Long-term outcomes of angioplasty for pediatric renovascular hypertension: A single-center experience

Abstract

Objectives

We used single-center data to evaluate the long-term outcome of percutaneous transluminal angioplasty (PTA) for pediatric renovascular hypertension (RVH) and to analyze the factors that influence effectiveness.

Methods

We retrospectively evaluated 33 pediatric RVH patients (18 boys; mean age: 9.1 ± 4 years, range: 2–16) who underwent PTA from January 2007 to December 2019. 15 patients had Takayasu arteritis (TA) and 18 were non-TA. The median follow-up from the initial PTA was 69 months (range: 12–157; IQR: 25.5–89).

Results

The technical success rate of 52 PTA procedures was 90.4% in 33 children. Renal artery stents were implanted in two patients, external guidewires were used in two patients, and a drug-coated balloon was used in only one patient. The overall effective rate of PTA was 63.6%, including cured 39.4% and improved 24.2%, at the end of follow-up. Overall clinical outcomes were not statistically different between the TA and non-TA groups (p = 0.316), nor were cure rates (p = 0.072). 15 patients received reintervention due to restenosis after the first successful PTA; the interval was 2–56 months (median: 12 months). Four patients received reintervention due to a failed PTA. A total of four patients received open surgery. Binary logistics regression analysis showed that stenosis length and residual stenosis rate were strongly correlated with effective PTA (p = 0.045, p = 0.044).

Conclusions

As a primary treatment for pediatric RVH, PTA can achieve satisfactory results, which are influenced by lesion length and residual stenosis rate.

Keywords

Renovascular hypertension children percutaneous transluminal angioplasty Takayasu arteritis

Introduction

Pediatric hypertension was reported to be 1–2%, of which about 10% are renovascular hypertension (RVH).¹ Takayasu arteritis (TA) and fibromuscular dysplasia (FMD) are the most common causes of RVH in children.^2,3 Percutaneous transluminal angioplasty (PTA) is a safe and effective treatment for RVH in children, and is increasingly being used as the preferred treatment.⁴ The number of pediatric patients with TA-related RVH in contemporary studies is still limited. Moreover, statistical analysis to identify the factors that influence the outcomes of PTA in these patients is a key imperative, rather than relying purely on clinical experience. We conducted a study to address these questions. Our center was the first to perform PTA for the treatment of pediatric RVH in China.⁵ Of note, TA is one of the most common etiologies of RVH in China.^3,6 In our previous work published in 2014, we had documented our 13-year-long institutional experience of treatment of RVH.⁶ The present study is a corollary to our previous work and includes a larger cohort of patients, providing more robust evidence.

Materials and methods

Patients

A total of 37 consecutive pediatric RVH patients received PTA at the Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, between January 2007 and December 2019. Four patients were lost to follow-up due to changes in contact information. Renal artery stenosis (RAS) is initially diagnosed by renal artery Doppler ultrasound, and confirmed by digital subtraction angiography (DSA). The diagnosis of TA was based on the EULAR/PRINTO/PRES criteria,⁷ and the National Institutes of Health’s Arteritis Score (NIHAS)⁸ was used to determine disease activity. Based on clinical and imaging features, patients who were considered as having FMD but could not be confirmed were classified as the non-TA group.

A detailed treatment plan was developed by a multidisciplinary team comprising experts in cardiology, pediatrics, pharmacy, anesthesiology, rheumatology and immunology, and vascular surgery. The general criteria for performing PTA for pediatric RVH at our center were (1) physical condition conducive to the procedure, (2) resistant hypertension after use of antihypertensive drugs, (3) stenosis ≥ 60%, and (4) no renal artery occlusion and long segment stenosis that cannot achieve PTA. For children who achieved normal or near normal blood pressure after antihypertensive therapy, the treatment plan was determined by experts after comprehensive evaluation. Children who already had severe kidney damage were advised to undergo open surgery.

Access to the medical records of patients included in this retrospective study was approved by the Ethics Committee of Research of the Xuanwu Hospital, Capital Medical University.

Medical therapy

Nifedipine sustained-release tablets (initial dose: 0.25–0.5 mg/kg/d; maximum dose: 3 mg/kg/d, upper limit: 120 mg/d, qd or bid) or metoprolol tartrate sustained-release tablets (initial dose: 1–2 mg/kg/d; maximum dose: 6 mg/kg/d; upper limit: 200 mg/d, bid) were used as the first-choice drugs. Other types of antihypertensive agents were added, if necessary.

