Boyer L, Ravel A, Chahid T, Garcier J M
Service de Radiologie, CHU G. Montpied, BP 69, 63003 Clermont-Ferrand Cedex.
J Mal Vasc. 2000 Dec;25(5):377-381.
Acute embolic renal artery occlusion is usually clinically typical. In case of early diagnosis, an in situ thrombolysis may be effective. As thrombosis often progressively completes a severe renal artery stenosis, the classical clinical description of renal infarction (lumbar pain, hematuria) is frequently not present. The kidney parenchyma downstream from the renal arterial occlusion is not always irreparably lost: collateral circulation may preserve nephron viability, which requires a lower perfusion pressure than glomerular filtration. An iodine, isotopic, or MR gadolinium nephrogram may prove this viability. Over the last 10 years, we attempted 21 percutaneous recanalizations of renal artery occlusion. Mean patient age was 62 years (44-85). All were hypertensive. Serum creatinin level of 17 patients was above 130 micromoles/ml. Three patients were previously hemodialysed. We observed 8 failures, without any complication. Thirteen immediate technical successes occurred, but one rethrombosis occurred at Day 1. Immediate complications were seen in 2 patients: 1 acute pulmonary edema, 1 puncture site false aneurysm. The mean follow up of the 12 technical successes was 26 months (18-60). One rethrombosis occurred at 6 months. Hypertension was unchanged in 4 patients and improved in 8. In all patients with renal insufficiency, a significative improvement of serum creatinine level was observed. It was possible to discontinue hemodialysis in the 3 patients previously hemodialysed. One predictive factor of success was recognized: a short delay (shorter than 90 days) between occlusion and recanalization. Percutaneous recanalization must be proposed in case of renal artery occlusion, especially to avoid vascular azotemia and dialysis, even if the kidney fed by the occluded artery is small.
急性栓塞性肾动脉闭塞通常在临床上具有典型表现。若能早期诊断，原位溶栓可能有效。由于血栓形成常逐渐导致严重的肾动脉狭窄，肾梗死的经典临床症状（腰痛、血尿）往往并不出现。肾动脉闭塞下游的肾实质并非总是不可挽回地丧失：侧支循环可维持肾单位的活力，这需要比肾小球滤过更低的灌注压力。碘造影、同位素或磁共振钆造影肾图可证实这种活力。在过去10年中，我们尝试了21例肾动脉闭塞的经皮再通术。患者平均年龄为62岁（44 - 85岁）。所有患者均患有高血压。17例患者的血清肌酐水平高于130微摩尔/毫升。3例患者此前接受过血液透析。我们观察到8例失败，无任何并发症。有13例即刻技术成功，但有1例在第1天发生再血栓形成。2例患者出现即刻并发症：1例急性肺水肿，1例穿刺部位假性动脉瘤。12例技术成功患者的平均随访时间为26个月（18 - 60个月）。6个月时发生1例再血栓形成。4例患者的高血压情况未变，8例有所改善。在所有肾功能不全患者中，血清肌酐水平均有显著改善。此前接受血液透析的3例患者得以停止透析。成功的一个预测因素被确认：闭塞与再通之间的时间间隔较短（短于90天）。对于肾动脉闭塞，尤其是为避免血管性氮质血症和透析，即使由闭塞动脉供血的肾脏较小，也必须考虑经皮再通术。
