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。     

The benefit of STent placement and blood pressure and lipid-lowering for the prevention of progression of renal dysfunction caused by Atherosclerotic ostial stenosis of the Renal artery. The STAR-study: rationale and study design

BACKGROUND: Atherosclerotic renal artery stenosis (ARAS) is associated with progressive loss of renal function and is one of the most important causes of renal failure in the elderly. Current treatment includes restoration of the renal arterial lumen by endovascular stent placement. However, this treatment only affects damage caused by ARAS due to the stenosis and ensuing post-stenotic ischemia. ARAS patients have severe general vascular disease. Atherosclerosis and hypertension can also damage the kidney parenchyma causing renal failure. Medical treatment focuses on the latter. Lipid-lowering drugs (statins) could reduce renal failure progression and could reduce the overall high cardiovascular risk. The additional effect on preserving renal function of stent placement as compared to medical therapy alone is unknown. Therefore, the STAR-study aims to compare the effects of renal artery stent placement together with medication vs. medication alone on renal function in ARAS patients. METHOD: Patients with an ARAS of > or = 50% and renal failure (creatinine (Cr) clearance < 80 mL/min/1.73 m2) are randomly assigned to stent placement with medication or to medication alone. Medication consists of statins, anti-hypertensive drugs and antiplatelet therapy. Patients are followed for 2 yrs with extended follow-up to 5 yrs. The primary outcome of this study is a reduction in Cr clearance > 20% compared to baseline. This trial will include 140 patients.     

Prevalence and predictors of renal artery stenosis in patients undergoing peripheral and coronary angiography

Background

Renal artery stenosis is a potential cause of secondary hypertension, ischemic nephropathy and end-stage renal disease. Atherosclerosis is by far the most common etiology of renal artery stenosis in elderly. We investigated whether the presence of significant atherosclerotic renal artery stenosis (ARAS) with luminal diameter narrowing ≥50 % could be predicted in patients undergoing peripheral and coronary angiography.

Methods

The records of 3,500 consecutive patients undergoing simultaneous renal angiography along with peripheral and coronary angiography were reviewed. The patients with known renal artery disease were excluded.

Results

Prevalence of ARAS was 5.7 %. Significant ARAS (luminal diameter narrowing ≥50 %) was present in 139 patients (3.9 %). Hypertension with altered serum creatinine and triple-vessel CAD were associated with significant renal artery stenosis in multivariate analysis. No significant relationship between the involved coronary arteries like left anterior descending, left circumflex, right coronary artery and ARAS was found. Only hypertension and altered serum creatinine were associated with bilateral ARAS. Extent of CAD or risk factors like diabetes, hyperlipidemia or smoking did not predict the unilateral or bilateral ARAS.

Conclusion

Prevalence of ARAS among the patients in routine cardiac catheterization was 5.7 %. Hypertension is closely associated with significant ARAS. Significant CAD in the form of triple-vessel disease and altered renal function tests are closely associated with ARAS. They predict the presence of significant renal artery stenosis in patients undergoing routine peripheral and coronary angiography. Moreover, hypertension and altered renal functions predict bilateral ARAS.     

Revascularization for atherosclerotic renal artery stenosis: the treatment of choice?

Atherosclerotic renal artery stenosis (ARAS) is an important cause of renal dysfunction and secondary hypertension, and is associated with adverse cardiovascular events and increased mortality. The natural history of ARAS is characterized by anatomic disease progression and/or renal dysfunction in only a minority of patients. Medical therapy for ARAS is directed primarily toward blood pressure control and cardiovascular risk factor reduction. Renal artery revascularization is an additional treatment option for ARAS associated with ischemic nephropathy or severe, poorly controlled hypertension despite aggressive medical therapy. Unfortunately, the benefits associated with revascularization versus medical therapy alone remain unproven. Renal artery revascularization may be accomplished through open surgical revascularization or angioplasty and stenting. Although surgical renal revascularization is associated with more durable results and relatively lower risk for postoperative renal function decline, the increased risk of death or major complications associated with this management approach limit its use in patients with significant comorbidities. Renal artery angioplasty and stenting is being utilized with increasing frequency but is of uncertain benefit and is associated with rates of post-intervention renal function improvement and deterioration that are approximately equal. Renal function outcomes associated with angioplasty and stenting may be improved through a selective treatment approach and utilization of distal embolic protection. Renal artery revascularization represents the only treatment alternative for patients unresponsive to medical management, and is therefore the 'treatment of choice' in this select group. Results of ongoing randomized trials are eagerly anticipated and may provide useful guidance for future management of ARAS.     