Patients with TA received oral prednisone acetate (0.5–1 mg/kg/d). In patients with active TA, PTA was postponed and immunosuppressive therapy was administered (cyclophosphamide 2–6 mg/kg/d for 10–14 days). PTA was performed during the inactive phase and aspirin was administered orally (3 mg/kg/d, upper limit: 100 mg) for at least 3 days before PTA.

Percutaneous transluminal angioplasty

PTA was performed through the femoral approach under general or local anesthesia, which was determined according to the patient’s age and condition. Intra-arterial injection of heparin (50–100 U/kg) was administered before angiography. Appropriate balloon size was selected according to the normal renal artery diameter and lesion characteristics observed on angiography. The diameter of the selected balloons in our cohort ranged from 1.25 to 6 mm and the length ranged from 15 to 120 mm. The balloon was inflated at 4–14 atm, 1–3 times by stepwise dilation, and each inflation lasted 0.5–3 mins. The inflating pressure was selected according to the disappearance of the “waist” sign of the stenosis lesions. If the previous dilation was not satisfactory, the inflating pressure was increased by 1–2 atm. Technical success of PTA was defined as residual stenosis ≤ 30% with no related complications such as flow-limiting dissection. An external guidewire or cutting balloon was used in case of resistant stenosis that could not be resolved by balloon. Finally, stent implantation was considered in case of severe residual stenosis or flow-limiting dissection. In addition, a paclitaxel drug-coated balloon (DCB) was used in one patient who developed restenosis.

The procedural details of PTA were influenced by the patients’ age, characteristics of lesions, technical difficulty, convenience of treatment, and the wishes of the patients’ guardians. All procedures were performed after obtaining written informed consent of the guardian.

Postoperative care and follow-up

Aspirin was prescribed for 3–6 months (3 mg/kg/d, upper limit: 100 mg/d). The dose of antihypertensive agents was adjusted according to the postoperative blood pressure (BP), and patients with TA continued with the relevant medical treatment. All patients were instructed to regularly monitor their BP after discharge. Outpatient reexamination was recommended at 1 month, 3 months, and 6 months after PTA and every 6–12 months thereafter. Follow-up evaluation typically included Doppler renal ultrasonography or computed tomography angiography (CTA). Repeat PTA procedures were recommended for patients with restenosis ≥ 60% and those who showed marked worsening of BP after effective procedural outcome.

Clinical outcomes were categorized as described elsewhere.^6,9 “Cured” was defined as normalization of BP without taking antihypertensive drugs, “improved” was defined as normalization of BP or reduction in diastolic blood pressure (DBP) by ≥15% with the same or fewer antihypertensive drugs, and “ineffective” was defined as no change or even increase in BP with the same antihypertensive drugs. PTA was considered “effective” if the patient was classified as cured or improved.

Statistical analysis

Statistical analysis was performed using SPSS version 26.0. The one sample KS test was used to assess the normality of distribution of continuous variables. Normally distributed continuous variables were analyzed using independent-sample or paired t test, while non-normally distributed variables were analyzed using nonparametric rank sum test. Rank sum test was also used to analyze ranked data. Categorical variables were analyzed using the Fisher’s exact test. The patency rate was calculated using the KaplanMeier method. Univariate analysis was performed to compare the demographic and clinical factors between the effective and ineffective groups. Variables associated with p values < 0.1 in univariate analysis were included in the multivariable logistic regression model to identify predictors of effective PTA. p values <0.05 were considered indicative of statistical significance.

Result

Clinical features

Finally, 33 children (18 boys; mean age: 9.1 ± 4 years, range: 2–16) were included in this single-center, retrospective study. The mean height was 134.5 ± 25 cm, and the mean weight was 35.1 ± 15.9 kg. Fifteen patients were diagnosed with TA and 18 were classified as non-TA group. The median duration of follow-up from the first PTA was 69 months (range: 12–157; IQR: 25.5–89). Before therapy, the mean systolic blood pressure (SBP) and DBP were 181.2 ± 33.4 mmHg and 111.2 ± 23.5 mmHg, respectively, which were higher than the corresponding P95 values of 64.5 ± 34.5 mmHg and 35.9 ± 24.6 mmHg. The patients’ symptoms are summarized in Table 1. 36.4% of the children had no obvious symptoms. The most common symptoms were dizziness (30.3%) and headache (18.2%). Some patients also showed severe symptoms such as syncope (9.1%), spasm (1 case), and cerebral infarction (1 case). Left ventricular hypertrophy was found in 30.3% of patients. Preoperative creatinine was normal in all patients (normal range: 17.7–106 mmol/L).

