Renal artery stenosis, defined as a narrowing
|
|
- Alvin Hardy
- 6 years ago
- Views:
Transcription
1 IN THE LITERATURE Is There Any Reason to Stent Atherosclerotic Renal Artery Stenosis? Commentary on ASTRAL Investigators. Revascularization versus medical therapy for renal artery stenosis. N Engl J Med. 2009;361(20): Renal artery stenosis, defined as a narrowing of one or both renal arteries or their branches, 1 most commonly is caused by atherosclerosis. The incidence of clinically evident atherosclerotic renal artery stenosis in the Medicare population is 0.5% overall and 5.5% in those with chronic kidney disease. 2 Because patients often are asymptomatic, the true incidence undoubtedly is higher, with one populationbased study of older individuals in North Carolina showing a prevalence of 7%. 3 Although renal artery stenosis is relatively common, the prevalence of hypertension or decreased kidney function caused by renal artery stenosis is unknown, 4,5 and 10% to 15% of patients with atherosclerotic renal artery stenosis develop intractable hypertension or progressive loss of kidney function. 6-8 Although renal artery lesions tend to progress, this may occur in the absence of worsening of hypertension or kidney function, and complete occlusion of renal arteries is uncommon. 6,9 Coronary artery disease, cerebrovascular disease, and peripheral vascular disease are common in patients with atherosclerotic renal artery stenosis. 2 Patients with renal artery stenosis also have worse outcomes from cardiovascular disease. In unselected patients who underwent renal arteriography at the time of cardiac catheterization, the incidence of subsequent adverse cardiovascular events was much higher in those with renal artery stenosis, and there was a direct correlation between stenosis severity and survival. 5 Decreased glomerular filtration rate at the time of presentation also adversely affects survival. 10 The explanation for the increased risk of cardiovascular disease in patients with atherosclerotic renal artery stenosis is uncertain, but may result from activation of the renin-angiotensinaldosterone and sympathetic nervous systems, decreased glomerular filtration rate, or concomitant atherosclerosis in other vascular beds Regardless of cause, the relatively poor prognosis of patients with renal artery stenosis provides a compelling reason to determine the most effective therapy to prevent adverse cardiovascular and renal events. However, the nature of this therapy is hotly debated. Specifically, whether angioplasty and stent placement improve outcomes for patients with atherosclerotic renal artery stenosis is not known, and there is no test that reliably identifies patients who will improve after revascularization. WHAT DOES THIS IMPORTANT STUDY SHOW? Conducted in the United Kingdom, Australia, and New Zealand, the ASTRAL (Angioplasty and Stenting for Renal Artery Lesions) trial 27 randomly assigned 806 participants with renal artery stenosis to renal artery stent placement plus medical therapy or medical therapy alone. The primary end point was the mean slope of decrease in reciprocal creatinine level at up to 5 years of follow-up, which correlates with mean rate of glomerular filtration rate decrease. Although the rate of decrease in inverse creatinine in the medical group was nearly double that in the stent group, the rate was much lower than expected in both groups, the difference was not statistically significant (P 0.06; Fig 1), and there was no significant difference in serum creatinine levels between groups at any time during the study or from baseline to study completion. Even if the difference had been significant, it would have had little clinical relevance because total change in kidney function during the course of the study was minimal. Differences in blood pressure, kidney and cardiovascular events, mortality, and subgroup analyses between groups were all similarly unimpressive, even in the highest risk groups, which included patients with Originally published online as doi: /j.ajkd on June 28, Address correspondence to Lance D. Dworkin, MD, Department of Medicine, Alpert Medical School of Brown University, Rhode Island Hospital, 593 Eddy St, Providence, RI ldworkin@lifespan.org 2010 by the National Kidney Foundation, Inc /10/ $36.00/0 doi: /j.ajkd American Journal of Kidney Diseases, Vol 56, No 2 (August), 2010: pp
2 260 Dworkin and Murphy Figure 1. Serum creatinine levels for participants in the ASTRAL (Angioplasty and Stenting for Renal Artery Lesions) trial. Contrary to investigators expectations, kidney function in this population did not deteriorate overall up to 5 years after randomization. Reproduced from ASTRAL Investigators 27 with permission of the Massachusetts Medical Society. global ischemia or impaired or rapidly decreasing kidney function. There also were serious complications associated with the stent procedure, including cholesterol embolism leading to amputations in 3 patients and 2 deaths. The investigators concluded that revascularization was associated with substantial risks but no evidence of a worthwhile clinical benefit. 27 There are several important caveats associated with the ASTRAL trial, and among the most significant is selection bias. Eligibility for the study was subjective in that potential participants were considered for inclusion only if their physician believed that the patient would not definitely benefit from revascularization. Accordingly, although baseline characteristics of the study population appear similar to those often treated clinically with stent placement, they were selected specifically because they were believed to be less likely to benefit from revascularization. The investigators state that this approach was based on the principle of equipoise, which requires uncertainty regarding the relative merits of the treatments being compared. However, in our view, the ethical issue of equipoise is satisfied if the evidence for or against a particular intervention is inconclusive 28,29 and does not have to be considered individually by every investigator for each patient. The approach in the ASTRAL trial might be considered less ethical because it severely limits our ability to draw meaningful conclusions from the data. As a result, participants were subjected to risk with less probability of generating data that are conclusive or, even worse, that support an incorrect result, thereby jeopardizing management of the entire affected population. There