Peds Renal Artery Stenosis - HAWKINS

Pediatric Renal Artery Stenosis

“Efficacy of Endovascular Interventions”

Matt Hawkins, MDAssistant Professor – Emory University SOM

Introduction

• 1-2% of children have sustained HTN• RAS = 5-25% of pediatric HTN cases• Renal scarring, aortic coarctation,

glomerular disease, and adrenal hypersecretion are the most common cause

• Renal artery stenosis (RAS) accounts for ~10% of HTN cases in kids.

Introduction

• Renal artery stenosis (RAS) accounts for ~10% of HTN cases in kids.

• Dominant etiologies include:• Fibromuscular dysplasia (FMD)• Neurofibromatosis 1• Williams syndrome• Mid-aortic syndrome

RAS in kids• 86% of stenoses in 1st or 2nd order branches• Stenoses in multiple 1st/2nd order branches = 32%• Bilateral disease = 30%• Intraparenchymal diasese = 30% (aneurysms, collaterals,

stenoses, etc.)

RAS in kids

FMD in adults• 29 women; 38 interventions (17 yr retrospective)• Technical success = <30% stenosis• 8% complication rate• 72% improved or cured (SBP<140)• Primary and assisted primary patency = 66%

and 76% at 5 years

FMD in adults• 59 patients (17 year retrospective)• 95% technical success• 34% needed repeat angioplasty• Cure = 24%• Improvement = 39%

FMD in adults

FMD in adults• 35 patients; 43 procedures• 100% technical success• Primary and primary assisted patency =

(95%, 71%, 50%) and (100% all) at 1, 5, & 9 years respectively

• 6% cure; 63% improved

FMD in adults• Meta-analysis of 50 studies of PTA for FMD• Technical success = 88.2%• Complication rate = 11.8% (major 6.3%)• Cure = 35.8%

Renal artery stenosis in kids


48 procedures in 33 patients

Renal artery stenosis in kids• 19 patients; 32 treated lesions• Technical success = 91%• 39% cure; 17% improvement; 44% failure• Cutting balloons successful in 5 of 7 uses• 1 renal artery perforation; 1 accelerated

hypertension; 1 groin hematoma

Renal artery stenosis in kids• 22 patients, 34 procedures• 16 = Takayasu; 6 = FMD• Technical success = 94.1%• 27.3% cure; 45.5% improvement• 41% restenosis (3-47 month range)• 1 minor complication

What about cutting balloons• Complications include • Dissection (3.6% in coronary studies)• Rupture • Renal artery thrombosis

What about cutting balloons

Literature Summary• Cure 1/3, Improve 1/3, Fail 1/3• Safe procedure• Technically successful >90% of the time• ~40% will re-stenose w/in 5 years• Avoid stents in children• Cutting balloons can be helpful with

resistant stenoses when used cautiously

• Should we look for extra-renal disease in these kids?

How do we do renal artery

angioplasty?

Equipment

• 4F 45cm sheath• 0.014 wire (BMW/RunThrough)• 2.5F Cantata & 0.014 Synchro (if needed)

• 1-2 cm Sterling monorail balloons• Flextome cutting balloons (if needed)

Medications

• Heparin 100U/kg – Before angioplasty– 10-20U/kg every 45 minutes thereafter

• Nitroglycerin 1mcg/kg (optional)

• ASA 325mg loading dose (if stenosis is known prior to case)

Post-Procedure Care

• Leg straight 2-3 hrs (if 4F sheath)

• ASA 81 mg for 6 months• If cutting balloon used:– Overnight ICU admission on heparin drip– Doppler ultrasound next day– ASA 81mg for 6 months

Case 1

Case 2

Case 2

Stenosis Post-stenotic dilation

Case 2

Stenosis Post dilation

Case 2 (second try)

Case 2Right kidney

Case 2

Case 2PRE

POST

Case 2

POST

Case 2 (3rd time is a charm)

Case 2

Matt Hawkins, MD@MattHawkinsMD

[email protected]

Peds Renal Artery Stenosis - HAWKINS

Documents

Transcript of Peds Renal Artery Stenosis - HAWKINS