Table 1.

Symptoms at the first visit.

Symptom	TA (n = 15)	Non-TA (n = 18)	Total (n = 33) (%)
Hypertension	15	18	33 (100)
Asymptomatic	5	7	12 (36.4)
Dizziness	4	6	10 (30.3)
Headache	3	3	6 (18.2)
Nausea and vomiting	1	2	3 (9.1)
Fatigue	2	1	3 (9.1)
Chest tightness	2	0	2 (6.1)
Syncope	3	0	3 (9.1)
Spasm	0	1	1 (3)
Cerebral infarction	0	1	1 (3)
Claudication	1	0	1 (3)
Visual complaints	1	0	1 (3)
Frequent micturition	1	1	1 (3)
Backache	1	0	1 (3)
Left ventricular hypertrophy	5	5	10 (30.3)

TA, Takayasu arteritis.

After administration of antihypertensive drugs (before PTA), the mean SBP and DBP were 145.8 ± 20.7 mmHg and 87.1 ± 18.0 mmHg, respectively. Although there was a significant improvement (p < 0.001), but 81.8% of patients still had BP higher than P95.

Finding on angiography

The main angiographic outcomes are listed in Table 2. Angiography showed left RAS in 15 patients (45.5%) and right RAS in 12 patients (36.4%). Six patients (18.2%) had bilateral RAS. The mean length of the lesion was 9.7 ± 7.9 mm, and the mean stenosis rate was 76.1%. Ostial RAS was found in 14 children (42.4%). Mid or distal RAS was observed in 19 children (57.6%). Beaded lesions were present in 6 of 18 non-TA patients. Nine TA patients had a concomitant arterial disease, and seven of them had mild or moderate mid-aortic stenosis. One non-TA patient had left posterior tibial artery stenosis and left anterior tibial artery occlusion.

Table 2.

Summary of angiographic outcomes.

Lesions’ feature	TA (n = 15)	Non-TA (n = 18)	Total (n = 33)
Bilateral stenosis	5	1	6 (18.2%)
Ostial stenosis	14	0	14 (42.4%)
Mid and distal stenosis	1	18	19 (57.6%)
Length (mm), mean ± SD	13.0 ± 9.0	6.9 ± 5.7	9.7 ± 7.9
Stenosis rate (%), mean	77.0%	75.3%	76.1%
Beading	0	6	6 (18.2%)
Aneurysms	4	9	13 (39.4%)
Concomitant arterial disease
Mid-aortic stenosis	7	0	7 (21.2%)
Left subclavian artery stenosis/occlusion	1/2	0	3 (9.1%)
Left carotid artery stenosis/occlusion	1/1	0	2 (6.1%)
Right carotid artery stenosis/occlusion	1/1	0	2 (6.1%)
Left vertebral artery occlusion	1	0	1 (3.0%)
Superior mesenteric artery occlusion	2	0	2 (6.1%)
Bilateral axillary artery occlusion	1	0	1 (3.0%)
Left posterior tibial artery stenosis	0	1	1 (3.0%)
Left anterior tibial artery occlusion	0	1	1 (3.0%)

TA, Takayasu arteritis; SD, standard deviation.

Outcomes of angioplasty

A total of 52 PTA procedures were performed in 33 pediatric patients (Table 3). Seventeen patients underwent a single procedure, 13 patients underwent two procedures each, and three patients underwent three procedures each. There was no difference in PTA times between TA and non-TA groups (p = 0.353). The technical success rate of 52 procedures was 90.4%. In two patients, the RAS was relieved by balloon dilation combined with an external guidewire (Figure 1(a)). A cutting balloon (CBA) (Figure 1(b)) was used in one patient with resistant bilateral stenosis, but was unsuccessful. Renal artery stents (Figure 1(c)) were implanted in two patients, one for severe residual stenosis and one for flow-limiting dissection. No restenosis was observed at 3-year and 6-year follow-up. In addition, a paclitaxel drug-coated balloon (Figure 1(d)) was used in one patient; no restenosis has occurred in 2 years, and the patient has shown improved BP. All mild and moderate mid-aortic stenosis lesions were not treated.