are a number of other notable flaws in the ASTRAL trial. Both the method of revascularization and medical therapy regimen were left to local practitioners and consequently were varied and poorly defined. Although it is well known that local investigators routinely overestimate stenosis severity, there was no central core laboratory that reviewed the angiographic studies. Even interpreted locally, 40% of participants included in the study had stenoses of 50%-70%, which may not be hemodynamically significant. The inclusion of many patients with mild stenoses might explain the slower than expected decrease in kidney function. In the group randomly assigned to stent placement, the procedure was attempted in only 83% and was successful in only 79% of patients. Approximately 6% of patients randomly assigned to medical therapy crossed over and underwent revascularization on average within the first 2 years of follow-up. Cross-contamination of the groups by patients treated according to the protocol for the other treatment group further compromised the power of the study. Finally, although hard clinical end points such as mortality and cardiovascular events were examined, the study was not adequately powered to detect differences in these important outcomes. HOW DOES THIS STUDY COMPARE WITH PRIOR STUDIES? Since 1998, five randomized clinical trials have compared percutaneous renal artery revascularization with medical therapy. 7,30-33 Consistent with results in the ASTRAL trial, none have reported a benefit of renal artery angioplasty with or without stent placement. At best, a metaanalysis suggested a small potential blood pressure benefit of questionable clinical relevance 34 ; namely, a decrease in the number of medications needed to control blood pressure. Paradoxically, during this same interval, there has been a consid-
3 In the Literature 261 erable increase in the frequency of renal artery stent procedures. 35 This may reflect the observation that some patients appear to benefit clinically and also because serious method problems in all the previous trials have caused physicians to doubt the validity of their findings. These include imprecise definitions of renal artery stenosis, likely leading to the inclusion of large numbers of unaffected patients; inadequate interventions, such as angioplasty without stent placement; crossovers; and lack of an intensive medical intervention. A review of percutaneous renal artery revascularization in 2006 concluded that The evidence from direct comparisons of interventions is sparse and inadequate to draw robust conclusions. 36 The STAR (Stent Placement and Blood Pressure and Lipid-Lowering for the Prevention of Progression of Renal Dysfunction Caused by Atherosclerotic Ostial Stenosis of the Renal Artery) trial, the largest and most recent of these studies before the ASTRAL trial, included 140 patients with creatinine clearance 80 ml/min and renal artery stenosis 50% who were randomly assigned to stent placement versus medical therapy. 33 The primary end point was a 20% decrease in creatinine clearance, which occurred in 22% of those in the medical treatment group compared with 16% in the stent group 33 (P 0.06). Again, interpretation of even this equivocal result was compromised further because of problems in the design and conduct of the trial; for example, 12 of 64 patients in the stent group had stenosis 50% and did not undergo revascularization. Accordingly, the investigators concluded that the study was inconclusive. WHAT SHOULD CLINICIANS AND RESEARCHERS DO? Up to and including publication of the ASTRAL trial results, data for renal artery revascularization remain insufficient to draw definite conclusions. In this context, there is little justification for widespread screening of at-risk populations for renal artery stenosis or performing interventions in individuals with anatomic stenoses that are clinically stable. The CORAL (Cardiovascular Outcomes With Renal Atherosclerotic Lesions) study is a large, prospective, randomized, multicenter clinical trial that is still ongoing. CORAL will enroll 900 patients and compare the effects of medical therapy plus stent placement with medical therapy alone on a composite end point of important clinical events, including heart attack, heart failure, kidney failure, stroke, and death. CORAL is rigorously determining patient eligibility using imaging core laboratories and centrally managing medical therapy according to current guidelines. At present, referring patients into this or a similar randomized clinical trial makes sense to definitively answer this important question. Absent entry into a clinical trial, it is our opinion that based on present data, revascularization should be reserved for patients with severe ( 70%) renal artery stenosis associated with refractory hypertension or deteriorating kidney function for whom medical therapy has failed. Even in this context, the potential risks and uncertain benefits of revascularization should be clearly discussed with the patient. Medical management also is a reasonable option for even clinically unstable patients until convincing data indicate otherwise. Regardless of whether revascularization is performed, patients with renal artery stenosis require intensive medical therapy, including tight control of blood pressure. This typically will require administration of multiple agents and should include a drug that blocks the renin-angiotensin-aldosterone system. Serum creatinine and potassium levels should be monitored closely when treatment with these agents is initiated and dosages should be titrated in patients with renal artery stenosis because a significant decrease in kidney function or serious hyperkalemia infrequently may occur. Administration of a statin and an antiplatelet agent also is indicated, as are treatment of diabetes and sequelae of chronic kidney disease to current guidelines, if present. Patients treated in this manner can achieve good blood pressure control and be remarkably stable, even in the presence of persistent high-grade stenosis. Lance D. Dworkin, MD Timothy Murphy, MD Alpert Medical School of Brown University Providence, Rhode Island