Prevalence of atherosclerotic renal artery stenosis in patients starting dialysis.

BACKGROUND: Atherosclerotic renal artery stenosis (ARAS) can lead to end-stage renal failure (ESRF). We determined the prevalence of ARAS in patients 45 years of age or older starting renal replacement therapy. METHODS: Forty-nine of 80 consecutive patients (37 males, 12 females) starting renal replacement therapy in our centre gave informed consent and underwent spiral computed tomographic angiography of their renal arteries. A renal artery diameter reduction of 50% or more assessed by two radiologists was considered as a significant stenosis. RESULTS: Twenty of 49 patients (41%) had an ARAS, and in eight cases (16%) this was bilateral or unilateral with a single kidney. Women were more likely to have an ARAS than men; 75 (9/12) vs 30% (11/37, P<0.01). However, relatively more women declined participation. Non-participants and participants did not differ in respect to other relevant clinical data. Nonetheless, findings in these patients would be negative, the prevalence of ARAS would still be 31% in women and 22% in men (NS). In 13 patients with ARAS the registered diagnosis of ESRF either was hypertension, renovascular disease or unknown. Assuming that in these patients atherosclerotic renovascular disease was the cause of renal failure, a total of 13 patients (13/49, 27%) entered the dialysis programme because of this problem. CONCLUSIONS: These results suggest that ARAS is an important cause of ESRF.     

Evidence-based medicine in renal artery stenting

Atherosclerotic renovascular disease is an increasingly recognized cause of severe hypertension and declining kidney function. Patients with atherosclerotic renovascular disease have been demonstrated to have an increased risk of adverse cardiovascular events. Over the course of the last two decades renal artery revascularization for treatment of atherosclerotic renal artery stenosis (RAS) has gained great increase via percutaneous techniques. However the efficacy of contemporary revascularization therapies in the treatment of renal artery stenosis is unproven and controversial. The indication for renal artery stenting is widely questioned due to a not yet proven benefit of renal revascularization compared to best medical therapy. Many authors question the efficacy of percutaneous renal revascularization on clinical outcome parameters, such as preservation of renal function and blood pressure control. None of the so far published randomized controlled trials could prove a beneficial outcome of RAS revascularization compared with medical management. Currently accepted indications for revascularization are significant RAS with progressive or acute deterioration of renal function and/or severe uncontrollable hypertension, renal function decline with the use of agents blocking the renin-angiotensin system and recurrent flash pulmonary edema. The key point for success is the correct selection of the patient. This article summarizes the background and the limitations of the so far published and still ongoing controlled trials.     

Diagnosis and therapy of atheromatous renal artery stenosis

Atheromatous renal artery stenosis (ARAS), a lesion of systemic atherosclerotic disease, is the leading cause of stenotic lesions in the renal artery, followed by fibromuscular dysplasia, a primary abnormality of the renal artery. As a result of several clinical trails, which failed to show an additional benefit of renal revascularization to medical therapy in ARAS, the treatment of ARAS has shifted, and renal revascularization is less commonly performed for ARAS. However, it is recognized that renal revascularization benefits some patients with ARAS. Advances in imaging modalities would allow more frequent detection of ARAS in a society with a growing elderly population, a group with an increased prevalence of systemic atherosclerotic disease. Therefore, it is imperative to identify the patients with ARAS who could benefit from renal revascularization. This review presents a strategy for the treatment of ARAS based on the results of our analysis.     

