腎動脈狹窄支架術(shù)現(xiàn)狀

patients發(fā)病率(%)Generalpeople0.1Hepertension1-5<50y,withHT(FMD)4-5>50y,wiht(ARAS)HT15CAD10-19criticalHT30HT+CAD20-30ESRD15-20HT+CAD+PVD40-60HT+CAD+Renaldysfunction40-60Prevalenceofrenalarterystenosis(RAS)當前第1頁\共有50頁\編于星期四\21點ARAS90%FMD10%

CommoncausesofrenalarterystenosisHTRenaldysfunctionAnginapectorisParoxysmalacutepulmonaryedemaPresentationofrenalarterystenosis當前第2頁\共有50頁\編于星期四\21點Haemodynamics:>50%Renalperfusionpressurereduction>70%RPP<75-85mmHg,autonomicregulationlosePathology:Glomcrulus：arteriosclerosis,mesenteriumproliferation，Nephrictubule：epithelialcellsdenudation、apoptosis,Focalnecrosis，Renalinterstitium：Inflammatorycellinfiltration、fibrocyteproliferationEndstage：renalatrophyAtheroscleroticnephrosis當前第3頁\共有50頁\編于星期四\21點NaturalcourseofARASstudyNF/U(mon)prograssion(%)Occlusion(%)Caps17033519Zierler80244811Tollefson4854539Schreiber85524416當前第4頁\共有50頁\編于星期四\21點Developtototalocclusionwithin5years15%Deteriorationgraduallywithin5years

10-20%DeveloptoESRDannually5-15%3-yearmortalityinPt.withESRDondislysis50%SurvivalofARASPt.withESRDondislysis:5-year18%10-year5%AtheroscleroticRASprogression當前第5頁\共有50頁\編于星期四\21點Conlonetal,KidneyInt2001Oct;60:490-7Renalangioin3987Pt.undergoingcath

Independentpredictorofmortality當前第6頁\共有50頁\編于星期四\21點Conlonetal,KidneyInt2001Oct;60:490-7Renalangioin3987Pt.undergoingcathIndependentpredictorofmortality當前第7頁\共有50頁\編于星期四\21點Case1:male，62y，HT當前第8頁\共有50頁\編于星期四\21點Case2:male,78y，HT,DM,Renaldysfunction當前第9頁\共有50頁\編于星期四\21點Renalfunction:improement：GFRincrese15%/Scrdecrease0.2mg/dLstable：GFRchange<15%/Scrchange<0.2mg/dLineffective：GFRdecrease>15%/Scrincrease>0.2mg/dL

benefit：ImproementorstableBloodpressure:cure：SBP<140mmHgandDBP<90mmHg,withoutanyanti-hypertensiondrugs，improement：SBP<140mmHgandDBP<90mmHg,or,DBPdecrease>15mmHgwithsimilarorlessanti-hypertensiondrugsineffective：BPchangenotmeettheabovestandardbenefit：cureandimprovementStandardforprognosisevaluationafterrenalarterystenting(Rundback)當前第10頁\共有50頁\編于星期四\21點RenalarterystentingsuccessratestudyNProceduralsuccess(%)Burket127100Rodriguez10898Rocha15097QueenMaryhospital64100RuijinHospital12899當前第11頁\共有50頁\編于星期四\21點PTRAonhepertensionstudyF/U(m)caursecure(%)Improve(%)Nochange（%)Lossino60FMDARAS571221512137Tegtmeyer39FMDARAS37256355020QMH34ARAS113257RJH6ARAS115633當前第12頁\共有50頁\編于星期四\21點PTRAonrenalfunctionstudyNtechniquestable/improve(%)deterioration（%)Rodriguez105stent7228Rocha150stent928Steinbach222stent928QMH31stent8713RJH87stent6327當前第13頁\共有50頁\編于星期四\21點Long-termeffectofstentingonRAS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：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: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: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[（109.8±24.6）μmol/L比（99.4±27.8）μmol/L]，腎小球濾過率[（57.6±19.3）ml/min比（68.5±18.9）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（148.6±22.6）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:腎動脈支架術(shù)治療腎動脈狹窄的遠期療效較好，且長期隨訪結(jié)果滿意。關(guān)鍵詞：動脈粥樣硬化；腎動脈梗阻；介入治療當前第14頁\共有50頁\編于星期四\21點當前第15頁\共有50頁\編于星期四\21點

