Outcomes of carotid artery stenting at a high-volume Brazilian interventional neuroradiology center

OBJECTIVES:

Carotid artery stenting is an emerging revascularization alternative to carotid endarterectomy. However, guidelines have recommended carotid artery stenting only if the rate of periprocedural stroke or death is < 6% among symptomatic patients and < 3% among asymptomatic patients. The aim of this study is to evaluate and compare clinical outcomes of symptomatic and asymptomatic patients who had undergone carotid artery stenting as a first-intention treatment.

METHOD:

A retrospective analysis of patients who underwent carotid artery stenting by our interventional neuroradiology team was conducted. Patients were divided into two groups: symptomatic and asymptomatic patients. The primary endpoints were ipsilateral ischemic stroke, ipsilateral parenchymal hemorrhage and major adverse cardiac and cerebrovascular events at 30 days. The secondary endpoints included ipsilateral ischemic stroke, ipsilateral parenchymal hemorrhage, ipsilateral transient ischemic attack and major adverse cardiac and cerebrovascular events between the 1- and 12-month follow-ups.

RESULTS:

A total of 200 consecutive patients were evaluated. The primary endpoints obtained in the symptomatic vs. asymptomatic groups were ipsilateral stroke (2.4% vs. 2.7%, p = 1.00), ipsilateral parenchymal hemorrhage (0.8% vs. 0.0%, p = 1.00) and major adverse cardiac and cerebrovascular events (4.7% vs. 2.7%, p = 0.71). The secondary endpoints obtained in the symptomatic vs. asymptomatic groups were ipsilateral ischemic stroke (0.0% vs. 0.0%), ipsilateral parenchymal hemorrhage (0.0% vs. 0.0%), ipsilateral TIA (0.0% vs. 0.0%, p = 1.00) and major adverse cardiac and cerebrovascular events (11.2% vs. 4.1%, p = 0.11).

CONCLUSIONS:

In this retrospective study, carotid artery stenting was similarly safe and effective when performed as a first-intention treatment in both symptomatic and asymptomatic patients. The study results comply with the safety requirements from current recommendations to perform carotid artery stenting as an alternative treatment to carotid endarterectomy.     

经颅多普勒超声诊断颅内段后循环动脉狭窄或闭塞的应用价值

目的 探讨经颅多普勒超声（TCD）诊断颅内段后循环动脉狭窄或闭塞的敏感性和特异性.方法 选取颅内段后循环动脉狭窄或闭塞的患者72例,进行TCD和CT血管造影术（CTA）检查,并进行对比分析.结果 与CTA相比,TCD对颅内段后循环动脉检查的敏感性为82.50％,特异性为94.64％,阳性预测值为91.67％,阴性预测值为88.33％,准确性为89.58％.结论 TCD对颅内段后循环动脉病变的诊断特异性高,敏感性一般,其中对颅内段椎动脉的诊断准确性最高.TCD可作为颅内动脉病变的早期筛查手段.     

冠状动脉金属支架术后再狭窄的研究进展

金属支架在冠状动脉疾病介入治疗中发挥着越来越重要的作用,再狭窄是困扰这一技术发展的主要原因之一,目前随着对其产生机理的逐渐明了,有关再狭窄防治研究日益活跃,并取得了令人瞩目的成绩。最新研究显示,药物涂层支架在预防再狭窄中较裸支架具有独特的应用价值,大大降低了再狭窄发生率,应用前景广阔,但远期疗效尚待进一步观察。     

支架置入术治疗颈动脉狭窄的临床研究

目的 观察颈动脉支架植入治疗颈动脉狭窄的疗效及其安全性。方法 72例颈动脉狭窄患者进行了经皮腔内血管成形和支架植入术治疗。结果 所有患者均经DSA血管造影汪实有颈内动脉狭窄，手术成功率100％，治疗后残余狭窄率均低于30％：72例患者中有2例出现可逆性小卒中；3例出现术中球囊扩张时对侧肢体局灶性癫痫发作；3例血管痉挛；25例出现低血压、心动过缓；1例出现术后高灌注综合征；5例出现其它部位出血。结论 血管内支架成形术是一种治疗颈动脉狭窄安全有效的方法，提高术者操作技巧及围手术期监护可以降低手术并发症和死亡率，提高安全性。     

