同种异体肾移植术后移植肾动脉狭窄 介入治疗的临床疗效分析

目的探讨同种异体肾移植术后移植肾动脉狭窄（TRAS）介入治疗的临床疗效。方法介入治疗同种异体肾移植术后TRAS患者22例,其中单纯球囊扩张治疗10例（球囊组）,内支架治疗12例（支架组）。对所有患者术前及术后2年内血压、肾功能以及生活质量进行评估,并与同期接受单纯药物治疗的6例TRAS患者（药物组）进行比较。结果球囊组技术成功率90.00%,支架组技术成功率100%。术后在血压及肾功能改善方面,球囊组和支架组均取得显著疗效,两组近期疗效未见明显差异,药物组疗效不满意。术后随访6个月～2年,支架组再狭窄率16.67%,除1例不明原因治疗无效外,其余11例均能比较健康的生活和工作。球囊组手术失败1例,再狭窄率达40.00%。结论内支架植入术可作为TRAS特别是I型及Ⅱ型狭窄的首选治疗方法。     

支架成形术治疗粥样硬化性肾动脉狭窄的疗效观察：附27 例报告

目的:探讨支架成形术治疗粥样硬化性肾动脉狭窄(ARAS)的临床疗效.方法:回顾性分析3年来应用支架成形术治疗的27例ARAS患者的临床资料.所有患者术后均定期(术后1,3,6,12个月)随访检测肾动脉狭窄率,肾动脉阻力指数(RI),血压,血肌酐(SCr),肾小球滤过率(GFR)及服用降压药物的种数.结果:27例患者手术均获成功,技术成功率100％.与术前比较,患者术后各时间点各项观察指标均明显改善,差异均有统计学意义(均P＜0.05).1年随访期间,肾动脉再狭窄发生率14.8％(4/27),肾动脉RI改善率92.6％ (25/27),收缩压改善率85.2％ (23/27),舒张压改善率74.1％ (20/27),SCr改善率66.7％(18/27),GFR改善81.5％(22/27),服用降压药物种数减少63.0％(17/27).结论:应用支架成形术治疗ARAS能明显改善肾功能,降低血压,减少口服降压药种类,有较好的安全性和疗效.     

经皮腔内血管成形术及支架治疗儿童和青少年肾动脉狭窄短期及长期疗效

目的 评估经皮经腔内血管成形术(PTA)及支架治疗儿童和青少年肾动脉狭窄的短期及长期疗效.方法 分析34例接受PTA及支架治疗的儿童和青少年肾动脉狭窄患者,并分为肌纤维发育不良(FMD,n=17)和大动脉炎(TA,n=17)两组,术后短期(围手术期< 30天)、3、6、12个月进行随访,之后每隔1年随访.记录介入治疗前及随访期血压,采用限定每日剂量(DDD)比较介入治疗前后药物剂量变化,比较介入治疗前后血肌酐水平,并比较两组的疗效.结果 34例患者(40支病变肾动脉)接受PTA,手术成功率为90.00%(36/40).随访中位时间30.0个月.随访期间血压较术前明显下降(P <0.001).患者术后短期DDD较术前无明显变化(P >0.05);但术后3个月、1年、3年、5年较术前差异有统计学意义(P <0.05).随访期间平均血肌酐较术前无明显变化(P >0.05).患者术后1年、3年、5年总体获益率(治愈+改善)分别为89.54%、66.89%、61.53%.随访期间FMD组的总体治愈率高于TA组.结论 采用PTA及支架治疗儿童和青少年RAS安全可靠,且短期及长期临床获益良好.PTA治疗对于FMD患者获益程度大于TA患者.     

肾动脉狭窄患者肾动脉支架置入术后再狭窄及肾功能和血压的改变

目的评估肾动脉支架术后再狭窄的发生及肾功能及血压的改变。方法对135 例单侧或双侧肾动脉明显狭窄(管腔内径减少≥70％)的患者行肾动脉支架置入术(PTRAS),术后行肾动脉造影、血压及血肌酐(Scr)的随访观察。结果 135例患者植入147枚支架均获成功。术后肾动脉造影随访率70％,平均随访时间为(7．2±5．6)月,再狭窄率为7．4％。血压及肾功能随访率为95％,平均随访时间(22±6)月,随访患者的收缩压与舒张压均明显下降,分别为 [(172±23)比(159±20)mm Hg,P<0．05,(93±16)比(85±13)mm Hg,P<0．05]。但术后12个月及24个月Scr和GFR与术前比较无显著性差异。结论肾动脉支架置入术后的再狭窄率较低,PTRAS有助于患者的血压控制。     

