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Duane%20S.%20Pinto,%20M.D.

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Interventional Cardiologist Beth Israel Deaconess Medical Center ... Epigastric bruit. Unexplained azotemia. Azotemia while on ACE or ARB ... – PowerPoint PPT presentation

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Title: Duane%20S.%20Pinto,%20M.D.


1
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
2
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

3
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

4
Making the Diagnosis of RAS Imaging Options
  • Renal arteriography
  • Duplex ultrasound
  • MRA
  • CTA
  • Nuclear Perfusion
  • Renal Vein Renin Sampling

5
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

6
Renal Arteriography Can Distinguish Integrity of
Main, Accessory, and Branch Vessels
  • Nonatherosclerotic forms of Renovascular Disease
  • FMD
  • Misc Spontaneous dissection, aneurysmal disease,
    Williams Syndrome, neurofibromatosis, trauma
  • Atherosclerotic Disease
  • Unilateral or Bilateral ostial disease (75)
  • Nonostial disease (lt20)
  • Isolated branch disease or segmental disease (5)

7
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.
220751-756 Haimovici, et al. J Cardiovasc Surg.
1962 3 259-62
8
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

9
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)
10
RRI Prognosis
  • RI gt80 is a strong predictor of death, dialysis
    or progressive disease
  • Seen with or without RAS
  • Found to be similar with GFR lt40 and Proteinuria
  • However, data only based on 25 patients with RI
    gt80

Radermacher J., et al. Hypertension. 2002 39
699-703)
11
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) (P0.047)
  • MAP decreased from 10212 mm Hg (meanSD) at
    baseline to 9210 mm Hg (Plt0.001)
  • Independent predictors of improved renal function
    were
  • Baseline serum Cr (odds ratio 95 CI, 2.58
    1.35 to 4.94, P0.004)
  • LV function (OR 1.51 1.04 to 2.21, P0.032)

Zeller. Circulation. 20031082244.
12
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. 20031082244.
13
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

14
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

15
Indications for Continued Medical Treatment
  • Mild HTN
  • Controlled BP on Meds
  • Stable and Good renal function
  • Advanced Age
  • Anatomic/Technical Considerations

16
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

17
Predictors of Success
  • Female Gender (p0.032)
  • MAP at baseline (plt0.001)
  • Renal Failure
  • More improvement if moderate dysfunction (1.5
    mg/dl) vs. severe (p0.025)
  • LV function normal (p0.032)
  • Neutral DM an nephrosclerosis

18
Case Selection Should You ?
  • BP 148/94
  • 2 Antihypertensive Meds
  • 12 mm Hg gradient

19
Case Selection Should You ?
  • Drive-by Aortogram
  • BP 148/94
  • Atenolol only
  • Creatinine 1.9

NO!
20
Case Selection Should You ?
  • 28 y/o nurse
  • BP 209/119 mm Hg
  • Meds None
  • Creat 0.9
  • LRA normal

YES!
21
Case Selection Should You ?
BP 196/104 Prinivil, HCTZ, Metoprolol
YES!!!
71 mm gradient
22
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.
23
Summary
  • 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
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