肾动脉支架植入术治疗肾动脉狭窄疗效及安全性评价探讨

目的分析和探讨肾动脉支架植入术治疗肾动脉狭窄的疗效和安全性。方法选取80例肾动脉造影提示单侧或双侧肾动脉狭窄≥50%的患者,随机分为对照组和治疗组各40例。对照组采用内科保守治疗,治疗组在此基础上加植入肾动脉支架治疗。结果 40例治疗组支架放置位置准确,肾动脉血液循环良好,无夹层残余和狭窄,支架通畅率100%。血压治愈总有效率为95%;对照组血压治愈总有效率为55%,两组患者血压改善例数比较差异具有统计学意义(P0.05)。治疗组患者肾功能治愈率75%,对照组患者肾功能治愈率40%,两组患者肾功能改善比较差异具有统计学意义(P0.05)。结论肾动脉支架置入术临床疗效肯定,手术成功率高,安全有效。     

两侧肾静脉肾素比值评价肾动脉支架植入术治疗单侧肾动脉狭窄

目的探讨肾静脉肾素活性及患侧肾静脉肾素与对侧肾静脉肾素的比值（RVRR）对肾动脉狭窄介入治疗高血压疗效的预测价值。方法72例合并高血压的肾动脉狭窄，根据术前RVRR水平分为≥1．5组（51例）和RVRR〈1．5组（21例）。予肾动脉支架植入术（PTRA），手术前后测定肾静脉肾素活性，并对患者进行1年的随访。结果RVRR≥1．5组PTRA后3个月、6个月及1年对高血压治疗无效率分别为3．92％、2．0％及2．0％。但RVRR〈1．5组均高达76．2％。结论对于单侧肾动脉狭窄患者，肾静脉肾素水平及RVRR对预测PTRA治疗高血压的疗效有重要价值。     

颈动脉狭窄合并糖尿病患者的护理体会

目的：分析颈动脉狭窄合并糖尿病患者的护理方法。方法通过对21例颈动脉狭窄合并糖尿病患者进行综合护理,总结颈动脉狭窄合并糖尿病患者的护理措施。结果21例患者均未出现并发症,正常出院。结论综合护理对预防颈动脉狭窄合并糖尿病患者发生并发症具有重要作用。     

肾动脉硬化性狭窄的预测模型研究

目的:探讨动脉硬化性肾动脉狭窄(ARAS)的独立危险因素及预测因子,建立在冠心病(CAD)患者中筛查ARAS的预测模型。方法:选择经肾动脉造影确诊的ARAS患者232例为ARAS组,263例无ARAS者为对照组,记录动脉硬化危险因素,测定血糖、血脂、肌酐等指标,计算内生肌酐清除率(Ccr)。采用Logistic回归分析ARAS的独立预测因子,构建筛查ARAS的预测模型,以接收者操作特征曲线(ROC)分析模型的预测价值。结果:老龄(Age,≥65岁)、糖尿病(DM)、难治性高血压(RH)、Ccr降低(≤90ml/min)是ARAS的独立预测因子,Logistic回归方程为P/(1-P)=EXP(-1.87+1.17Age+1.87RH+0.58DM+0.70Ccr),预测ARAS的最佳概率值是0.41(敏感度78.4%,特异度71.1%),ROC曲线下面积为0.80。结论:年龄≥65岁、DM、RH、Ccr降低是CAD患者并发ARAS的独立预测因子,由这些独立预测因子拟合的预测模型可用于在CAD患者中筛查ARAS。     

Renovascular disease is associated with low producer genotypes of the anti-inflammatory cytokine interleukin-10