4 262 ACKNOWLEDGEMENTS Financial Disclosure: Dr Dworkin is an investigator on several industry-funded multicenter clinical trials in the areas of hypertension and cardiovascular disease and receives grant support for his work on these trials. He is the study chair of the CORAL trial, which is funded primarily by the National Heart, Lung and Blood Institute, but also supported by Johnson & Johnson, AstraZeneca, and Pfizer. Dr Murphy is the co-principal investigator of the CORAL trial. REFERENCES 1. Simon G. What is critical renal artery stenosis? Implications for treatment. Am J Hypertens. 2000;13(11): Kalra PA, Guo H, Kausz AT, et al. Atherosclerotic renovascular disease in the United States patients aged 67 years or older: risk factors, revascularization, and prognosis. Kidney Int. 2005;68(1): Hansen KJ, Edwards MS, Craven TE, et al. Prevalence of renovascular disease in the elderly: a population-based study. J Vasc Surg. 2002;36(3): Suresh M, Laboi P, Mamtora H, Kalra PA. Relationship of renal dysfunction to proximal arterial disease severity in atherosclerotic renovascular disease. Nephrol Dial Transplant. 2000;15(5): Conlon PJ, Little MA, Piper K, Mark DB. Severity of renal vascular disease predicts mortality in patients undergoing coronary angiography. Kidney Int. 2001;60(4): Caps MT, Zierler RE, Polissar NL, et al. Risk of atrophy in kidneys with atherosclerotic renal artery stenosis. Kidney Int. 1998;53(3): van Jaarsveld BC, Krijnen P, Pieterman H. et al. The effect of balloon angioplasty on hypertension in atherosclerotic renal-artery stenosis. Dutch Renal Artery Stenosis Intervention Cooperative Study Group. N Engl J Med. 2000;342(14): Chabova V, Schirger A, Stanson AW, McKusick MA, Textor SC. Outcomes of atherosclerotic renal artery stenosis managed without revascularization. Mayo Clin Proc. 2000; 75(5): Zierler RE, Bergelin RO, Isaacson JA, Strandness DE Jr. Natural history of atherosclerotic renal artery stenosis: a prospective study with duplex ultrasonography. J Vasc Surg. 1994;19(2): ; discussion, Dorros G, Jaff M, Mathiak L, et al. Four-year follow-up of Palmaz-Schatz stent revascularization as treatment for atherosclerotic renal artery stenosis. Circulation. 1998;98(7): Wahlander H, Isgaard J, Jennische E, Friberg P. Left ventricular insulin-like growth factor I increases in early renal hypertension. Hypertension. 1992;19(1): Losito A, Fagugli RM, Zampi I. et al. Comparison of target organ damage in renovascular and essential hypertension. Am J Hypertens. 1996;9(11): de Simone G, Devereux RB, Camargo MJ, et al. In vivo left ventricular anatomy in rats with two-kidney, one clip and one-kidney, one clip renovascular hypertension. J Hypertens. 1992;10(8): Gavras H, Lever AF, Brown JJ, Macadam RF, Robertson JI. Acute renal failure, tubular necrosis, and myocardial Dworkin and Murphy infarction induced in the rabbit by intravenous angiotensin II. Lancet. 1971;2(7714): Yamazaki T, Shiojima I, Komuro I, Nagai R, Yazaki Y. Involvement of the renin-angiotensin system in the development of left ventricular hypertrophy and dysfunction. J Hypertens Suppl. 1994;12(10): S Hocher B, George I, Rebstock J, et al. Endothelin system-dependent cardiac remodeling in renovascular hypertension. Hypertension. 1999;33(3): Robertson AL Jr, Khairallah PA. Angiotensin II: rapid localization in nuclei of smooth and cardiac muscle. Science. 1971;172(988): Ehmke H, Faulhaber J, Munter K, Kirchengast M, Wiesner RJ. Chronic ETA receptor blockade attenuates cardiac hypertrophy independently of blood pressure effects in renovascular hypertensive rats. Hypertension. 1999;33(4): Cohen MG, Pascua JA, Garcia-Ben M, et al. A simple prediction rule for significant renal artery stenosis in patients undergoing cardiac catheterization. Am Heart J. 2005;150(6): Roberts JC Jr, Wilkins RH, Moses C. Autopsy studies in atherosclerosis. II. Distribution and severity of atherosclerosis in patients dying with morphologic evidence of atherosclerotic catastrophe. Circulation. 1959;20: Rossi GP, Rossi A, Zanin L. Excess prevalence of extracranial carotid artery lesions in renovascular hypertension. Am J Hypertens. 1992;5(1): Horvath JS, Waugh RC, Tiller DJ, Duggin GG. The detection of renovascular hypertension: a study of 490 patients by renal angiography. Q J Med. 1982;51(202): Iglesias JI, Hamburger RJ, Feldman L, Kaufman JS. The natural history of incidental renal artery stenosis in patients with aortoiliac vascular disease. Am J Med. 2000; 109(8): Uzu T, Inoue T, Fujii T, et al. Prevalence and predictors of renal artery stenosis in patients with myocardial infarction. Am J Kidney Dis. 1997;29(5): Missouris CG, Belli AM, MacGregor GA. Apparent heart failure: a syndrome caused by renal artery stenoses. Heart. 2000;83(2): Korner PI. Cardiovascular hypertrophy and hypertension: causes and consequences. Blood Press Suppl. 1995;2: ASTRAL Investigators. Revascularization versus medical therapy for renal artery stenosis. N Engl J Med. 2009;361(20): Freedman B. Equipoise and the ethics of clinical research. N Engl J Med. 1987;317(3): Freedman B, Glass KC, Weijer C. Placebo orthodoxy in clinical research. II: ethical, legal, and regulatory myths. J Law Med Ethics. 1996;24(3): Weibull H, Bergqvist D, Bergentz SE, Jonsson K, Hulthén L, Manhem P. Percutaneous transluminal renal angioplasty versus surgical reconstruction of atherosclerotic renal artery stenosis: a prospective randomized study. J Vasc Surg. 1993;18(5): ; discussion, van de Ven PJ, Kaatee R, Beutler JJ, et al. Arterial stenting and balloon angioplasty in ostial atherosclerotic
5 In the Literature 263 renovascular disease: a randomised trial. Lancet. 1999; 353(9149): Webster J, Marshall F, Abdalla M, et al. Randomised comparison of percutaneous angioplasty vs continued medical therapy for hypertensive patients with atheromatous renal artery stenosis. Scottish and Newcastle Renal Artery Stenosis Collaborative Group. J Hum Hypertens. 1998; 12(5): Bax L, Woittiez AJ, Kouwenberg HJ, et al. Stent placement in patients with atherosclerotic renal artery stenosis and impaired renal function: a randomized trial. Ann Intern Med. 2009;150(12): , W Nordmann AJ, Woo K, Parkes R, Logan AG. Balloon angioplasty or medical therapy for hypertensive patients with atherosclerotic renal artery stenosis? A meta-analysis of randomized controlled trials. Am J Med. 2003;114(1): Murphy TP, Soares G, Kim M. Increase in utilization of percutaneous renal artery interventions by Medicare beneficiaries, AJR Am J Roentgenol. 2004;183(3): Balk E, Raman G, Chung M, et al. Effectiveness of management strategies for renal artery stenosis: a systematic review. Ann Intern Med. 2006;145(12):
RAS Epidemiology. Renal Artery Stenosis. Pathophysiology of RAS. Disclosure of Potential Conflicts. Background Pathophysiology of RAS.
