Percutaneous Revascularization of

the Renal Arteries: Predictors

of Outcome1
Marie-France Giroux, MD PURPOSE: To identify predictors of clinical outcome after percuta-
Gilles Soulez, MD neous revascularization of the renal arteries.
Eric Thérasse, MD
MATERIALS AND METHODS: In 63 patients, the therapeutic re-
Viviane Nicolet, MD
sponse was retrospectively assessed after percutaneous revascular-
Daniel Froment, MD
ization of the renal arteries indicated for hypertension (41.3%), re-
Maryse Courteau, MD
nal failure (4.8%), or both (53.9%). All patients underwent percuta-
Vincent L. Oliva, MD
neous transluminal renal angioplasty, complemented by stent in-
sertion in 30 patients. The authors analyzed the role of clinical and
Index terms: Renal arteries, stenosis
imaging factors, including scintigraphy, Doppler sonography, and
or obstruction ● Renal arteries, translumi- angiography for predicting clinical success.
nal angioplasty ● Renal angiography ● Ul-
trasound (US), Doppler studies RESULTS: In the hypertensive population, there were three cures
(5.6%), 26 improvements (48.1%), and 25 failures (46.3%). Among pa-
JVIR 2000; 11:713–720
tients with renal insufficiency, 12 were improved (37.5%), 11 were
Abbreviations: FMD ⫽ fibromuscular stabilized (34.4%), and nine deteriorated (28.1%). Predictors of fa-
dysplasia, PRRA ⫽ percutaneous revascu- vorable outcome for hypertension were shorter duration of hyper-
larization of the renal arteries, PTrA ⫽
tension, higher diastolic blood pressure, fibromuscular dysplasia,
percutaneous transluminal renal angio-
plasty, RAS ⫽ renal artery stenosis abnormal Doppler study, higher percentage of angiographic steno-
sis, and lower grade of aortic atheromatous disease. Predictors of
favorable outcome for renal failure were nondiabetic status, abnor-
mal Doppler study, and higher percentage of angiographic steno-
sis. Abnormal Doppler and scintigraphic examinations predicted
successful treatment of hypertension in 60% and 53.8% of cases, re-
spectively, and renal insufficiency in 85% and 60% of cases, respec-
tively.
CONCLUSION: Clinical and angiographic variables were the best
predictors of therapeutic success for hypertension. Doppler sonog-
raphy was useful in patients with renal failure.

LESS than 5% of the hypertensive To this day, angiography remains

population has an underlying reno- the gold standard for diagnosing the
vascular etiology (1). In addition, presence of a RAS. However, be-
the finding of a renal artery steno- tween 30%–50% of patients with
sis (RAS) in a patient with hyper- significant angiographic RAS will
1
tension does not prove the presence not have a positive clinical response
From the Departments of Radiology
(M.F.G., G.S., E.T., V.N., V.L.O.) and Ne- of renovascular hypertension. after percutaneous revasculariza-
phrology (D.F., M.C.), CHUM—Notre- Percutaneous revascularization tion (6 –11); this illustrates the diffi-
Dame Hospital, 1560 Sherbrooke East, of the renal arteries (PRRA) im- culty of adequately selecting pa-
Montreal, Quebec, Canada, H2L 4M1.
proves or stabilizes the clinical evo- tients for PRRA. In the recent liter-
Received November 9, 1999; revision re-
quested December 11; revision received lution of hypertension and renal ature, renal scintigraphy before and
January 6, 2000; accepted January 7. Ad- failure in a number of patients after captopril administration has
dress correspondence to G.S.; E-mail: (2,3). A number of clinical parame- been suggested as a good test for
[email protected]
ters are believed to be predictive of identifying true renovascular dis-
© SCVIR, 2000 a favorable clinical response (4,5). ease (12,13). Doppler sonography
713
714 ● Percutaneous Revascularization of the Renal Arteries
June 2000 JVIR

