What is the role of PTRA in the treatment of renovascular hypertension (RVHT)?

Updated: Dec 01, 2020
  • Author: Rebecca J Schmidt, DO, FACP, FASN; Chief Editor: Vecihi Batuman, MD, FASN  more...
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Answer

PTA is a therapeutic nonsurgical procedure using pressure expansion of a small balloon on a special vascular catheter to dilate narrow areas in a blood vessel.  PTA is cheaper and less invasive than surgical revascularization and can be performed at the time of angiography. If the stenosis is refractory to treatment or if restenosis develops, surgical revascularization can still be performed.

In patients with RVHT, PTA is performed to open stenotic renal arteries (percutaneous transluminal renal angioplasty [PTRA]), the most amenable lesions being those without total occlusion. PTRA is most effective against midvessel stenosis. Lesions involving segmental arteries or the ostia of renal arteries and lesions in patients with neurofibromatosis are especially refractory to balloon angioplasty.

Outcomes appear to be significantly better in patients with fibromuscular dysplasia (FMD) than in those with atherosclerotic stenosis: Cure was reported in 50-85% of patients in the former group and 8-20% of patients in the latter group. Restenosis necessitating repeat angioplasty was reported in fewer than 10% of patients with FMD and in 8-30% of those with atherosclerotic stenosis. Improvement in blood pressure control with fewer antihypertensive medications was achieved in 30-35% of patients with FMD and 50-60% of those with atherosclerotic lesions. [39]

However, in a study of 64 patients with a high coronary artery disease burden who underwent baseline captopril renal scintigraphy followed by renal angiography, Stratigis et al reported that in those patients with atherosclerotic renal artery stenosis of 70% or greater, captopril renal scintigraphy positivity had 100% sensitivity and specificity for both a hypertension and renal benefit  from percutaneous renal revascularization. [40]

A Swedish study of 105 patients treated with PTRA reported a 5-year survival rate of 83% for patients with arteriosclerotic renovascular disease. [41] The rate for patients with fibromuscular vascular disease was even higher, reaching 100%.

PTRA has yielded mixed results in children. Long-term maintenance of blood pressure improvement ranges from 38% to 90%. Guzzetta et al [42] and Tyagi et al [12] found that approximately 25% of patients treated with PTRA developed restenosis. Casalini et al, evaluating PTRA in a selected group of 36 children with RVHT, found that 34 (94%) of the patients were normotensive 2 years after the procedure. [43]

The results of PTRA in patients with bilateral renal artery disease have been relatively poor, suggesting that surgical intervention should be a strong consideration in this setting. In patients with diffuse atherosclerosis, the complication rate is relatively high with either surgery or angioplasty; medical therapy may be preferred in this setting.


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