RESIST: Embolic Protection and Platelet Inhibition During Renal Artery Stenting

Luis Gruberg, MD, FACC

Disclosures

April 27, 2007

RESIST is a small, but certainly interesting study that may help us improve the outcomes of patients who undergo renal artery revascularization with stents.

Stenting is a common, albeit controversial, treatment for atherosclerotic renal artery stenosis. The improvement in renal function seen in 25% of patients who are treated with this technique is offset by a decline in renal function following the procedure that is observed in 20% of patients. Atheroembolization is implicated in renal dysfunction following this procedure.

The Prospective Randomized Study Comparing Renal Artery Stenting With or Without Distal Protection (RESIST) trial was designed to evaluate the impact of the Angioguard (Cordis Corporation, Miami Lakes, Florida) distal embolic protection device and the glycoprotein (GP) IIb/IIIa inhibitor abciximab during renal artery stenting.

RESIST was a multicenter, prospective, randomized 2 x 2 factorial design study that enrolled a total of 100 patients with atherosclerotic renal artery stenosis > 50% who were undergoing stenting. Patients were randomized to either:

  • Control (n = 28);

  • Angioguard only (n = 22);

  • Abciximab only (n = 25); and

  • Combined Angioguard and abciximab (n = 25).

Endpoints: Change in the Modification of Diet in Renal Disease (MDRD)-derived glomerular filtration rate (GFR) from baseline to 1 month.

Baseline clinical characteristics are shown in the following Table .

The Angioguard was successfully deployed in all patients, and the study drug was discontinued in 2 patients. Angiographic stenosis decreased from 66% ± 14% to 0% ± 15% following the procedure. There was a -10% change in GFR in patients not treated with distal embolic protection compared with a -2% change in those treated with the Angioguard device.

Similarly, there was a -11% change in GFR in patients treated with placebo vs 0% change in those treated with abciximab. There was a significant interaction between Angioguard and abciximab with a 9% improvement in GFR (Figure). Furthermore, there was a substantial reduction in platelet-rich thrombi in the filter recovered from patients treated with both the device and abciximab vs the amount recovered in patients treated with only the Angioguard device (7% vs 42%; P < .001).

RESIST: percent (%) change in GFR.

  • The use of GP IIb/IIIa inhibitors appears to be beneficial for the preservation of renal function during renal artery stenting.

  • A positive interaction was observed between the Angioguard embolic protection device and abciximab treatment.

  • Platelet thromboemboli were surprisingly common despite activated coagulation times (ACTs) > 300 seconds.

RESIST is a small, but certainly interesting study that may help us improve the outcomes of patients who undergo renal artery revascularization with stents. Although helpful, the use of a distal embolic protection device may also be challenging due to tortuosity of the vessel and the lack of an appropriate landing zone.

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