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Arterial stenting and balloon angioplasty in ostial atherosclerotic renovascular disease

2016-03-30 / Categories:arterial, hemostasis,
  
Atherosclerotic renal-artery stenosis is associated with hypertension and progressive loss of renal function. Despite antihypertensive therapy, atherosclerotic stenosis tends to progress, leading to renal ischaemia and loss of renal mass.

1 Ischaemic nephropathy may be one of the most important causes of terminal renal failure in the elderly.

2 Restoration of vessel patency reduces the need for antihypertensive medication

3,4 and may slow the progression of renal failure.

5,6 Atherosclerotic stenosis located in the truncus of the renal artery can be successfully treated by standard percutaneous transluminal angioplasty (PTA) in most patients.3,7 Ostial stenosis is less easy to treat, although the rate of acute failure varies between 9% and 76%7–13 and rates of late retenosis vary between 25% and 45%.10,12,14 Angioplasty with balloon-expandable stent placement (PTAS) is more successful, with an acute failure rate of only 0–4% and secondary restenosis rate of 3–39%.5,15–19 Whether this technique also has greater clinical benefit is less clear. Angioplasty cures or ameliorates hypertension in 23–90% of patients and is followed by stable or improved renal function in 54–96% of patients,10,12,13 compared with 39–78% and 71–100%, respectively, for intra-arterial stent placement.5,15–19 Patency and clinical results of primary PTAS and primary PTA have not been compared in a randomised trial. Stent placement is more expensive, and may involve more intra-arterial manipulation and complications. Therefore, a logical treatment policy would be to try PTA first, and apply stents only after primary failure of PTA or after secondary restenosis. Whether this policy is better than primary stent placement depends on the number of patients who need secondary stenting. We undertook a randomised comparison of PTA and PTAS for the treatment of atherosclerotic ostial renal-artery stenosis. We studied whether PTAS has better primary success than PTA, whether there is less restenosis after PTAS during 6 months of follow-up, and whether improved radiographic results are associated with better clinical results. We also compared the two strategies in terms of efficacy and clinical outcomes.

Methods

Between December, 1993, and March, 1997, we recruited patients referred to Utrecht University Hospital who had confirmed ostial atherosclerotic renal-artery stenosis or patients in whom this disorder was diagnosed during angiography for suspected renal-artery stenosis. Ostial atherosclerotic renal-artery stenosis was defined as a reduction of 50% or more in luminal diameter within the first 10 mm of the aortic lumen, in association with atherosclerotic changes of the abdominal aorta.20 Patients were included only if they were hypertensive (blood pressure >160/95 mm Hg with or without medication), and if the stenosis was shown to affect renal function by positive captopril renography21 or by an increase of 20% or more in plasma creatinine concentration during standardised use of an angiotensin-converting-enzyme (ACE) inhibitor.22 Exclusion criteria were: a history of cholesterol embolism; a pole-to-pole distance of the affected kidney of 8 cm or less on ultrasonography plus 25% renal function or less in renography; or a renal tumour. Informed consent was obtained, and the study was approved by the hospital’s ethics committee.