Renovascular Disease: Core Curriculum
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Transcript of Renovascular Disease: Core Curriculum
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Renovascular Disease:
Core Curriculum
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Renal Artery StenosisRenal Artery Stenosis
Etiology + PathophysiologyIncidence DiagnosisIndications for RevascularizationTreatment Options
- Medical Therapy- PTA- Surgical
Technical ConsiderationsComplicationsPrognosis
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Causes of Ischemic Renal DiseaseCauses of Ischemic Renal Disease
• Atherosclerotic Renal Artery Stenosis• Fibromuscular dysplasia • Nephroangiosclerosis (HTN injury)• Diabetic nephropathy (small vessels)• Renal thromboembolic disease• Atheroembolic renal disease• Aortorenal dissection• Post renal transplant RAS • Renal artery vasculitis• Trauma• Neurofibromatosis• Thromboangiitis obliterans• Scleroderma
#1 Renal Artery Stenosis
#2 Fibromuscular Dysplasia
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Atherosclerotic Renal Artery StenosisAtherosclerotic Renal Artery Stenosis• Atherosclerosis accounts for approximately 90% of the
cases of RAS and is the predominant lesion detected in patients >50 years of age
• The presence and number of diseased coronary arteries predicts the likelihood of ARAS
• RAS resulting from atherosclerotic disease is common in (18% to 20%) individuals undergoing coronary angiography 1
• RAS resulting from atherosclerotic disease is even more common (35% to 50%) in individuals undergoing peripheral vascular angiography for occlusive disease of the aorta and legs 2
1. Rihal et al Mayo Clin Proc 2002; 77: 309–316
2. Olin et al J Vasc Surg 2002; 36: 443–451
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Fibromuscular Dysplasia (FMD)Fibromuscular Dysplasia (FMD)
• Unknown etiology• Second most common cause of RAS• Affects middle-aged women• More common in first-degree relatives and in the
presence of the ACE-I allele.• Renal artery involvement is seen in 60% of cases
- frequently bilateral compromise. • Progressive renal stenosis is seen in 37% of
cases and loss of renal mass in 63%
Grossmans “Catheterization” 7th Ed. pg. 562-603.
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A. Classic “string of beads” appearance of fibromuscular dysplasia. B. Intravascular ultrasound (IVUS) with a 40-MHz catheter demonstrating
multiple fine fibrous bands and foci of interband aneurysmal dilatation. C. Translesional gradient measured between a 6Fr guide catheter placed
in the aorta and a 4F glide catheter placed in the distal renal artery. A 60-mm Hg resting gradient is demonstrated.
Grossmans “Catheterization” 7th Ed. pg. 562-603.
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Fibromuscular Dysplasia (FMD)Fibromuscular Dysplasia (FMD)TreatmentTreatment
• Balloon angioplasty alone: FMD localized within the main renal artery or its primary branches
• Stenting: Reserved for failure or complications of balloon angioplasty
• Surgery: FMD that involves multiple branch vessels or is associated with aneurysmal disease
Grossmans “Catheterization” 7th Ed. pg. 562-603.
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D. Post-balloon angioplasty with a 4.5mm diameter balloon demonstrating improvement in the angiographic appearance.
E. Intravascular ultrasound (IVUS) confirms the postangioplasty improvement
F. Postprocedure IVUS demonstrates fracture of the fibrous bands, resulting in resolution of the gradient seen before the procedure.
Grossmans “Catheterization” 7th Ed. pg. 562-603.
