Erich Minar Medizinische Universität Wien

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Printerventionelle Diagnostik und Indikation zur Behandlung von Nierenarterienstenosen: Stent PTA Erich MinarMedizinische Universitt Wien

Wiener Gesprchstage, Juni 2013

Renal-Artery StenosisSafian R and Textor S;N Engl J Med 2001; 344:431-442 NAST = Renovaskulre HypertonieDefinition der renovaskulren HypertonieHmodynamisch signifikante Stenose einer oder beider Nierenarterien, die zur Blutdruckerhhung fhrt (Goldblattmechanismus)

Derzeitig einziger Beweis fr das Vorhandensein einer renovaskulren Ursache der Hypertonie liegt in der Beseitigung der signifikanten Stenose mit darauf einsetzender Normalisierung/ Reduktion des Blutdruckes

NAST im Trend (USA 1992-2004)Atherosclerotic renovascular disease in the United States Kalra et al; Kidney Int 2010;77: 37-43

White CJ et al. Indications for renal arteriography at the time of coronary arteriography: ascience advisory from the American Heart Association Committee on Diagnostic and Interventional Cardiac Catheterization, Council on Clinical Cardiology, and the Councils on Cardiovascular Radiology and Intervention and on Kidney in Cardiovascular Disease. Circulation 2006; 114:1892 1895

Circulation 2006; 114:1892 1895

Der Oculostenotische Reflex(Reflexangioplastie) [Topol EJ, Nissen SE; Circulation 1995]Unklarer Benefit - Unklare Kosten - Mgliche Komplikationen?Jatrogenosis fulminansSoran O et al. Circulation 2000

Courtesy M.Haumer

Conlon PJ et al, Kidn Int 2001; 60: 1490-97Amighi J et al. Eur J Clin Invest 2009;39:784-92NAST Prognose(Wien 2004 2006; n=487 )

NAST 1.5 cm Seitenunterschied der Nierengre bei der Sonographie

Diagnostic strategies for RAD

CTA = computed tomography angiography; DSA = digital subtraction angiography; DUS = duplex ultrasonography; MRA = magnetic resonance angiography; RAS = renal artery stenosis.Diagnostic strategies for RAD

CTA = computed tomography angiography; DSA = digital subtraction angiography; DUS = duplex ultrasonography; MRA = magnetic resonance angiography; RAS = renal artery stenosis.Diagnostic strategies for RAD

CTA = computed tomography angiography; DSA = digital subtraction angiography; DUS = duplex ultrasonography; MRA = magnetic resonance angiography; RAS = renal artery stenosis.Diagnostic strategies for RAD

CTA = computed tomography angiography; DSA = digital subtraction angiography; DUS = duplex ultrasonography; MRA = magnetic resonance angiography; RAS = renal artery stenosis.

May AG et al. Hemodynamic effects of arterial stenosis.Surgery 1962;53:513-524Pressure drop & severity of RASRenal Artery Stenosis- Severity16

N Engl J Med 2001;344:410-7

RI als Erfolgsprdiktor ?RI = {1-[Vmin/Vmax]} x 100Clinical outcomes after percutaneous revascularization versus medical management in patients with significant renal artery stenosis: A meta-analysis of randomized controlled trialsKumbhani DJ ; Am Heart J 2011;161:622-630Mean FU 29 Mo

Background We sought to systematically evaluate whether percutaneous revascularization is associated withadditional clinical benefit in patients with renal artery stenosis (RAS) as compared with medical management alone.Methods We included randomized controlled trials that compared percutaneous revascularization in addition to medicaltherapy versus medical management alone in patients with RAS. Six trials with 1,208 patients were included.Results At a mean follow-up of 29 months, there was no change in systolic blood pressure (weighted mean difference[WMD] = 1.20 mm Hg, 95% CI 1.18 to 3.58 mm Hg) or diastolic blood pressure (WMD = 1.60 mm Hg, 95% CI 4.22 to1.02 mm Hg) from baseline in the percutaneous revascularization arm compared with the medical management arm. Therewas a reduction in the mean number of antihypertensive medications (WMD = 0.26, 95% CI 0.39 to 0.13, P b .001), butnot serum creatinine (WMD = 0.14 mg/dL, 95% CI 0.29 to 0.007 mg/dL), in the percutaneous revascularization arm at theend of follow-up. Percutaneous revascularization was not associated with a significant difference in all-cause mortality (relativerisk [RR] = 0.96, 95% CI 0.74-1.25), congestive heart failure (RR = 0.79, 95% CI 0.56-1.13), stroke (RR = 0.86, 95% CI0.50-1.47), or worsening renal function (RR = 0.91, 95% CI 0.67-1.23) as compared with medical management.Conclusions In patients with RAS, percutaneous renal revascularization in addition to medical therapy may result in alower requirement for antihypertensive medications, but not with improvements in serum creatinine or clinical outcomes, ascompared with medical management over an intermediate period of follow-up. Further studies are needed to identify theappropriate patient population most likely to benefit from its use. (Am Heart J 2011;161:622-630.e1.)19

Clinical outcomes after percutaneous revascularization versus medical management in patients with significant renal artery stenosis: A meta-analysis of randomized controlled trialsKumbhani DJ ; Am Heart J 2011;161:622-630ConclusionsIn patients with RAS, percutaneous renal revascularization in addition to medical therapy may result in a lower requirement for antihypertensive medications, but not with improvements in serum creatinine or clinical outcomes, as compared with medical management over an intermediate period of follow-up. Further studies are needed to identify the appropriate patient population most likely to benefit from its use.

