Corriere Matthew A, Pearce Jeffrey D, Edwards Matthew S, Stafford Jeanette M, Hansen Kimberley J
Division of Surgical Sciences, Section on Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston-Salem, NC 27157-1095, USA.
J Vasc Surg. 2008 Sep;48(3):580-7; discussion 587-8. doi: 10.1016/j.jvs.2008.04.050.
This retrospective review examines periprocedural morbidity and early functional responses to primary renal artery angioplasty and stenting (RA-PTAS) for patients with atherosclerotic renovascular disease (RVD).
Consecutive patients undergoing primary RA-PTAS for hemodynamically significant atherosclerotic RVD with hypertension and/or ischemic nephropathy were identified from a prospectively maintained registry. Hypertension responses were determined based on pre- and post-intervention blood pressure measurements and medication requirements. Estimated glomerular filtration rate (eGFR) was used to determine renal function responses. Both hypertension and renal function responses were assessed at least three weeks after RA-PTAS. Stepwise multivariable regression analysis was used to examine associations between blood pressure and renal function responses to RA-PTAS and select clinical variables.
One-hundred ten primary RA-PTAS were performed on 99 patients with atherosclerotic RVD with a mean angiographic diameter-reducing stenosis of 79.2 +/- 12.9%. All patients had hypertension (mean of 3.4 +/- 1.3 antihypertensive agents). Mean pre-intervention eGFR was 49.9 +/- 22.7 mL/min/1.73 m(2), and 74 patients had a pre-intervention eGFR < 60 mL/min/1.73 m(2). The technical success rate for RA-PTAS was 94.5%. The periprocedural complication rate was 5.5%; there were no periprocedural deaths. Statistically significant decreases in mean systolic blood pressure (161.3 +/- 25.2 vs. 148.5 +/- 25.2 post-intervention, P < .0001), diastolic blood pressure (78.6 +/- 13.3 versus 72.5 +/- 13.5 post-intervention, P < .0001), and number of antihypertensive agents (3.3 +/- 1.2 versus 3.1+/- 1.3 post-intervention, P = .009) were observed. Assessed categorically, hypertension response to RA-PTAS was cured in 1.1%, improved in 20.5%, and unchanged in 78.4%. Categorical eGFR response to RA-PTAS was improved in 27.7%, unchanged in 65.1%, and worsened in 7.2%. Multivariable stepwise regression revealed associations between pre- and post-intervention systolic blood pressure (P < .0001), diastolic blood pressure (P < .0001), and eGFR (P < .0001), as well as a trend toward improved diastolic blood pressure response among patients managed with staged bilateral intervention (P = .0589).
Primary RA-PTAS for atherosclerotic RVD was associated with low peri-procedural morbidity and mortality but only modest early improvements in blood pressure and renal function. Results from ongoing prospective trials are needed to assess the long term outcomes associated with RA-PTAS and clarify its role in the management of atherosclerotic RVD.
本回顾性研究探讨动脉粥样硬化性肾血管疾病（RVD）患者接受原发性肾动脉血管成形术和支架置入术（RA-PTAS）的围手术期发病率及早期功能反应。
从一个前瞻性维护的登记处识别出连续接受原发性RA-PTAS治疗的血流动力学显著的动脉粥样硬化性RVD伴高血压和/或缺血性肾病患者。根据干预前后的血压测量值和药物需求确定高血压反应。采用估计肾小球滤过率（eGFR）来确定肾功能反应。在RA-PTAS术后至少三周评估高血压和肾功能反应。采用逐步多变量回归分析来研究血压和肾功能对RA-PTAS的反应与选定临床变量之间的关联。
对99例动脉粥样硬化性RVD患者进行了110次原发性RA-PTAS，平均血管造影显示直径缩小狭窄率为79.2±12.9%。所有患者均患有高血压（平均使用3.4±1.3种抗高血压药物）。干预前平均eGFR为49.9±22.7 mL/min/1.73 m²，74例患者干预前eGFR<60 mL/min/1.73 m²。RA-PTAS的技术成功率为94.5%。围手术期并发症发生率为5.5%；无围手术期死亡病例。观察到平均收缩压（干预前161.3±25.2，干预后148.5±25.2，P<.0001）、舒张压（干预前78.6±13.3，干预后72.5±13.5，P<.0001）和抗高血压药物数量（干预前3.3±1.2，干预后3.1±1.3，P=.009）有统计学意义的下降。分类评估显示，RA-PTAS对高血压的反应治愈占1.1%，改善占20.5%，不变占78.4%。RA-PTAS对eGFR的分类反应改善占27.7%，不变占65.1%，恶化占7.2%。多变量逐步回归显示干预前后收缩压（P<.0001）、舒张压（P<.0001）和eGFR（P<.0001）之间存在关联，并且在接受分期双侧干预的患者中舒张压反应有改善趋势（P=.0589）。
原发性RA-PTAS治疗动脉粥样硬化性RVD的围手术期发病率和死亡率较低，但血压和肾功能仅在早期有适度改善。需要正在进行的前瞻性试验结果来评估与RA-PTAS相关的长期结局，并阐明其在动脉粥样硬化性RVD管理中的作用。
