Renal artery revascularization: outcomes stratified by indication for intervention

Virendra I Patel, Mark F Conrad, Christopher J Kwolek, Glenn M LaMuraglia, Thomas K Chung, Richard P Cambria
Journal of Vascular Surgery 2009, 49 (6): 1480-9

OBJECTIVES: Application of endovascular therapy has led to increasing rates of renal artery intervention with unclear effect on hypertension (HTN) and/or renal salvage (RS). We evaluated the role of procedure indication on outcomes of both open (OR) and percutaneous (PR) revascularization.

METHODS: Retrospective review of all consecutive renal artery interventions performed from January 1, 2002 to December 31, 2006 was conducted. OR patients were included for analysis only if independent renovascular indications for revascularization existed.

RESULTS: Forty-seven OR and 203 PR (97% stent) patients were treated with 98% initial technical success. Patients with OR were younger (65 +/- 11 vs 72 +/- 9; P < .01), on more blood pressure (BP) medications (2.3 +/- 1.2 vs 1.8 +/- 1.2; P < .05), had more peripheral arterial disease (75% vs 37%; P < .01), and higher baseline creatinine (2.2 +/- 1.6 mg% vs 1.8 +/- 1 mg%; P < .05). Indications for PR were HTN in 46% and RS in 54%, and indications for OR were HTN in 51% and RS in 49% of cases. PR was unilateral in 169 (83%) and bilateral in 44/203 (17%). OR consisted of bypass in 26 (53%) and endarterectomy in 21/47 (47%) with 20 (43%) bilateral procedures. Peri-procedural complications were different (P < .01) and more frequent in OR (23% vs 12%). Survival was similar at three years (72% +/- 4% PR vs 71% +/- 9% OR; P = .9). Assisted patency was similar (P = .6) at one (94% +/- 2% PR vs 97% +/- 3% OR) and three years (90% +/- 3% PR vs 91% +/- 5% OR). One year (97% +/- 1% PR vs 97% +/- 3% OR) and three year (93% +/- 3% PR vs 91% +/- 7% OR) freedom from reintervention was similar (P = .8). Clinical outcomes showed patients with OR and PR having similar rates of cure or improvement in BP (76% PR vs 90% OR; P = .1) and favored OR with stable or improved renal function (97% vs 89%; P < .01) by the first postoperative visit. Hypertension control remained similar (P = .2) in both groups with cure/improvement in BP in 74% of PR and 89% of OR patients at one year. OR remained durable in regards to renal salvage with 52% of OR patients having improved renal function compared with 24% of PR (P < .01) patients at one year. At one year, BP control was achieved if treatment indication was HTN in 100% (18/18) of OR patients and 74% (46/63) (P = .04) of those having PR. Renal function stabilized or improved in 16/19 (85%) of OR and 70/81 (86%) of PR patients when performed for RS (P = .4).

CONCLUSIONS: PR and OR are similarly efficacious for treatment of HTN associated with renal artery stenosis. While immediate and long-term outcomes favor OR for RS, this may impart from the triage of patients more likely to benefit from renal artery revascularization to OR.

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