于ARAS患者中筛选经皮肾动脉腔内成形术适应证

动脉粥样硬化性肾动脉狭窄（ARAS）是诱发继发性高血压及缺血性肾病的重要因素,应否采用经皮肾动脉腔内成形术（PTRA）加以治疗目前尚存争议;如何于ARAS患者中筛选PTRA适应证为目前亟待解决的临床问题。本文针对最可能受益于PTRA的ARAS患者的特征进行综述。     

肾动脉狭窄的治疗

肾血管性高血压是一综合征,是指由于肾血管损伤造成肾脏灌注压下降、血压升高。肾血管疾病包括肾动脉狭窄（reno—artery stenosis,RAS）,肾动脉或肾静脉血栓、栓塞及其梗阻等,其中以RAS居多。引起RAS的常见病因为动脉粥样硬化性肾动脉狭窄（atherosclerotic renal artery stenosis,ARAS）、多发性大动脉炎和肌纤维发育不良。     

肾血管性高血压的介入治疗

我们评价经皮肾动脉腔内成形术（PTRA）及内支架植入术治疗肾血管性高血压（RVH）的疗效。 一、对象和方法 1．对象：肾动脉狭窄19例，其中男5例，女14例，平均年龄39．3岁（21～73岁），均符合血管成形术适应证，并排除了禁忌证。单侧肾动脉狭窄12例，双肾动脉狭窄7例。肾动脉开口病变4例，非开口病变15例。动脉粥样硬化性狭窄18例，多发性大动脉炎1例，其中4例患者合并肾功能不全。     

肾动脉狭窄的无创性检查研究进展

肾动脉狭窄(renal artery stenosisRAS)是常见的可治愈的继发性高血压之一,其确切发病率还不十分清楚,有研究表明其约占高血压患者的1％[1]。此外,RAS也是终末期肾功能衰竭(ERSD)的常见病因之一[2]。RAS的常见临床表现包括难治性高血压和肾功能不全,经过肾血管成形术治疗,高血压和肾功能不全可得到好转或痊愈。因此,在临床上对本病的及时诊断具有重要意义。目前,肾动脉造影仍然是诊断RAS的金标准,但由于该项检查系有创性检查、价格昂贵,且检查过程中需使用造影剂,部分患者可发生造影剂肾损害,作为筛选和初步诊断RAS的检查方法在临床普遍应用受到较大限制。近年来,开博通肾图、     

肾动脉狭窄的介入治疗分析

目的 分析介入治疗肾动脉狭窄（RAS）的疗效。方法自2003年3月至2008年3月共收治45例RAS患者,53支肾动脉中单纯行腔内球囊扩张术（PTA）治疗11支,行球囊扩张及内置支架术（PTA／Stent）治疗者42支,随访9～48个月,检测患者的血压与血肌酐水平,并作肾动脉彩超。结果手术成功率为100％。手术后高血压治愈者9例,改善28例,肾功能改善12例。肌纤维发育不良及多发性大动脉炎的血压改善有效率均为100％,高于动脉粥样硬化的有效率65．1％（P〈0．05）。行彩色多普勒超声检查肾动脉18支,发现再狭窄者7支。结论PTA和PTMStent治疗肾动脉狭窄具有微创、安全、有效的优点。     

肾动态显像在介入治疗肾动脉狭窄中的应用

肾动脉狭窄（RAS）是临床常见疾病。经皮肾动脉腔内支架成形及植入术（PTRAS）是治疗RAS的主要方法,但其应用尚存争论,且缺乏筛选PTRAS适应证的有效方法。肾动态显像是能反映肾血流灌注及肾功能的无创性检查方法,可早期提示肾功能下降、预测术后肾功能改善情况。本文对肾动态显像在介入治疗RAS中的应用进行综述。     

