肾动脉成形术治疗肾血管性高血压

评估DSA下的肾动脉成形术对治疗肾血管性高血压的作用。材料和方法：对6例不同病因所致的肾血管性高血压患者在DSA下作了球囊成形术治疗，包括大动脉炎和动脉粥样硬化各二例及纤维肌肉增生、及肾移植后所致的肾动脉狭窄各1例。结果：6例病人作球囊成形术均获得成功，术后血压有较为明显的下降。结论：DSA下的肾动脉成形术对治疗肾血管性高血压是一安全、有效的方法。     

肾动脉金属内支架置入治疗肾血管性高血压的临床应用

目的　评价经皮腔内肾动脉支架置入术治疗肾动脉狭窄所致肾血管性高血压患者的临床效果。方法　 10例大动脉炎和6例动脉粥样硬化所致肾动脉狭窄患者 ,术后定期复查血压和记录降压药物用量 ,并采用超声复查支架通畅状况。结果　 16例患者支架植入技术成功率 10 0 % ,随访 3～ 45个月血压恢复正常 10例 ,好转 4例 ,2例无改善。无严重并发症发生。结论　支架植入术治疗肾血管性高血压效果满意 ,创伤小 ,是治疗肾动脉狭窄所致肾血管性高血压理想的方法     

肾动脉狭窄的介入治疗

目的:评价介入治疗肾动脉狭窄性病变的疗效.材料和方法:对28例肾动脉狭窄性病变的肾动脉球囊成形术(PTA)与内支架植入术进行回顾性分析.肾动脉狭窄病因:动脉粥样硬化11例,多发性大动脉炎8例,肌纤维结构不良7例,肾移植后肾动脉狭窄2例.肾动脉狭窄分类:Ⅰ型8例,Ⅱ型12例,Ⅲ型8例.结果:26例成功进行了介入治疗,其中PTA治疗15例,内支架植入治疗9例,经PTA和内支架植入治疗2例.2例介入治疗失败,其中死亡1例.介入治疗后9例高血压治愈,17例高血压改善,7例肾功能改善.26例介入治疗成功者随访9～36个月,无发生再狭窄.结论:PTA及内支架治疗肾动脉狭窄具有微创、安全、有效的优点.病因、分型和介入治疗方法的选择是影响疗效的重要因素.     

肾动脉狭窄的介入治疗——附4例报告

肾动脉狭窄所致肾血管性高血压以往依赖药物及外科手术治疗 ,196 4年Ｄｏｔｔｅｒ和Ｊｕｄｋｉｎｇ首先开展了经皮穿刺血管腔内成形术 ,肾动脉狭窄的介入治疗随之应用于临床 ,球囊或血管内支架加压扩张狭窄的肾动脉 ,改善和恢复正常的肾血流灌注而达到治疗目的 ,由于其简便、安全、并发症少 ,介入治疗肾动脉狭窄已成为首选方法之一。1　资料和方法1 1　一般资料　 4例中男 2例 ,女 2例 ,年龄 16— 5 8岁 ,平均 33岁 ,因有不同程度高血压而就诊 ,经内科治疗效果不明显 ,作肾动脉造影证实为肾动脉狭窄 ,血管纤维肉增生症1例、多发性大动脉炎 1…     

移植肾动脉狭窄的球囊扩张及支架治疗

目的评价肾移植术后肾动脉狭窄球囊扩张及支架植入治疗的疗效。方法对2002年6月～2008年12月肾移植病房的16例肾移植后3个月～4年发生的肾动脉狭窄患者行经皮肾动脉成形术。结果手术成功率100%,术后除1例血压在支架置入2h后下降,术后3d又升高外,其余血肌酐、血压均明显下降,症状缓解率93.7%。1例出现穿刺点血肿;3例发生再狭窄,通过二次球囊扩张及支架植入治疗缓解。结论球囊扩张及支架置入治疗肾移植术后肾动脉狭窄安全有效,是首选治疗方法 。     

