Presentation is loading. Please wait.

Presentation is loading. Please wait.

FAUT-IL ENCORE RECHERCHER UNE STENOSE ARTERIELLE RENALE ? Docteur Guillaume BOBRIE Service dHTA - HEGP - Paris.

Similar presentations


Presentation on theme: "FAUT-IL ENCORE RECHERCHER UNE STENOSE ARTERIELLE RENALE ? Docteur Guillaume BOBRIE Service dHTA - HEGP - Paris."— Presentation transcript:

1 FAUT-IL ENCORE RECHERCHER UNE STENOSE ARTERIELLE RENALE ? Docteur Guillaume BOBRIE Service dHTA - HEGP - Paris

2 ANGIOPLASTY FOR LOWERING BP Mean[95% CI]p SBP, mmHg-6.3[-11.7, -0.8]0.02 DBP, mmHg-3.3[-6.2, -0.4]0.03 DDD Creatinine, µM-6[-13, 1]0.06 Between-group differences in changes from baseline Metaanalysis of EMMA, Scottish and DRASTIC trials N Ives et al. Nephrol Dial Transplant 2003;18:298 Limitations: near normal GFR, small trials, few stents

3 Van de Ven et al., Lancet 1999;353:282 STENTING TO PREVENT RESTENOSIS StentNo stentp No. randomized 4242 Primary success, %8857<0.05 Restenosis, %1448< month patency, %8051 < month BP, mmHg160/90165/90 NS 6-month creatinine, µM/l NS Revascularisation improves renal artery patency, not upstream aortic stiffness, nor downstream parenchymal microvascular disease and fibrosis

4 COMPLICATIONS IN 37 PROSPECTIVE STUDIES Death by 30 daysup to 3% Transient reduction in GFR1-13% Renal artery or parenchymal injuryup to 5% Peri-procedural CV eventsup to 3% Distal athero-embolisationunknown E Balk et al. Ann Intern Med 2006;145:901 J Hiramoto et al. J Vasc Surg 2005;41: >1 mm guide wire first balloon second balloon Emboli released

5 EMBOLIC PROTECTION / ABCIXIMAB FOR STENTING 100 patients with HTN, low GFR, heart failure or angina and RAS >50%, factorial design Protection device + abciximab n=25 No protection device + abciximab n=25 No protection device, no abciximab n=28 Protection device, no abciximab n=22 Abciximab (Reopro) bolus + infusion/12 h Filter-based embolic protection device CJ Cooper et al. Circulation 2008;117:2752

6 GFR at baseline and 1 month No difference in procedural or bleeding complications

7 RANDOMIZED TRIALS WITH LONG-TERM FU STAR 1 STent placement in Atherosclerotic ostial RAS Indication: controllable HTN and GFR n=140, 2-year FU, renal events ASTRAL 2 Angioplasty + STent for Renal Artery Lesions Indication: uncertain whether to revascularise 2n=1000, 5-year FU, reciprocal creatinine plot CORAL 3 Cardiovascular Outcomes in RA Lesions Indication: SBP >155, >2 drugs, RAS >60% 2n=1080, 5-year FU, CV and renal events 1 Utrecht University & Dutch Kidney Foundation 2 MRC and University of Birmingham CTU 3 NHLBI, Cooper CJ et al, Am Heart J 2006;152:59

8 STAR MedicalRevasc. No7664 BP, mmHg163/82160/83 Rx score eGFR, ml/min46±1645±15 Bilateral stenosis, %4650 Primary endpoint,* %2216ns BP at FU155/79151/77ns eGFR at FU46±2050±22ns All cause mortality, %88ns * >20% decrease in eGFR L Bax et al. Ann Intern Med 2009;150:840 3 lethal complications

9 Primary end point plus death Cumulative survival Caution: limited power, included patients falsely identified as having RAS >50% by noninvasive imaging STAR

10 ASTRAL Results from patients who completed one year of follow-up Philip Kalra, ACC Chicago, March/April 2008 MedicalRevasc N eGFR, ml/min46±1645±15 BP, mmHg163/82160/83 Rx score Bilateral stenosis, %4040 Serious procedural complications3% No between group differences in Scr or BP at one year FU Early termination for futility

11 ASTRAL: time to first CV event and death Death from any cause Time to first of MI, stroke vascular death, CHF Philip Kalra, ACC Chicago, March/April 2008

12 Caution: mild to moderate stenoses Scottish, DRASTIC, Van de Ven, STAR: stenosis >50% ASTRAL: stenosis suitable for angioplasty and stenting EMMA: stenosis >75% or >60% + positive lateralization test Test for functional RASminimal grade ACEI-induced GFR (n=48) 1 bilat >> 50% May result in occlusion over 33 mo (n=170) 2 60% Renal vein renin st/ivc >2 (n=49) 3 80% Pd/Pa gradient >0.90 (n=47) 4 65% 1 van de Ven, Kidney Int 1998;53: Caps, Circulation 1998;98: Simon, Am J Hypertens 2000;13: Drieghe, Eur Heart J 2008;29:517 Benefit diluted by inclusion of non-critical stenoses?

13 ASTRAL: pre-specified subgroup analyses SubgroupGroups SCr 250 mol/l GFR 45 ml/min Stenosis 90% Renal length 10 cm Rapid increase in SCr Yes, No, Not Known No benefit at any stenosis grade

14 ACEI/ARB in patients with RAS DG Hackam et al. Am Heart J 2008;156:549 Inhib.Inhib. betterworse Death, MI or stroke 1° outcome0.70 [ ] Death0.56 [ ] Stroke0.86 [ ] MI1.07 [ ] CHF0.69 [ ] Acute renal F*1.87 [ ] Hemodialysis0.62 [ ] *36/60 reversible Adjusted HR [95%CI] 3570 patients aged >65 y with renovascular disease Incidence of primary outcome 14% per year

15 Consider PTRA RAS >60% yes Resistance index > 80 Kidney length < 80 mm HTN plus high CV and renal risk Rx including ACEI statin, aspirin Resistant HTN, CHF or in Ccr CT- or MR-angio in Ccr or kidney size no yes Full preventive Rx, 6-monthly follow-up Watchful waiting KJ Rocha-Singh et al, Circulation 2008;118:2873 Grade III RAS: reduced GFR, refractory HTN, Congestive HF

16 Conclusions Atherosclerotic renovascular disease is a renal and CV condition associated with RAS Patients need CV prevention, including ACEI/ARB Revascularisation improves renal artery patency, not upstream aortic stiffness, nor downstream parenchymal microvascular disease Angioplasty ± stenting should only be considered in patients with stenosis >60% and uncontrollable or malignant HTN, acute pulmonary edema, or acute drop in GFR on ACEI/ARB Renovascular HTN, defined as HTN associated with RAS and cured by revascularisation, does not exist in patients with atherosclerotic RAS

17 AHA Conference Proceedings Atherosclerotic Peripheral Vascular Disease Symposium II Intervention for Renal Artery Disease Rocha-Singh KJ et al for Writing Group 8. Circulation. 2008; 118:


Download ppt "FAUT-IL ENCORE RECHERCHER UNE STENOSE ARTERIELLE RENALE ? Docteur Guillaume BOBRIE Service dHTA - HEGP - Paris."

Similar presentations


Ads by Google