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1、Management of Renovascular Hypertension阜外心血管病医院心内科蒋雄京 Interrelation among Renal Artery Stenosis, Hypertension, and Chronic Renal Failure DefinitionofRenalArteryStenosisRenal artery stenosisRenal artery stenosis(RAS)isdefinedas(RAS)isdefinedasnarrowingofthelumennarrowingofthelumen oftherenalartery.of
2、therenalartery.*angiographicdiameterstenosis50%*angiographicdiameterstenosis50%*translesionalpressuregradientof20*translesionalpressuregradientof20 mmHgpeaksystolicmmHgpeaksystolicor10mmHgmeanor10mmHgmeanThemostcommoncausesofRASareatherosclerosis(80%)ThemostcommoncausesofRASareatherosclerosis(80%),a
3、ortoarteritis(15%),andfibromusculardysplasia(5%)inChinaaortoarteritis(15%),andfibromusculardysplasia(50% 9.7Bilateral, %1.7IndicationSuspected CHDWang et al23014.8NRCHDShen et al28015.35.0Suspected CHDLiu et al14118.4NRSuspected CHDMean185111.8NRProgressive Atherosclerosis, Renal Artery Stenosis, an
4、d Progressive Atherosclerosis, Renal Artery Stenosis, and Ischemic NephropathyIschemic Nephropathy the clinical manifestations of ARVD ClinicalfeaturessuggestiveofrenovascularhypertensionClinicalfeaturessuggestiveofrenovascularhypertensionJNC-VIJNC-VI Onsetofhypertensionaged30y;Abdominalbruit;Accele
5、ratedorresistanthypertension;Flashpulmonaryedemawithnormalleftventricularfunction;Renalfailureofuncertaincause;Coexisting,diffuseatheroscleroticvasculardiseaseAcuterenalfailureprecipitatebyantihypertensivetherapy,particularlyACEIorAIIreceptorblockers;InthepresenceoftheseclinicalcluestheprevalenceofR
6、VHis40%.Screening for Renovascular Hypertension1.1.Radionucliderenalfractionalflow/GFRRadionucliderenalfractionalflow/GFR2.Plasmareninactivity2.Plasmareninactivity3.Captoprilrenoscitigraphy3.Captoprilrenoscitigraphy4.Colordopplorultrasonography4.Colordopplorultrasonography5.MRAngiography/CTAngiograp
7、hy5.MRAngiography/CTAngiographyMulti-slicesCTAismostusefulforRASscreeningMulti-slicesCTAismostusefulforRASscreeningSeverityofrenalvasculardiseasepredictsmortalityinpatientsundergoingcoronaryangiographyKidney InternationalKidney International (2001) (2001) 6060, 14901497, 14901497ClinicalCriteriaforR
