Lynne Mathiak

Four-Year Follow-up of Palmaz-Schatz Stent Revascularization as Treatment for Atherosclerotic Renal Artery Stenosis

BACKGROUND Stent revascularization is perceived as superior to balloon angioplasty and surgical revascularization, but the paucity of stent publications precludes even historical comparison with surgical data. METHODS AND RESULTS Palmaz-Schatz stent revascularization of renal artery stenosis was successfully performed on 163 consecutive patients for poorly controlled hypertension or preservation of renal function. Of these, 145 were eligible for > or =6-month clinical follow-up of the effect of the procedure on renal function, blood pressure control, number of antihypertensive medications, and survival. At 4 years, systolic and diastolic blood pressures significantly decreased (from 166+/-26 to 148+/-22 mm Hg and from 86+/-14 to 80+/-11 mm Hg, respectively; P<0.05), and blood pressure control was more facile in approximately half of the patients. Creatinine decreased or remained stable in approximately two thirds of the patients. The cumulative probability of survival was 74+/-4% at 3 years, with few deaths related to end-stage renal disease. Survival was good in patients with normal (92+/-4%) baseline renal function, fair (74+/-7%) in those with mildly impaired renal function, and poor (52+/-7%) in patients with elevated baseline creatinine levels (> or =2.0 mg/dL). The combination of impaired renal function and bilateral disease adversely affected survival. CONCLUSIONS Renal artery stent revascularization in the presence of normal or mildly impaired renal function had a beneficial effect on blood pressure control and a nondeleterious effect on renal function. Survival was adversely affected by renal dysfunction despite adequate revascularization. Early diagnosis and adequate revascularization before the onset of renal dysfunction could beneficially affect blood pressure control, preserve or prevent deterioration of renal function, and improve patient survival.

Follow-up of primary Palmaz-Schatz stent placement for atherosclerotic renal artery stenosis

A Palmaz-Schatz stent was successfully placed in 92 stenotic renal arteries (76 patients) for (1) hypertension in 62 (82%), and/or (2) chronic renal failure (serum creatinine > or = 1.5 mg/dl) and preservation of renal function in 39 (51%). Patients were followed to assess clinical and angiographic 6-month outcome. Angiography, performed in 45 of 62 eligible patients (73%) and in 56 of 74 treated arteries (76%), showed restenosis occurring in 14 renal arteries (25%). Serum creatinine improved or remained stable in 78% of patients. In patients with chronic renal failure, improvement or stability was observed in 55%. Blood pressure recordings significantly decreased for the entire cohort (systolic: 168 +/- 25 to 156 +/- 22 mm Hg, p < 0.0001; diastolic: 87 +/- 11 to 81 +/- 11 mm Hg, p < 0.005), and for hypertensive patients with normal creatinine (systolic: 179 +/- 20 to 155 +/- 23 mm Hg, p < 0.0001; diastolic: 92 +/- 9 to 83 +/- 12 mm Hg, p < 0.002). These follow-up data of a prospective, nonrandomized, observational study showed that stent recanalization of atherosclerotic renal artery stenoses was beneficial with regard to renal function and blood pressure response, and had a restenosis incidence of 25%.

Multicenter Palmaz stent renal artery stenosis revascularization registry report: Four-year follow-up of 1,058 successful patients

Palmaz‐Schatz stent revascularization of renal artery stenosis was successfully performed on 1,058 patients who were entered into a voluntary, multicenter registry. The revascularization procedures were performed because of poorly controlled hypertension, preservation of renal function, and congestive heart failure. All 1,058 patients were eligible for ≥ 6‐month clinical follow‐up, which focused on subsequent renal function, blood pressure, number of antihypertensive medications, and survival. At 4‐year follow‐up, systolic and diastolic blood pressures had significantly decreased (168 ± 27 mm Hg to 147 ± 21 mm Hg, and 84 ± 15 to 78 ± 12 mm Hg; P < 0.05) and the blood pressure appeared to be more facilely controlled as indicated by the concomitant decrease in number of antihypertensive medications (2.4 ± 1.1 to 2.0 ± 1.0; P < 0.05). Serum creatinine had also significantly decreased (1.7 ± 1.1 to 1.3 ± 0.8 mg/dl; P < 0.05). The cumulative probability of survival was 74% ± 3% at 4 years. Survival was good for patients with normal (85% ± 3%) baseline renal function, fair (78% ± 5%) with mildly impaired renal function, and poor (49% ± 5%) with severely impaired renal function (baseline creatinine ≥ 2.0 mg/dl). The combination of impaired renal function and bilateral disease adversely effected survival (unilateral 55% ± 6% vs. bilateral 36% ± 11%; P < 0.05). Renal artery stent revascularization, in the presence of normal or mildly impaired renal function, had a beneficial effect on blood pressure control and on renal function (through stabilization or improvement). Survival was adversely effected by renal dysfunction despite adequate revascularization. Perhaps early diagnosis of renal artery stenosis and adequate revascularization prior to the onset of renal dysfunction could beneficially impact blood pressure control, preserve or prevent deterioration of renal function, and improve patient survival. Cathet Cardiovasc Intervent 2002;55:182–188.