08-9Garovic VD, Textor SC. Circulation 2005;112:1362-1374
Schematic of Pressor Mechanisms Identified Schematic of Pressor Mechanisms Identified in Renovascular Hypertensionin Renovascular Hypertension
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““Goldblatt” Model Goldblatt” Model (1934)(1934)
FMD Model: “Atherosclerotic” Model (1970’s):
•No comorbidityNo comorbidity
•Hypertension outHypertension out
of contextof context
•Sole mechanism of Sole mechanism of
hypertension
•Young patients
(female)
•Limited comorbidity
•Hypertension out off
context (detection)
•Sole mechanism of
Hypertension
•Older patients
•Associated
comorbidity
•Hypertension in
context
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Renal Artery Stenosis
Etiology + Pathophysiology Incidence
DiagnosisIndications for RevascularizationTreatment Options
- Medical Therapy- PTA- Surgical
Technical ConsiderationsComplicationsPrognosis
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Prevalence of Renal Artery StenosisPrevalence of Renal Artery StenosisMost Common Cause of 2Most Common Cause of 2oo HTN HTN
0
10
20
30
40
50
60
70
All HTNPts
>50 yrsWith
ESRD
Pts withCAD
AccHTN
AortographyFor PAD
5-10%
15% 20%
30%
50-59%
Rihal et al Mayo Clin Proc 2002; 77: 309–316
Olin et al J Vasc Surg 2002; 36: 443–451
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Prevalence of Renal Artery StenosisPrevalence of Renal Artery Stenosis 834 patients undergoing ultrasound screening 834 patients undergoing ultrasound screening
• Mean age of 77 years • Significant (>60%) RAS in 6.8% of the study cohort• 2 x as many men (9.1%) as women (5.5%, P=0.053)• RAS showed no association with ethnicity, even distribution among
white (6.9%) and black (6.7%) participants • RAS was significantly and independently associated with increasing
age, low high-density lipoprotein cholesterol levels, and increasing systolic blood pressure.
Hansen et al J Vasc Surg 2002;36:443-51
08-14Buller CE et al JACC 2004: 43:1606
Severe Renal Artery Stenosis Severe Renal Artery Stenosis Multivariate AssociationsMultivariate Associations
837 patients undergoing screening angiography837 patients undergoing screening angiography
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Incidence of Renal Artery Stenosis at Incidence of Renal Artery Stenosis at Cardiac Catheterization Cardiac Catheterization
Study Authors Patients,n Any RAS,%RAS >50%,% Bilateral, %
Aqel et al 90 NR 28 10
Weber-Mzell et al 177 25 11 8
Rihal et al 297 34 19 4
Vetrovec et al 116 29 23 29
Harding et al 1302 30 15 36
Jean et al 196 33 18 NR
Mean±SD 2178 30.2±3.6 19±6 17.4±14.2
RAS indicates renal artery stenosis; NR, not reported.
White, C. J. Circulation. 2006;113:1464-1473
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Approximately 50% of renal artery stenoses progress over time
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Progression Of RASProgression Of RASDisease progression is associated with a decline in renal functionDisease progression is associated with a decline in renal function
Crowley JJ et al Am Heart Journal 1998;136:913
97 ± 44 μmol/L97 ± 44 μmol/L
141 ± 114 μmol/L
Patients with normal renal arteries at baseline
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Progression of Renovascular Disease Progression of Renovascular Disease Results in Renal AtrophyResults in Renal Atrophy
•204 kidneys in 122 patients with RAS•6 monthly serial duplex scanning•Defined as > 1cm reduction in length
2 year incidence of renal atrophy:2 year incidence of renal atrophy:
Normal RANormal RA 5.5%5.5%
< 60 % stenosis< 60 % stenosis 11.7%11.7%
> 60 % stenosis> 60 % stenosis 20.8%20.8%
Risk of atrophy increased by systolic hypertension Risk of atrophy increased by systolic hypertension
(> 180mm Hg) and a high peak systolic velocity(> 180mm Hg) and a high peak systolic velocity
Caps et al, Kidney International, 1998
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4 Year Mortality4 Year Mortality1235 cath lab patients screened for RAS > 50%1235 cath lab patients screened for RAS > 50%
Conlon PJ et al, J Am Soc Nephrol 9:252;1998
MultivariablePredictors
AgeGenderGFR (per 5 ml/min)SBP (per 5 mmHg)Abdominal or LE DiseaseCarotid Disease
OR
1.721.910.861.082.06
3.13
PValue
0.0040.0290.0040.0050.037
0.0007
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Renal Artery Stenosis
Etiology + PathophysiologyIncidence
DiagnosisIndications for RevascularizationTreatment Options
- Medical Therapy- PTA- Surgical
Technical ConsiderationsComplicationsPrognosis
08-21Garovic VD, Textor SC Circulation. 2005;112:1362-1374
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Renal Artery ObstructionRenal Artery ObstructionThe Dilemma of DiagnosisThe Dilemma of Diagnosis
Atherosclerosis, hypertension and renal insufficiency exist and co-exist commonly. When there is renal artery stenosis:
Is it the Is it the causecause of hypertension? of hypertension?Is it the Is it the causecause of renal insufficiency? of renal insufficiency?Will treatment improve either?Will treatment improve either?Will treatment prevent deterioration?Will treatment prevent deterioration?
