高血压英文ppt精品课件renovascular disease recognition and

Renovascular Disease recognition and management Craig A. Thompson, M.D., MMSc. Cardiac and Vascular Interventional Services Dartmouth Hitchcock Medical Center Lebanon, NH Old Medical Adage: “Even a monkey can do angioplasty.” Caveat: It takes a real doctor to decide: What the diagnostic studies do and dont say What to do afterward How to address this problem in the context of a living, breathing patient When to When not to In whom Renovascular Disease: The Clinical Perspective Progress in Renovascular Disease 1) The disease 2) Clinical diagnosis 3) Laboratory diagnosis / imaging modalities 4) Patient selection: who benefits from intervention? 5) Limiting contrast-induced nephropathy 6) Atheroembolic protection 7) Expanding the pool of eligible patients / interventions 8) Limiting restenosis Progress in Renovascular Disease 1) The Disease 2) Clinical diagnosis 3) Laboratory diagnosis / imaging modalities 4) Patient selection: who benefits from intervention? 5) Limiting contrast-induced nephropathy 6) Atheroembolic protection 7) Expanding the pool of eligible patients / interventions 8) Limiting restenosis Etiology of Renal Artery Stenosis Fibromuscular dysplasia lAtherosclerosis lPolyarteritis Nodosa lRadiation-induced lTakayasus arteritis Defining the Problem RAS is an important cause of secondary hypertension Renovascular disease under-appreciated as cause of CRF 23% of malignant hypertension is the result of renovascular causes Not all patients with RAS are hypertensive as a result What is “medical therapy” for renovascular disease? Natural History of Renal Artery Stenosis Serial U/S examination of 170 patients with 295 renal arteries Exclusion for congenitally absent / occluded / prior PCI / poor window Referred for renal U/S for hypertension or renal insufficiency Only included in study if not a candidate for immediate revascularization U/S evaluation every 6 months until time of intervention Duplex evaluation: Peak Systolic Velocity (PSV) in proximal, middle, and distal RA and AO Yielding the RAR (Renal-to-Aortic Ratio) Caps et al. Circulation 1998; 98:2866-2872. Natural History of Renal Artery Stenosis Caps et al. Circulation 1998; 98:2866-2872. Role of lipid lowering and Aggressive risk factor modification? L. Gabriel Navar and L. Lee Hamm Mark A. Pohl L. Gabriel Navar and L. Lee Hamm Progress in Renovascular Disease 1) The Disease 2) Clinical diagnosis 3) Laboratory diagnosis / imaging modalities 4) Patient selection: who benefits from intervention? 5) Limiting contrast-induced nephropathy 6) Atheroembolic protection 7) Expanding the pool of eligible patients / interventions 8) Limiting restenosis Clinical Clues Onset of diastolic hypertension after age 55 Refractory or malignant hypertension Development of resistant hypertension in a previously well-controlled patient Progressive increase in Creatinine, even if still “normal” Presence of atherosclerotic macrovascular disease elsewhere heightens suspicion Left heart failure out-of-proportion to LV dysfunction or ischemic burden Clinically silent RAS Progress in Renovascular Disease 1) The Disease 2) Clinical diagnosis 3) Laboratory diagnosis / imaging modalities 4) Patient selection: who benefits from intervention? 5) Limiting contrast-induced nephropathy 6) Atheroembolic protection 7) Expanding the pool of eligible patients / interventions 8) Limiting restenosis vClinical syndrome most important in patient selection vVarious diagnostic modalities: Serologic markers Duplex ultrasound - in experienced hands can predict with great accuracy the presence or absence of significant RAS Captopril renal scan - 10-25% false negative MR angiography - rare false negatives / common false positives. Equipment/experience dependent Contrast angiography Screening for Renovascular Disease Duplex U/S for Renovascular Disease Prospective Duplex U/S evaluation and Renal Angiography in 102 pts Goal: Validate renal artery U/S as a viable non-invasive modality Drawbacks: Time and labor intensive Technologist dependent Not available NPO