Print this pageThe Management of Renal Artery Atherosclerosis for Renal Salvage: Does Stenting Help?
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Vikram S. Kashyap, M.D., Ricardo N. Sepulveda, M.D., Joseph Nally, M.D., Roy K. Greenberg, M.D., Kenneth Ouriel, M.D..
The Cleveland Clinic Foundation, Cleveland, OH, USA.
Objective: The use of endovascular techniques to treat renal artery stenosis (RAS) has increased in recent years, but remains controversial. The purpose of this study was to review the outcomes and durability of percutaneous transluminal angioplasty (PTA) and stenting (S) for patients with RAS and decreasing renal function.
Methods: Between 1999 and 2004, 126 consecutive patients underwent angiography and intervention for renal salvage and formed the basis of this study. Inclusion criteria for this study included: serum creatinine (Cr) > 1.5 mg/dL, ischemic nephropathy, and high-grade RAS perfusing a single functioning kidney. Patients undergoing PTA/S for renovascular hypertension, fibromuscular dysplasia, or in conjunction with endovascular stent-grafting for aneurysm repair were excluded. Original angiographic imaging was evaluated for lesion grade and parenchymal kidney size. All medical records and non-invasive testing were reviewed. Pre- and post-operative patient data were standardized and analyzed using Fisher’s exact test for nominal values and t-test for continuous variables. The MDRD equation was used to estimate glomerular filtration rate (GFR).
Results: Preoperative variables included the presence of diabetes (45%), smoking (52%), and hypercholesterolemia (74%). RAS was suspected based on preoperative Duplex imaging or MRA. Aortography and PTA/S was performed in 126 patients (mean age 71, 59% male) with a baseline Cr of 2.3 mg/dL. Use of non-nephrotoxic contrast agents for aortography including gadolinium and CO2 was routine with limited amounts of visipaque for completion renal arteriography. Distal protection was utilized in patients with a single functioning kidney. Estimated GFR mildly improved from 32.9 ml/min to 38.7 ml/min at 6 months (P = .037). Renal function did not deteriorate over long-term follow-up (GFR 37.2 ml/min, mean 20 months, P = .065 vs preoperative values). Ten patients required reintervention for in-stent restenosis.
Conclusions: Renal artery stenoses causing renal dysfunction can be treated via endovascular means. In-stent restenoses can be treated with repeat PTA. Renal function improves at 6 months post-procedure, but long-term renal salvage is unknown. Prospective studies in this area are warranted.