Renal Artery Stenosis RAS Epidemiology Common Disease Incidence General Population 0.1% Hypertensive Population 4% HTN & Suspected CAD 10-20% Malignant HTN 20-30% Malignant HTN and CKD 30-40% Alexander
More informationRenal Artery Stenosis: Insights from the CORAL Trial
Renal Artery Stenosis: Insights from the CORAL Trial Christopher J. Cooper, M.D., FACC, FACP Dean and Senior Vice President University of Toledo, College of Medicine President, Ohio Chapter ACC State of
More informationAtherosclerotic Renovascular Hypertension : Lessons from Recent Clinical Studies
Review ISSN 1738-5997 (Print) ISSN 2092-9935 (Online) Electrolyte Blood Press 8:87-91, 2010 doi: 10.5049/EBP.2010.8.2.87 Atherosclerotic Renovascular Hypertension : Lessons from Recent Clinical Studies
More informationLife After CORAL: What Did CORAL Prove? David Paul Slovut, MD, PhD Co-director TAVR, Dir of Advanced Intervention
Life After CORAL: What Did CORAL Prove? David Paul Slovut, MD, PhD Co-director TAVR, Dir of Advanced Intervention No Relationships to Disclose The Need for Modern Renal Trials Increased rate of RAS diagnosis
More informationDisclosure of Potential Conflicts. Renal Artery Stenosis. RAS Epidemiology. Road Map. Background. ASDIN 7th Annual Scientific Meeting
Renal Artery Stenosis Disclosure of Potential Conflicts Cytopherx, Inc. R4 Vascular, Inc. Bard Peripheral Vascular Spectranetics, Inc. Alexander S. Yevzlin, MD Associate Professor of Medicine (CHS) ASDIN
More informationEndovascular treatment
210..217 NEPHROLOGY 2010; 15, S210 S217 doi:10.1111/j.1440-1797.2009.01243.x Endovascular treatment Date written: February 2009nep_1243 Final submission: August 2009 Authors: Robert MacGinley, Subramanian
More informationA Closer Look: Renal Artery Stenosis. Renal artery stenosis (RAS) is defined as a TOPICS FROM CHEP. Shawn s stenosis
TOPICS FROM CHEP A Closer Look: Renal Artery Stenosis On behalf of the Canadian Hypertension Education Program (CHEP), Dr. Tobe gives an overview of renal artery stenosis, including the prevalence, screening
More informationEffective Health Care
Number 5 Effective Health Care Comparative Effectiveness of Management Strategies for Renal Artery Stenosis Executive Summary Background Renal artery stenosis (RAS) is defined as the narrowing of the lumen
More informationControversies in the management of the renal artery stenosis
REVIEW ARTICLE Cardiology Journal 2013, Vol. 20, No. 1, pp. 11 16 10.5603/CJ.2013.0003 Copyright 2013 Via Medica ISSN 1897 5593 Controversies in the management of the renal artery stenosis Khalil Kanjwal
More informationCurrent Role of Renal Artery Stenting in Patients with Renal Artery Stenosis
Current Role of Renal Artery Stenting in Patients with Renal Artery Stenosis Young-Guk Ko, M.D. Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea Etiology Fibromuscular
More informationMichael Meuse, M.D. Vascular and Interventional Radiology
Michael Meuse, M.D. Vascular and Interventional Radiology Which patient would likely benefit from renal artery revascularization? Patient A- 60 y/o male with 20 year hx of htn; on 2 drug therapy for 10
More informationRENAL ARTERY PTA. JH PEREGRIN IKEM, Prague
RENAL ARTERY PTA JH PEREGRIN IKEM, Prague PTRA/Stenting PTRA technical success rate > 90 % In some patients helps control hypertension In some patients can improve kidney function Serious complications
More informationRenal artery stenosis is the most common cause of secondary hypertension. Over 90% of renal
General cardiology ARTERIOSCLEROTIC RENAL ARTERY STENOSIS: CONSERVATIVE VERSUS INTERVENTIONAL MANAGEMENT c RENAL Additional references appear on the Heart website Correspondence to: Priv. Doz. Dr C Haller,
More informationRenal Artery Stenting With Embolic Protection
Renal Artery Stenting With Embolic Protection Embolic protection during renal stenting may be beneficial, but new device designs are necessary. BY RAJESH M. DAVE, MD Renal artery stenosis (RAS) is the
More informationAtherosclerotic renal artery stenosis and reconstruction
http://www.kidney-international.org & 2006 International Society of Nephrology mini review Atherosclerotic renal artery stenosis and reconstruction B Krumme 1 and J Donauer 2 1 Deutsche Klinik für Diagnostik,
More informationNatural history and progression of atherosclerotic renal vascular stenosis
204..209 NEPHROLOGY 2010; 15, S204 S209 doi:10.1111/j.1440-1797.2009.01242.x Natural history and progression of atherosclerotic renal vascular stenosis Date written: December 2008nep_1242 Final submission:
More informationRenal Artery Stenting
Renal Artery Stenting J.P. Reilly, MD, FSCAI Ochsner Medical Center Speaker s bureau: Astra Zeneca and Lilly/Diachi Sankyo Prevalence of RAS is high in cath population. Renal artery intervention can help
More informationAtherosclerotic renovascular disease in United States patients. aged 67 years or older: Risk factors, revascularization, and prognosis.