Requires a cooperative patient Olin et al. Ann Intern Med. 1995; 122:833-838. Degree Stenosis Renal PSV RAR Normal 180 cm/sec 60% 180 cm/sec 3.5 Occlusion No signal No signal MRA 16;319-31. Chronic Renal Insufficiency and RAS Who Benefits From Revascularization? Trial of 51 patients with Creat2.0 before revascularization with 75% Bilateral RAS: 67% had improvement in renal function 27% had stabilization in renal function Only 6% had worsening in renal function No demonstrated impact upon mortality Novick et al. J Urol 1983; 129:907-12. Experimental Data supporting Stenting for Preservation of Renal Function 61 vessels in 31 patients with “global” obstructive atherosclerotic renal disease All with chronic renal insufficiency (Creat 1.5 4.0) Stenting with non-articulated Palmaz stents Follow-up Renal U/S, Serum Creat , BP measurements: - Improvement in reciprocal slope of serum creatinine - Improved BP control (SBP from 17021 Pre-stent vs. 148 15mmHg Post-stent; p50%) in only 1 of 61 vessels - Stabilization of pole-to-pole renal dimension Watson et al. Circulation. 2000; 102:1671-1677. Renal Artery Stenting pre post Global Renal Revascularization Watson et al. Circulation. 2000; 102:1671-1677. Watson et al. Circulation. 2000; 102:1671-1677. Dutch Renal Artery Stenosis Intervention Cooperative Study Study Design: 106 hypertensive patients with RAS (50%) and Creat Anatomic definition -Gadopentatate dimeglumine -Renally cleared by GF -Not nephrotoxic to 0.4mmol/kg -Changing kV may improve image quality AC and hydration reduce Creatinine hydration alone in CT with CRI (2% vs 21%) May decrease incidence of RCN vs. historical controls (4.7% vs 18.8%) Progress in Renovascular Disease 1) The Disease 2) Clinical diagnosis 3) Laboratory diagnosis / imaging modalities 4) Patient selection: who benefits from intervention? 5) Limiting contrast-induced nephropathy 6) Atheroembolic protection 7) Expanding the pool of eligible patients / interventions 8) Limiting restenosis Guarding Against Atheroembolism vMeticulous “no touch” technique vUse of low profile, atraumatic catheters vLimited catheter manipulation vPrimary stenting when feasible vGP 2b3a Antagonists vDistal protection devices Distal Atheroembolic Protection: The Ideal Capture all debris Continued renal perfusion during procedure Limitless reservoir Atraumatic to vessel wall Technically easy to use Low profile Trackable Pathology of Atheroembolism Plaque / cholesterol Endothelial cells Platelet-Fibrin Thrombi Calcified tissue Evolution of Distal Protection Devices Initially used in the treatment of patients with coronary bypass graft disease These interventions commonly plagued by angiographic “No Reflow” phenomenon Cardiac enzyme leak Clinical myocardial infarction Long attributed to RBC lysis and platelet activation with resultant microvascular spasm Initial Reports: Atheroembolic Protection “Percusurge Guardwire” 47% of patients with SVG intervention had gross, macroscopic evidence of red-yellow debris An additional 20% of patients had evidence of microscopic debris Carlino et al.Circulation 1999; 99: 3221-3223 SAFER Trial vRandomized comparison of SVG lesions treated +/- PercuSurge Guardwire vImproved outcomes: 42% decrease MACE vLower laboratory MIs vSafe vHigh procedural success Baim et al. Circulation 2002. Distal Protection in Renovascular Disease: An Opportunity vMost RAS caused by atheromatous disease vOstial / proximal segments of disease are common vKidney will tolerate longer balloon occlusion time than coronary / cerebral circulation vAtheroembolism has long been viewed as a major risk / complication of percutaneous intervention of the renal arteries. FILTER DEVICES OCCLUSION DEVICES Preserve flow Limit Ischemic Time More complete capture Small debris Vascular Injury No antegrade flow Prolonged Ischemic Time Vascular Injury Shoulder Regions + - FILTER DEVICES Cordis OCCLUSION DEVICES Atheroembolization Protection Percusurge Guardwire A. Traverse B. Inflate C. Intervene D. Embolectomize Early Experience: Distal Protection in Renovascular Intervention 28 patients with 