Recent advances in renal artery stenting.

Renal artery stenosis (RAS) is frequent and increasingly recognized thanks to technical improvements in duplex ultrasound, magnetic resonance angiography, computed tomography (CT) scanning, systematic renal angiography during cardiac catheterisation, coronary procedures and particularly in hypertensive or multivascular diseased patients. Renal artery angioplasty and stenting is the first treatment to be proposed for patients suffering from RAS. This procedure is largely performed with very good technical results, good anatomical results, a low complication rate and a good long-term patency. The technique has proven to be beneficial for preserving RF and stabilizing or improving BP in a large number of patients. Nevertheless, deterioration in RF after the procedure in 20-30% of cases may limit the immediate benefits of this technique. Atheroembolism seems to play an important role. Renal angioplasty with protection devices seems a promising technique that might become the standard of care in the future. Even so, some problems remain: the cost of the technique; the best protection device needs to be determined; protection devices specifically designed for the renal arteries are needed; indications have to be specified. Larger, randomised studies are awaited to confirm the usefulness of the technique.

Carotid angioplasty and stenting under protection. State of the art.

A carotid stenosis is responsible for about 30% of strokes occurring. Carotid endarterectomy (CEA) is considered to be the gold standard treatment of a carotid stenosis. Carotid angioplasty and stenting (CAS) is emerging as a new alternative treatment for a carotid artery stenosis, but the risk of neurological complications and brain embolism remain the major drawback to this procedure. So as to reduce the risk, we need: good indications, good patient and lesion selection; correct techniques; brain protection devices (cerebral protection devices should be routinely used and are mandatory for any procedure. Three types of protection devices are available: filters are the most commonly used. Nevertheless, all protection devices have limitations and cannot prevent from embolic events. However neurological complications can be reduced by 60%. New protection devices will be discussed); good choice of the stent and correct implantation (all stents are not equivalent and have different geometrical effects); pharmacological adjuncts; good team. Indications are well accepted for high-risk patients and recent studies have shown that CAS has superior short-term outcomes than CEA in this group of patients. Indications for low-risk and asymptomatic patients are controversial. New selection criteria have to be discussed. But there are enough reported data to conclude that CAS is also not inferior to CEA in low-risk and asymptomatic patients. In our series of 844 procedures, without protection (n = 187) 30-day death and stroke rate was 3.7% and with protection (n = 657) 1% (1.3% for symptomatic patients, 0.9% for asymptomatic patients, 1.4% in high-risk patients, 0.4% in low-risk patients). CAS under protection is the standard of care and is maybe becoming the gold standard treatment of a carotid stenosis at least in some subgroups of patients.

Carotid angioplasty in asymptomatic patients undergoing CABG surgery.

AIM: Although there are studies reporting that carotid endarterectomy (CEA) is recommended before or concomitant to coronary artery bypass grafting (CABG) in patients with severe carotid stenosis, controversies still exist. Carotid artery stenting (CAS) has been recently introduced as an alternative revascularization therapy in high-risk patients. The aim of this study was to demonstrate, whether CAS is safe as an alternative treatment to carotid CEA, in asymptomatic candidates for CABG surgery. METHODS: Forty-one patients with severe carotid and coronary artery disease were studied. The mean age was 65 years; 91% were males. Within 1 week of the CAS intervention all patients underwent CABG surgery. A brain protection device was used in all CAS interventions. Balloon PTA and stenting was performed in all subjects. Adjunctive therapy with heparin was used during the procedure and clopidogrel was started immediately after cardiac surgery. Patients were assessed neurologically before and after the procedure (immediately after the CAS, at 24h, at 30 days, at 3, 6 and 12 months). The primary end point was the incidence of TIA, stroke, or death at 30 days. RESULTS: Internal carotid artery lesions of > 80%, were reduced by CAS to < 20% in all cases, achieving a procedural success of 100%. There were no neurological complications, such as TIA and stroke, or death, up to 12 months follow up. One patient developed acute coronary syndrome the day after CAS and was treated accordingly. CONCLUSION: Our results show that CAS, with brain protection in asymptomatic patients undergoing CABG surgery is feasible and safe and could be a good alternative to CEA.