El trasplante renal es en la actualidad el tratamiento de elección de la insuficiencia renal terminal. Existen muchas complicaciones que pueden provocar la pérdida funcional del injerto u obligar a su extracción y comprometer el pronóstico vital del receptor. Entre ellas, las complicaciones vasculares son frecuentes y conllevan una morbilidad elevada. El papel de las técnicas endoluminales en el tratamiento de estas complicaciones aumenta de forma constante. Aunque las complicaciones vasculares precoces, como la trombosis de la arteria o de la vena del injerto suelen requerir un tratamiento quirúrgico urgente, la mayor parte de las complicaciones vasculares tardías, como la estenosis de la arteria del injerto o las complicaciones iatrogénicas post-biopsia se tratan con éxito mediante técnicas de radiología intervencionista.

L’hématome disséquant spontané de l’artère rénale est une pathologie non exceptionnelle mal connue et souvent non diagnostiquée (1, 2) ou diagnostiquée avec trop de retard pour permettre le sauvetage du parenchyme rénal.

Renal artery angioplasty using the same techniques employed for coronary arteries has developed considerably. A register was set up in France to evaluate the efficacy of this treatment for improving renal function and lowering blood pressure in cardiac patients. Between 2001 and 2005, 205 patients (234 lesions) were treated in 14 centres (mean age: 69.2 +/- 10.4 years, 59% male). All of the patients had hypertension and the majority of them (171) had renal failure (creatinine clearance<90 ml/min). Direct implantation of a stent was performed in 75.2% of the cases, successfully in 196 patients (96%) with 220 lesions (95.2%). The complications encountered were segmental renal infarction in two patients (0.9%), and four cases of minor vascular complications at the puncture site (2%). The mean value for pre-implantation creatinine clearance was 54.6 +/- 32.8 ml/min and 58.1 +/- 36.0 post- implantations. The duration of follow up was 5.9 +/- 2.7 months. Mortality was 3.5% (seven patients, of whom two died from renal causes). The mean systolic and diastolic blood pressure was 142.2 +/- 16.2 and 78.9 +/- 9.5 respectively versus 164.9 +/- 25.2 and 89.1 +/- 14.8 before treatment (p<0.0001). A non-significant improvement in creatinine clearance at six months was also observed in patients with renal failure prior to treatment: 48.7 +/- 17.1 ml/min vs. 69.2 +/- 160.3. Renal artery stenting in cardiac patients with renal artery stenosis is associated with a very high success rate, with few complications and an improvement in hypertension and renal function.

L'echocardiographie reste la methode d'imagerie du cardiologue la plus utilisee. Son evolution technique rapide lui ouvre regulierement de nouveaux champs d'application et c'est pourquoi elle est toujours l'objet de tres nombreuses recherches et donc de publications. L'annee 2003 n'a pas fait exception puisque la litterature sur le sujet est tres abondante. L'echographie 3D-temps reel, apparue l'an dernier, est en cours d'evaluation et des travaux preliminaires montrent son interet potentiel dans des domaines aussi varies que les valvulopathies ou l'echographie de stress. L'analyse quantifiee de la fonction systolique segmentaire se heurte toujours a la reproductibilite des parametres utilises en particulier ceux du doppler tissulaire. Certaines equipes obtiennent cependant des resultats encourageants, le meilleur parametre en routine restant a definir. L'echographie pendant l'effort est en developpement avec des travaux sur la viabilite post-infarctus et l'etude des insuffisances mitrales fonctionnelles en cas de dysfonction ventriculaire gauche. L'echographie de contraste reste un sujet de recherche pour bon nombre d'equipes avec cependant des resultats pour la perfusion qui restent a confirmer sur de plus larges series. Enfin l'interet d'un test a la dobutamine faibles doses pour evaluer le risque operatoire des stenoses aortiques avec dysfonction ventriculaire gauche severe a ete bien mis en evidence par un tres beau travail multicentrique francais.

