Successful Wallstent implantation for extensive iatrogenic renal artery dissection in a patient with fibromuscular dysplasia.

PURPOSE: To describe a case of renal artery stenosis with fibromuscular dysplasia (FMD) and extensive iatrogenic dissection treated with Wallstent implantation. METHODS AND RESULTS: An 83-year-old woman with a history of coronary artery disease and hypertension presented at another facility with exertional angina and poorly controlled hypertension. Renal arteriography uncovered a critical right renal artery stenosis with severe FMD. However, angioplasty resulted in extensive dissection of the renal artery, for which the patient was referred to our institution. The renal artery was recanalized via the left brachial approach with restoration of flow using a Wallstent and a Palmaz stent. The patient's blood pressure was controllable after this procedure, and follow-up duplex imaging with flow velocities at 6 months showed patent right renal artery stents. CONCLUSIONS: Owing to its length and flexibility, the Wallstent endoprosthesis was a useful treatment modality in this case of extensive renal artery dissection.     

多层螺旋CT图像后处理诊断移植肾动脉狭窄

背景:对肾移植后并发移植肾动脉狭窄患者的诊断及随访是否可采用一种无创伤、特异性高、安全的检查方法。目的:评估多层螺旋CT图像后处理技术对移植肾动脉狭窄的诊断价值。方法:对11例临床怀疑为移植肾动脉狭窄的患者进行移植肾动脉期的增强扫描,扫描后所得到的数据经容积重建、最大密度投影、曲面重建、多平面重建处理成像。结果与结论:11例患者均诊断为移植肾动脉狭窄,10例多层螺旋CT图像后处理技术显示移植肾动脉狭窄程度54%～75%,1例移植肾动脉狭窄程度<50%。吻合口狭窄10例,其中合并移植肾动脉主干狭窄2例;移植肾动脉分支狭窄1例。经数字减影血管造影检查9例,狭窄程度75%～95%,8例置入支架,1例球囊扩张;1例给予药物治疗随访,于2年后出现肾功能进一步恶化及难治性高血压,置入支架。1例无临床症状,经多层螺旋CT移植肾动脉狭窄程度<50%,随访4年肾功能、血压正常。支架置入治疗的患者中1例行球囊扩张者2年后彩色多普勒提示移植肾吻合口狭窄,行多层螺旋CT检查移植肾动脉狭窄程度<50%,随访4年3个月,肾功能、血压正常。提示多层螺旋CT后成像技术可作为移植肾动脉狭窄的诊断依据,对区分临床疑似病例,制定支架置入治疗方案,以及术后随访观察有一定的临床参考价值。     

