Page 8 - Carotid and peripheral vascular interventions textbook

A

CAROTID AND PERIPHERAL VASCULAR INTERVENTIONS: STEP-BY-STEP

A B

A B

B
Figure 10-6. Comparison imaging resolution between computerized tomography angiography (A) and magnetic resonance angiography
(B) of renal arteries.

INDICATION FOR REVASCULARIZATION and ESC also recommended balloon angioplasty together

with bailout stenting in case of FMD with hypertension
A The following organizations have published and/or indications of renal impairment (Class IIa) (23,34).
B
guidelines for the treatment of RAS: 2013 American In 2018, ACC/AHA/SCAI/SIR/SVM produced
College of Cardiology (ACC)/American Heart Association an appropriate use criteria (AUC) statement for PTRAS
(AHA) (34), 2014 Society of Cardiovascular Angiography (36). Using an expert panel to scientif cally review data,
and Interventions (SCAI) (35), and 2017 European Society they concluded that patients with the following were
of Cardiology (23). There are some discrepancies among most likely to gain advantage from PTRAS (36,37).
these guidelines, but all guidelines favor medical therapy 1. Cardiac destabilization syndromes: f ash pulmonary
for the primary management of RAS. edema with severe hypertension
The 2013 ACC/AHA guidelines recommend PTRAS 2. Resistant (refractory) hypertension
in patients who have hemodynamically signif cant RAS 3. Rapidly progressive ischemic nephropathy, CKD
together with any of the following (34) : with eGFR less than 45 cc/min/m , and global
2
• Recurrent CHF or sudden unexplained pulmonary renal ischemia.
edema (Class I, LOE B) Table 10-3 summarizes the AUC for treatment of ARAS
256 • Unstable angina (Class IIa, LOE B) in different indications (36). Both clinical and anatomical
• Accelerated, resistant, or malignant hypertension lesion criteria have to be met. Severe RAS is def ned as
or hypertension with unexplained unilateral small a stenosis diameter ≥70-99% or a stenosis 50-69% with
kidney and hypertension with medication intolerance a translesional peak pressure gradient (measured with
(Class IIa, LOE B) a ≤ 5-Fr catheter or pressure wire) ≥20 mmHg or a resting
• RAS and chronic renal insuff ciency (CRI) with mean pressure gradient ≥10 mmHg, a hyperemic mean
bilateral RAS or RAS to solitary functioning kidney gradient ≥10mmHg or FFR performed with dopamine
(Class IIa, LOE B) (50 µg/kg) or papaverine (32 mg) of <0.8 or any stenosis
• Asymptomatic bilateral or solitary viable kidney ≥70% diameter by intravascular ultrasound (36).
with a hemodynamically signif cant RAS (Class IIb,
LOE C) SURGICAL REVASCULARIZATION
• Asymptomatic unilateral hemodynamically
signif cant RAS in a viable kidney (Class IIb, LOE C) Although surgical renal revascularization is associated
• RAS and CRI with unilateral RAS (2 kidneys with more durable long-term results, the high surgical risk
present) (Class IIb, LOE C) limits its use. Surgical revascularization should be appraised
The 2017 ESC guidelines recommended balloon only for patients who have complex renal arteries’ anatomy,
angioplasty, without or with stenting, only selected RAS following a failed endovascular procedure, or during
patients and unexplained repeated congestive heart failure or open aortic surgery (i.e., presence of abdominal aortic
sudden pulmonary edema (Class IIb) (23). Both ACC/AHA aneurysm, renal artery dissection or aneurysm) (23,34).