Le Coz, S.; Chedid, A.; Rossignol, P.; Raynaud, A.; Bobrie, G.; Plouin, P. F. Author Information

Endovascular treatment has an increasing role in the treatment of patients with critical limb ischemia. particularly in diabetic patients with a majority of infrapopliteal lesions.The aim of the procedure is to obtain a "straight-line flow to the foot" by treating all the significant stenoses and short occlusions that impair distal vascularization. Stents are indicated when there is a suboptimal results following balloon angioplasty (recoil or dissection). Restenosis rate after primary stenting for long lesion is high.Angioplasty is a safe and effective procedure. allowing limb salvage rate in a majority of the cases with a low mortality and morbidity rate.

Rapporter le cas d’un vol vasculaire par un abord d’hémodialyse diagnostiqué par angiographie et traité par une embolisation percutanée. Un homme de 84 ans, porteur d’un abord d’hémodialyse radio-radial droit, présentait une ischémie subaiguë de la main droite. Une angiographie diagnostique et thérapeutique a été réalisée. L’artériographie par voie humérale droite montrait une artère radiale perméable alimentant une fistule radio-radiale de bon calibre, sans anomalie de son anastomose ni de son drainage veineux profond. L’artère interosseuse était athéromateuse de petit calibre donnant naissance à des collatérales au poignet. L’artère ulnaire était occluse. De plus, il existait un vol des arcades palmaires avec une circulation rétrograde de l’artère radiale distale. Les prises de pressions sanglantes des arcades montraient la gravité de l’ischémie. Une occlusion endovasculaire d’épreuve confirmait le phénomène de vol par la fistule. Une embolisation percutanée de l’artère radiale distale à l’aide de 3 coils permettait une disparition du vol tout en conservant l’abord d’hémodialyse. L’évolution était immédiatement favorable. Devant une ischémie de main, chez un sujet afhéromateux porteur d’un abord d’hémodialyse au poignet, le vol vasculaire doit être évoqué. L’angiographie en fait facilement le diagnostic et permet son traitement par une embolisation.

Recent articles reported excellent results in the percutaneous declotting of native fistulas for hemodialysis with use of thromboaspiration, mechanical devices, or thrombolytic drugs, with success rates ranging from 76% to 100%. These results challenge the surgical approach, the effectiveness of which is not supported by comparable publications. Although it is more difficult to declot forearm native fistulas than grafts, declotting of fistulas is more rewarding because it achieves better long-term patency (1-year primary rates as high as 50% and secondary rates of 80%). The results reported from declotting of fistulas in the upper arm are not as good. The unmasking of stenoses in close to 100% of cases warrants stenosis detection programs similar to those used for grafts.

This study analyzed the initial presentation and revascularization outcomes of patients with radiation-induced renal artery stenosis, a rare complication of therapeutic irradiation. Of 11 patients with renal artery stenosis after irradiation, 7 patients fulfilled the following criteria: normotension before irradiation, radiation dose greater than 25 grays delivered to the renal arteries, associated perirenal radiation-induced lesions, and absence of arterial disease outside the radiation field. The median age at irradiation was 30 years, and the median local irradiation dose was 40 grays. The median time from irradiation to referral was 13 years. All patients were hypertensive at referral, with a median blood pressure (BP) of 171/102 mm Hg and median treatment score of two. The median glomerular filtration rate was 67 mL/min. Two patients had bilateral stenoses and 1 patient had stenosis affecting a single kidney. Stenoses were proximal in 6 patients and truncal in 1 patient, and all had the appearance of atherosclerotic stenosis. Percutaneous transluminal renal artery angioplasty (PTRA) was successful in 5 patients, but required multiple insufflations. PTRA failed in 1 patient, who subsequently underwent an aortorenal bypass. After a median follow-up of 36 months, 2 patients had died of noncardiovascular causes and 4 patients remained hypertensive, with a median BP of 136/85 mm Hg and median treatment score of two. No restenosis occurred, but aneurysms developed at the site of angioplasty in 1 patient. If hypertension occurs even decades after irradiation, a radiation-induced renal artery stenosis should be sought in patients who have undergone abdominal irradiation. [copy ] 2001 by the National Kidney Foundation, Inc.

