PCI for Renal Artery stenosis - summitmd.com
Transcript of PCI for Renal Artery stenosis - summitmd.com
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Cardiovascular Research Foundation ANGIOPLASTY SUMMIT
PCI forPCI for
Renal Artery Renal Artery stenosisstenosis
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Cardiovascular Research Foundation ANGIOPLASTY SUMMIT
Why should we treat Renal Artery Stenosis?
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Cardiovascular Research Foundation ANGIOPLASTY SUMMIT
Natural History of RASNatural History of RASRAS is progressive disease RAS is progressive disease
Rimmer et al. Ann Intern Med 1993;118:712-9
Study
WollenweberMeaneyDeanSchreiberTollefson
TOTAL
Totalocclusion
3 (8%)4 (11)
14 (16)7 (15)
28 (14)
ProgressionN (%)
21 (70 %)14 (36)10 (29)37 (44)34 (71)
116 (49)
Follow-up(months)
12 ~ 886 ~ 1206 ~ 10212 ~ 60
15 ~ 180
6 ~ 180
Pts
3039358548
237
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Cardiovascular Research Foundation ANGIOPLASTY SUMMIT
• Angina pectoris• “Flash” pulmonary
edema• Myocardial infarction• Left ventricular
hypertropy• Stroke• Aortic dissection
CardiovascularCardiovascular
Renal Artery Stenosis
• Chronic renal insufficiency
• End-stage renal disease
Renal
Clinical ConsequencesClinical ConsequencesRenal Artery Renal Artery StenosisStenosis
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Cardiovascular Research Foundation ANGIOPLASTY SUMMIT
Renal Artery Renal Artery StenosisStenosis
Independent Predictor of
Mortality
0
20
40
60
80
100
No RAS RAS
4 year adjusted survival
89%
57%
%
Conlon et al. Kidney Int 2001;60(4):1490-7
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Cardiovascular Research Foundation ANGIOPLASTY SUMMIT
Severity of RAS Severity of RAS vsvs SurvivalSurvival
0
10
20
30
40
50
60
70
50%
70% 68%
%4
year
adj
uste
d su
rviv
al
75% > 95%
48%
Severity of StenosisConlon et al. Kidney Int 2001;60(4):1490-7
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Cardiovascular Research Foundation ANGIOPLASTY SUMMIT
Why should we treat Why should we treat Renal Artery Renal Artery StenosisStenosis??
Improve Morbidity / Mortality
Salvage Renal Function
AdequateBP Control
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Cardiovascular Research Foundation ANGIOPLASTY SUMMIT
Medical TreatmentAggressive pharmacologictherapy is sufficient for adequate BP control and maintenance of renal function ?
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Cardiovascular Research Foundation ANGIOPLASTY SUMMIT
Outcome of RASOutcome of RASMedical treatment
• Mean Cr : 1.4 → 2.0 mg/dl (p<0.05)• SBP : 157 mmHg → 155 mmHg (p=NS)• 10 % progressed to ESRD
10 % progressed to renal intervention29 % mortality
69 pts with RAS > 70%, Follow-up 36 Mo
Chabova V et al. Mayo Clin Proc 2000;75:437-44
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Cardiovascular Research Foundation ANGIOPLASTY SUMMIT
Outcome of RASOutcome of RASManaged without Revascularization
Renal Insufficiency can be progressivedespite aggressive BP control
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Cardiovascular Research Foundation ANGIOPLASTY SUMMIT
Renal Artery Renal Artery StenosisStenosisRationale for Invasive Treatment
• Progressive disease • Cause of hypertension and
decline in renal function • Associated with increased mortality• Limited benefit of aggressive medical
therapy
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Cardiovascular Research Foundation ANGIOPLASTY SUMMIT
Renal Artery Renal Artery stenosisstenosis
Should we stent it ?
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Cardiovascular Research Foundation ANGIOPLASTY SUMMIT
0
20
40
60
80
100
Balloon Stent
Van de Ven et al. Lancet 1999;353:282-86
Initial Success
57%
88%
29%
75%
%
6 moPatency
*P< 0.05
POBA vs StentPOBA vs Stent
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Cardiovascular Research Foundation ANGIOPLASTY SUMMIT
Renal Artery Renal Artery StentingStentingTechnical Success
Study series
Rodriguez-Lopez Henry Rocha-Singh Tuttle Dorros
OstialLesion(%)
667743
100
Success(%)9899989899
No. ofArteries
125104180148202
~ 98%Lim and Rosenfield, Curr Int Cardiol 2000;2:130-9
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Cardiovascular Research Foundation ANGIOPLASTY SUMMIT
Renal Artery Renal Artery StentingStentingRestenosis
Study (year)
van de Ven Rocha-Singh Rundback Tuttle White
F/U(mo)
6131289
Restenosis(%)2112261419
RA evaluated(% original total a.)