Cytokines are important mediators of inflammatory and proliferative responses in disease states including atherosclerosis. Genetic variations in cytokine production could potentially influence the outcome of these responses. The aim of this study was to determine whether cytokine gene polymorphism might influence the development of atherosclerotic renal artery stenosis. Sixty-six patients with atherosclerotic renal artery stenosis and 100 normal healthy individuals were genotyped for interleukin-10 (IL-10), tumor necrosis factor-alpha (TNF-alpha), IL-6, and IL-2 promoter region polymorphism. TNF-a, TNF-d, and IL-10 microsatellite polymorphisms were also analyzed. The frequency of the anti-inflammatory cytokine IL-10 promoter (-1082 A positive) GA and AA genotypes which are associated with low production were higher in the patient group when compared to the control group. The AA-TT-AA homozygous genotype combination of three single-nucleotide polymorphisms at -1082, -819, and -592 in the IL-10 gene was also observed at a higher frequency in the patient group compared to the controls. The frequency of TNF-alpha, IL-6, and IL-2 polymorphisms did not show any significant difference between the patient and control groups. To correlate IL-10 genotypes with differences in IL-10 protein expression, in vitro mRNA and protein levels were analyzed in lipopolysaccharide-stimulated peripheral blood mononuclear cells from 22 patients with renal artery stenosis and 33 controls. Individuals genotyped as A positive at position -1082 produced lower levels of IL-10 protein and had lower copy numbers of mRNA when compared to individuals genotyped as A negative in both patient and control groups. The increased frequency of the low producer IL-10 promoter, -1082 A-positive genotype in patients with renal artery stenosis, suggests that IL-10 may protect against the development of atherosclerotic renovascular disease.     

Lp-PLA2的检测在冠状动脉狭窄患者中的临床意义

目的探讨血浆脂蛋白相关性磷脂酶A2(LP-PLA2)水平与冠状动脉不同分支狭窄的关系,进一步分析LP-PLA2水平的检测在冠心病患者中的临床意义。方法本次研究共包括268例患者,根据经皮冠状动脉造影术(CAG)结果分组为,对照组(无狭窄),粥样硬化组(主要冠脉分支狭窄≤50%,≥20%),单支病变组(单支狭窄>50%),双支病变组(双支狭窄>50%)和三支病变组(三支或以上狭窄>50%)。采用横断面分析LP-PLA2以及高密度脂蛋白C(HDL-C)、低密度脂蛋白(LDL-C)、总胆固醇(CHOL)、甘油三酯(TG)、载脂蛋白B(ApoB)、载脂蛋白A1(ApoA1)、葡萄糖(GLU)、尿酸(BUA)等生化指标和患者基本情况与冠状动脉狭窄的关系。结果经单因素分析,与对照组比较冠心病传统因素高血压、GLU、HDL-C、ApoA1、BUA或从粥样硬化组,或从单支病变组、双支病变组、三支病变组开始与冠状动脉狭窄相关(P <0.05),而LP-PLA2从单支病变组开始与冠状动脉狭窄显著相关(P <0. 01);通过比较各组间LP-PLA2水平发现,随着冠状动脉病变支数增加Lp-PLA2显著增加(P<0.01),而双支病变组与三支病变组比较其值变化不明显(P>0.05);进一步多元回归分析发现,从单支病变开始LP-PLA2与冠状动脉狭窄独立相关,OR值1.013,95%CI(1.006,1.020),<0.01。结论从冠状动脉单支变化开始LP-PLA2显著增加,并且与冠状动脉狭窄独立相关,因此检测LP-PLA2对冠状动脉狭窄患者病情的评估有重要的临床意义。     

Hyperemic versus non-hyperemic indexes for coronary physiology assessment in patients with severe aortic stenosis

PurposeRecent data suggests that fractional flow reserve (FFR) may underestimate intermediate coronary stenosis in the presence of severe aortic stenosis (AS), whereas instantaneous wave-free ratio (iFR) values may remain similar after treatment of AS, yet the evidence still lacks to use iFR as the reference. We aimed to compare FFR/iFR values in the AS setting.Materials and methodsThe functional significance of 416 coronary lesions in 221 patients with severe AS was investigated with iFR and FFR.ResultsThe diagnostic agreement between iFR and FFR has been tested, using the cut-off value of 0.89 for iFR and 0.80 for FFR. The mean diameter stenosis was 58.6 ​± ​13.4% with FFR of 0.85 ​± ​0.07 and iFR of 0.90 ​± ​0.04. FFR ≤0.80 was identified in 26.0% and iFR≤0.89 in 33.2% of interrogated vessels. Good agreement between iFR and FFR was confirmed (Intraclass Correlation Coefficient 0.83 [95%CI 0.79-0.85]). The overall diagnostic accuracy (AUC in ROC analysis) of FFR in detecting iFR≤0.89 was 0.997 (95%CI 0.986 to 1.000; p<0.001) and of iFR in detecting FFR≤0.80 was 0.995 (95%CI 0.983 to 0.999; p<0.001). The optimal cut-off value for FFR to detect iFR≤0.89 was 0.82 with sensitivity, specificity, and accuracy of 97.1%, 98.9%, and 97.7%, respectively, and for IFR to detect FFR≤0.80 was 0.88 with sensitivity, specificity, and accuracy of 99.1%, 95.8%, and 97.4%, respectively.ConclusionIn the presence of AS, FFR has good agreement with iFR. However, the optimal FFR/iFR threshold to identify iFR≤0.89/FFR≤0.80 may be different from the standard thresholds of ischemia.     