has been used with success for the sure gradient ⬎ 10 mm Hg after to the results of the other imaging
detection of RAS but its role in pre- PTrA. For the present study, we studies. For outcome analysis, all
dicting the clinical outcome after defined technical success after Doppler variables, as well as longi-
PRRA is not well-defined. The pur- PRRA as patency of the treated ste- tudinal kidney size, were recorded
pose of this study was to identify notic site with a residual stenosis for each revascularized kidney.
predictors of clinical outcome after ⬍ 50% and a pressure gradient When bilateral PRRA was per-
PRRA by evaluating several clinical ⬍ 10 mm Hg. Following these crite- formed in the same patient, the
and imaging variables, including ria, technical success was achieved Doppler variables of the more ste-
renal Doppler sonography and scin- in 60 of the 63 patients (95%). The notic kidney were recorded.
tigraphy. clinical outcome was analyzed at The scintigraphic diagnosis of
the time of the last follow-up in the RAS was based on a semiquantita-
60 patients with technically suc- tive approach to renogram patterns
cessful PRRA. and quantitative indexes, such as
MATERIALS AND METHODS Restenosis was diagnosed in six uptake of the tracer and time to
Between January 1995 and De- patients during the follow-up pe- peak activity and/or residual corti-
cember 1997, 63 patients (mean riod. This diagnosis was made with cal activity, as well as modification
age, 63.6 ⫾ 11.9 years; 34 men, 29 angiography in three patients, of these parameters after captopril
women) were included in this retro- Doppler sonography in two patients, administration (12). Indeterminate
spective study. All patients under- and scintigraphy in one patient. Doppler or scintigraphic studies
went percutaneous transluminal The medical records of all pa- were considered abnormal. All scin-
renal angioplasty (PTrA) with or tients were reviewed and the follow- tigraphic studies were reviewed by
without stent placement for RAS ing clinical parameters were record- one investigator (M.F.G.) who was
ⱖ 60% in our institution, and pa- ed: sex, age, duration of hyperten- blind to the results of the other im-
tients also had a medical file acces- sion, systolic/diastolic blood pres- aging studies.
sible for obtaining follow-up data. sure, presence of diabetes, smoking All angiographic stenoses were
habit, serum creatinine, and etiol- measured with precision calipers
During the same period, 36 addi-
ogy of RAS. A clinical and labora- and a magnifying lens. For each
tional patients referred for renal
tory follow-up was obtained for all RAS, the severity of the stenosis
PTrA, mostly from other institu-
patients after PRRA. The mean fol- was calculated as a percentage of
tions, were not included in the
low-up period for patients treated the diameter of the normal artery,
study population because of absence
for hypertension and renal failure the length of the stenosis was mea-
of an accessible medical file. Fifty- was 12.6 ⫾ 10 months (range, sured, the size of the renal artery
six patients had atheromatous RAS 3– 43.4 months) and 11.3 ⫾ 8.7 was noted, and the location of the
and seven patients had fibromuscu- months (range, 3–36 months), re- stenosis relative to the ostium was
lar dysplasia (FMD). The indica- spectively. recorded. In cases of multiple RAS,
tions for PRRA were hypertension All patients had undergone trans- the artery with the most severe ste-
in 26 patients (41.3%), renal failure renal Doppler sonography and/or nosis was selected. In cases of bilat-
in three patients (4.8%), and both in scintigraphy (Tc-99m diethylenetet- eral RAS, the artery with the most
the remaining 34 patients (53.9%). riamine pentraacetic acid or Tc-99m severe stenosis was considered, if
Therefore, 60 of the 63 patients un- mercaptoacetyl-triglycine) prior to only one side was treated (ie, atro-
derwent PRRA for hypertension and PRRA: 29 patients (46%) underwent phic controlateral kidney), the
37 patients for renal failure. Twen- Doppler sonography, 15 (23.8%) un- treated artery was considered. Ath-
ty-four patients had bilateral RAS. derwent scintigraphy, and 19 eromatous disease of the aorta was
In the hypertensive population, the (30.2%) underwent both examina- graded as follows: grade 1 ⫽ nor-
mean systolic and diastolic blood tions. Eight Doppler sonograms mal; grade 2 ⫽ minimal atheroma
pressure measurements were 162 ⫾ were obtained before and after an (small irregularities of the aortic
28 mm Hg and 85 ⫾ 14 mm Hg, oral dose of 25 mg of captopril. Ten wall without luminal reduction or
respectively, prior to PRRA, and the scintigraphic studies were per- ulceration); grade 3 ⫽ moderate
mean duration of hypertension was formed before and after captopril atheroma (several aortic plaques
7.4 ⫾ 10.5 years. For patients with administration and 24 were per- with less than 30% of aortic diame-
renal failure, the mean serum cre- formed after captopril administra- ter reduction without ulcerations);
atinine level was 182 ⫾ 74 ␮mol/L tion only. grade 4 ⫽ severe atheroma (numer-
before PRRA. The Doppler criteria for identify- ous aortic plaques, lesions of more
Thirty-three (52.4%) patients had ing RAS were based on intrarenal than 30% of aortic diameter reduc-
balloon angioplasty alone, and 30 waveform morphology (14,15). How- tion and/or ulcerated plaques; previ-
(48.6%) patients also underwent ever, acceleration, acceleration time, ous abdominal aortic, aortofemoral
stent insertion (Palmaz; Johnson & and resistive index were also mea- or aortoiliac bypass). After PRRA,
Johnson Interventional Systems, sured. All Doppler sonographic ex- the residual stenosis percentage
Warren, NJ) because of a residual aminations were reviewed by one and pressure gradient were noted.
stenosis ⬎ 50% or a residual pres- investigator (V.L.O.) who was blind All angiographic studies were re-
 Giroux et al ● 715
Volume 11 Number 6