The acute outcome of tibioperoneal vessel angioplasty in 417 cases with claudication and critical limb ischemia.

A non-randomized, consecutive series of 417 first procedure tibioperoneal vessel angioplasty (TPVA) cases were analyzed to determine if angioplasty were an alternative revascularization technique for critical limb ischemia (CLI) and claudicants patients. TPVA was performed on 312 patients (70% male; age 66 +/- 10 years) with success attained in 406/417 cases (96%) of 605/657 lesions (92%): [461/469 stenoses (98%) and 144/188 occlusions (77%) *(P < 0.05)]. Claudication and CLI patients had similar rates of success. In claudication patients clinical success was 130/133 (98%); lesion success was 197/208 (92%); stenosis was 148/151 (98%); and occlusion was 49/57 (86%). In CLI patients clinical success was 270/284 (95%); lesion success was 408/449 (91%); stenosis was 313/318 (98%); and occlusion was 95/131 (73%). We conclude that TPVA is an effective revascularization technique for obstructed tibioperoneal vessels, with excellent success in stenotic (98%) and reasonable results in occluded vessels (77%). These data demonstrate TPVA effectiveness in CLI patients and in carefully selected claudicants with appropriate indications (severe, lifestyle limiting claudication) and readily amenable anatomy, and TPVA for CLI patients appears to be an effective revascularization technique.

Coronary blood flow velocities during rotational atherectomy.

This study was designed to evaluate the alterations in doppler derived coronary blood flow velocities and flow reserve following rotational ablation. Changes in doppler derived coronary blood flow velocity variables have been valuable in assessing the physiological outcome following coronary balloon angioplasty. Rotational ablations mechanism of plaque removal could alter distal vascular bed characteristics, and, as a result, intracoronary blood flow velocities and the coronary flow reserve. A 12-MHz doppler guidewire recorded intracoronary phasic velocities and coronary flow reserve (as assessed by the hyperemic response to adenosine [12-18 mcg intracoronary]) in 28 patients, before and after rotational ablation of 30 lesions. Adjunctive balloon angioplasty was performed in 27 of 28 patients (96%). Rotational ablation and adjunctive balloon angioplasty successfully reduced the lesion diameter (87 +/- 9% to 14 +/- 11%; P < 0.001). A significant increase in the mean distal average peak velocity (25 +/- 13 cm/sec, before; 47 +/- 22 cm/sec, after; P < 0.001), and decrease in the proximal to distal average peak velocity ratio, (2.1 +/- 1.3; to 1.2 +/- 0.4; P = 0.002) was recorded. The mean distal diastolic to systolic velocity ratio (before, 1.4 +/- 0.7; after, 1.6 +/- 0.8; P = 0.44) and the coronary flow reserve (before, 1.6 +/- 0.6; after, 1.5 +/- 0.5; P = 0.34) did not increase despite increases in distal velocities, following successful intervention. Doppler derived distal coronary blood flow velocities increased following rotational ablation and adjunctive balloon angioplasty, with resolution of transstenotic velocity gradient. Changes in distal phasic velocity pattern and coronary flow reserve, immediately after the intervention, were not useful in the assessment of the functional outcome and may be related to abnormalities in distal vascular bed vasoreactivity produced by rotational ablation.

Complex Coronary Angioplasty: The Outcome and Long-term Effect of Angioplasty in Multivessel Coronary Disease and Multiple Lesion Angioplasty

Percutaneous transluminal coronary angioplasty (PTCA)1 is an accepted treatment for selected patients with isolated single-vessel obstructive coronary disease.2–4 The use of PTCA has been successful in multivessel coronary artery disease (MVD) patients.5–7 The demonstrated safety and efficacy of angioplasty in patients with isolated proximal coronary stenosis(es) permitted its evaluation in patients with extensive coronary disease.7–14 However, the continuous merging of words, which only ensure the reader, has led us to define the two major subgroups most often discussed so as to clarify what has happened. The acute outcome and follow-up of PTCA in MVD patients who underwent single- or multiple-lesion angioplasty (group I), and in patients (with single or multivessel coronary disease) who underwent multiple lesion angioplasty (MLA; group II) is discussed.