Table 3.

Results of percutaneous transluminal angioplasty.

	TA (n = 15)	Non-TA (n = 18)	p *	Total (n = 33)
Number of PTA
1	6	11	—	17 (51.5%)
2	8	5	—	13 (39.4%)
3	1	2	0.353	3 (9.1%)
Open surgery	1	3	0.607	4 (12.1%)
Reintervention	9	10	1	19 (57.6%)
Technical success rate	96.0% (24/25)	85.2% (23/27)	0.669	90.4% (47/52)
Residual stenosis rate	19.2%	26.5%	0.156	23.2%
Decrease in BP (mmHg)
Systolic	27.3 ± 19.6	10.6 ± 13.1	0.426	18.2 ± 18.2
Diastolic	20.5 ± 17.1	12.3 ± 14.4	0.574	16.0 ± 16.0
Clinical outcome
Cured	3	10	0.072^P1	13 (39.4%)
Improved	7	1	—	8 (24.2%)
Ineffective	5	7	0.316^P2	12 (36.4%)

The comparison between TA and non-TA groups.

^P1The comparison of cured rate between TA and non-TA groups.

^P2The comparison of overall clinical outcomes between TA and non-TA groups.

TA, Takayasu arteritis; PTA, percutaneous transluminal angioplasty; BP, blood pressure.

Figure 1.

Additional measures of percutaneous transluminal angioplasty: (a) Common balloon dilation with an external guidewire, (b) cutting balloon, (c) renal artery stent, and (d) drug-coated balloon.

As of the most recent follow-up, the overall effective rate was 63.6%, including cured 39.4% and improved 24.2% (Table 3). The effectiveness rate was 66.7% in TA patients (cured, 20.0%; improved, 46.7%), and 61.1% in non-TA patients (cured: 55.5% and improved: 5.5%). Overall, there were no significant between-group differences with respect to clinical outcomes (p = 0.316) or the cure rate (p = 0.072). After PTA, 33 patients showed a significant decrease in SBP and DBP (p < 0.001). 36.4% of pediatric RVH patients showed no response to PTA or the outcome was not categorized as effective. Reinterventions, including repeated PTA and open surgery, were performed in 19 patients (9 TA patients and 10 non-TA patients). 15 patients received reintervention due to restenosis after the first successful PTA; the interval ranged from 2 to 56 months (median: 12 months). The other four reinterventions were due to failed PTA. On the KaplanMeier curve analysis, the primary patency rates at 6 months, 1 year, 3 years, and 5 years were 72.4%, 58.6%, 36%, and 36%, respectively. The secondary patency rates at 6 months, 1 year, 3 years, and 5 years were 100%, 96.2%, 96.2%, and 82.3%, respectively (Figure 2).

Figure 2.

KaplanMeier survival curves of the primary and secondary patency rate after PTA.

Open surgery

A total of four patients received open surgery as a reintervention. Two recurrent patients were cured by nephrectomy. The first patient was a 9-year non-TA boy with left RAS who developed severe restenosis 18 months after the first successful PTA. The glomerular filtration rate (GFR) of the left kidney was 8.05 mL/min. PTA was not considered feasible after angiography. The other was a 6-year TA boy with right RAS who developed restenosis after 36 months. The second PTA showed no response, and the right renal GFR was 10.56 mL/min. Both patients were cured after nephrectomy. Renal autotransplantation was performed in two patients who had normal GFR in the diseased side. A 3-year TA boy with severe right RAS received renal autotransplantation after PTA failure and was cured. Another patient was a 2-year-old non-TA girl who had left renal artery occlusion and resistant right RAS. Residual stenosis of the right renal artery after PTA was 50%, but BP was improved. One year later, her BP worsened and she received a right renal autotransplantation. After surgery, she died of renal vein thrombosis, renal failure, and lung infection.