Kidney International, Vol. 8 (2005), pp. 2 01 Atherosclerotic renovascular disease in United States patients aged 7 years or older: Risk factors, revascularization, and prognosis PHILIP A. KALRA, HAIFENG
More informationRevascularization versus Medical Therapy for Renal-Artery Stenosis
The new england journal of medicine original article versus Medical Therapy for Renal-Artery Stenosis The ASTRAL Investigators* Abstract Background Percutaneous revascularization of the renal arteries
More informationRENAL ARTERY STENOSIS. Grand Rounds 10/11/2011
RENAL ARTERY STENOSIS Grand Rounds 10/11/2011 ARAS Prevalence- 0.5% overall population, 5.5% in ckd pts No correlation between ischemic nephropathy and severity of stenosis Increased risk of vascular events-
More informationCase yr old lady; type 2 Diabetes 10 yrs; PVD; hypertension
Does this patient have flash pulmonary oedema? Philip A Kalra Professor of Nephrology, Salford Royal Hospital and University of Manchester, UK 73 yr old lady; type 2 Diabetes 1 yrs; PVD; hypertension Acute
More informationAtherosclerotic renovascular disease
Cardiology 69 Atherosclerotic renal artery stenosis Atherosclerotic renal artery stenosis is largely a disease of the elderly and is commonly associated with hypertension and renal dysfunction. Blood pressure
More informationThe Centers for Medicare & Medicaid Services
Percutaneous Renal Revascularization and Medicare Coverage The Society of Interventional Radiology s position on the current CMS coverage of renal interventions. BY DAVID SACKS, MD, AND TIMOTHY P. MURPHY,
More informationCORAL Trial Aftermath: What Do We Do Now? Renal Revascularization in Perspective
CORAL Trial Aftermath: What Do We Do Now? Renal Revascularization in Perspective Michael R. Jaff, DO Massachusetts General Hospital Boston, Massachusetts, USA Michael R. Jaff, DO Conflicts of Interest
More informationAtherosclerotic Renal Artery Stenosis
Atherosclerotic Renal Artery Stenosis When is open surgical reconstruction the best treatment option? BY THOMAS A. ABBRUZZESE, MD, AND RICHARD P. CAMBRIA, MD Atherosclerotic disease is the most common
More informationVascular Imaging Original Research
MDCT Angiography of Renal Arteries Vascular Imaging Original Research Adam D. Talenfeld 1 Ryan B. Schwope Huntley J. Alper Emil I. Cohen Robert A. Lookstein Talenfeld AD, Schwope RB, Alper HJ, Cohen EI,
More informationArterial stenting and balloon angioplasty in ostial atherosclerotic renovascular disease: a randomised trial
Early reports Arterial stenting and balloon angioplasty in ostial atherosclerotic renovascular disease: a randomised trial Peter J G van de Ven, Robert Kaatee, Jaap J Beutler, Frederick J A Beek, Arend-Jan
More informationCorporate Medical Policy
Corporate Medical Policy Endovascular Therapies for Extracranial Vertebral Artery Disease File Name: Origination: Last CAP Review: Next CAP Review: Last Review: endovascular_therapies_for_extracranial_vertebral_artery_disease
More informationCoral Trials: A personal experience that challenges its results in patients with uncontrolled blood pressure.
Coral Trials: A personal experience that challenges its results in patients with uncontrolled blood pressure.. Dr. Javier Ruiz Aburto, FACS, FICS Assistant Professor Ponce School of Medicine Puerto Rico
More informationOutcome and cost comparison of percutaneous transluminal renal angioplasty, renal arterial stent placement, and renal arterial bypass grafting
Outcome and cost comparison of percutaneous transluminal renal angioplasty, renal arterial stent placement, and renal arterial bypass grafting Xue F Y, Bettmann M A, Langdon D R, Wivell W A Record Status
More informationDelay of dialysis in end-stage renal failure: Prospective study on percutaneous renal artery interventions
Kidney International, Vol. 65 (24), pp. 251 258 CLINICAL NEPHROLOGY EPIDEMIOLOGY CLINICAL TRIALS Delay of dialysis in end-stage renal failure: Prospective study on percutaneous renal artery interventions
More informationRenal artery stenosis
Renal artery stenosis Dr. Alexander Woywodt Consultant Renal Physician, Royal Preston Hospital Preston, 31.10.2007 Menu anatomy of the renal arteries diseases of the large renal arteries atherosclerotic
More informationThe role of percutaneous revascularization for renal artery stenosis
The role of percutaneous revascularization for renal artery stenosis Gregory J Dubel and Timothy P Murphy Abstract: Renal artery stenosis (RAS) is usually caused by atherosclerosis or fibromuscular dysplasia.
More informationPCI for Renal Artery stenosis
PCI for Renal Artery stenosis Why should we treat Renal Artery Stenosis? Natural History of RAS RAS is progressive disease Study Follow-up (months) Pts Progression N (%) Total occlusion Wollenweber Meaney
More informationKEY WORDS: Bilateral Renal Artery Stenosis, Cardiac Catherization, Incidental Findings, Associated Co- morbidity
BILATERAL RENAL ARTERY STENOSIS - AN INCIDENTAL FINDING DURING CARDIAC CATHETERIZATION Review of 15 Cases of BRAS Stenting at Queen Alia Heart Institute in Jordan Hatem Hamdan Salaheen Abbadi 1 ABSTRACT:
More informationChapter 8: Cardiovascular Disease in Patients with ESRD
Chapter 8: Cardiovascular Disease in Patients with ESRD Cardiovascular disease (CVD) is common in adult end-stage renal disease (ESRD) patients, with coronary artery disease (CAD) and heart failure (HF)
More informationAdvances in the treatment of posterior cerebral circulation symptomatic disease
Advances in the treatment of posterior cerebral circulation symptomatic disease Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery Faculty of Medicine, School of Health
More informationORIGINAL ARTICLE. Department of Nephrology, Endocrinology and Metabolic Diseases, Silesian Medical University, Katowice, Poland
ORIGINAL ARTICLE Cardiology Journal 2009, Vol. 16, No. 6, pp. 514 520 Copyright 2009 Via Medica ISSN 1897 5593 Comparison of early and late efficacy of percutaneous transluminal renal angioplasty with
More informationRenal artery stenosis treated with stent deployment: Indications, technique, and outcome for 108 patients
Renal artery stenosis treated with stent deployment: Indications, technique, and outcome for 108 patients Julio A. Rodriguez-Lopez, MD, Alan Werner, MD, Lance I. Ray, MD, Christos Verikokos, MD, Luis J.
