1、Renovascular Disease recognition and management,Craig A. Thompson, M.D., MMSc. Cardiac and Vascular Interventional Services Dartmouth Hitchcock Medical Center Lebanon, NH,Old Medical Adage: “Even a monkey can do angioplasty.”,Caveat: It takes a real doctor to decide:,What the diagnostic studies do a
2、nd dont sayWhat to do afterwardHow to address this problem in the context of a living, breathing patient,Renovascular Disease: The Clinical Perspective,Progress in Renovascular Disease,The disease Clinical diagnosis Laboratory diagnosis / imaging modalities Patient selection: who benefits from inter
3、vention? Limiting contrast-induced nephropathy Atheroembolic protection Expanding the pool of eligible patients / interventions Limiting restenosis,Progress in Renovascular Disease,The Disease Clinical diagnosis Laboratory diagnosis / imaging modalities Patient selection: who benefits from intervent
4、ion? Limiting contrast-induced nephropathy Atheroembolic protection Expanding the pool of eligible patients / interventions Limiting restenosis,Etiology of Renal Artery Stenosis,Fibromuscular dysplasia,Atherosclerosis,Polyarteritis Nodosa,Radiation-induced,Takayasus arteritis,Defining the Problem,RA
5、S is an important cause of secondary hypertension Renovascular disease under-appreciated as cause of CRF 23% of malignant hypertension is the result of renovascular causes Not all patients with RAS are hypertensive as a result,What is “medical therapy” for renovascular disease?,Natural History of Re
6、nal Artery Stenosis,Serial U/S examination of 170 patients with 295 renal arteries Exclusion for congenitally absent / occluded / prior PCI / poor window Referred for renal U/S for hypertension or renal insufficiency Only included in study if not a candidate for immediate revascularization U/S evalu
7、ation every 6 months until time of intervention Duplex evaluation: Peak Systolic Velocity (PSV) in proximal, middle, and distal RA and AO Yielding the RAR (Renal-to-Aortic Ratio),Caps et al. Circulation 1998; 98:2866-2872.,Natural History of Renal Artery Stenosis,Caps et al. Circulation 1998; 98:286
8、6-2872.,Role of lipid lowering and Aggressive risk factor modification?,L. Gabriel Navar and L. Lee Hamm,Mark A. Pohl,L. Gabriel Navar and L. Lee Hamm,Progress in Renovascular Disease,The Disease Clinical diagnosis Laboratory diagnosis / imaging modalities Patient selection: who benefits from interv
9、ention? Limiting contrast-induced nephropathy Atheroembolic protection Expanding the pool of eligible patients / interventions Limiting restenosis,Clinical Clues,Onset of diastolic hypertension after age 55 Refractory or malignant hypertension Development of resistant hypertension in a previously we
10、ll-controlled patient Progressive increase in Creatinine, even if still “normal” Presence of atherosclerotic macrovascular disease elsewhere heightens suspicion Left heart failure out-of-proportion to LV dysfunction or ischemic burden Clinically silent RAS,Progress in Renovascular Disease,The Diseas
11、e Clinical diagnosis Laboratory diagnosis / imaging modalities Patient selection: who benefits from intervention? Limiting contrast-induced nephropathy Atheroembolic protection Expanding the pool of eligible patients / interventions Limiting restenosis,Clinical syndrome most important in patient sel
12、ection Various diagnostic modalities: Serologic markers Duplex ultrasound - in experienced hands can predict with great accuracy the presence or absence of significant RAS Captopril renal scan - 10-25% false negative MR angiography - rare false negatives / common false positives. Equipment/experienc
13、e dependent Contrast angiography,Screening for Renovascular Disease,Duplex U/S for Renovascular Disease,Prospective Duplex U/S evaluation and Renal Angiography in 102 pts Goal: Validate renal artery U/S as a viable non-invasive modality Drawbacks: Time and labor intensive Technologist dependent Not
14、available NPO Requires a cooperative patient,Olin et al. Ann Intern Med. 1995; 122:833-838.,MRA & Contrast Angiography,Screening Aortography,Progress in Renovascular Disease,The Disease Clinical diagnosis Laboratory diagnosis / imaging modalities Patient selection: who benefits from intervention? Li
15、miting contrast-induced nephropathy Atheroembolic protection Expanding the pool of eligible patients / interventions Limiting restenosis,What Are the Goals of Treatment for RAS?,Control hypertension Aid in medical management Prevent deterioration in renal function Forestall need for dialysis Defer d
16、eath and disability,Hypertension and RAS,Among 152 patients with Unilateral or Bilateral RAS undergoing surgical revascularization: 90% had improvement in BP control Only 15% had “cure” of hypertensionAmong 20 published series of PCI for atherosclerotic renal artery disease: 54% had improvement in h