Prognostic factors

According to the clinical outcomes, all patients were divided into the effective group (n = 21) or ineffective group (n = 12). Clinical data of both groups are presented in Table 4. There were significant differences between the two groups with respect to the stenosis length and residual stenosis rate (p = 0.016, p = 0.009). On binary logistics regression analysis, stenosis length and residual stenosis rate showed a significant correlation with clinical outcomes (p = 0.045, p = 0.044) (Table 5). This implies that shorter lesions and smaller residual stenosis were more likely to be associated with effective PTA.

Table 4

Univariate analysis between effective and ineffective groups.

	Effective (cured/improved)	Ineffective	p
Gender (male/female)	10/11	8/4	0.469
Etiology (TA/non-TA)	10/11	5/7	1.000
Side (left/right)	10/6	5/6	1.000
Location (ostial/mid-distal)	9/12	5/7	0.452
Age (years)	9.1 ± 3.9	9.0 ± 4.3	0.923
Stenosis length (mm)	7.1 ± 5	13.1 ± 9.8	0.016
Pre-PTA SBP (mmHg)	142.3 ± 20.6	151.8 ± 20.4	0.214
Pre-PTA DBP (mmHg)	85.9 ± 17.2	89.1 ± 19.9	0.593
Pre-PTA stenosis rate (%)	75.5 ± 8.7	77.3 ± 10.0	0.589
Residual stenosis rate (%)	18.1 ± 7.6	30.3 ± 16.6	0.009

TA, Takayasu arteritis; SBP, systolic blood pressure; DBP, diastolic blood pressure; PTA, percutaneous transluminal angioplasty.

Table 5.

Multivariable logistic regression analysis.

	Beta	Odds ratio (95% CI)	p
Stenosis length	2.078	7.99 (1.043–61.226)	0.045
Residual stenosis rate	0.156	1.168 (1.004–1.359)	0.044

CI, confidence interval.

HosmerLemeshow test for goodness of fit was 0.839.

Adverse events of PTA

One patient developed a small groin hematoma which resolved after 2 weeks of conservative management. In another patient, a flow-limiting dissection appeared after balloon dilation and was treated with a renal artery stent. No perforation or thrombosis was found. None of the children showed significant deterioration in serum creatinine after PTA, nor during follow-up. As of the most recent follow-up, none of the patients showed any new adverse events. None of the two patients who received renal artery stents showed in-stent restenosis (ISR) or thrombosis.

Discussion

Renovascular hypertension is caused by renal artery stenosis. Resolving stenosis is the key to restore perfusion and protect renal function.¹⁰ Significantly high BP in these patients is often difficult to control with antihypertensive drugs alone.⁴ PTA has been proven to be effective in adult RVH^11,12 and has also been considered as the first-line treatment for pediatric patients.^6,9 In previous reports, the effective rate of PTA for pediatric RVH was 53.3–90% (cured: 13.3–50% and improved: 39.7–50%).^6,9,13–15 With respect to the underlying etiology, the effective rate was 68.8–100% in children with TA and 70–100% in children with FMD.^6,13,14 The efficacy of PTA in pediatric RVH patients and the reintervention rates in previous studies show some variability; this is likely attributable to the differences in race, sample size, distribution of underlying etiology, procedure details, and the duration of follow-up. This may also explain why the improvement rate among non-TA patients in our cohort was only 5.5%. Nonetheless, our results demonstrate the effectiveness of PTA in the treatment of pediatric RVH.

The outcome of PTA may be influenced by the patient’s age, etiology, characteristics of lesions, and the degree of impairment of the target organ. Srinivasan et al.¹ found that most pediatric RVH patients who were cured or showed improvement after PTA had lesions less than 10 mm in length. In the study by Tyagi et al.,¹⁶ PTA showed the best outcomes in patients with discrete, non-ostial stenosis, and with residual stenosis of ≤ 20%. In a retrospective study by Eliason et al.,¹⁷ 22 out of the 24 children with RVH in whom PTA therapy failed had ostial stenosis. In our previous study, the length of stenosis showed an inverse correlation with effective PTA,⁶ but the analysis did not involve residual stenosis. The present study includes a larger cohort of patients, and provides a more comprehensive analysis. Combined with our previous experience, we found that patients who were categorized as cured or improved had shorter lesions and smaller residual stenosis. On logistic regression analysis, both lesion length and residual stenosis rate showed an inverse correlation with effective PTA. No other significant determinants of effective PTA were identified.