N Engl J Med 2009;361:1953-62ConclusionsWe found substantial risks but no evidence of a worthwhile clinical benefit from revascularization in patients with atherosclerotic renovascular disease.Angioplasty and Stenting for Renal Artery Lesions ASTRAL Studiendesign Nierenarterienstenose Randomisierung 9/2000 10/2007 58 Zentren - 806 Patienten Revaskularisation (N=403)(Angioplastie (7%) oder Stent (93%) und medikamentse Therapie Keine Revaskularisation (N=403) Nur medikamentse Therapie 14 Patienten/ Zentrum 2 Patienten/Zentrum/Jahr

Primary Endpoint at 2 years

Stenting versus konservativN Engl J Med 2009;361:1953-62

ASTRAL Limitationen/Probleme im Design* Selektions-Bias: wenn der Untersucher sich bezglich der Therapie sicher war, wurde der Patient nicht randomisiert. Frage: wei einer von uns wirklich was er bei NAST tun soll?

* Primrer Endpunkt war Nierenfunktion: allerdings: bei 25 % war diese normal und bei weiteren 15 % fast normal viele Patienten hatten unilaterale Erkrankung

* Es gabe kein Core-Labor zur Adjudizierung der morphologischen Daten. Dies fhrt erfahrungsgem zur berschtzung des Stenosegrades.

* Die Patienten hatten generell eine mige Erkrankung, oft sogar unilateral: 40% hatten 50-70% Stenose bzw wahrscheinlich sogar weniger.

* Die Studienzentren hatten offensichtlich wenig Erfahrung ( 42% rekrutierten 1-5 Patienten im Verlaufe von 7 Jahren)

* Nebenwirkungen viel hufiger als in anderen Studien.

27Nierenfunktionsverschlechterung nach Intervention bei 3 30%

* NAST nicht Ursache der Niereninsuffizienz * KM-induzierte Nephropathie * Distale Atheroembolisation

Das wichtigste Kriterium fr eine klinische Verbesserung nach Revaskularisation einer Nierenarterienstenose ist die geeignete Patientenselektion!

Treatment of Renal Artery Fibromuscular Dysplasia with BalloonAngioplasty: a Prospective Follow-up StudyM. Birrer et al Eur J Vasc Endovasc Surg 2002; 23: 146

Gradient 71 mm HgRR 196/104 3 verschiedene AntihypertensivaSollte man ? JA !!

Kein Update der Sektion Nierenarterien bei Fassung 2011

NAST Angioplastie und berleben

RCT: PTRA + BMT vs. BMTn=1.080Einschlusskriterien1) aNAST 60% und 20 mmHg Gradsyst oder 80% 2) Systolische Hypertonie 155 mmHg trotz 2 Antihypertensiva1EP Tod (CV oder renal) / MI / Hosp.(CHF), Insult / S-Krea x 2 / Dialyse2EP Tod (gesamt) / Nierenfunktion / Offenheitsrate / Blutdruck

Bitte warten bis 2014

Stent revascularization for the prevention ofcardiovascular and renal events among patients withrenal artery stenosis and systolic hypertension:Rationale and design of the CORAL trialChristopher J. Cooper, MD,a Timothy P. Murphy, MD,b Alan Matsumoto, MD,c Michael Steffes, MD,dDavid J. Cohen, MD,e Michael Jaff, DO,f Richard Kuntz, MD,g Kenneth Jamerson, MD,h Diane Reid, MD,iKenneth Rosenfield, MD,f John Rundback, MD,j Ralph DTAgostino, MD,k William Henrich, MD,land Lance Dworkin, MDb Toledo, OH; Providence, RI; Charlottesville, VA; Minneapolis, MN; Boston, MA;Ann Arbor, MI; Bethesda and Baltimore MD; and Teaneck, NJBackground Atherosclerotic renal artery stenosis is a problem with no consensus on diagnosis or therapy. Theconsequences of renal ischemia are neuroendocrine activation, hypertension, and renal insufficiency that can potentiallyresult in acceleration of atherosclerosis, further renal dysfunction, myocardial infarction, heart failure, stroke, and death.Whether revascularization improves clinical outcomes when compared with optimum medical therapy is unknown.Methods CORAL is a randomized clinical trial contrasting optimum medical therapy alone to stenting with optimummedical therapy on a composite cardiovascular and renal end point: cardiovascular or renal death, myocardial infarction,hospitalization for congestive heart failure, stroke, doubling of serum creatinine, and need for renal replacement therapy. Thesecondary end points evaluate the effectiveness of revascularization in important subgroups of patients and with respect toall-cause mortality, kidney function, renal artery patency, microvascular renal function, and blood pressure control. We willalso correlate stenosis severity with longitudinal renal function and determine the value