肾血管性高血压大鼠模型的建立和评测

背景:建立一种有效并简便可靠的高血压动物模型,对研究高血压的机制和治疗有重要的意义。目前,国内外常利用犬、大鼠、兔等实验制作高血压动物模型,其中肾动脉狭窄性高血压模型由于简便可靠被广泛应用于人类高血压及其并发症的研究。目的:建立简便、可靠的大鼠实验性肾动脉狭窄性高血压模型。设计:随机分组设计、动物实验。单位:青岛大学医学院附属医院脑血管病研究所。材料:实验于2005-09/2006-02在山东省脑病防治重点实验室完成。选择健康Wistar大鼠81只,随机数字表法分为单侧肾动脉狭窄组18只,双侧肾动脉狭窄组17只,单侧肾动脉结扎组15只,双侧肾动脉结扎组15只,单侧肾动脉狭窄假手术组6只,双侧肾动脉狭窄假手术组4只,正常对照组6只。方法:单侧肾动脉狭窄组,微型银夹夹闭右侧肾动脉,12d后手术切除左侧肾脏。双侧肾动脉狭窄组,微型银夹夹闭右侧肾动脉,12d后左侧做同样处理。单侧肾动脉结扎组,丝线结扎右侧肾动脉,12d后手术切除左侧肾脏。双侧肾动脉结扎组,丝线结扎右侧肾动脉,12d后左侧做同样处理。单侧肾动脉狭窄假手术组,手术暴露右侧肾脏,不做处理放回原位。12d后切除左侧肾脏。双侧肾动脉狭窄假手术组,手术暴露右侧肾脏,不做处理放回原位,12d后左侧做同样处理。正常对照组6只,不作任何处理。应用RBP-2大鼠血压计测量鼠尾血压和心率。主要观察指标:造模成功率、大鼠血压、心率。结果:纳入动物81只,死亡61只,均进入结果分析。①血压:单侧肾动脉狭窄组、双侧肾动脉狭窄组、双侧肾动脉结扎组血压明显高于正常对照组、双侧肾动脉狭窄假手术组[分别为(138.0±36.5),(154.2±11.6),(160.5±0.7),(101.3±17.6),(108.3±5.7)mmHg]。②心率:各肾动脉狭窄组动物心率变化不稳定,单侧肾动脉狭窄组、双侧肾动脉狭窄组、双侧肾动脉结扎组、正常对照组、双侧肾动脉狭窄假手术组分别为[(367.5±47.2),(420.2±47.8),(386.0±4.2),(390.3±42.4),(417.3±27.5)次/min]。③存活率:肾动脉狭窄组存活率(单侧22%,双侧29%)显著高于肾动脉结扎组(单侧0,双侧12%),以双侧肾动脉狭窄组存活率最高。结论:双侧肾动脉夹闭法可建立稳定的肾动脉狭窄性高血压大鼠模型。     

Renal artery aneurysm in a solitary kidney

A 55-year-old hypertensive female was referred for renal artery color Doppler examination because of a suspicion of renovascular hypertension. Renal artery aneurysm was occasionally detected at the distal portion of the artery in the single left kidney, without the presence of stenosis. An aneurysm was confirmed via magnetic resonance angiography and arteriographical examination.     

Clinical characteristics useful in screening for renovascular disease

In an effort to detect renovascular hypertension, clinical characteristics are used to select patients likely to have renal artery stenosis. We prospectively evaluated the ability of commonly used clinical features to predict the presence of renal artery stenosis in 100 hypertensive adults. All subjects had conventional renal arteriography. Renal artery stenosis was diagnosed if there was 50% or more stenosis of a main renal artery. Eighteen of the 100 had renal artery stenosis. The presence of a bruit was strongly associated with renal artery stenosis (P less than .0005). In patients without a bruit, only refractory hypertension was associated with the presence of renal artery stenosis (P = .051). These data suggest that a bruit and refractory hypertension are associated with renal artery stenosis, but that other clinical features investigated may not be and that other means of screening for renovascular disease are needed.     

冠状动脉造影患者中肾动脉狭窄的相关研究

目的在进行冠状动脉造影的患者中同时进行肾动脉造影,观察肾动脉狭窄的发生率及相关因素研究。方法200例冠状动脉造影患者全部行选择性双侧肾动脉造影,对临床资料和肾动脉狭窄之间的关系进行单变量分析。结果肾动脉狭窄者27例,占13.5%,其中轻度狭窄者（〈50%）13例,占6.5%,明显狭窄者14例,占7.0%。明显肾动脉狭窄单变量分析,年龄、吸烟、高血压、糖尿病、颈动脉斑块形成、严重冠状动脉病变是肾动脉狭窄的影响因素。结论在冠状动脉造影尤其冠心病患者中,肾动脉狭窄发生率高,多见于老年合并高血压、严重冠状动脉病变患者,在冠心病患者行冠状动脉造影的同时应常规进行肾动脉造影,以便及早发现肾动脉狭窄。     

Safety of angiotensin-converting enzyme inhibitors in patients with bilateral renal artery stenosis following successful renal artery stent revascularization

