Transcript
Pediatric Renal Artery Stenosis
“Efficacy of Endovascular Interventions”
Matt Hawkins, MDAssistant Professor – Emory University SOM
Introduction
• 1-2% of children have sustained HTN• RAS = 5-25% of pediatric HTN cases• Renal scarring, aortic coarctation,
glomerular disease, and adrenal hypersecretion are the most common cause
• Renal artery stenosis (RAS) accounts for ~10% of HTN cases in kids.
Introduction
• Renal artery stenosis (RAS) accounts for ~10% of HTN cases in kids.
• Dominant etiologies include:• Fibromuscular dysplasia (FMD)• Neurofibromatosis 1• Williams syndrome• Mid-aortic syndrome
RAS in kids• 86% of stenoses in 1st or 2nd order branches• Stenoses in multiple 1st/2nd order branches = 32%• Bilateral disease = 30%• Intraparenchymal diasese = 30% (aneurysms, collaterals,
stenoses, etc.)
RAS in kids
FMD in adults• 29 women; 38 interventions (17 yr retrospective)• Technical success = <30% stenosis• 8% complication rate• 72% improved or cured (SBP<140)• Primary and assisted primary patency = 66%
and 76% at 5 years
FMD in adults• 59 patients (17 year retrospective)• 95% technical success• 34% needed repeat angioplasty• Cure = 24%• Improvement = 39%
FMD in adults
FMD in adults• 35 patients; 43 procedures• 100% technical success• Primary and primary assisted patency =
(95%, 71%, 50%) and (100% all) at 1, 5, & 9 years respectively
• 6% cure; 63% improved
FMD in adults• Meta-analysis of 50 studies of PTA for FMD• Technical success = 88.2%• Complication rate = 11.8% (major 6.3%)• Cure = 35.8%
Renal artery stenosis in kids
Renal artery stenosis in kids
48 procedures in 33 patients
Renal artery stenosis in kids
Renal artery stenosis in kids• 19 patients; 32 treated lesions• Technical success = 91%• 39% cure; 17% improvement; 44% failure• Cutting balloons successful in 5 of 7 uses• 1 renal artery perforation; 1 accelerated
hypertension; 1 groin hematoma
Renal artery stenosis in kids• 22 patients, 34 procedures• 16 = Takayasu; 6 = FMD• Technical success = 94.1%• 27.3% cure; 45.5% improvement• 41% restenosis (3-47 month range)• 1 minor complication
What about cutting balloons• Complications include • Dissection (3.6% in coronary studies)• Rupture • Renal artery thrombosis
What about cutting balloons
What about cutting balloons
Literature Summary• Cure 1/3, Improve 1/3, Fail 1/3• Safe procedure• Technically successful >90% of the time• ~40% will re-stenose w/in 5 years• Avoid stents in children• Cutting balloons can be helpful with
resistant stenoses when used cautiously
• Should we look for extra-renal disease in these kids?
How do we do renal artery
angioplasty?
Equipment
• 4F 45cm sheath• 0.014 wire (BMW/RunThrough)• 2.5F Cantata & 0.014 Synchro (if needed)
• 1-2 cm Sterling monorail balloons• Flextome cutting balloons (if needed)
Medications
• Heparin 100U/kg – Before angioplasty– 10-20U/kg every 45 minutes thereafter
• Nitroglycerin 1mcg/kg (optional)
• ASA 325mg loading dose (if stenosis is known prior to case)
Post-Procedure Care
• Leg straight 2-3 hrs (if 4F sheath)
• ASA 81 mg for 6 months• If cutting balloon used:– Overnight ICU admission on heparin drip– Doppler ultrasound next day– ASA 81mg for 6 months
Case 1
Case 1
Case 1
Case 2
Case 2
Case 2
Stenosis Post-stenotic dilation
Case 2
Stenosis Post dilation
Case 2 (second try)
Case 2Right kidney
Case 2
Case 2
Case 2
Case 2
Case 2PRE
POST
Case 2
POST
Case 2 (3rd time is a charm)
Case 2
Case 2
Case 2
Matt Hawkins, MD@MattHawkinsMD
matt.hawkins@emory.edu
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