08-23www.Cardiosource .com. ACC/AHA Guidelines
08-24www.Cardiosource .com. ACC/AHA Guidelines
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Noninvasive diagnostic modalitiesNoninvasive diagnostic modalities Renal Artery Ultrasound Renal Artery Ultrasound
• Body habitus dependent• Operator dependent• May miss accessory arteries• No additional anatomical information• Physiological information• Allows post intervention surveillance
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74 y/o man with difficult to control HTN
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Duplex Assessment of RASDuplex Assessment of RAS
Duplex Criteria Stenosis
RAR<3.5 and
PSV<200 cm/sec
0-59%
RAR >3.5 and
PSV>200 cm/sec
60-99%
RAR>3.5 and
EDV > 150 cm/sec
80-99%
Absence of flow and low amplitude parenchymal signal
Occluded
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Power Doppler image of a stenosis of right RA. The arrows indicate the stenosis.
Manganaro et al. Cardiovascular Ultrasound 2004 2:1
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40 y/o woman with well controlled HTN
Noninvasive diagnostic modalitiesNoninvasive diagnostic modalitiesDigital Subtraction AngiographyDigital Subtraction Angiography
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Noninvasive diagnosis: MRANoninvasive diagnosis: MRA
• Identifies accessory renal arteries
• Provides additional anatomical information
• No radiation• No nephrotoxic contrast• Allows 3-D reconstruction• May “overcall” lesions• Looses accuracy in distal
segments (FMD) Mild (30%) left RAS and severe (90%) right RAS in 70-year-old man
Fenchel, M. et al. Radiology 2006;238:1013-1021
08-31Herborn, C. U. et al. Radiology 2006;239:263-268
Severe stenosis of left renal artery in a 72 y/o man
Normal renal arteries in a 61 y/o man
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40 y/o woman with well controlled HTN40 y/o woman with well controlled HTN
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74 y/o man with difficult to control HTN74 y/o man with difficult to control HTN
Motion artifact
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Renal Artery StenosisRenal Artery Stenosis
Etiology + PathophysiologyIncidence DiagnosisIndications forRevascularizationTreatment Options
- Medical Therapy
- PTA- Surgical
Technical ConsiderationsComplicationsPrognosis
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Reasons to Revascularize Reasons to Revascularize
Atherosclerotic Renovascular DiseaseAtherosclerotic Renovascular Disease
Treat SymptomsTreat Symptoms
Prevent Future IllnessPrevent Future Illness• Lower BPLower BP• Preserve Renal FunctionPreserve Renal Function• “ “Bystander” EffectsBystander” Effects
- - Prevent DeathPrevent Death
-- Prevent MI Prevent MI
- Prevent CHF - Prevent CHF
- Prevent CVA- Prevent CVA
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Indications for Revascularization of RASIndications for Revascularization of RAS
Circulation 2005;112:1362-1374.