nine ⬎ 150 ␮mol/L. The outcome of

hypertension after PRRA was clas-
sified in one of three categories: 1)
cure (diastolic blood pressure less
than 90 mm Hg without any hyper-
tensive medication); 2) improve-
ment—(a) diastolic blood pressure
less than 90 mm Hg with (i) a de-
crease of the diastolic pressure of at
least 15% without an increase of
antihypertensive medication, or (ii)
a reduction of antihypertensive
medication; or (b) diastolic pressure
between 90 and 110 Hg with a de-
crease of the diastolic pressure of at
least 15% without an increase of
the medication; and 3) failure (all
other situations). Therapeutic suc-
cess for hypertension included cure
or improvement. The outcome of
renal failure after PRRA was also
Figure 1. Evolution of systolic blood pressure (mm Hg) before and after (at the classified in one of three categories:
time of the last follow-up) percutaneous revascularization of the renal arteries in (i) improvement (a decrease of at
the therapeutic success (A) and therapeutic failure (B) groups (SD ⫽ standard de- least 15% of the serum creatinine
viation). level); (ii) stabilization (less than
15% variation of the serum creati-
nine level); and (iii) deterioration
(greater than 15% increase of the
serum creatinine level). Improve-
ment and stabilization defined ther-
apeutic success for renal failure.
The results of Doppler sonogra-
phy and scintigraphy were corre-
lated to those of angiography for
calculating sensitivity values. Sta-
tistical analyses for finding predic-
tors of clinical outcome included pa-
tients with technically successful
procedures (as defined previously)
and adequate follow-up data. Fifty-
four of the 60 patients were avail-
able for analyzing hypertension
(three technical failures and three
lost to follow-up) and 32 of the 37
patients were available for analyz-
ing renal failure (three technical
failures and two lost to follow-up).
Figure 2. Evolution of diastolic blood pressure (mm Hg) before and after (at the A number of clinical, biologic, and
time of the last follow-up) percutaneous revascularization of the renal arteries in
imaging variables were analyzed in
the therapeutic success (A) and therapeutic failure (B) groups (SD ⫽ standard de-
viation). relation to the outcome of hyperten-
sion and renal failure after PRRA.
Both univariate and multivariate
analyses were performed but Dopp-
viewed by one investigator (G.S.) was diagnosed when three blood ler and scintigraphic variables were
who was blind to the results of the pressure measurements were ob- only tested with univariate analysis
other imaging studies. tained at rest, with a diastolic read- because they were not available for
Standard criteria were used for ing greater than 90 mm Hg and/or all patients. A Cox model was used
defining hypertension and renal a systolic reading greater than 160 for performing multivariate analy-
failure, as well as their respective mm Hg. Renal failure was defined ses. Baseline factors such as sex,
clinical response (16). Hypertension as elevation of the serum creati- age, and diabetes were included in
716 ● Percutaneous Revascularization of the Renal Arteries
June 2000 JVIR

