Non-invasive diagnosis of pulmonary hypertension: ESC/ERS Guidelines with Updated Commentary of the Cologne Consensus Conference 2011.

The 2009 European Guidelines on Diagnosis and Treatment of Pulmonary Hypertension have been adopted for Germany. The guidelines contain detailed recommendations for the diagnosis of pulmonary hypertension. However, the practical implementation of the European Guidelines in Germany requires the consideration of several country-specific issues and already existing novel data. This requires a detailed commentary to the guidelines, and in some aspects an update already appears necessary. In June 2010, a Consensus Conference organized by the PH working groups of the German Society of Cardiology (DGK), the German Society of Respiratory Medicine (DGP) and the German Society of Pediatric Cardiology (DGPK) was held in Cologne, Germany. This conference aimed to solve practical and controversial issues surrounding the implementation of the European Guidelines in Germany. To this end, a number of working groups was initiated, one of which was specifically dedicated to the non-invasive diagnosis of pulmonary hypertension. This manuscript describes in detail the results and recommendations of the working group which were last updated in October 2011.

Stent-supported angioplasty of severe atherosclerotic renal artery stenosis preserves renal function and improves blood pressure control: long-term results from a prospective registry of 456 lesions.

PURPOSE: To report a prospective study evaluating the long-term impact of stent-supported angioplasty on renal function and blood pressure control. METHODS: In a 6-year period, 456 hemodynamically significant de novo renal artery stenoses > or =70% were treated in 340 consecutive hypertensive patients (223 men; mean age 66+/-10 years, range 44-84) with or without impaired renal function. Baseline data on serum creatinine (sCr), intrarenal resistance index, ambulatory 24-hour blood pressure monitoring, and documentation of the number and dose of antihypertensive drugs were compared to values obtained during follow-up. The primary endpoint was a 10% decrease in sCr; the glomerular filtration rate and changes in blood pressure control were additional outcome measures. RESULTS: During a mean follow-up of 34+/-20 months, sCr decreased significantly from 1.45+/-0.87 to 1.39+/-0.73 mg/dL (p=0.048). In 34% of the patients, sCr decreased >10%, 39% were unchanged, and 27% had an increase >10%. Glomerular filtration rate increased from 59+/-26 to 62+/-26 mL/min/1.73 m(2) (p=0.6). Systolic, diastolic, and mean blood pressure measurements significantly improved immediately after the intervention (132/72/93 versus 144/79/102 mmHg at baseline, p<0.0001) and remained improved during follow-up (p<0.0001). Blood pressure control was improved in 46%, unchanged in 43%, and deteriorated in 11%. Baseline sCr, bilateral intervention, percent diameter stenosis, and 3-vessel coronary disease were independent predictors of improved renal function during follow-up; the number of antihypertensive drugs taken before the intervention predicted improved blood pressure control. CONCLUSIONS: Stent-supported angioplasty of renal artery stenoses preserves renal function and improves blood pressure control in a broader spectrum of patients than previously thought.

Technological advances in the design of catheters and devices used in renal artery interventions: impact on complications.

PURPOSE: To analyze the impact of technical improvements in stent devices and guiding catheters (e.g., reduced device diameter, increased flexibility) on the complication rates associated with percutaneous renal artery interventions. METHODS: During a 5-year period (1997-2001), 268 consecutive patients (178 men; mean age 67+/-9 years) had 370 atherosclerotic renal artery stenoses (RAS) > or =70% treated with angioplasty/stenting in 320 procedures. The guiding catheter technique was used routinely until 2000; in 2001, a guiding sheath was used in 29% of cases. From 1997 to 2000, sealing devices were frequently used for sheath removal; during the last year, the sheaths were removed using the Femostop device. RESULTS: In 320 interventions, 32 (10%) complications occurred, with a decreasing frequency during the last 2 years (1996/97: 13% [7/53]; 1998: 16% [9/57]; 1999: 15% [11/74]; 2000: 4% [3/70]; 2001: 3% [2/66]). There were 21 (6.6%) local complications, including 4 cases requiring permanent hemodialysis after the intervention and 11 (3.4%) access site complications. No procedure-related death occurred. During the study period, the average sheath diameter was reduced from 8.15+/-0.76 F to 6.15+/-0.63 F (p<0.05). Mean procedural time was reduced from 42+/-13 minutes to 23+/-11 minutes (p<0.05). The initial heparin dose was reduced from 10,000 to 5000 units. CONCLUSIONS: In parallel with the use of more flexible catheters and premounted stents of lower profile, the complication rate of renal angioplasty/stenting of atherosclerotic RAS has been reduced significantly during a 5-year period.

Predictors of improved renal function after percutaneous stent-supported angioplasty of severe atherosclerotic ostial renal artery stenosis.