1. Resistant hypertension- Failure of medical therapy despite full doses of 3 drugs, including
diuretic
- Compelling need for ACE inhibition/angiotensin blockade with angiotensin-dependent GFR
2. Progressive renal insufficiency with salvagable kidneys- Recent rise in serum creatinine- Loss of GFR during antihypertensive therapy (e.g., ACEI)- Evidence of preserved diastolic blood flow (low resistive index)
3. Circulatory congestion, recurrent “flash” pulmonary edema
4. Refractory congestive heart failure with bilateral renal artery stenosis
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Who Will Benefit: Who Will Benefit: Renal Resistive IndexRenal Resistive Index
• Reflection of intrarenal vascular surface area and resistance
• Calculated using Doppler U/S • Resistive Index
• [1-(EDV/PSV)]x100• 4950 patients underwent U/S calculation of
renal resistive index• 138 RAS patients treated• Followed for improvement in BP and Cr
Radermacher et al NEJM. 2001;344:2244-49
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Outcomes Predicted By RRIOutcomes Predicted By RRI
Radermacher et al NEJM. 2001;344:2244-49
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Renal RevascularizationRenal Revascularization
• Useful when:• Renal artery stenosis is SEVERE, and...• Renal function is “salvageable”
• Preserved size• Preserved intrinsic vasculature (“low” RI)
• Not useful when:• Renal artery stenosis is not severe• Renal function is “unsalvageable”
• Unknown:• Prophylactic use• Value of screening• Role of atheroembolization / Protection
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Renal Artery StenosisRenal Artery Stenosis
Etiology + PathophysiologyIncidence DiagnosisIndications for RevascularizationTreatment Options
- Medical Therapy- PTA- Surgical
Technical ConsiderationsComplicationsPrognosis
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Goals Of Renal Artery RevascularizationGoals Of Renal Artery Revascularization
• Improve control of hypertension
• Preserve or restore renal function
• Treat other potential adverse physiologic effects of severe renal artery stenosis (congestive heart failure, recurrent flash pulmonary edema, and angina)
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• •
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• ACE inhibitors are effective medications for treatment of hypertension associated with RAS.
• Calcium-channel blockers are effective medications for treatment of hypertension associated with unilateral RAS.
• Beta-blockers are effective medications for treatment of hypertension associated with RAS.
Pharmacological Treatment of Pharmacological Treatment of Renal Artery StenosisRenal Artery Stenosis
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII • Angiotensin receptor blockers are effective medications for treatment of hypertension associated with unilateral RAS.
ACC/AHA Guidelines
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Catheter- Based Interventions for RASCatheter- Based Interventions for RAS
• Renal stent placement is indicated for ostial atheroesclerosic RAS lesions that meet the clinical crietria for intervention.
• Balloon angioplasty with “bail-out” stent placement if necessary is recommended for fibromuscular dysplasia lesions.
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ACC/AHA Guidelines
08-44Zeller T. Journal of Interv Card 18 (6), 497-506.
Renal Artery Stent PlacementRenal Artery Stent Placement
Ostial atheroma
Stent with protrusion into aortic lumen
2 mm into aorta
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Renal Artery Stenting: ResultsRenal Artery Stenting: ResultsPublished series before 1998Published series before 1998
Leertouwer et al Radiology 2000, 216 78-85
1188 patients, mean follow up 16 months
Hypertension cured 20%Hypertension improved 49%Renal function improved 30%Renal function stabilized 38%
69%
78%
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Renal Artery Stenting StudiesRenal Artery Stenting Studies
– Meta-analysis of 349 pts in 8 clinical series- Hypertension improved in 56%; cured in 10%- Renal artery function improved in 27%;
stabilized in 38%- Restenosis occurred in 16%- Major complications in 4.9
Palmaz JC et al J Vasc Intervent Radiol 1998;9:539-43
– DRASTIC Trial- 106 patients treated with PTA or medical therapy- Although no difference in outcomes, stenting reserved for “bailout”, 44% of medical therapy crossed over to PTA due to HTN, occlusion seen in 16% of medical treated patients
Van Jaarsveld BC et al. N Engl J Med 2000; 342: 1007-1014
08-47White CJ Circulation 2006;113:1464-1473
Superiority of renal artery stent compared with balloon Superiority of renal artery stent compared with balloon angioplasty for procedure success and restenosis ratesangioplasty for procedure success and restenosis rates
Restenosis
Per
cen
t
Procedure Success
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Surgery for Renal Artery StenosisSurgery for Renal Artery Stenosis
• Endarterectomy
• Aortorenal bypass
• Extra-anatomic bypass using hepatorenal, splenorenal, ileorenal, or superior mesenteric artery – renal anastomosis.
