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VIII.StentAngioplasty
While balloonangioplastyremainsanimportanttherapyforthetreatmentofpulmonaryarterystenoses,
long-term results are often unsatisfactory.14 This is particularly true in stenoses related to external
compression,kinking,orstretchingofthepulmonaryartery.Animalandclinicalstudieshaveshownthat
intravascular stents can maintainpulmonaryarterypatency and improve distal vasculature growth
22-26
(Fig.7.2B,D,andE).Restenosisduetoneointimalproliferationdoesoccurinpulmonaryarterystentsand
has been associated with overdilation, insufficient overlap between adjacent stents, and bifurcation
stenosisstenting25(Fig.7.4).Whileearlierreportsdemonstratedrestenosisratesof2%-3%,
24,27
amore
recentreportbyHallbergsonetalshowedrestenosisin24%ofpatients.PatientswithtetralogyofFallot
andmajor aortopulmonary collaterals appear to be atparticular riskfor restenosis and warrant close
follow-upafterstentplacement.28Restenosiscanmostoftenbeaddressedwithrepeatangioplasty.
24,25,27
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FIGURE7.4 BalloonpulmonaryangioplastyinapatientwithWilliamssyndrome.A,Pulmonaryangiogram
demonstratingseverein-stentrestenosis(arrow).B,Balloonangioplastydemonstratingadiscretewaist(arrow)as
theballoonexpands.C,Highpressureballoonangioplastyresultsincompleteresolutionofthewaist(arrow).D,
Post-angioplastyangiogramdemonstratingnoresidualstenosis(arrow).
A.ConsiderationsandCircumstancesforStentAngioplasty
4,8,29
1.Centralbranchpulmonaryarterystenosis
2.Stenosisduetostretchorkinking
3.Stenosisthatexhibitsrecoilfollowingballoonangioplasty
4.Stenosisduetoexternalcompression
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5.Earlypostoperativestenosis
6.Stenosisduetoocclusiveintimalflapsfollowingballoonangioplasty
7.Long-segmentstenosis
B.AdditionalConsiderations
Standard or cutting balloon angioplasty is frequently attempted as a first-line therapy in stenotic
pulmonaryarterieswithstentplacementreservedforthosevesselsthatexhibitimmediatefailuredueto
significantrecoil,occlusivedissection,orlaterestenosisafterangioplasty.Primarystentangioplastymay
be considered in long segment stenoses, stenoses due to external compression or “kinking,” and
bifurcation stenoses as these lesions typically do not respond to simple balloon angioplasty. Stent
angioplastyinlesionsresistanttoballoonexpansioncanworsenobstructionduetointimalgrowthifthe
stenosis is not relieved. Stents places to treat stenoses in the distal vasculature may exhibit greater
degreesoflatestentstenosis.
30
Early postoperative pulmonary artery stenoses following congenital heart surgery can significantly
increasemorbidityandmortality.Stentangioplastyofsuchstenoseshasbeenshowntobemoreeffective
andsaferthanballoonangioplasty.4Althoughrare,primarystentangioplastyhasalso beeneffectivein
the relief of pulmonary artery obstruction caused by fibrosing mediastinitis and systemic arteritis
involving the pulmonary arteries. Reintervention is frequently required due to recurrent obstruction;
however,significantimprovementinsymptomsandsurvivalispossible.
31-33
IX.StentSelection
Therearenostentsspecificallydesignedorapprovedforuseinthepulmonaryarteries.Thusoperators
must repurposesystemic vascularandbiliarystents (Table7.2). Stent selectionmust takeintoaccount
patient age and growth potential; the ultimate “adult” pulmonary vessel size must be considered. For
example, a stent implanted in the proximal right pulmonary artery must ultimately be able to reach a
diameterofatleast16-18mm.Recenteffortstofracturepulmonaryarterystentswithultrahigh-pressure
balloons have shown promise. This technique allows for relief of obstruction caused by small but
maximallydilatedstentsthatwouldotherwiserequiresurgicalmodification.