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當前第31頁\共有50頁\編于星期四\21點WhysomePt.gainnobenefitfromRASstenting?當前第32頁\共有50頁\編于星期四\21點RenalparenchymaimpairmentdiabeticnephropathyrenalimpairmentduetoHTrenalimpairmentduetoothersIschemicnephropathyAgeCINRestenosisfactorsInfluencingtheoutcomesinRASunderwentstent當前第33頁\共有50頁\編于星期四\21點 nephronredunctionvolume-dependenthypertension：(BilRAS/renaldysfunction)renin-dependenthypertension：(uniRAS)sympatheticnervoussystemvasoactivesubstancesecretedfromkidney：natriuretichormonevasopressinMechanismofhypertensioninCKD當前第34頁\共有50頁\編于星期四\21點RenalarteriolarsclerosisinbenignhypertensionEarlystage：hyalinizationinafferentglomerulararterioleandarteriainterlobularesadvancedstage：glomerulus,nephrictubule,renalinterstitiumdiseaserenalarteriolarsclerosisinmalignanthypertension(DBP>120mmHg)Necroticarteriolitis,ProliferatingendarteritisPathologyofhypertension-inducedrenalimpairment當前第35頁\共有50頁\編于星期四\21點NephrosisduttocholesterolcrystalembolizationEpidemiology：authorpopulationcasesincidence(%)FloryAortaAS2673.3Orossautopsy37222.4JonesUnexplainedrenaldysfunction2451.0Preston>65years3344.2etiologicalfactor：AS、endovascularprocedure當前第36頁\共有50頁\編于星期四\21點Henry(Percusurge)AJCOct,2000TCT30RASof24Pt.(27ostial)Allhadrenalimpairement,71%hadHTSuccessrate100%Occlusiontime418sec(149-797)Embolizationafterstenting當前第37頁\共有50頁\編于星期四\21點EmbolizationafterstentingImprovedrenalfunction46%Unchanged4%Acutedeterioration0%Norenalfunctiondeterioretionat6month6/30(20%)empty24/30(80%)hadfiltercontentChronicthrombusCholesterolcleftsfragment當前第38頁\共有50頁\編于星期四\21點KidneyinelderlyKidneychange

vesselofkidney：renalarteriolarsclerosis

renalglomerulus：normaladult1.3million，1/3-1/2lostin70year-old

renaltubule：epithelialcellhypertrophia,renalinterstitium：atrophy,fibrosisRenalfunctionchange

renalbloodflow：10%redunctionper10years

GFR：Among40-80year-old,GFRdecrease0.8-1ml/minevery1year

當前第39頁\共有50頁\編于星期四\21點Kidneyinelderly當前第40頁\共有50頁\編于星期四\21點Contrastinducednephrosis(CIN)AcuterenalimpairmentaftercontrastapplicationScrincrease>44.2μmol/LOr,increase>25%comparedtobaselinePrevalence:unselectedPt.:1-6%，Highrisk40-50%

當前第41頁\共有50頁\編于星期四\21點RiskfactorsrelatedtoCINExistedrenaldysfunctionDMVasculardiseaseElderlyLowerEFhypovolemiadehydrationCongestiveheartfailurenephroticsyndrome;LiverCirrhosisBergKJ,ScandJUrolNephrol2000;34:317-322當前第42頁\共有50頁\編于星期四\21點EffectofDMandrenalfunctionontheincidenceofCIN(n=1196）RI：renalimpairmentDM：diabetes

Rudnicketal.(1995)0510152025+RI+DM+RI–DM–RI+DM–RI–DM0%5.7%19.7%%0.6%當前第43頁\共有50頁\編于星期四\21點EffectofDMandrenalfunctiononCINwithdifferentcontrastapplication0102030405060*定義為血清肌酐升高＞44.2μmol/l或＞25%（Laμtinetal.應(yīng)用的標準為＞26.5μmol/l或＞20%）**基線血清肌酐＞133μmol/l（Barrettetal.的研究中＞124μmol/l）Patients(%)VisipaqueOmnipaqueorthersAspelinetal.2003Manskeetal.1990Wangetal.2000Rudnicketal.1995Taliercioetal.1991Lautinetal.1991Barrettetal.1992當前第44頁\共有50頁\編于星期四\21點RenalarterystentingrestonosisauthorscasesF/Urestenosis(%)Shammas1322-20月26Wienklin403.3年12.5Zeller1564年11.4IIkay2614.3Yutan88531QueenMaryhospital641212.5RuijinHospital1086-20月11.5當前第45頁\共有50頁\編于星期四\21點2006AHA/ACC

Guideline

IndicationsforRASRevascularization(a)AsymptoaticStenosis（ClassIIb）1.asymptomaticbilateralorsolitaryviablekidneywithahemodynamicallysignificantRAS.(Levelofevidence:C)

2.asymptomaticunilateralhemodynamicallysignificantRASinaviablekidneyisnotwellestablishedandispresentlyclinicallyunproven.(Levelofevidence:C)(b)Hypertension（ClassIIa）hemodynamicallysignificantRASandacceleratedhypertension,resistanthypertension,malignanthypertension,hypertensionwithanunexplainedunilateralsmallkidney,andhypertensionwithintolerancetomedication.(Levelofevidence:B)JVascIntervRadiol.2006Sep;17(9):1383-97當前第46頁\共有50頁\編于星期四\21點

PreservationofRenalFunctionClassIIaRASandprogressivechronickidneydiseasewithbilateralRASoraRAStoasolitaryfunctioningkidney.(Levelofevidence:B)ClassIIbRASandchronicrenalinsufficiencywithunilateralRAS.(Levelofevidence:C)ImpactofRASonCongestiveHeartFailureandUnstableAnginaClassIhemodynamicallysignificantRASandrecurrent,unexplainedcongestiveheartfailureorsudden,unexplainedpulmonaryedema(Levelofevidence:B)ClassIIaPercutaneousrevascularizationisreasonableforpatientswithhemodynamicallysignificantRASandunstableangina(Levelofevidence:B)JVascIntervRadiol.2006Sep;17(9):1383-97當前第47頁\共有50頁