17、ypertension 9% had “cure” of hypertension,Hansen et al. J Vasc Surg 1992;16;319-31.,Chronic Renal Insufficiency and RAS Who Benefits From Revascularization?,Trial of 51 patients with Creat2.0 before revascularization with 75% Bilateral RAS: 67% had improvement in renal function 27% had stabilization
18、 in renal function Only 6% had worsening in renal function No demonstrated impact upon mortality,Novick et al. J Urol 1983; 129:907-12.,Experimental Data supporting Stenting for Preservation of Renal Function,61 vessels in 31 patients with “global” obstructive atherosclerotic renal disease All with
19、chronic renal insufficiency (Creat 1.5 4.0) Stenting with non-articulated Palmaz stents Follow-up Renal U/S, Serum Creat , BP measurements:- Improvement in reciprocal slope of serum creatinine- Improved BP control (SBP from 17021 Pre-stent vs. 148 15mmHg Post-stent; p50%) in only 1 of 61 vessels- St
20、abilization of pole-to-pole renal dimension,Watson et al. Circulation. 2000; 102:1671-1677.,Renal Artery Stenting,pre,post,Global Renal Revascularization,Watson et al. Circulation. 2000; 102:1671-1677.,Watson et al. Circulation. 2000; 102:1671-1677.,Dutch Renal Artery Stenosis Intervention Cooperati
21、ve Study,Study Design: 106 hypertensive patients with RAS (50%) and Creat2.3 mg/dlPTA vs. Medical rx with follow-up of BP/meds/ renal fxn at 3&12 mths,Results: BP same in both groups Fewer meds (2.1 vs. 3.2) in the PTA vs. Medical group Renal function similar between groups,Shortcomings: Crossover o
22、f patients from medical-to-PTA No stents Is 50% stenosis physiologically significant? Pts with elevated creatinine excluded Is the goal of renal artery revascularization improvement in BP control?,N Engl J Med 2000; 342:1007-14,Resistive Index Predicts Fate of Renal Function,Radermacher et al. NEJM
23、2001 344: 410-17,Resistive Index,Factors That Predict Failure,Radermacher et al. NEJM 2001; 344: 410-417.,Progress in Renovascular Disease,The Disease Clinical diagnosis Laboratory diagnosis / imaging modalities Patient selection: who benefits from intervention? Limiting contrast-induced nephropathy
24、 Atheroembolic protection Expanding the pool of eligible patients / interventions Limiting restenosis,Options:,Contrast minimizing maneuversUse of low-osmolar, non-iodinated contrastCO2 AngiographyGadolinium contrastMucomyst (Acetylcysteine)Selective DA-1 agonists,Progress in Renovascular Disease,Th
25、e Disease Clinical diagnosis Laboratory diagnosis / imaging modalities Patient selection: who benefits from intervention? Limiting contrast-induced nephropathy Atheroembolic protection Expanding the pool of eligible patients / interventions Limiting restenosis,Guarding Against Atheroembolism,Meticul
26、ous “no touch” technique Use of low profile, atraumatic catheters Limited catheter manipulation Primary stenting when feasible GP 2b3a Antagonists,Distal protection devices,Distal Atheroembolic Protection: The Ideal,Capture all debris Continued renal perfusion during procedure Limitless reservoir At
27、raumatic to vessel wall Technically easy to use Low profile Trackable,Pathology of Atheroembolism,Plaque / cholesterol Endothelial cellsPlatelet-Fibrin ThrombiCalcified tissue,Evolution of Distal Protection Devices,Initially used in the treatment of patients with coronary bypass graft disease These
28、interventions commonly plagued by angiographic “No Reflow” phenomenon Cardiac enzyme leak Clinical myocardial infarction Long attributed to RBC lysis and platelet activation with resultant microvascular spasm,Initial Reports: Atheroembolic Protection,“Percusurge Guardwire” 47% of patients with SVG i
29、ntervention had gross, macroscopic evidence of red-yellow debris An additional 20% of patients had evidence of microscopic debris,Carlino et al.Circulation 1999; 99: 3221-3223,SAFER Trial,Randomized comparison of SVG lesions treated +/- PercuSurge Guardwire Improved outcomes: 42% decrease MACE Lower
30、 laboratory MIs Safe High procedural success,Baim et al. Circulation 2002.,Distal Protection in Renovascular Disease: An Opportunity,Most RAS caused by atheromatous disease Ostial / proximal segments of disease are common Kidney will tolerate longer balloon occlusion time than coronary / cerebral ci
31、rculation Atheroembolism has long been viewed as a major risk / complication of percutaneous intervention of the renal arteries.,FILTER DEVICES,OCCLUSION DEVICES,Preserve flow Limit Ischemic Time,More complete capture,Small debris Vascular Injury,No antegrade flow Prolonged Ischemic Time Vascular In
32、jury Shoulder Regions,+,-,FILTER DEVICES,Cordis,OCCLUSION DEVICES,Atheroembolization Protection,Percusurge Guardwire Traverse Inflate Intervene Embolectomize,Early Experience: Distal Protection in Renovascular Intervention,28 patients with 32 renal arteries 29 Lesions ostial location 100% Technical
33、success with GuardWire Visible debris aspirated: 100% cases Mean RA occlusion time: 6.55 min (2.29-13.21 min) Creatinine post-procedure and at follow-up stable or improved in all cases.,Conclusion: Distal protection against atheroembolism is feasible and safe,But is it effective?,Henry et al.J Endov