34,35
Table7.2
AvailableStentsforPulmonaryArteryStenting
UnmountedStents(handcrimpingrequired)
Stent AvailableLengths(mm) MaxDiameter(mm) CellDesign PulmonaryArteryApplication
PalmazXL 30,40,50 28 Closed/fixed Centralpulmonaryarterybranches
MaxLD 16,26,36 26 Open/dilateable12mm Centralpulmonaryarterybranches;
Lobarbranches
MegaLD 16,26,36 18 Open/dilateable12mm Centralpulmonaryarterybranches;
Lobarbranches
GenesisXD 19,25,29,59 18 Closed/dilateable Centralpulmonaryarterybranches;
Lobarbranches
PremountedStents
Balloon AvailableDiameters(mm) MaxDiameter(mm) AvailableLengths Guidewire CellDesign
LargeGenesis
OptaPro 5-10 10 19,29,39,59,79 0.035 Closed/dilateable
Me diumGenesis
OptaPro 4-8 8 12,15,18,24 0.035 Closed/dilateable
Slalom 3-8 8 15,18,24,39 0.018 Closed/dilateable
PalmazBlue
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Aviator 4-7 7 15,17,20,25 0.014 Closed/dilateable
Although attractive for their flexibility and low-profile delivery system requirements, use of selfexpandingstentsinthepulmonaryarteries shouldbeavoided.Thesestentsexhibitexuberantneointimal
proliferation,lackpotentialforover-dilation,andhavebeenshowntomigrateafterimplant.
36
A.CommonlyUsedStents
ThemostcommonlyusedstentsforpulmonaryarterystenosesarethePalmazGenesisseries,PalmazXL
series,andtheIntraStentMaxLDBiliaryStent(Table7.2).
1.TheGenesisstentsareavailablein3sizeranges—medium,large,andXD“extra-diameter.”Whilethe
medium- andlarge-size Genesis stentsare attractive becausetheycome premountedonanangioplasty
balloon,onlytheunmountedGenesisXDstentscanreachdiameters>12mm.MediumGenesisstentscan
only reach 8-9 mm in diameter, and thus their use should be limited to segmental and subsegmental
pulmonary artery branches. Despite their labeling, large Genesis stents can only reach 10-12 mm in
diameter.Thus,althoughusefulforlobarorsmallerpulmonaryarterybranches,theyshouldnotroutinely
beusedinproximalbranchpulmonaryarteries.GenesisXDstentscanreach18mmindiameterandthus
canbeusedinthecentralbranchpulmonaryarteries.However,thesestentsareonlyavailableunmounted
andmust be crimped byhand onto an angioplasty balloon for delivery. The closed-cell design ofthe
PalmazGenesisseriesmaylimittheabilitytoopenthecellsinsituationswhereasidebranchiscrossed.
However,withcurrentlyavailableultrahigh-pressureballoons,the stent strutscanusually befractured
whennecessary;thismaynegativelyimpactstentintegrity.
2. ThePalmazXL seriesstentsarecapableofexpanding to28-30 mm indiameter. However,atthese
diameters,thereismarkedforeshortening.Thesestentshavehighradialstrengthbutareinflexible,making
deliverytothe branchpulmonaryarteries challenging. Incurrent practice theyare most oftenused for
stenting inthemainpulmonaryarteryandrightventricularoutflow tractbeforetranscatheterpulmonary
valveimplantation.LiketheGenesisXDseries,PalmazXLstentsareonlyavailableunmountedandmust
be hand-crimped onto an angioplasty balloon. They are closed-cell, and fracture of the struts can be
difficult.Thusifaside-branchjailingisnecessaryinacentralpulmonaryartery,considerationshouldbe
giventouseoftheIntraStentMaxLDstents(seebelow).
