RESUMO
PURPOSE: To describe a single-center experience with robotic-assisted endovascular treatment for transplant renal artery stenosis. MATERIALS AND METHODS: This is a single-center, retrospective, feasibility study of 4 consecutive cases of robotic-assisted endovascular surgery for transplant renal artery stenosis from October 2021 to August 2022. RESULTS: All lesions were identified, and stenting was performed with no complications. Conversion to manual control was not necessary. The mean fluoroscopy time was 25.25 min (range 12-60.9). A control Doppler ultrasound was routinely performed, demonstrating no residual lesions in all cases. There was no reintervention during the follow-up period. The operator learning curve was felt to be acceptable. CONCLUSION: Robotic-assisted endovascular treatment is a feasible technique for transplant renal artery stenosis.
Assuntos
Procedimentos Endovasculares , Estudos de Viabilidade , Transplante de Rim , Obstrução da Artéria Renal , Procedimentos Cirúrgicos Robóticos , Humanos , Obstrução da Artéria Renal/diagnóstico por imagem , Obstrução da Artéria Renal/cirurgia , Obstrução da Artéria Renal/terapia , Estudos Retrospectivos , Masculino , Feminino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Robóticos/métodos , Procedimentos Endovasculares/métodos , Stents , Adulto , Resultado do Tratamento , Idoso , Artéria Renal/diagnóstico por imagem , Artéria Renal/cirurgiaRESUMO
OBJECTIVE: Endovascular treatment through either percutaneous transluminal angioplasty (PTA) alone or stenting has been previously used as a treatment for transplant renal artery stenosis (TRAS). This review aimed to investigate the results of endovascular treatment for renal artery stenosis in transplanted kidneys as compared with the outcomes of interventions, medical management, and graft survival in non-TRAS patients. METHODS: A systematic review of PubMed, Google Scholar, Cochrane, and Scopus was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in which studies that reported outcomes of the treatment of TRAS via the endoluminal approach were identified, and their results were meta-analyzed. RESULTS: Fifty-four studies with a total of 1522 patients were included. A significant reduction of serum creatinine level was found, favoring the stenting group, with a mean difference of 0.68 mg/dL (95% confidence interval (CI), 0.17-1.19; Z=2.60, p=0.0009). Comparison of pre- and post-intervention values of any intervention revealed a significant decrease in overall serum creatinine level (0.65 mg/dL; 95% CI, 0.40-0.90; Z=5.09, p=0.00001), overall blood pressure, with a mean difference of 11.12 mmHg (95% CI, 7.29-14.95; Z=5.59, p=0.00001), mean difference in the use of medications (0.77; 95% CI, 0.29-1.24; p=0.002), and peak systolic velocity (190.05; 95% CI, 128.41-251.69; p<0.00001). The comparison of serum creatinine level between endovascular interventions and best medical therapy favored endovascular intervention, with a mean difference of 0.23 mg/dL (95% CI, 0.14-0.32; Z=5.07, p<0.00001). Graft survival was similar between the treated patients and those without TRAS (hazard ratio, 0.98; 95% CI, 0.75-1.28; p=0.091). The overall pooled success rate was 89%, and the overall complication rate was 10.4%, with the most prevalent complication being arterial dissection. CONCLUSION: The endovascular treatment of TRAS improves graft preservation and renal function and hemodynamic parameters. PTA + stenting appears to be a more effective option to PTA alone in the stabilization of renal function, with additional benefits from decreased restenosis rates. Further high-quality studies could expand on these findings.
Assuntos
Transplante de Rim , Obstrução da Artéria Renal , Angioplastia/efeitos adversos , Humanos , Transplante de Rim/efeitos adversos , Obstrução da Artéria Renal/diagnóstico por imagem , Obstrução da Artéria Renal/etiologia , Obstrução da Artéria Renal/terapia , Estudos Retrospectivos , Stents/efeitos adversos , Resultado do TratamentoRESUMO
Abstract Renal transplant remains the preferred therapy for end-stage renal disease (ESRD). Given the shortage of suitable donor kidneys, use of an expanded criteria donor (ECD) allows marginal kidneys to be transplanted; albeit at risk of increased graft failure due to lower nephron mass. To reduce the risk of graft failure, double kidney transplant (DKT) is advocated, with favorable outcomes. Transplant renal artery stenosis (TRAS) is one of the most common vascular complications following renal transplant. Unlike single kidney transplants, where TRAS usually presents with fluid overload, uncontrolled hypertension, and worsening kidney functions; it may be clinically silent in DKT patients since they have two functional transplanted kidneys. We hereby report a case of TRAS in a DKT patient who had 2 years of favorable clinical outcomes following successful endovascular stenting. He however recently died of COVID-19 associated pneumonitis.
