Renal Artery Stenting

Transcription

1 Renal Artery Stenting J.P. Reilly, MD, FSCAI Ochsner Medical Center

2 Speaker s bureau: Astra Zeneca and Lilly/Diachi Sankyo

3 Prevalence of RAS is high in cath population. Renal artery intervention can help patients Need to identify which patients will benefit

4 Incidental RAS at Cath n RAS > 50% Bilateral Harding et al Jean et al NR Vetrovec et al Rihal et al Weber-Mzell et al Harding MB, Smith LR, Himmelstein SI, et al. J Am Soc Nephrol 2:1608, Jean WJ, Al-Bitar I, Zwicke DL, et al. Cathet Cardiovasc Diagn 32:8, Vetrovec GW, Landwehr DM, Edwards VI. J Interven Cardiol 2:69, Rihal CS, Textor SC, Breen JF, et al. Mayo Clin Proc 77:309, Weber-Mzell D, Kotanko P, Schumacher M, et al. Eur Heart J 23:1684, 2002.

5 Incidental RAS at Cath n RAS > 50% Bilateral Harding et al Jean et al NR Vetrovec et al Rihal et al Weber-Mzell et al Harding MB, Smith LR, Himmelstein SI, et al. J Am Soc Nephrol 2:1608, Jean WJ, Al-Bitar I, Zwicke DL, et al. Cathet Cardiovasc Diagn 32:8, Vetrovec GW, Landwehr DM, Edwards VI. J Interven Cardiol 2:69, Rihal CS, Textor SC, Breen JF, et al. Mayo Clin Proc 77:309, Weber-Mzell D, Kotanko P, Schumacher M, et al. Eur Heart J 23:1684, 2002.

6 Incidental RAS at Cath n RAS > 50% Bilateral Harding et al % Jean et al NR Vetrovec et al Rihal et al Weber-Mzell et al Harding MB, Smith LR, Himmelstein SI, et al. J Am Soc Nephrol 2:1608, Jean WJ, Al-Bitar I, Zwicke DL, et al. Cathet Cardiovasc Diagn 32:8, Vetrovec GW, Landwehr DM, Edwards VI. J Interven Cardiol 2:69, Rihal CS, Textor SC, Breen JF, et al. Mayo Clin Proc 77:309, Weber-Mzell D, Kotanko P, Schumacher M, et al. Eur Heart J 23:1684, 2002.

7 Incidental RAS at Cath n RAS > 50% Bilateral Harding et al % Jean et al NR Vetrovec et al Rihal et al Weber-Mzell et al Harding MB, Smith LR, Himmelstein SI, et al. J Am Soc Nephrol 2:1608, Jean WJ, Al-Bitar I, Zwicke DL, et al. Cathet Cardiovasc Diagn 32:8, Vetrovec GW, Landwehr DM, Edwards VI. J Interven Cardiol 2:69, Rihal CS, Textor SC, Breen JF, et al. Mayo Clin Proc 77:309, Weber-Mzell D, Kotanko P, Schumacher M, et al. Eur Heart J 23:1684, 2002.

8 CLINICAL CLUES Onset HTN 30 yrs or 55 yrs. Previous control of HTN, now uncontrolled. Malignant hypertension. Resistant hypertension. Systolic/diastolic abdominal bruit. Discrepancy in renal sizes. Azotemia with ACE inhibitor. Azotemia in elderly with diffuse ASCVD. Multivessel coronary artery disease.

9 Indications for Renal Stent NOT Artery beautification. Oculostenotic reflex.

10 Clinical Indications Renovascular HTN Blood pressure control. Ischemic Nephropathy Preservation or salvage of renal function. Cardiac Disturbance Syndromes CHF or refractory angina pectoris.

