Percutaneous transluminal angioplasty of renal artery fibromuscular dysplasia: mid-term results.

OBJECTIVE: To evaluate mid-term imaging, clinical follow-up, and restenosis rates from patients that had undergone percutaneous transluminal renal artery angioplasty (PTRA) for symptomatic renal artery fibromuscular dysplasia (FMD). MATERIALS AND METHODS: Between March 1999 and July 2006, 16 consecutive renal artery FMD patients underwent PTRA for poorly controlled hypertension. The patients were enrolled into this retrospective study after receiving 19 primary and four secondary PTRAs in 19 renal artery segments. Follow-up monitoring of blood pressure, use of antihypertensive medication, and the serum creatinine level after PTRA were assessed at 1, 3, 6, 9, 12 months, and each following year. The degree of restenosis was evaluated with computed tomographic angiography (CTA) after PTRA at 6, 12 months, and every year if possible. Technical and clinical success rates for the treatment of FMD, and restenosis rates for the renal artery were evaluated. RESULTS: The technical success rate for primary PTRA was 79% (15/19) and the complication rate was 16% (3/19). Hypertension improved in 80% (12/15) of the patients after four weeks follow-up, and was finally cured or improved in 93% (14/15) during the mean follow-up period of 23.6 months. There was a cumulative 22% (4/18) restenosis rate during the follow-up period. All of the patients were treated with a second PTRA without complications and all of the patients were cured of hypertension after the second PTRA. CONCLUSION: Percutaneous transluminal renal artery angioplasty for clinically symptomatic renal FMD is technically and clinically successful and safe to perform. For all patients with restenosis, there was a good response after undergoing a second PTRA.     

Focal renal artery stenosis caused by fibromuscular dysplasia: treatment by percutaneous transluminal angioplasty

We performed percutaneous transluminal angioplasty of the renal artery in five hypertensive patients with focal renal artery stenoses caused by fibromuscular dysplasia. In four patients, the hypertension decreased or resolved. In all patients, the stenoses displayed considerable resistance to dilatation, requiring maximum inflation of the angioplasty balloon with 10 atm of pressure (10.1 x 10(5) Pa). In two patients, the stenoses were extremely firm with a persistent waist noted in the maximally inflated balloon. One of these patients was left with a residual 40-50% stenosis after initial angioplasty, and a second attempt at dilatation after restenosis was also unsuccessful. This patient's blood pressure did not improve. When the results of our experience in these five patients were combined with 22 cases reported in the literature, we found that 23 (85%) of the 27 patients with focal renal artery stenoses caused by fibromuscular dysplasia had a decrease in blood pressure after percutaneous dilatation. Percutaneous transluminal angioplasty is an effective treatment for patients with renovascular hypertension caused by focal renal artery stenoses resulting from fibromuscular dysplasia.     

Intimal fibromuscular dysplasia and Takayasu arteritis: delayed response to percutaneous transluminal renal angioplasty

Percutaneous transluminal renal angioplasty has been shown to be an effective technique to dilate renal artery lesions, particularly those due to fibromuscular dysplasia. However, four of 70 patients in this study experienced atypical responses to angioplasty. Their lesions initially resisted dilation and had incomplete dilatation immediately after angioplasty. Long-term follow-up (1 week to 2 years) angiograms, however, demonstrated fully dilated arteries. In cases of focal nonatherosclerotic lesions from intimal or adventitial fibroplasia, initial incomplete dilatation may be satisfactory in the long term whereas repeated inflations may result in undesirable complications.     

Intimal dissection following percutaneous transluminal carotid angioplasty for fibromuscular dysplasia

Summary Fibromuscular dysplasia (FMD) is an unusual form of segmental arteriopathy and may affect the internal carotid artery (ICA). We report a case of carotid FMD in which percutaneous transluminal angioplasty (PTA) was complicated by an intimal tear and required surgical exploration. PTA is a useful form of treatment, but there is a risk of intimal dissection. If this occurs, it may be necessary to excise the intimal flap surgically.     