8、evascularizationHypertension:acceleratedhypertension;refractoryhypertension;malignanthypertension;hypertensionwithaunilateralsmallkidney;orhypertensionwithintolerancetomedication.Renal salvage:suddenunexplainedworseningofrenalfunction;impairmentofrenalfunctionsecondarytoantihypertensivetreatment,par
9、ticularlywithanangiotensin-convertingenzymeinhibitororangiotensinIIreceptorblocker;orrenaldysfunctionnotattributabletoanothercause.Cardiac disturbance syndromes:recurrentflashpulmonaryedemaoutofproportiontoanyimpairmentofleftventricularfunction,orunstableanginainthesettingofsignificantRAS.MedicalThe
10、rapy control of blood pressure : ACEinhibitorsorAngiotensinreceptorblockers ?antiplatelet therapysmoking cessationaggressive control of hyperlipidemia and DMThebestmedicaltherapyforARVDremainsunclear.MedicaltherapyhardlypreventsrenalfunctionworseninpatientswithbilateralRASorRASofsinglekidney.Chabova
11、V,et al. Mayo Clin Proc 2000;75:437-444BaboolalK Am J Kidney Dis 1998;31:971-977肾动脉支架置入 meta-analysisdatademonstratingsuperiorityofrenalarterystentmeta-analysisdatademonstratingsuperiorityofrenalarterystentcomparedwithballoonangioplastyforproceduresuccessandrestenosiscomparedwithballoonangioplastyfo
12、rproceduresuccessandrestenosisratesrates术前准备术前准备阿斯匹林阿斯匹林0.10.3QD,氯吡格雷氯吡格雷75mgQD，2-3天天;降压降压,血压控制在血压控制在90%90%） GFR 左（min/l） 右（ min/l ）术前 24.0 20.4术后（第3天) 21.3 34.6肾肾照相（照相（99mTc-DTPA）术后随访拜新同拜新同30mg30mg,Qd;,Qd;阿托伐他丁阿托伐他丁10mg,Qn;10mg,Qn;阿斯匹林阿斯匹林0.1 ,Qd;0.1 ,Qd;氯吡格雷氯吡格雷7575mgmg,Qd,1,Qd,1个月个月术后术后2 2周周 ：Bp1
13、20/82mmHgBp120/82mmHg, ,CrCrCrCr125.4umol/L125.4umol/L,BUN7,BUN7,BUN7,BUN7.39mmol/L.39mmol/L术后术后6 6个月个月 ：Bp132/86mmHgBp132/86mmHg, ,CrCrCrCr115umol/L115umol/L,BUN,BUN,BUN,BUN6.2mmol/L6.2mmol/L术后术后1212个月：个月：Bp128/84mmHgBp128/84mmHg, ,CrCrCrCr118umol/L118umol/L,BUN,BUN,BUN,BUN7.2mmol/L7.2mmol/L术后术后181
14、8个月：个月：Bp136/88mmHgBp136/88mmHg, ,CrCrCrCr128umol/L128umol/L,BUN,BUN,BUN,BUN7.9mmol/L7.9mmol/LARVDRandomizedStudiesPTRAvsMedication肾动脉支架的临床结果文献汇总分析：文献汇总分析：肾功能：肾功能： 1/3提高提高1/3不变不变1/3恶化恶化高血压：高血压：治愈治愈改善改善FMD5085%85-100%ARAS515%5070%TA40-60%75-90%ASTRALA Angioplasty and ngioplasty and STSTent for ent fo
