腎動脈狹窄支架術現(xiàn)狀

1、Renal stenting in renal artery stenosis----contented and uncontented 腎 動 脈狹窄支架術,patients 發(fā)病率(%) General people

2、 0.1Hepertension 1-550y, wiht (ARAS) HT 15 CAD

3、 10-19 critical HT 30 HT+CAD 20-30 ESRD

4、 15-20 HT+CAD+PVD 40-60 HT+CAD+Renal dysfunction 40-60,,,Prevalence of renal artery stenosis (

5、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 re

6、duction　>70%　RPP<75-85mmHg, autonomic regulation lose　Pathology:Glomcrulus：arteriosclerosis, mesenterium proliferation，Nephric tubule：epithelial cells denudation、apoptosis,Focal necrosis，Renal interstitium：Inf

7、lammatory cell infiltration、fibrocyte proliferationEnd stage ：renal atrophy,Atherosclerotic nephrosis,Natural course of ARAS,Develop to total occlusion within 5 years 15%Deterioration gradually within

8、 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:

9、 5-year 18% 10-year 5%,Atherosclerotic RAS progression,Conlon et al, Kidn

10、ey Int 2001 Oct;60:490-7Renal angio in 3987 Pt. undergoing cath,Independent predictor of mortality,Conlon et al, Kidney Int 2001 Oct;60:490-7Renal angio in 3987 Pt. undergoing cath,Independent predictor of mortality,Ca

11、se 1: male，62y，HT,,,Case 2: male, 78y，HT, DM, Renal dysfunction,Renal function:improement： GFR increse 15% /Scr decrease 0.2mg/dLstable： GFR change15% / Scr increase >0.2mg/dL benefit： Improement

12、or stableBlood pressure:cure： SBP 15mmHg with similar or less anti-hypertension drugsineffective： BP change not meet the above standardbenefit： cure and improvement,Stan

13、dard 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,腎動脈支架術治療腎動脈狹窄患者的倪鈞 張瑞巖 胡健 張憲 鄭愛芳 沈

14、衛(wèi)峰上海交通大學附屬瑞金醫(yī)院心臟科（200025）摘要：目的: 評價腎動脈支架術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。記錄患者術前?術后24小時? 1年和2年長期的血清肌酐（sCr），和血壓變化情況。結果: 134例患者均成功置入支架，術后24小時肌酐較術前升高[（109.8±24.6）μmol/L比（99.4±27.8）μmol/L]，腎小球濾過率 [（57.6&#

15、177;19.3）ml/min比（68.5±18.9）ml/min]較術前降低，但術后1年和2年的平均肌酐和術前比較差異無顯著性。腎動脈介入治療術后6月，64例血壓得到改善。術后1年的平均血壓為（148.6±22.6）mmHg，與術前比較有顯著性意義。術后1年和2年分別有56例(50.9%)和50例(49.6%)患者獲益。結論:腎動脈支架術治療腎動脈狹窄的遠期療效較好，且長期隨訪結果滿意。關鍵詞：動脈粥樣硬化；腎動

16、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 CINRestenos

17、is,factors Influencing the outcomes in RAS underwent stent,nephron redunctionvolume-dependent hypertension：(Bil RAS/renal dysfunction) renin-dependent hypertension：(uni RAS)sympathetic nervous systemvasoactive substa

18、nce secreted from kidney：natriuretic hormone vasopressin,Mechanism of hypertension in CKD,Renal arteriolar sclerosis in benign hypertensio

19、nEarly stage：hyalinization in afferent glomerular arteriole and arteria interlobularesadvanced stage：glomerulus, nephric tubule, renal interstitium diseaserenal arteriolar sclerosis in malign

20、ant hypertension (DBP>120mmHg) Necroticarteriolitis, Proliferating endarteritis,Pathology of hypertension-induced renal impairment,Nephrosis dut to cholesterol crystal embolization,Epidemiology：,etiological fa

21、ctor：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,Embo

22、lization 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 content

23、Chronic 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：

24、 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

25、,Kidney in elderly,Contrast induced nephrosis (CIN),Acute renal impairment after contrast applicationScr increase >44.2μmol/LOr, increase >25% compared to baselinePrevalence: unselected Pt. : 1-6 %，High risk

26、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;

27、 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,,+RI–DM,–RI+DM,–RI–D

28、M,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,*定義為血清肌酐升高＞44.2μmol/l或＞25%（Laμtin et al. 應用的標準為＞26.5μmol/l或＞20%）**基線血清肌酐＞133μmol/l（Barrett et al

29、. 的研究中＞124μmol/l）,,,,,,,,,,,,Patients (%),VisipaqueOmnipaqueorthers,,,,Aspelinet al.2003,Manskeet al.1990,Wanget al.2000,Rudnicket al.1995,Taliercioet al.1991,Lautinet al.1991,Barrettet al.1992,,,,,,,,Ren

30、al 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.

31、 (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）hem

32、odynamically significant RAS and accelerated hypertension, resistant hypertension, malignant hypertension, hypertension with an unexplained unilateral small kidney, and hypertension with intolerance to medication. (Leve

33、l 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

34、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

35、, 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

36、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

37、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

38、increase is common in patients with hypertension Silva studyBaseline BNP>80pgml 77% Pts BP improved post procedure 30％ 94％ BP improved<30％ 10％ BP improved,Predictor for RAS s

39、tenting,,Doppler wireFFR≦0.8 BP and renal function improvePressure wire Distal renal/ Aorta80 97 % Pts. No BP improve 80 % Pts. No renal function improveIndicating : small vessel disease or renal parenc

40、hyma disease,,Total patients 240Requiring Renal revascularization Yes (20%)48 No (80%)192RRI (estimated) &

41、lt; 80 (2/3) ≥ 80 (1/3) < 80(2/3) ≥80 (1/3)N 32 16 128 64Randomized to revascularization Y/N

42、 Y/N 16/16 8/8,Purpose:1.compare renal revascularization to medical management for people with ARVD2.whether the RRI can identify patients with RAS who w

43、ill not benefit from renal revascularization procedures,Renal Athersosclerotic reVascularization Evaluation (RAVE Study),,High prevelence of RASHigh acute procedural success rateDifficult in evaluating the efficacy