血管内支架成形术治疗肾动脉狭窄的临床研究

目的探讨血管内支架成形术治疗肾动脉狭窄的安全性及临床疗效。方法回顾性分析2008年8月~2015年9月我院行血管内支架置入术的85例肾动脉狭窄患者临床资料,观察其手术成功率、围手术期并发症发生率及临床疗效。结果 85例患者共成功植入85枚球扩式肾动脉支架,手术成功率100%。围手术期未发生动脉夹层、支架内血栓形成、急性肾功能衰竭等并发症。术后血压较术前呈逐渐下降趋势,服用降压药数减少,肾功能-血肌酐稳定。85例患者随访6个月~7年,平均(21.3±18.4)个月。随访期间发现肾动脉再狭窄8例(9.4%),均为无症状性狭窄。无责任血管相关的肾功能恶化。结论血管内支架成形术治疗肾动脉狭窄能解除血管狭窄,可有效改善血压,防止肾功能恶化,是一种安全有效的治疗方法。     

移植肾动脉狭窄腔内治疗的中期结果

目的探讨移植肾动脉狭窄经皮血管腔内成形(PTA)及支架置入的安全性及中远期结果。方法回顾性分析2011年1月至2018年12月解放军总医院血管外科收治的18例移植肾动脉狭窄患者的临床资料。结果3例经同侧股动脉,15例经对侧股动脉人路治疗。4例单纯PTA治疗,8例PTA后置入支架,6例直接置入支架。共置入14枚支架,均为球扩式支架,其中2枚为药涂支架,技术成功率100%。平均造影剂用量64ml,治疗前肾动脉狭窄率为50%〜99%,腔内治疗后狭窄率降为10%〜30%。收缩压由术前的(157.2±43.0)mmHg降至术后的(129.8±8.6)mmHg;血清肌酐(SCr)水平由术前的(258.8±214.7)μmol/L降至术后的(176.3±101.1)μmol/L,尿素氮由术前的(15.7±1.6)mmol/L降至术后(10.6±1.1)mmol/L(均P<0.05)。术后中位随访42.4个月(3~93个月),治愈17例,无效1例,1例单纯球囊扩张后术后30 d出现再狭窄,予以置入支架。除1例移植肾动脉出血外无其他并发症。结论移植肾动脉狭窄是导致移植肾失功的常见血管因素,腔内治疗安全、有效。     

移植肾动脉狭窄的诊治(附3例报告)

目的探讨移植肾动脉狭窄的诊治方法. 方法回顾性分析253例肾移植术后发生的3例移植肾动脉狭窄(transplant renal artery stenosis, TRAS)的诊治经过. 结果 3例TRAS均发生于肾移植术后半年内,经彩超和肾动脉造影确诊.3例均行经皮穿刺移植肾动脉球囊扩张成形(percutaneous transluminal renal angioplasty, PTRA)和血管内支架置入,获临床治愈.随访15～24个月,无TRAS复发,移植肾功能正常. 结论彩超是筛选TRAS的首选检查方法,肾动脉造影是TRAS的确诊手段.PTRA/血管内支架置入是治疗TRAS的安全、有效和首选方法.     

主动脉-肾动脉自体大隐静脉旁路术治疗大动脉炎性肾动脉狭窄33例分析

目的 分析主动脉-肾动脉自体大隐静脉旁路术治疗大动脉炎性肾动脉狭窄的近期及中长期疗效.方法 回顾性分析1997年3月至2009年3月采用主动脉-肾动脉大隐静脉旁路术治疗的连续33例大动脉炎性肾动脉狭窄患者的临床资料.其中男性9例,女性24例;年龄8 ～ 54岁,平均(25±11)岁;病程3～26个月,平均(9±5)个月.所有患者存在高血压,其中17例为难控性高血压,平均血压( 175±26)/(100±19)mmHg(1 mmHg =0.133 kPa),平均降压药物用量(2.1±0.6)个每日规定量(DDD).3例合并充血性心力衰竭,1例依靠持续血液滤过治疗生存.术前估算肾小球滤过率为(78±5)mL/min.结果 共对39条肾动脉行旁路术治疗,包括单侧27例和双侧6例.肾动脉即时复通率100％.所有患者存活并成功随访12～146个月,平均(56±18)个月.随访过程中发生移植物闭塞2例,移植物狭窄4例,4例狭窄均通过经皮球囊扩张术成功治疗,其中1例6个月后发生再狭窄.1年、3年、5年一期通畅率分别为92％、89％、79％,一期辅助通畅率和二期通畅率相同,分别为95％、95％、91％.末次随访平均血压降至136/80 mmHg(P =0.000),平均降压药物用量降为0.6 DDD(P =0.000),平均估算肾小球滤过率增至91 ml/min(P =0.044).3例充血性心力衰竭均缓解,1例肾功能不全患者不再依赖持续血液滤过治疗.结论 主动脉-肾动脉自体大隐静脉旁路术治疗大动脉炎性肾动脉狭窄近远期疗效确实,通畅率高.     

