Renal Artery Stenosis in Patients With Resistant Hypertension

doi:10.1016/j.amjcard.2013.06.030

The American Journal of Cardiology

Volume 112, Issue 9, 1 November 2013, Pages 1417-1420

https://doi.org/10.1016/j.amjcard.2013.06.030 Get rights and content

The aim of the study was to assess the significance of renal translesional pressure gradients in predicting improvement in resistant hypertension after stenting for moderate renal artery stenosis (RAS). In 37 patients with RAS and resistant hypertension subjected to renal stenting, translesional pressure gradients both at rest and hyperemic were measured using a pressure guidewire. Twenty-four-hour ambulatory blood pressure measurements were performed in all patients on admission and 3 months after the intervention. Angioplasty was successful in all patients, with reduction of artery diameter stenosis from 60 ± 12% to 10 ± 6% (p <0.0001). At 3 months, with maintained hypotensive agents (4.0 ± 1.4 vs 4.0 ± 1.6), significant reductions in systolic blood pressure (SBP) and diastolic blood pressure were noted (−5 and −2 mm Hg, respectively). In multivariate analysis, the mean baseline gradient (MBG) was the only independent predictor of improvement in SBP (regression coefficient 0.292; standard error 0.11; p value 0.014). In the receiver operating characteristic curve analysis, MBG had a larger area under the curve than other parameters, and the MBG >22 mm Hg had the highest sensitivity, specificity, and accuracy (50%, 95%, and 0.74%, respectively) in predicting hypertension improvement after stenting. In patients with MBG >22 mm Hg, SBP decreased by 12 versus 3 mm Hg (p <0.01) in patients with MBG ≤22 mm Hg, whereas diastolic blood pressure in both groups decreased by 3 versus 1 mm Hg, respectively (NS). In conclusion, MBG value of >22 mm Hg provides the highest accuracy in predicting hypertension improvement after stenting for moderate RAS in patients with resistant hypertension.

Section snippets

Methods

The study conducted in 2 centers included 37 consecutive patients with resistant hypertension and RAS, angiographically categorized as moderate (50% to 70%). All patients signed the informed consent form, and the study protocol was approved by local ethic committees. Resistant hypertension was defined as randomly measured values of arterial blood pressure exceeding the guideline values for diabetic and nondiabetic patients (>140/90 and >130/80 mm Hg, respectively), despite the use of ≥3

Results

Baseline parameters and angiographic data of all 37 patients are listed in Table 1. Procedural success was obtained in all cases. None of the patients demonstrated a significant aggravation of renal function in the follow-up. Measurements of TPG were conducted in all patients. Values obtained after hyperemia induction were significantly higher than those in baseline conditions. The results of pressure gradient measurements are listed in Table 2.

The entire study population was subjected to a

Discussion

This is one of the first studies of pressure gradient–guided renal artery stenting in patients with moderate RAS and resistant hypertension. We showed that referring to the TPG measurements in the population of patients with resistant renovascular hypertension and moderate RAS (50% to 70%) may be useful in identifying those patients who would benefit from the procedure of renal artery stenting. Our data demonstrated that MBG >22 mm Hg, measured using a pressure wire, is an independent predictor

Disclosures

The authors have no conflicts of interest to disclose.

References (18)

D. Lao et al.
Atherosclerotic renal artery stenosis—diagnosis and treatment
Mayo Clin Proc
(2011)
R.D. Safian et al.
Refining the approach to renal artery revascularization
JACC Cardiovasc Interv
(2009)
S.C. Textor et al.
The uncertain value of renal artery interventions: where are we now?
JACC Cardiovasc Interv
(2009)
M.A. Leesar et al.
Prediction of hypertension improvement after stenting of renal artery stenosis: comparative accuracy of translesional pressure gradients, intravascular ultrasound, and angiography
J Am Coll Cardiol
(2009)
G. Manoharan et al.
Assessment of renal flow and flow reserve in humans
J Am Coll Cardiol
(2006)
C. Mounier-Vehier et al.
Changes in renal blood flow reserve after angioplasty of renal artery stenosis in hypertensive patients
Kidney Int
(2004)
C.J. White
Catheter-based therapy for atherosclerotic renal artery stenosis
Circulation
(2006)
A. Levin et al.
Controversies in renal artery stenosis: a review by the American Society of Nephrology Advisory Group on Hypertension
Am J Nephrol
(2007)
P.F. Plouin et al.
Blood pressure outcome of angioplasty in atherosclerotic renal artery stenosis: a randomized trial: Essai Multicentrique Medicaments vs Angioplastie (EMMA) Study Group
Hypertension
(1998)

There are more references available in the full text version of this article.