Complications after percutaneous transluminal angioplasty of peripheral and renal arteries

This review deals with complications after percutaneous transluminal angioplasty (PTA). First some methodologic points are discussed. It seems important to standardize the way in which complications are reported. Our own complications in peripheral and renal PTA are summarized and taken as a basis for an analysis of various types of complications. Principally these may occur at different levels: at the puncture site, at the dilatation site as well as distant and general complications. To make comparisons with surgical series relevant it is suggested that all complications and mortality within 30 days are reported.     

Percutaneous transluminal angioplasty of fibromuscular dysplasia of the internal carotid artery

Percutaneous transluminal angioplasty via the common femoral artery was performed in a 32-year-old woman with neurologic symptoms secondary to stenosis of the left internal carotid artery due to fibromuscular dysplasia. Good anatomic results after dilatation and gradual normalization of the neurologic symptoms show that this technique can be used for the treatment of nonarteriosclerotic stenosis of the internal carotid artery.     

Side branch occlusion complicating percutaneous transluminal coronary angioplasty

A frequent concern during angioplasty is the possibility of occluding important side branches that originate in arterial stenoses subjected to balloon dilatation. The effect of dilatation on 93 side branches (greater than or equal to 1 mm in diameter) was evaluated in 86 patients undergoing percutaneous transluminal coronary angioplasty (PTCA) in whom those branches arose directly in dilated segments of the left anterior descending, circumflex, or right coronary arteries. Seventy-six of the 93 side branches had minor (less than 50%) narrowing at their origin. Among these side branches, nine (12%) were compromised by PTCA. Seventeen of the 93 side branches had greater than 50% ostial stenosis. Significantly more of these side branches (seven of seventeen, or 41%) were compromised by PTCA (P less than .01). Even when compromise does occur, it usually takes the form of increased stenosis rather than total occlusion. The presence of side branches originating in stenotic lesions is not a contraindication to PTCA since serious compromise of such branches rarely results from this procedure.     

Early and late results of percutaneous transluminal angioplasty of renal artery stenoses

The initial and long-term results of percutaneous transluminal angioplasty of renal artery stenoses are reported. In 4 out of 73 (5.5%) patients the angioplasty catheter could not be placed in the stenotic area. In 67 patients partial or complete dilatation of the segments treated was possible. Complications requiring therapy occurred in 12.3%. Most (80.3%) of the patients were discharged from hospital with completely corrected or improved hypertension. Cure or improvement was noted more often in patients with fibromuscular dysplasia, short history of hypertension, pathologic renin quotient, normal total hippuric acid clearance, or age under 40 years. On follow-up examination a mean of over 14 months after angioplasty 51.7% of the patients had normal blood pressure or less pronounced hypertension, while in 60.9% the total hippuric acid clearance had increased.     

Percutaneous transluminal angioplasty: the treatment of choice for renovascular hypertension due to fibromuscular dysplasia

Twenty-three renal artery stenoses in 21 hypertensive patients, caused by fibromuscular dysplasia, were treated with percutaneous transluminal angioplasty (PTA). Follow-up over a period of 1 to 30 months, including angiography, renal vein renin assay, and radionuclide flow studies, was performed in 8 patients, each with one stenosis. Dilatation was initially successful in all cases and was successfully repeated in 1 case. The mean systolic pressure decreased by 61.81 mm Hg and the mean diastolic pressure by 36.28 mm Hg in response to treatment. Thirteen patients were cured, 8 were felt to have better control of blood pressure on medication, and there was no failures. This study demonstrates that PTA is a clinically effective method of treating renovascular hypertension due to fibromuscular dysplasia.     

Rotational angiography of the femoropopliteal arteries after percutaneous transluminal angioplasty: technical aspects and preliminary results