Angiotensin-converting enzyme inhibitors (ACEIs) are contraindicated in patients with bilateral renal artery stenosis due to risk of azotemia resulting from preferential efferent arteriolar vasodilation in the renal glomerulus due to inhibition of angiotensin II. Patients with renal artery stenosis who can derive survival benefit from ACE inhibition, therefore, may not receive ACEI therapy. We evaluated the safety of ACEI therapy in patients with bilateral renal artery stenosis following successful revascularization using renal artery stenting. This study is a retrospective analysis of 25 patients who underwent bilateral renal artery stenting for refractory hypertension and had a strong clinical indication for long-term ACEI use (left ventricular dysfunction or diabetes). Eighteen of the 25 patients (72%) have been safely maintained on a target dose of ACEIs, 2 of the 25 have been treated with angiotensin receptor blockers due to cough, and 5 of the 25 are being treated with a hydralazine/nitrate combination due to cough (2 patients) or baseline renal insufficiency (3 patients). We conclude that patients with bilateral renal artery stenoses that have been successfully revascularized using renal stenting may be safely treated with long-term ACEI therapy.     

Chronic Total Occlusion and Successful Drug-Eluting Stent Placement in Takayasu Arteritis–Induced Renal Artery Stenosis

Takayasu arteritis-induced renal artery stenosis (TARAS) is a condition rarely described in the literature. Although percutaneous transluminal angioplasty and stenting has been well-described in the treatment of atherosclerotic renal artery stenosis, its role has not been established in non-atherosclerotic TARAS. We report a case of a female, age 17 years, with Takayasu arteritis who presented to the hospital with seizures and hypertensive crisis. A renal angiogram showed chronic total occlusion (CTO) of the left renal artery. Renal angioplasty and stenting was successfully performed after multiple attempts to deliver a wire distal to the CTO. After sequential balloon predilation, a drug-eluting stent was deployed, resulting in full reperfusion of the kidney. The patient’s blood pressure improved dramatically, and patency of the stent was demonstrated with magnetic resonance angiography over 9 months after the procedure.     

Renal Artery Stenosis Presenting with Status Epilepticus: A Report of One Case

In children, renal artery stenosis is an uncommon but important cause of secondary hypertension. In this report, the authors describe a 5-year-old boy with no history of seizures who experienced status epilepticus. Postictal blood pressure, relative hypotension, was misinterpreted as normal on the day of admission. Two days later, his blood pressure rose gradually and peripheral plasma renin activity showed more than 1,700 micro U/mL. Magnetic resonance angiography suggested renal artery stenosis. After successful percutaneous transluminal angioplasty, the patient was seizure-free and had well-controlled blood pressure. This case describes renal artery stenosis present with status epilepticus, and emphasizes the importance of serial measurements of blood pressure in children.     

对照CTA评价SLEEK序列显示高血压患者肾动脉及其病变的能力

目的评估多翻转脉冲空间标记技术的非对比剂增强磁共振血管成像序列(non-contrast enhanced magnetic resonance angiography spatial labeling with multiple inversion pulses,NCE-MRA SLEEK)对肾动脉及肾动脉病变的显示能力。材料与方法收集中南大学湘雅医院2015年7月至2016年8月行NCE-MRA SLEEK检查的高血压患者,NCE-MRA SLEEK显示肾血管及肾血管病变的能力由两名副主任医师进行评估。所有患者接受SLEEK后10 d内行CT血管造影(CT angiography,CTA)检查,以CTA显示肾动脉的结果为对照来评估NCEMRA SLEEK显示肾血管及肾血管病变的准确性。结果 52例患者中共有46例接受了CTA和NCE-MRA SLEEK两项检查。NCE-MRA SLEEK显示了109根肾动脉(CTA:114根),其中正常肾动脉77根(CTA:82根),肾动脉狭窄(renal artery stenoses,RAS)28根(CTA:26根),肌纤维发育不良4根(CTA:6根);在显示肾动脉分支方面,NCE-MRA SLEEK则明显优于CTA(P0.05)。NCE-MRA SLEEK与CTA在评估RAS程度方面具有很好的相关性(Rs=0.85,P=0.001)。结论 NCEMRA SLEEK能较好地显示肾动脉及准确评价肾动脉狭窄,比CTA能更加清晰地显示肾动脉分支,它可以替代CTA成为筛查肾动脉病变的一种有效检查方法。     