Resumo O transplante renal continua sendo a terapia preferida para doenças renais em fase terminal. Dada a escassez de rins de doadores adequados, o doador com critérios expandidos permite que rins marginais sejam transplantados, embora haja um maior risco de falha do enxerto devido à diminuição da massa nefrótica. Para diminuir o risco de falha do enxerto, recomenda-se o transplante renal duplo (TRD), com resultados favoráveis. A estenose de artéria renal transplantada (EART) é uma das complicações vasculares mais comuns após o transplante renal. Ao contrário dos transplantes de rim simples, nos quais a EART geralmente se manifesta como sobrecarga de fluido, hipertensão descontrolada e piora das funções renais, ela pode ser clinicamente silenciosa em pacientes com TRD, pois eles têm dois rins funcionais transplantados. Relatamos aqui um caso de EART em um paciente com TRD que teve resultados clínicos favoráveis por dois anos após o sucesso do implante de stent endovascular. No entanto, ele morreu recentemente de pneumonite associada à covid-19.
Assuntos
Humanos , Masculino , Pessoa de Meia-Idade , Obstrução da Artéria Renal/terapia , Trombose , Transplante de Rim/efeitos adversos , Angioplastia , Stents Farmacológicos , Artéria Renal , Transplante de Rim/métodos , Seleção do Doador/métodos , Procedimentos Endovasculares , TransplantadosRESUMO
A 53-year-old man with stable coronary disease and dyslipidemia was admitted with sudden pain of severe intensity in the left flank. Selective catheterization of the left renal artery, followed by alteplase infusion for 6 hours, resolved the patient's symptoms.
Assuntos
Angiografia por Tomografia Computadorizada/métodos , Ventrículos do Coração/diagnóstico por imagem , Infarto , Rim , Obstrução da Artéria Renal , Terapia Trombolítica/métodos , Ecocardiografia/métodos , Fibrinolíticos/administração & dosagem , Humanos , Infarto/diagnóstico por imagem , Infarto/fisiopatologia , Infarto/terapia , Infusões Intra-Arteriais/métodos , Rim/irrigação sanguínea , Rim/diagnóstico por imagem , Rim/patologia , Masculino , Pessoa de Meia-Idade , Obstrução da Artéria Renal/diagnóstico , Obstrução da Artéria Renal/fisiopatologia , Obstrução da Artéria Renal/terapia , Trombose/diagnóstico por imagem , Trombose/terapia , Ativador de Plasminogênio Tecidual/administração & dosagemRESUMO
BACKGROUND: The indications for conservative "best medical treatment" (BMT) versus additional renal artery stenting are a matter of ongoing debate. The RADAR study aimed to evaluate the impact of percutaneous renal artery stenting on the impaired renal function in patients with hemodynamically significant atherosclerotic renal artery stenosis (RAS). METHODS: RADAR is an international, prospective, randomized (1:1) controlled study comparing BMT alone versus BMT plus renal artery stenting in patients with duplex sonographic hemodynamically relevant RAS. Follow-up assessments were at 2, 6, and 12 months and at 3 years. The primary endpoint was change in estimated glomerular filtration rate (eGFR) at 12 months. RESULTS: Due to slow enrollment, RADAR was terminated early after inclusion of 86 of the scheduled 300 patients (28.7%). Change in eGFR between baseline and 12 months was 4.3 ± 15.4 ml/min/1.73 m2 (stent group) and 3.0 ± 14.9 ml/min/1.73 m2 (BMT group), p > 0.999. Clinical event rates were low with a 12-month composite of cardiac death, stroke, myocardial infarction, and hospitalization for congestive heart failure of 2.9% in the stent and 5.3% in the BMT group, p = 0.526, and a 3-year composite of 14.8% and 12.0%, p = 0.982. At 3 years, target vessel (re-)vascularization occurred in one patient (3.0%) in the stent group and in 8 patients (29.4%) in the BMT group. CONCLUSION: In RADAR, outcomes of renal artery stenting were similar to BMT. These results have to be interpreted with the caveat that the study did not reach its statistically based sample size. TRIAL REGISTRATION: Clinicaltrials.gov, NCT00640406. Registered on 17 March 2008.
