Mike Broce

Factors affecting long-term survival following renal artery stenting

Introduction: This study defines clinical variables at the time of renal artery stenting that may be predictors of long‐term all‐cause mortality. Methods: The data are derived from the single operator, single center, renal stent retrospective study (SOCRATES) and includes a review of 748 (336 men, 412 women) consecutive symptomatic patients with de novo atherosclerotic renal artery stenosis treated over an 11‐year period. All patients had clinical indications for renal revascularization, including, but not limited to; suboptimal control of hypertension, chronic kidney disease, and cardiac disturbance syndromes. Clinical variables at the time of the index procedure were evaluated as predictors of all‐cause mortality using multivariate analysis. Mortality data were derived from hospital records and formal queries of the State Department of Health and Human Services, Health and Vital Statistics Division database. Results: In‐hospital, 30‐day and 6‐month mortality rates were 0.5, 2.0, and 6.3%, respectively. Overall patient survival at years 1, 5, and 10 was 91.2, 66.6, and 40.9%, respectively. Comorbid conditions, including chronic obstructive pulmonary disease and congestive heart failure, were independently associated with increased mortality. There were incremental changes in mortality in patients with baseline azotemia, [preprocedure serum creatinine (sCr) 1.5–2.09 mg/dL hazard ratio 1.52; sCr >2.5 mg/dL hazard ratio 3.39]. Therapy with lipid lowering agents offered a survival advantage (hazard ratio 0.69, P = 0.0.049); however, this study was not designed to evaluate a “protective effect” of lipid lowering medications. Conclusions: Patients with chronic obstructive pulmonary disease and congestive heart failure undergoing renal artery stent revascularization have a poor long‐term prognosis. Baseline azotemia is the strongest independent predictor of all cause mortality, with more than 70% of patients with marked azotemia (sCr >2.5) dead at 5 years.

Short- and long-term outcomes of percutaneous transluminal angioplasty/stenting of renal fibromuscular dysplasia over a ten-year period.

OBJECTIVES The purpose of this study was to evaluate short and long-term outcomes of percutaneous transluminal intervention in patients with symptomatic renal artery stenosis due to fibromuscular dysplasia (RAFMD) and/or the combination of RAFMD with aorto-ostial atherosclerotic disease. METHODS A retrospective analysis of all patients with renal artery RAFMD who underwent transcatheter therapy between January 1999 and December 2009 was performed. Blood pressure (BP) measurement, number of BP medications, and hypertension defined by a systolic BP >140 ± diastolic BP >90 were recorded. Renal function was defined by estimated glomerular filtration rate (eGFR). Restenosis was defined by stenosis >60% and was determined by renal artery duplex and/or angiography. Freedom from event (restenosis, renal failure, or recurrent hypertension) was performed using life table analysis. RESULTS Forty-three procedures were performed on 35 patients with RAFMD. Thirty-two patients (91%) were women, with mean age of 61.9 years old. Technical success was 100% with adjunctive stent placement required in the FMD segment for dissection in 1 patient (2.3%) and in the non-FMD aorto-ostial atherosclerotic lesion in 4 patients (9.3%). Short-term outcomes: the majority (69%) had an immediate clinical benefit for hypertension, 6% were cured without BP medications, and 63% improved with less than or equal to preoperative BP medications. Postintervention, 17% remained at moderately reduced renal function (<60), whereas the percent above >60 mL/minute eGFR increased significantly (from 51% to 69%; P = .002). For the entire cohort, renal function (mean eGFR) significantly increased from 71.9 mL/minute + 5.8 to 80.8 mL/minute + 5.2 (P = .007). Long-term outcomes: freedom from recurrent or worsening hypertension (>140 systolic blood pressure [SBP] and >90 diastolic blood pressure [DBP]) was (93%, 75%, and 41%) and freedom from reduced renal function (eGFR <30 mL/minute) was (100%, 95%, and 64%) at 1, 5, and 8 years, respectively. Patients with reduced baseline renal function (<60 mL/minute) and combined atherosclerotic disease were more likely to experience long-term reduced renal function (eGFR <30 mL/minute; P = .003). Primary and assisted primary patency was (95%, 71%, and 50%) and (100%, 100%, and 100%) at 1, 5, and 9 years, respectively. CONCLUSION Renal angioplasty is a safe and durable modality for treating RAFMD with favorable short and long-term clinical outcomes. Patients with combined atherosclerotic disease and FMD were older and were more likely to have declining renal function over time. Early intervention may be imperative to achieve possible cure of hypertension.