Cited by (20)

Hemodynamic Measurements for the Selection of Patients With Renal Artery Stenosis: A Systematic Review
2017, JACC: Cardiovascular Interventions
Citation Excerpt :
A total of 565 records were found after searching MEDLINE and Embase, and after removal of 265 duplicates, 300 records were screened for eligibility, resulting in 15 studies with relevant information on the diagnostic value of renal hyperemia (Figure 2) (30–44). Because 3 selected studies had overlapping study cohorts (40–42) and study cohorts were heterogeneous, no qualitative synthesis of study data could be performed. An overview of the selected studies is included in Table 1.
Interventions targeting renal artery stenoses have been shown to lower blood pressure and preserve renal function. In recent studies, the efficacy of catheter-based percutaneous transluminal renal angioplasty with stent placement has been called into question. In the identification of functional coronary lesions, hyperemic measurements have earned a place in daily practice for clinical decision making, allowing discrimination between solitary coronary lesions and diffuse microvascular disease. Next to differences in clinical characteristics, the selection of renal arteries suitable for intervention is currently on the basis of anatomic grading of the stenosis by angiography rather than functional assessment under hyperemia. It is conceivable that, like the coronary circulation, functional measurements may better predict therapeutic efficacy of percutaneous transluminal renal angioplasty with stent placement. In this systematic review, the authors evaluate the available clinical evidence on the optimal hyperemic agents to induce intrarenal hyperemia, their association with anatomic grading, and their predictive value for treatment effects. In addition, the potential value of combined pressure and flow measurements to discriminate macrovascular from microvascular disease is discussed.
Comparison of the renal hyperemic effects of papaverine and dopamine in patients with renal artery stenosis
2015, Journal of the American Society of Hypertension
Citation Excerpt :
A large randomized trial would be necessary to prove the hypothesis that measurement of post–dopamine translesional pressure gradient in RAS may be helpful in selecting patients who benefit from renal revascularization. However, based on previous observations,6,7 we believe that patients with dopamine–induced hyperemic translesional gradients of 20 mm Hg or more could be randomly assigned to undergo renal revascularization plus medical therapy or to receive medical therapy alone. Patients with hyperemic translesional gradients less than 20 mm Hg should receive medical therapy alone and be included in a registry.
The purpose of this study was to assess the hyperemic effects of papaverine and dopamine in the renal microcirculation of hypertensive patients with renal artery stenosis (RAS). Although a poor correlation between angiographic lesion assessment and its hemodynamic significance is known, angiography is a major criterion for the decision of renal artery stenting. Assessment of the hyperemic translesional pressure gradient was recently shown to be conducive in identifying patients who may benefit from renal revascularization. The study included 14 patients (mean age, 66 ± 11.2 years) with resistant hypertension and moderate RAS. Using a pressure–sensing catheter, systolic, diastolic, and mean translesional pressure gradients, and the distal pressure (Pd):aortic pressure (Pa) ratio (Pd/Pa) were analyzed at baseline and after administration of 40 mg papaverine and 50 μg/kg dopamine. We did not observe significant changes in DG. Dopamine administration resulted in significant changes in systolic and mean translesional pressure gradients and Pd/Pa when compared with baseline (P < .05 for all). Changes in these parameters were caused by a decrease in systolic Pd in comparison with baseline conditions (119 ± 34 mm Hg vs. 101 mm Hg; P < .05). Systolic Pd pressure after papaverine (104 mm Hg) did not change significantly. Systolic and diastolic Pa values did not differ from baseline after either dopamine or papaverine bolus administration.This study indicates that, compared with papaverine, the intrarenal bolus of dopamine in hypertensive patients with RAS remains a more powerful hyperemic agent.
CT-based fractional flow reserve: Development and expanded application
2021, Global Cardiology Science and Practice
Pressure gradient measurement to verify hemodynamic results of the chimney endovascular aortic repair (chEVAR) technique
2021, PLoS ONE
How should we define appropriate patients for percutaneous transluminal renal angioplasty treatment?
2020, Hypertension Research
Selection of Patients for Angioplasty for Treatment of Atherosclerotic Renovascular Disease: Predicting Responsive Patients
2020, American Journal of Hypertension

View all citing articles on Scopus

: This study was partially supported by Project “WroVasc—Integrated Cardiovascular Center”, cofinanced by the European Regional Development Fund, within Innovative Economy Operational Program, 2007 to 2013 realized in Regional Specialist Hospital, Research and Development Center in Wroclaw. “European Funds—for the development of innovative economy” (Wroclaw, Poland).

: See page 1420 for disclosure information.

View full text

Systemic hypertensionRenal Artery Stenosis in Patients With Resistant Hypertension

Section snippets

Methods

Results

Discussion

Disclosures

Mayo Clin Proc

JACC Cardiovasc Interv

JACC Cardiovasc Interv

J Am Coll Cardiol

J Am Coll Cardiol

Kidney Int

Catheter-based therapy for atherosclerotic renal artery stenosis

Circulation

Controversies in renal artery stenosis: a review by the American Society of Nephrology Advisory Group on Hypertension

Am J Nephrol

Blood pressure outcome of angioplasty in atherosclerotic renal artery stenosis: a randomized trial: Essai Multicentrique Medicaments vs Angioplastie (EMMA) Study Group

Hypertension

Systemic hypertension
Renal Artery Stenosis in Patients With Resistant Hypertension