DIgital intravenous subtraction angiography for investigating renovascular hypertension: comparison with hypertensive urography

We used digital intravenous subtraction angiography (DSA) to evaluate 105 patients with suspected renovascular hypertension. Unilateral renal artery stenoses were identified in 14 patients, two of whom had previously had contralateral nephrectomy. In addition, one of three renal transplant recipients was found to have stenosis of the nutrient artery. Bilateral renal artery stenosis was demonstrated by DSA in three patients. Of the 88 patients who had concomitant minute sequence (hypertensive) urography (HIVP) delayed excretion suggested a renal artery lesion in only 8 patients. In the group of 88 patients, HIVP was able to detect renal artery stenosis in only 50% (eight of the 16) of patients whose stenosis was detected by DSA. When the patients with a single kidney are excluded, HIVP showed 62% (eight of 13) of the lesions detected by DSA. There were no significant complications in the patients examined by either modality. DSA has replaced HIVP as the screening examination for renovascular causes of hypertension in our institution.     

肾移植后血管并发症介入治疗8例

背景:肾移植后血管并发症采用介入治疗已成为一种安全有效的治疗方法。目的:探讨肾移植后血管并发症介入治疗的经验及价值评估。方法:回顾性分析8例肾移植后血管并发症患者介入治疗的临床资料。结果与结论:8例移植后5例肾移植肾动脉狭窄,2例假性动脉瘤,1例肾静脉血栓,均经彩色多普勒血流显像作出初步诊断,其中5例进一步行磁共振血管成像明确诊断。5例移植肾动脉狭窄行球囊扩张,分别随访6,8,20,36,40个月,1例出现再狭窄,随访血肌酐维持在130~160μmol/L之间,其余4例移植肾狭窄无复发,随访血肌酐均正常。2例假性动脉瘤患者经动脉鞘放入支架释放系统释放带膜支架后动脉瘤消失,目前常规血液透析治疗。1例肾静脉血栓形成患者,尿激酶介入溶栓治疗后血栓消失,患者发生移植肾功能延迟恢复,35d后血肌酐降至210μmol/L,此后患者血肌酐维持在200～250μmol/L。8例介入治疗临床效果说明肾移植后血管并发症治疗可选用介入治疗方法。     

Diagnostic strategy in suspected renovascular hypertension

iv-DSA is an excellent method for detecting suspected stenosis of the renal arteries. In essential hypertension among 19 patients a frequency of 15.8% was found, in patients with accelerated hypertonus (n = 23) the percentage of renal artery stenosis was twice this rate (30.4%). In case of a positive or unclear outcome of iv-DSA, intraarterial angiography with ever ready PTRA is advisable.     

Pheochromocytoma and fibromuscular hyperplasia

We have described a case which documents two possible surgical correctable causes for hypertension in a 55-year-old white man. Preoperative renal arteriograms and renal vein renin determinations suggested the possibility of renal artery stenosis due to fibromuscular hyperplasia. At operation, a pheochromocytoma was found in the left suprarenal area. The presence of two unusual causes for hypertension in a single patient suggests that more than one remediable cause of hypertension should at least be considered in a given hypertensive patient.     

Doppler ultrasound for post-angioplasty follow-up in pediatric segmental branch renal artery stenosis: A case report

