Clinical benefit of renal artery angioplasty with stenting for the control of recurrent and refractory congestive heart failure

Abstract

Renal artery stenosis (RAS) may cause hypertension, azotemia, episodes of flash pulmonary edema and congestive heart failure. Renal artery angioplasty and stenting was performed in 207 patients from 1991 to 1997. Thirty-nine of these patients (19%) underwent renal artery stenting for the control of recurrent episodes of congestive heart failure and flash pulmonary edema. All patients had angiographic evidence of severe (>70%) bilateral RAS (n = 18) or severe RAS to a solitary functioning kidney (n = 21). Sixteen patients (41%) were male and 23 (59%) were female, mean age 69.9 years (range 50-85 years). Of the 18 patients with bilateral RAS, 12 (66.6%) underwent bilateral stenting. Mean blood pressure decreased from 174/85 +/- 32/23 mmHg to 148/72 +/- 24/14 mmHg (p < 0.001). Mean number of blood pressure medications decreased from 3 +/- 1 to 2.5 +/- 1 (p = 0.006). Twenty-eight patients (71.8%) had improvement in blood pressure control. The mean serum creatinine decreased from 3.16 +/- 1.61 to 2.65 +/- 1.87 (p = 0.06). Six of 39 patients (15.4%) used angiotensin converting enzyme (ACE) inhibitors prior to stenting whereas 19 of 39 patients (48.7%) used ACE inhibitors poststenting (p = 0.004). Twenty of 39 patients (51.4%) demonstrated improvement in serum creatinine, 10 of 39 patients (25.6%) had stabilization of serum creatinine and nine of 39 patients (23%) demonstrated worsening. The number of hospitalizations due to congestive heart failure in the year preceding renal artery stenting was 2.4 +/- 1.4 and poststenting was 0.3 +/- 0.7 (p < 0.001). The New York Heart Association Functional Class decreased from 2.9 +/- 0.9 prestenting to 1.6 +/- 0.9 poststenting (p < 0.001). Thirty of 39 patients (77%) had no hospitalizations for congestive heart failure during a mean follow-up period of 21.3 months. Nine patients expired during the course of follow up; eight of the nine patients died within the first year after renal artery stenting. Renal artery stenting decreased the frequency of congestive heart failure, flash pulmonary edema, and the need for hospitalization in most patients. Blood pressure was markedly improved in the majority of patients with improved or stabilized renal function. Evaluation for RAS is important in hypertensive patients who present with recurrent congestive heart failure or flash pulmonary edema.

ACC/AHA 2005 Practice Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic)

“…Individuals with RAS may experience sudden-onset or "flash" pulmonary edema (756)(757)(758)(759)(760)(761). Patients with hemodynamically severe bilateral or solitary RAS may manifest a volume-overload state because they lack normal renal function to respond to pressure natriuresis (762,763).…”

Masterclass series in peripheral arterial disease

“…Therefore, it is recommended that patients with PAD should be investigated for the presence of RAS only if: (1) the blood pressure cannot be controlled to goal levels with a good multidrug regimen; 22 (2) renal insufficency is present and not explained by another cause; 23 or (3) the patient has unexplained episodes of pulmonary edema or congestive heart failure. 24 …”

Efficacy of Renal Revascularization in a Patient With Fibromuscular Renal Artery Stenosis and Heart Failure

“…Many of those patients with atherosclerotic RAS and heart failure have been reported to benefit from renal revascularization for the control of blood pressure and also heart failure. 5) In contrast, FMD is more common among females and most cases of FMD correspond to patients younger than 50 years. There have been few reports describing patients with RAS caused by FMD who presented congestive heart failure, and the outcome of renal revascularization in those patients was not clear.…”

“…5,15) The reason for improved heart failure after revascularization may include less activation of the renin-angiotensin-aldosterone system, leading to less retention of sodium and water in the body, lower blood pressure, and prevention of cardiovascular and renal tissue remodeling. In addition, there was a safer utilization of ACE inhibitors or ARBs, which could worsen renal function in patients with bilateral RAS or those with RAS in a solitary functioning kidney.…”