15、r R Renal enal A Artery rtery L LesionsesionsUK MULTI-CENTRE TRIAL INUK MULTI-CENTRE TRIAL INATHEROSCLEROTIC RENOVASCULAR DISEASEATHEROSCLEROTIC RENOVASCULAR DISEASEPhilipAKalraLeadNephrologistforASTRAL,HopeHospital,Salford,UK,OnbehalfoftheASTRALTMCandcollaboratorsASTRAL Trial: DesignDesign806403Med
16、icalRx 403StentAssigned308Stent(76%)44NotAttempted17Failed34NotKnownPrimaryandsecondaryendpointsinASTRALPrimaryandsecondaryendpointsinASTRALPrimary end pointSecondary end pointsBlood pressure controlRenal events (such as acute renal failure, dialysis, transplant or nephrectomy)Serious vascular event
17、s (such as myocardial infarction, angina or stroke)MortalityRate of progression of renal dysfunction (using serum creatinine analysed by reciprocal creatinine plots over time)StentMedRxpValueAge7071NSMale63%63%NSDiabetes31%29%NSCr179178NSGFR4039NSBilateral50%50%NSACE/ARB47%38%NSBaselineCharacteristi
18、csASTRAL: Lesion SeverityMean = 76% (Range: 20% 100%)Site reported: no core labNo.ofpatientsStenosis(%)ASTRAL: TreatmentRevascularizationStrategies:Stenting 93% PTA alone 7%Post-stent residual stenosis 50%: 12%Complications: 7% Perforations: 4 (1%) Cholesterol Emboli 3 (1%) Death 180/110mmHg180/110m
19、mHg或正规三联降压药治疗血压或正规三联降压药治疗血压或正规三联降压药治疗血压或正规三联降压药治疗血压140/90mmHg140/90mmHg；(3)(3)血肌酐血肌酐血肌酐血肌酐264mol/L7.0cm7.0cm，并且残余的，并且残余的，并且残余的，并且残余的GFR10ml/minGFR10ml/min；(5)(5)年龄年龄年龄年龄 3030岁，性别不限。岁，性别不限。岁，性别不限。岁，性别不限。排除标准：排除标准：排除标准：排除标准：(1)(1)病情不稳定，无法耐受介入治疗；病情不稳定，无法耐受介入治疗；病情不稳定，无法耐受介入治疗；病情不稳定，无法耐受介入治疗；(2)(2)造影剂过敏；
20、造影剂过敏；造影剂过敏；造影剂过敏；(3)(3)肾动脉病变的解剖条件不适合进行介入治疗肾动脉病变的解剖条件不适合进行介入治疗肾动脉病变的解剖条件不适合进行介入治疗肾动脉病变的解剖条件不适合进行介入治疗 结果结果- -患者的基本临床特征患者的基本临床特征 患者患者(n=238)(n=238)的基线临床特征的基线临床特征年龄年龄( (岁岁) )333383(64.283(64.29.5)9.5)男性男性, ,例例(%)(%)178(74.8)178(74.8)糖尿病糖尿病, ,例例(%)(%)62(26.1)62(26.1)高脂血症高脂血症, ,例例(%)(%)136(57.1)136(57.1)
21、吸烟吸烟( (目前或曾经目前或曾经),),例例(%)(%)141(59.2)141(59.2)合并其他外周血管疾病合并其他外周血管疾病, ,例例(%)(%)105(44.1)105(44.1)术前蛋白尿术前蛋白尿, ,例例(%)(%)20(8.4)20(8.4)脑卒中或短暂脑缺血发作史脑卒中或短暂脑缺血发作史, ,例例(%)(%)45(18.9)45(18.9)冠心病冠心病, ,例例(%)(%)156(65.5)156(65.5)心肌梗死史心肌梗死史, ,例例(%)(%)53(22.3)53(22.3)瓣膜性心脏病瓣膜性心脏病, ,例例(%)(%)12(5.0)12(5.0)严重慢性心衰严重慢
