Invasive treatment for renovascular disease. A twenty year experience from a population based registry.
ABSTRACT To analyze time trends in invasive treatment of renovascular disease in one country.
Data have been analyzed from registrations in the Swedish Vascular Registry.
Invasive treatment for renovascular disease contributes around 1% of all vascular surgery within the Swedish Vascular Registry. Over the twenty-year period 1987-2006 the population-based frequency of invasive treatment for renovascular disease has increased; 1 597 procedures have been registered with an increase over time. The age of the treated patients has increased over the period (P<0.001). There has been a shift from open to endovascular procedure and from isolated percutaneous transluminal renal angioplasty (PTRA) to PTRA combined with a stent. Complications and mortality are significantly higher in patients undergoing open reconstruction (P<0.01). One year follow-up is incomplete and long-term results are therefore not possible to evaluate through registry-data only.
Using nation-wide registry data it is possible to analyze time-trends also concerning rare diseases or interventions. The changing pattern toward endovascular treatment of renovascular disease is obvious. Follow-up data at one year are incomplete.
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ABSTRACT: Occlusion of the renal arteries can threaten the viability of the kidney when severe, in addition to accelerating hypertension and circulatory congestion. Renal artery stenting procedures have evolved from a treatment mainly for renovascular hypertension to a maneuver capable of recovering threatened renal function in patients with 'ischemic nephropathy' and improving management of congestive heart failure. Improved catheter design and techniques have reduced, but not eliminated, hazards associated with renovascular stenting. Expanded use of endovascular stent grafts to treat abdominal aortic aneurysms has introduced a new indication for renal artery stenting to protect the renal circulation when grafts cross the origins of the renal arteries. Although controversial, prospective randomized trials to evaluate the added benefit of revascularization to current medical therapy for atherosclerotic renal artery stenosis until now have failed to identify major benefits regarding either renal function or blood pressure control. These studies have been limited by selection bias and have been harshly criticized. While studies of tissue oxygenation using blood-oxygen-level-dependent (BOLD) magnetic resonance establish that kidneys can adapt to reduced blood flow to some degree, more severe occlusive disease leads to cortical hypoxia associated with microvascular rarefaction inflammatory injury, and fibrosis. Current research is directed toward identifying pathways of irreversible kidney injury due to vascular occlusion and to increase the potential for renal repair after restoring renal artery patency. The role of nephrologists likely will focus upon recognizing the limits of renal adaptation to vascular disease and identifying kidneys truly at risk for ischemic injury at a time point when renal revascularization can still be of benefit to recovering kidney function.Kidney International advance online publication, 14 November 2012; doi:10.1038/ki.2012.363.Kidney International 11/2012; · 8.52 Impact Factor
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ABSTRACT: The management of renal artery stenosis (RAS) remains controversial. While some evidence suggests that treatment with stent placement is beneficial, randomized trials have failed to demonstrate a significant benefit. Ongoing clinical trials should help to better define the role for stenting of RAS while avoiding limitations seen with earlier trials. When it comes to stenting for RAS, several stents have been used; however, many stents which have been used previously and which are still being used are biliary stents that are used "off-label." These stents have typically come onto the market through the 510(k) pathway. To date, a total of five stents have been approved by the United States Food and Drug Administration for use in the renal arteries. Of the five stents that have received approval, the Bridge™ Extra Support (Medtronic Cardio- Vascular, Santa Rosa, CA) and the Palmaz(®) (Cordis Corporation, Bridgewater, NJ) stents are no longer available. Currently, the Express(®) SD (Boston Scientific, Natick, MA), Formula™ (Cook Medical, Bloomington, IN), and Herculink Elite(®) (Abbott Vascular, Santa Clara, CA) stents are Food and Drug Administration approved and available for use. The Herculink Elite is the most recently approved of the renal stents, having received approval in late 2011. The Herculink Elite stent is the only cobalt chromium stent approved for use in the renal arteries. Although trial data are limited and direct comparisons among renal stents is not possible, the Herculink Elite stent has demonstrated good performance. Additionally, the design of the Herculink Elite offers some advantages that may translate into improved outcomes.Medical Devices: Evidence and Research 01/2012; 5:67-73.
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ABSTRACT: With an aging population, more patients might be treated for atherosclerotic renal artery stenosis (ARAS). The goal of this treatment is to achieve a dialysis-free life or a well-controlled blood pressure with reduced risks of cardiovascular complications. To analyze the clinical outcome of percutaneous transluminal renal artery angioplasty without stenting (PTRA) or with stenting (PTRS) for ARAS at one center. The study group comprised 152 patients who underwent 203 PTRA/PTRS. All had hypertension, and 45% had azotemia. A retrospective collection of baseline and postprocedural number of antihypertensive drugs, blood pressure, and serum creatinine were analyzed during a follow-up of 3-18 months. Technical success rate was 95%, and clinical benefit was seen in 63% of patients. Complications included a 30-day mortality rate of 1.5%, a total complication rate of 35%, and major adverse events in 13%. The major adverse events were highly related to azotemia. Major adverse events within 30 days, with permanent disability, were seen in 5% and almost exclusively in patients with moderate or severe renal impairment. A subgroup analysis of 28 patients with renal duplex resistive index (RI) pre-PTRA/S and 6 months' follow-up showed a benefit of PTRA/PTRS in 17 (68%) of the 25 patients with RI <80 and in all three (100%) of the patients with RI >or=80. Endovascular treatment of ARAS has an excellent technical success rate, with a clinical improvement rate of >60%. However, it is associated with a considerable complication rate. Serious complications are seen mainly in azotemic patients. Predictors of clinical response could not be identified. Renal duplex RI is questioned as a predictor of clinical outcome.Acta Radiologica 02/2009; 50(3):256-64. · 1.33 Impact Factor