faut-il encore rechercher une stenose arterielle renale ?
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FAUT-IL ENCORE RECHERCHER UNE STENOSE ARTERIELLE RENALE ?
Docteur Guillaume BOBRIE
Service d’HTA - HEGP - Paris
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 -0.8 0.001
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
Van de Ven et al., Lancet 1999;353:282
STENTING TO PREVENT RESTENOSIS
Stent No stentp
No. randomized 42 42
Primary success, % 88 57<0.05
Restenosis, % 14 48<0.01
6-month patency, % 80 51 <0.05
6-month BP, mmHg 160/90 165/90 NS
6-month creatinine, µM/l 140 134 NS
Revascularisation improves renal artery patency, not upstream aortic stiffness, nor downstream parenchymal microvascular disease and fibrosis
COMPLICATIONS IN 37 PROSPECTIVE STUDIES
Death by 30 daysDeath by 30 days up to 3%up to 3%
Transient reduction in GFRTransient reduction in GFR 1-13%1-13%
Renal artery or parenchymal injuryRenal artery or parenchymal injury up to 5%up to 5%
Peri-procedural CV eventsPeri-procedural CV events up to 3%up to 3%
Distal athero-embolisationDistal athero-embolisation unknownunknown
E Balk et al. Ann Intern Med 2006;145:901
J Hiramoto et al. J Vasc Surg 2005;41:1026
346 2
74
38
92
78
45
103
59
0.1-0.2 0.2-0.5 0.5-1 >1 mm
guide wire
first balloonsecond balloon
Em
boli
rele
ased
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 protectiondevice + abciximab
n=25
No protectiondevice, no abciximab
n=28
Protection device, no abciximab
n=22
Ab
cix
ima
b (
Re
op
ro)
bo
lus
+ in
fusi
on
/12
h
Filter-based embolic protection device
CJ Cooper et al. Circulation 2008;117:2752
GFR at baseline and 1 month
No difference in procedural or bleeding complications
RANDOMIZED TRIALS WITH LONG-TERM FU
STAR1 STent placement in Atherosclerotic ostial RAS
Indication: controllable HTN and GFR 15-802n=140, 2-year FU, renal events
ASTRAL2 Angioplasty + STent for Renal Artery Lesions
Indication: uncertain whether to revascularise
2n=1000, 5-year FU, reciprocal creatinine plot
CORAL3 Cardiovascular Outcomes in RA LesionsIndication: SBP >155, >2 drugs, RAS >60%2n=1080, 5-year FU, CV and renal events
1 Utrecht University & Dutch Kidney Foundation2 MRC and University of Birmingham CTU3 NHLBI, Cooper CJ et al, Am Heart J 2006;152:59
STAR
Medical Revasc.No 76 64
BP, mmHg 163/82 160/83
Rx score 2.9 2.8
eGFR, ml/min 46±16 45±15
Bilateral stenosis, % 46 50
Primary endpoint,* % 22 16ns
BP at FU 155/79 151/77ns
eGFR at FU 46±20 50±22ns
All cause mortality, % 8 8ns
* >20% decrease in eGFR
L Bax et al. Ann Intern Med 2009;150:840
3 lethalcomplications
Primary end point Primary end pointplus death
Cum
ulat
ive
surv
ival
Caution: limited power, included patients falsely identified as having RAS >50% by noninvasive imaging
STAR
ASTRAL
Results from patients who completed one year of follow-upPhilip Kalra, ACC Chicago, March/April 2008
Medical Revasc
N 403 403
eGFR, ml/min 46±16 45±15
BP, mmHg 163/82 160/83
Rx score 2.8 2.8
Bilateral stenosis, % 40 40
‘Serious procedural complications’ 3%
No between group differences in Scr or BP at one year FU
Early termination for futility
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
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 RAS
minimal 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;53:986. 2 Caps, Circulation 1998;98:28663 Simon, Am J Hypertens 2000;13:1189. 4 Drieghe, Eur Heart J 2008;29:517
Benefit diluted by inclusion of non-critical stenoses?
ASTRAL: pre-specified subgroup analyses
Subgroup Groups
SCr <150, 151-249, >250 mol/l
GFR <30, 30-45, >45 ml/min
Stenosis <70%, 71-89%, >90%
Renal length <9, 9-10, >10 cm
Rapid increase in SCr
Yes, No, Not Known
No benefit at any stenosis grade
ACEI/ARB in patients with RAS
DG Hackam et al. Am Heart J 2008;156:549
Inhib. Inhib. better worse
Death, MI or stroke
1° outcome 0.70 [0.59-0.82]Death 0.56 [0.47-0.68]Stroke 0.86 [0.58-1.29]MI 1.07 [0.76-1.51]CHF 0.69 [0.53-0.90]Acute renal F* 1.87 [1.05-3.33]Hemodialysis 0.62 [0.42-0.92]
*36/60 reversible
Adjusted HR [95%CI]
3570 patients aged >65 y with renovascular disease
Incidence of primary outcome 14% per year
Consider PTRA
RAS >60%
yesResistance index > 80Kidney length < 80 mm
HTN plus high CV and renal risk
Rx including ACEIstatin, aspirin
Resistant HTN, CHF or
in Ccr
CT- or MR-angio
inCcr 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
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
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