126例血管造影患者动脉粥样硬化性肾动脉狭窄的临床分析

目的了解中老年冠心病患者动脉粥样硬化性肾动脉狭窄（ARAS）的发生率及探讨患者ARAS的相关因素。方法对126例确诊或疑诊冠心病的中老年患者行冠状动脉、肾动脉造影。以肾动脉狭窄（RAS）为因变量，临床因素为自变量，进行单变量Logistic回归分析。结果126例中24例有RAS,占19．04％；13例有明显RAS，占10．32％。24例RAS患者有28支狭窄肾动脉，狭窄位于肾动脉开El处为60．7％（17／28），肾动脉主干处为35．7％（10／28），分支处狭窄为3．57％（1／28）。64例确诊为冠状动脉粥样硬化患者中18例有肾动脉狭窄，ARAS的发生率为28．13％（18／64）；62例冠脉造影阴性患者有6例存在肾动脉狭窄，ARAS发生率为9．68％（6／62）。Logistic回归分析显示，冠脉病变、高脂血症、吸烟、肾功能不全与ARAS病变密切相关。结论在确诊或疑诊冠心病的中老年患者中，ARAS的发生率为19．04％；在确诊冠脉粥样硬化的患者中．ARAS的发生率明显高于冠脉造影阴性者。冠脉病变、高脂血症、吸烟、肾功能不全是ARAS的相关因素。     

彩色多普勒超声评价经皮肾镜技术围手术期肾脏血流动力学

目的探讨经皮肾镜技术（PCNL）对围手术期肾脏血流动力学的影响。方法应用CDFI观察30例接受单侧、单通道PCNL患者术前1天及术后5-7天患侧各级肾动脉血流参数,并进行统计学分析。结果术后各级肾动脉阻力指数（RI）均低于术前,肾门处主肾动脉、叶间动脉、小叶间动脉舒张末期血流速度（Vmin）升高（P〈0.05）。重度积水患者术后段动脉、叶间动脉RI降低（P〈0.05）,叶间动脉Vmin增加（P〈0.05）;中度积水患者术后各级肾动脉RI降低（P〈0.05）,主肾动脉、小叶间动脉Vmin增加（P〈0.05）;轻度积水患者术后主肾动脉、段动脉RI降低（P〈0.05）,段动脉Vmin增加（P〈0.05）;无积水患者术后段动脉、叶间动脉RI降低（P〈0.05）。结论 PCNL术后短期内患侧肾脏肾动脉舒张期灌注改善,RI降低。CDFI可观察肾内血流灌注,并量化肾内血流动力学信息。     

肾动脉狭窄与低血钠-高血压综合征的临床分析

目的收集和分析肾动脉狭窄与低血钠-高血压综合征患者的临床特点。方法回顾性分析2001～2（）11年我院住院治疗的肾动脉狭窄、低血钠-高血压综合征。结果9例患者符合低血钠-高血压综合征的入选标准。除2例患者外,均为规律吸烟患者。所有患者中,8例患者与肾动脉粥样硬化有关,1例患者与纤维肌性发育不良有关。血管紧张素II和血浆醛固酮水平明显升高,而且与患者的最低血钠浓度呈明显负相关（r=-0．90,P〈0．01;r=-0．81,P〈0．05）。结论低血钠-高血压综合征的主要病因是动脉粥样硬化导致的肾动脉狭窄。肾素-血管紧张素系统激活可能是低血钠-高血压综合征病理生理机制的核心。该病是肾动脉狭窄的少见并发症,但值得临床医生提高认识和进一步研究。     

血管活性物质对缺血性肾病的影响

缺血性肾病（ischemic renal disease,IRD）是导致慢性肾衰竭的重要原因之一。缺血性肾病是由于双侧肾动脉狭窄（tenal artery stenosis,RAS）或孤立性肾动脉狭窄（≥60％）、严重肾血流动力学改变导致的肾小球滤过率下降及继发性肾脏损伤。     

肾动脉狭窄的腔内治疗经验

目的探讨腔内治疗肾动脉狭窄的临床疗效及影响因素。方法2003年2月至2005年6月共收治19例肾动脉狭窄患者,分析其中行腔内治疗12例的临床资料。其中动脉硬化9例,多发性大动脉炎1例,纤维肌性发育不良2例。结果本组12例,均有严重高血压,1例肾功能异常。支架置入10例,技术成功率91．7％(11／12)。随访12例,随访时间3—15个月,随访平均6．5个月,患者血压从(172±26／98±15)降至(156±22／88±14)mmHg。高血压治愈2例,改善6例,未愈4例,高血压控制率为66．7％。术后肾功能无明显变化。无并发症和死亡病例。再狭窄1例,再狭窄率为8．3％。结论严格掌握手术适应证,腔内治疗肾动脉狭窄是安全、有效的。     