TA is an idiopathic granulomatous vasculitis of the aorta and its main branches. Inflammation and subsequent intimal proliferation results in wall thickening, stenotic or occlusive lesions, and thrombosis.¹⁸ Adequate antiinflammation is of fundamental importance because active TA is associated with an increased risk of operation-related death, complications, and restenosis.^19,20 In our study, there was no significant difference in overall clinical outcomes (p = 0.316) or cure rates (p = 0.072) between the TA and non-TA groups, although the cure rate was 20% in the TA group versus 55.5% in the non-TA group. Future studies with larger samples may find different results.

For resistant RAS in children, CBA seems to be more effective,²¹ but further research is required to provide more definitive evidence. We performed CBA in a 15-year non-TA boy with bilateral resistant RAS, but the stenosis was not successfully resolved. The external guidewire acts like a CBA’s metal blade which can cause directional cutting of the vascular intima. We successfully relieved resistant stenosis in two patients by placing a guidewire on the common balloon surface during dilation. Pediatric renal artery stents need to be used with caution, especially in younger children who have not completed their growth period. The smaller artery diameter and the possible effect of growth factors on the child’s vasculature may lead to a higher restenosis rate than adults.²² In Kari’s study of 78 children with RVH,⁹ 31 renal arteries were implanted with renal artery stents; the restenosis rate was 35.5%, and three patients developed renal artery thrombosis. Shroff et al.²² implanted stents in 19 renal arteries in a study spanning 20 years, with a restenosis rate of 36.8%. In both studies, the restenosis rate of stenting was significantly higher than that of only balloon dilatation (p < 0.05). Their consensus is that stents should be considered for severe or recurrent stenosis or in case of iatrogenic dissection. DCB was used only in one TA patient with restenosis, and no restenosis has occurred in the past 2 years. Bi et al.²³ used DCB to effectively treat five TA-related RVH patients (≤ 18 years old); no restenosis occurred during follow-up (range: 5.1–23.8 months). Larger studies are required to provide more definitive evidence of the effectiveness of DCB in pediatric RVH.

Restenosis may be related to inflammation, intimal hyperplasia, and elastic recoil. Some patients required further intervention because of restenosis or inadequate results of the first PTA. Reintervention rates reported in previous studies ranged from 28.2% to 50%.^2,6,9 In our study, 15 patients (45.5%) required reintervention because of restenosis and four patients (12.1%) because of failed PTA. There was no significant difference in the reintervention rates between the TA and non-TA groups. This may be attributable to the adequate anti-inflammatory treatment of children with TA.

Open surgery, including nephrectomy and revascularization, usually resolves vascular lesions definitively during the same procedure,²⁴ but is highly invasive and technically challenging. Two previous large studies reported an overall effective rate of 94% and 90% for open surgery (cure rate: 82% and 44%),^24,25 indicating that surgery still holds a prominent place in the treatment of pediatric RVH. However, there is a paucity of data concerning open surgery of TA children, as only a few small-sample studies have reported satisfactory results.^26,27 Eliason et al.¹⁷ reported the complexity of salvage surgery and high nephrectomy rate after the failure of endovascular procedure in children. In a retrospective study of children and adults with RVH, open surgery was associated with more complications and higher costs than PTA.²⁸ Similar to many other centers, we prefer open surgery as a reintervention procedure only if angioplasty has failed or is not feasible; however, initial open surgery may be recommended for patients with long, diffuse stenosis or complete occlusion of renal arteries. The most important point is to choose a more effective, minimally invasive, reasonable, and economical treatment strategy based on accumulated experience and patient’s details. The overall effective rate in our study was 72.7% (24/33) with an individualized treatment strategy involving medical management, PTA, and open surgery. Our results were similar to most studies conducted in other countries, except for the high number of TA patients in our cohort.

There are still some limitations to our study. This is a single-center retrospective study with a limited sample size; this may have introduced an element of bias. Prospective studies involving a larger cohort of patients with different underlying etiology are still required. Moreover, renal dynamic imaging was not performed in all children to determine the GFR of each kidney.

In conclusion, individualized treatment strategies involving multidisciplinary, multi-therapeutic approaches are important for pediatric patients with RVH. As a primary treatment for pediatric RVH, PTA can achieve satisfactory results. The outcomes of PTA are largely influenced by the lesion length and residual stenosis rate. No difference in clinical outcomes was observed between TA and non-TA patients in our cohort.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Julong Guo

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