tients studied, for a sensitivity of

Table 1
Univariate Analysis: Relation of Variables with Successful Treatment of
96%, and scintigraphy detected RAS
Hypertension in 27 of the 34 patients studied, for
a sensitivity of 77%. The therapeu-
Variables Success Failure P tic success of PRRA for hyperten-
sion was 53.7% (three cures and 26
Sex (female) 16/29 (55.2) 10/25 (40) .27
Age (y) 61.8 ⫾ 12.6 65.8 ⫾ 8.0 .18
improvements) because 25 of the 54
Duration of hypertension (y)* 3.5 ⫾ 3.9 11.7 ⫾ 13.5 .01 patients (46.3%) failed to respond.
Systolic blood pressure (mm Hg) 166.1 ⫾ 27.1 159.5 ⫾ 28.3 .41 In the hypertensive population, the
Diastolic blood pressure (mm Hg)* 89.9 ⫾ 13.2 81.6 ⫾ 13.0 .03 mean systolic pressure before and
Diabetes 3/29 (10.3) 6/24 (25.0) .16 after PRRA was 162 ⫾ 28 mm Hg
Smoking 15/29 (51.7) 9/25 (36.0) .10 and 152 ⫾ 24 mm Hg respectively
FMD (vs atheroma)* 6/29 (20.7) 0/25 (0.0) .02 (P ⫽ .012) and, similarly, the mean
Stenting (vs angioplasty) 16/29 (55.2) 13/25 (52.0) .82 diastolic pressure was 85 ⫾ 14 mm
Bilateral (vs unilateral) stenosis 10/29 (34.5) 11/25 (44.0) .47 Hg before and 80 ⫾ 9.6 mm Hg
Ostial (vs nonostial) stenosis 18/29 (62.1) 16/25 (64.0) .88
after PRRA (P ⫽ .001). Figure 1
Size of artery (mm) 5.4 ⫾ 0.7 5.2 ⫾ 0.6 .26
Degree of angiographic stenosis (%)* 79.1 ⫾ 8.7 74.3 ⫾ 9.2 .05 illustrates the difference (P ⬍ .001)
Length of stenosis (mm) 6.8 ⫾ 4.9 7.4 ⫾ 4.2 .63 of the mean systolic pressure be-
Grading of atheroma (3–4 vs 1–2)* 17/29 (58.6) 24/25 (96) .001 tween patients in the therapeutic
Intrarenal Doppler sonography success group (144 ⫾ 17 mm Hg)
Stenosis (pattern recognition)* 23/23 (100) 15/18 (83.3) .04 and the therapeutic failure group
Kidney size (mm) 98.2 ⫾ 13.6 100 ⫾ 12.4 .67 (161 ⫾ 28 mm Hg) after PRRA.
Acceleration time/C⫺ (sec) 0.12 ⫾ 0.06 0.11 ⫾ 0.09 .68 Figure 2 displays the significant
Acceleration time/C⫹ (sec) 0.08 ⫾ 0.04 0.14 ⫾ 0.1 .41 decrease (P ⬍ .001) of the diastolic
Acceleration/C⫺ (m/sec2) 397.2 ⫾ 446.7 355.0 ⫾ 368.3 .75 pressure from 90 ⫾ 13 mm Hg to
Acceleration/C⫹ (m/sec2) 421.9 ⫾ 242.0 335.4 ⫾ 338.8 .71
Resistive index/C⫺ 0.61 ⫾ 0.13 0.64 ⫾ 0.11 .34
80 ⫾ 9 mm Hg after PRRA in the
Resistive index/C⫹ 0.61 ⫾ 0.11 0.59 ⫾ 0.14 .84 therapeutic success group, as opposed
Scintigraphy: stenosis 14/16 (87.5) 12/15 (80.0) .57 to the therapeutic failure group.
Univariate analysis (Table 1)
Note.—FMD ⫽ fibromuscular dysplasia; C⫺ ⫽ without captopril; C⫹ ⫽ after reveals that the following factors
captopril. Numbers in parentheses are percentages. are associated with a favorable out-
* Statistically significant variables. come of hypertension after PRRA:
shorter duration of hypertension
(P ⫽ .01), higher preprocedural
diastolic blood pressure (P ⫽ .03),
Table 2 stenosis related to fibromuscular
Cox Regression Analysis for Correlating Variables with Unsuccessful dysplasia (P ⫽ .02), higher degree
Treatment of Hypertension of angiographic RAS (P ⫽ .05),
Variables Reference OR 95% CI P low-grade (grades 1–2) aortic ather-
omatous disease (P ⫽ .001), and ab-
Sex (female) Male 0.47 0.20–1.14 .10 normal Doppler study (based on
Age (y) Continuous 1.04 0.98–1.10 .20 morphologic waveform analysis)
Diabetes Non-diabetic 1.58 0.53–4.76 .41 (P ⫽ .04).
Diastolic blood pressure Continuous 0.98 0.94–1.01 .23
With multivariate analysis, low-
Stenosis (%)* Continuous 0.95 0.90–0.99 .03
Grading of atheroma (grade 3–4)* Grade 1–2 11.91 1.52–93.3 .02 grade atheromatous aortic disease
FMD Atheroma nc nc .48 (P ⫽ .02) and a higher degree of
angiographic stenosis (P ⫽ .04)
Note.—OR ⫽ odds ratio; FMD ⫽ fibromuscular dysplasia; nc ⫽ not calculable were associated with a better out-
(due to intercorrelation with other variables); CI ⫽ confidence interval. come of hypertension after PRRA
* Statistically significant variable. (Table 2).
The positive predictive value of
Doppler sonography and scintigra-
phy for successfully treating hyper-
the multivariate analysis, as well Statistical significance was set at a tension after PRRA was 60% (23
as every factor that appeared to be level of P ⱕ .05. therapeutic successes/38 positive
significant on the univariate analy- Doppler examinations) and 53.8%
sis. Categorical variables were as- (14 therapeutic successes/26 posi-
sessed using ␹2 test or Fisher exact RESULTS tive scintigraphy examinations), re-
test, and linear variables were ana- Doppler sonography detected the spectively. Because the samples
lyzed with use of the Student t test. presence of RAS in 46 of the 48 pa- were not independent, no P value
 Giroux et al ● 717
Volume 11 Number 6

