肾动脉狭窄支架术现状

1、Renal stenting in renal artery stenosis-contented and uncontented 肾肾 动动 脉狭窄支架术脉狭窄支架术 patients 发病率(%) General people 0.1Hepertension 1-550y, wiht (ARAS) HT 15 CAD 10-19 critical HT 30 HT+CAD 20-30 ESRD 15-20 HT+CAD+PVD 40-60 HT+CAD+Renal dysfunction 40-60Prevalence of renal artery stenosis (RAS)ARAS

2、90%FMD 10% Common causes of renal artery stenosisHTRenal dysfunctionAngina pectorisParoxysmal acute pulmonary edemaPresentation of renal artery stenosisHaemodynamics:50%Renal perfusion pressure reduction70%RPP75-85mmHg, autonomic regulation losePathology:Glomcrulus：arteriosclerosis, mesenterium prol

3、iferation，Nephric tubule：epithelial cells denudation、apoptosis,Focal necrosis，Renal interstitium：Inflammatory cell infiltration、fibrocyte proliferationEnd stage ：renal atrophyAtherosclerotic nephrosisNatural course of ARASstudyNF/U(mon)prograssion(%)Occlusion(%)Caps17033519Zierler80244811Tollefson48

4、54539Schreiber85524416Develop to total occlusion within 5 years 15%Deterioration gradually within 5 years 10-20%Develop to ESRD annually 5-15%3-year mortality in Pt. with ESRD on dislysis 50%Survival of ARAS Pt. with ESRD on dislysis: 5-year 18% 10-year 5%Atherosclerotic RAS progressionConlon et al,

5、 Kidney Int 2001 Oct;60:490-7Renal angio in 3987 Pt. undergoing cath Independent predictor of mortalityConlon et al, Kidney Int 2001 Oct;60:490-7Renal angio in 3987 Pt. undergoing cathIndependent predictor of mortalityCase 1: male，62y，HTCase 2: male, 78y，HT, DM, Renal dysfunctionRenal function:impro

6、ement： GFR increse 15% /Scr decrease 0.2mg/dLstable： GFR change15% / Scr change 15% / Scr increase 0.2mg/dLbenefit： Improement or stableBlood pressure:cure： SBP140mmHg and DBP90mmHg, without any anti-hypertension drugs，improement： SBP140mmHg and DBP 15mmHg with similar or less anti-hypertension drug

7、sineffective： BP change not meet the above standardbenefit： cure and improvementStandard for prognosis evaluation after renal artery stenting (Rundback)Long-term effect of stenting on RAS肾动脉支架术治疗肾动脉狭窄患者的肾动脉支架术治疗肾动脉狭窄患者的倪钧 张瑞岩 胡健 张宪 郑爱芳 沈卫峰上海交通大学附属瑞金医院心脏科（200025）摘要摘要：目的目的: 评价肾动脉支架术治疗肾动脉狭窄的长期疗效。 方法方法:

8、连续134例显著肾动脉狭窄患者接受肾动脉支架术。记录患者术前?术后24小时? 1年和2年长期的血清肌酐（sCr），和血压变化情况。结果结果: 134例患者均成功置入支架，术后24小时肌酐较术前升高（109.824.6）mol/L比（99.427.8）mol/L，肾小球滤过率 （57.619.3）ml/min比（68.518.9）ml/min较术前降低，但术后1年和2年的平均肌酐和术前比较差异无显著性。肾动脉介入治疗术后6月，64例血压得到改善。术后1年的平均血压为（148.622.6）mmHg，与术前比较有显著性意义。术后1年和2年分别有56例(50.9%)和50例(49.6%)患者获益。结论

9、结论:肾动脉支架术治疗肾动脉狭窄的远期疗效较好，且长期随访结果满意。关键词：关键词：动脉粥样硬化；肾动脉梗阻；介入治疗 Why some Pt. gain no benefit from RAS stenting?Renal parenchyma impairmentdiabetic nephropathyrenal impairment due to HTrenal impairment due to othersIschemic nephropathyAge CINRestenosisfactors Influencing the outcomes in RAS underwent ste

