腎動(dòng)脈狹窄支架術(shù)現(xiàn)狀

1、Renal stenting in renal artery stenosis-contented and uncontented 腎腎 動(dòng)動(dòng) 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)Commo

2、n causes of renal artery stenosisHTRenal dysfunctionAngina pectorisParoxysmal acute pulmonary edemaPresentation of renal artery stenosisAtherosclerotic nephrosisNatural course of ARASAtherosclerotic RAS progressionConlon et al, Kidney Int 2001 Oct;60:490-7Renal angio in 3987 Pt. undergoing cath Inde

3、pendent 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 dysfunctionStandard for prognosis evaluation after renal artery stenting (Rundback)Long-term effect of s

4、tenting on RAS腎動(dòng)脈支架術(shù)治療腎動(dòng)脈狹窄患者的腎動(dòng)脈支架術(shù)治療腎動(dòng)脈狹窄患者的倪鈞 張瑞巖 胡健 張憲 鄭愛(ài)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(píng)價(jià)腎動(dòng)脈支架術(shù)治療腎動(dòng)脈狹窄的長(zhǎng)期療效。 方法方法:連續(xù)134例顯著腎動(dòng)脈狹窄患者接受腎動(dòng)脈支架術(shù)。記錄患者術(shù)前?術(shù)后24小時(shí)? 1年和2年長(zhǎng)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(shí)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(guò)率 （57.619.3）ml/min比（68.518.9）ml/min較術(shù)

5、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(wú)顯著性。腎動(dòng)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)論結(jié)論:腎動(dòng)脈支架術(shù)治療腎動(dòng)脈狹窄的遠(yuǎn)期療效較好，且長(zhǎng)期隨訪結(jié)果滿意。關(guān)鍵詞：關(guān)鍵詞：動(dòng)脈粥樣硬化；腎動(dòng)脈梗阻；介入治療 Why some Pt. gain no benefit from RAS stenting?Renal parenchyma impairmentdiabetic nephropathyrenal impairment du

6、e to HTrenal impairment due to othersIschemic nephropathyAge CINRestenosisfactors Influencing the outcomes in RAS underwent stentEpidemiology：etiological factor：AS、endovascular procedureHenry (Percusurge)AJC Oct,2000 TCT30 RAS of 24 Pt. (27 ostial)All had renal impairement, 71% had HTSuccess rate 10

7、0%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 monthvessel of kidneyrenal arteriolar sclerosisrenal glomerulusnormal adult 1.3 million， 1/3-1/2 lost in 70 year-ol

8、drenal tubuleepithelial cell hypertrophia, renal interstitiumatrophy, fibrosisrenal blood flowGFRContrast induced nephrosis (CIN)Risk factors related to CINBerg KJ, Scand J Urol Nephrol 2000; 34: 317-322Effect of DM and renal function on the incidence of CIN (n=1196）RI：renal impairment DM：diabetes R

9、udnick 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. 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

10、 al.2003Manskeet al.1990Wanget al.2000Rudnicket al.1995Taliercioet al.1991Lautinet al.1991Barrettet al.19922006 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

11、 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, malignan

12、t 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 t

13、o 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 s

14、udden, 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

15、 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):1383-97Catheter-based Interventions for RAS

16、 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. No

17、 renal function improveIndicating : small vessel disease or renal parenchyma disease Total patients 240Requiring Renal revascularization Yes (20%)48 No (80%)192RRI (estimated) 80 (2/3) 80 (1/3) 80(2/3) 80 (1/3)N 32 16 128 64Randomized to revascularization Y/N Y/N 16/16 8/8Purpose:pare renal revascularization to medical management for people with ARVD2.whether the RRI can identify patients with RAS who will not benefit from renal re