肾动脉狭窄80例外科治疗

目的 探讨肾动脉狭窄外科治疗方法的选择和疗效.方法 回顾性分析1997年11月到2008年8月80例肾动脉狭窄患者的外科治疗经验.男性53例,女性27例,年龄9～80岁.病变包括动脉硬化42例,大动脉炎23例,肌纤维发育不良11例.共接受外科治疗83人次,其中腹主动脉肾动脉旁路术13例,自体肾移植术5例,肾切除术1例,肾动脉内膜切除术1例,肾动脉狭窄段切除吻合术1例,球囊扩张术14例,支架成形术48例.结果 围手术期死亡1例.63例获得随访,随访时间1～129个月,2例死亡.随访患者血压(135.7±15.8)/(80.1±8.5)mm Hg(1 mm Hg=0.133kPa),较术前(149.8±18.3)/(88±13.6)mm Hg下降(P<0.01).总的降压有效率为65.6%,动脉硬化、大动脉炎、肌纤维发育不良患者的降压有效率分别为50%、73.3%和100%(P<0.05).随访患者肌酐(112.7±53.6)/μmol/L,低于术前(131.7±91.7)μmol/L(P<0.05).结论 肾动脉狭窄通过外科治疗可以有效改善血压和肾功能,动脉硬化病变首选支架成形,肌纤维发育不良性病变首选球囊扩张,大动脉炎性病变首选手术治疗.     

对比经皮腔内肾动脉球囊扩张成形术与支架植入术治疗移植肾动脉狭窄的有效性及安全性

目的 对比经皮腔内肾动脉球囊扩张成形术与经皮腔内肾动脉支架植入术治疗移植肾动脉狭窄(TRAS)的安全性及有效性。方法 纳入39例接受腔内治疗的TRAS患者,根据治疗方式分为经皮腔内肾动脉球囊扩张成形术组(球囊组,n=21)及植入肾动脉支架组(支架组,n=18);比较组间治疗前、后的收缩压、舒张压、血肌酐、移植肾动脉峰值血流速度(PSV)及段间动脉阻力指数(RI)变化,以及并发症率、手术成功率和术后6个月一期通畅率。结果 2组治疗成功率均为100%,并发症发生率差异无统计学意义(P>0.05)。治疗前及治疗后1、6个月,2组各指标差异均无统计学意义(P均>0.05)。治疗后1、6个月,2组血肌酐、PSV均较术前降低,RI均较术前升高(P均<0.05);治疗后6个月2组收缩压、舒张压均较术前及术后1个月降低(P均<0.05)。治疗后6个月支架组一期通畅率高于球囊组(94.44%vs. 66.67%,P<0.05)。结论 经皮腔内肾动脉球囊扩张成形术与经皮腔内肾动脉支架植入术治疗TRAS均安全、有效;相比前者,采用后者治疗后肾动脉再狭窄发生率更低。     

“The Challenge Facing Renal Artery Revascularization: What Have we Not Proven and Why we Must?”

Endovascular renal artery stent therapy for atherosclerotic renal artery stenosis (RAS) is associated with excellent acute technical success, low complication rates and acceptable long-term patency. However, the clinical benefits to patients of renal artery stenting remain uncertain.

To facilitate debate regarding the treatment of RAS, we need to understand the epidemiology, basic physiology and clinical consequences of renal artery stenosis. We must attempt to determine which patients are likely to benefit from renal artery stenting, assess the nuances of the percutaneous procedure and review the current literature pertaining to renal artery stenting.     

Clinical outcomes from hepatic artery stenting in liver transplantation.