儿童泌尿系统疾病介入治疗的临床评价

目的 评价介入治疗在儿童肾母细胞瘤、肾血管性病变及输尿管狭窄的应用。方法 共治疗38例患儿。对18例肾母细胞瘤患儿行术前肾动脉造影及灌注化疗加栓塞术。13例不明原因的高血压行肾血管造影及血浆肾素水平的测定,并对部分患儿行PTA治疗。6例输尿管狭窄行球囊扩张。1例血尿患儿行小动脉柃塞术。结果 栓塞术后肾母细胞瘤肿瘤血管减少,受肿瘤影响的病肾缩小,肿瘤周围组织与正常组织分界清晰,减少肿瘤细胞进入血流及向远处转移。肾血管性高血压得到了明确诊断及治疗。输尿管梗阻得到改善。结论 介入治疗在泌尿系统应用是完全可行的,有着广泛的临床应用价值。     

经皮球囊血管成形术与肾动脉支架术治疗肾动脉狭窄的疗效对比观察

目的观察经皮球囊血管成形术和肾动脉支架植入术治疗肾动脉狭窄的疗效。资料和方法 112例肾动脉狭窄患者随机分为2组:A组,经皮球囊血管成形术组;B组,肾动脉支架术组。比较两组的首次手术成功率、术后6个月并发症发生率、通畅率及术后即刻再狭窄率,术后6个月血压及血肌酐变化情况。结果 B组成功率高于A组(94.64%对76.79%,P<0.01),通畅率B组高于A组(73.21%对30.36%,P<0.01),再狭窄率B组低于A组(10.71%对28.57%,P<0.01),两组并发症发生率差异无统计学意义(P>0.05)。B组高血压治愈率较A组高(P<0.01),肾动脉支架术对动脉粥样硬化所致高血压的改善情况最好,而经皮球囊血管成形术对肌纤维结构不良所致肾血管性高血压的改善情况最好。术后血肌酐B组降低不明显(P>0.05),A组显著降低(P<0.05)。A组术后TGFR、RGFR较术前显著改善(P<0.05),B组术后TGFR较术前显著改善(P<0.05);A组术后TGFR改善更明显,较B组差异有统计学意义(P<0.05)。结论肾动脉支架术操作成功率高、通畅率高、再狭窄率低,对动脉粥样硬化引起的肾动脉狭窄所致高血压改善明显,较经皮球囊血管成形术有较大优势,可作为治疗肾动脉狭窄的一种重要的介入治疗方法。     

动脉粥样硬化性缺血性肾病的血管内介入方法选择和疗效探讨

目的评价动脉粥样硬化性肾动脉狭窄血管内介入治疗的方法和临床疗效。方法28例肾动脉狭窄采用导引导管法(A组19例)和导丝交换法(B组9例)，行经皮肾动脉内支架成形术，共植入支架31枚(Palmaz支架22枚，Wallstent4枚，Symphony支架5枚)。随访6个月～1年，观察血压、血肌酐、抗高血压药用药情况，并与术前比较。结果两组肾动脉内支架成形术技术成功率为100％，B组中有2例患者术中发生肾动脉远端分支栓塞，两组共有4支血管发生再狭窄。结论导引导管法肾动脉内支架是动脉粥样硬化性肾动脉狭窄介入治疗首选方法；维护肾功能是该治疗的首要目的。     

肾移植术后动脉并发症的介入治疗

目的总结肾移植术后动脉性并发症介入治疗的经验及价值评估。方法回顾分析肾移植患者中进行血管造影检查者52例，介入治疗方法包括动脉内血管成形术治疗动脉狭窄，动脉内用尿激酶溶栓治疗急性血栓栓塞和假性动脉瘤的栓塞治疗。结果12例移植肾动脉基本正常，21例显示动脉吻合13狭窄，2例吻合13处动脉瘤形成(其中1例合并吻合13狭窄)，14例为移植肾动脉内血栓形成，3例为移植肾内动脉稀少。单纯移植。肾动脉狭窄中，16例行经动脉内血管成形术(单纯球囊扩张12例，血管内支架4例)治疗，其中14例肾功能逐渐恢复正常，2例术后肾功能恢复不良，移植肾切除。13例动脉血栓患者接受溶栓治疗(1例溶栓后放置支架)，其中3例溶栓失败，1例血管通畅后肾功能未见明显恢复，余9例。肾功能恢复正常。1例假性动脉瘤合并吻合口狭窄接受吻合口球囊扩张及支架治疗，动脉瘤栓塞治疗，造影复查动脉瘤消失，临床症状改善。结论血管内介入治疗为肾移植术后并发症提供进一步治疗，可及早挽救移植肾。     