Assuntos
Angioplastia com Balão/instrumentação , Anti-Hipertensivos/uso terapêutico , Aterosclerose/terapia , Término Precoce de Ensaios Clínicos , Hemodinâmica/efeitos dos fármacos , Hipertensão Renovascular/terapia , Obstrução da Artéria Renal/terapia , Stents , Adulto , Idoso , Idoso de 80 Anos ou mais , Angioplastia com Balão/efeitos adversos , Angioplastia com Balão/mortalidade , Anti-Hipertensivos/efeitos adversos , Aterosclerose/diagnóstico por imagem , Aterosclerose/mortalidade , Aterosclerose/fisiopatologia , Brasil , Europa (Continente) , Feminino , Taxa de Filtração Glomerular/efeitos dos fármacos , Humanos , Hipertensão Renovascular/diagnóstico por imagem , Hipertensão Renovascular/mortalidade , Hipertensão Renovascular/fisiopatologia , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Estudos Prospectivos , Obstrução da Artéria Renal/diagnóstico por imagem , Obstrução da Artéria Renal/mortalidade , Obstrução da Artéria Renal/fisiopatologia , Tamanho da Amostra , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia Doppler DuplaRESUMO
A doença renovascular aterosclerótica é a principal causa de hipertensão secundária. A história natural da doença demonstra taxas de progressão de 4 a 12% ao ano. Entre os métodos de tratamento existe a angioplastia com stent de artérias renais; porém, poucos estudos clínicos demonstraram seus resultados a longo prazo. Esta revisão sistemática da literatura se propõe a apresentar os resultados a longo prazo (acima de 24 meses) da angioplastia com stent de artérias renais na doença aterosclerótica em relação à função renal e aos níveis pressóricos no controle da hipertensão. Foi realizada uma ampla pesquisa, utilizando os termos apropriados, nas bases de dados LILACS, EMBASE, SCIELO, Cochrane Library e MEDLINE. De um total de 2.170 referências, apenas sete artigos contemplavam todos os critérios de inclusão. Conclui-se que, a longo prazo, há uma estabilização da função renal, redução dos níveis pressóricos e diminuição do número de classes de medicamentos anti-hipertensivos
Atherosclerotic renovascular disease is the most important cause of secondary hypertension. The natural history of the disease reveals progression rates of 4 to 12% per year. Angioplasty with renal artery stenting is one treatment option; but there are few studies that have reported long-term results. The objective of this systematic literature review is to discuss the long-term results (at least 24 months) of angioplasty with stenting of renal arteries for atherosclerotic disease, in terms of renal function and blood pressure levels for control of hypertension. A thorough search was conducted of LILACS, EMBASE, SCIELO, Cochrane Library, and MEDLINE using the appropriate terms. Just seven out of 2170 references identified met all inclusion criteria. It was concluded that over the long term renal function was stabilized, blood pressure levels were reduced, and the number of classes of antihypertensive medication decreased
Assuntos
Humanos , Masculino , Feminino , Idoso , Angioplastia/métodos , Aterosclerose/diagnóstico , Aterosclerose/terapia , Obstrução da Artéria Renal/diagnóstico , Obstrução da Artéria Renal/terapia , Stents , Resultado do Tratamento , Anti-Hipertensivos/uso terapêutico , Base de Dados , Hipertensão Renovascular/diagnóstico , Hipertensão Renovascular/terapia , Nefropatias/diagnóstico , Nefropatias/terapia , Artéria Renal , Fatores SexuaisRESUMO
Abstract. The aim of this study is to demonstrate the outcomes and efficacy of percutaneous treatment in patients with refractory or poorly controlled hypertension and renal insufficiency secondary to renal artery stenosis. Retrospective study including 16 patients treated by angioplasty and stent implantation. Blood pressure and renal function were evaluated in the first 24 hours, and at 6 months and 12 months follow-up. The mean systolic blood pressure decreased from 170 mm Hg to 145 mm Hg in the first 24 hrs, and to 138 mm Hg after 12 months of follow-up, with the diastolic pressure decreasing from 95 mm Hg to 77 mm Hg in the first 24 hrs and to 70 mm Hg after 12 months of follow-up. The renal function, according to the creatinine values remained stable.
En este estudio proporcionaremos los resultados y la eficacia de la angioplastia con stent en pacientes con estenosis de la arteria renal que presentaron secundariamente una hipertensión arterial mal controlada o refractaria e insuficiencia renal. Estudio retrospectivo donde se incluyeron a 16 pacientes tratados mediante angioplastia con stent, con seguimiento en las primeras 24 h, 6 meses y 12 meses postangioplastia, para vigilancia de las cifras tensionales y de la función renal, logrando reducir la tensión arterial sistólica de 170 mm Hg a 145 mm Hg en las primeras 24 h y a 138 mm Hg en el control de los 12 meses; la presión arterial diastólica pasó de 95 mm Hg a 77 mm Hg en las primeras 24 h, y 70 mm Hg en el control a los 12 meses. En cuanto a la función renal hubo estabilidad.
Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Obstrução da Artéria Renal/terapia , Stents , Angioplastia/métodos , Obstrução da Artéria Renal/diagnóstico por imagem , Estudos Retrospectivos , Resultado do Tratamento , Constrição PatológicaRESUMO
BACKGROUND: The endovascular approach has shown high initial technical success rates, good patency rates, and minimal complications in treating transplant renal artery stenosis (TRAS). The objective of this study was to describe our experience with an endovascular approach to TRAS. MATERIAL AND METHODS: We performed a retrospective single-institutional review of all kidney transplant procedures performed at our institution from September 2009 to September 2014. All consecutive cases of TRAS were included. RESULTS: From a total of 183 kidney transplantations, 16 patients had TRAS. Mean time from transplantation to TRAS diagnosis was 201.8 days. Stenoses or hemodynamic significant kinkings were located at the anastomosis (7), proximal (5) and middle (4) portions of the transplant artery. All patients were treated with angioplasty and primary balloon-expanding stenting. Early technical success was 93.75% and local complication rate was 12.5%. No deaths occurred. Mean serum creatinine level dropped from 3.87 mg/dL to 2.91 mg/dL after 24 hours; 1.85 mg/dL after one month; and 1.67 mg/dL after three months (P<0.05). Mean estimated glomerular filtration rate increased from 31.60 mL/min to 39.53 mL/min after 24 hours; 50.92 mL/min after one month; and 55.05 mL/min after three months (P<0.05). Doppler ultrasound criteria normalized after the procedure. Number of classes of antihypertensive drugs was not different before and after the procedure (P=0.38). Mean follow-up time was 9.75 months. One patient had a restenosis and required surgical intervention to restore graft function. CONCLUSIONS: The endovascular approach to TRAS with primary balloon-expanding stenting was safe and had a high rate of technical success. It was effective for restore and maintain the renal function in transplant kidney grafts with a low rate of restenosis.
Assuntos
Angioplastia com Balão/métodos , Transplante de Rim/efeitos adversos , Obstrução da Artéria Renal/etiologia , Obstrução da Artéria Renal/terapia , Grau de Desobstrução Vascular/fisiologia , Adulto , Idoso , Brasil , Estudos de Coortes , Creatinina/sangue , Feminino , Seguimentos , Taxa de Filtração Glomerular , Rejeição de Enxerto , Sobrevivência de Enxerto , Humanos , Testes de Função Renal , Transplante de Rim/métodos , Angiografia por Ressonância Magnética/métodos , Masculino , Pessoa de Meia-Idade , Obstrução da Artéria Renal/diagnóstico , Estudos Retrospectivos , Medição de Risco , Índice de Gravidade de Doença , Estatísticas não Paramétricas , Resultado do TratamentoRESUMO
For people enrolled in Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL), we sought to examine whether variation exists in the baseline medical therapy of different geographic regions and if any variations in prescribing patterns were associated with physician specialty. Patients were grouped by location within the United States (US) and outside the US (OUS), which includes Canada, South America, Europe, South Africa, New Zealand, and Australia. When comparing US to OUS, participants in the US took fewer anti-hypertensive medications (1.9 ± 1.5 vs. 2.4 ± 1.4; P < .001) and were less likely to be treated with an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker (46% vs. 62%; P < .001), calcium channel antagonist (37% vs. 58%; P < .001), and statin (64% vs. 75%; P < .05). In CORAL, the identification of variations in baseline medical therapy suggests that substantial opportunities exist to improve the medical management of patients with atherosclerotic renal-artery stenosis.