10、ntvolume-dependent hypertensionrenin-dependent hypertensionsympathetic nervous systemvasoactive substance secreted from kidneyRenal arteriolar sclerosis in benign hypertensionEarly stage：hyalinization in afferent glomerular arteriole and arteria interlobularesadvanced stageglomerulus, nephric tubule

11、, renal interstitiumrenal arteriolar sclerosis in malignant hypertension Necroticarteriolitis, Proliferating endarteritisNephrosis dut to cholesterol crystal embolizationEpidemiology：incidenceAorta ASautopsyetiological factor：AS、endovascular procedureHenry (Percusurge)AJC Oct,2000 TCT30 RAS of 24 Pt

12、. (27 ostial)All had renal impairement, 71% had HTSuccess rate 100%Occlusion time 418 sec(149-797)Embolization after stentingEmbolization after stentingImproved renal function 46%Unchanged 4%Acute deterioration 0%No renal function deterioretion at 6 monthKidney in elderlyvessel of kidneyrenal arteri

13、olar sclerosisrenal glomerulusnormal adult 1.3 million， 1/3-1/2 lost in 70 year-oldrenal tubuleepithelial cell hypertrophia, renal interstitiumatrophy, fibrosisrenal blood flowGFRKidney in elderlyContrast induced nephrosis (CIN)Risk factors related to CIN_hypovolemiaBerg KJ, Scand J Urol Nephrol 200

14、0; 34: 317-322Effect of DM and renal function on the incidence of CIN (n=1196）RI：renal impairment DM：diabetes Rudnick et al. (1995)0510152025+RI+DM+RIDMRI+DMRIDM0%5.7%19.7%0.6%Effect of DM and renal function on CIN with different contrast application0102030405060*定义为血清肌酐升高44.2mol/l或25%（Latin et al.

15、应用的标准为26.5mol/l或20%）*基线血清肌酐133mol/l（Barrett et al. 的研究中124mol/l） Patients (%)VisipaqueOmnipaqueorthersAspelinet al.2003Manskeet al.1990Wanget al.2000Rudnicket al.1995Taliercioet al.1991Lautinet al.1991Barrettet al.19922006 AHA/ACC Guideline Indications for RAS Revascularization(a) Asymptoatic Stenos

16、is（Class IIb）1. asymptomatic bilateral or solitary viable kidney with a hemodynamically significant RAS. (Level of evidence: C) 2. asymptomatic unilateral hemodynamically significant RAS in a viable kidney is not well established and is presently clinically unproven. (Level of evidence: C)(b) Hypert

17、ension（Class IIa）hemodynamically significant RAS and accelerated hypertension, resistant hypertension, malignant hypertension, hypertension with an unexplained unilateral small kidney, and hypertension with intolerance to medication. (Level of evidence: B)J Vasc Interv Radiol. 2006 Sep;17(9):1383-97

18、 Preservation of Renal FunctionClass IIaRAS and progressive chronic kidney disease with bilateral RASor a RAS to a solitary functioning kidney. (Level of evidence: B)Class IIbRAS and chronic renal insufficiency with unilateral RAS. (Level of evidence: C)Impact of RAS on Congestive Heart Failure and

19、Unstable Angina Class Ihemodynamically significant RAS and recurrent, unexplained congestive heart failure or sudden, unexplained pulmonary edema (Level of evidence: B)Class IIaPercutaneous revascularization is reasonable for patients with hemodynamically significant RAS and unstable angina (Level o

20、f evidence: B)J Vasc Interv Radiol. 2006 Sep;17(9):1383-97 Class I1. Renal stent placement is indicated for ostial atherosclerotic RAS lesions that meet the clinical criteria for intervention. (Level of evidence: B)2. Balloon angioplasty with bailout stent placement if necessary is recommended for F

21、MD lesions. (Level of evidence:B) J Vasc Interv Radiol. 2006 Sep;17(9):1383-97Catheter-based Interventions for RAS BNP increase is common in patients with hypertension Silva studyBaseline BNP80pgml 77% Pts BP improved post procedure 30 94 BP improved30 10 BP improvedPredictor for RAS stenting Doppler wireFFR0.8 BP and renal function improvePressure wire Distal renal/ Aorta80 97 % Pts. No BP improve 80 % Pts.