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Surgery for Renal Artery StenosisSurgery for Renal Artery Stenosis
• Atherosclerotic RAS in combination with pararenal aortic reconstructions (in treatment of aortic aneurysms or severe aortoiliac occlusive diseease.
• Fibromuscular dysplastic RAS with clinical indications, especially those exhibiting complex disease that extends into the segmental arteries and those having macroaneurysms.
• Atheroeclerotic RAS and clinical indications for intervention, especially those with multiple small renal arteries or early primary branching of the main renal artery.
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
ACC/AHA Guidelines
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Renal Artery StenosisRenal Artery Stenosis
Etiology + PathophysiologyIncidence DiagnosisIndications for RevascularizationTreatment Options
- Medical Therapy- PTA- Surgical
Technical ConsiderationsComplicationsPrognosis
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Renal ArteriographyRenal Arteriography
• Abdominal Aortogram: identification of ostia of the renal arteries and accessory renal arteries (25% of population)
• Arteriography should include both the arterial phase and the nephrographic phase
• Disease involving renal bifurcations require cranial or caudal angulation to open out the lesion
• Evidence of aortic atheroma: technique of no-touch angiography is recommended
IVUS provides a further method of renal artery evaluation for indeterminate lesions
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Brachial ApproachBrachial Approach
• For renal arteries that are oriented cephalad.
• When the aorta is occluded distally or the renal artery takeoff is severely angulated
• Proximal renal artery segment initially courses inferiorly and posteriorly braquial approach allows more coaxial alignment.
• Greater incidence of vascular site complications
Zeller T. Journal of Interventional Cardiology 18 (6), 497-506
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Femoral ApproachFemoral Approach• Renal artery angioplasty and stenting are usually
performed via retrograde femoral approach.
• When the real artery origin is oriented horizontally or caudally with respect to the aorta, femoral approach is preferred.
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Renal Artery StenosisRenal Artery Stenosis
Etiology + PathophysiologyIncidence DiagnosisIndications for RevascularizationTreatment Options
- Medical Therapy
- PTA- Surgical
Technical ConsiderationsComplicationsPrognosis
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Registry Stent Complications Registry Stent Complications
Renal Stents
Blum
Harjai
Tuttle
Rocha-Singh
Burket
White
Borros
Total
Number
74
88
148
180
171
133
163
957
Death
0
0
0
0.6
0
0
0.6
<1%
Dialysis
0
0
0
0
0.7
0
0
<1%
Major
Compls
0
0
4.1
2.6
0.7
0.75
1.80
1.4%
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Complications Of Percutaneous Renal Complications Of Percutaneous Renal RevacularizationRevacularization
• Atheroembolism into the renal or peripheral vascular bed cholesterol embolization
• Dissection of renal artery or the wall of the aorta
• Acute or delayed thrombosis• Infection• Rupture of renal artery• Renal perforation
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Complication Rates for Renal Stent Complication Rates for Renal Stent Placement Placement
Study AuthorsPatients,
n Death, % Dialysis, %Major
complications, %
Rocha-Singh et al 180 0.6 0 2.6
Tuttle et al 148 0 0 4.1
White et al 133 0 0 0.75
Burket et al 171 0 0.7 0.7
Dorros et al 163 0.6 0 1.8
Total 795 <1% <1% 2.0%
Major complications include death, myocardial infarction, emergency surgery, need for dialysis, or blood transfusion.