PURPOSE: The angiographic evaluation of the results of femoropopliteal balloon angioplasty (PTA) is fundamental for monitoring long term success, but, often, the examination is performed only with one or two orthogonal projections. The aim of this study is to report our experience with a new digital angiography system able to perform "rotational" acquisitions to assess the results after femoro-popliteal PTA. MATERIALS AND METHODS: Twenty-eight patients underwent femoro-popliteal PTA due to steno-obstructive lesions varying in length between 1 and 10 cm. All examinations were performed on a Philips Integris Allura system able to perform "rotational angiography"(RA). The two frames showing the greatest degree of stenosis and the presence of subintimal "flaps" induced by PTA were compared with the frame obtained in the AP projection. RESULTS: RA after PTA was possible in all cases. In 12/28 (42.4%) cases there was no difference between the static AP projection and RA, whereas in 13/28 (46.5%) the static acquisition, compared with RA, underestimated the extent of residual stenosis by 10-30%. In 6 out of these 13 cases a discordance on the presence and extent of subintimal flap between static and rotational acquisition was identified. In three other cases (10.7%) there was substantial agreement on the residual stenosis but not on the PTA-induced dissection which was always better visible on RA. CONCLUSIONS: RA allowed optimal analyses of all cases improving the information of the conventional technique based on one projection only. It also proved very useful in demonstrating residual stenosis and PTA-induced dissections. In our experience this information modified our therapeutic approach leading to repeated balloon angioplasty or stenting in about 50% of cases.     

Femoral, popliteal, and tibial arteries: percutaneous transluminal angioplasty

We attempted percutaneous transluminal angioplasty in 70 patients with obliterative atherosclerosis of the femoral, popliteal, and tibial arteries. Patients with limb threatening ischemia (rest pain, nonhealing ulcer, or gangrene) or lifestyle-limiting claudication were acceptable candidates. Stenoses less than 4 cm long or occlusions less than 10 cm long and less than 2 years old were considered favorable for angioplasty, but less desirable lesions were accepted for limb salvage. Patients with increased surgical risk, inadequate saphenous veins, poor runoff, or in whom temporizing was necessary or desirable, were offered angioplasty for revascularization as an alternative to surgical reconstruction. Technical success was achieved in 62 (88%) of 70 patients with five early failures for an overall initial success rate of 57 (81%) of 70. Complete relief of clinical symptoms was achieved in 53 patients (92%) and 54 had improved lower limb perfusion when measured noninvasively. Patency rate at 1 year was 89% +/- 5% and in 2 years 84% +/- 6% by life table analysis. Major complications occurred in eight (11.4%) of 70 procedures. We conclude that angioplasty of femoral, popliteal, and tibial vessels is an effective and safe alternative to traditional surgical bypass grafting for revascularization of the ischemic lower extremity. Early patency rates are comparable to saphenous vein grafts and considerably better than prosthetic reconstruction.     

Delayed rupture of renal artery after renal percutaneous transluminal angioplasty

Two cases are reported in which rupture of the renal artery occurred many hours after renal percutaneous transluminal angioplasty. Delayed rupture can be recognized by the angiographic appearance and by the presence of persistent flank pain. The typical angiographic finding is a poorly defined zone of contrast medium at the site of perforation.     

Outpatient percutaneous transluminal renal artery angioplasty: a Canadian experience

PURPOSE: The authors performed a retrospective study of their experience and complication rate while performing outpatient percutaneous transluminal renal artery angioplasty (PTRA) during a 5-year period. MATERIALS AND METHODS: From July 1992 to July 1997, 87 PTRAs were performed. Of these, 62 PTRA procedures were performed on 53 outpatients. In total, 66 arteries were dilated in 62 PTRA sessions using standard, established techniques. During the same period, only 25 PTRAs were performed on inpatients. Angioplasties were performed on those patients with demonstrated renal artery stenosis and poorly controlled hypertension and/or renal failure. Patients chosen for PTRA were picked by a team that included a vascular surgeon, a nephrologist, and a radiologist. Patients who were deemed suitable for an outpatient procedure were recommended by a nephrologist. Radiological input was sought at that time. Specific guidelines were used to select these patients who were otherwise healthy, well-orientated, and able to respond to an emergency situation. None of the subjects had significant risk factors. All were accompanied by an adult for the first 24 hours and all lived no more than an hour's travel time from a hospital. All were stable on discharge and were seen within 24 hours by a nephrologist. RESULTS: The technical success rate, defined as a residual stenosis on imaging of less than 30% and/or by a pressure gradient of less than 10 mm Hg across the stenosis, was 85%. The early complication rate was 5.6%, including two patients who developed a localized hematoma. In all, four patients were admitted to the hospital rather than being discharged to home after an average of 4.2 hours of observation. The late complication rate was 3% and involved two patients. One patient, who reported pain after balloon deflation, was readmitted 6 hours after discharge with hypotension, and a diagnosis of renal artery rupture was confirmed with computed tomography. Another patient developed peripheral atheroemboli 20 days after the procedure. CONCLUSION: Outpatient PTRA can be performed on selected patients. In this study, late complications occurred in only 3% of patients. Early complications were readily recognized in 5.6% of patients, and these patients were admitted for observation after the procedure.     