Utility of computed tomographic renal angiogram in the management of childhood hypertension

The purpose of this study was to evaluate the utility of computed tomography (CT) renal angiogram (CTRA) in the management of childhood hypertension. This is a retrospective study of 24 children with clinical suspicion of renovascular disease who underwent CTRA examinations. CTRA demonstrated surgically correctable etiology of hypertension in 38% of the patients [5 with renal artery stenosis (RAS) and 4 with renal pathology]. In 5 patients, CTRA findings of RAS were confirmed by catheter angiogram. CTRA missed RAS in 1 patient in whom catheter angiogram showed beaded narrowing of the renal artery. All 6 patients with RAS had resolution of hypertension immediately after angioplasty or surgery. One patient with diffuse renal artery stenosis had an ipsilateral multicystic dysplastic kidney. In this patient hypertension resolved spontaneously as the dysplastic kidney shrunk in size. Seven patients had a renal etiology for hypertension. In 3 of these patients hypertension resolved after nephrectomy. Malignant hypertension in the 4th patient with reflux nephropathy was controlled medically after she underwent bilateral ureteral reimplantation. The remaining 3 patients with renal etiology were managed medically. We found that the etiology was central for hypertension in 4 patients with brain abnormalities, obesity in 1 overweight patient, essential hypertension in 4 patients, and thoracic aorta coarctation in 1 patient. Our study showed that in all except 1 instance CTRA could diagnose a surgically correctable cause for hypertension. CTRA provided useful information for the management of pediatric hypertension in all our patients.     

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。     

Renal Artery Stenosis: To Intervene,or Not to Intervene, “That is the Question”

Renal artery stenosis (RAS) due to atherosclerosis continues to be a major cause of secondary hypertension. It can also lead to renal dysfunction due to ischemic nephropathy. While major clinical trials have emphasized that medical management should be preferred over angioplasty and stenting for the treatment of renal artery stenosis, clinical scenarios continue to raise doubts about the optimal management strategy. Herein, we present two cases that were admitted with hypertensive emergency and renal function deterioration. Medical therapy failed to control the blood pressure and in one patient, renal failure progressed to a point where renal replacement therapy was required. Both patients underwent angioplasty (for >90% stenosis) and stent insertion with successful resolution of stenosis by interventional radiology. Postoperatively, blood pressure gradually decreased with improvement in serum creatinine. Dialysis therapy was discontinued. At 4‐ and 8‐month follow‐up, both patients continue to do well with blood pressure readings in the 132–145/70–90 mmHg range. This article highlights the importance of percutaneous interventions in the management of atherosclerotic RAS and calls for heightened awareness and careful identification of candidates who would benefit from angioplasty and stent insertion.     

Diagnostic criteria for renovascular disease: where are we now?

Renovascular disease, especially atherosclerotic renal artery stenosis (ARAS) in older subjects, is commonly encountered in clinical practice. This is at least in part due to the major advances in non-invasive imaging techniques that allow greater diagnostic sensitivity and accuracy than ever before. Despite increased awareness of ARAS, renal revascularization is less commonly performed, likely as a result of several prospective, randomized, clinical trials which fail to demonstrate major benefits of renal revascularization beyond medical therapy alone. Primary care physicians are less likely to investigate renovascular disease and nephrologists likely see more patients after a period of unsuccessful medical therapy with more advanced ARAS. The goal of this review is to revisit current diagnostic and therapeutic paradigms in order to characterize more clearly which patients will likely benefit from further evaluation and intensive treatment of renal artery stenosis.     

Fifteen years' experience of treating atherosclerotic renal artery stenosis by interventional nephrologists in India

Atherosclerotic renal artery stenosis (ARAS) is an important cause of kidney disease, accelerated hypertension (HTN), and its treatment is controversial. Our aim was to evaluate the outcomes, safety, and efficacy of percutaneous transluminal angioplasty (PTA) for ARAS. Retrospective analysis of ARAS was performed among 470 angiographies during 1995–2010. Patients with nonatherosclerotic RAS and renal transplant were excluded. We assessed preintervention and postintervention mean arterial pressure (MAP), antihypertensive medications, and renal function to classify as deteriorated (>10% increase in MAP/increase in drugs/>20% reduced GFR), improved (>10% reduced MAP/reduced drugs/>20% increased eGFR), or stabilized (<10% change in MAP/same antihypertensive drugs/<20% change in eGFR) at last follow‐up. A total of 220 subjects with mean age of 57.6 ± 10.4 years underwent PTA and/or stenting. The average follow‐up was 23.07 ± 21.2 months. Accelerated HTN, HTN onset >50 years, unexplained renal failure, and unilateral small kidney were the most common presentations. In all, 255 significant stenotic lesions in 220 patients (119 unilateral, 66 single functioning kidney, and 35 bilateral) were observed. In total, 255 PTA were performed, including 177 stenting. Technical success was seen in 220/243 (90.5%) subjects. Combined MAP and antihypertensive drugs improved in 154/220 (70%) patients. Renal function improved/stabilized in 175/220 (79.5%). Angioplasty and stenting are relatively safe and feasible tools for control of blood pressure (BP) in ARAS. Angioplasty produced improvement/stabilization of BP in 70%, and the renal function in 79.5% subjects.     

