1. PINC in Kraków 14
11th Peripheral Interventions Workshop
8-9 May 2014
Current status and future ppeerrssppeeccttiivveess ooff rreennaall
sstteennttiinngg aanndd rreennaall ddeenneerrvvaattiioonn::
WWhhoo iiss ssttiillll iinnddiiccaattiioonnss ffoorr rreennaall aarrtteerriieess sstteennttiinngg??
TTaaddeeuusszz PPrrzzeewwłłoocckkii
Institute of Cardiology – Collegium Medicum,
Jagiellonian University, John Paul II Hospital
Kraków

2. Renal aarrtteerryy sstteennoossiiss ((RRAASS))--ffrreeqquueennccyy
GGeenneerraall ppooppuullaattiioonn
PPAAOODD ppaattiieennttss
3300 –– 4455 %%
00,,11 –– 11 %%
HHaarrddiinngg eett aall..JJ AAmm SSoocc NNeepphhrrooll 11999922,, 22,, 11660088
OOlliinn eett aall.... AAmm JJ MMeedd.. 11999900,, 8888,, 4466
HHyyppeerrtteennssiivvee ppaattiieennttss
22 –– 55 %%
CCAADD ppaattiieennttss
1100 –– 3344 %%
Hypertensive patients
with renal insufficiency
30 – 40 %

3. RAS – renal iisscchheemmiiaa,, RRAAAA-- aaccttiivvaattiioonn
CCoonnsseeqquueenncceess-- HHAA,, LLVV hhyyppeerrttrroopphhyy,, vvaassccuullaarr
rreemmooddeelliinngg,, aacccceelleerraatteedd aatthheerroosscclleerroossiiss
 HHeeaarrtt ffaaiilluurree
 PPuullmmoonnaarryy ooeeddeemmaa
 nneepphhrrooppaatthhyy
 EESSRRDD
 ssttrrookkee
 CCAADD –– MMII ,, UUAA
 aaoorrttiicc ddiisssseeccttiioonn
ccaarrddiiaacc
rreennaall
vvaassccuullaarr

4. The impact ooff RRAASS oonn ssuurrvviivvaall

5. Goals for renal revascularization
in RAS patients
1. Preservation of renal function
2. Improved blood pressure control
3. Prevention of CHF or angina pectoris
Survival improvement
QOL improvement

7. Kaltra P, Zeller T. - SSaallffoorrdd && BBaadd KKrroozziinnggeenn –– 222200 cchh

9. RAS vs BMT – results of randomized trials
Balloon PTA Stenting
EMMA
SNRASCG
DRASTIC
STAR
ASTRAL
ASPIRE 2
RREENNAAIISSSSAANNCCEE
No difference
Better hypertension control
CORAL
8 randomized trials
only 2 positive (in respect of hypertension)

10. How to explain discrepancy between observational
investigations and randomized trials?
What is „significant renal artery stenosis”?
Physiological stenosis assessment

11. Gradient of the systolic
blood pressure over 20
mmHg and over 10 mmHg
of the mean blood pressure
impacts on the physiology
of renal blood flow
Rest Pd/Pa ratio <0,90
is
assoc. with increased
renin production
Ratio is more import.
than gradient alone

12. Renal Fractional FFllooww RReesseerrvvee ((RRFFFFRR))
RFFR = Qmax stenosis / Qmax normal
Qmax normal = (Pa-Pv)/ R
Qmax stenosis = (Pd-Pv)/ R
Pa = Mean aortic pressure
Pd = Mean pressure distal to stenosis
Pv = Mean central venous pressure
Qmax normal = Maximum renal blood
flow in the absence of stenosis
Qmax stenosis = Maximum renal
blood flow in the presence of
stenosis
R = Renal arteriolar vascular
resistance at maximum hyperemia
Measurements must be taken at maximal hyperemia.

13. Renal arterial bed dilators
NTG – 0,3 – 1 mg – intrarenally (Gross, Beregi)
RBF mean increase 40%
Papaverine – 8 – 40 mg intrarenally (Subramanian, De Bruyne)
RBF mean increase 50%
Dopamine – 50ug/kg – intrarenally (De Bruyne)
RBF mean increase 95%
In contrast to coronary arteries best renal dilators occured
dopamine De Bruyne at al.

14. FFR Guided Renal Angioplasty
MMeeaann HHyyppeerreemmiicc GGrraaddiieenntt
100
% sr ednopseR
>20mm Hg
<20mm Hg
0
Hyperemic mean gradient >20mmHg (dopamine) independent predictor of blood pressure
control improvement after RAS

15. Blood PPrreessssuurree RReessppoonnddeerrss
Improvement: BP < 140/90 mmHg, or a decrease of DBP
by 15 mm Hg on the same or reduced # of medications.
< .80
RFFR<0,80

16. In summary it seems we have two ways of physiological
stenosis assessment:
Gradient - across the lesion – resting or hyperemic>20 mmHg
(De Bruyne, Massoud, Trana),
Pd/Pa ratio - resting - <0,9 (De Bruyne)
hyperemic (RFFR)<0,8 (Mitchell, De
Bruyne,),
Renal FFFFRR ooff <<00..8800 pprreeddiiccttss aann iinnccrreeaasseedd
lliikkeelliihhoooodd ooff BBPP rreessppoonnssee..

17. Renal artery stenosis – criteria ffoorr iinntteerrvveennttiioonn
Clinical arterial hypertension(IIa)-resistant, malignant, accelerated
failed 3 drugs in max dose
renal dysfunction - severe, progressive – bilateral stenosis
solitaire kidney (IIa), unilateral stenosis (IIb)
heart failure-unexpected recurrent pulmonary oedema (IC)
CAD - recurrent instability episodes (IIa)
Anatomic
stenosis >70 % diameter stenosis or >85 % area reduction
- 50-70 % with a peak gradient >20 mmHg
- RFFR<0,80
renal length difference ł 1,5 cm or documented decrease > 1 cm
but renal length should be > 7,5 cm