22、性心衰(NYHA(NYHA级级),),例例(%)(%)17(7.1)17(7.1)结果结果- -患者的基本临床特征患者的基本临床特征患者患者(n=238)(n=238)的基线临床特征的基线临床特征( (续续) ) 高血压病史高血压病史( (月月) )1 1600(159.5600(159.5143.9)143.9)收缩压收缩压(mmHg)(mmHg)161.6161.622.222.2舒张压舒张压(mmHg)(mmHg)94.694.68.88.8服用降压药种类数服用降压药种类数( (种种) )1 15(2.95(2.91.6)1.6)狭窄程度狭窄程度(%)(%)6060100(82.9100
23、(82.98.1)8.1)单侧肾动脉狭窄单侧肾动脉狭窄, ,例例(%)(%)172(72.3)172(72.3)双侧肾动脉狭窄双侧肾动脉狭窄, ,例例(%)(%)66(27.7)66(27.7)开口和开口和( (或或) )近端狭窄近端狭窄, ,条条(%)(%)292(95.4)292(95.4)中远端狭窄中远端狭窄, ,条条(%)(%)14(4.6)14(4.6)术前管腔直径术前管腔直径(mm)(mm)0 02.45(1.02.45(1.00.5)0.5)血肌酐水平血肌酐水平(umol/L)(umol/L)44.044.0263.92(108.9263.92(108.942.3)42.3) 血
24、肌酐血肌酐133umol/L,133umol/L,例例(%)(%)202(84.9)202(84.9) 血肌酐血肌酐133133177umol/L,177umol/L,例例(%)(%)26(10.9)26(10.9) 血肌酐血肌酐177umol/L,177umol/L,例例(%)(%)10(4.2)10(4.2)血尿素水平血尿素水平(mmol/L)(mmol/L)2.92.923.8(7.523.8(7.53.3)3.3)PTRASPTRAS的造影和支架结果及并发症的造影和支架结果及并发症 238238例患者中例患者中2 2例的例的2 2条肾动脉发生严重夹层，条肾动脉发生严重夹层，1 1例的例
25、的1 1条分支血管被支架压闭，条分支血管被支架压闭，总的血运重建技术成功率总的血运重建技术成功率99%(303/306)99%(303/306)。PTRAS相关并发症总计相关并发症总计5.5%(13/238).并发症并发症转归转归股动脉穿刺点大血肿股动脉穿刺点大血肿2 2例，出血例，出血1 1例例均经输血和延长加压包扎后治愈均经输血和延长加压包扎后治愈股动脉穿刺点假性动脉瘤形成股动脉穿刺点假性动脉瘤形成1 1例例经外科手术修补后治愈经外科手术修补后治愈急性肾功能不全急性肾功能不全3 3例例(2(2例夹层例夹层) )1 1例例2 2周后恢复至术前水平，周后恢复至术前水平，1 1例持续恶化，例持续
26、恶化，1 1例例术后第术后第6 6日心源性猝死日心源性猝死1 1例的例的1 1条分支血管被支架压闭条分支血管被支架压闭 肾功能未受影响肾功能未受影响 手术侧肾囊血肿伴血色素进行性下降手术侧肾囊血肿伴血色素进行性下降2 2例例考虑系肾动脉穿孔所致，经输血后好转，随访考虑系肾动脉穿孔所致，经输血后好转，随访观测基本吸收观测基本吸收脑卒中脑卒中3 3例例缺血性缺血性2 2例，例，1 1例无后遗症，例无后遗症，1 1例有后遗症，出例有后遗症，出血性血性1 1例，术后第例，术后第3 3日死亡日死亡结果结果- -随访及失访情况随访及失访情况 随访时间随访时间( (月月) )6 61212181824243
27、0303636424248485454606066667272应有人数应有人数( (例例) )238238225225193193159159134134112112969675756363454537372626实际随访到的实际随访到的总人数总人数( (例例) )228228219219192192158158131131111111969674746363454537372626失访人数失访人数( (例例) )10106 61 11 13 31 10 01 10 00 00 00 0死亡人数死亡人数( (例例) )7 74 40 01 10 01 11 10 01 10 00 00 0实际
28、随访到的实际随访到的存活人数存活人数( (例例) )2212212082081811811461461191199898828260604848303022221111 随访随访6 672(29.272(29.219.6)19.6)个月，共失访个月，共失访2323例例(9.7%)(9.7%)PTRASPTRAS对血压的影响对血压的影响临床判定的支架内再狭窄率临床判定的支架内再狭窄率3.0%(7/238)3.0%(7/238)PTRASPTRAS对肾功能的影响对肾功能的影响PTRASPTRAS后血压和肾功能转归后血压和肾功能转归3636例术前肾功能异常的患者，例术前肾功能异常的患者，PTRSPT
29、RS后肾功能改善后肾功能改善2121例例(77.8%)(77.8%)无变化无变化9 9例例(25%)(25%) ，恶化，恶化3 3例例(8.3%)(8.3%)( (其中其中2 2例发展至肾衰竭尿毒症期，已行透析治疗例发展至肾衰竭尿毒症期，已行透析治疗) )，失访，失访2 2例例(5.6%)(5.6%) ，死亡，死亡1 1例例(2.7%)(2.7%)。 术后术后6 6、1212个月时患者的血压和肾功能转归个月时患者的血压和肾功能转归( (例例) )观察时间观察时间例数例数血压血压肌酐肌酐治愈治愈改善改善无效无效改善改善无变化无变化恶化恶化术后术后6 6个月个月221(100)221(100)3(