Influence of hypoxia on hepatic and renal endothelin gene expression

This study aimed to investigate the influence of different forms of tissue hypoxia on the expression of the endothelin genes in kidneys and livers. Tissue hypoxia in rats was induced by five different manoeuvres, namely hypoxia (8% O₂), functional anaemia (0.1 % CO), haemorrhage (haematocrit, hct = 0.12), cobalt treatment (60 mg/kg) for 6 h each and renal artery stenosis (0.2-mm clips) for 2 days. Endothelin-1 (ET-1) mRNA levels in the kidneys were increased by 200% with renal artery stenosis, 70% by hypoxia, 50% by anaemia, 30% by CO, but were not changed by cobalt. ET-3 mRNA in the kidneys decreased during renal artery clipping and cobalt treatment and were not significantly changed under the other conditions. ET2 mRNA was not detected in the kidneys and livers. The abundance of ET-1 in the livers of normoxic animals was about 15% of that found in the kidney. Hypoxia increased ET-1 mRNA by 200%, haemorrhage by 400%, whilst CO and cobalt did not change hepatic ET-1 gene expression. The abundance of ET-3 mRNA in the livers of normoxic animals was about 6% of that found in the kidneys. The expression of the ET-3 gene in the livers was decreased by CO, but was not changed by any of the other experimental conditions used. These findings suggest that hypoxaemia and tissue hypoxia are moderate stimuli for the expression of the ET-1 gene but not for the ET-3 gene in the kidney and more potent stimuli in the liver, whilst cobalt does not activate ET-1 gene expression in the kidneys nor the livers.     

Renal findings in 40 individuals with Williams syndrome

We tabulated the frequency of renal abnormalities in 40 Williams syndrome individuals presenting for medical and/or developmental assessment to a multi-disciplinary Williams syndrome program. The average age at time of assessment was 7²/12 years. Seven individuals (7/40 = 18%) had abnormalities detected, including nephrocalcinosis = 2; marked asymmetry in kidney size = 2; small kidneys = 1; solitary kidney = 1; and pelvic kidney = 1. Renal function was also assessed. Two individuals had evidence of renal dysfunction, one secondary to nephrocalcinosis and the second due to hypercalcemia and interstitial nephritis of unclear pathogenesis. We examined the frequency of renal artery stenosis in 9 individuals who underwent abdominal angiography during cardiac catheterization. We found unilateral or bilateral mild renal artery narrowing in 4 individuals and normal renal arteries in the remaining 5. Persistent hypertension occurred in only 2 individuals and did not correlate with renal artery status. We conclude that intrinsic renal anomalies, as well as problems secondary to hypercalcemia, occur with sufficient frequency to warrant baseline renal screening in all individuals with Williams syndrome. © 1993 Wiley-Liss, Inc.     

Left main renal artery entrapment by diaphragmatic crura: spiral CT angiography

Entrapment of renal artery by the diaphragmatic crus is a rare cause of renal artery stenosis. Spiral computed tomography angiography provides a definitive diagnosis and shows the precise relationship of the artery to the diaphragmatic crus. The authors present a case of hypertension developing in a young 20-year-old female due to entrapment of the left renal artery by the diaphragmatic crus. This condition should be considered in young hypertensive patients with renal artery stenosis without cardiovascular risk factors.     

