肾动脉狭窄支架术现状

Renal stenting in renal artery stenosis-contented and uncontented 肾 动 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 40-60,Prevalence of renal artery stenosis (RAS),ARAS 90%FMD 10%,Common causes of renal artery stenosis,HTRenal dysfunctionAngina pectorisParoxysmal acute pulmonary edema,Presentation of renal artery stenosis,Haemodynamics:50%Renal perfusion pressure reduction70%RPP0.2mg/dL benefit： Improement or stableBlood pressure:cure： SBP 15mmHg with similar or less anti-hypertension drugsineffective： BP change not meet the above standardbenefit： cure and improvement,Standard for prognosis evaluation after renal artery stenting (Rundback),Renal artery stenting success rate,PTRA on hepertension,PTRA on renal function,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 impairmentdiabetic nephropathyrenal impairment due to HTrenal impairment due to othersIschemic nephropathyAge CINRestenosis,factors Influencing the outcomes in RAS underwent stent,nephron redunctionvolume-dependent hypertension：(Bil RAS/renal dysfunction) renin-dependent hypertension：(uni RAS)sympathetic nervous systemvasoactive substance secreted from kidney：natriuretic hormone vasopressin,Mechanism of hypertension in CKD,Renal arteriolar sclerosis in benign hypertensionEarly stage：hyalinization in afferent glomerular arteriole and arteria interlobularesadvanced stage：glomerulus, nephric tubule, renal interstitium diseaserenal arteriolar sclerosis in malignant hypertension (DBP120mmHg) Necroticarteriolitis, Proliferating endarteritis,Pathology of hypertension-induced renal impairment,Nephrosis dut to cholesterol crystal embolization,Epidemiology：,etiological factor：AS、endovascular procedure,Henry (Percusurge)AJC Oct,2000 TCT30 RAS of 24 Pt. (27 ostial)All had renal impairement, 71% had HTSuccess 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 month6/30(20%) empty24/30(80%)had filter contentChronic thrombusCholesterol cleftsfragment,Kidney in elderly,Kidney 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, fibrosisRenal function change renal blood flow：10% redunction per 10 years GFR：Among 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 applicationScr increase 44.2mol/LOr, increase 25% compared to baselinePrevalence: unselected Pt. : 1-6 %，High risk 40-50 %,Risk factors related to CIN,Existed renal dysfunctionDMVascular diseaseElderly Lower EFhypovolemiadehydrationCongestive heart failurenephrotic 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,+RIDM,RI+DM,RIDM,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 (%),VisipaqueOmnipaqueorthers,Aspelinet al.2003,Manskeet al.1990,Wanget al.2000,Rudnicket al.1995,Taliercioet al.1991,Lautinet al.1991,Barrettet al.1992,Renal artery stenting restonosis,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 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 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 of evidence: B),J Vasc Interv Radiol. 2006 Sep;17(9):1383-97,Class IRenal 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 studyBaseline BNP80pgml 77% Pts BP improved post procedure 30 94 BP improved30 10 BP improved,Predictor for RAS stenting,Doppler wireFFR0.8 BP and renal function improvePressure wire Distal renal/ Aorta80 97 % Pts. No BP improve 80 % Pts. No renal function improveIndicating : small