52 (95%)158 (88%)28 (52%)49 (33%)80 (60%)
~ 20%Lim and Rosenfield, Curr Int Cardiol 2000;2:130-9
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Cardiovascular Research Foundation ANGIOPLASTY SUMMIT
Renal Artery Renal Artery StentingStenting
• Technically Feasible• Safe & Durable• Superior to Balloon
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Cardiovascular Research Foundation ANGIOPLASTY SUMMIT
Renal Artery Renal Artery StentingStenting
However,However,
Is it effective in improving Is it effective in improving Hypertension Hypertension & & slowing slowing progressive decline in renal progressive decline in renal function ?function ?
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Cardiovascular Research Foundation ANGIOPLASTY SUMMIT
Renal artery stenting ?
Effect on hypertension
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Cardiovascular Research Foundation ANGIOPLASTY SUMMIT
BP Change after Stenting
200168±27
146±24144±19
mmHg P< 0.05145±22 147±21
76±12
160SBP
120 84±15 75±1278±1276±10
80 DBP40
Baseline 1 yr 2 yrs 3 yrs 4 yrs
Doroso G, et al. Cathet Cardiovasc Intervent 2002;55:182-188
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Cardiovascular Research Foundation ANGIOPLASTY SUMMIT
BP Change by Baseline BP
Burket MW, et al. Am Heart J 2000;139:64-71
6040200
-20-40-60-80
-100-120-140
120 140 160 180 200 220 240Baseline Systolic BP (mmHg)
Cha
nge
in S
ysto
lic B
P (m
mH
g)P < 0.001R2 = 0.43
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Cardiovascular Research Foundation ANGIOPLASTY SUMMIT
Renal Artery Renal Artery StentingStentingEffect on Hypertension
Study series (year)
TegtmeyerKlingeMartinLossinoRodriguez-PerezBlumPooled Result
Improved(%)
71684651816263
Benefits(%)
947868638178
No.
6513494
1533774
586
Cure(%)
231022120
1614 ~ 77%
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Cardiovascular Research Foundation ANGIOPLASTY SUMMIT
Effect on hypertension
Cure 12 ~ 23 %Improved 46 ~ 81 %
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Cardiovascular Research Foundation ANGIOPLASTY SUMMIT
Renal artery stenting
Can We Salvage Renal Function ?
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Cardiovascular Research Foundation ANGIOPLASTY SUMMIT
Stabilization of Renal FunctionReciprocal serum Reciprocal serum creatinine creatinine plotplot
01234567
0 200 400 600-200-400-600
Seru
m cr
eatin
ine×1
0-31
Time (days)
Post Stent
Natural course
StentHarden, et al. Lancet 1997;349:1133-6
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Cardiovascular Research Foundation ANGIOPLASTY SUMMIT
Renal Artery Renal Artery StentingStenting
Study
Van de VenRocha-SinghTuttleDorrosRundbackHarden
Stable(%)
627081484738
Deteriorated(%)
2684
343328
No
421501291634532
Improved(%)
122215182034
Effect on Renal FunctionEffect on Renal Function
TOTAL 19 %19% 62%561Lim and Rosenfield, Curr Int Cardiol 2000;2:130-9
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Cardiovascular Research Foundation ANGIOPLASTY SUMMIT
Renal Artery Renal Artery StentingStenting
Effect on Renal Function
• Improved 23 ~ 41%• Stabilized 29 ~ 100 %• Deteriorated 5 ~ 38 %
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Cardiovascular Research Foundation ANGIOPLASTY SUMMIT
Renal Artery Renal Artery StentingStenting
•• Technically Feasible• Safe & Durable• Superior to Balloon• Effective in improving HTN• Beneficial to preserve renal
function
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Cardiovascular Research Foundation ANGIOPLASTY SUMMIT
Renal Artery Renal Artery StentingStentingSuperior to Surgery ?
No Randomized Trials of Renal Artery Stenting vs Surgery
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Cardiovascular Research Foundation ANGIOPLASTY SUMMIT
Surgical Surgical RevascularizationRevascularizationAorto-renal bypassRenal endarterectomy
Death 2 ~ 6 %MI 2 ~ 9 %Stroke 0 ~ 3 %Bleeding 2 ~ 3 %Cholesterol Emboli 1 ~ 4 %
Libertino JA, et al. J Urol 1992;147:1485-7Cambria RP, et al. J Vasc Surg 1994;20:76-87
Clair DG, et al. J Vasc Surg 1995;21:926-34
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Cardiovascular Research Foundation ANGIOPLASTY SUMMIT
Late Results of SurgeryLate Results of Surgery
5 year results
•• Graft failure 6 ~ 18 %• Reoperation 5 ~ 15 %
Libertino JA, et al. J Urol 1992;147:1485-7Cambria RP, et al. J Vasc Surg 1994;20:76-87
Clair DG, et al. J Vasc Surg 1995;21:926-34
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Cardiovascular Research Foundation ANGIOPLASTY SUMMIT
Renal artery stenting
• Acute succees rate > 98 %• Restenosis < 15 %
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Cardiovascular Research Foundation ANGIOPLASTY SUMMIT
Renal Artery Renal Artery StentingStenting
• Technically Feasible• Safe & Durable• Superior to Balloon• Effective in improving HTN• Beneficial to preserve renal
function• Safer than surgery• FDA approved (July 10, 2002)
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Cardiovascular Research Foundation ANGIOPLASTY SUMMIT
Renal artery stentingLong-Term Survival
Do All Benefit ?