Predictors of percutaneous access failure requiring open femoral surgical conversion during endovascular aortic aneurysm repair

OBJECTIVE To determine predictors of percutaneous (PEVAR) access failure requiring conversion to an open approach (OEVAR) during endovascular aortic aneurysm repair (EVAR). METHODS A single-center retrospective review of all EVAR patients from January 2009 through June 2011 with multivariate analysis of clinical and anatomic variables that could impact access outcome was conducted. Target vessel calcification was categorized as mild, moderate, or severe based on circumferential calcium arc (<⅓, ⅓ to ½, and >½ respectively), dyslipidemia (defined as low-density lipoprotein >130 mg/dL or receiving lipid lowering medication), and obesity (defined as body mass index [BMI] >30). RESULTS We investigated 400 access sites for 200 patients who underwent EVAR. The study cohorts characteristics included an average age of 72.8 ± 9.0 years, vessel size of 9.6 ± 1.8 mm, sheath size of 17.1 ± 3.0 Fr, BMI of 27.6 ± 5.3, and estimated glomular filtration rate of 68.5 ± 24.2 mL/min. Comorbidities included dyslipidemia in 129 patients (64.5%) and diabetes in 54 patients (27%). There were 132 OEVAR (66 patients), two mixed OEVAR with contralateral PEVAR (one patient), and 266 (133 patients) PEVAR approaches. Use of PEVAR increased over time (45.5% [2009], 77.8% [2010], and up to 88.5% [2011]; P = .001) while conversions decreased (24.3% [2009], 8.7% [2010], and 4.3% [2011]; P = .001]. More OEVAR patients (35.8%) stayed longer than 3 days compared with 21.1% for PEVAR (P = .028). For the 266 PEVAR approaches, 32 access sites (12.0%) had to be converted. Severely calcified arteries were most predictive of conversion (odds ratio [OR], 36.4; P < .001). Year of procedure (2010; OR, 0.17; P = .001; 2011, OR, 0.20; P = .049), female gender (OR, 3.1; P = .017), moderately calcified arteries (OR, 2.5; P = .085), and age (OR, 2.3 [per decade]; P = .002) were all also significant. Vessel size, sheath size, and BMI were found to be nonsignificant predictors of conversion. CONCLUSIONS PEVAR was found to be safe, reliable, and feasible. Several factors, including learning curve, vessel calcification, age, and female gender predicted conversion of PEVAR to OEVAR.

Ten-year experience with renal artery in-stent stenosis

BACKGROUND Atherosclerotic renal artery stenosis (RAS) is the most common cause of secondary hypertension. Renal stenting has become the treatment of choice for RAS in most centers. Primary patency of RAS is well defined, but limited data are available on outcomes of secondary interventions for treatment of in-stent restenosis. METHODS This was a retrospective analysis of a 10-year experience with renal artery stenting in patients presenting with recurrent symptomatic stenosis. End points included freedom from tertiary procedures, change in baseline renal function by ≥20% measured by estimated glomerular filtration rate (eGFR), patency confirmed by duplex imaging, long-term hypertension response, freedom from hemodialysis, and survival. RESULTS We reviewed 948 patients with 1150 treated renal arteries. Of these, 107 patients (122 renal stents) returned with symptomatic in-stent restenosis and required reintervention (target vessel revascularization [TVR] rate, 10.6%): 97% had recurrent or worsening hypertension, and 67% had worsening renal function. There were 69 women (64%) and 38 men (35%) with an average age of 68.9 years. Mean follow-up was 35.5 months (range, 1.0-104.7 months) for patency and 37.7 months (range, 0.03-100.9 months) for renal function (creatinine). Secondary interventions included 27 percutaneous transluminal angioplasties (PTAs), 10 PTAs with cutting balloon, 77 repeat renal artery stenting, and 8 placements of drug-eluting stents (DES). Twenty-five of the 122 arteries (20%) required tertiary interventions in 23 patients, a significantly higher TVR rate vs de novo interventions (11%; P = .003). Freedom from tertiary interventions at 60 months was similar among treatment groups undergoing PTA (66%), cutting balloon (100%), stent (80%), and DES (75%; P = .348). Seventeen (16%) had an increase of >20%, 50 (47%) had a decrease of >20%, and 30 (28%) had no change in renal function. Ultimately 25 (23%) remained or progressed to renal failure (eGFR < 30%), and 8 required hemodialysis. The survival rate was 73% at 5 years. Mean follow-up for long-term hypertension response was 3.2 years, with 56% improved, 28% with no improvement or deterioration, 16% without long-term data available, and no patients cured. CONCLUSIONS Secondary interventions for renal in-stent restenosis had higher TVR vs de novo renal stents in this large series (21% vs 11%; P = .003). Definitive recommendations on the best secondary treatment strategy cannot be made because a medical treatment control group was not available for comparison.