支架成形术治疗肾动脉狭窄

目的　分析支架成形术治疗肾动脉狭窄临床疗效。方法　本组肾血管性高血压患者 15例 ,肾动脉狭窄病变血管 15支 (13例 ,89% ) ,闭塞病变血管 2支 (11% )并肾功能衰竭。其中 ,双侧肾动脉受累 2例。狭窄病例中 ,治疗前狭窄程度为 6 0 %～ 90 %。共植入支架 16枚。术后观察患者状况及血管造影随访结果。结果　技术成功率 10 0 % ,未发生严重并发症。随访 6～ 15个月 ,显示临床治愈 4例(2 6 % ) ,改善 9例 (6 0 % ) ,无效 2例 (13% ) ,临床总有效率 86 %。收缩压由术前平均 (2 7.12± 3.0 9)kPa降至术后随访平均 (18.6 2± 3.12 )kPa ,舒张压由术前平均 (17.73± 1.92 )kPa降为术后平均 (11.12± 2 .4 3)kPa(P <0 .0 5 )。术后肾功能保持稳定者 9例 (6 0 % ) ,明显好转者 5例 (33% ) ,继续恶化者 1例 (6 % )。造影复查 1例 (6 .7% ) ,于术后 6个月出现支架内再狭窄 (约狭窄 70 % ) ,经支架内球囊扩张后 ,随访 2次血管造影其再狭窄程度稳定在 2 0 %左右。结论　内支架成形术治疗肾动脉狭窄 ,临床疗效显著 ;闭塞病例支架成形治疗的成功 ,为介入治疗此病的进一步发展开辟了广阔的前景     

Median arcuate ligament syndrome: multidetector computed tomography findings

OBJECTIVE: We aimed to describe the clinical and multidetector computed tomography (MDCT) angiography findings of celiac, mesenteric, and renal artery entrapment by the median arcuate ligament. MATERIALS AND METHODS: Patients (n = 453) who underwent MDCT abdominal aorta angiography in a period of 3 years were retrospectively reviewed for vascular compression by median arcuate ligament known as median arcuate ligament syndrome. The MDCT examinations were performed with 16-slice (n = 292) and 64-slice scanners (n = 161). The median arcuate ligament itself and adjacent vascular branches of abdominal aorta were assessed for compression by 2 different radiologists who are experienced on MDCT angiography more than 3 years. Both axial, multiplanar reformatted images and 3-dimensional angiographies were used for interpretation. RESULTS: Twelve patients were found to have clinically significant vessel entrapments by median arcuate ligament; 6 of them with celiac artery, 4 of them with renal artery, and 2 of them with both celiac and mesenteric artery involvement. Patients with celiac and mesenteric vessel entrapments presented with epigastric pain. All patients with renal artery entrapment had resistant hypertension. The MDCT showed the proximal narrowing caused by compression of median arcuate ligament. The proximal portions of renal arteries pulled down and in toward the aorta, with mild to moderate narrowing. CONCLUSIONS: The MDCT exanimation with multiplanar images and 3-dimensional angiography is a noninvasive imaging technique that can be used with high accuracy in the diagnosis of median arcuate ligament syndrome.     

