Outcomes of endoluminal reintervention for restenosis after percutaneous renal angioplasty and stenting.
Outcomes of endoluminal reintervention for restenosis after percutaneous renal angioplasty and stenting.
复制标题
经皮肾血管成形术和支架置入术后再狭窄的腔内再干预的结果。
DOI：
10.1016/j.jvs.2008.11.039
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发表时间：
2009
影响因子：
4.3
通讯作者：
A. Lumsden
中科院分区：
文献类型：
--
作者：
M. Davies;W. Saad;J. Bismuth;E. Peden;Joseph J. Naoum;A. Lumsden
血管内治疗症状性动脉粥样硬化性肾动脉狭窄（ARAS）是常见的，但与显著的再狭窄率相关。本研究评价了肾介入治疗后症状性再狭窄（血管造影>50%）的经皮腔内治疗的结果。METHODS我们对1990年1月至2008年1月期间接受ARAS血管内介入治疗的患者的记录进行了回顾性分析，并进行了双功超声扫描。临床获益定义为无复发性高血压或肾相关发病率（持续肌酐增加>基线的20%，进展为血液透析，肾相关原因导致的死亡），解剖通畅率，再狭窄和患者生存率进行了测量。共有80支血管再狭窄，5年时的精算再狭窄率为19%。在这些再狭窄中，65例（81%）与复发症状有关（复发性高血压84%，或肾功能持续恶化16%）。55例（85%）接受了再次血管成形术，10例接受了旁路手术。其余的被观察到。对51例患者（61%为女性，平均年龄62岁，范围51-85岁）进行了55次经皮介入治疗。共有73%的患者患有代谢综合征，58%的患者患有高脂血症，51%的患者被认为患有糖尿病;所有患者均在首次手术期间接受了初次支架植入术。两组的技术失败率均为4%。在再狭窄组中，支架存在与9%的技术失败率相关，而在没有支架的情况下，技术失败率仅为3%（P <0.05）。5年时，初次和复发组的生存率（76 ± 2% vs 75 ± 8%，初次vs复发）、累积通畅率（82 ± 3% vs 70 ± 10%）、无再狭窄率（81 ± 3% vs 81 ± 9%）和保留临床受益率（44 ± 4% vs 46 ± 10%）的结局相同。通过考克斯比例风险和多变量分析，他汀类药物治疗与复发性病变无再狭窄相关。他汀类药物、对侧肾脏大小（>9 cm）和3个月内基线肌酐改善≥20%与无复发症状相关。复发性病变治疗后的缓解与复发症状显著相关（斯皮尔曼r = 0.4614，P <0.0004）。结论经皮再介入治疗肾动脉再狭窄是安全有效的，其疗效与初次介入治疗相当。与接受初级干预的患者相比，患者更有可能出现复发性高血压，并且更年轻，女性更易出现复发性高血压。再次介入后的功能结局等同于初次介入。
BACKGROUNDEndovascular therapy for symptomatic atherosclerotic renal artery stenosis (ARAS) is common but is associated with a significant restenosis rate. This study evaluates the outcomes of percutaneous endoluminal therapy for symptomatic restenosis (>50% on angiography) after renal intervention.METHODSWe performed a retrospective analysis of records from patients who underwent endovascular intervention for ARAS and were followed by duplex ultrasound scan between January 1990 and January 2008. Clinical benefit defined as freedom from recurrent hypertension or renal-related morbidity (increase in persistent creatinine >20% of baseline, progression to hemodialysis, death from renal-related causes), anatomic patency, restenosis, and patient survival were measured.RESULTSA total of 447 patients underwent 619 renal artery interventions. A total of 80 vessels restenosed with an actuarial restenosis rate of 19% at 5 years. Of these restenoses, 65 (81%) were associated with recurrent symptoms (recurrent hypertension 84%, or continuing deterioration in renal function 16%). Fifty-five (85%) underwent repeat angioplasty and 10 underwent bypass surgery. The remainder was observed. The 55 percutaneous interventions were performed in 51 patients (61% female, average age 62 years, range, 51-85). A total of 73% had metabolic syndrome, 58% had hyperlipidemia, and 51% were considered diabetic; all of them had primary stenting during their first procedure. There was a 4% technical failure rate in both groups. In the restenosis group, the presence of stent was associated with a 9% technical failure rate, while in the absence of a stent the technical failure rate was only 3% (P < .05). At 5 years, outcomes were equivalent between the primary and recurrent groups for survival (76 ± 2% vs 75 ± 8%, primary vs recurrent), cumulative patency (82 ± 3% vs 70 ± 10%), freedom from restenosis (81 ± 3% vs 81 ± 9%), and retained clinical benefit (44 ± 4% vs 46 ± 10%). By Cox proportional hazards and multivariate analysis, administration of statins were associated with freedom from restenosis in the recurrent lesions. Statins, contralateral kidney size (>9 cm) and a ≥20% improvement in baseline creatinine with 3 months were associated with freedom from recurrent symptoms. Restenosis after therapy in recurrent lesions was significantly correlated with recurrent symptoms (Spearman r = 0.4614, P < .0004).CONCLUSIONPercutaneous reintervention for renal artery restenosis is safe and effective with equivalent outcomes to primary intervention. The patients are more likely to present with recurrent hypertension and be younger and of female gender than patients presenting for primary intervention. Functional outcomes after reintervention are equivalent to primary intervention.