30、1.4)3(1.4)184(83.2)184(83.2)34(15.4)34(15.4)71(32.1)71(32.1)133(60.2)133(60.2)17(7.7)17(7.7)术后术后1212个月个月208(100)208(100)5(2.4)5(2.4)176(84.6)176(84.6)27(13.0)27(13.0)65(31.3)65(31.3)122(58.7)122(58.7)21(10.0)21(10.0)本研究本研究本研究本研究PTRASPTRASPTRASPTRAS后的无事件生存率后的无事件生存率后的无事件生存率后的无事件生存率Severityofrenalvascu
31、lardiseasepredictsmortalityinpatientsundergoingCAGKidney InternationalKidney International (2001) (2001) 6060, 14901497, 14901497PTRASPTRAS后的心血管事件后的心血管事件共发生心血管事件共发生心血管事件2424例例(10.1%)(10.1%)，另有其他原因死亡，另有其他原因死亡4 4例。例。 心血管事件心血管事件例数例数肾脏事件肾脏事件5 5例例(2.1%)(2.1%)急性心肌梗死急性心肌梗死4 4例例(1.7%)(1.7%)脑卒中脑卒中4 4例例(1.7%)
32、(1.7%)心脑血管死亡心脑血管死亡1111例例(4.6%)(4.6%)随访期患者发生各种心血管事件的相关因素随访期患者发生各种心血管事件的相关因素事件事件相关因素相关因素优势比优势比(95%CI)(95%CI)P P心脑血管死亡心脑血管死亡术后术后1212个月高血压治愈或改善个月高血压治愈或改善0.070(0.011-0.453)0.070(0.011-0.453)0.0080.008术后术后1212个月肾功能改善或稳定个月肾功能改善或稳定0.090(0.016-0.476)0.090(0.016-0.476)0.0090.009总死亡总死亡术后术后1212个月高血压治愈或改善个月高血压治愈
33、或改善0.002(0.000-0.151)0.002(0.000-0.151)0.0050.005术后术后1212个月肾功能改善或稳定个月肾功能改善或稳定0.013(0.000-0.785)0.013(0.000-0.785)0.0380.038年龄年龄1.640(1.071-2.513)1.640(1.071-2.513)0.0230.023术前基线收缩压值术前基线收缩压值1.067(1.002-1.137)1.067(1.002-1.137)0.0440.044肾脏事件肾脏事件术后术后1212个月肾功能改善或稳定个月肾功能改善或稳定0.009(0.000-0.524)0.009(0.000
34、-0.524)0.0250.025术前基线尿素氮值术前基线尿素氮值1.409(1.049-2.157)1.409(1.049-2.157)0.030.03所有心血管事件所有心血管事件术后术后1212个月高血压治愈或改善个月高血压治愈或改善0.098(0.019-0.499)0.098(0.019-0.499)0.0050.005术后术后1212个月肾功能改善或稳定个月肾功能改善或稳定0.134(0.035-0.509)0.134(0.035-0.509)0.0030.003术前基线收缩压值术前基线收缩压值1.032(1.005-1.059)1.032(1.005-1.059)0.0190.01
35、9Case1:Bilateralrenalarterystenosesinaaged69elderlywithrenalCase1:Bilateralrenalarterystenosesinaaged69elderlywithrenalinsufficiency,insufficiency,3antihypertensivemedications,BP178/88mmHg,Cr187umol/l3antihypertensivemedications,BP178/88mmHg,Cr187umol/l Follow-upOne antihypertensive drug 3 days BP13
36、4/82mmHg,Cr132umol/l 14 days BP132/84mmHg,Cr118umol/l6 mons BP128/72mmHg,cr107umol/l12mons BP126/76mmHg,cr112umol/l Male,61yrMale,61yr，Hypertension10yrHypertension10yr，BP180/110mmHgwithBP180/110mmHgwithfiveantihypertensivemedications.fiveantihypertensivemedications.CHD,2yearsagoLADPCI,Smoking,Hyperl
