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CLINICAL RESEARCH: HYPERTENSION

Prediction of Hypertension Improvement After Stenting of Renal Artery Stenosis

Comparative Accuracy of Translesional Pressure Gradients, Intravascular Ultrasound, and Angiography

Massoud A. Leesar, MD^_*,_*, Jai Varma, MD^_*, Adam Shapira, MD^_*, Ibrahim Fahsah, MD^_*, Seyed T. Raza, MD, Ziad Elghoul, MD^_*, Anthony C. Leonard, PhD, Karthikeyan Meganathan, MS and Sohail Ikram, MD^_*

^_* Division of Cardiology, University of Louisville, Louisville, Kentucky
Jewish Hospital Heart and Lung Institute, Louisville, Kentucky
Department of Public Health Sciences, University of Cincinnati, Cincinnati, Ohio

Manuscript received December 1, 2008; revised manuscript received February 17, 2009, accepted March 3, 2009.

^_* Reprint requests and correspondence: Dr. Massoud A. Leesar, Division of Cardiology, University of Cincinnati, 231 Albert Sabin Way, MSB-3054, Cincinnati, Ohio 45267 (Email: leesarma{at}uc.edu).

Objectives: We investigated the comparative accuracy of renal translesional pressure gradients (TPG), intravascular ultrasound (IVUS), and angiographic parameters in predicting hypertension improvement after stenting of renal artery stenosis (RAS).

Background: The degree of RAS that justifies stenting is unknown.

Methods: In 62 patients with RAS, TPG (resting and hyperemic systolic gradient [HSG], fractional flow reserve, and mean gradient) were measured by a pressure guidewire; IVUS and angiographic parameters (minimum lumen area and diameter, area stenosis, and diameter stenosis) were measured by quantitative analyses.

Results: The HSG had a larger area under the curve than most other parameters and an HSG 21 mm Hg had the highest sensitivity, specificity, and accuracy (82%, 84%, and 84%, respectively) in predicting hypertension improvement after stenting of RAS. The average IVUS area stenosis was markedly greater in RAS with an HSG 21 mm Hg versus <21 mm Hg (78% vs. 38%, respectively; p < 0.001). After stenting, hypertension improved in 84% of patients with an HSG 21 mm Hg (n = 36) versus 36% of patients with an HSG <21 mm Hg (n = 26) at 12 months, p < 0.01; the number of antihypertensive medications was significantly lower in patients with an HSG 21 mm Hg versus <21 mm Hg (2.30 ± 0.90 vs. 3.40 ± 0.50, respectively; p < 0.01). By multivariable analysis, HSG was the only independent predictor of hypertension improvement (odds ratio: 1.39; 95% confidence interval: 1.05 to 1.65; p = 0.013).

Conclusions: An HSG 21 mm Hg provided the highest accuracy in predicting hypertension improvement after stenting of RAS, suggesting that an HSG 21 mm Hg is indicative of significant RAS.

Key Words: renal artery stenosis • renal translesional pressure gradients • intravascular ultrasound • angiography

Abbreviations and Acronyms   AUC = area under the curve   FFR = fractional flow reserve   HMG = hyperemic mean gradient   HSG = hyperemic systolic gradient   IVUS = intravascular ultrasound   MLA = minimum lumen area   MLD = minimum lumen diameter   RAS = renal artery stenosis   ROC = receiver-operating characteristic   RSG = resting systolic gradient   TPG = translesional pressure gradients