Endovascular brachytherapy for renal artery in-stent restenosis.

OBJECTIVE: Renal artery in-stent restenosis (RAISR) is not an infrequent occurrence and may be in part responsible for the failure of renal stents to improve clinical outcome. A variety of treatments have been used to restore patency, with mixed results. These include repeated percutaneous transluminal renal angioplasty (PTRA), repeated PTRA with bare-metal stents, and repeated PTRA with drug-eluting stents or covered stents. Endovascular brachytherapy (EVBT) has been proven effective in preventing recurrent neointimal hyperplasia in coronary bare-metal stents. This prompted our group to study the effect of EVBT on RAISR. METHODS: From 2004 to 2012, 21 patients (23 renal arteries) developed RAISR ≤ 30 months after the initial procedure and were subsequently treated with EVBT. Five patients had at least one prior PTRA for recurrent restenosis. Renal artery duplex scanning was performed as a baseline study within a few days of the EVBT and then every 6 months. All patients who had EVBT were concurrently treated by PTRA and EVBT on the basis of existing protocols. Patency of the treated stents was evaluated by Kaplan-Meier survival curves. RESULTS: The average onset of the original RAISR was 11 ± 9 months (range, 2-30 months; median, 8 months). The initial technical success of combined PTRA and EVBT was 100%. Mean follow-up was 44 ± 18 months (range, 14-84 months). Of five patients who had PTRA before EVBT, four were available for long-term follow-up. These four patients had a combined total number of five PTRAs before EVBT, with recurrent stenosis developing on average by 12 months. After EVBT, three stents were patent at 39, 48, and 65 months, and one stent restenosed at 42 months. This was the only patient in the entire series to develop restenosis after EVBT. CONCLUSIONS: This retrospective experience with a relatively small number of patients undergoing concurrent EVBT/PTRA for recurrent stenosis in stents placed to treat atherosclerotic renal artery stenosis suggests that EVBT is safe and provides long-term freedom from recurrent stenosis.

Comparison of early and late efficacy of percutaneous transluminal renal angioplasty with or without subsequent brachytherapy: the effect on blood pressure in patients with renovascular hypertension.

BACKGROUND: Scarce data exist concerning the long-term effect of percutaneous transluminal renal angioplasty (PTRA) enhanced with intravascular gamma brachytherapy (IVBT) in patients with renovascular hypertension. METHODS: Seventy one patients aged 52 +/- 8 years with refractory renovascular hypertension were randomized to Group I (PTRA + IVBT) or Group II (PTRA). For the IVBT procedure, the PARIS catheter and Microselectron HDR (Nucletron) system was employed. Both baseline and 9-month follow-up quantitative computerized angiography (QCA) and ambulatory blood pressure monitoring analysis was performed to assess luminal parameters of restenosis and the effect of treatment on blood pressure. RESULTS: Thirty three patients from Group I and 29 patients from Group II underwent successful procedure. During nine months of follow-up, three patients died; including two patients in Group I (cardiac causes) and one patient in Group II (stroke). The follow-up lumen diameter stenosis was 30.6 +/- 13.7% and 40.4 +/- 11% in Groups I and II, respectively (p = 0.004). Late lumen loss in quantitative computerized angiography was 1.2 +/- 0.7 mm and 1.7 +/- 0.7 mm in Groups I and II, respectively (p = 0.004). CONCLUSIONS: Intravascular gamma brachytherapy using self-centering source performed after balloon angioplasty is a safe and effective method of prevention of restenosis after PTRA in patients with renovascular hypertension.

Brachytherapy for renal [corrected] artery in-stent restenosis.

Percutaneous transluminal angioplasty with stenting is now an established modality for treatment of atherosclerotic renal artery stenosis. However, the rate of restenosis can be as high as 20%. While intravascular brachytherapy has proven efficacy in coronary artery in-stent stenosis, its role in the treatment of renal artery in-stent stenosis is not well understood. We report a case of recurrent in-stent renal artery stenosis treated successfully by brachytherapy with excellent follow up results at 22 months.

The use of brachytherapy to treat renal artery in-stent restenosis.