Assuntos
Anti-Hipertensivos/uso terapêutico , Aterosclerose/patologia , Hipertensão Renal/diagnóstico , Hipertensão Renal/tratamento farmacológico , Obstrução da Artéria Renal/terapia , Idoso , Anti-Hipertensivos/farmacologia , Aterosclerose/terapia , Canadá , Gerenciamento Clínico , Europa (Continente) , Feminino , Humanos , Internacionalidade , Modelos Lineares , Masculino , Medicina , Pessoa de Meia-Idade , Análise Multivariada , Nova Zelândia , Padrões de Prática Médica , Estudos Prospectivos , Obstrução da Artéria Renal/patologia , Medição de Risco , Índice de Gravidade de Doença , África do Sul , América do Sul , Estados UnidosRESUMO
Increased lifespan in the last few decades has substantially changed the scenario for renal artery stenosis. Indeed, because older populations show a higher prevalence of atherosclerotic disease, the incidence of atheromatous renal artery stenosis has also increased. Intuitively, one could surmise that stenosis removal should void both the hypertension and the kidney damage resulting from the obstructive stenosis. Surprisingly, a number of important clinical trials have failed to show the reversion seen in experimental models. The reasons for these differences may be linked to chronicity and inflammation associated with the atherosclerotic lesion. However, the failure to obtain a favorable response may also be related to abnormalities in the contralateral kidney. Indeed, this apparently normal kidney should work to compensate the hemodynamic effects of the ipsilateral stenosed kidney. Instead, structure and function in the contralateral kidney can be altered in renal artery stenosis to the point that this nonstenotic kidney may sustain both, hypertension and progressive kidney disease. Certainly, comparing the effects of clip removal in the Goldblatt model to angioplasty in clinical settings with atherosclerotic lesions may be totally inappropriate. Nevertheless, there remain certain clinical situations such as bilateral renal arterial disease, congestive heart failure, and progressive renal failure, where angioplasty may be an alternative. These approaches however are yet to be tested.
Assuntos
Arteriosclerose/terapia , Hipertensão/etiologia , Obstrução da Artéria Renal/terapia , Angioplastia/métodos , Animais , Arteriosclerose/complicações , Arteriosclerose/patologia , Progressão da Doença , Humanos , Hipertensão/terapia , Incidência , Nefropatias/etiologia , Nefropatias/terapia , Prevalência , Obstrução da Artéria Renal/complicações , Obstrução da Artéria Renal/fisiopatologiaRESUMO
O presente artigo revisa o importante papel na escolha da melhor opção de tratamento da hipertensão arterial de etiologia renovascular. Infelizmente a luz das últimas e mais atuais evidências científicas não houve diferença significativa entre as duas modalidades terapêuticas mais utilizadas, tratamento medicamentoso versus tratamento intervencionista percutâneo, na redução da morbidade e mortalidade cardiovascular do paciente com hipertensão arterial e estenose de artéria renal. Sabe-se, porém, que a doença renovascular quando presente em pacientes com perda progressiva da função renal, naqueles com edema agudo de pulmão de repetição, nos pacientes com doença arterial coronária ou disfunção ventricular esquerda onde um melhor controle da pressão arterial é necessário e o mesmo não é alcançado apesar do adequado tratamento medicamentoso, a intervenção percutânea se impõe. É certo que, independente da opção terapêutica utilizada, é necessário que todas as comorbidades presentes sejam corrigidas para que melhores resultados finais sejam alcançados. A investigação precoce baseada em critérios clínicos de probabilidade somada ao auxílio de exames complementares permitirão maiores chances de acerto diagnóstico, cuja certeza só existirá após a realização da intervenção escolhida. Infelizmente a certeza que hoje temos em relação à opção diagnóstica mais adequada não existe quanto aos resultados tardios, exceto nas condições já exposta.
This article reviews the important role of the choice of best treatment option for arterial hypertension of renovascular etiology. Unfortunately, according to the latest and most upto-date scientific evidence, there is no significant difference between the two most commonly used modes of therapy: drug treatment vs. percutaneous interventionist treatment,in reducing cardiovascular morbidity and mortality in patients with arterial hypertension and stenosis of the renal artery. However, it is known that in renovascular disease, when present in patients with progressive loss of renal function, in those with acute repetition edema of the lung, and in those with coronary arterial disease or left ventricular dysfunction, where better control of blood pressure is necessary but is not achieved despite adequate drug treatment, percutaneous intervention is necessary. Undoubtedly, regardless of the therapeutic option used, it is necessary for all the comorbidities present to be corrected, in order to improve the final results. Early investigation based on clinical criteria of probability, with the aid of complementary exams, will result in higher chances of obtaining the correct diagnosis, which will only be certain after the chosen intervention has been carried out. Unfortunately, the certainty that we have today as to the most appropriate diagnostic options is not borne out in the most recent results, except in the conditions mentioned above.