3.TheIntraStentMaxLDstentscanachievediametersupto26mm.Thesestentsaresignificantlymore
flexiblethanthePalmazXLstentsbuthavelessradialstrengthandaremorepronetolatefracture.They
haveanopen-celldesignallowingexpansionofthecellstoatleast12mm.Theirflexibilityandopen-cell
design allow them to be placed within curvilinear vessels with less distortion than is seen with the
closed-cellstents.Lobar,segmental,andsubsegmentalpulmonaryarterystenosescanlargelybemanaged
with premounted stents. However, theproximal branch pulmonaryarteries and main pulmonary artery
require placement of stents capable of reaching diameters of at least 16-18 mm. None of the stents
capable of reaching these diameters are currently available premounted. Rather, one must choose a
ballooncatheterofappropriatesizeandhand-crimpthestentontotheballoon.Inourpractice,wemost
oftenselectaBIBballoon(BBraun)forstentdelivery.Thisballoon-in-ballooncatheterconsistsoftwo
“nested,” independentlyinflatableballoonsona singlecatheter shaft.Itisavailable withouterballoon
diametersof8-30mm.Theinnerballoonis½thediameterand10mmshorterthantheouterballoon.The
stentiscenteredandcrimpedontheouterballoon.Onceatthetargetlesion,theinnerballoonisinflated
expandingthecenterofthestentbeforetheproximalanddistalends.Thisprevents“dog-boning,”where
theshouldersoftheballoonandhencetheendsofthestentexpandfirst.Theriskofstentdislodgementis
thusreduced.Furthermore,withthestentfixedat½itsintendeddiameter,angiographyandrepositioncan
beperformedbeforeinflationoftheouterballoon.
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4. For implant of unmounted stents at diameters <8 mm, we use the OptaPro PTA Dilation Catheter
(Cordis).Whileotherlowerprofileballoonsareavailable,wehavefoundthatitisdifficulttosecurely
hand-crimpastentontothesevery-low-profileballoons.
D.TechniqueConsiderations
Excellent and detailed discussion of the techniques and materials required for pulmonary artery stent
angioplastycanbefoundinDr.CharlesMullins’textbook“CardiacCatheterizationinCongenitalHeart
Disease;”(Chapters22and23).37Thefollowingkeypointsshouldbeconsidered:
1.Stentproceduresshouldbeperformedinabiplaneangiography–equippedlaboratory.
2.Generalanesthesiashouldbeusedforthesecomplexprocedures.
3.Cross-matchedbloodshouldbeimmediatelyavailable.
4.Arterialaccessforbloodpressuremonitoringisrecommended.
5. As a consequence of the manufacturing process, premounted mediumand large Genesis stents are
tightlyadherenttotheirdeliveryballoonandcanthusbesafelydeliveredtothepulmonaryarteriesovera
guidewirewithouttheuseofalongdeliverysheath.38While thistechnique may be advantageouswhen
implanting stents in infants or postoperative stenoses, in the majority of cases this practice is to be
discouraged.
6.Hand-crimpedstentsshouldalwaysbedeliveredtotheirtargetvesselthroughalongsheath.Manually
crimpedstents can snaganddislodgeonChiari networkstrands,tricuspid valve leaflets andchordae,
outflowtractmusclebands,calcifiedpatches,etcastheytransittherightheart.
7. To accommodate the added stent material, a sheath 2-3 French sizes larger than required for the
angioplastyballoonshouldbechosen.
8. Stiff wires, sheaths, and catheters can distort the target anatomy. Check-angiography should be
performed through the side-arm of the long sheath or through an additional catheter positioned via a
separateaccesssitebeforeballooninflation.Afterconfirmingposition,acontrolledinflationshouldbe
performed.Rapidinflationlimitstheoperator’sabilitytorespondtochangesinballoonpositionandcan
resultinstentmalposition.
9.Thefreshlyimplantedstentis notadherenttothevesselwallandis atriskfordislodgement;thisis
particularly true where the stent is not addressing a rigid stenosis (ie stenoses due to external
compression or vessel stretch). Techniques to avoid dislodgement should be considered in such
situations.
39
E.Complications
Complicationsassociatedwithstentangioplastyincludestentmalposition,stentmigration/dislodgement,
occlusion/jailing of side branches, vessel rupture, dissection, compression of adjacent structures
includingbronchiandcoronaryarteries,pulmonaryedema,andthrombosis.