Two cases of atherosclerotic renal artery stenosis treated by percutaneous transluminal renal angioplasty and intravascular stent placement, leading to improvement of hypertension and renal function

We describe here two cases of renal artery stenosis(RAS) caused by atherosclerosis. Both patients were treated by percutaneous transluminal renal angioplasty(PTRA) and stent placement, leading to the improvement of renal function as well as hypertension. The two patients were a 75-year-old male(case 1) and a 56-year-old male(case 2), who both showed mild proteinuria, renal dysfunction, and refractory hypertension. Case 1 showed a unilateral ostial stenosis in the left main renal artery. On the other hand, case 2 showed an ostial stenosis in the left renal artery and a widespread narrowing in the right renal artery. After evaluation of the lesions by renal Doppler sonography, renogram, magnetic resonance signal intensity, and magnetic resonance angiography(MRA), each stenosis was treated by balloon angioplasty and intravascular stent placement without any major complications. Thereafter, in addition to hypertension, renal function also ameliorated significantly, and has remained stable for more than 12 months. Non-invasive screening tests and appropriate therapy for renovascular lesion should be considered in the case of elderly patients with refractory hypertension and progressive renal dysfunction, since ischemic nephropathy is increasing as a common cause of end stage renal disease and is showing favorable outcomes of revascularization.     

Interventional radiology in the treatment of renal artery stenosis.

Percutaneous transluminal renal angioplasty (PTRA) alone or in combination with stent implantation, is increasingly used as an alternative technique to surgical revascularization for treatment of renal artery stenosis (RAS) wich may cause hypertension or jeopardize renal function. Herein we report the results obtained with 305 PTRAs performed in 242 hypertensive patients, 144 of whom had atherosclerotic RAS, 69 fibromuscolar dysplasia, 15 Ras in transplanted kidneys, 6 restenosis in surgically revascularized kidneys, 4 Takayasu arteritis and 4 neurofibromatosis. Stents were implanted in 68 cases, mostly in atherosclerotic stenoses. The technical success was achieved in 261 arteries (85.6%), with 33 failures (10.8%) and 11 (3.6%) procedures not completed for anatomical reasons. PTRA related complications were observed in 23 cases (7.5%), but no fatalities occurred. An overall benefit on blood pressure control was observed in 41% of patients with atherosclerotic RAS and in 68% of those with fibromuscolar dysplasia. It appears that independently from the ethiology PTRA is technically effective in correcting RAS; yet the position of PTRA with respect to that of medical or surgical treatment needs to be better delineated through randomized, controlled studies aimed at comparing the clinical efficacies of these different approaches.     

Treatment of severe renal artery stenosis by percutaneous transluminal renal angioplasty and stent implantation

The clinical course of two children with mid-aortic syndrome and renal artery stenosis (RAS) who suffered from severe arterial hypertension is described. Hypertension was uncontrollable by antihypertensive medication and was managed by percutaneous transluminal renal angioplasty (PTRA) with stent implantation. The pediatric experience with PTRA is limited, and there are only few cases reported with additional stent implantation. Complications of these procedures are well known from experience with adult patients. However, since surgical revascularization may be technically difficult especially in small children, PTRA with or without stenting should be considered as a valuable treatment option in pediatric RAS.     

Angioplasty of the renal artery: antihypertensive and renal effects

Percutaneous transluminal angioplasty of the renal artery (PTRA) has been increasingly used over the past 20 years for treating renovascular hypertension (RVH). From the experience gathered so far it is justified to state that this technique is the first choice for patients with fibromuscular renal artery stenosis (RAS) because their cure rate is 50% and 42% improve. In contrast in patients with atherosclerotic RAS the cure rate after PTRA is 8-10% although 40-50% still improve. Since PTRA is associated with a 23% rate of major/minor complications and 30% restenosis (23% requiring stent implantation), it is obvious that in patients with atherosclerotic RAS the decision to attempt this procedure must be taken after careful selection of those who may actually benefit from the dilation. PTRA can be used more extensively for salvaging the function of the ischemic kidney than for treating hypertension because of the progressive nature of the atherosclerotic RAS and the lack of effective agents against such progression. After PTRA 35% of patients have some improvement in renal function and another 35% are stabilized. Yet most studies addressing the renal effects of PTRA suffer the limitation of having used serum creatinine levels as an indicator of glomerular filtration rate (GFR). More recent studies which used radioisotopic techniques to evaluate the changes of GFR induced by PTRA in the stenotic kidney indicate that after a successful procedure the increase is, on average, 8-10 ml/min. Interestingly it appears that this improvement is slower in kidneys of patients with atherosclerotic RAS than in those with fibromuscular RAS.     

