Year : 2005 | Volume
: 6 | Issue : 2 | Page : 57--62
Bilateral renal artery stenting at Queen Alia heart institute: A review of 15 cases
Hatem Salaheen Abbadi
King Hussein Medical Center, Queen Alia Heart Institute, Amman, Jordan
Hatem Salaheen Abbadi
King Hussein Medical Center, Queen Alia Heart Institute, Amman
Objective: To review the clinical pattern and associated features in 15 cases of bilateral renal artery stenosis who underwent bilateral renal artery setting at the Queen Alia Heart Institute in Jordan.
Methods: Between January 2000 and December 2004, a total of 15 patients were found to have significant bilateral renal artery stenosis on routine renal angiogram during cardiac catheterization for coronary or valve diseases. These 15 patients underwent bilateral renal artery stenting. Their medical records were retrieved and clinical and laboratory data were reviewed. Unilateral renal cases were excluded. Data parameters were age, risk factors, clinical presentation, kidney function test, lipid profile, severity of coronary artery disease, left ventricular dysfunction, use of angiotensin converting enzyme inhibitors, and associated atheromatous vascular diseases.
Results: The mean age was 64.4 years, two thirds were male, 80% had hypertension, and 46% had diabetes mellitus. 86% had significant coronary artery disease (13 patients), six of whom underwent coronary artery bypass surgery. Two patients had creatinine level of > 2 mg/dl, the rest were normal. As to clinical presentation, 6 presented with myocardial infarction, 6 angina, and 3 presented with pulmonary edema. Bilateral renal artery stenting was performed in all 15 patients with 93% success rate. One patient died during surgery.
Conclusion: Bilateral renal artery stenosis is commonly associated with coronary artery disease. In such clinical setting, patients usually present with cardiac symptoms and minimal derangement of kidney function. Bilateral renal artery stenting can be done safely in such patients. Bilateral renal artery stenting would decrease the progression to ischemic nephropathy and improve cardiac symptoms like pulmonary edema, angina, and allow use of angiotensin converting enzyme inhibitors safely in addition to undergoing cardiac surgery with no or minimal renal complications.
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Abbadi HS. Bilateral renal artery stenting at Queen Alia heart institute: A review of 15 cases.Heart Views 2005;6:57-62
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Abbadi HS. Bilateral renal artery stenting at Queen Alia heart institute: A review of 15 cases. Heart Views [serial online] 2005 [cited 2023 Mar 21 ];6:57-62
Available from: https://www.heartviews.org/text.asp?2005/6/2/57/64011
In recent years, studies have appeared using screening aortography of the abdominal aorta and peripheral vasculature as part of the angiographic study of the coronary arteries , . Results of these studies indicate that atherosclerotic vascular disease in the coronary and peripheral vascular beds is commonly associated with renal artery disease. A recent series identified stenosis of more than 50% of the lumen in 19% of hypertensive individuals during coronary angiography. These lesions exceeded 70% stenosis in 7% of subjects and were occasionally bilateral  . Given its prevalence in the elderly population, and its propensity for bilateral involvement, atherosclerotic renal artery stenosis (ARAS) has been estimated to be the cause of 10 to 15% of new onset end-stage renal diseases in individuals over 50 years  .
Revascularization is considered when the presence of hemodynamically significant renal artery stenosis (RAS) is judged to be contributing to poorly controlled hypertension or progressive renal impairment. Other less common but equally important clinical indications for RAS revascularization include episodic pulmonary edema  , congestive cardiac failure, and unstable angina  . Hemodynamic significance of the lesion is usually indicated by a stenosis of at least 50% diameter reduction by angiography or the presence of a significant pressure gradient across the lesion (5 mm Hg mean), keeping in mind that functional impact of the stenosis is a continuum, and that the dichotomous definition is inexact. Therefore, the goals of revascularization of RAS are 1) to cure or improve control of hypertension; 2) to preserve or restore renal function; and 3) to treat the physiologic effects of severe RAS, including congestive cardiac failure, recurrent flash pulmonary edema, and angina. One of the manifestation of bilateral RAS may be flash pulmonary edema  , with or without left ventricular systolic dysfunction. The pathogenesis is incompletely understood, but postulated to be related to increased afterload from neurohormonal activation and cytokine release.