Hepatic artery stenosis after liver transplantation may affect liver function and result in hepatic artery thrombosis. Surgical reconstruction has been the first choice for treatment. Interventional radiologic technique can be used, but there is no report on long-term outcome. The aim of this paper is to assess current outcome and complications of hepatic artery stenting. Twenty-six adult patients were stented for hepatic artery stenosis between 1998 and 2003. Nine patients had previous surgical reconstruction for hepatic artery stenosis. Seventeen patients suffered newly developed hepatic artery stenosis. Three patients were retransplanted. After stenting, the patients were followed by Doppler ultrasound at day 1, 1 month, and 6 months. Angiography was scheduled in 6 months. Four patients died within 2 months. The other 22 patients were followed for mean 31 +/- 14 months (8-71 months). One of 22 patients died from renal failure 2 years later. Twelve patients' hepatic arteries looked normal after stenting. Restenosis was seen in 8 patients (36%). Other complications were artery thrombosis (n = 1) and long segment stricture (n = 1). In 2 patients (25%) restenosis resulted in thrombosis. Six of the 8 patients who developed recurrent stenosis were successfully treated interventionally: restent (n = 5) and balloon dilation (n = 3). However, 3 patients (38%) restenosed. Kaplan-Meier complication-free survival was 54% at 1 year after stenting. In conclusion, hepatic artery stenting is a viable treatment for hepatic artery stenosis with reasonable results. Stenting is useful as adjuvant treatment after surgical revision.     

The results of treatment in renal artery stenosis due to Takayasu disease: comparison between surgery,angioplasty, and stenting. A monocentrique retrospective study

Purpose

To evaluate retrospectively and compare the long-term patency and the antihypertensive effect of open surgery, angioplasty, and stent insertion of the renal artery stenosis due to Takayasu’s arteritis.

Patients and methods

We retrospectively analyzed and compared the effects on blood pressure and permeability of the renal artery over 23 patients (age ranging from 16 to 60 years, mean 33.9 years); with renovascular hypertension caused by Takayasu’s arteritis. those patients underwent surgical treatment (11 arteries) or endovascular (19) including angioplasty (11) and stenting (8) for 30 stenotic renal arteries.

Results

Technical success was 96.7% (29/30) without major complications (but longer period of hospitalization among patients who had surgery). In the last follow-up CT angiography (mean 60 ± 36 months), restenosis was 18.2% (2/11) in the surgery, 9% (1/11) in the angioplasty, and 62.5% (5/8) in the stenting. Rate of the permeability of the surgery was 100%, 90.9%, 81.8%, the permeability of the angioplasty was 100%, 90.9%, 90.9%, primary patency rate stenting was 62.5%, 37.5%, 37.5%, assists permeability was 87.5%, 75%, 50% at 1, 3 and 5 years, respectively.In the clinical follow-up (mean 60 ± 37.8 months, range 48–96 months) beneficial effects on blood pressure were achieved into 91.3% of patients (21/23), and there was no significant difference between patients who have been treated by surgery and angioplasty alone and the patients who received a stent in at least one renal artery.

Conclusion

Angioplasty has shown better long-term patency and a similar clinical benefit of renovascular hypertension in renal artery stenosis caused by Takayasu’s arteritis compared with the surgery and the stenting. We suggest that stenting should be reserved in case of clear failure of the angioplasty. The surgery is our choice for patients who do not meet the indication of endovascular treatment or failure of this treatment.     

Reappraisal of Primary Balloon Angioplasty without Stenting for Patients with Symptomatic Middle Cerebral Artery Stenosis

There is a controversy regarding the safety and efficacy of intracranial stenting. We describe our experience with primary balloon angioplasty without stenting for symptomatic middle cerebral artery (MCA) stenosis. All patients who underwent balloon angioplasty without stenting for MCA stenosis between 1996 and 2010 were retrospectively reviewed. We evaluated technical success rates, degrees of stenosis, and stroke or death within 30 days. Among patients who were followed-up for > 1 year we evaluated latest functional outcomes, stroke recurrence at 1 year, and restenosis. In total 45/47 patients (95.7%) were successfully treated. Average pre- and postprocedure stenosis rates were 79.9% and 39.5%, respectively. Three neurological complications occurred within 30 days: one thromboembolism during the procedure; one lacunar infarction; and one fatal intraparenchymal hemorrhage after the procedure. Stroke or death rate within 30 days was 6.4%. Thirty-three patients were available for follow-up analysis with a mean period of 51.5 months. The combined rate of stroke or death within 30 days and ipsilateral ischemic stroke of the followed-up patients within 1 year beyond 30 days was 9.4%. Restenosis was observed in 26.9% of patients and all remained asymptomatic. In our retrospective series, balloon angioplasty without stenting was a safe, effective modality for symptomatic MCA stenosis. For patients refractory to medical therapy, primary balloon angioplasty may offer a better supplemental treatment option.     

