Ari Mandil

Hospital Felcio Rocho

Hospital Lifecenter
Belo Horizonte-Brasil
Interveno percutnea na artria renal: quais
as reais indicaes, os benefcios e a melhor
tcnica?
Estenose de artria renal 6 a 9% dos pacientes > 65 anos
Quando suspeitar?

Hipertenso < 35 > 55 anos
Hipertenso acelerada
Insuficincia renal de inicio recente
Tamanho do rim
Edema agudo dos pulmes
ICC no explicada
Angina refratria
Hirsch AT Circulation 2006:113;1474-1547
Hipertenso renovascular
Predominncia do sexo feminino
Idade 15-50 anos
Tero mdio e distal da artria
Aparncia frisada ( colar de contas)
Balo
Displasia fibromuscular
6 meses aps stent
1 medicao
PA= 115x80 mmHg
65 fem, HAS
3 medicaes (usava 1)
PA= 150x85 mmHg
Interveno percutnea na artria renal
Success 98%
Death 1%
Hypertension cure 20%
Hypertension improved 49%
Renal function improved 30%
Renal function stabilized 38%
Renal insufficiency 5%
Restenosis 17%
Leertouwer TC Radiology 2000; 216:7885
Meta-analysis of Renal Artery Stent Placement
14 articles 678 patients
Walker C. M. at CIT 2011 - China
Stent em artria renal no to simples!
Estenose aterosclertica da artria renal
Em 90% dos casos ostial ou no tero proximal.
Stent
Indicao de tratamento percutneo
Paciente com leso grave e rim maior que 8 cm.
Presso diastlica > 100 mmHg em uso de 3
medicaes ou intolerncia a medicao
Piora progressiva da funo renal
Episdios de flash edema
Angina instvel.
Avaliao dos mtodos de imagem
Study Sensitivity/
specificity
Advantages Disadvantages
Angio Gold Standard
Intervention can be done at
same setting
Most accurate way to
exclude FMD
Ostial lesions can be missed with
improper obliquity
Contrast RXN and complications
Cost
Duplex 84-88%/ 62-99%
Least expensive
Best way to follow stents
Technician dependent
Obesity limits window
Bowel gas is an issue
Can miss accessories
MRA 90-100%/ 76-94%
No radiation
Defines anatomy for access
(roadmap)
Expensive
Poor for FMD specificity
Stent artifact
Nephrogenic Systemic Fibrosis
False + more common
Claustrophobia and breath hold
issues
CTA 89-100%/ 82-100%
Defines anatomy for access
(roadmap)
Defines peri-renal aorta
status (hostile aorta)
Contrast risk
Expensive
Radiation exposure
Funo renal quantidade de contraste
Baseada em exames de imagem: acesso, tamanho
do stent
Implante de stent em artria renal: Estratgia
Angiotomografia e RNM
Femoral: 90% dos casos
Radial: Ateno aos tamanhos dos materiais
Acesso
Radial: Cateter guia MP 6 French
Limitaes do acesso radial ou braquial
Distncia Radial Artria renal
Pode ser proibitiva em pacientes altos
Tortuosidade da artria subclvia
Pode ser desafiadora em algumas anatomias
Problemas com acesso
Complicaes maiores com o acesso braquial
Sucesso com acesso radial depende de curva
de aprendizado.
HS RDC RDC1 MP LIMA
Acesso femoral:
Cateteres guias para
angioplastia renal
Ateroembolismo durante a angioplastia
Mais comum do
que se imagina ou
reconhecido.
Pode levar
semanas para ser
diagnosticado.
Frequentemente
imprevisvel e
inevitvel.
Tcnica de cateterizao da artria renal
No Touch Step 1
.035 support wire
Angle of primary curve increases
Step 2
.014 Support wire
Guia 0.014
Evite utilizar guias hidroflicos
Observe sempre a ponta do guia
Angiografia final deve observar as margens do rim
Guide relaxes into
ostium
Angle of
primary curve
decrease
Step 3
.035 wire removed
Step 4:
Stent advanced into position
Step 4
Placa ostial
Posicionamento do stent
Liberao do Stent
Alinhar o stent com cateter guia ( coaxial)
Liberao lenta
Fique atento as queixas do paciente.
Em caso de dor, pare e reavalie.
No procure estenose 0%
Ps dilatao com balo mais proximal (flare)
Implante de stent em pacientes com insuficincia renal
Sistemas de proteo emblica
Embolizao ocorre em todos os casos
Teoricamente faz sentido... Porm:
Beneficio no bem estabelecido
No existe um dispositivo ideal
Dimetro muito pequeno
Landing zone muito curta
Bifurcao precoce
Suporte varivel
Bifurcao precoce
Bifurcao Tardia
Finalizando, e controle tardio
Mantenha coaxial para retirada do balo.
No retire o guia 0,014 totalmente para
angiografia final
Mantm o cateter na posio
Acesso para tratamento de complicaes
Controle com duplex scan peridico (1 semana,
3 meses, 6 meses, 1 ano e anualmente)
Comportamento da PA um timo indicador se
houver mudana inicial
N Engl J Med 2009; 361:1953-1962
What ASTRAL (Angioplasty and stenting for
Renal Artery Lesions) has shown?
ASTRAL Trial
N Engl J Med 2009; 361:1953-1962
806 patients with severe renal artery stenosis and
Physician was uncertain that the patient would benefit from
revascularization
Substantial risks but no evidence of a worthwhile
clinical benefit from revascularization in patients
with atherosclerotic renovascular disease
In the interventional group only 83% had
intervention attempted.
Even those patients that didnt get a stent
were analyzed as if they had.
N Engl J Med 2009; 361:1953-1962
ASTRAL Trial
N Engl J Med 2009; 361:1953-1962
Major complication rates were 9%
65% of all participating centers randomized
fewer than 1 patient per year
ASTRAL Trial
Angiographic and hemodynamic measures of lesion severity do not
correlate well
Subramanian R. Catheter Cardiovasc Interv 2005;64:480
Is angiographic lesion evaluation good enough?
Correlation between renal FFR and the hyperemic mean
translesional pressure gradient
Subramanian R. Catheter Cardiovasc Interv 2005;64:480
Sensitivity of 72%
Specificity of 82%
A dopamine-induced (mean
gradient) 32 mm Hg was
95% predictive
Mangiacapra F. Circ Cardiovasc Interv. 2010;3:537-542
Dopamine induce mean gradient of 20 mmHg may
identify who should respond for renal stent
CORAL STUDY:
947 subjects enrolled, follow-up ongoing

