Outcomes of endoluminal reintervention for restenosis after percutaneous renal angioplasty and stenting.
BACKGROUND
Endovascular therapy for symptomatic atherosclerotic renal artery stenosis (ARAS) is common but is associated with a significant restenosis rate. This study evaluates the outcomes of percutaneous endoluminal therapy for symptomatic restenosis (>50% on angiography) after renal intervention.


METHODS
We performed a retrospective analysis of records from patients who underwent endovascular intervention for ARAS and were followed by duplex ultrasound scan between January 1990 and January 2008. Clinical benefit defined as freedom from recurrent hypertension or renal-related morbidity (increase in persistent creatinine >20% of baseline, progression to hemodialysis, death from renal-related causes), anatomic patency, restenosis, and patient survival were measured.


RESULTS
A total of 447 patients underwent 619 renal artery interventions. A total of 80 vessels restenosed with an actuarial restenosis rate of 19% at 5 years. Of these restenoses, 65 (81%) were associated with recurrent symptoms (recurrent hypertension 84%, or continuing deterioration in renal function 16%). Fifty-five (85%) underwent repeat angioplasty and 10 underwent bypass surgery. The remainder was observed. The 55 percutaneous interventions were performed in 51 patients (61% female, average age 62 years, range, 51-85). A total of 73% had metabolic syndrome, 58% had hyperlipidemia, and 51% were considered diabetic; all of them had primary stenting during their first procedure. There was a 4% technical failure rate in both groups. In the restenosis group, the presence of stent was associated with a 9% technical failure rate, while in the absence of a stent the technical failure rate was only 3% (P < .05). At 5 years, outcomes were equivalent between the primary and recurrent groups for survival (76 +/- 2% vs 75 +/- 8%, primary vs recurrent), cumulative patency (82 +/- 3% vs 70 +/- 10%), freedom from restenosis (81 +/- 3% vs 81 +/- 9%), and retained clinical benefit (44 +/- 4% vs 46 +/- 10%). By Cox proportional hazards and multivariate analysis, administration of statins were associated with freedom from restenosis in the recurrent lesions. Statins, contralateral kidney size (>9 cm) and a >/=20% improvement in baseline creatinine with 3 months were associated with freedom from recurrent symptoms. Restenosis after therapy in recurrent lesions was significantly correlated with recurrent symptoms (Spearman r = 0.4614, P < .0004).


CONCLUSIONS
Percutaneous reintervention for renal artery restenosis is safe and effective with equivalent outcomes to primary intervention. The patients are more likely to present with recurrent hypertension and be younger and of female gender than patients presenting for primary intervention. Functional outcomes after reintervention are equivalent to primary intervention.
Davies
Mark G
MG
Department of Cardiovascular Surgery, Methodist DeBakey Heart and Vascular Center, The Methodist Hospital, Houston, Tex, USA.
Saad
Wael A
WA
Bismuth
Jean X
JX
Peden
Eric K
EK
Naoum
Joseph J
JJ
Lumsden
Alan B
AB
D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D017130:Angioplasty / Q000295:instrumentation*; D003404:Creatinine / Q000097:blood; D005260:Female; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000627:therapeutic use; D006973:Hypertension / Q000209:etiology / Q000517:prevention & control; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D012008:Recurrence; D012078:Renal Artery Obstruction / Q000150:complications / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D006435:Renal Dialysis; D051437:Renal Insufficiency / Q000209:etiology / Q000517:prevention & control; D012086:Reoperation; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012737:Sex Factors; D015607:Stents; D013997:Time Factors; D016896:Treatment Outcome; D018616:Ultrasonography, Doppler, Duplex; D014654:Vascular Patency
D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors; D003404:Creatinine