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Predicting Success After Endovascular Intervention for Renal Artery Stenosis

Charles S. Joels, Matthew G. Healey, Eugene M. Langan, III, Corey A. Kalbaugh, Anna Cass, Bruce H. Gray.
Greenville Hospital System, Greenville, S.C.

OBJECTIVES: With increased need for healthcare cost containment, expenditures for endovascular therapy must be justified with successful outcomes. The value of percutaneous transluminal renal artery angioplasty with stenting (PTRAS) has come under fire due to increased costs with questionable benefit over medical therapy. The purpose of this study is to create a new definition of successful PTRAS combining multiple pertinent endpoints and to identify factors associated with success to improve selection of patients for whom this cost is justified.

METHODS: Patients undergoing PTRAS for hypertension (HTN) and/or chronic kidney disease (CKD) were identified from the GHS UMC vascular registry. Demographic and clinical factors were gathered retrospectively. Successful PTRAS was defined as patency for at least one year after intervention, patient survival for at least one year after intervention, stable (within 20% of initial) or improved (greater than 20% reduction) creatinine post-procedure, and if HTN was an indication for intervention, improved blood pressure control, based on the AHA 2002 guidelines. Bivariate and multivariate analysis was used to evaluate success relative to 35 demographic, clinical, and procedure-related factors.

RESULTS: Between 9/98 and 8/06, 159 patients underwent PTRAS with adequate documentation for study inclusion. Indications for intervention were HTN (n=96, 60.4%), CKD (n=17, 10.7%) and both (n=46, 28.9%). Stents were used in 92.9% of patients. The one-year restenosis rate was 23.4%, while the composite clinical success rate was 30.2%. Factors associated with success using bivariate analysis are listed in Table 1. Using multivariate analysis, calcium-channel blockers (OR 2.4) were associated with composite clinical success while HTN as an indication for intervention (OR 0.09) was associated with composite clinical failure.

CONCLUSIONS: Calcium channel blockers are associated with composite clinical success, but the mechanism for this is unknown. Success is elusive when treating HTN with PTRAS. Additional factors need consideration to predict which HTN patients will benefit. Patients with renal artery stenosis and associated CKD respond to PTRAS dramatically better than those with HTN, and should be treated aggressively when this condition is identified.
AUTHOR DISCLOSURES: C.S. Joels, None; M.G. Healey, None; E.M. Langan, None; C.A. Kalbaugh, None; A. Cass, None; B.H. Gray, None.