Assuntos
Humanos , Guias como Assunto , Guias como Assunto/normas , Hipertensão Renovascular/terapia , Hipertensão/terapia , Artéria Renal/fisiopatologia , Obstrução da Artéria Renal/complicações , Obstrução da Artéria Renal/terapia , Tratamento Farmacológico/métodos , Resultado do Tratamento , Sensibilidade e Especificidade , Stents , Ultrassonografia/métodos , Valor Preditivo dos TestesRESUMO
Tropical aortitis is a rare and poorly described aortic disease, sometimes confounded with Takayasu's disease, mainly in people from Africa. In this case report, the panaortic aneurysmal disease in a young woman from Haiti, first diagnosed after a work-up on renovascular hypertension, would appear to approach this particular arterial disease with no clinical, radiological or biological argument for an infectious etiology. The initially suspected diagnosis of Takayasu's disease had to be rethought because of the presence of several saccular aneurysms extending from the aortic arch to the infrarenal aorta, rarely described in Takayasu's aortitis. Expert opinions from vascular surgeons and clinicians tagged this aortic disease as similar to tropical aortitis which remained asymptomatic for more than a decade. Hypertension was managed with successful balloon angioplasty of the left renal artery stenosis and anti-hypertensive combination therapy. Surgical management of the extended aortic aneurysms was not proposed because of the stability and asymptomatic nature of the aneurysmal disease and the high risk of surgical morbidity and mortality. More than ten years after diagnosis, the course was marked with inaugural and sudden-onset chest pain concomitant with contained rupture of the descending thoracic aortic aneurysm. This case report underlines the persistent risk of aneurysmal rupture and the importance of an anatomopathological study for the diagnosis of complex aortic disease.
Assuntos
Aneurisma Roto/etiologia , Aneurisma da Aorta Torácica/etiologia , Aortite/complicações , Aneurisma Roto/cirurgia , Angioplastia com Balão , Anti-Hipertensivos/uso terapêutico , Aneurisma da Aorta Abdominal/complicações , Aneurisma da Aorta Abdominal/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Aortite/diagnóstico , Aortografia , Terapia Combinada , Diagnóstico Diferencial , Feminino , Haiti/etnologia , Humanos , Hipertensão Renovascular/complicações , Hipertensão Renovascular/terapia , Angiografia por Ressonância Magnética , Pessoa de Meia-Idade , Obstrução da Artéria Renal/complicações , Obstrução da Artéria Renal/terapia , Ruptura Espontânea , Arterite de Takayasu/diagnósticoRESUMO
Se presenta el caso clínico de una paciente que debutó con hipertensión arterial (HTA) grado II realizándose los estudios sistematizados correspondientes para descartar patologías secundarias. Dentro de los estudios de primera línea en la valoración merece destacarse la ecografía Doppler renal por la información que ella aporta, orientado al diagnóstico de estenosis de la arteria renal. La identificación de una HTA de origen renovascular supone el hallazgo de una de las causas reversibles de hipertensión. Dentro de esta etiología la más frecuente es la displasia fibromuscular (DFM) que mejora con la corrección de la estenosis mediante técnicas quirúrgicas o percutáneas con angioplastia con balón o stent. El objetivo es presentar un caso clínico para mostrar la complejidad del proceso diagnóstico y la importancia que tiene la sospecha clínica para la corrección oportuna de este tipo de HTA reversible...
Assuntos
Humanos , Adolescente , Feminino , Displasia Fibromuscular/complicações , Displasia Fibromuscular/diagnóstico , Displasia Fibromuscular/terapia , Hipertensão Renovascular/etiologia , Obstrução da Artéria Renal/terapia , Ecocardiografia Doppler , Exame FísicoRESUMO
Se presenta el caso clínico de una paciente que debutó con hipertensión arterial (HTA) grado II realizándose los estudios sistematizados correspondientes para descartar patologías secundarias. Dentro de los estudios de primera línea en la valoración merece destacarse la ecografía Doppler renal por la información que ella aporta, orientado al diagnóstico de estenosis de la arteria renal. La identificación de una HTA de origen renovascular supone el hallazgo de una de las causas reversibles de hipertensión. Dentro de esta etiología la más frecuente es la displasia fibromuscular (DFM) que mejora con la corrección de la estenosis mediante técnicas quirúrgicas o percutáneas con angioplastia con balón o stent. El objetivo es presentar un caso clínico para mostrar la complejidad del proceso diagnóstico y la importancia que tiene la sospecha clínica para la corrección oportuna de este tipo de HTA reversible.