Factors influencing the need for target vessel revascularization after renal artery stenting.

Purpose: To provide additional insight into factors that may be associated with the need for target vessel revascularization (TVR) following de novo renal artery stenting during long-term follow-up. Methods: A retrospective chart and database review was conducted to analyze the progress of all patients with de novo symptomatic renal artery stenosis who underwent stent-supported angioplasty under the auspices of the Single Operator, Single Center, Renal Stent Retrospective Study (SOCRATES). The records review identified 782 patients who were enrolled in the study between 1993 and 2004; after excluding 34 (4.5%) patients (lost to follow-up or inadequate data), 748 consecutive patients (412 women; mean age 70.7±9.7 years, range 37–92) were suitable for longitudinal analysis. The need for TVR was based on strict clinical criteria (≥20% rise in serum creatinine, worsening hypertension, and/or recurrent flash pulmonary edema), and all patients underwent multidisciplinary evaluation before stenting and during follow-up. Results: Follow-up spanned a mean 45.8±26.5 months. TVR was needed in 88 (10.03%) of 877 arteries and was best predicted by patient age ≤67 years (OR 2.91, p=0.0001), stent diameter ≤5.0 mm (OR 2.31, p=0.001), solitary functioning kidney (OR 2.01, p=0.048), history of lower extremity peripheral artery disease (OR 1.87, p=0.008), and antecedent history of stroke (OR 1.73, p=0.026). Conclusion: Renal artery stenting appears to be durable, with only 10% of stented arteries requiring TVR during clinically-based long-term follow-up. Arteries with a final stent diameter ≤5.0 mm were more than twice as likely to need TVR, as were patients with a solitary kidney. The authors acknowledge that clinical recurrence is not a surrogate for ultrasound surveillance after renal artery stenting, so prospective controlled trials will be needed to determine risk factors for restenosis.

Serum Creatinine Stabilization Following Renal Artery Stenting

The impact of renal artery stenting on renal function in a subgroup of consecutive de novo patients with atherosclerotic renal artery stenosis from the single operator, single center, retrospective renal stent trial is defined. Patients with inadequate preprocedure and/or follow-up renal function studies were excluded. Abnormal baseline serum creatinine (sCr) was defined as ≥1.5 mg/dL. Follow-up sCr was improved, unchanged, or worsened if the variance from baseline decreased by >20%, stayed within 20%, or increased >20%, respectively. For the total cohort (194 patients), renal function stabilized or improved in 72% of patients. Plotting 1/sCr demonstrated a decline in renal function before the procedure that stabilized following renal artery stenting. Bilateral renal artery stenting predicted normal follow-up sCr, and baseline sCr >2.1 mg/dL was associated with improvement in sCr long-term. In conclusion, renal artery stenting results in overall stabilization of renal function, and bilateral renal artery stenting seems to have added benefit.

Comprehensive hospital care improvement strategies reduce time to treatment in ST-elevation acute myocardial infarction

BACKGROUND Delay in treatment of patients with ST-elevation acute myocardial infarction (STEMI) has an adverse effect on patient outcomes. Limited data are available on the effectiveness of hospital care improvement strategies (HCIS) to reduce time to reperfusion by percutaneous coronary intervention (PCI). This study evaluated the combined effect of HCIS implementation to reduce door-to-balloon time in patients with STEMI. METHODS Retrospective chart review was done for 95 consecutive patients with STEMI who underwent PCI at Charleston Area Medical Center. Patients with non-STEMI and patients transferred from other medical centers were excluded. Door-to-balloon time was defined as time from emergency department arrival to first PCI balloon inflation. A program of 3 HCIS was implemented: 1) a fast-track catheterization laboratory protocol, 2) feedback to cardiologists on their treatment times, and 3) a weekday 24-hour inhouse catheterization laboratory team. Patients were separated into groups before (n = 46), during (n = 18), and after (n = 31) HCIS implementation. RESULTS Mean age was 60.3 +/- 13 years and 74% were male. The majority (64%) arrived by ambulance; 29% had a prehospital electrocardiogram done. Most patients presented during the day (68%) on weekdays (75%). Symptom onset-to-door time was 289 +/- 393 minutes. No significant differences were found between the groups for these variables. Door-to-PCI time in minutes was reduced in the group after versus the group before HCIS implementation (94.3 +/- 37 vs 133.5 +/- 53; P < 0.0001). CONCLUSION Implementation of HCIS shortened door-to-PCI time for patients with STEMI by 39.2 +/- 10 minutes. Thus, HCIS may be effective in improving patient outcomes.