11 Hypertension RECOMMENDATIONS Class IIa Percutaneous revascularization is reasonable for patients with hemodynamically significant RAS and accelerated hypertension, resistant hypertension, malignant hypertension, hypertension with an unexplained unilateral small kidney, and hypertension with intolerance to medication. (Level of Evidence: B) Hirsch et al. ACC/AHA PAD Practice Guidelines

12 Preservation of Renal Function RECOMMENDATIONS Class IIa Percutaneous revascularization is reasonable for patients with RAS and progressive chronic kidney disease with bilateral RAS or a RAS to a solitary functioning kidney. (Level of Evidence: B) Class IIb Percutaneous revascularization may be considered for patients with RAS and chronic renal insufficiency with unilateral RAS. (Level of Evidence: C) Hirsch et al. ACC/AHA PAD Practice Guidelines

13 Impact of RAS on Congestive Heart Failure and Unstable Angina RECOMMENDATIONS Class I Percutaneous revascularization is indicated for patients with hemodynamically significant RAS and recurrent, unexplained congestive heart failure or sudden, unexplained pulmonary edema. (Level of Evidence: B) Class IIa Percutaneous revascularization is reasonable for patients with hemodynamically significant RAS and unstable angina. (Level of Evidence: B) Hirsch et al. ACC/AHA PAD Practice Guidelines

14 Asymptomatic Stenosis RECOMMENDATIONS Class IIb 1. Percutaneous revascularization may be considered for treatment of an asymptomatic bilateral or solitary viable kidney with a hemodynamically significant RAS. (Level of Evidence: C) 2. The usefulness of percutaneous revascularization of an asymptomatic unilateral hemodynamically significant RAS in a viable kidney is not well established and is presently clinically unproven. (Level of Evidence: C) Hirsch et al. ACC/AHA PAD Practice Guidelines

15 Balloon Angioplasty Poor technology for bulky aortic plaque. Therapy of choice for fibromuscular disease. FMD ATHEROSCLEROSIS

16 Balloon Angioplasty Poor technology for bulky aortic plaque. Therapy of choice for fibromuscular disease. FMD ATHEROSCLEROSIS

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23 Balloon Stent Leertouwer TC, et al. Radiology 2000;216:78-85.

24 Cured Improved Boisclair Blum Henry Rees Kuhn Wilms Percent Leertouwer TC, et al. Radiology 2000;216:78-85.

25 Randomized Controlled Trials DRASTIC STAR ASTRAL

26 Randomized Controlled Trials DRASTIC STAR ASTRAL

27 Randomized Controlled Trials DRASTIC STAR ASTRAL

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30 ASTRAL Multicenter RCT 806 patients randomized with RAS by CTA, MRA, USG or angiography substantial atherosclerotic stenosis if the patient s doctor was uncertain that the patient would definitely have a worthwhile clinical benefit from revascularization, 59% had >70% stenosis 33.6 months follow-up

31 ASTRAL Multicenter RCT 806 patients randomized with RAS by CTA, MRA, USG or angiography substantial atherosclerotic stenosis if the patient s doctor was uncertain that the patient would definitely have a worthwhile clinical benefit from revascularization, 59% had >70% stenosis 33.6 months follow-up

32 CORAL NIH sponsored, aim to enroll 1080 pts RADAR RCT of 300 pts >70% RAS

33 Large scale RCTs have failed to prove a benefit for revascularization This does not prove that renal revascularization cannot be of benefit We must be broad in whom we screen, but selective in whom we treat.

34 Renal FFR measured with a pressure wire. Hyperemia induced with papaverine (32 mg). Repeat FFR at end of procedure.

35 Improvement: BP < 140/90 mmhg, or a decrease of DBP by 15 mm Hg on the same or reduced # of medications p value = 0.02 Percent >.80 Renal FFR

36 27 consecutive pts with 70% RAS by angiography prospective enrolled. Atherosclerotic RAS within 5 mm of ostium. Unilateral RAS in 18, Bilateral RAS in 9. Interventionalists blinded to BNP levels. All patients treated with PTA & Stent based upon angiographic lesions severity and refractory hypertension. Silva JA, et al Circulation 2005;111:

37 Silva JA, et al Circulation 2005;111:

38 RESIST Trial Control EPD Abciximab EPD + Abciximab 9% 6% 9% 3% 0% -3% -10% -12% -10% -6% -9% -12% -15% % change GFR Cooper et al, Circulation May 27;117(21):

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44 Femoral vs Radial Approach Some renal arteries have a marked inferior direction May be more accessible from above

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50 RAS is prevalent in cardiologists practice We must be discerning in identifying patients who will benefit We must continue to optimize renal stenting procedures