幽门螺杆菌感染与轻度颈动脉狭窄患者OGTT水平的关联分析

目的 分析幽门螺杆菌感染与轻度颈动脉狭窄患者OGTT水平的关联.方法 选取颈动脉轻度狭窄患者105例,根据感染情况分为幽门螺杆菌感染组和非幽门螺杆菌感染组.分析幽门螺杆菌感染与轻度颈动脉狭窄患者OGTT水平的关联,应用SPSS 20.0进行分析.结果 OGTT实验中2组患者摄入葡萄糖后0.5h血糖水平达到最高峰值,然后开始下降,摄入葡萄糖后1h的血糖水平感染组显著高于非感染组(P＜0.05).胰岛素水平也是空腹水平较低,在摄入葡萄糖后0.5h水平达到最高峰值,然后开始下降,2组在5个时间点的胰岛素水平差异均有统计学意义(P＜0.05).C肽水平也是空腹水平较低,在摄入葡萄糖后0.5h水平达到最高峰值后下降.比较2组患者OGIT检测结果中的C肽水平在空腹状态下差别无统计学意义,摄人葡萄糖后检测的4个时间点差异均有统计学意义(P＜0.05).结论 Hp感染的患者糖代谢开始1h左右血糖水平与无Hp感染者的情况差别有统计学意义.在Hp感染的患者基础胰岛素水平值就较高,随着摄人葡萄糖以及糖代谢的开始,始终存在胰岛素水平高于无Hp感染者的情况.Hp感染的患者基础C肽水平值与非感染患者相当,随着摄人葡萄糖以及糖代谢的开始,始终存在C肽水平高于无Hp感染者的情况.     

肾动脉狭窄对心肌内去甲肾上腺素的含量及血压的影响

本文研究了35只京都种大白鼠(WKY)肾动脉狭窄手术后对心肌内去甲肾上腺素(NA)含量及血压的影响,发现左肾动脉狭窄(2K1C)型与右肾切除后再作左肾动脉狭窄(1K1C)型心肌内NA含量在实验组都低于对照组,而血压则高于对照组,两者有统计学意义。实验组(或对照组)心肌内NA含量在2K1C型都高于1K1C型,两者有显著性差异,但血压则2K1C型低于1K1C型。     

Duplexsonography in the diagnosis of renovascular hypertension

Summary Duplexsonography (DS) has become a well established method for diagnosing peripheral vascular diseases. Technical developments (higher resolution of transducer and deeper penetration) have made also abdominal and retroperitoneal vessels, including renal arteries, accessible for duplexsonography. This method provides the opportunity to recognize renal artery stenoses causing renovascular hypertension without invasive procedures. We therefore examined 86 hypertensive patients with a high likelihood of renovascular hypertension. Due to technical problems (bowel gas, adipositas) we excluded 7 patients. 79 patients (17–79 years) were included in our study. Flow patterns of several renal vascular areas were evaluated while the renal artery was demonstrated on a B-scan. A spectrumanalysis included the evaluation of the frequency pattern (widening of the frequency band and loss of a frequency free window below the systolic rise?), the sloping of the diastolic shoulder, and the calculation of different parameters like accelerationindex, decelerationindex, resistanceindex, accelerationtime, and systolic peak velocity. The accuracy of DS in diagnosing renal artery stenoses was compared with arterial digital substraction angiography (DSA).Renal artery stenoses was diagnosed in 21 out of 158 renal arteries (13%). Except for the systolic peak velocity no significant correlations could be found of any of the indices from spectrumanalysis with hemodynamically significant stenoses (>50%). However, the following 3 criteria proved to be valuable signs of a hemodynamically significant stenoses: 1) Maximal systolic accelaration >3 m/s, 2) Steep sloping diastolic shoulder, and 3) Turbulence of all frequency ranges without a frequency free window below the systolic rise.Compared with DSA the sensitivity of DS was 84,0%, the specificity was 98,5%, and the predictive value 91% in significant stenoses. Abdominal DS seems to be a potent noninvasive method in diagnosing renal artery stenoses with a good sensitivity and a high specifity and a high predictive value.Abbrevations DSA arterial Digital substraction angiography Herrn Prof. Dr. med. W. Seitz zum 85. Geburtstag gewidmet.