肾动脉狭窄支架术现状课件

Renal stenting in renal artery stenosis -contented and uncontented 肾 动 脉狭窄支架术 patients 发病率(%) General people 0.1 Hepertension 1-5 50y, 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 40-60 Prevalence of renal artery stenosis (RAS) ARAS 90% FMD 10% Common causes of renal artery stenosis HT Renal dysfunction Angina pectoris Paroxysmal acute pulmonary edema Presentation of renal artery stenosis Haemodynamics: 50% Renal perfusion pressure reduction 70% RPP15% / Scr increase 0.2mg/dL benefit： Improement or stable Blood pressure: cure： SBP 15mmHg with similar or less anti-hypertension drugs ineffective： BP change not meet the above standard benefit： cure and improvement Standard for prognosis evaluation after renal artery stenting (Rundback) Renal artery Renal artery stentingstenting success rate success rate study NProcedural success(%) Burket127100 Rodriguez10898 Rocha15097 Queen Mary hospital 64 100 Ruijin Hospital 12899 PTRA on PTRA on hepertensionhepertension study F/U(m)caursecure(%)Improve (%) No change （%) Lossino60FMD ARAS 57 12 21 51 21 37 Tegtmeyer39FMD ARAS 37 25 63 55 0 20 QMH34ARAS113257 RJH6ARAS11 56 33 PTRA on renal functionPTRA on renal function study Ntechniquestable/improve (%) deterioration （%) Rodriguez105stent7228 Rocha150stent928 Steinbach222stent928 QMH31stent8713 RJH87 stent6327 Long-term effect of stenting on RAS 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：目的: 评价肾动脉支架术治疗肾动脉狭窄的长期疗效。 方法: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: 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: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：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 impairment diabetic nephropathy renal impairment due to HT renal impairment due to others Ischemic nephropathy Age CIN Restenosis factors Influencing the outcomes in RAS underwent stent nephron redunction volume-dependent hypertension：(Bil RAS/renal dysfunction) renin-dependent hypertension：(uni RAS) sympathetic nervous system vasoactive substance secreted from kidney：natriuretic hormone vasopressi n Mechanism of hypertension in CKDMechanism of hypertension in CKD Renal arteriolar sclerosis in benign hypertension Early stage：hyalinization in afferent glomerular arteriole and arteria interlobulares advanced stage：glomerulus, nephric tubule, renal interstitium disease renal arteriolar sclerosis in malignant hypertension (DBP120mmHg) Necroticarteriolitis, Proliferating endarteritis Pathology of hypertension-induced renal impairmentPathology of hypertension-induced renal impairment Nephrosis dut to cholesterol crystal embolization Epidemiology： authorpopulationcases incidence(%) Flory Aorta AS 2673.3 Oross autopsy 37222.4 JonesUnexplained renal dysfunction 2451.0 Preston65 years3344.2 etiological factor：AS、endovascular procedure Henry (Percusurge)AJC Oct,2000 TCT 30 RAS of 24 Pt. (27 ostial) All had renal impairement, 71% had HT Success rate 100% Occlusion time 418 sec(149-797) Embolization after stenting Embolization after stenting Improved renal function 46% Unchanged 4% Acute deterioration 0% No renal function deterioretion at 6 month 6/30(20%) empty6/30(20%) empty 24/30(80%)had filter content24/30(80%)had filter content Chronic thrombusChronic thrombus Cholesterol cleftsCholesterol clefts fragmentfragment Kidney in elderly Kidney changeKidney change vessel of kidney： renal arteriolar sclerosis renal glomerulus： normal adult 1.3 million， 1/3-1/2 lost in 70 year-old renal tubule： epithelial cell hypertrophia, renal interstitium： atrophy, fibrosis Renal function changeRenal function change renal blood flow：10% 10% redunctionredunction per 10 years per 10 years GFR：Among 40-80 year-old, GFR decrease 0.8-1ml/min every 1 yearAmong 40-80 year-old, GFR decrease 0.8-1ml/min every 1 year Kidney in elderly Contrast induced nephrosis (CIN) Acute renal impairment after contrast application _Scr increase 44.2mol/L _Or, increase 25% compared to baseline _Prevalence: unselected Pt. : 1-6 %，High risk 40-50 % Risk factors related to CIN _Existed renal dysfunction _DM _Vascular disease _Elderly _Lower EF _hypovolemia _dehydration _Congestive heart failure _nephrotic syndrome; Liver Cirrhosis Berg KJ, Scand J Urol Nephrol 2000; 34: 317-322 Effect of DM and renal function on the incidence of CIN (n=1196） RI：renal impairment DM：diabetes Rudnick et al. (1995) 0 5 10 15 20 25 +RI+DM+RIDMRI+DMRIDM 0% 5.7% 19.7% % 0.6% Effect of DM and renal function on CIN with different contrast application 0 10 20 30 40 50 60 *定义为血清肌酐升高44.2mol/l或25%（Latin et al. 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 (%) Visipaque Omnipaque orthers Aspelin et al. 2003 Manske et al. 1990 Wang et al. 2000 Rudnick et al. 1995 Taliercio et al. 1991 Lautin et al. 1991 Barrett et al. 1992 Renal artery Renal artery stentingstenting restonosisrestonosis authorscasesF/Urestenosis(%) Shammas1322-20月26 Wienklin403.3年12.5 Zeller1564年11.4 IIkay2614.3 Yutan88531 Queen Mary hospital 64 1212.5 Ruijin Hospital1086-20月11.5 2006 AHA/ACC Guideline Indications for RAS Revascularization (a) Asymptoatic Stenosis（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) Hypertension（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 Preservation of Renal Function Class IIa RAS and progressive chronic kidney disease with bilateral RAS or a RAS to a solitary functioning kidney. (Level of evidence: B) Class IIb RAS and chronic renal insufficiency with unilateral RAS. (Level of evidence: C) Impact of RAS on Congestive Heart Failure and Unstable Angina Class I hemodynamically significant RAS and recurrent, unexplained congestive heart failure or sudden, unexplained pulmonary edema (Level of evidence: B) Class IIa Percutaneous revascularization is reasonable for patients with hemodynamically significant RAS and unstable angina (Level of evidence: B) J Vasc Interv Radiol. 2006 Sep;17(9):1383-97 Class I 1. 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 FMD lesions. (Level of evidence:B) J Vasc Interv Radiol. 2006 Sep;17(9):1383-97 Catheter-based Interventions for RAS BNP increase is common in patients with hypertension Silva study Baseline BNP80pgml 77% Pts BP improved post proced