32 renal arteries 29 Lesions ostial location 100% Technical success with GuardWire Visible debris aspirated: 100% cases Mean RA occlusion time: 6.55 min (2.29-13.21 min) Creatinine post-procedure and at follow-up stable or improved in all cases. Conclusion: Distal protection against atheroembolism is feasible and safe But is it effective? Henry et al.J Endovasc Ther 2001; 8(3): 227-37. Characterization of Debris Characterize debris in carotid intervention Can we extrapolate to renal artery intervention? Both atheromatous Similar patient population Tuber et al.Circulation 2001; 104: 2791-6. Characterization of Debris Tuber et al.Circulation 2001; 104: 2791-6. What type of debris was not captured? Why did complications still occur? Characterization of Debris Tuber et al.Circulation 2001; 104: 2791-6. CO2 Aortogram RRA Splenic A LRA Gadolinium Renal Angiogram No trans-lesional gradient with 5F catheter R Gadolinium Renal Angiogram 60mmHg gradient with 4F catheter IVUS with 87% stenosis c/t reference vesselL Gadolinium Renal Angiogram With PercuSurge RESIST Trial Study Design: Multicenter, randomized trial of renal PTA/Stent +/- Distal atheroembolic protection (Cordis Angioguard XP) +/- Anti-platelet therapy with 2b 3a antagonist (Reopro) Endpoints: 1) Renal function as measured by - Nuclear renal scan with DTPA - GFR estimated by Iohexol clearance - Serum Creatinine 2) Bleeding complications 3) Microscopic assessment of atheromatous debris within the Angioguard XP PI: Christopher J. Cooper, M.D. Medical College of Ohio Progress in Renovascular Disease 1) The Disease 2) Clinical diagnosis 3) Laboratory diagnosis / imaging modalities 4) Patient selection: who benefits from intervention? 5) Limiting contrast-induced nephropathy 6) Atheroembolic protection 7) Expanding the pool of eligible patients / interventions 8) Limiting restenosis What are the benefits of PCI over Surgical revascularization? Shortened hospital stays Reduced post-procedural morbidity / mortality (J Vasc Surg 1994; 20: 76-87) Early graft failure 5% Peri-operative mortality 5.6% 43% of patients required aortic grafting l Comparable procedural success and improvement in renal function (J Vasc Surg 1993; 18:841-52) l Procedural success: PTRA 83% vs. Surgery 97% (p=NS) l Improved or stable renal function: PTRA 83% vs. Surgery 72% (p=NS) l Broadens pool of patients eligible for revascularization Benefit of Renal TO Revascularization v Surgical revascularization vs. Nephrectomy in 95 patients with 100 Occluded Renal Arteries. v All patients hypertensive v 88% of patients with renal dysfunction v Renal function, blood pressure response and survival followed after procedure. Oskin et al. J Vasc Surg 1999. 29 (1):140-149. Study Results Blood pressure improved in both groups 87% with nephrectomy 92% with revascularization (p=NS) Only revascularized patients (49%) demonstrated improved glomerular filtration rate (GFR). 9 revascularized patients were no longer dialysis-dependant The absence of a nephrogram or distal reconstitution of the vessel did not preclude revascularization (done in 48% of these cases) Selective renal vein renins or nuclear renal scan may be of benefit in guiding therapy Renal biopsy may show hyalinization of glomeruli, tubular atrophy, and loss of cortical thickness, but is not an absolute predictor of renal recovery or failure to recover Oskin et al. J Vasc Surg 1999. 29 (1):140-149. Renal TO: Technical Difficulties Occluded renal artery without collateral filling of distal vessel still may be a surgical candidate Cautious recanalization to avoid perforation Acquisition of both indirect and direct evidence of intravascular position. Small balloon predilatation Minimize iodinated contrast as most patients have significant baseline CRI Stenting a must as there is marked elastic recoil and bulky plaque prolapse DSA Abdominal Aortogram Abdominal Aortogram: Late Phase Early PhaseLate Phase Selective Left Renal Angiogram Selective Right Renal Angiogram ? Selective Right Lumbar Angiogram Collateral Circulation of The Kidney A. Suprarenal Complex B. Lu