Use of endovascular stents has substantially improved the acute technical success rate of angioplasty, in particular for the treatment of ostial RAS  . The success with renal artery stenting has made it a preferred alternative to the surgical approach, and has led to a lower threshold for intervention for ARAS. The challenge remains to identify in advance which patients are likely to benefit from revascularization.
In our study, we reviewed the clinical profile of 15 patients found to have significant bilateral renal artery stenosis and managed by bilateral renal stenting. These patients were discovered by abdominal aortography or renal angiogram during cardiac catheterization.
A total number of 15 patients were found to have significant bilateral renal artery stenosis. These patients were managed by bilateral renal stenting, These cases were selected among all patients who had routine screening aortography during cardiac catheterization, from January 2000 until December 2004 at Queen Alia Heart Institute. Those who had unilateral renal stenting were excluded.
The aim was to look at and review the clinical profile of those patients, and therefore, patient files were reviewed. Parameters analyzed were: age, gender, risk factors, cardiac presentation, laboratory results including serum creatinine level, lipid profile, and associated carotid or peripheral vascular disease. Coronary angiographic finding were reviewed, considering severity of the disease, left ventricular function, and management of coronary artery disease, either by medical, surgical, or interventional treatment. The use of angiotensin converting enzyme inhibitors, and the number of antihypertensive medications were analyzed.
Age of the patients varied from 41 to 84 years, with a mean 64.4 years. There were 6 females and 9 males; 12 had hypertension (80%) and 4 of them had recent high readings. Those who were taking two drugs or more were 5 patients (33%) and 10 patients (60%) were on Angiotensin Converting Enzyme Inhibitors. Diabetes mellitus was present in 46% of our patients and 46% were smokers. Hypercholestolemia was present in 11 patients (73%). History of associated other atherosclerotic disease included: 3 patients with transient ischemic attacks, one of them with history of carotid surgery; another 3 patients had peripheral vascular disease. The cardiac presentation consisted of: myocardial infarction 40% (6 patients), 40% angina, and 3 patients presented with pulmonary edema.
Laboratory results: serum creatinine > 2mg /dl in 2 patients (3.8 and 2.4 mg/dl), hematocrit of less than 35% in 4 patients, total cholesterol > 200mg/dl and low density lipoprotein > 150mg/dl in 73% (11 pateints).
Angiographic finding: 6 patients (40%) had severe three vessel disease, treated by coronary bypass, bilateral renal artery stenting was performed before surgery .and 3 patients had percutaneous coronary intervention. Another 3 patients had mild to moderate coronary artery disease treated with medical therapy. Two patients had normal coronaries, one of them with mild left ventricular impairment, the second with infarction on top of normal coronaries, hence, 86% (13) patients had significant coronary artery disease. Only 4 patients had left ventricular ejection fraction of less than 40%. One female patient had severe aortic stenosis and 3 patients had peripheral vascular disease.
Renal artery stenosis: 53% of renal artery lesions were ostial and average stent size was 5.87 mm, minimum and maximum length was 13mm and 20 mm respectively. Success rate was 93%. In one case, the stent was lost had to be snared, hence, we were satisfied with balloon angioplasty to that renal artery. One patient with low ejection fraction died post-bypass surgery.
Interest in the detection and treatment of RAS is increasing with the growing awareness of the prevalence and implications of this disease. ARAS is increasingly diagnosed in the expanding number of elderly population, who also has a high prevalence of hypertension and other atherosclerotic diseases. It is therefore important to make a distinction between RAS and its two major associated disease processes, namely renovascular hypertension and ischemic nephropathy  . RAS refers to the presence of anatomic narrowing; whereas renovascular hypertension and ischemic nephropathy imply a causative role of this stenosis in the disease processes of hypertension and renal dysfunction. Unfortunately, such a cause and effect relationship is often unclear. Many of the hypertensive patients with RAS also have coexisting essential hypertension. Furthermore, some individuals with RAS remain normotensive. This uncertainty complicates the decision making surrounding revascularization. Similarly, in any given patient with renal insufficiency, it is often difficult to determine to what degree the RAS is responsible for the impairment of renal function  .