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Cardiovascular Research Foundation ANGIOPLASTY SUMMIT
Survival after Stenting
Dorros, et al. Circulation 1998;98:642-647
0
20
40
60
80
100
Cr ≤ 1.5 mg/dl
1
Cr 1.5~1.9 mg/dlCr ≥ 2.0 mg/dl
2 3 4Years
Surv
ival
(%)
Categorized by baseline Creatinine
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Cardiovascular Research Foundation ANGIOPLASTY SUMMIT
Survival after StentingUnilateral vs Bilateral Stenosis
20
40
60
Surv
ival
(%) *P< 0.01100
79 ± 9 %80
63 ± 17 %Unilateral
Bilateral stenosis
001 2 3 4 Years
Dorros, et al. Circulation 1998;98:642-647
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Cardiovascular Research Foundation ANGIOPLASTY SUMMIT
Survival after Stenting
Baseline creatinine• Cr ≤ 1.4 mg/dL 85±3% (622)• 1.5 - 1.9 mg/dL 78±5% (168) *• Cr ≥ 2.0 mg/dL 49±5% (268) *
Doroso G, et al. Cathet Cardiovasc Intervent 2002;55:182-188
4 year survival (N=1058)
*P< 0.05
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Cardiovascular Research Foundation ANGIOPLASTY SUMMIT
Survival after Stenting
4 year survival (N=1058)Renal artery Renal artery stenosisstenosis
Baseline creatinine Unilateral Bilateral• Cr ≤ 1.4 mg/dL 86±3% (397) 85±7% (225)• 1.5 - 1.9 mg/dL 78±7% (103) 78±5% (65)• Cr ≥ 2.0 mg/dL 49±5% (173) 49±5% (95)
Doroso G, et al. Cathet Cardiovasc Intervent 2002;55:182-188
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Cardiovascular Research Foundation ANGIOPLASTY SUMMIT
Renal Artery StentingRenal Artery StentingBeneficial impact on survival Beneficial impact on survival
Renal artery stenting before the onset of renal dysfunction !!!
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Cardiovascular Research Foundation ANGIOPLASTY SUMMIT
“Dark side” of Renal Artery Stenting
Atheroembolism…
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Cardiovascular Research Foundation ANGIOPLASTY SUMMIT
Incidence of Incidence of Atheroembolism Atheroembolism
During Renal Artery During Renal Artery StentingStenting
Study
Van de VenRocha-Singh
White
No
4242
150
Embolism
7 %5.9 %
2 %
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Cardiovascular Research Foundation ANGIOPLASTY SUMMIT
Promoting Factors of Promoting Factors of AtheroembolismAtheroembolism
• Length of the procedure
• Difficulties of the procedure
• Size of the devices• Primary stenting• High pr. dilatation• Guiding catheter
intubation
Procedural Clinical• Elderly (> 60 years)• Male• Renal insufficiency• Multisegment dis• Associated aorta /
peripheral lesions• Anticoagulants –
Fibrinolytic drugs
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Cardiovascular Research Foundation ANGIOPLASTY SUMMIT
Distal ProtectionDuring Renal Artery Stenting
Will it make a difference ?
Should we use it ?
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Cardiovascular Research Foundation ANGIOPLASTY SUMMIT
Distal ProtectionDistal Protection(Pilot Study)(Pilot Study)
28 pts, 32 renal arteries(29 ostial lesions) •• Debris retrieved in all (Success 100%)Debris retrieved in all (Success 100%)•• At 6At 6--mo F/U, mo F/U,
Renal function deteriorationRenal function deterioration 0 pts0 ptsimprovement 5 pts
Stent with PercuSurge GuardWIre
improvement 5 pts
Distal Protection may prevent renal insufficiency after procedure.
Henry, et al. J Endocasx Ther 2001;8:227-237
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Cardiovascular Research Foundation ANGIOPLASTY SUMMIT
Renal Artery Renal Artery StentingStentingIn ConclusionIn Conclusion
• Effective and Safe• Sustained Benefit• Choice for Complex
Renal Artery Stenosis
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Cardiovascular Research Foundation ANGIOPLASTY SUMMIT
Renal Artery Renal Artery StentingStentingIn the near future In the near future ……..
Outcomes will be advanced by• Improved stents/delivery systems• Distal protection device• Drug – eluting stent