Subendocardial ischemia without coronary artery disease: is elevated left ventricular end diastolic pressure the culprit?

SUMMARY Background: The aim was to investigate the association between elevated left ventricular end diastolic pressure (LVEDP) and subendocardial ischemia. Methods: A retrospective chart review was performed of 1846 consecutive patients admitted between January and September 2002 who had chest pain, stress testing and coronary angiography. Results: 1592 patients were excluded due to a positive coronary angiogram for coronary artery disease (CAD), 254 patients had an angiogram compatible with non-significant CAD and an ejection fraction >45%; of whom 210 (82.7%) had a positive stress test (study group) and the others 44 (17.3%) had a negative stress test (control group). The mean LVEDP value for the study group (11.8 ± 6.1 mmHg) was significantly higher than the mean LVEDP value for the control group (7.8 ± 4.6mmHg) (p < 0.001). In addition, there were more people with abnormal LVEDP (>12 mmHg) in the study group (n = 103,49.05%) compared with the control group (n = 10, 22.73%) (p < 0.001). Furthermore, the results of logistic regression revealed that patients with abnormal LVEDP values were 11 times more likely to have had a positive stress test. Conclusions: There appears to be a positive association between elevated LVEDP and subendocardial ischemia that manifests as a positive stress test in patients without evidence of significant CAD.

Detection of stress-induced myocardial ischemia from the depolarization phase of the cardiac cycle—a preliminary study

BACKGROUND Electrocardiogram (ECG)-based detection of ischemia is typically dependent on identifying changes in repolarization. Analysis of high-frequency QRS (HFQRS) components, related to the depolarization phase of the cardiac action potential, has been reported to better identify ischemia. Our aim was to test the hypothesis that HFQRS analysis is both more sensitive and specific than standard ECG for detecting exercise-induced ischemia in patients undergoing exercise myocardial perfusion imaging (MPI). METHODS Exercise MPI was performed in 133 consecutive patients (age, 63 +/- 12; 100 males) and used as the gold standard for ischemia. Patients with QRS duration more than 120 milliseconds (n = 20), technical problems (n = 8), or inconclusive MPI (n = 4) were excluded, leaving 101 patients for analysis. Conventional ECG was combined with high-resolution ECG acquisition that was digitized and analyzed using the HyperQ System (BSP, Tel Aviv, Israel). The relative HFQRS intensity change during exercise was used as an index of ischemia. RESULTS Of the 101 patients who were included in the analysis, 19 exhibited MPI ischemia. The HFQRS index of ischemia was found to be more sensitive (79% vs 41%; P < .05) and more specific (71% vs 57%; P < .05) than conventional ST analysis. CONCLUSIONS The HFQRS analysis was more sensitive and specific than conventional ECG interpretation in detecting exercise-induced ischemia and exhibited enhanced diagnostic performance in both women and men. Thus, it may aid in the noninvasive diagnosis of ischemic heart disease.

The Ability of the Quadruple Test to Predict Adverse Perinatal Outcomes in a High-risk Obstetric Population:

Objective To determine the ability of the quadruple Downs syndrome screening test (quad screen) to predict other adverse perinatal outcomes (APO) in a high-risk obstetric population. Setting A tertiary medical centre in West Virginia. Methods We retrospectively reviewed 342 obstetric patients with quad screen data from a single clinic. The quad screen included maternal serum levels of alphafetoprotein (AFP), human chorionic gonadotrophin (hCG), uncongjugated oestriol (uE3), and inhibin A. The risk of APO was compared between patients with at least one abnormal marker versus no abnormal markers and ≥2 abnormal markers versus <2 abnormal markers. Abnormal markers were determined by cut-off values produced by Receiver Operator Characteristic (ROC) curves and the FASTER trial. Unadjusted and adjusted effects were estimated using logistic regression analysis. Results The risk of having an APO increased significantly for patients with abnormal markers by about three-fold using ROC and two-fold using FASTER trial thresholds. Conclusions The quad screen shows value in predicting risk of APO in high-risk patients.