The general use of bilateral rather than separate renal function evaluation has led to the publication of conflicting results concerning the effect of percutaneous transluminal renal angioplasty (PTRA) on renal function, especially in patients with atherosclerotic renal artery stenosis. The aim of this study was to evaluate prospectively, in standardized conditions, split renal function (SRF) and GFR outcome after successful PTRA, by measuring single kidney GFR with synchronous inulin or (51)Cr-ethylenediaminetetraacetic acid clearance and (99m)Tc-diethylenetriamine pentaacetic acid scintigraphy, in a well-defined population of patients with unilateral renal artery stenosis. Thirty-two consecutive hypertensive patients (18 with atherosclerotic and 14 with dysplastic disease) with significant unilateral stenosis of the main native renal artery (> or = 60%) and normal renal function were included in the study. Renal and angiographic follow-up evaluations were performed 6 mo after PTRA. PTRA alone or combined with stenting (n = 2) was technically successful in all patients. Repeat PTRA was necessary in two patients, evaluated 6 mo after the second PTRA. Six mo after PTRA, total GFR had increased slightly but significantly in the 29 patients with positive lateralization indices. SRF and single-kidney GFR of the stenotic kidney increased significantly, whereas concurrently the GFR and SRF of the nonstenotic kidney decreased significantly. Six mo after successful PTRA reducing renal ischemia, a reversal of both the hypoperfusion of the stenotic side and the hyperperfusion of the nonstenotic side was observed, which was accompanied by a slight increase in total GFR.

Takayasu's arteritis; antihypertensive agents (60 mg/day furosemide, transluminal angioplasty 10 mg/day bisoprolol, 120 mg/day urapidil, 5 mg/day amlodipine and 1 mg/day guanfacine).The right brachial blood pressure was 212/94 mmHg and blood pressure in the left arm was 192/99 mmHg.There was

PURPOSE: To evaluate the efficacy of stent deployment in the treatment of recurrent stenosis of transplant renal arteries (TRAs).PATIENTS AND METHODS: This retrospective study includes six consecutive patients who underwent a mean of 3.66 previous treatments of TRA stenosis per patient before stent implantation (20 ansoplasties and two surgical procedures), The endoprostheses were a Wallstent in four patients and a Palmaz stent in two patients. Clinical, laboratory, and duplex scanning follow-up was performed every 6 months after stent placement in all patients,RESULTS: The procedure was a technical success in all patients, At 6 months, mean systolic blood pressure decreased from 179 to 152 mm Hg (P = .018) and mean diastolic blood pressure decreased from 102 to 90 mm Hg (P = .09). Mean serum creatinine level dropped from 269 to 182 mmol/L (P = .03) and the number of antihypertensive drugs per patient decreased from 2.5 to 1.6, At a mean follow-up of 34 months (range, 7-60 months), all TRAs were patent, with a stenosis less than 50% without clinical consequences in one patient. No secondary procedure was necessary.CONCLUSION: Stent placement seems to be an effective treatment of TRA recurrent stenosis, Midterm follow-up shows satisfactory clinical results and TRA patency rates. This technique might be considered as a valuable therapeutic option for the treatment of TRA recurrent stenosis.