37、ipidimiaCHD,2yearsagoLADPCI,Smoking,HyperlipidimiaSCr205umol/lSCr205umol/l3 days after procedure BP132/84mmHg with two antihypertensive medications SCr128umol/l24 months after procedure BP124/72 84mmHg with two antihypertensive medications SCr116umol/l64-slicesCTAfindingona64-slicesCTAfindingonafema
38、le, 65 yo. High blood pressure 20 female, 65 yo. High blood pressure 20 years ,Maximal BP 210/120mmHG, out of control with nifedipine IGTS years ,Maximal BP 210/120mmHG, out of control with nifedipine IGTS 30mg qd, bisoprolol 5mg qd, and perindopril 4mg qd, for 5 years, 30mg qd, bisoprolol 5mg qd, a
39、nd perindopril 4mg qd, for 5 years, Exacerbate 3mExacerbate 3m结论结论我我们们的的单单中中心心研研究究表表明明支支架架置置入入重重建建血血运运治治疗疗粥粥样样硬硬化化性性肾肾动动脉脉严严重重狭狭窄窄有有较较好好的的安安全全性性，中中远远期降压和稳定肾功能的获益肯定。期降压和稳定肾功能的获益肯定。本本研研究究也也提提示示肾肾动动脉脉支支架架术术有有可可能能显显著著减减少少心心血血管管事事件件的的发发生生率率并并降降低低死死亡亡率率，但但还还需需要要进进一一步步研究予以证实。研究予以证实。 阜外医院阜外医院肾动脉狭窄研究肾动脉狭窄研究的
40、现状的现状1999-至今至今已积累已积累550例肾动脉介入病例。近年来例肾动脉介入病例。近年来新来我院诊治的肾动脉狭窄患者新来我院诊治的肾动脉狭窄患者300例例/年以上，年以上，实施介入治疗病例实施介入治疗病例150例例/年，欧美国家达到如年，欧美国家达到如此规模的医学中心不到此规模的医学中心不到5家。家。 肾动脉介入治疗的现状肾动脉介入治疗的现状技术成功率技术成功率有效率有效率并发症并发症围手术期死亡率围手术期死亡率阜外医院阜外医院99%86.7%3.6%0.4%国际文献国际文献95100%5076%415%0.31%以肾功能不全的进展率为主要终点事件的研究，如以肾功能不全的进展率为主要终点
41、事件的研究，如果要取得阳性结果，则需要满足二个关键点：果要取得阳性结果，则需要满足二个关键点：1.病例入选要严格，即双侧或单功能肾的肾动脉严重病例入选要严格，即双侧或单功能肾的肾动脉严重狭窄（狭窄（70%）所致的缺血性肾病。对于单侧肾动脉）所致的缺血性肾病。对于单侧肾动脉狭窄狭窄,患肾较对照侧肾功能下降至少患肾较对照侧肾功能下降至少25% 。2.从事肾动脉介入的治疗团队富有经验，能有效防从事肾动脉介入的治疗团队富有经验，能有效防范介入对肾脏直接损害。范介入对肾脏直接损害。 以控制高血压为目的的肾动脉支架术以控制高血压为目的的肾动脉支架术如果入选标准定在肾动脉直径狭窄如果入选标准定在肾动脉直径狭
42、窄 50%，可能包括部分没有，可能包括部分没有血流动力学意义的狭窄血流动力学意义的狭窄(50-70%)，肾动脉支架术不但无效，肾动脉支架术不但无效，而且要承担介入治疗本身的风险。而且要承担介入治疗本身的风险。实践表明，入选患者要满足二个关键点：实践表明，入选患者要满足二个关键点：1.肾动脉狭窄肾动脉狭窄 70%，且能证明狭窄与高血压存在因果关系；，且能证明狭窄与高血压存在因果关系；2.顽固性高血压或不用降压药高血压达顽固性高血压或不用降压药高血压达III级水平。级水平。 如何保证肾动脉支架术疗效如何保证肾动脉支架术疗效?1.严格把握肾动脉介入的适应征严格把握肾动脉介入的适应征2.防范介入对肾脏
43、的直接损害，提高手术成功率。防范介入对肾脏的直接损害，提高手术成功率。肾动脉支架术后急性肾功能损害的主要原因肾动脉支架术后急性肾功能损害的主要原因1.介入操作过程中发生的肾动脉栓塞介入操作过程中发生的肾动脉栓塞及其它损伤；及其它损伤；2.造影剂诱发的肾毒性；造影剂诱发的肾毒性；3.血容量不足导致的肾灌注不足。血容量不足导致的肾灌注不足。 重视控制危险因素重视控制危险因素ARVD是全身动脉粥样硬化的一部分，肾动脉支架术成是全身动脉粥样硬化的一部分，肾动脉支架术成功并不意味着动脉粥样硬化进程的终止。功并不意味着动脉粥样硬化进程的终止。降脂治疗、降糖治疗、降压治疗及阿斯匹林等对防止动降脂治疗、降糖治