BACKGROUND: Percutaneous stent-supported angioplasty is a treatment option for atherosclerotic ostial renal artery stenosis. Improvement of renal function by such intervention, however, is controversial and thought to be limited to specific subsets, such as nondiabetic patients and bilateral stenoses. In this prospective study, we investigated predictors for improvement of renal function and blood pressure after renal artery stent placement. METHODS AND RESULTS: The study included 215 consecutive patients with ostial renal artery stenosis of > or =70% diameter stenosis undergoing stent-supported angioplasty. The primary end point was decrease in serum creatinine concentration at 1 year; the secondary end point, decrease in average mean arterial blood pressure assessed by 24-hour monitoring. One-year follow-up was complete in 191 surviving patients. In 52% (99/191) of the patients, serum creatinine concentration decreased during 1-year follow-up. Median serum creatinine concentration dropped significantly from 1.21 mg/dL (quartiles: 0.92, 1.60 mg/dL) at baseline to 1.10 mg/dL (quartiles: 0.88, 1.50 mg/dL) at 1 year (P=0.047). On average, mean arterial blood pressure decreased significantly, from 102+/-12 mm Hg (mean+/-SD) at baseline to 92+/-10 mm Hg at 1 year (P<0.001). Significant independent predictors of improved renal function were baseline serum creatinine (odds ratio [95% CI], 2.58 [1.35 to 4.94], P=0.004) and left ventricular function (OR 1.51 [1.04 to 2.21], P=0.032). Female sex, high baseline mean blood pressure, and normal renal parenchymal thickness were independent predictors for decreased mean blood pressure. CONCLUSIONS: Stent-supported angioplasty for severe ostial renal artery stenosis improves renal function and blood pressure in a broader spectrum of patients than previously thought.

Gold coating and restenosis after primary stenting of ostial renal artery stenosis.

Predictors of restenosis after stent angioplasty of ostial renal artery stenosis (RAS) and long-term technical success, particularly the influence of gold coating, are unknown. During a 4-year period (1996-2000), we treated 156 consecutive patients with 219 ostial RAS of > or = 70% diameter stenosis. Gold-coated stents were used in 29% of RAS (n = 64); the vessel diameter ranged from 3 to 9 mm. The restenosis rate was 11.4% at 12 months, 12.2% for gold-coated stents and 11.1% for noncoated stents. Restenosis rates were 16% for < or = 4 mm, 17% for 5 mm, 10% for 6 mm, and 0% for > or = 7 mm (P < or = 0.05). In a backward stepwise logistic regression analysis including gold coating, vessel diameter, gender, diabetes, smoking status, as well as lesion diameter stenosis before and after stenting, vessel diameter was found the only independent predictor of restenosis (odds ratio = 0.57; 95% CI = 0.35-0.93; P = 0.02, for an increase in vessel diameter of 1 mm). Gold coating was not a significant predictor (odds ratio = 1.09; 95% CI = 0.39-3.03; P = 0.87). Seven major (4.5%) complications occurred. There were no procedural fatalities. The restenosis rate after stent angioplasty of ostial RAS is influenced by the vessel diameter but not by gold coating.

Gadodiamide as an alternative contrast agent during angioplasty in patients with contraindications to iodinated media.

PURPOSE: To evaluate gadodiamide as an alternative contrast agent for peripheral and renal angioplasty in patients with contraindications to iodinated contrast media. METHODS: Seventeen patients (10 men; mean age 74 years, range 68-83) with contraindication to iodinated contrast media were given gadodiamide as the contrast agent during peripheral and renal intra-arterial digital subtraction angiography (DSA) and subsequent percutaneous interventions (balloon angioplasty, stent placement). RESULTS: The mean volume of gadodiamide used was 136 +/- 46 mL (range 60-200). No serious side effects were observed, especially no change in renal or thyroid function; no exanthema or other allergic reactions were noted. In patients without renal artery intervention, serum creatinine at discharge remained unchanged (2.57 +/- 1.43 mg/dL to 2.40 +/- 1.28 mg/dL, p=NS). In patients undergoing angioplasty/stenting of renal artery stenoses, serum creatinine decreased significantly from 3.53 +/- 1.75 mg/dL to 2.36 +/- 1.15 mg/dL (p<0.01). All but 1 intervention was successful. Using a simple scoring system, 2 judges blinded to the contrast agent graded the quality of the peripheral DSAs as "good," whereas renal DSA images were only "sufficient." CONCLUSIONS: For patients with contraindications to iodinated materials, gadodiamide may be a suitable alternative for renal or peripheral DSA followed by angioplasty.

Acute thrombotic subclavian artery occlusion treated with a new rotational thrombectomy device.

PURPOSE: To report the use of a new rotational thrombectomy device for percutaneous thrombectomy of an acutely occluded subclavian artery. CASE REPORT: A 71-year-old woman with a history of multivessel coronary disease complained of sudden onset of pain at rest and paleness of the left arm. Duplex ultrasound showed a localized thrombotic occlusion of the postvertebral subclavian artery and another at the bifurcation of the brachial artery. After angiographic confirmation, the subclavian artery was recanalized with an 8-F Rotarex device via a percutaneous transfemoral access; the bifurcation of the brachial artery was recanalized by local thrombolysis (50 mg rtPA) because the thrombectomy device was too short to reach the occlusion. Follow-up examinations up to 1 year have shown normalized perfusion of the left arm. CONCLUSIONS: This new thrombectomy device is a useful tool for the percutaneous treatment of acute occlusion in the brachiocephalic arteries.