25,40,41
X.TherapeuticAlgorithm
Therapeuticalgorithmsforpulmonaryarterystenosisarecomplexandrequireconsiderationofetiology,
location,patient ageandgrowth potential, underlyingcardiopulmonary physiology, and need for future
surgery.BergersenandLock10provide anexcellentreview ofcatheter-based therapies for pulmonary
arterystenosis.AsageneralframeworkthefollowingalgorithmcanbefollowedasshowninFig.7.5.
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FIGURE7.5 Therapeuticalgorithmforthemanagementofpulmonaryarterystenosis.
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C H A P T E R 8
RenovascularDisease
JohnF.SetaroMD,FACC,FSCAI
I.Introduction
II.AnatomicConsiderations
III.PathophysiologicFactorsandNaturalHistory
A.SystemicHypertensionCausedbyRenovascularDisease
B.PulmonaryCongestion
C.LateRenalIschemiaandDysfunction
D.AtheroscleroticRenovascularDisease
IV.ClinicalPresentations
A.Literature
B.Population
V.AtheroscleroticRenovascularDisease
VI.NonatheroscleroticRenovascularDisease
A.FibromuscularDysplasia
B.OtherRareNonatheroscleroticFormsofRenovascularDisease
VIIDiagnosticExaminations
A.RenalDuplexUltrasound
B.CaptoprilRenalArteryScintigraphy
C.Angiography
D.DiscoveryofStenosis
VIII.RenalRevascularization:EarlySurgicalExperience
IX.RenalRevascularization:BalloonAngioplasty
X.RenalRevascularization:EndoluminalStenting
A.No-TouchTechnique
B.DirectMethod
C.ProcedureStepsandOptions
XI.MedicalVersusTranscatheterManagement:ClinicalTrialEvidence
A.EMMA(EssaiMulticentriqueMedicamentsvsAngioplastie)StudyGroup
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B.ScottishandNewcastleRenalArteryStenosisCollaborativeGroup
C.DutchRenalArteryStenosisInterventionCooperativeStudyTrial(DRASTIC)
D.STARTrial(StentPlacementinPatientsWithAtheroscleroticRenalArteryStenosisandImpairedRenalFunction)
E.ASTRALTrial(AngioplastyandStentingforRenalArteryLesions)
F.CORAL(CardiovascularOutcomesinRenalAtheroscleroticLesions)
XII.RenalVeinThrombosis
XIII.RenalSympatheticDenervationforResistantHypertension:TheoryandEarlyExperience
XIV.RenalSympatheticDenervationforResistantHypertension:RandomizedProspectiveData
A.EarlyCatheter-BasedTrials:SymplicityHTN-1Study
B.SymplicityHTN-2Trial
C.SymplicityHTN-3Trial
D.SPYRALHTN-OFFMEDTrial
XV.RenalSympatheticDenervationforExtrarenalCirculatoryDisorders
XVI.ContemporaryManagementofRenovascularDiseaseandFutureDirections
A.InterventionalTherapies
B.GuidelinesandIndications
XVII.Summary
KeyPoints
■Atheroscleroticdiseaseunderliesrenalarterystenosisin90%ofcases.
■Guidelines recommend revascularization as a Class I indication for hemodynamically
significantrenovasculardiseasewithrecurrentunexplainedheartfailureorflashpulmonary
edema.
■Invasive evaluationmayinclude angiographywith measurementofpercentagestenosis as
well asmore physiologic measures such as resting ratio ofdistalartery to aorticpressure
(Pd/Pa) <0.90, hyperemic fractional flow reserve value (Pd/Pa) <0.80, hyperemic mean
gradient >20mm Hg,hyperemic systolic gradient >20mm Hg,or intravascular ultrasound
(IVUS)–derivedMLA<8.6mmsq.
■Self-expanding stent placement by femoral access is the most common technique in
treatmentofrenalarterystenosis.
I.Introduction
Thischapteraimstosurveydisordersoftherenalvessels,withanemphasisondiagnosisandtreatmentof
arterialdisease(medical, transcatheter,surgical), aswellastoreviewnovelcatheter-basedtechniques
(such as renal sympathetic denervation) designed to treat multidrug-resistant hypertension and other
circulatoryconditions.
Renovascular disease, oftentermed renalarterystenosis,istypicallyofatheroscleroticorigin and is a
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