Reduction in renal function after renal arteriography and after renal artery angioplasty.

OBJECTIVE: To investigate the incidence and risk factors for renal function deterioration after renal angiography and angioplasty or stenting. METHODS: A retrospective study of 85 consecutive patients undergoing selective renal artery arteriography (n = 53) or renal artery angioplasty % (PTRA) stenting (n = 32) for renal artery stenosis. Multivariate logistic regression analysis was used to determine independent predictors of deterioration of renal function, defined as an increase of serum creatinine by at least one third within 24 h. RESULTS: Deterioration of renal function occurred in 13 patients (15%), [8/53 (15%) after angiography and 5/32 (16%) after PTRA/stenting]. Only pre-existing renal impairment (se-creatinine > or = 177 mumol/l) (Odds ratio: 40; 95% confidence interval 1.2-72, p = 0.02) and administered dosage of contrast agent (more than 225 ml) (OR 67; 95% CI 11.8-100, p = 0.02) were independently associated with renal function deterioration. CONCLUSION: Transient renal dysfunction after renal artery angiography or PTRA/stenting occurs in about 15% of patients, but persistent renal failure is uncommon. Pre-existing renal impairment and amount of contrast agent are independent risk factors. Endovascular treatment of renal artery stenosis is not associated with a higher risk of renal deterioration compared to selective renal angiography.     

Percutaneous transluminal renal angioplasty

Summary Percutaneous transluminal renal angioplasty (PTRA) is a simple, efficient procedure with a low risk/benefit ratio when carried out by experienced interventional radiologists. The role of radiology in the diagnosis and treatment of renovascular hypertension (RVH) is discussed, with special attention to technique. PTRA and surgical results are dependent on the etiology and location of renal artery stenosis (RAS). At New York Hospital-Cornell Medical Center, PTRA is the procedure of choice in fibromuscular dysplasia (FMD), unilateral non-ostial atheroma, arteritis, renal transplantation, and pediatrics. The choice between surgery and PTRA in patients with bilateral and ostial atherosclerotic disease and/or azotemia depends on the surgical risk category of the patient. At our institution, coronary and cerebrovascular disease do not preclude PTRA.     

Evaluating patients with renal failure for renal artery stenosis with gadolinium-enhanced magnetic resonance angiography

The incidence and prevalence of end-stage renal disease (ESRD) continues to increase, especially in the elderly population. The role of renovascular disease in contributing to ESRD is still not well defined. The objective of this study was to determine the utility of gadolinium (Gd)-enhanced magnetic resonance angiography (MRA) in evaluating elderly patients with renal insufficiency for renal artery stenosis (RAS). A 7-month prospective study conducted in a tertiary referral center evaluated 40 consecutive patients with progressive renal insufficiency (18 men and 22 women; mean age, 70 +/- 5.6 [standard deviation] years) and high clinical suspicion for renovascular disease with Gd-enhanced MRA. Digital subtraction angiography (DSA) was obtained in only those patients with significant RAS detected by MRA. Twelve patients had significant RAS. Six of these patients had percutaneous transluminal renal angioplasty (PTRA), five patients had renal artery bypass surgery, and one patient had a stent placed after PTRA. Seventy-eight renal arteries were satisfactorily evaluated by MRA. Twenty-two renal arteries were evaluated by both MRA and DSA. Of the 12 significant stenoses detected by the MRA, 11 were confirmed by DSA and 1 was confirmed at the time of surgical revascularization. It is concluded that Gd-enhanced MRA is a useful test for the evaluation of RAS in patients with compromised renal function.