Interventions in the reno-visceral circulation

The PCR Textbook

Summary

Significant renal artery stenosis (RAS) may result in deterioration of arterial hypertension and/or renal insufficiency, contributing to congestive heart failure, hypertensive encephalopathy and progressive general atherosclerosis. Plain balloon angioplasty (POBA) is the established therapy for RAS, caused by fibromuscular disease (FMD) and inflammatory processes. Here, the role of cutting balloon angioplasty is still investigational.

In atherosclerotic RAS, stenting has shown superior acute and long-term technical outcomes compared to POBA alone. Technical improvements have made both interventions more successful and safer. Single-centre studies have reported the beneficial clinical effect of percutaneous revascularisation of RAS of different aetiologies. However, the randomised STAR, ASTRAL and CORAL trials did not show any benefit of RAS revascularisation over best medical therapy alone in selected patient cohorts; yet evidence exists that stenting of haemodynamically relevant atherosclerotic RAS has an impact on blood pressure control, renal function, left ventricular hypertrophy and patient survival.

Similarly, chronic mesenteric ischaemia (CMI) is caused mainly by atherosclerosis and sometimes by external compression, fibromuscular dysplasia and inflammation. Symptomatic CMI is an uncommon, potentially under-diagnosed condition caused by fixed stenosis or occlusion usually of at least two visceral arteries. If only one of the three major arteries supplying the bowel (celiac trunk, superior and inferior mesenteric arteries) is affected, the patient is usually asymptomatic due to a well-developed collateral network. Symptoms and clinical signs of CMI may vary from postprandial pain, weight loss and upper abdominal bruit to nonspecific symptoms. CMI of atherosclerotic origin is associated with a high morbidity and mortality. Despite higher restenosis rates, endovascular revascularisation has recently replaced surgical revascularisation as the therapy of choice in most centres. This chapter introduces the interventional techniques, including the management of complications and periprocedural care.

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