IntroductionSegmental branch renal artery stenosis is an important cause of renovascular hypertension in the pediatric population that is often managed with angioplasty and may require imaging multiple times pre- and post-procedure. Gold standard imaging is angiography, which exposes children to radiation and intravenous contrast. There is not a clear guideline for imaging during follow-up, but patients are monitored for symptom recurrence, which could then trigger repeat imaging. The following case highlights a method of follow-up that has not been broadly studied that may offer benefits over clinical monitoring alone, and how interprofessional cooperation could offer effective surveillance and reassurance for families through a cost-effective method that minimizes potential for harm.Case and outcomesThis report describes the clinical course of a child with hypertension secondary to segmental branch renal artery stenosis who was treated with angioplasty and who received follow-up imaging with renal Doppler ultrasound. This method allows the care team to ensure stability of the caliber of the repaired vessel and non-recurrence of stenosis at follow-ups through monitoring for intra-arterial velocity and waveform changes.DiscussionClose follow-up of children with renal artery stenosis is vital following intervention due to high risk of recurrence. Clinical follow-up alone could be sufficient for some patients, however many still require CTA, sometimes even more than once, when symptoms worsen or there is evidence of end-organ damage. During follow-up, collaboration with skilled sonographers to monitor post-repair velocities and waveforms using Doppler ultrasound presents several possible advantages. This includes providing reassurance to patient families, minimizing harmful radiation and contrast exposure, and the potential for early detection of recurrence of stenosis. Especially in cooperative, older pediatric patients with a normal BMI who have a main renal artery stenosis or even in those with a segmental branch stenosis identified through CTA such as in this case.ConclusionThis case demonstrates how coordination with sonographers and the use of ultrasound with Doppler could improve the follow-up of pediatric patients with segmental branch renal artery stenosis post-angioplasty to provide further reassurance to families, minimize harm to patients, and ensure post-procedure stability beyond just clinical parameters.     

256层螺旋CT血管成像术前评价肾癌肾动脉解剖及肿瘤供血动脉

目的 采用256层MSCTA观察肾癌患者肾动脉解剖及肿瘤供血动脉情况,为肾癌患者术前评估提供影像学信息。方法 回顾性分析56例经手术后病理确诊的肾癌患者(肾癌组)及300例非肾癌患者(对照组)肾动脉CTA资料,采用VR及MPR技术重建肾动脉图像,观察肿瘤供血动脉形态改变、肿瘤与肾动脉空间解剖关系及肿瘤肾外迷走供血动脉情况;比较肾癌组及对照组肾动脉解剖及变异差异。结果 肾癌组肿瘤位于左肾者31例、位于右肾者24例、双肾癌1例,肿瘤最大径(5.86±2.48)cm;肾动脉主干及分支、肾盂、肾静脉呈各种受压、受侵改变;患侧肾动脉直径分别为左侧(7.14±0.72)mm、右侧(7.04±0.70)mm,较对照组 明显增粗(P<0.05);共发现肿瘤肾外迷走供血动脉27支,分别来自脾动脉、肠系膜下动脉、膈下动脉、肾包膜动脉、肝动脉、腰动脉及肠系膜上动脉。肾癌组肾动脉变异率与对照组比较差异无统计学意义     

Usefulness of the fusion imaging of 3D-CT and MRA for carotid artery stenting with minimum use of contrast medium in patient with renal dysfunction

Patients with severe internal carotid artery (ICA) stenosis with multiple medical problems generally undergo carotid artery stenting (CAS). However, it is difficult to perform CAS in some patients because iodinated contrast medium is hard to use. We report a patient with asymptomatic ICA stenosis and chronic renal failure, in whom successful treatment was achieved using CAS with minimal use of iodinated contrast medium. A 68-year-old man with severely chronic renal failure was consulted for treatment of left ICA stenosis. Magnetic resonance angiography (MRA) and carotid echography revealed left ICA severe stenosis, and systemic non-contrast MRA showed left femoral artery constriction, but right femoral artery to be intact. CAS was therefore performed through the right femoral artery, using non-contrast three-dimensional computed tomography (3D-CT) with MRA fusion imaging, intravascular ultrasonography, and a small amount of iodinated low-osmolar contrast medium. Postoperative course was uneventful with no aggravation of renal dysfunction, and he was discharged 7 days postoperatively. These techniques are very useful for patients with chronic renal failure, and this present case represents the first report of CAS treated by using non-contrast 3D-CT with MRA fusion image technique.     

