Outcomes after stenting of renal artery stenosis in patients with high-risk clinical features

Abstract

Background: In patients with renal artery stenosis, revascularization was seen as a mean to improve outcomes, but large studies failed to show significant benefit in general population. However, data on benefits of renal artery stenting in patients with high-risk features, such as rapidly declining renal function and cardiac destabilization syndromes, are limited, as they were excluded from trials. In this descriptive study, we aimed to evaluate short- and long-term outcomes in high-risk patients with renal artery stenosis, treated by angioplasty and stenting. We have retrospectively interrogated our local databases for renal artery percutaneous interventions; patients at high-risk (rapidly declining renal function; stable chronic renal failure and bilateral renal artery disease; severe hypertensive crisis) were selected for the current analysis.

Results: Of 30 patients undergoing renal artery stenting, 18 patients were deemed "high-risk." On short term, good in-hospital control of hypertension and cardiac stabilization were obtained in all patients. Renal function improved significantly only in patients admitted with rapidly declining renal function, with significant creatinine level fall from median 3.98 mg/dL to 2.02 mg/dL, p = 0.023. However, for the whole group, creatinine change was non-significant (- 0.12 mg/dL, p = NS). On the long term, five patients (27.8%) ended-up on chronic hemodialysis and six patients died (33.3%) after a median of 20 months. No death occurred during the first year after the procedure.

Conclusions: Percutaneous procedures are feasible and safe in patients with high-risk renal artery stenosis, especially in those with rapidly declining renal function, probably saving some of them from the immediate need for renal replacement therapy, but long-term results are negatively influenced by the precarious general and cardio-vascular status of these patients and by the pre-existing significant renal parenchymal disease, non-related to the renal artery stenosis.

Keywords: Cardiac destabilization syndromes; Rapidly declining renal function; Renal artery disease; Renal artery stenting.

Fig. 1

Creatinine level evolution of the 18 studied patients at the four time-points considered (baseline, preprocedural level, postprocedural maximum level, and at discharge). A Creatinine level for every patient, represented differently by the presence of the initial rapidly declining renal function: present (green, round dots), absent (red, square dots), and respective medians (corresponding dark colors, dotted line; black, dotted line—median for all patients). B The same representation for the medians only, rescaled for improved visibility (green, round dots—initial rapid decline present; dark red, square dots—initial rapid decline absent; black—whole group)

Fig. 2

Bilateral renal artery stenosis in a patient with flash pulmonary edema and rapidly declining renal function. The tight stenosis on the right renal artery (panel A) was stented (panel C) with a good final result (panel D). The subocluded left renal artery (Panel B) subtended a small kidney (presumably, non-viable). Serum creatinine normalized 72 h after the procedure, there were no recurrences of pulmonary edema at 2 years of follow-up and hypertension was controlled with a single drug