Revaskularisation der Nierenarterienstenose: State of the Art

Zusammenfassung

Arteriosklerotische Nierenarterienstenosen (aNAS) sind oft mit einer arteriellen Verschlusskrankheit vom aorto-iliakalen Typ assoziiert, die u. a. zu einer Verschlechterung der Blutdruckeinstellung, Beeinträchtigung der Nierenfunktion und myokardialer Dysfunktion führen kann. Seit Einführung der Stentimplantation hat die Angioplastie die Gefäßchirurgie als Therapie der Wahl abgelöst. Der Nutzen revaskularisierender Maßnahmen zur Verbesserung der Blutdruckkontrolle und der Nierenfunktion ist seit Publikation der ASTRAL- und STAR-Studien umstritten. Aufgrund der methodischen Mängel im Studiendesign lassen sich die Resultate der genannten Studien nur auf einen kleinen Teil der betroffenen Patienten übertragen. Klinische Konsequenzen ergeben sich aus einer Revaskularisation nur bei korrekter Indikationsstellung, wesentlich dabei ist der Nachweis der hämodynamischen Relevanz einer Stenose durch nicht invasive (Duplexsonographie) und invasive Methoden (Druckgradienten Messung). Klinischen Prädiktoren werden bei der Therapieentscheidung noch zu selten Beachtung geschenkt. Diese beinhalten Pulsdruck > 50 ± 10 mmHg, hohen diastolischen Blutdruck, hoher BNP-Spiegel, Niereninsuffizienz, Ratio des Druckes distal der Stenose zu Aortendruck in Ruhe < 0,9 und einen hyperämischen systolischen Druckgradient > 20 mmHg. In den internationalen Leitlinien unbestritten ist die Indikation zur Revaskularisation bei hämodynamisch relevanten Stenosen funktioneller Einzelnieren, bilateralen Stenosen, therapieresistenter Hypertonie, progressiver Verschlechterung der Nierenfunktion und jeder Form einer relevanten Stenose nicht arteriosklerotischer Genese (z. B. fibromuskulärer Dysplasie).

Abstract

Atherosclerotic renal artery stenoses (aRAS) are often associated with an aorto-iliac type of peripheral occlusive artery disease and may result in deterioration of blood pressure control, chronic kidney disease and myocardial dysfunction. Stenting of aRAS has almost replaced surgical revascularisation. However, the benefit of endovascular treatment of aRAS was challenged by the results of the STAR and ASTRAL trials demonstrating similar outcomes for revascularisation and conservative treatment. Due to severe limitations in trial design, the study results can only be applied to a small proportion of the affected patient population. A clinical benefit of renal stenting can only be expected if the indication for endovascular procedure was correct, in particular if the hemodynamic relevance of the lesion was verifiedby non-invasive (duplex) or invasive (pressure gradient) methods. The known predictors (pulse pressure > 50 ± 10 mmHg, high diastolic blood pressure, elevated BNP levels, renal insufficiency) for clinical success are often not sufficiently implemented in the decision-making process. Unquestioned by international guidelines is the indication for revascularisation of aRAS of a single functioning kidneys, severe bilateral lesions, resistant hypertension, worsening of renal function, and in each kind of severe RAS of non-atherosclerotic nature.

Schlüsselwörter

Nierenarterienstenosen - Stent - Angioplastie - Niereninsuffizienz - Hypertonie - Myokardhypertrophie - Fibromuskuläre Dysplasie

Keywords

renal artery stenosis - stent, angioplasty - renal insufficiency - hypertension - myocardial hypertrophy - fibromuscular dysplasia

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