Accessory renal arteries are not related to hypertension risk: a review of MR angiography data

OBJECTIVE: It has been hypothesized that accessory renal arteries are related to the risk of hypertension. Our goal was to determine the prevalence of accessory renal arteries in hypertensive patients using MR angiography and to assess the relationship between accessory renal arteries and hypertension risk. MATERIALS AND METHODS: From 1996 to 2002, 185 hypertensive patients underwent MR angiography of the renal arteries at our institution for assessment of renal artery stenosis. MR angiograms were obtained using a 1.5-T magnet, IV gadolinium, and 3D gradient-echo sequences. Interpretations of the MR angiograms were retrospectively reviewed. RESULTS: Of 185 hypertensive patients, 45 (24%) showed accessory renal arteries. Of these 45 patients, nine (20%) showed renal artery stenosis and 36 (80%) showed no significant stenosis. Of the 140 patients with a single renal artery, 42 (30%) showed renal artery stenosis and 98 (70%) showed no stenosis. The odds ratio of renal artery stenosis in the accessory renal artery group versus the single renal artery group was 0.58 (95% confidence interval, 0.26-1.3%), which is not statistically significant at a power of 0.85 (chi(2) = 1.705; p = 1.0). CONCLUSION: We found no statistically significant difference in the prevalence of renal artery stenosis between patients with accessory renal arteries and those without accessory renal arteries. Assuming that the presence of two separate causes of hypertension in the same patient would be unlikely, this finding implies that accessory renal arteries are a vascular anomaly and not a direct cause of hypertension. The findings are potentially relevant in refuting the theory of accessory renal arteries as an anatomically treatable cause of hypertension.     

Percutaneous transluminal renal angioplasty in children and adolescents

Percutaneous transluminal renal angioplasty (PTRA) was performed in 12 children and adolescents with renal artery stenosis. Patients were divided into three groups: those with a short stenosis in the middle or distal part of the renal artery (n = 5), those with a short stenosis at or near the origin of the renal artery (n = 3), and those with a long stenosis at or near the origin (n = 4). The patients in the first group responded to PTRA. Those in the second group had a poor clinical response, and dilation was unsuccessful in the patients in the third group, who remained hypertensive. The location and length of the renal artery stenosis and its underlying cause appear to be important in determining the results of PTRA.     

Renal Artery Embolization Using a New Liquid Embolic Material Obtained by Partial Hydrolysis of Polyvinyl Acetate (Embol): Initial Experience in Six Patients

Objective

To evaluate the therapeutic efficacy of a new liquid embolic material, Embol, in embolization of the renal artery.

Materials and Methods

Embol is a new embolic material obtained by partial hydrolysis of polyvinyl acetate mixed in absolute ethanol and Iopromide 370 and manufactured by Schering Korea, Kyonggido, Korea. Six patients who underwent embolization of the renal artery using Embol were evaluated. Four were male and two were female and their ages ranged from 11 to 70 (mean, 53) years. Clinical and radiologic diagnoses referred for renal artery embolization were renal cell carcinoma (n = 3), renal angiomyolipoma (n = 2) and pseudoaneurysm of the renal artery (n = 1). After selective renal angiography, Embol was injected through various catheters, either with or without a balloon occlusion catheter. Changes in symptoms and blood chemistry which may have been related to renal artery embolization with Embol were analyzed.

Results

The six patients showed immediate total occlusion of their renal vascular lesions. One of the three in whom renal cell carcinoma was embolized with Embol underwent radical nephrectomy, and the specimen thus obtained revealed 40% tumor necrosis. In the two patients with angiomyolipomas, the tumors decreased in size and abdominal pain subsided. Bleeding from pseudoaneurysm of the renal artery was successfully controlled. Four patients showed symptoms of post-embolization syndrome, and one of these also showed increased levels of blood urea nitrogen and creatinine. One patient experienced transient hypertension.

Conclusion

Embol is easy to use, its radiopacity is adequate and it is a safe and effective embolic material which provides immediate and total occlusion of renal vascular lesions.     