Our understanding of renovascular disease has advanced considerably during the last decade. The reasons for this include a greater appreciation of the natural history of both the atherosclerotic and fibromuscular forms of the disease the increasing recognition of athero-embolic disease; the widespread use of percutaneous transluminal angioplasty (PTRA) and the introduction of renal artery stenting  ; the advent of new and more effective techniques for surgical revascularization; and the realization that bilateral renovascular disease is an important and potentially reversible cause of acute and chronic renal failure in the elderly  and of recurrent pulmonary edema , in patients with poorly controlled hypertension and renal insufficiency.
Bilateral renal artery stenosis (or unilateral stenosis in a solitary functioning kidney) should be suspected in patients with acute, severe, or refractory hypertension who also have otherwise unexplained renal insufficiency (plasma creatinine concentration above 1.5 mg/dl or 132΅mol/L) or who have developed an acute decline in renal function following therapy with an angiotensin converting enzyme (ACE) inhibitor or angiotensin II receptor blocker  .
Treatment is indicated both for blood pressure (BP) control and, in some cases, for preservation of renal function. It has been estimated, for example, that as many as 24 percent of patients over the age of 50 who have advanced renal failure have bilateral atherosclerotic disease  . On the other hand, bilateral renovascular disease can be an incidental finding, occurring in patients with little or no hypertension Such patients do not require therapy directed at the renal vasculature , .
Renal artery stenosis is a particularly relevant comorbid condition in cardiological practice, since the risk factors for coronary artery disease and renal artery disease are identical. Consequently both vascular beds are commonly affected by atherosclerosis in the same patient  . Renal artery stenosis causes or aggravates hypertension and/or interferes with its treatment. Renal artery stenosis, therefore, has a negative impact on both primary and secondary prevention of coronary heart disease. In patients undergoing cardiac catheterization, renal artery stenosis is an independent risk factor for mortality and correlates with the severity of the renal artery disease  . Moreover, ischemic renal disease is the most rapidly increasing cause of end stage renal disease in the USA  . Renal failure impairs the outcome of coronary artery bypass grafting and percutaneous coronary interventions.
Because of the interrelation between atherosclerotic renal and coronary artery disease cardiologists are frequently confronted with "cardiorenal" problems. They are not only experts in the conservative treatment of atherosclerosis, but they also have the expertise necessary for interventional treatment of the complications of atherosclerosis. The angioplasty/stent implantation of ostial renal artery lesions can be performed effectively with equipment adapted from coronary artery interventions. Indeed, the largest single centre series on primary renal artery stenting comes from a group of cardiologists  . This team treated 363 renal artery stenoses in 300 patients between 1993 and 1998 with stent implantation. The procedural success rate was 100% without procedural deaths or emergency surgical procedures. The overall restenosis rate during a median follow up of 16 months was 21%, 12% in renal arteries with a diameter of 4.5 mm. These results show that primary renal artery stenting can be performed safely and effectively.
Renal artery stenosis may worsen angina or congestive heart failure in patients with coronary artery disease, left ventricular dysfunction, or cardiomyopathy due to alterations in the rennin-angiotensin-aldosterone axis resulting in a state of volume overload and peripheral vascular constriction ,, . Renal revascularization may result in relief of these cardiac syndromes due to normalization of excess renin production, which reduces sodium and water retention and vasoconstriction caused by aldosterone and angiotensin and causes natriuresis because of improved glomerular filtration. Restoring unobstructed renal blood flow has the additional benefit of allowing safe usage of angiotensin-converting enzyme inhibitors without the risk of worsening renal failure and reducing coronary perfusion. Bilateral renal artery stenosis or stenosis of a solitary functioning kidney are frequently present in a patient with a cardiac syndrome who is likely to receive benefit from percutaneous renal revascularization  . More than 70% of 73 patients with cardiac disturbance syndromes with this vascular profile who were treated with percutaneous angioplasty and stent placement were free of congestive heart failure and unstable angina at 12-month mean follow-up. Additional benefits in this patient group also frequently include improvement of hypertension control and renal function ,, .