Primary Outcome: composite of attributable CV and
renal events

Cardiovascular or renal death
Myocardial infarction
Stroke
Hospitalization for heart failure
Doubling of Cr
Renal replacement therapy
Inclusion Criteria
1. CLINICAL:
Hypertension on 2 or more drugs
CKD: MDRD estimate <60 ml/min
-AND-
2. ANATOMIC:
1 Atherosclerotic stenosis
60% by Angiography
+ MRA/CTA at Core Lab
300 cm/sec Duplex Ultrasound

CORAL STUDY:
Circulation 2006;113;1474-1547
ACC/AHA 2005 Guidelines for the Management of Patients With
Peripheral Arterial Disease
Class I - Unexplained congestive
heart failure or sudden,
unexplained pulmonary edema

Class IIa - bilateral RAS or a RAS
to a solitary functioning kidney.
Uncontrolled hypertension

Class IIb Unilateral, well
controlled hypertension, even with
renal insufficiency.


Estudos randomizados publicados at o
momento no comprovaram benefcios porm no
representam a realidade .

A melhora da tcnica para implante de stent, o
uso dos sistemas de proteo, podem ser
determinantes para os resultados e consequente
expanso das indicaes.
Concluses
Concluses
A eficcia do stent renal depende da habilidade de
identificar qual paciente propenso a responder
revascularizao.

Provavelmente estamos tratando pacientes com
estenose renal no significativas.