诱生型一氧化氮合酶和内皮素-1在内毒素休克家兔血管反应性变化中的作用

目的了解诱生型-氧化氮合酶（iNOS）和内皮素-1（ET-1）在内毒素休克后家兔血管反应性变化中的作用。方法家兔128只,随机分为3组：脂多糖（LPS）对照组（n=48）,氨基胍（AG）＋LPS组（n=40）,PD-142893＋LPS组（n=40）。LPS对照组再分为6亚组：正常对照组、给LPS后0．5、1、2、4、6小时组（n=8）,测各组肠系膜上动脉（SMA）、腹腔动脉（CA）和左肾动脉（LRA）的血管反应性及组织iNOS、ET-1mRNA水平。AG＋LPS组和PD-142893＋LPS组均再分为5亚组：正常对照组、给LPS后1、2、4、6小时组（n：8）,测各组SMA、CA、LRA的血管反应性。结果内毒素休克早期CA的血管收缩和舒张反应性增加要多于SMA和LRA,且CA组织iNOSmRNA水平升高明显高于SMA和LRA,而3根血管ET-1mRNA水平均无明显变化;休克晚期SMA和LRA的血管收缩和舒张反应性的丢失均要多于CA,且SMA和LRA血管组织中iNOS和ET—1mRNA水平升高要高于CA。使用AG和PD．142893抑制iNOS和ET-1后各血管的反应性得到明显恢复。结论内毒素休克后iNOS和ET-1在各器官血管的差异表达可能参与了血管低反应性器官差异的形成。     

血管内栓塞治疗肾脏良性血管性病变

目的探讨选择性肾动脉栓塞治疗肾脏良性血管病变的临床价值。方法收集2008年3月至2011年7月肾脏良性血管病变患者27例,其中肾损伤12例(外伤8例,医源性损伤4例),肾血管畸形10例(动静脉畸形5例,动静脉瘘3例,动脉瘤2例),肾血管平滑肌脂肪瘤3例,多囊肾2例。27例中,血尿19例,腹部疼痛15例,腰部酸痛3例,低血压休克3例。术前均进行CT或MRI检查明确诊断。采用Seldinger技术穿刺行股动脉插管,先行肾动脉造影,了解病变性质、部位、范围、程度及血供情况,然后超选择插管至病变处,进行栓塞治疗。栓塞方法及栓塞剂的种类、剂量根据病变性质、造影表现及插管具体位置进行选择。术后随防1～36个月。结果 27例患者均由肾动脉参与病变供血。介入治疗后所有患者临床症状消失。随访中,除1例多囊肾患者栓塞后2个月又出现血尿外,其余患者均无相关临床症状复发,CT显示栓塞满意。结论血管内栓塞治疗肾良性血管性病变安全有效、创伤小、并发症少,并能最大程度地保护肾功能,是可靠的治疗方法。     

Transvenous digital subtraction angiography (DSA) for diagnostic control following percutaneous transluminal angioplasty (PTA) in patients with renovascular hypertension

Transvenous digital subtraction angiography (DSA) of the kidneys has shown to be useful in detection of renovascular abnormalities in hypertensive patients. In this study DSA was performed in 27 patients (fibrom. dyspl. n = 12, arterioscl. n = 15) following percutaneous transluminal angioplasty (PTA) of renal artery stenosis. Concerning PTA-effect on blood pressure, patients were classified in 3 groups (normal n = 13, improved n = 10, failure n = 4). DSA images and simultaneously determined effective renal plasma flow (ERPF) were correlated with response of blood pressure to PTA. The results demonstrate the usefulness and accuracy of transvenous renal DSA-imaging in follow-up studies. Normal ERPF correlated with a completely re-opened renal artery and normal renal parenchyma in DSA in normotensive patients. In patients with persistent or recurrent hypertension (n = 14) ERPF was reduced in 10 cases and DSA demonstrated disorders such as peripheral renal infarction or reduced renal size (n = 6) and re-stenosis (n = 2).     

Ethiodized oil-ethanol capillary embolization in rabbit kidneys: temporal histopathologic findings