What is the clinical significance of detecting renal artery lesions when they are otherwise unsuspected? This question has been the subject of controversy in recent nephrologic and cardiovascular debates, particularly since the introduction of endovascular stents. Some authors argue that a substantial number of patients reaching end-stage renal failure have no other apparent explanation and that unsuspected "ischemic nephropathy" may account for 14% to 20% of patients undergoing dialysis 4. Some argue, therefore, that "open renal arteries are better than closed renal arteries  and that stenoses should be subjected to arterial repair routinely, usually with endovascular stents. Conversely, others argue that RAS is commonly an incidental "bystander" with little effect on renal function  . Follow-up studies of incidentally identified lesions managed without revascularization identify remarkably few cases of progression to advanced renal failure  . Recognition that interventional procedures in patients in atherosclerotic disease sometimes pose risks and can worsen both renal function and hypertension control intensifies the debate.
In one prospective study, serial duplex Doppler ultrasonography was performed on 295 kidneys in 170 patients with atherosclerotic renal artery stenosis, almost all of whom were on antihypertensive therapy  . The cumulative incidence of progression at three years was 28 percent among arteries with an initial stenosis that was less than 60 percent and 49 percent among arteries with more than 60 percent stenosis at entry. Complete occlusion occurred in nine renal arteries (3 percent), seven of which were initially classified as having > 60 percent stenosis, so many RAS lesions are thereby identified long before they pose a hemodynamic constraint to blood flow or renal perfusion.
Nearly all reports of improved cardiac status after renal revascularization have been confined to patients with tight stenoses of both renal arteries, unilateral occlusion with tight contralateral stenosis, or tight stenosis to a single functioning kidney  . The benefits of renal revascularisation in patients with cardiorenal failure and renovascular disease are more consistently cardiac than renal  . Failure of revascularization to lower serum creatinine concentration in renovascular disease must reflect other mechanisms in the pathophysiology of renal failure, particularly hypertensive nephrosclerosis (intrarenal artery stenosis) and atheroembolic renal disease  . In one study, the pattern of atherosclerotic involvement at presentation was of prognostic importance  . Patients with bilateral renovascular disease in whom one artery was totally occluded appeared to be at greatest risk. Among those patients who survived two years, more than 50 percent with initial unilateral occlusion had progressed to end-stage renal disease as compared to only 18 percent of those with bilateral renal artery stenosis without occlusion. Watson et al  prospectively studied the effect of renal artery stenting on renal function and size in thirty three patients with chronic renal insufficiency and bilateral renal artery stenosis or unilateral stenosis in the presence of a solitary or single functional. Before stent deployment, all patients had evidence of progressive renal insufficiency. After stent deployment, renal function improved in 18 and slowed in 7 patients. Ultrasonography revealed preservation of renal size. Harden et al  studied 33 patients with atherosclerotic RAS undergoing renal stenting. Renal function improved or stabilized in 69% of patients.
Runback  evaluated the effect of renal artery stenting in 45 patients with renal impairment (creatinine Ž or =1.5 mg/dl) and atheromatous renal artery stenosis untreatable by, or recurrent after, balloon angioplasty. Stent implantation was unilateral in 32 cases and bilateral in 11 cases. With use of life-table analysis, clinical benefit was seen in 78% of patients at 6 months (n = 36), 72% at 1 year (n = 24). In patients with clinical benefit, average creatinine concentration was reduced from 2.21 mg/dL +/- 0.91 before treatment to 2.05 mg/dL +/- 105 after treatment. Lower initial serum creatinine concentration was associated with a better chance of clinical benefit. Another study described the use of renal artery stents in the solitary functioning kidney of 21 patients with impaired renal function as a result of atherosclerotic RAS. At follow-up (range, 6-25 months), renal function had returned to normal in five patients (24%), improved in four patients (19%), stabilized in six patients (29%), and deteriorated in six patients (29%). Dialysis was discontinued in all four dialysis patients.
Based on available evidence, the following patient groups appear most likely to derive benefit from revascularization: 1) dialysis-dependent renal failure with RAS and salvageable kidneys; 2) global renal ischemia from bilateral RAS or unilateral RAS supplying single functioning kidney and progressive renal failure; 3) bilateral RAS with recurrent flash pulmonary edema, with preserved or only mildly impaired systolic and diastolic ventricular function; and 4) bilateral RAS in patients with hypertension that is difficult to control.
Bilateral renal artery stenosis is associated with severe coronary artery disease. It can be discovered incidentally. The challenge for cardiologists is to identify patients with cardiorenal failure, and in particular those who will benefit from revascularization in order to improve cardiac problems like angina, heart failure, and decrease medical and surgical complications.
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