Kadoya Yoshito, Zen Kan, Matoba Satoaki
Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan.
BMC Cardiovasc Disord. 2018 Aug 22;18(1):172. doi: 10.1186/s12872-018-0909-y.
Transplant renal artery stenosis (TRAS) is a serious complication after renal transplantation, leading to hypertension, deterioration in renal function, and/or graft loss. The incidence of TRAS reportedly varies from 1 to 23%, depending on its definition or diagnostic tools. The hemodynamic definition or therapeutic indication of TRAS is unclear.
A 66-year-old man with a history of diabetes, chronic kidney disease, and angina presented with a 2-week history of dyspnea and leg edema. He had undergone living-donor kidney transplantation for end-stage renal disease secondary to diabetic nephropathy 7 years earlier. He developed acute deterioration in renal function after the administration of an angiotensin II receptor blocker and required emergency hospitalization owing to acute congestive heart failure with pulmonary edema. A vasodilator and loop diuretics were administered following his admission, and the patient's symptoms resolved quickly. Further investigation, including magnetic resonance angiography and ultrasonography, revealed severe stenosis of the transplant renal artery. Renal arteriography and pressure gradient measurement using a 0.014-inch pressure wire were performed. The systolic pressure gradient was 40 mmHg, and the resting Pd/Pa ratio (ratio of mean distal to lesion and mean proximal pressures) was 0.90 without hyperemia. Hemodynamically significant stenosis was suspected. Intravascular ultrasonography revealed vessel shrinkage in the stenotic area, suggestive of the end-to-end anastomosis site. Pre-dilation using a 4-mm balloon, implantation of a 6-mm self-expandable stent, and post-dilatation using a 5-mm balloon were performed. Although the moderate stenosis persisted angiographically, the systolic pressure gradient dropped to 20 mmHg with the mean systolic pressure ratio increased to 0.95, which was considered an acceptable result. One month after the procedure, the patient's renal function and blood pressure control had significantly improved.
Hemodynamic assessment using a pressure wire is useful in determining the appropriate therapeutic indication and endpoint of endovascular treatment of TRAS.
移植肾动脉狭窄（TRAS）是肾移植后的一种严重并发症，可导致高血压、肾功能恶化和/或移植肾丢失。据报道，TRAS的发生率在1%至23%之间，具体取决于其定义或诊断工具。TRAS的血流动力学定义或治疗指征尚不清楚。
一名66岁男性，有糖尿病、慢性肾脏病和心绞痛病史，出现了为期2周的呼吸困难和腿部水肿。他于7年前因糖尿病肾病继发的终末期肾病接受了活体供肾移植。在服用血管紧张素II受体阻滞剂后，他的肾功能出现急性恶化，并因急性充血性心力衰竭伴肺水肿而需要紧急住院。入院后给予血管扩张剂和袢利尿剂治疗，患者症状迅速缓解。进一步检查，包括磁共振血管造影和超声检查，发现移植肾动脉严重狭窄。进行了肾动脉造影和使用0.014英寸压力导丝测量压力梯度。收缩压梯度为40 mmHg，静息状态下Pd/Pa比值（平均病变远端与近端压力比值）为0.90，无充血。怀疑存在血流动力学意义上的显著狭窄。血管内超声显示狭窄区域血管收缩，提示端端吻合部位。使用4毫米球囊进行预扩张，植入6毫米自膨胀支架，并使用5毫米球囊进行后扩张。尽管血管造影显示仍存在中度狭窄，但收缩压梯度降至20 mmHg，平均收缩压比值升至0.95，这被认为是一个可接受的结果。术后1个月，患者的肾功能和血压控制有了显著改善。
使用压力导丝进行血流动力学评估有助于确定TRAS血管内治疗的合适治疗指征和终点。
