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Title: Impact of stent-assisted angioplasty of atherosclerotic renal artery stenosis on renal function and blood pressure
Abstract:
The primary aim of this work was to identify characteristics of patients who benefit from renal artery revascularization in contrast to those for whom the balance of benefits and risks would not justify interventional treatment. A detailed analysis of the effects of RAS revascularization on kidney function, blood pressure and cardiovascular outcomes was performed, taking into account a range of demographic, procedural, angiographic, ultrasonographic and clinical factors. One primary focus was the search for predictors of improvement. Moreover, search for restenosis factors and restenosis symptoms was performed. The PhD dissertation includes a series of three related publications. Two hundred and twenty-nine patients aged 65.3 (20 to 85) years (51.5% men) were enrolled, including 211 patients with a significant atherosclerotic renal artery stenosis (ARAS) and 18 patients with RAS associated with another etiology (fibromuscular dysplasia - FMD, vasculitis or trauma). Revascularization (using, in all cases, the endovascular route) was performed by means of stent-assisted angioplasty between 2003 and 2017. The average follow-up period was 53 months (range 1 to 163 months). The follow-up visits included clinical interview and examination, renal arteries DUS, blood pressure measurements, verification of hypotensive medications and blood sampling for serum creatinine concentration to ; estimate GFR. On the basis of investigations series reported in the dissertation, the following conclusions were drawn: 1. Stent-assisted renal artery angioplasty is a highly effective and mostly safe method of RAS management, with technical success 99.2% and incidence of serious periprocedural complications 2.84%, including in-hospital mortality 0.47%. This is despite the high-risk patient profile including documented significant CAD (69.2%), multilevel atherosclerosis (47.4%) and renal dysfunction (eGFR <60 ml / min / 1.73 m2 in 61.6%). 2. Successful PTA is associated with a significant reduction in systolic (12 mmHg on average) and diastolic (5 mmHg on average) blood pressure and an improvement in renal function (average eGFR increase by 4 ml / min / 1.73 m2). 3. Renal function improvement (defined as eGFR increase > 11 ml / min / 1.73 m2) predictors are baseline kidney dysfunction (creatinine concentration > 117 μmol / L) but with an eGFR value exceeding 30 ml / min / 1.73 m2, low resistive index both in the renal artery and intra-renaly (RI <0.77 and IRI <0.68), as well as index kidney length > 98 mm; while history of poor blood pressure control with documented multidrug regimen of at least 4 antihypertensive drugs reduces the chances of eGFR improvement. 4. Blood pressure reduction predictors are high blood pressure values prior to revascularization (> 145 mm Hg for s ; ystolic and > 80 mmHg for diastolic blood pressure despite maximized medical treatment), stenosis of the single functioning kidney (for DBP improvement), history of myocardial infarction (for SBP improvement), while documented history of ARAS progression reduces the chances of SBP improvement after PTA. 5. Long-term MACCE affects a large proportion (1 in 3) patients, most likely as a result of the baseline risk burden. Independent predictors of MACCE identified in the present work are the following: male gender, multivessel CAD, hyperlipidemia and concomitant atherosclerosis in the contralateral renal artery. CVD predictors include male gender, history of any previous revascularization or atherosclerotic lesions > 50% in at least 2 additional arterial territories, history of hypertensive crisis and concomitant atherosclerosis in the contralateral renal artery. 6. Improvement of outcome after PTA for RAS, manifested as a reduction of long-term MACCE (by 46%) and in CVD (by 58%) is associated with an increase in eGFR exceeding 11 ml / min / 1.73 m2; this can be achieved in a significant proportion (ie, one in every four) patients. Decrease in SBP by 20 mmHg or DBP by 5 mmHg 12 months after PTA is associated with a 90% reduction in the risk of ischemic stroke and can be achieved in, respectively, 46% and 35% of the successfully revascularized patients. 7. Restenosis rate is 14 ; % and it is highly dependent on the etiology of RAS. In particular, in fibromuscular dysplasia patients the restenosis is practically absent, in patients with atherosclerosis patients the restenosis rate is 17% and in patients with inflammatory etiology it reaches 60%. 8. Independent predictors of restenosis are the following: inflammatory etiology of RAS, hyperlipidemia, small diameter of treated renal artery, and diabetes. The symptoms of stenosis recurrence are lack of decrease or an increase in blood pressure and lack of improvement (or worsening) kidney function. 9. Restenosis can be successfully (and safely) treated with repeated angioplasty, regarding subsequent stenosis recurrence in 1/5 patients. TO SUMMARIZE: our investigation provide characteristics of potential responders to RAS revascularization and define the group of patients who most likely benefit in relation with improvement of renal function, blood pressure and cardiovascular outcome as well as long term patency of revascularized renal artery.
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Rada Dyscypliny Nauki medyczne
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Last modified:
Apr 8, 2024
In our library since:
Feb 9, 2022
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http://dl.cm-uj.krakow.pl:8080/publication/4509
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| Edition name | Date |
|---|---|
| ZB-132968 | Apr 8, 2024 |
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