Severe renovascular hypertension in an infant with congenital solitary pelvic kidney

Renal artery stenosis (RAS) is one of the most common causes of severe arterial hypertension in infants. Its management is very difficult, especially when present in a single kidney. We report a case of severe hypertension caused by RAS of congenital single pelvic kidney in a 4-month-old boy. The patient presented with cardiorespiratory insufficiency that was first treated as acute fulminate myocarditis. Medical treatment of arterial hypertension was disappointing, as it had to be balanced between congestive cardiac failure and acute renal failure. Percutaneous transluminal angioplasty (PTA) done by coronary balloon dilatation catheters through the left axillary access was successful. Following dilatation of the renal artery, blood pressure decreased and its good control was possible by only one drug. With improved medical blood pressure control and normal growth development, the reassessment of clinical therapy options adjusted to a larger vessel size would be possible. Renovascular hypertension due to RAS in infants with a solitary kidney is difficult to control by medical treatment alone. PTA should be considered as a viable option in infants with refractory hypertension due to renal artery stenosis in a solitary kidney, since it has the potential of improving hypertension while preserving renal function.     

A review of the current treatment of renal artery stenosis.

PURPOSE: Atherosclerotic renal artery stenosis (ARAS) is associated with morbidity and mortality consequent to progressive ischemic renal failure and the cardiovascular consequences of hypertension. There is considerable uncertainty concerning the optimal management of patients with this condition. This review considers the aetiological factors and the physiologic consequences of ARAS and compares the results of clinical studies of medical and endovascular therapies on blood pressure control and preservation of renal function. RESULTS: Although, in patients with fibromuscular disease the results of percutaneous transluminal angioplasty (PTA) are clearly superior to medical therapy and surgery, in asymptomatic patients with ARAS the antihypertensive benefits and preservation of renal function of endovascular, surgical and medical therapies appear similar. In selected symptomatic patients interventions may, however, be life-saving. Surgery is generally reserved for arterial occlusions with preserved renal parenchyma and function. CONCLUSIONS: The results of larger, multicentre, randomised, controlled trials are required to clearly clarify the role of interventional therapy in asymptomatic patients.     

冠心病患者动脉粥样硬化性肾动脉狭窄的临床筛选方法研究

目的建立从临床上筛选出动脉粥样硬化性肾动脉狭窄（ARAS）的简单易行的预测公式。方法分析892例冠状动脉造影并行非选择性肾动脉造影患者的临床资料，采用单因素相关分析得出与ARAS相关的风险因素，再通过多因素Logisitc回归分析得出各风险因素之间的比例关系，根据这种比例关系建立简单的评分系统，再将评分代人患者中，分析其敏感性及特异性。结果在冠状动脉粥样硬化人群中ARAS的患病率为12．7％，风险因素为年龄、体质量指数、血肌酐、高血压病史、糖尿病病史、缺血性脑血管病病史与顽固性高血压。根据以上风险因素建立相应的评分系统，患者的评分分值由5．5分至20．5分不等。随着分值的增加，ARAS的发病率明显升高。结论本研究所建立的简单临床预测公式可以有效的对冠状动脉粥样硬化患者进行初步的筛选，为是否采取敏感度高但较为昂贵的检查进行确诊提供参考。     

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.     

