肾动脉支架置入术治疗老年粥样硬化性肾动脉狭窄的研究

Clinical outcome of percutaneous transluminal renal angioplasty with stent implantation in elderly

目的回顾性研究老年动脉粥样硬化性肾动脉狭窄(ARAS)患者行经皮腔内肾动脉支架置入术(PTRAS)的临床疗效。方法选择2003年1月至2006年3月在解放军总医院经肾动脉造影确诊为ARAS、肾动脉面积狭窄≥70%、年龄≥65岁病例,分为治疗组(35例,行PTRAS术治疗)和对照组(8例,给予药物治疗)。统计分析两组血压、肾功能的变化趋势和PTRAS术后支架内再狭窄发生率。结果治疗组行PTRAS术后3天血压明显下降[术前(155.4±24.8)/(79.4±10.8)mmHg比术后(126.8±10.9)/(67.3±8.9)mmHg;P<0.01),术后12个月血压[(134.6±15.5)/(68.6±7.4)mmHg]仍明显低于术前(P<0.01),至术后24个月时血压回升,逐渐接近术前水平。治疗组口服降压药物的种类术后明显减少(术前2.6±1.0种比术后6个月1.9±0.9种;P<0.01),但术后12个月以后用药种类开始增加,接近术前水平。对照组在肾动脉造影术后12个月内血压水平及口服降压药物种类均较造影前无显著变化。治疗组术后12个月时68.8%的患者肾功能无变化,15.6%的患者肾功能可改善,但是术后肾功能恶化的比例逐渐增加,至24个月时达到35.7%。对照组肾动脉造影术后12个月内肾功能全部为不变化。Logistic多元回归分析显示,PTRAS术后12个月时发生肾功能恶化与患者术前合并3期以上慢性肾脏病有关(P=0.005,OR=46.5),与术后采用水化治疗有关(P=0.019,OR=0.24)。治疗组PTRAS术后支架内再狭窄率为20%。多元回归分析示PTRAS术后发生支架内再狭窄与患者术前合并糖尿病有关(P=0.027,OR=47.82)。结论PTRAS术可在24个月内明显降低老年ARAS患者的血压。但是PTRAS术改善老年ARAS患者肾功能的作用有限,且存在肾功能恶化的风险。

Objective To study the clinical outcome of percutaneous transluminal angioplasty with stent implantation （PTRAS） in the elderly with atherosclerotic renal artery stenosis （ARAS）. Methods Retrospective analysis was carried out on 35 elderly patients （ age ≥ 65 years ） who had angiography confirmed ARAS （ artery stenosis ≥ 70% ） and received PTRAS in our hospital during January 2003 to March 2006. Their changes in blood pressure level, renal function and incidence of operation related complication were monitored during the follow up. Eight patients with ARAS who were admitted during the same period but refused to undergo PTRAS were enrolled as the control. Results Compared with the preoperational level, blood pressure of the patients in the PTRAS group showed noticible decrease 3 days after the operation （ 155.4 ±24. 8/79.4 ±10. 8 mm Hg vs. 126. 8±10. 9/67. 3±8.9 mm Hg, P 〈 0. 01 ） and the decrease substained till 12 months after the operation （ P 〈 0. 01 ）, but the blood pressure resumed gradually to the pre-operational level after 24 months. The mean number of antihypertensive drugs decreased from 2.6± 1.0 to 1.9± 0. 9 at 6 months after PTRAS （ P 〈 0. 01 ）. The blood pressure of the control group had no statistical changes. The renal function of 68. 8% patients in the PTRAS group was stable within 12 months after PTRAS and 15.6% of the patients showed improvement in their renal function. Renal function deteriorated in 35.7% of the patients in the PTRAS group 24 months after the operation compared with their pre-operational level. Logistic regression analysis showed that factors including complication of CKO stage 3 before the operation and post operational hydration therapy were related to deterioration of renal function （ P =0. 005, OR =46. 5 and P =0. 019, OR =0. 24, respectively）. The restenosis rate in this study was 20%.Regression analysis showed that comorbidity of diabetes mellitus was related to restenosis （ P = 0. 027 ; OR = 47. 82）. Conclusion PTRAS could decrease blood pressure level in the elderly with ARAS in the first 24 months after operation but its effect on amelioration of renal function was limited.