More informationMEET /06/2013 SESSION : RENAL AND VISCERAL
MEET 2003 11/06/2013 SESSION : RENAL AND VISCERAL AFTER 35 YEARS, WHAT ARE THE INDICATIONS AND RESULTS OF PTRA IN PATIENTS WITH RI OR RVH? THOMAS SOS, MD NYPH CORNELL New York, NY THOMAS SOS, MD NYPH CORNELL
More informationOverview of Subclavian & Innominate Artery Interventions
TCT 2016 Washington, DC, USA Tuesday November 1st, 2016 Peripheral vascular interventions Overview of Subclavian & Innominate Artery Interventions Dr Jacques Busquet Vascular & Endovascular Surgery Paris,
More informationEvaluation of the Safety and Effectiveness of Renal Artery Stenting After Unsuccessful Balloon Angioplasty The ASPIRE-2 Study
Journal of the American College of Cardiology Vol. 46, No. 5, 2005 2005 by the American College of Cardiology Foundation ISSN 0735-1097/05/$30.00 Published by Elsevier Inc. doi:10.1016/j.jacc.2004.11.073
More informationIncidence and Prevalence of Atherosclerotic Renal Artery Stenosis (RAS) in Patients with Coronary Artery Disease (CAD)
Incidence and Prevalence of Atherosclerotic Renal Artery Stenosis (RAS) in Patients with Coronary Artery Disease (CAD) AHMW Islam, S Munwar, S Talukder, AQM Reza Dept. of Invasive & Interventional Cardiology,
More informationChapter 9: Cardiovascular Disease in Patients With ESRD
Chapter 9: Cardiovascular Disease in Patients With ESRD Cardiovascular disease is common in adult ESRD patients, with atherosclerotic heart disease and congestive heart failure being the most common conditions
More informationImpact of coronary atherosclerotic burden on clinical presentation and prognosis of patients with coronary artery disease
Impact of coronary atherosclerotic burden on clinical presentation and prognosis of patients with coronary artery disease Gjin Ndrepepa, Tomohisa Tada, Massimiliano Fusaro, Lamin King, Martin Hadamitzky,
More informationFibromuscular Dysplasia (FMD) of the renal arteries Angiographic features and therapeutic options
Fibromuscular Dysplasia (FMD) of the renal arteries Angiographic features and therapeutic options Poster No.: C-0630 Congress: ECR 2012 Type: Educational Exhibit Authors: K. I. Ringe, B. Meyer, F. Wacker,
More informationRenal Intervention. Douglas E. Drachman, MD, FSCAI Division of Cardiology Vascular Medicine Section December 9, 2014
Renal Intervention Douglas E. Drachman, MD, FSCAI Division of Cardiology Vascular Medicine Section December 9, 2014 Disclosure Information Douglas E. Drachman, MD, FACC Abbott Vascular, Inc.: Advisory
More informationCoronary Artery Disease: Revascularization (Teacher s Guide)
Stephanie Chan, M.D. Updated 3/15/13 2008-2013, SCVMC (40 minutes) I. Objectives Coronary Artery Disease: Revascularization (Teacher s Guide) To review the evidence on whether percutaneous coronary intervention
More informationLXIV: DRUGS: 4. RAS BLOCKADE
LXIV: DRUGS: 4. RAS BLOCKADE ACE Inhibitors Components of RAS Actions of Angiotensin i II Indications for ACEIs Contraindications RAS blockade in hypertension RAS blockade in CAD RAS blockade in HF Limitations
More informationORIGINAL INVESTIGATION. Carotid and Lower Extremity Arterial Disease in Patients With Renal Artery Atherosclerosis
ORIGINAL INVESTIGATION Carotid and Lower Extremity Arterial Disease in Patients With Renal Artery Atherosclerosis R. Eugene Zierler, MD; Robert O. Bergelin, MS; Nayak L. Polissar, PhD; Kirk W. Beach, PhD,
More informationRenal artery stenosis (RAS) is a widely recognized
The Renal Stenting Downturn Why are we stenting less? By George V. Moukarbel, MD, and Mark W. Burket, MD Renal artery stenosis (RAS) is a widely recognized cause of secondary hypertension, renal dysfunction,
More informationNew Trials in Progress: ACT 1. Jon Matsumura, MD Cannes, France June 28, 2008
New Trials in Progress: ACT 1 Jon Matsumura, MD Cannes, France June 28, 2008 Faculty Disclosure I disclose the following financial relationships: Consultant, CAS training director, and/or research grants
More informationIschemic nephropathy: Detection and therapeutic intervention
Kidney International, Vol. 68, Supplement 99 (2005), pp. S131 S136 Ischemic nephropathy: Detection and therapeutic intervention JOSÉ A. GARCíA-DONAIRE and JOSÉ M. ALCÁZAR Department of Nephrology, Hospital
More informationIndications of Coronary Angiography Dr. Shaheer K. George, M.D Faculty of Medicine, Mansoura University 2014
Indications of Coronary Angiography Dr. Shaheer K. George, M.D Faculty of Medicine, Mansoura University 2014 Indications for cardiac catheterization Before a decision to perform an invasive procedure such
More informationVascular disease. Structural evaluation of vascular disease. Goo-Yeong Cho, MD, PhD Seoul National University Bundang Hospital
Vascular disease. Structural evaluation of vascular disease Goo-Yeong Cho, MD, PhD Seoul National University Bundang Hospital resistance vessels : arteries
More informationCindy L. Grines MD FACC FSCAI
Cindy L. Grines MD FACC FSCAI Hofstra Northwell School of Medicine Chair, Cardiology Academic Chief of Cardiology, Northwell Health North Shore University Hospital, Manhasset NY Multivessel Disease in
More informationSafety of Single- Versus Multi-vessel Angioplasty for Patients with AMI and Multi-vessel CAD
Safety of Single- Versus Multi-vessel Angioplasty for Patients with AMI and Multi-vessel CAD Mun K. Hong, MD Associate Professor of Medicine Director, Cardiovascular Intervention and Research Weill Cornell
More informationRenal Artery Disease. None > 65,000,000. Learning objectives: Renal Artery Disease
Renal Artery Disease Robert D. McBane, M.D. Division of Cardiology Mayo Clinic Rochester Financial Disclosure Information Renal Artery Disease Robert McBane, MD None To appreciate: Learning objectives:
More information(J Exper Med 59: , 1934)
(J Exper Med 59:347-379, 1934) Goldblatt experiments Allowed the discovery of the renin-angiotensinaldosterone system -- Braun-Menendez: 'hypertensin' -- Bumpus: 'angiotonin' Angiotensin Led to surgical/interventional
More informationAsymptomatic celiac and superior mesenteric artery stenoses are more prevalent among patients with unsuspected renal artery stenoses
Asymptomatic celiac and superior mesenteric artery stenoses are more prevalent among patients with unsuspected renal artery stenoses R. James Valentine, MD, John D. Martin, MD, Smart I. Myers, MD, Matthew
More informationDeakin Research Online
Deakin Research Online This is the published version: MacGinley, Rob and Mangos, George 2010, Renal artery stenosis and hypertension: whom and how to screen and treat, Medicine today, vol. 11, no. 2, pp.