Divergent outcomes after percutaneous therapy for symptomatic renal artery stenosis

OBJECTIVE: Percutaneous intervention for symptomatic renal artery atherosclerosis is rapidly replacing surgery in many centers. This study evaluated the anatomic and functional outcomes of endovascular therapy for atherosclerotic renal artery stenosis on a combined vascular surgery and interventional radiology service at an academic medical center. METHODS: This was a retrospective analysis of patients who underwent renal artery angioplasty with or without stenting between January 1990 and June 2002. Indications included hypertension (86%) and rising serum creatinine concentration (55%). One hundred forty-six patients (80 women; average age, 71 years [range, 44-89 years]) underwent 183 attempted interventions (64 to treat bilateral stenosis). Forty-five percent of patients had significant bilateral disease: 27% had greater than 50% bilateral stenosis, and the remainder had nonfunctioning, absent, or occluded vessels. RESULTS: Of 183 planned interventions, technical success (<30% residual stenosis) was achieved in 179 vessels (98%) with placement of 137 stents (75%). Thirty-day mortality was 0.7%. The major morbidity rate was 4%, and the procedure-related complication rate was 18%. Five-year cumulative patient mortality was 25%. Primary patency, assisted primary patency, and recurrent stenosis rates were 82% +/- 9%, 100% +/- 0%, and 30% +/- 7%, respectively, at 5 years. Within 3 months of the procedure, 52% of patients who received treatment of hypertension demonstrated clinical benefit (hypertension improved or cured), which was maintained in 68% of patients at 5 years. Serum creatinine concentration was lowered or stabilized in 87% of patients within 3 months of the procedure, but this benefit, including freedom from dialysis, was maintained in only 45% of patients at 5 years. CONCLUSIONS: Endovascular intervention for symptomatic atherosclerotic renal artery stenosis is technically successful. There were excellent patency and low recurrent stenosis rates. There is immediate clinical benefit for most patients, but divergent long-term functional outcomes. Endovascular interventions modestly enhance the care of the patient with hypertension, but poorly preserve long-term renal function in the patient with chronic renal impairment.     

肾动脉狭窄血管腔内治疗的临床研究

目的评估肾动脉狭窄血管腔内治疗的安全性与疗效。方法33例肾动脉狭窄患者因严重高血压或伴有肾功能不全而进行了肾动脉经皮血管腔内成形和支架植入术（PTRAS）,随访7～49个月,平均（244-2）个月,观察手术对患者血压、肾功能及病死率的影响。结果手术技术成功率为97．0％;2例（6．1％）术后4个月内死于心肌梗死;5例（15．2％）术前血清肌酐（Scr）≥177μmol／L,术后血压、Scr无明显改善,其中4例术后17～28个月死于尿毒症;总的病死率为18．2％。术前Scr〈177μmol／L的患者,术后12、24个月,收缩压及舒张压明显下降,服用降压药物种类明显减少（P〈0．05）。结论无严重心肾疾病的患者,PTRAS能明显降低血压,稳定肾功能,减少口服降压药种类,有较好的安全性和疗效;术前Scr≥177μmol／L的患者,术后病死率高,行PTRAS要慎重。肾保护装置可能对肾功能有保护作用。     

Minimally invasive salvage therapy for transplanted renal allografts

Abstract

Purpose: To evaluate the effectiveness of interventional therapy for complications of transplanted renal allografts. Materials and methods: Between January 2009 and March 2014, 14 patients underwent interventional therapy for complications of renal allografts. Complications included transplant renal artery stenosis (TRAS), TRAS combined with pseudoaneurysms, transplant renal venous kinking and ureteral obstruction (UO). Serum creatinine (S.Cr) levels were evaluated before and after procedure. The characteristics and procedure outcomes of these patients with vascular and nonvascular complications were also analyzed. Results: All primary procedures were successfully performed, which included percutaneous transluminal angioplasty (PTA) for TRAS (n?=?4), stenting and coil embolization for TRAS combined with pseudoaneurysms (n?=?1), stenting for renal vein kinking (n?=?2), and percutaneous nephrostomy (PCN) for UO (n?=?7) and secondary antegrade stent placement in six UO patients after 1 week of PCN. No major procedure related complications occurred. S.Cr level subsequently improved from 6.0?±?3.6 to 2.6?±?2.1?mg/dL (p?<?0.001), as well as patients’ clinical features within 1 week after procedure. In our study, the onset time of vascular complications was earlier (<6 months) than nonvascular complications with significant difference (p?<?0.001). During follow-up, the patient with TRAS and pseudoaneurysms suffered acute rejection 1 month after treatment and received transplant renal artery embolization. One patient with TRAS showed restenosis 4 months after procedure, and was retreated successfully with stenting. Thirteen cases reserved their transplanted renal allografts. Conclusion: Interventional therapy could be prior considered for transplanted renal allograft complications as its effectiveness and minimal invasiveness in saving the transplanted renal grafts.