to assess the long term outcomes associated with RA-PTAS and clarify its role in the management of atherosclerotic RVD.
aDivision of Surgical Sciences, Section on Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
bDepartment of Biostatistical Sciences, Wake Forest University School of Medicine, Winston-Salem, NC
Reprint requests to: Kimberley J. Hansen, MD, Wake Forest University School of Medicine, Section on Vascular and Endovascular Surgery, Department of General Surgery, Medical Center Boulevard, Winston-Salem, NC 27157-1095
ABSTRACT