The percutaneous treatment of renal artery stenosis has become the accepted revascularization strategy by most physicians treating this disorder. Unfortunately, as renal artery angioplasty and stent implantation become increasingly prevalent the Achilles heel of angioplasty, in-stent restenosis, also rises. There are currently no data suggestive of the optimal treatment strategy for renal artery in-stent restenosis. However, given the similarities in the pathophysiology between renal artery and coronary artery in-stent restenosis, brachytherapy is considered a reasonable option. This is the strategy that has been suggested and used by a number of operators. This case report describes two examples of renal artery in-stent restenosis treated with angioplasty and brachytherapy.

A case of renal artery brachytherapy for in-stent restenosis: four-year follow-up.

Renal artery stent implantation is associated with high rates of restenosis, particularly in vessels less than 4.5 mm in diameter. We describe 4-year follow-up results in the first patient to receive renal artery brachytherapy for this indication. A 68-year-old man who presented with flash pulmonary edema, hypertension and renal impairment was found to have severe bilateral renal artery stenosis and was treated with bilateral stent implantation. Following clinical deterioration due to severe in-stent restenosis, he underwent repeat angioplasty followed by intra-stent brachytherapy. To our knowledge, this is the first use of such therapy and hence the 4-year follow-up demonstrating excellent bilateral patency is the longest to date.

Endovascular brachytherapy for the treatment of renal artery in-stent restenosis using a beta-emitting source: a report of five patients.

We report five cases of renal artery in-stent restenosis treated with endovascular brachytherapy. This procedure has been previously used extensively for the treatment of coronary artery in-stent restenosis with successful results. Therefore, it follows logically that noncoronary in-stent restenoses would also be successfully treated in this manner. Though our experience is limited, we feel that this report provides adequate data to justify the formation of a prospective trial for a more adequate evaluation of the potential utility of this intriguing approach.

Brachytherapy for renal artery in-stent restenosis.

We describe a 66-year-old female who presented with recurrent acute pulmonary edema and uncontrolled hypertension. She was diagnosed with left renal artery stenosis and treated with angioplasty and stent placement. Her clinical status improved initially but symptoms recurred within 4 months. Further evaluation documented renal artery in-stent restenosis, which was successfully treated with cutting balloon angioplasty followed by brachytherapy. The feasibility of renal artery brachytherapy and short-term follow-up is presented.

Hipertensión vasculorrenal y nefropatía isquémica secundaria a radioterapia / Radiation-induced renovascular hypertension

Se describe el caso de un paciente de 24 años de edad que desarrolló lesiones isquémicas en distintos órganos provocadas por la administración de radioterapia por un orquioblastoma en la infancia. Más de 20 años después de recibir irradiación con cobalto a altas dosis sobre la región abdominogenital presentó una pancreatitis crónica y una colangitis esclerosante, una nefropatía isquémica, con hipertensión arterial vasculorrenal secundaria a estenosis bilateral de arterias renales y un infarto isquémico del cono medular. De todas las lesiones, la que evolucionó más favorablemente fue la renal, ya que aunque la arteria renal derecha tenía una obstrucción prácticamente completa, la izquierda se consiguió dilatar mediante angioplastia transluminal percutánea, con buen resultado final y progresiva mejoría de la función renal. Sin embargo, fue necesario mantener la mayoría de los fármacos antihipertensivos, probablemente debido al efecto presor que seguía ejerciendo la arteria renal derecha ocluida. Tras más de dos años de seguimiento la función renal sigue siendo prácticamente normal y no existen datos de reestenosis de la arteria renal izquierda (AU)

Successful treatment of intimal hyperplasia in renal arteries by endovascular brachytherapy.

PURPOSE: The present study shows the possibility of preventing restenosis of renal arteries by endovascular brachytherapy. METHODS AND MATERIALS: We present a patient suffering from rapid restenosis of both renal arteries with decreasing renal function. Percutaneous transluminal angioplasty (PTA) and stent implantation were unable to stop hypertension and to stabilize renal function. Both renal arteries and the right pole artery were treated by endovascular brachytherapy in one session. RESULTS: Six months after intervention, intraarterial digital subtraction angiography (DSA) showed no evidence of recurrence, and the blood pressure remained normal without medical treatment. CONCLUSION: Endovascular brachytherapy can help to prevent restenosis in renal arteries. It is possible to treat both renal arteries and one pole artery in one session without any disadvantage.