Transient hypertension after percutaneous transluminal renal artery angioplasty

A retrospective analysis of 128 technically successful percutaneous transluminal renal angioplasty (PTRA) procedures was performed. After the procedures, transient systemic hypertension (TSH) developed in 39 patients. The phenomenon usually occurred within 30 minutes of balloon dilation and always within 2 hours of PTRA. TSH lasted less than 5 hours in 35 patients and never persisted for more than 24 hours. TSH is a self-limiting process and should not be confused with the more sustained hypertension that arises from a complication of balloon angioplasty.     

Percutaneous transluminal renal angioplasty: initial and long-term results

Renal artery stenosis in 201 patients with hypertension was treated with percutaneous transluminal renal angioplasty (PTRA). A total of 213 procedures were performed as treatment of 262 separate stenosis. The stenosis was caused by atherosclerosis in 134 cases and by fibromuscular dysplasia (FMD) in 52 cases; the cause was indeterminate in 27 cases. Of the 213 procedures, 172 were successful or resulted in improvement, for a technical success rate of 80.8%. The initial clinical results could be evaluated in 210 cases; cure or improvement was achieved in 80%. There were 23 cases in which neither technical nor clinical success was achieved. Data on the remaining 187 cases were the basis of this long-term follow-up study. The cumulative patency rate at 5 years was 80% in the atherosclerosis group, 89% in the FMD group, and 74% in the indeterminate group. The mortality was less than 1%. Because spasm occurred in 33 cases, causing an infarction in ten instances, antispasmodic medication seems warranted. These long-term results indicate that PTRA is the treatment of choice in patients with renovascular hypertension.     

Percutaneous transluminal angioplasty of the infrapopliteal arteries: results in 53 patients

Recent reports suggest that percutaneous transluminal angioplasty is a satisfactory alternative to surgical treatment of occlusion of the infrapopliteal arteries. To evaluate further the merits of percutaneous angioplasty of these vessels, we retrospectively analyzed the results of 57 procedures in 53 patients. Seventy-six infrapopliteal arteries were dilated: 26 anterior tibial arteries, 10 posterior tibial arteries, 18 peroneal arteries, and 22 tibioperoneal trunks. Thirty-three (62%) of the patients had concomitant angioplasties of the femoropopliteal arteries or vein grafts. There were three major complications (one death due to cardiac arrest 5 hr after the procedure and two puncture-site hematomas requiring surgery). Twenty minor complications did not affect clinical course. In the first 14 procedures (25%), tapered catheters were used, and technical success occurred in only four (29%). In the succeeding 43 procedures (75%), Gruentzig balloon catheters and low-profile balloons were used, and technical success occurred in 37 procedures (86%). Prompt clinical improvement was seen in 32 (80%) of 40 technically successful procedures. Prompt clinical improvement occurred in 28 (97%) of 29 procedures in which angioplasty restored straight-line flow to the foot (i.e., nonobstructed blood flow in at least one calf vessel that is narrowed by no more than 75% of its diameter). When such flow was not restored, clinical improvement occurred in only four (36%) of 11 cases (p less than .001). These results show that with current technology, infrapopliteal artery angioplasty is an effective and safe procedure. The greatest benefit is achieved when straight-line blood flow to the foot is restored.     

Percutaneous transluminal angioplasty of the renal arteries: double- catheter technique

A technique is described for angioplasty of the renal arteries using two catheters in a patient with two renal arteries to the left kidney. Injury to the nonstenotic supplemental artery during balloon dilatation of the stenotic main artery was avoided with the use of this technique.