44、疗、降压治疗及阿斯匹林等对防止动脉粥样硬化发展有深远的影响，对预防心血管并发症有脉粥样硬化发展有深远的影响，对预防心血管并发症有重大意义，应予高度重视。重大意义，应予高度重视。 纤维肌性结构不良纤维肌性结构不良(FMD)及大动脉炎及大动脉炎所致的肾动脉狭窄所致的肾动脉狭窄 PTA的指征相对宽松的指征相对宽松：1.肾动脉狭窄肾动脉狭窄50%;2.持续高血压持续高血压160/100mmHg大动脉炎活动期不宜手术，一般要用糖皮质激素治疗大动脉炎活动期不宜手术，一般要用糖皮质激素治疗使血沉降至正常范围后使血沉降至正常范围后2个月以上方可考虑行个月以上方可考虑行PTA 一般不使用血管内支架一般不使用血管
45、内支架,仅作为仅作为PTA失败的补救措施失败的补救措施:1.单纯单纯PTA治疗治疗FMD及大动脉炎的结果很好及大动脉炎的结果很好;2.这类病变放置支架远期结果并清楚。这类病变放置支架远期结果并清楚。 ClinicaloutcomesofPTRAasTreatmentforRenalClinicaloutcomesofPTRAasTreatmentforRenalArteryStenosiscausedbyaortoarteritisorFMDArteryStenosiscausedbyaortoarteritisorFMDJiangXiongjing,etal.JiangXiongjing,e
46、tal. Hypertension Division, Cardiovascular Institute and Fu Wai Hypertension Division, Cardiovascular Institute and Fu Wai Hospital, CAMS and PUMCHospital, CAMS and PUMCMETHODPatients selection for PTRAInpresenceofrenalartery60%diameterstenosis,Inpresenceofrenalartery60%diameterstenosis,PatientshadP
47、oorlycontrolledhypertensionwhilereceiving3PatientshadPoorlycontrolledhypertensionwhilereceiving3antihypertensivemedicationsorHBPgradeIIIwithoutantihypertensiveantihypertensivemedicationsorHBPgradeIIIwithoutantihypertensivemedications.medications.a.Increasedrenalveinrenina.Increasedrenalveinreninb.Ca
48、ptoprilRenoscitigraphyPositiveb.CaptoprilRenoscitigraphyPositivec.serumcreatininelevel264umol/L(3.0mg/dl)c.serumcreatininelevel30%residualstenosisafterPTAd.StentingIncaseof30%residualstenosisafterPTAe.Longitudinalkidneylength7.0cmwithGFR10ml/mine.Longitudinalkidneylength7.0cmwithGFR10ml/minIndicatio
49、nsforinclusionwerenotmutuallyexclusive.Indicationsforinclusionwerenotmutuallyexclusive.Clinical characteristics of 80 study patientsGENDER(m/f)28/52GENDER(m/f)28/52AGE(YR)AGE(YR)1358(291358(29 1414) ) ETIOLOGY(N)ETIOLOGY(N) FIBROMUSCULARDYSPLASIA18(22.5%)FIBROMUSCULARDYSPLASIA18(22.5%)ARTERITIS62(77
50、.5%)ARTERITIS62(77.5%)Lesionsstenoses(%)60%100%Lesionsstenoses(%)60%100%(82(82 1515) ) Blood pressure response Blood pressure response (SBP/DBP,mmHg)(SBP/DBP,mmHg) after PTRAafter PTRA baselinedischarge6monthbaselinedischarge6monthArteritisArteritis174.532.8/106.820.4129.221.6/80.211.5*134.625.3/83.
