Presentation on theme: "Harvard Medical School Duane S. Pinto, M.D. Director Peripheral Angiographic Core Laboratory, TIMI Data Coordinating Center Director, Cardiology Fellowship."— Presentation transcript:
Harvard Medical School Duane S. Pinto, M.D. Director Peripheral Angiographic Core Laboratory, TIMI Data Coordinating Center Director, Cardiology Fellowship Training Program Interventional Cardiologist Beth Israel Deaconess Medical Center Assistant Professor of Medicine, Harvard Medical School Renal Artery Stenosis: Diagnosis and Indications for Revascularization
Harvard Medical School Clinical Clues for RAS Onset of HTN after 55 yrs Exacerbation of well-controlled HTN Malignant or resistant HTN Epigastric bruit Unexplained azotemia Azotemia while on ACE or ARB Atrophic kidney or size discrepancy Recurrent CHF or “flash” pulmonary edema Atheroscerosis elsewhere
Harvard Medical School Making the Diagnosis of RAS: Imaging Requirements 1.Identify main and accessory renal arteries 2.Localize site of stenosis or disease 3.Provide hemodynamic significance of disease 4.Identify associated pathology
Harvard Medical School Making the Diagnosis of RAS: Imaging Options Renal arteriography Duplex ultrasound MRA CTA Nuclear Perfusion Renal Vein Renin Sampling
Harvard Medical School Renal Arteriography Advantages Meets all 4 criteria Can size RA and intervene at the same time of diagnosis Sensitivity and Specificity are Gold Standard Disadvantages Expense Risks: Atheroembolis, CIN Oculostenotic
Harvard Medical School Renal Arteriography Can Distinguish Integrity of Main, Accessory, and Branch Vessels Nonatherosclerotic forms of Renovascular Disease FMD Misc: Spontaneous dissection, aneurysmal disease, William’s Syndrome, neurofibromatosis, trauma Atherosclerotic Disease Unilateral or Bilateral ostial disease (75%) Nonostial disease (<20%) Isolated branch disease or segmental disease (5%)
Harvard Medical School Hemodynamic Assessment Hemodynamic Assesment confirms visual estimate 60% stenosis diameter stenosis correlates with 84% CSA reduction to create a pressure drop Magic number is 20 mm Hg Gross, et al. Radiology 2001. 220:751-756 Haimovici, et al. J Cardiovasc Surg. 1962; 3: 259-62
Harvard Medical School Duplex Ultrasound Meets 3 or 4 criteria Least expensive Predict whether stenting will be effective Sensitivity 84-88% Specificity 62-99% Accessory arteries missed Limited imaging in obese, gaseous patients Technician dependent
Harvard Medical School Renal Resistive Index Offers prognosis for intervention Avoid Compression and Valsalva which increase RI RI= PSV-EDV/PSV RI=(1-[Vmin/Vmax]) Multiply by 100 Radermacher J., et al. Hypertension. 2002; 39: 699-703)
Harvard Medical School RRI: Prognosis RI >80 is a strong predictor of death, dialysis or progressive disease Seen with or without RAS Found to be similar with GFR <40 and Proteinuria However, data only based on 25 patients with RI >80 Radermacher J., et al. Hypertension. 2002; 39: 699-703)
Harvard Medical School Outcomes: 215 patients with ≥70% RAS treated with stenting In 52% (99/191) of the patients, Cr decreased during 1-year follow-up 1.21 mg/dL (quartiles: 0.92, 1.60 mg/dL) to 1.10 mg/dL (quartiles: 0.88, 1.50 mg/dL) (P=0.047) MAP decreased from 102±12 mm Hg (mean±SD) at baseline to 92±10 mm Hg (P<0.001) Independent predictors of improved renal function were: Baseline serum Cr (odds ratio [95% CI], 2.58 [1.35 to 4.94], P=0.004) LV function (OR 1.51 [1.04 to 2.21], P=0.032) Zeller. Circulation. 2003;108:2244.
Harvard Medical School Outcomes: 215 patients with ≥70% RAS treated with stenting Female sex, high baseline mean blood pressure, and normal renal parenchymal thickness were independent predictors for decreased mean blood pressure. 1yr mortality was approximately 7.5% CHF or MI (73%) Stroke (13.5%) 7 patients hospitalized with flash pulmonary edema and/or acute renal failure requiring acute hemodialysis could be withdrawn from the chronic hemodialysis program Zeller. Circulation. 2003;108:2244.
Harvard Medical School MRA of the Renals 3 of the 4 requirements No radiation or nephrotoxins Short duration scans Sensitivity 90-100% Specificity 76-94% Expensive Claustrophobia May miss FMD Overcalls Stenoses Stent Artificact
Harvard Medical School CTA of the Renals 3 of the 4 requirements Widely available Visualize stents No Flow Artifact Short duration scans Sensitivity 89-100% Specificity 82-100% Expensive Radiation Contrast Claustrophobia
Harvard Medical School Indications for Continued Medical Treatment Mild HTN Controlled BP on Meds Stable and Good renal function Advanced Age Anatomic/Technical Considerations
Harvard Medical School Indications for Renal Revascularization Hypertensive Control Reasonable Likelihood of Improvement Recent escalation on top of essential HTN Refractory, accelerated or malignant HTN Renal Salvage Unexplained Azotemia or ACE induced Loss of renal mass over time Progression of RAS Cardiac disturbance USA, “Flash Pulmonary Edema”, CHF
Harvard Medical School Predictors of Success Female Gender (p=0.032) MAP at baseline (p<0.001) Renal Failure More improvement if moderate dysfunction (1.5 mg/dl) vs. severe (p=0.025) LV function normal (p=0.032) Neutral: DM an nephrosclerosis
Harvard Medical School Case Selection: Should You ? BP 148/94 2 Antihypertensive Meds 12 mm Hg gradient
Harvard Medical School Case Selection: Should You ? “Drive-by Aortogram” BP 148/94 Atenolol only Creatinine 1.9 NO!
Harvard Medical School Case Selection: Should You ? 28 y/o nurse BP 209/119 mm Hg Meds: None Creat 0.9 LRA normal YES!
Harvard Medical School Case Selection: Should You ? YES!!! BP 196/104 Prinivil, HCTZ, Metoprolol 71 mm gradient
Harvard Medical School What about the incidentalomas? Normal BP, No Meds, Normal GFR Pro Prevent renal injury Treat before it occludes Con ?Data Complications Cost I say, No.
Harvard Medical School SummarySummary Evaluate patient for clues suggesting RAS Perform imaging if patient is a candidate for revascularization Combine imaging studies if necessary Intervene on those who have reasonable life expectancy and potential to benefit from revascularization