More informationRole of interventions for atherosclerotic renal artery stenoses
TRANS-ATLANTIC DEBATE Thomas L. Forbes, MD, and Jean-Baptiste Ricco, MD, PhD, Section Editors Role of interventions for atherosclerotic renal artery stenoses Vikram S. Kashyap, MD, a Fabrice Schneider,
More informationCardiac evaluation for the noncardiac. Nathaen Weitzel MD University of Colorado Denver Dept of Anesthesiology
Cardiac evaluation for the noncardiac patient Nathaen Weitzel MD University of Colorado Denver Dept of Anesthesiology Objectives! Review ACC / AHA guidelines as updated for 2009! Discuss new recommendations
More informationDilemmas in the management of renal artery stenosis
Dilemmas in the management of renal artery stenosis Ching M. Cheung, Janet Hegarty and Philip A. Kalra* Department of Renal Medicine, Hope Hospital, Stott Lane, Salford M6 8HD, UK Atherosclerotic renovascular
More informationAngioplasty with stent in renal artery stenosis: our experience
Rev Chil Radiol 2016; 22(1): 13-19. Angioplasty with stent in renal artery stenosis: our experience Johanna Marcela Vasquez Veloza *, José Luis Abades Vázquez, José Luis Cordero Castro. Interventional
More informationThe MAIN-COMPARE Study
Long-Term Outcomes of Coronary Stent Implantation versus Bypass Surgery for the Treatment of Unprotected Left Main Coronary Artery Disease Revascularization for Unprotected Left MAIN Coronary Artery Stenosis:
More information2017 OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY. MEASURE TYPE: Outcome
Measure #344: Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2) National Quality Strategy Domain: Effective Clinical
More informationTitle: Statins for haemodialysis patients with diabetes? Long-term follow-up endorses the original conclusions of the 4D study.
Manuscript type: Invited Commentary: Title: Statins for haemodialysis patients with diabetes? Long-term follow-up endorses the original conclusions of the 4D study. Authors: David C Wheeler 1 and Bertram
More informationEpidemiologic and clinical comparison of renal artery stenosis in black patients and white patients
ORIGINAL ARTICLES Epidemiologic and clinical comparison of renal artery stenosis in black patients and white patients Andrew C. Novick, MD, Safwat Zald, MD, David Goldfarb, MD, and Ernest E. Hodge, MD,
More informationShould percutaneous transluminal renal angioplasty be applied to ostial renal artery atherosclerosis?
Should percutaneous transluminal renal angioplasty be applied to ostial renal artery atherosclerosis? artery Jens Eldrup-Jorgensen, MD, H. Russell Harvey, MD, Lawrence N. Sampson, MD,* Steven M. Amberson,
More informationJoshua A. Beckman, MD. Brigham and Women s Hospital
Peripheral Vascular Disease: Overview, Peripheral Arterial Obstructive Disease, Carotid Artery Disease, and Renovascular Disease as a Surrogate for Coronary Artery Disease Joshua A. Beckman, MD Brigham
More informationClinical Practice Guideline
Clinical Practice Guideline Secondary Prevention for Patients with Coronary and Other Vascular Disease Since the 2001 update of the American Heart Association (AHA)/American College of Cardiology (ACC)
More informationThe Case for Intravenous EDTA Chelation Therapy, August, 2006 update.
The Case for Intravenous EDTA Chelation Therapy, August, 2006 update. Positive Dr. Johanna Mendez (Columbia, S.A.) and Dr. Martin Dayton discussing contents of a chelation treatment in a clinical setting
More informationContrast Induced Nephropathy
Contrast Induced Nephropathy O CIAKI refers to an abrupt deterioration in renal function associated with the administration of iodinated contrast media O CIAKI is characterized by an acute (within 48 hours)
More informationRegistry Assessment of Peripheral Interventional Devices (RAPID)
Registry Assessment of Peripheral Interventional Devices (RAPID) Adding Data Sources May 2, 2018 W. Schuyler Jones, MD Duke Clinical Research Institute Duke Heart Center Disclosures Research Grants: Agency
More informationProgression of atherosclerotic renovascular disease: a prospective population-based study
From the Southern Association for Vascular Surgery Progression of atherosclerotic renovascular disease: a prospective population-based study Jeffrey D. Pearce, MD, a Brandon L. Craven, BS, a Timothy E.