(37.5%), 11 stabilized patients

(34.4%), and nine deteriorated pa-
tients (28.1%). The clinical success
rate for renal insufficiency was
71.8%. For the whole renal failure
population, there was a nonsignifi-
cant change in the mean serum cre-
atinine from 182 ⫾ 74 ␮mol/L be-
fore PRRA to 168.62 ⫾ 62 ␮mol/L
at the last follow-up (P ⫽ .27). In
the therapeutic failure group, the
mean serum creatinine increased
from 169.43 ⫾ 59.87 ␮mol/L to
223.57 ⫾ 68.98 ␮mol/L after PRRA
(P ⫽ .03) (Fig 3). Conversely, the
mean serum creatinine decreased
from 185.95 ⫾ 78.53 ␮mol/L to
148.36 ⫾ 57.08 ␮mol/L after PRRA
in the therapeutic success group
Figure 3. Evolution of mean serum creatinine level (␮mol/L) before and after (at (P ⫽ .009).
the time of the last follow-up) percutaneous revascularization of the renal arteries The results of univariate analy-
in the therapeutic success (A) and therapeutic failure (B) groups (SD ⫽ standard sis, which correlates variables
deviation).
with the outcome of renal insuffi-
ciency after PRRA, are summa-
Table 3 rized in Table 3. A nondiabetic
Univariate Analysis: Relation of Variables with Successful Treatment of status (P ⫽ .02) and abnormal re-
Renal Failure
sults of Doppler study (based on
Factors Success Failure P intrarenal waveform morphologic
analysis) (P ⫽ .04) were associated
Sex (female) 9/23 (39.1) 4/9 (44.4) .78
with a better evolution of renal
Age (y) 67.4 ⫾ 6.9 70.9 ⫾ 5.2 .18
Creatinine 186.0 ⫾ 78.5 169.4 ⫾ 60.0 .62 insufficiency after PRRA. The
Creatinine clearance 34.0 ⫾ 16.7 30.3 ⫾ 13.8 .62 mean resistive index was slightly
BUN 12.4 ⫾ 5.7 14.3 ⫾ 5.8 .43 lower in patients with therapeutic
Diabetes* 2/22 (9.1) 4/9 (44.4) .02 success (0.62 ⫾ 0.12) when com-
Smoking 8/23 (34.8) 3/9 (33.3) .71 pared to patients with therapeutic
FMD (vs atheroma) 1/23 (4.3) 0/9 (0.0) .53 failure (0.71 ⫾ 0.11) but this dif-
Stenting (vs angioplasty) 16/23 (69.6) 5/9 (55.6) .45
Bilateral (vs unilateral) stenosis 12/23 (52.2) 6/9 (66.7) .46
ference was not significant (P ⫽
Ostial (vs nonostial) stenosis 16/23 (69.6) 7/9 (77.8) .64 .17).
Size of artery (mm) 5.2 ⫾ 0.7 5.6 ⫾ 0.5 .16 Multivariate analysis revealed
Angiographic stenosis (%) 76.0 ⫾ 10.7 73.2 ⫾ 10.8 .52 only a marginally significant associa-
Length of stenosis (mm) 7.4 ⫾ 4.8 7.7 ⫾ 3.8 .90 tion (P ⫽ .06) between nondiabetic
Grading of atheroma (3–4 vs 1–2) 19/23 (82.6) 9/9 (100) .07 patients and a favorable outcome of
Doppler sonography renal insufficiency after PRRA
Stenosis (pattern recognition)* 17/18 (94.4) 3/5 (60.0) .04
Kidney size (mm) 95.8 ⫾ 13.2 108.1 ⫾ 10.6 .07 (Table 4).
Acceleration time/C⫺ (sec) 0.14 ⫾ 0.08 sec 0.09 ⫾ 0.05 .23 The value of Doppler sonography
Acceleration/C⫺ (m/sec2) 388.2 ⫾ 495.3 410.1 ⫾ 430.5 .93 and scintigraphy for predicting suc-
Resistive index/C⫺ 0.62 ⫾ 0.12 0.71 ⫾ 0.11 .17 cessful treatment of renal insuffi-
Scintigraphy: stenosis 9/11 (81.8) 6/7 (85.7) .83 ciency with PRRA was 85% (17
Note.—BUN ⫽ blood urea nitrogen; FMD ⫽ fibromuscular dysplasia; C⫺ ⫽
therapeutic successes of 20 abnor-
without captopril. Numbers in parentheses are percentages. mal Doppler examinations) and
* Statistically significant variable. 60% (nine therapeutic successes of
15 abnormal scintigraphic exami-
nations), respectively. For the
was calculated to compare Doppler none had normal results of Doppler same reasons mentioned previ-
sonography and scintigraphy. Of study. ously, Doppler sonography and
the hypertensive patients who were In the renal failure population, scintigraphy could not be com-
successfully treated with PRRA, PRRA resulted in 12 improvements pared with P values.
718 ● Percutaneous Revascularization of the Renal Arteries
June 2000 JVIR