Assuntos
Humanos , Feminino , Adolescente , Hipertensão Renovascular/etiologia , Obstrução da Artéria Renal/terapia , Displasia Fibromuscular/complicações , Displasia Fibromuscular/diagnóstico , Displasia Fibromuscular/terapia , Exame Físico , Ecocardiografia DopplerRESUMO
FUNDAMENTO: A estenose arterial renal (EAR) é uma causa potencialmente reversível de hipertensão arterial sistêmica (HAS) e nefropatia isquêmica. Apesar da revascularização bem sucedida, nem todos os pacientes (pt) apresentam melhora clínica e alguns podem piorar. OBJETIVO: O presente estudo se destina a avaliar o valor do índice de resistividade renal (IR) como preditor dos efeitos da revascularização renal. MÉTODOS: Entre janeiro de 1998 e fevereiro de 2001, 2.933 pacientes foram submetidos ao duplex ultrassom renal. 106 desses pacientes apresentaram EAR significativa e foram submetidos a angiografia e revascularização renal. A pressão arterial (PA) foi medida antes e depois da intervenção, em intervalos de até 2 anos e as medicações prescritas foram registradas. Antes da revascularização, o IR foi medido em 3 locais do rim, sendo obtida uma média dessas medições. RESULTADOS: Dos 106 pacientes, 81 tiveram IR<80 e 25 RI>80. A EAR foi corrigida somente por angioplastia (PTA) em 25 pts, PTA + stent em 56 pts e cirurgicamente em 25 pts. Dos pacientes que se beneficiaram da revascularização renal; 57 dos 81 pacientes com IR <80 apresentaram melhora em comparação a 5 de 25 com IR > 80. Usando um modelo de regressão logística múltipla, o IR esteve significativamente associado à evolução da PA (p = 0,001), ajustado de acordo com os efeitos da idade, sexo, PAS, PAD, duração da hipertensão, o tipo de revascularização, número de fármacos em uso, nível de creatinina, presença de diabete melito, hipercolesterolemia, volume sistólico, doença arterial periférica e coronariana e tamanho renal (OR 99,6-95 por centoCI para OR 6,1-1.621,2). CONCLUSÃO: A resistividade intrarrenal arterial, medida por duplex ultrassom, desempenha um papel importante na predição dos efeitos pós revascularização renal para EAR.
BACKGROUND: Renal artery stenosis (RAS) is a potentially correctable cause of hypertension and ischemic nephropathy. Despite successful renal revascularization, not all patients (pt) overcome it and some get worse. OBJECTIVE: This study was designed to assess the value of renal resistance index (RI) in predicting the outcome of renal revascularization. METHODS: Between Jan 1998 and Feb 2001, 2,933 pts were referred to renal duplex ultrasound. 106 out of these had significant RAS and underwent angiography and renal revascularization. Arterial blood pressure (BP) was measured before and after the intervention, at intervals of up to 2 years and medications recorded. Prior to revascularization, RI was measured at 3 sites of each kidney and averaged. RESULTS: Out of the 106 patients, 81 had RI<80 and 25 RI>80. RAS was corrected with angioplasty (PTA) alone in 25 pts, PTA + stent in 56 pts and corrected by surgery in 25 pts. Of patients who benefited from renal revascularization; 57 of the 81 patients with RI <80 improved as compared to 5 of 25 with RI>80. Using a multiple logistic regression model, RI was significantly associated with BP outcome (p=0.001), adjusted for the effects of age, sex, SBP, DBP, duration of hypertension, type of revascularization, number of medication in use, creatinine level, presence of diabetes mellitus, hypercholesterolemia, stroke, peripheral and coronary artery disease and kidney size (OR 99.6 - 95 percentCI for OR 6.1 to 1,621.2). CONCLUSION: Intrarenal arterial resistance measured by duplex ultrasound plays an important role in predicting BP outcome after renal revascularization for RAS.
Assuntos
Idoso , Feminino , Humanos , Masculino , Hipertensão Renovascular/terapia , Obstrução da Artéria Renal/terapia , Artéria Renal , Resistência Vascular/fisiologia , Angioplastia com Balão/métodos , Pressão Sanguínea/fisiologia , Métodos Epidemiológicos , Obstrução da Artéria Renal/fisiopatologia , Stents , Resultado do Tratamento , Ultrassonografia Doppler DuplaRESUMO
BACKGROUND: Renal artery stenosis (RAS) is a potentially correctable cause of hypertension and ischemic nephropathy. Despite successful renal revascularization, not all patients (pt) overcome it and some get worse. OBJECTIVE: This study was designed to assess the value of renal resistance index (RI) in predicting the outcome of renal revascularization. METHODS: Between Jan 1998 and Feb 2001, 2,933 pts were referred to renal duplex ultrasound. 106 out of these had significant RAS and underwent angiography and renal revascularization. Arterial blood pressure (BP) was measured before and after the intervention, at intervals of up to 2 years and medications recorded. Prior to revascularization, RI was measured at 3 sites of each kidney and averaged. RESULTS: Out of the 106 patients, 81 had RI<80 and 25 RI>80. RAS was corrected with angioplasty (PTA) alone in 25 pts, PTA + stent in 56 pts and corrected by surgery in 25 pts. Of patients who benefited from renal revascularization; 57 of the 81 patients with RI <80 improved as compared to 5 of 25 with RI>80. Using a multiple logistic regression model, RI was significantly associated with BP outcome (p=0.001), adjusted for the effects of age, sex, SBP, DBP, duration of hypertension, type of revascularization, number of medication in use, creatinine level, presence of diabetes mellitus, hypercholesterolemia, stroke, peripheral and coronary artery disease and kidney size (OR 99.6 - 95%CI for OR 6.1 to 1,621.2). CONCLUSION: Intrarenal arterial resistance measured by duplex ultrasound plays an important role in predicting BP outcome after renal revascularization for RAS.