PURPOSE: To report the authors' experience in treatment of ruptures complicating percutaneous transluminal angioplasty (PTA) of hemodialysis access with implantation of a Wallstent,MATERIALS AND METHODS: Between January 1, 1990, and October 1, 1995, the authors performed 2,414 PTAs of angioaccesses, A severe rupture occurred in 40 (1.7%) of these procedures and was treated by means of stent placement. Wallstents were implanted in 37 of these ruptures. The angioaccesses comprised 22 grafts and 15 fistulas, The indications for stent placement were four isolated pseudoaneurysms and 33 cases of bleeding: 15 major leaks, five moderate leaks that persisted despite prolonged inflation at low pressure, seven leaks associated with greater than 50% residual stenosis, four leaks associated with pseudoaneurysm, and two leaks associated with both greater than 50% residual stenosis and pseudoaneurysm Seventeen ruptures were located on a vein, 19 on the venous anastomosis of a graft, and one on a graft itself.RESULTS: Stent placement stopped the bleeding immediately in 28 cases and after prolonged inflation within the stent in four cases. Residual bleeding required implantation of a covered Cragg stent within the Wallstent in one case. A pseudoaneurysm was still visible at the end of the intervention in 11 cases. Two complications occurred; one hematoma was drained surgically and one access occluded on day 2, Follow-up angiography showed a small pseudoaneurysm in only one patient with impaired platelet function, The primary and secondary patency of the angioaccesses were 48% and 86% at 1 year, respectively.CONCLUSION: Wallstent implantation is very effective for both immediate and long-term treatment of rupture of angioaccess during PTA.

We report on a novel approach to correcting iliac artery occlusions caused by aortic counterpulsation. Two patients who had leg ischemia after retrieval of an intraaortic balloon pump underwent angiograms that showed occlusion of the right external iliac artery because of dissection (one case) or thrombosis (one case). Percutaneous self-expandable stents were implanted-in the occluded vessels, and they fully restored normal iliac patency with no complications and satisfactory midterm follow-up results, We conclude that iliac artery occlusion induced by aortic counterpulsation can be safely treated by implanting self-expandable stents in cases of acute iatrogenic dissection.

PURPOSE: To report midterm follow-up after implantation of covered stents for hemodialysis access.PATIENTS AND METHODS: Over a 2-year period, a Cragg Endopro stent was placed in 14 patients (mean age, 66.6 years +/- 15) to treat angioplasty-induced ruptures (n = 3), pseudoaneurysm (n = 1), postangioplasty residual stenosis (n = 2), and early restenosis (n = 8, four of them in a Wallstent).RESULTS: Initial placement was successful in all cases. A clinical inflammatory reaction was observed in all three cases of placement in the forearm. When the covered stent was placed in a stenotic vessel, restenosis always occurred within 6 months. Primary and secondary patencies were 28.5% +/- 13.9 and 67.8% +/- 14.5, respectively, at 6 months, Covered stents were of undoubtable benefit in one case of rupture after Wallstent failure and in one case of restenosis in a Wallstent.CONCLUSION: Covered Cragg stents are effective in controlling angioplasty-induced rupture and sometimes for maintaining patency after restenosis in a Wallstent. They do not prevent restenosis and are responsible for an inflammatory reaction of unknown origin and long-term effect.

PURPOSE: To assess the safety and efficacy of secondary procedures in iliac artery stents. MATERIALS AND METHODS: Thirty-four patients (36 limbs) underwent one or more interventional procedures in iliac artery stents to treat restenosis (n = 30) or occlusion (n = 6). All patients were followed up by means of clinical and angiographic examination. Primary and secondary patency were assessed with angiography, duplex ultrasound, or both. Primary patency was determined after one interventional procedure, and secondary patency was determined at the end of the study (mean +/- standard deviation, 20.1 months +/- 17.5; range, 1-58 months). RESULTS: Immediate angiographic success was achieved in all cases. Four complications were observed. The primary and secondary cumulative patency rates were 77.5% +/- 7.6 and 94% +/- 4.1 at 6 months, 73% +/- 8.4 and 89.3% +/- 6 at 12 months, and 51.4% +/- 10.9 and 78.8% +/- 8.8 at 2 years. At the end of the study, 80% of the arteries were still nominally patent. CONCLUSION: Restenosis and chronic occlusion in iliac artery stents can be treated with percutaneous interventional procedures; however, stenosis can still recur.