动脉粥样硬化性肾动脉狭窄与良性小动脉肾硬化临床特点的差异分析

目的 分析比较动脉粥样硬化性肾动脉狭窄(ARAS)与良性小动脉肾硬化(BN)患者的临床特征，以提高对这2种疾病的认识。方法 回顾性分析82例拟诊BN患者的肾血管彩色多普勒超声及肾动脉造影检查结果，统计ARAS的发生率。比较ARAS与BN患者的年龄、性别、家族史、血压、尿蛋白排泄、血清学等指标以及眼底、心脏结构、血管形态等临床参数的差异，探讨2种疾病与各临床参数的相关关系。 结果 82例拟诊BN患者中确诊缺血性肾病(IRD)17例(20.7%)，其中13例(15.9%)为ARAS。血管彩色多普勒超声诊断符合率为89.5%(17例/19例)。ARAS组与BN组在年龄、高血压家族史、高血压病程、冠心病史、体重指数、吸烟、总胆固醇、血糖、左心室重量指数、双肾长径等的差异有统计学意义。肾血管彩色多普勒超声显示ARAS组与BN组在肾动脉与主动脉峰值流速比、收缩期峰值速度、舒张末期速度、叶间动脉阻力指数等的差异有统计学意义。结论 临床拟诊的BN患者不能排除ARAS。部分BN与ARAS临床特征相似，病史、实验室检查等只能作为初步筛查手段。血管多普勒超声诊断在临床上实用性强。肥胖、吸烟、高血脂、高血糖是ARAS的危险因素。     

Prophylactic repair of renal artery stenosis is not justified in patients who require infrarenal aortic reconstruction

Purpose: Simultaneous prophylactic repair of asymptomatic renal artery stenosis (ARAS) in patients who require infrarenal aortoiliac reconstruction is controversial. This study documents the natural history of ARAS in patients who require aortic reconstruction. Methods: Two hundred patients who required aortic reconstruction from 1985 to 1990 for indications other than hypertension or renal salvage were identified. ARAS was not repaired. Preoperative angiograms were available for 171 of 200 patients and were reviewed for renal artery stenosis. Patients were assessed for atherosclerotic risk factors, survival, preoperative and follow-up blood pressure, serum creatinine level, antihypertensive medication usage, and need for dialysis. Results: The mean duration of follow-up was 6.3 years. Twenty-four of 171 patients (14%) had preoperative unilateral 70% to 99% diameter reduction ARAS, and eight (5%) had bilateral 70% to 99% ARAS. Clinical features associated with ≥70% ARAS included coronary artery disease, increased age, and a diagnosis of hypertension (p < 0.05). Patients with ≥70% ARAS did not have a decreased 7-year survival rate (66% vs 84%; p = 0.10) but had higher systolic blood pressures (153 ± 25 vs 138 ± 30 mm Hg; p < 0.05) as well as increased numbers of antihypertensive medications at follow-up (1.1 ± 0.2 vs 0.7 ± 1; p < 0.05). The mean serum creatinine level (1.1 ± 0.3 preoperative vs 1.4 ± 0.8 mg/dl; p = NS) was not increased. One patient (0.58%) with polycystic kidney disease and minimal renal artery stenosis required dialysis. Conclusions: High-grade ARAS in patients who are undergoing infrarenal aortic reconstruction is associated at late follow-up with increased systolic blood pressure and a need for increased numbers of antihypertensive medications, but not decreased survival rate, dialysis dependence, or an increase in serum creatinine level. These data do not support renal artery repair in patients with ARAS who undergo infrarenal aortic reconstruction. (J Vasc Surg 1998;28:14-22.)     

Renovascular hypertension

Renovascular hypertension is the most common cause of secondary hypertension. Interest in identifying patients with renal artery stenosis has been stimulated recently by advances in three areas. First, is the realization that not only can renal artery stenosis cause renovascular hypertension, but it can also lead to progressive renal failure (ischemic nephropathy) caused by progression of disease, usually atherosclerotic in nature. Second, advances in percutaneous transluminal renal angioplasty and, especially, the recent use of renal stents has led to a less invasive management of these patients as compared with traditional renal revascularization. Finally, the development of newer less invasive diagnostic techniques, both for the identification of patients with renal artery stenosis and to follow patients with known renal artery stenosis, has simplified the diagnostic aspect of the disease.     

Aldosterone-producing adenoma accompanied with renal artery stenosis

We describe a case of secondary hypertension in which aldosterone-producing adenoma (APA) and renal artery stenosis (RAS) coexisted. RAS caused a significant pressure gradient, and successful angioplasty of it improved the affected renal function but did not reduce the systemic blood pressure (SBP). Surgical resection of APA performed several months later reduced SBP. In cases of suspected secondary hypertension, other cause(s) of hypertension should be considered, if hypertension persists after correction of one possible cause.