Doppler sonography for predicting

Table 4
Cox Regression Analysis for Correlating Variables with Unsuccessful
the clinical outcome after PRRA be-
Treatment of Renal Insufficiency cause few studies are available on
this subject (29,30). Kaplan et al
Variables Reference OR 95% CI P (29) reported positive predictive val-
ues of 86% for captopril scintigra-
Sex (female) Male 0.39 0.06–2.39 .31
Age (y) Continuous 1.04 0.92–1.17 .52 phy and 85% for Doppler sonogra-
Diabetes Nondiabetic 5.91 0.96–36.6 .06 phy, for predicting successful con-
Aortic atheroma (grade 3–4) Grade 1–2 nc nc .18 trol of hypertension after PRRA. We
obtained lower positive predictive
Note.—OR ⫽ odds ratio; CI ⫽ confidence interval; nc ⫽ not calculable
values with respect to hypertension
(insufficient data).
for both tests (60% for Doppler
sonography and 53.8% for scintigra-
phy). The discrepancy in the perfor-
also were found to be predictive of a mance of scintigraphy between the
DISCUSSION favorable outcome of hypertension study of Kaplan et al and ours can
in our study. be explained in part by the high
In keeping with the results found
Interestingly, we also observed proportion of bilateral stenoses (24
in other studies (6,7,17–21), we ob-
that a higher grade of atheromatous of 63 patients) and renal failure (37
served a discrepancy between the
aortic disease favored clinical fail- of 63 patients), two conditions
high technical success rate of PRRA
ure, showing a strong association in known for decreasing the perfor-
and the modest clinical success ob-
the hypertensive group and a weak mance of scintigraphy (12,31). The
tained in our study. We obtained
association in the renal insuffi- fact remains that, in our experi-
better clinical results for renal fail-
ure than for hypertension, even ciency group. Generalized athero- ence, Doppler sonography and scin-
when comparing with the results sclerosis has been reported to nega- tigraphy did not predict clinical suc-
found in the literature. Our hyper- tively affect the outcome of renal cess better than clinical and angio-
tensive population included a high insufficiency (2), but atheromatous graphic factors in the hypertensive
proportion of patients with athero- disease was mainly related to the population.
sclerotic lesions and concomitant outcome of hypertension in our se- Interestingly however, morpho-
renal insufficiency, two conditions ries. Similarly, the severity of an- logic waveform analysis-based
known for reducing the effect of in- giographic stenosis was a better in- Doppler sonography proved to be
tervention on blood pressure in pa- dicator of the hypertensive response useful for predicting successful out-
tients with RAS (22). The effective- when compared to renal failure. We come of renal insufficiency after
ness of correcting RAS for treating observed the opposite association PRRA. Abnormalities of intrarenal
hypertension also has been shown with diabetes mellitus, which is Doppler waveform morphology re-
to be limited in the presence of uni- known to cause end-stage renal dis- flect the hemodynamic significance
lateral atherosclerotic lesions (23). ease (26,27). As expected, a diabetic of proximal RAS; this may relate to
Furthermore, the benefits of per- status was associated to failure of renal function more directly than to
forming PRRA are more difficult to PRRA to correct renal insufficiency the complex mechanisms involved
demonstrate when strict criteria are in our series, probably because of in renovascular hypertension.
utilized for evaluating the outcome irreversible microvascular damage Contrary to other studies, we did
of hypertension, as was the case in produced by diabetes. However, it not find quantitative Doppler crite-
our study. This relatively low suc- did not negatively affect the thera- ria to be of significant prognostic
cess rate for treating hypertension peutic outcome of hypertension value with respect to PRRA. High
highlights the importance of finding among our patients. resistive indexes have been associ-
outcome predictors for selecting pa- In contradiction with previously ated to therapeutic failure (30,32).
tients who will benefit from PRRA. published results that were based The mean resistive index was lower
Several such predictors already on series with conventional angio- in the therapeutic success group for
have been reported in the litera- plasty (8,28), bilateral or ostial RAS patients with renal failure but this
ture. Male gender, duration of hy- were not associated with clinical difference was not significant. This
pertension for less than 10 years, a failure in our study. This is proba- can be related to the small sample
diastolic pressure greater than 80 bly related to the use of stents, size of patients with renal failure.
mm Hg, FMD, and a younger age which improve the patency rate of In addition, because of the small
have been associated with a better renal arteries as compared to PTrA number of patients who underwent
outcome of hypertension after arte- alone (19). The size of the revascu- postcaptopril Doppler sonography,
rial revascularization of the kidney larized kidney did not predict suc- we were unable to demonstrate the
(4,5,24,25). Some of these factors cess or failure of PRRA in our pa- usefulness of captopril for detecting
(shorter duration of hypertension, a tients. curable renovascular disease.
higher diastolic pressure, and FMD) Most interesting is the value of The limitations of our study are
 Giroux et al ● 719
Volume 11 Number 6

