腎動脈狹窄支架術(shù)現(xiàn)狀

1、Renal stenting in renal artery stenosis-contented and uncontented 腎腎 動動 脈狹窄支架術(shù)脈狹窄支架術(shù) patients 發(fā)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腎動脈支架術(shù)治療腎動脈狹窄患者的腎動脈支架術(shù)治療腎動脈狹窄患者的倪鈞 張瑞巖 胡健 張憲 鄭愛芳 沈衛(wèi)峰上海交通大學(xué)附屬瑞金醫(yī)院心臟科（200025）摘要摘要：目的目的: 評價腎動脈支架術(shù)治療腎動脈狹窄的長期療效。 方法方法:

8、連續(xù)134例顯著腎動脈狹窄患者接受腎動脈支架術(shù)。記錄患者術(shù)前?術(shù)后24小時? 1年和2年長期的血清肌酐（sCr），和血壓變化情況。結(jié)果結(jié)果: 134例患者均成功置入支架，術(shù)后24小時肌酐較術(shù)前升高（109.824.6）mol/L比（99.427.8）mol/L，腎小球?yàn)V過率 （57.619.3）ml/min比（68.518.9）ml/min較術(shù)前降低，但術(shù)后1年和2年的平均肌酐和術(shù)前比較差異無顯著性。腎動脈介入治療術(shù)后6月，64例血壓得到改善。術(shù)后1年的平均血壓為（148.622.6）mmHg，與術(shù)前比較有顯著性意義。術(shù)后1年和2年分別有56例(50.9%)和50例(49.6%)患者獲益。結(jié)論

9、結(jié)論:腎動脈支架術(shù)治療腎動脈狹窄的遠(yuǎn)期療效較好，且長期隨訪結(jié)果滿意。關(guān)鍵詞：關(guān)鍵詞：動脈粥樣硬化；腎動脈梗阻；介入治療 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*定義為血清肌酐升高44.2mol/l或25%（Latin et al.

15、應(yīng)用的標(biāo)準(zhǔn)為26.5mol/l或20%）*基線血清肌酐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.