Assuntos
Hipertensão Renovascular/terapia , Obstrução da Artéria Renal/terapia , Artéria Renal/diagnóstico por imagem , Resistência Vascular/fisiologia , Idoso , Angioplastia com Balão/métodos , Pressão Sanguínea/fisiologia , Métodos Epidemiológicos , Feminino , Humanos , Masculino , Obstrução da Artéria Renal/fisiopatologia , Stents , Resultado do Tratamento , Ultrassonografia Doppler DuplaRESUMO
BACKGROUND: Women have higher risk of contrast-induced nephropathy than men. The purpose of this study was to determine the relative impact of gender on long-term renal function after percutaneous renal interventions (PRI). METHODS AND RESULTS: We included all patients undergoing PRI. Men (n = 72) and women (n = 28) had similar age, men had more diabetes, coronary and peripheral artery disease, higher serum creatinine and similar glomerular filtration rate (GFR), and prevalence of chronic kidney disease (CKD) stage > or =3 when compared with females. At follow-up, men had a significant improvement in GFR and systolic blood pressure, while females did not. The presence of severe CKD and male gender were the only predictors of long-term GFR improvement. CONCLUSION: Male patients and patients with poor baseline renal function showed an important benefit with PRI, suggesting that it is not too late for renal revascularization if properly indicated.
Assuntos
Taxa de Filtração Glomerular , Obstrução da Artéria Renal/terapia , Stents , Idoso , Creatinina/sangue , Progressão da Doença , Feminino , Humanos , Rim/irrigação sanguínea , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Recuperação de Função Fisiológica , Obstrução da Artéria Renal/epidemiologia , Obstrução da Artéria Renal/fisiopatologia , Estudos Retrospectivos , Fatores SexuaisRESUMO
We describe a 6-year-old girl with arterial hypertension secondary to fibromuscular dysplasia with stenoses of both renal arteries and transient ischemic attack due to extracranial right internal carotid artery subtotal occlusion as well as left internal carotid artery stenosis. She was treated with percutaneous angioplasty of both renal and both carotid arteries.
Assuntos
Angioplastia com Balão , Displasia Fibromuscular/complicações , Hipertensão Renovascular/terapia , Ataque Isquêmico Transitório/terapia , Obstrução da Artéria Renal/terapia , Angiografia Digital , Aortografia , Estenose das Carótidas/diagnóstico , Estenose das Carótidas/etiologia , Criança , Feminino , Humanos , Hipertensão Renovascular/etiologia , Hipertrofia Ventricular Esquerda/diagnóstico , Hipertrofia Ventricular Esquerda/etiologia , Ataque Isquêmico Transitório/etiologia , Obstrução da Artéria Renal/diagnóstico , Obstrução da Artéria Renal/etiologiaRESUMO
A aterosclerose em artérias renais é um importante fator desencadeante de tromboses com subsequente comprometimento da função e da viabilidade renal. A oclusão aguda das artérias renais por trombo ou êmbolo é causa incomum e potencialmente reversível de falência renal. Todavia, a duração e ograu de oclusão arterial compatível com a manutenção da viabilidade do parênquima renal ainda não estão bem estabelecidos, razão pela qual o diagnóstico precoce e a intervenção são importantes. O objetivo deste artigo é descrever um caso de trombose de artéria renal de rim funcional único, com lise espontânea e tardia do trombo seguida de recuperação funcional inesperada.
Atherosclerosis in the renal arteries is an important triggering factor for thrombosis with subsequent impairment of renal function and viability. Acute occlusion of the renal arteries by a thrombus or embolus is unusual and potentially reversible cause of renal failure. However, the duration of arterial occlusion and ograu compatible with maintaining the viability of renal parenchyma are not well established, which is why early diagnosis and intervention are important. The aim of this paper is to describe a case of renal artery thrombosis functional single kidney with spontaneous lysis of thrombus and late functional recovery after unexpected.