linked to its retrospective design lower than reported in the litera- progressive renal failure. Ann In-
and the fact that many patients had ture. An abnormal intrarenal Dopp- tern Med 1993; 118:712–719.
not been investigated with both ler waveform is associated with a 10. Canzanello VJ, Millan VG, Spiegel
Doppler sonography and scintigra- favorable outcome of renal failure JE, Ponce SP, Kopelman RI, Madias
phy. As such, these two diagnostic after PRRA. NE. Percutaneous transluminal
studies could not be included in a renal angioplasty in management of
atherosclerotic renovascular hyper-
multivariate analysis for direct Acknowledgments: The authors tension: results in 100 patients. Hy-
comparison. In addition, the small would like to thank Mr. Marc Dumont, pertension 1989; 13:163–172.
number of negative Doppler or scin- PhD, for his statistical advice, and Mrs. 11. Pattynama PMT, Becker GJ, Brown
tigraphic examinations did not al- Andrée Cliche, RN, for her research as- J, Zemel G, Benenati JF, Katzen
low evaluation of their negative pre- sistance. BT. Percutaneous angioplasty for
dictive value. Another limitation is atherosclerotic renal artery disease:
the presence of hypertension in References effect on renal function in azotemic
most patients with renal failure, 1. Subcommittee on definition and patients. Cardiovasc Intervent Ra-
which can be a confounding factor prevalence of the 1984 Joint Na- diol 1994; 17:143–146.
when analyzing the therapeutic re- tional Committee. Hypertension 12. Prigent A. The diagnosis of reno-
prevalence and the status of aware- vascular hypertension: the role of
sponse of renal failure. Inclusion of
ness, treatment, and control in the captopril renal scintigraphy and re-
patients with FMD in the same United States (final report). Hyper- lated issues. Eur J Nucl Med 1993;
sample as patients with atheroma- tension 1985; 7:457– 468. 20:625– 644.
tous lesions can be another limita- 2. Ascer E, Gennaro M, Rogers D. 13. Pederson EB. Angiotensin-convert-
tion because of different clinical Unilateral renal artery revascular- ing enzyme inhibitor renography:
characteristics between these two ization can salvage renal function pathophysiological, diagnostic and
populations (especially better thera- and terminate dialysis in selected therapeutic aspects in renal artery
peutic response and low degree of patients with uremia. J Vasc Surg stenosis. Nephrol Dial Transplant
atheromatous infiltration in pa- 1993; 18:1012–1018. 1994; 9:482– 492.
tients with FMD). Only one patient 3. Zierler RE, Bergelin RO, Davidson 14. René PC, Oliva VL, Bui BT, et al.
RC, Cantwell-Gab K, Polissar NL, Renal artery stenosis: evaluation of
with FMD was in the renal failure Strandness DE. A prospective
group and FMD was not a signifi- Doppler US after inhibition of an-
study of disease progression in pa- giotensin converting enzyme with
cant predictor. Conversely, six pa- tients with atherosclerotic renal ar- captopril. Radiology 1995; 196:675–
tients with FMD were included in tery stenosis. Am J Hypertens 1996; 679.
the hypertensive group. In the uni- 9:1055–1061. 15. Oliva VL, Soulez G, Lesage D, et al.
variate analysis, FMD was a signifi- 4. Barri YM, Davidson RA, Senler S, Detection of renal artery stenosis
cant variable (P ⫽ .02) and the et al. Prediction of cure of hyper-
with Doppler sonography before and
variable atheromatous grading was tension in atherosclerotic renal ar-
after administration of captopril:
highly significant (P ⫽ .001). In the tery stenosis. South Med J 1996;
value of early systolic rise. AJR
89:679 – 683.
Cox regression analysis, which is a 1998; 170:169 –175.
5. Davidson RA, Barri Y, Wilcox CS.
multivariate analysis, FMD was no Predictors of cure of hypertension in
16. Maxwell MH, Bleifer KH, Franklin
longer a significant predictor and fibromuscular renovascular disease. SS, Varady PD. Cooperative study
the variable atheromatous grading Am J Kidney Dis 1996; 28:334 –338. of renovascular hypertension: demo-
was still significant but at a lower 6. Boisclair C, Therasse E, Oliva VL, graphic analysis of the study. JAMA
level (P ⫽ .02). There is probably et al. Treatment of renal angio- 1972; 220:1195–1204.
plasty failure by percutaneous renal 17. Rees CR, Palmaz JC, Becker GJ, et
some collinearity between both vari-
artery stenting with the palmaz al. Percutaneous angioplasty for
ables (statistical association) but, atherosclerotic stenoses involving
considering the multivariate analy- stent: midterm technical and clinical
results. AJR 1997; 167:245–251. the ostia of the renal arteries: pre-
sis, the degree of atheromatous in- liminary report of a multicenter
7. Iannone LA, Underwood PL, Nath
filtration is a stronger predictor A, Tannenbaum MA, Ghali MGH, study. Radiology 1991; 181:507–514.
than FMD and this association can Clevenger LD. Effect of primary 18. Blum U, Flugel P, Gabelmann A, et
be extrapolated to the atheromatous balloon expandable renal artery al. Treatment of ostial renal artery
population. stents on long-term patency, renal stenoses with vascular endoprosthe-
In conclusion, already estab- function, and blood pressure in hy- ses after unsuccessful balloon angio-
lished clinical criteria are of value pertensive and renal insufficient pa- plasty. N Engl J Med 1997;
for selecting patients who will bene- tients with renal artery stenosis. 336:459 – 465.
fit from PRRA. Angiographic crite- Cathet Cardiovasc Diagn 1996; 37: 19. Hennequin LM, Joffre FG, Rous-
243–250. seau HP, et al. Renal artery stent
ria, such as the severity of angio-
8. Sos TA. Angioplasty for the treat- placement: long-term results with
graphic stenosis and grading of aor- the Wallstent endoprosthesis. Radi-
ment of azotemia and renovascular
tic atheromatous disease, seem hypertension in atherosclerotic renal ology 1994; 191:713–719.
valuable for predicting the response artery disease. Circulation 1991; 83: 20. Dorros G, Prince C, Mathiak L.
of hypertension to PRRA. Contrary I162–I166. Stenting of a renal artery stenosis
to previous data, the prognostic 9. Rimmer JM, Gennari FJ. Athero- achieves better relief of the obstruc-
value of scintigraphy seems to be sclerotic renovascular disease and tive lesion than balloon angioplasty.
720 ● Percutaneous Revascularization of the Renal Arteries
June 2000 JVIR