34、asc Ther 2001; 8(3): 227-37.,Characterization of Debris,Characterize debris in carotid intervention Can we extrapolate to renal artery intervention?Both atheromatousSimilar patient population,Tuber et al.Circulation 2001; 104: 2791-6.,Characterization of Debris,Tuber et al.Circulation 2001; 104: 279
35、1-6.,What type of debris was not captured?,Why did complications still occur?,Characterization of Debris,Tuber et al.Circulation 2001; 104: 2791-6.,CO2 Aortogram,Gadolinium Renal Angiogram,R,Gadolinium Renal Angiogram,IVUS with 87% stenosis c/t reference vessel,L,Gadolinium Renal Angiogram With Perc
36、uSurge,RESIST Trial,Study Design: Multicenter, randomized trial of renal PTA/Stent+/- Distal atheroembolic protection (Cordis Angioguard XP)+/- Anti-platelet therapy with 2b 3a antagonist (Reopro) Endpoints:1) Renal function as measured by- Nuclear renal scan with DTPA- GFR estimated by Iohexol clea
37、rance- Serum Creatinine2) Bleeding complications3) Microscopic assessment of atheromatous debris within the Angioguard XPPI: Christopher J. Cooper, M.D. Medical College of Ohio,Progress in Renovascular Disease,The Disease Clinical diagnosis Laboratory diagnosis / imaging modalities Patient selection
38、: who benefits from intervention? Limiting contrast-induced nephropathy Atheroembolic protection Expanding the pool of eligible patients / interventions Limiting restenosis,What are the benefits of PCI over Surgical revascularization?,Shortened hospital stays Reduced post-procedural morbidity / mort
39、ality(J Vasc Surg 1994; 20: 76-87) Early graft failure 5% Peri-operative mortality 5.6% 43% of patients required aortic grafting,Comparable procedural success and improvement in renal function(J Vasc Surg 1993; 18:841-52) Procedural success: PTRA 83% vs. Surgery 97% (p=NS) Improved or stable renal f
40、unction: PTRA 83% vs. Surgery 72% (p=NS) Broadens pool of patients eligible for revascularization,Benefit of Renal TO Revascularization,Surgical revascularization vs. Nephrectomy in 95 patients with 100 Occluded Renal Arteries. All patients hypertensive 88% of patients with renal dysfunction Renal f
41、unction, blood pressure response and survival followed after procedure.,Oskin et al. J Vasc Surg 1999. 29 (1):140-149.,Study Results,Blood pressure improved in both groups 87% with nephrectomy 92% with revascularization (p=NS) Only revascularized patients (49%) demonstrated improved glomerular filtr
42、ation rate (GFR). 9 revascularized patients were no longer dialysis-dependant The absence of a nephrogram or distal reconstitution of the vessel did not preclude revascularization (done in 48% of these cases) Selective renal vein renins or nuclear renal scan may be of benefit in guiding therapy Rena
43、l biopsy may show hyalinization of glomeruli, tubular atrophy, and loss of cortical thickness, but is not an absolute predictor of renal recovery or failure to recover,Oskin et al. J Vasc Surg 1999. 29 (1):140-149.,Renal TO: Technical Difficulties,Occluded renal artery without collateral filling of
44、distal vessel still may be a surgical candidate Cautious recanalization to avoid perforation Acquisition of both indirect and direct evidence of intravascular position. Small balloon predilatation Minimize iodinated contrast as most patients have significant baseline CRI Stenting a must as there is
45、marked elastic recoil and bulky plaque prolapse,DSA Abdominal Aortogram,Abdominal Aortogram: Late Phase,Early Phase,Late Phase,Selective Left Renal Angiogram,Selective Right Renal Angiogram,?,Selective Right Lumbar Angiogram,Collateral Circulation of The Kidney,A. Suprarenal ComplexB. Lumbar Complex
46、C. Ureteric ComplexD. Capsular Complex,Selective Lumbar Angiogram: Wire Position,Selective Lumbar Angiogram: Wire Position,Angioplasty and Stenting,6 x 18mm Herculink Stent,6.5mm Post-dilatation,Right Renal Angio: Final,Progress in Renovascular Disease,The Disease Clinical diagnosis Laboratory diagn
47、osis / imaging modalities Patient selection: who benefits from intervention? Limiting contrast-induced nephropathy Atheroembolic protection Expanding the pool of eligible patients / interventions Limiting restenosis,Summary,Renovascular disease is an often-unrecognized contributor to: Uncontrolled h
48、ypertension Volume overload Chronic and progressive renal failure Existing literature allows data-driven decision making, helping clinicians to properly manage their patients with renovascular disease. However, the optimal treatment of patients with unilateral disease or “clinically silent” disease
49、is ill defined. New technologies have expanded the pool of patients eligible for percutaneous intervention, and help to limit procedural risk with renal revascularization. Atheroembolic distal protection devices are likely to be a mainstay of therapy in the near future. Vascular medicine allows cooperation and collaboration across departmental boundaries.,