51、413.6*#174.532.8/106.820.4129.221.6/80.211.5*134.625.3/83.413.6*#FMDFMD156.426.8/104.612.4126.415.2/75.69.8*128.817.6/76.210.4*156.426.8/104.612.4126.415.2/75.69.8*128.817.6/76.210.4* No.ofmedNo.ofmed2.91.31.01.1*1.21.4*#2.91.31.01.1*1.21.4*# *P0.001compared *P0.001compared with with baseline. basel
52、ine. # # P0.05 P0.05 compared compared with with values values at at discharge. SBP= systolic blood pressure; DBP=diastolic blood pressure discharge. SBP= systolic blood pressure; DBP=diastolic blood pressure The effect of PTRA on hypertension at 6-month follow-upThe effect of PTRA on hypertension a
53、t 6-month follow-up EtiologyEtiology Cure(%)Cure(%) Improved(%)Improved(%) NoNoimprovement(%)improvement(%) TotalTotal(%)(%)Arteritis35(56.5)19(30.6)8(12.9)62(100)Arteritis35(56.5)19(30.6)8(12.9)62(100)FMD14(77.8)3(16.7)1(5.6)18(100)FMD14(77.8)3(16.7)1(5.6)18(100) Cure:SBP140mmHg Cure:SBP140mmHg & &
54、 DBP90mmHg DBP10% 10% or or DBPDBP 15%15% with with taking taking same same medications, medications, SBPSBP 10% 10% or or DBPDBP 15%15% with with taking taking fewer fewer medications; medications; No No improvement: improvement: the the aforementioned aforementioned criteria were not met.criteria
55、were not met.Estimatedrestenosisrate:Estimatedrestenosisrate:8ptswitharteritis&1ptswithFMD8ptswitharteritis&1ptswithFMDThe serum Creatinine and Blood Urea Nitrogen The serum Creatinine and Blood Urea Nitrogen response after PTRAresponse after PTRA RenalfunctionBaselinedischarge6-monthRenalfunctionBa
56、selinedischarge6-month CrCr（umol/Lumol/L） 96.811.2102.116.8#94.29.996.811.2102.116.8#94.29.9 BUNBUN（mmol/Lmmol/L） 6.11.86.31.3#6.01.66.11.86.31.3#6.01.6#P0.05 compared with baseline#P0.05 compared with baselineDuring follow-up normal renal function remains in all patientsDuring follow-up normal rena
57、l function remains in all patientsConclusionPTRA is appropriate for such patients when there is good evidence of a potentially hemodynamically significant RAS. Stenting should be considered in case of suboptimal result or PTA failure. ConclusionBased Based on on the the available available data, dat
58、a, One One thing thing appears appears certain: certain: no no one one therapeutic therapeutic approach approach is is appropriate appropriate for for all all patients. patients. In In each each patient, patient, the the individual individual risks risks and and benefits benefits associated associat
59、ed with with each each potential potential treatment treatment needs needs to to be be considered. considered. Percutaneous Percutaneous intervention intervention should should be be undertaken undertaken when when there there is is good good evidence evidence of of a a potentially potentially hemod
60、ynamically significant RAS.hemodynamically significant RAS. Female, 68yo,HT随访随访 & & 预预 后后本病为慢性进行性血管病变。本病为慢性进行性血管病变。对所有对所有TA患者均需要进行大血管影像学检查及长期随访患者均需要进行大血管影像学检查及长期随访, 动态观察动脉受累情况。动态观察动脉受累情况。预后主要取决于高血压的程度及重要脏器的累及情况。预后主要取决于高血压的程度及重要脏器的累及情况。受累后的动脉一般侧支循环形成丰富，故发生脏器缺血坏死少见。受累后的动脉一般侧支循环形成丰富，故发生脏器缺血坏死少见。糖皮质激素或联合免疫抑制剂积极治疗可改善预后糖皮质激素或联合免疫抑制剂积极治疗可改善预后, ,但减量或停药有复发可能。但减量或停药有复发可能。血管重建能改善缺血，但远期有一定的再狭窄率血管重建能改善缺血，但远期有一定的再狭窄率。T Th ha an nk ks s