Cathet Cardiovasc Diagn 1993; 29: ence in Spain. JVIR 1994; 5:101– topril renography and duplex Dopp-
191–198. 109. ler sonography in the diagnosis of
21. White CJ, Ramee SR, Collins TJ, 25. Losinno F, Zuccalà A, Busato F, renovascular hypertension. Nephrol
Jenkins JS, Escobar A, Shaw D. Zucchelli P. Renal artery angio- Dial Transplant 1998; 13:313–317.
Renal artery stent placement: util- plasty for renovascular hyperten- 30. Frauchiger B, Zierler R, Bergelin
ity in lesions difficult to treat with sion and preservation of renal RO, Isaacson JA, Strandness DE.
balloon angioplasty. J Am Coll Car- function: long-term angiographic Prognostic significance of intrarenal
diol 1997; 30:1445–1450. and clinical follow-up. AJR 1994; resistance indices in patients with
22. Harden PN, Mac leod MJ, Rodger 162:853– 857. renal artery interventions: a prelim-
RSC, et al. Effect of renal-artery 26. Connolly JO, Higgins RM, Walters inary duplex sonographic study.
stenting on progression of renovas- HL, et al. Presentation, clinical fea- Card Vasc Surg 1996; 4:324 –330.
cular renal failure. Lancet 1997; tures and outcome in different pat- 31. Mc Lean AG, Hilson AJ, Scoble JE,
349:1133–1136. terns of atherosclerotic renovascular et al. Screening for renovascular
23. Webster J, Marshall F, Dominiczak disease. QJM 1994; 87:413– 421. disease with captopril-enhanced
A, et al. Randomized comparison 27. Mailloux LU. Atherosclerotic reno- renography. Nephrol Dial Trans-
of percutaneous angioplasty vs con- vascular disease causing end-stage plant 1992; 7:211–215.
tinued medical therapy for hyper- renal disease: the case for earlier 32. Petersen LJ, Petersen JR, Talleru-
tensive patients with atheromatous diagnosis and therapy. J Vasc Med phuus U, Ladefoged SD, Mehlsen J,
renal stenosis. J Human Hypertens Biol 1993; 4:277–284. Jensen HA. The pulsatility index
1998; 12:329 –335. 28. Martin L, Cork R, Kaufman S. and the resistive index in renal ar-
24. Rodriguez-Pérez JC, Plaza C, Reyes Long-term results of angioplasty in teries: associations with long-term
R, et al. Treatment of renovascular 110 patients with renal artery ste- progression in chronic renal failure.
hypertension with percutaneous nosis. JVIR 1992; 3:619 – 626. Nephrol Dial Transplant 1997; 12:
transluminal angioplasty: experi- 29. Kaplan-Pavloveie S, Nadja C. Cap- 1376 –1380.