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FAUT-IL ENCORE RECHERCHER UNE STENOSE ARTERIELLE RENALE ?
Docteur Guillaume BOBRIE
Service d’HTA - HEGP - Paris
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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
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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
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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
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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
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GFR at baseline and 1 month
No difference in procedural or bleeding complications
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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
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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
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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
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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
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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
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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?
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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
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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
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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
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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