White et al, Circulation. 2006;113:1464-1473
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Atheroembolization ProtectionAtheroembolization Protection
What is the cause of What is the cause of deterioration in renal deterioration in renal function after function after revascularization?revascularization?
•Iodinated contrast?Iodinated contrast?
•Atheroembolization?Atheroembolization?
•Something else?Something else?
What is the cause of What is the cause of deterioration in renal deterioration in renal function after function after revascularization?revascularization?
•Iodinated contrast?Iodinated contrast?
•Atheroembolization?Atheroembolization?
•Something else?Something else?
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Filterwire Embolic ProtectionFilterwire Embolic Protection
08-60White CJ Circulation 2006;113:1464-1473
A, Baseline selective renal angiogram showing tight ostial stenosis with normal filling of the renal arteries to the cortex
B, Poststent angiogram with poor filling of the distal renal arteries caused by embolization
Renal Artery EmbolizationRenal Artery Embolization
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Renal Artery StenosisRenal Artery Stenosis
Etiology + PathophysiologyIncidence DiagnosisIndications for RevascularizationTreatment Options
- Medical Therapy- PTA- Surgical
Technical ConsiderationsComplicationsPrognosis
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Favorable PredictorsFavorable PredictorsSuccessful Outcome For Control Of HypertensionSuccessful Outcome For Control Of Hypertension
• Rapid acceleration of hypertension over the prior weeks or months
• Presence of “malignant” hypertension • Hypertension in association with flash
pulmonary edema• Contemporaneous rise in serum creatinine• Development of azotemia in response to ACE
inhibitors administered for control of hypertension.
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Favorable PredictorsFavorable PredictorsSuccessful Salvage Or Preservation Of Renal FunctionSuccessful Salvage Or Preservation Of Renal Function
• Recent rapid rise in creatinine, unexplained by other factors
• Azotemia resulting from ACE inhibitors• Absence of diabetes or other cause of intrinsic
kidney disease• Presence of global renal ischemia, wherein the
entire functioning renal mass is subtended by bilateral critically narrowed renal arteries or a vessel supplying a solitary kidney.
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Unfavorable PredictorsUnfavorable Predictors
• Renal atrophy demonstrated by kidney length <7.5 cm on ultrasound
• High renal resistance index detected by duplex ultrasound
• Proteinuria > 1gm/day• Hyperuricemia• Creatinine clearance <40 mL/minute
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Outcomes Following Renal StentingOutcomes Following Renal StentingMajor Predictor was the RRIMajor Predictor was the RRI
Radermacher et al NEJM. 2001;344:2244-49
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Outcomes Following Renal StentingOutcomes Following Renal StentingMajor Predictor was the RRI at 32 monthsMajor Predictor was the RRI at 32 months
Radermacher et al NEJM. 2001;344:2244-49
↓ MAP ≥ 10 mm Hg
↓ Cr Cl ≥ 10%
Dialysis
Death
RRI < 80N = 96
94%
3%
3%
3%
RRI > 80N = 35
3%
80%
46%
29%
P < 0.001 for all outcomes
08-67Harden et al. Lancet 1997;349:1133
Stabilization of Renal FunctionStabilization of Renal Function
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Cardiovascular Outcomes in Renal Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL)Atherosclerotic Lesions (CORAL)
Enrollment: April 2004 – March 2010
1080 patients withRAS >60% and hypertension (>155 mmHg on ≥ 2 meds)
Composite cardiovascular and renal endpoint: Cardiovascular or renal death, MI, hospitalization for CHF, stroke, doubling of serum creatinine level, need
for renal replacement therapy
Optimal medical therapy alone vs stenting with optimum medical therapy
1:1 Randomization to:
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Renal Artery StenosisRenal Artery Stenosis
Etiology + PathophysiologyIncidence DiagnosisIndications for RevascularizationTreatment Options
- Medical Therapy- PTA- Surgical
Technical ConsiderationsComplicationsPrognosis