Pharmacologic nephrectomy with chronic angiotensin converting enzyme inhibitor treatment in renovascular hypertension in the rat

Angiotensin converting enzyme (ACE) inhibitor treatment in renovascular hypertension is associated with acute compromise of renal function in patients with bilateral renal artery stenosis or with arterial stenosis to a single functioning kidney. Recent evidence has suggested that renal function is also compromised in the stenosed kidney of patients with unilateral renal artery stenosis. The long-term consequence of this reduction in renal function is not known. We have studied the effect of chronic ACE inhibition with enalapril on renal structure and function in rats with the two-kidney one-clip model of renovascular hypertension. Four weeks after placement of a clip on the left renal artery, hypertensive rats were randomized to treatment with enalapril, minoxidil, or to a no treatment group. Twelve months later split kidney function was determined by chromium 51-labeled ethylenediamine-tetraacetic acid clearance in surviving rats. Clearance of the clipped kidney was 0.0 ml/min (enalapril group), 0.26 +/- 0.23 ml/min (minoxidil group), and 0.74 +/- 0.13 ml/min (untreated group). The clipped kidney from the enalapril treated rats weighed much less than the minoxidil group or the untreated group (0.46 +/- 0.1 gm, 1.2 +/- 0.07 gm, and 1.14 +/- 0.10 gm, respectively). Enalapril treatment was stopped for 2 weeks in five rats. The clipped kidney remained small and nonfunctional. Histologic examination revealed marked interstitial fibrosis and tubular atrophy of the clipped kidneys from the enalapril treated group in contrast to minor changes in the minoxidil treated and untreated groups. After 12 months of treatment, survival in the enalapril group was 84%, 48% in the minoxidil group, and 15% in the untreated group.(ABSTRACT TRUNCATED AT 250 WORDS)     

早期慢性肾病患者血管内皮功能及肾脏病理相关性研究

目的：研究早期慢性肾病患者的血管内皮功能损害程度及其与肾脏病理损伤的关系。方法：60例研究对象分为3组：A组为20例正常对照组;B组为20例早期慢性肾病患者血压正常组;C组为20例早期慢性肾病患者肾性高血压组。对各组患者应用高频超声检测肱动脉充血前后管径变化率,评价早期慢性肾病患者血管内皮功能损害程度。对病例组行超声引导下穿刺活检,并对肾组织损伤程度行半定量积分,分析血管内皮功能与年龄、血压、肾脏病理损伤的关系。结果：①C组血流介导的血管舒张功能（Flow-mediated dilation,FMD）低于A组和B组（P＜0.05）,A组与B组之间FMD无差异性（P＞0.05）;②FMD与收缩压、肾小球损伤积分、肾间质损伤积分有相关性（P＜0.05）,与年龄、舒张压无相关性（P＞0.05）。结论：①肾性高血压患者在肾功能损害之前已经存在血管内皮功能的异常;②血管内皮功能紊乱对肾脏的病理损伤有一定的促进作用;③高频超声早期检测慢性肾病患者的血管内皮功能有重要的临床意义。     

彩色多普勒超声在肾动脉狭窄诊断中的应用

目的评价彩色多普勒超声对肾动脉狭窄（ARAS）的诊断指标及准确性。方法 1999年10月2008年12月对患有高血压病的58例共113根肾动脉进行彩色多普勒超声检查。每例患者均测量肾动脉峰值流速（PSV）与肾内段动脉的阻力指数及肾脏长轴。在双盲条件下,以患者肾动脉造影、MRI血管造影及CT血管造影为标准,评价彩色多普勒超声诊断ARAS的诊断指标及准确性。结果彩色多普勒超声诊断肾动脉狭窄的敏感性为60%,特异性为83%,阳性预测值为83%,阴性预测值为61%。患侧肾长轴小于健侧肾长轴,患侧肾峰值流速高于健侧肾峰值流速,患侧肾阻力指数低于健侧肾阻力指数。结论肾动脉彩色多普勒超声对于肾动脉狭窄初筛诊断以及评价肾动脉狭窄介入治疗后的近、远期疗效,是一种简便可靠的无创检查手段。