More informationPharmacologic Therapy of Coronary Disease
Pharmacologic Therapy of Coronary Disease M. MOHSEN IBRAHIM, MD Prof. of Cardiology- Cairo University President of the Egyptian Hypertension Society Introduction Coronary artery disease (CAD) is possibly
More informationLIST OF ABBREVIATIONS
Diabetes & Endocrinology 2005 Royal College of Physicians of Edinburgh Diabetes and lipids 1 G Marshall, 2 M Fisher 1 Research Fellow, Department of Cardiology, Glasgow Royal Infirmary, Glasgow, Scotland,
More informationGrand Rounds. Renal Artery Disease: Diagnosis and Management. Abstract
Grand Rounds Renal Artery Disease: Diagnosis and Management JEFFREY W. OLIN, D.O. Abstract Renal artery stenosis (RAS) is most commonly due to either fibromuscular dysplasia or atherosclerosis. The former
More informationEvidence Supporting Post-MI Use of
Addressing the Gap in the Management of Patients After Acute Myocardial Infarction: How Good Is the Evidence Supporting Current Treatment Guidelines? Michael B. Fowler, MB, FRCP Beta-adrenergic blocking
More informationRenal ischemia resulting from stenosis of the renal artery
Prospective Study of Atherosclerotic Disease Progression in the Renal Artery Michael T. Caps, MD; Claudio Perissinotto, MD; R. Eugene Zierler, MD; Nayak L. Polissar, PhD; Robert O. Bergelin, MS; Michael
More informationComparative Effectiveness Review (Update) Comparative Effectiveness of Management Strategies for Renal Artery Stenosis: 2007 Update
This report is based on research conducted by the Tufts-New England Medical Center Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville,
More informationEffective Health Care Program
Comparative Effectiveness Review Number 37 Effective Health Care Program Chronic Kidney Disease Stages 1 3: Screening, Monitoring, and Treatment Executive Summary Objectives This systematic review evaluates
More informationChapter 4: Cardiovascular Disease in Patients With CKD
Chapter 4: Cardiovascular Disease in Patients With CKD Introduction Cardiovascular disease is an important comorbidity for patients with chronic kidney disease (CKD). CKD patients are at high-risk for
More informationPeripheral Arterial Occlusive Disease- The Challenge in patients with diabetes
Peripheral Arterial Occlusive Disease- The Challenge in patients with diabetes Ashok Handa Reader in Surgery and Consultant Surgeon Nuffield Department of Surgery University of Oxford Introduction Vascular
More informationSTATINS FOR PAD Long - term prognosis
STATINS FOR PAD Long - term prognosis Prof. Pavel Poredos, MD, PhD Department of Vascular Disease University Medical Centre Ljubljana Slovenia DECLARATION OF CONFLICT OF INTEREST No conflict of interest
More informationBernard Ashby-PGY2 ICCR IRB Proposal December 18, 2008
Treatment of Refractory Hypertension Due to Tertiary Hyperaldosteronism with Spironolactone Following Percutaneous Renal Artery Intervention (PTRI): A Prospective Randomized Control Trial A. Study Purpose
More information03/30/2016 DISCLOSURES TO OPERATE OR NOT THAT IS THE QUESTION CAROTID INTERVENTION IS INDICATED FOR ASYMPTOMATIC CAROTID OCCLUSIVE DISEASE
CAROTID INTERVENTION IS INDICATED FOR ASYMPTOMATIC CAROTID OCCLUSIVE DISEASE Elizabeth L. Detschelt, M.D. Allegheny Health Network Vascular and Endovascular Symposium April 2, 2016 DISCLOSURES I have no
More informationTrans-Atlantic Debate: The Role of Interventions for Atherosclerotic Renal Artery Stenoses *
Eur J Vasc Endovasc Surg (2011) 42, 135e143 EDITORS INTRODUCTION Trans-Atlantic Debate: The Role of Interventions for Atherosclerotic Renal Artery Stenoses * J.-B. Ricco a, *, T.L. Forbes b Part One: The
More informationEvolving Challenges in the Evaluation and Treatment of Lower Extremity PAD -- The Peripheral Academic Research Consortium (PARC)
Evolving Challenges in the Evaluation and Treatment of Lower Extremity PAD -- The Peripheral Academic Research Consortium (PARC) W. Schuyler Jones, MD FACC Director, Adult Cardiac Catheterization Laboratory
More informationSummary Protocol ISRCTN / NCT REVIVED-BCIS2 Summary protocol version 4, May 2015 Page 1 of 6
Summary Protocol REVIVED-BCIS2 Summary protocol version 4, May 2015 Page 1 of 6 Background: Epidemiology In 2002, it was estimated that approximately 900,000 individuals in the United Kingdom had a diagnosis
More informationMasahiko Fujihara, MD
Verify the efficacy of renal artery stenting to define the predictive factors by physiological assessment with pressure wire gradient VERDICT study Masahiko Fujihara, MD Kishiwada Tokushukai Hospital Osaka,
More informationThe case favoring renal artery stenting for individuals
CONTROVERSIES IN CARDIOVASCULAR MEDICINE Is renal artery stenting the correct treatment of renal artery stenosis? The Case for Renal Artery Stenting for Treatment of Renal Artery Stenosis Christopher J.
More informationControversies in Cardiac Surgery
Controversies in Cardiac Surgery 3 years after SYNTAX : Percutaneous Coronary Intervention for Multivessel / Left main stem Coronary artery disease Pro ESC Congress 2010, 28 August 1 September Stockholm
More informationThis clinical study synopsis is provided in line with Boehringer Ingelheim s Policy on Transparency and Publication of Clinical Study Data.
abcd Clinical Study Synopsis for Public Disclosure This clinical study synopsis is provided in line with s Policy on Transparency and Publication of Clinical Study Data. The synopsis which is part of the
More informationIs Renal Artery Stenting Still Relevant? A Cohort Analysis
Is Renal Artery Stenting Still Relevant? A Cohort Analysis Sunil Naik, MD*, Brijesh Patel, DO, Anas Souqiyyeh, MD, Marc Zughaib, David Eastes, MPH, Marcel Zughaib, MD Abstract Atherosclerotic renal artery
More informationHEART AND SOUL STUDY OUTCOME EVENT - MORBIDITY REVIEW FORM
REVIEW DATE REVIEWER'S ID HEART AND SOUL STUDY OUTCOME EVENT - MORBIDITY REVIEW FORM : DISCHARGE DATE: RECORDS FROM: Hospitalization ER Please check all that may apply: Myocardial Infarction Pages 2, 3,
More informationMORTALITY AND MORBIDITY RISK FROM CAROTID ARTERY ATHEROSCLEROSIS. 73 year old NS right-handed male applicant for $1 Million life insurance
MORTALITY AND MORBIDITY RISK FROM CAROTID ARTERY ATHEROSCLEROSIS October 17, 2012 AAIM Triennial Conference, San Diego Robert Lund, MD What Is The Risk? 73 year old NS right-handed male applicant for $1
More information