PURPOSE: To determine the temporal histopathologic findings associated with selective arterial injection of a 1:1 ethiodized oil-ethanol mixture (EEM) in normal rabbit kidney followed by administration of pure ethanol into the main renal artery. MATERIALS AND METHODS: In five rabbits, the EEM was injected sequentially into each segmental renal artery of the right kidney until capillary stasis occurred. Pure ethanol was then injected into the main renal artery to achieve complete arterial stasis. Before sacrifice, the left kidney in each animal was acutely (ie, with a short follow-up period) embolized by using the same technique. The 10 kidneys of the five rabbits were evaluated microscopically at 1 (n = 3), 1(1/2) (n = 1), and 3 hours (n = 1) and 1 (n = 1), 3 (n = 1), 5 (n = 1), 7 (n = 1), and 14 days (n = 1) after embolization. RESULTS: Injection of the EEM (mean volume, 0.46 mL +/- 0.14 [SD]) followed by ethanol alone (mean volume, 0.25 mL +/- 0.09) led to complete stasis in all kidneys. There was no recanalization in the chronically (ie, with a longer follow-up period) embolized kidneys. Microscopically, uniform distribution of the EEM was evident in all slices at all time points. From 1 to 3 hours, sloughing of endothelium, formation of thrombi, and deposition of eosinophilic material along the renal, interlobar, and arcuate arteries were observed, without evidence of parenchymal damage. Within 24 hours, complete coagulative necrosis of the entire kidney occurred as a result of an occluding thrombus in the main renal artery. Analysis at subsequent time points revealed liquefaction of necrotic tissue and replacement with granulation tissue. CONCLUSION: In the rabbit, selective renal arterial injection of EEM followed by administration of ethanol produces vascular endothelial damage initiating thrombosis that results in renal infarction and ablation within 24 hours.     

Low-profile stent placement with the monorail technique for treatment of renal artery stenosis: midterm results of a prospective trial

PURPOSE: To determine feasibility, safety, and midterm patency of a monorail balloon stent device for the treatment of renal artery stenosis (RAS). MATERIALS AND METHODS: During a period of 30 months, 47 patients (with severe hypertension, n=45; renal insufficiency, n=20) with 50 cases of RAS and indications for stent implantation (calcified ostial lesion, n=41; insufficient percutaneous transluminal angioplasty, n=6; dissection, n=3) were enrolled into the prospective evaluation. After predilation, 59 stents (Rx-Herculink 4 mm, n=2; 5 mm, n=19; 6 mm, n=35; 7 mm, n=3) were implanted under manometer control with use of the long-sheath technique (5 F; 6 F for 7-mm stents) via a femoral (n=44) or transbrachial approach (n=6). Parameters of hypertension and renal insufficiency were determined before and after the procedure and for a maximum of 18 months. Restenosis rate was determined with color duplex ultrasonography. RESULTS: Renal artery stent placement (mean diameter, 5.7 mm; mean length, 16 mm) was technically successful in all cases (100%). Mean blood pressure and serum creatinine level decreased from 177/93 mm Hg to 145/78 mm Hg and from 1.8 mg/dL to 1.5 mg/dL, respectively. Within 48 hours after the implantation, acute occlusions occurred in two patients, supposedly triggered by cholesterol embolization. Primary and primary assisted patency rates were 87% and 92% at 6 months and 75% and 84% at 18 months. CONCLUSIONS: Renal artery stent placement with the rapid-exchange monorail system is a safe procedure with promising patency rates. In combination with the long-sheath technique, adequate control of stent deployment is guaranteed during the entire intervention. The low profile of the device facilitates the use of small sheaths (5 F) to minimize access-site complications.     

Gd-DOTA tubular transit asymmetry induced by angiotensin-converting enzyme inhibitor in experimental renovascular hypertension

In stenosis of a renal artery, angiotensin-converting enzyme inhibitor (ACEI) can induce a decrease in ipsilateral glomerular filtration. Dynamic MR imaging with gadolinium chelate enhancement was tested to detect this glomerular filtration reduction in experimental renovascular hypertension in the rat. Thirteen rats, with surgically induced left renal artery stenosis, developed hypertension and were studied before and after intravenous injection of ACEI with sequential Gd-DOTA-enhanced MR imaging. The time to onset of the tubular phase, the time of the maximal drop of signal, and the medullary signal-time curves of both kidneys were compared. Before ACEI, tubular phases were symmetric in 11 rats and slightly asymmetric in 2. Twelve rats showed ACEI-induced changes (positive test): absence of tubular phase on the left side (n=8) or delay (n=4) with significant differences (P<.01). Tubular phases remained symmetric in one (negative test). Dynamic MR imaging can identify ACEI-induced Gd-DOTA tubular transit asymmetry, indicative of functionally significant renal artery stenoses, in rats.