Chapter 127 - renovascular disease endovascular treatment

Question 1

Three clinical trials on renal artery stenosis and endovascular treatment

Answer 1

ASTRAL: angioplasty and stenting for renal artery lesions (Europe) STAR: atherosclerotic ostial stenosis of renal artery (Europe) CORAL: Cardiovascular outcomes in renal atherosclerotic lesion (NA)

Question 2

ASTRAL key point

Answer 2

1) prophylactic or drive by revascularization has no benefit

Question 3

CORAL key points

Answer 3

1) no clinical benefit of widespread application of revascularization 2) no prognostic value of any secondary analysis yielded results

Question 4

Guidelines for revascularization

Answer 4

1) presence of hemodynamic significant renal stenosis 2) with difficult-to-control HTN 3) +/- renal dysfunction 4) +/- HTN associated cardiac disturbance syndrome

Question 5

Cardiac disturbance syndrome

Answer 5

1) flash pulmonary edema 2) HTN encephalopathy 3) MI 4) AKI

Question 6

Contraindication to treat renovascular disease with endo

Answer 6

1) Anatomic reasons 2) open more optimal 3) prophylactic treatment only

Question 7

Natural history of atherosclerotic renal artery stenosis

Answer 7

Anatomic progression 10-30% Occlusion 0-7%

Question 8

Definition of treatment success for RAS with endo

Answer 8

1) < 30% residual stenosis 2) < 10 mmHg persistent systolic gradient 3) 20% change of eGFR

Question 9

Technical success rate, mortality and complication of RA PTAS

Answer 9

Tech success 88-100% Mortality 0-5% Complication 0-43% CORAL had better tech success 95%; no mortality and complication < 5%

Question 10

Most common complication for RA-PTAS according to CORAL

Answer 10

dissection

Question 11

Hypertension response in ASTRAL

Answer 11

No significant improvement in SBP between endo and med Modest decrease in DBP Decrease in number of antihypertensive meds

Question 12

Hypertensive response in CORAL

Answer 12

small significant decrease in SBP but no change in med use

Question 13

Predictor of hypertension response after stenting

Answer 13

1) duration of preoperative HTN 2) age 3) percent angiographic stenosis 4) bilateral disease 5) female gender 6) preoperative BNP (debatable)

Question 14

renal function response in ASTRAL

Answer 14

Lower rates of renal function decline in medical arm

Question 15

Predictors of renal function response to PTAS

Answer 15

1) bilateral disease 2) elevated Cr at baseline 3) worse CKD 4) rapid preop decline in renal function 5) impaired left ventricular function 6) no metabolic syndrome 7) smaller prevascularization renal parenchymal volume 8) improved renal volume after revasc

Question 16

Rates of restenosis after RA-PTAS

Answer 16

5-66% More common in women Less common with statins

Question 17

2, 3 and 5 year survival after RA-PTAS

Answer 17

2 year - 80% 3 year - 74% 5 year - 58% Worse in baseline renal dysfunction and bilateral disease

Question 18

Renal protection against contrast

Answer 18

1) hydration other poor evidence: 2) N-acetylcysteine 3) sodium bicarbonate 4) ascorbic acid

Question 19

Meds to be held for elective RA-PTAS

Answer 19

1) NSAID 2) diuretics 3) metformin 4) warfarin

Question 20

Benefit of performing staged bilateral RA-PTAS

Answer 20

1) minimize damage from contrast

Question 21

Selective catheters different types

Answer 21

FIGURE 127.5

Question 22

RESIST trial

Answer 22

Randomized comparison of safety and efficacy of renal stenting Improvement with embolic protection device use when in combined with glycoprotein IIb/IIIa inhibitor abciximab

Question 23

Recurrent stenosis duplex criteria

Answer 23

> 180 cm/s

Question 24

Management of retroperitoneal/perinephric hematoma

Answer 24

Endovascular embolization Open surgical repair