Aterosklerotik Renal Arter Darlıklarında Endovasküler Tedavi
Özet
Aterosklerotik renal arter darlığı, sekonder hipertansiyon ve iskemik nefropatinin önemli nedenlerinden biridir. Güncel yaklaşım, yalnızca anjiyografik darlığın varlığını değil, lezyonun klinik ve hemodinamik önemini esas almaktadır. Son yıllarda ASTRAL, STAR ve CORAL gibi çalışmalar stentlemenin genel hasta grubunda sınırlı yararını göstermiş olsa da, bu çalışmaların yüksek riskli hastaları yeterince temsil etmediği anlaşılmıştır. Patofizyolojide renal perfüzyon basıncının azalmasına bağlı renin-anjiotensin-aldosteron sistemi aktivasyonu, vazokonstriksiyon, volüm artışı ve ilerleyici parankimal hasar temel rol oynar. Özellikle bilateral darlık ya da soliter böbrek varlığında gelişen global renal iskemi, Pickering sendromu olarak tanımlanan ani pulmoner ödem tablolarına yol açabilir. Bugün için dirençli veya malign hipertansiyon, tekrarlayan flash pulmoner ödem ya da konjestif kalp yetmezliği atakları ve hızlı kötüleşen fakat kurtarılabilir böbrek fonksiyonu olan olgular, revaskülarizasyondan en çok fayda görebilecek grubu oluşturmaktadır. Tanıda renal Doppler ultrasonografi ilk basamak yöntemdir; gerekli olgularda darlığın hemodinamik etkisi de değerlendirilmelidir. Endovasküler tedavide uygun damar yolu seçimi, embolizasyon riskinin azaltılması ve damar çapına göre stent tercihi önemlidir. Geniş damarlarda çıplak metal stentler, küçük çaplı damarlarda ise ilaç salınımlı stentler öne çıkabilir. Doğru seçilmiş hastalarda renal arter stentlemesi kan basıncı kontrolünü iyileştirebilir, kalp yetmezliği yatışlarını azaltabilir, böbrek fonksiyonlarını stabilize edebilir ve uzun dönem klinik sonuçlara olumlu katkı sağlayabilir; burada uygun hasta seçimi belirleyicidir.
Atherosclerotic renal artery stenosis is an important cause of secondary hypertension and ischemic nephropathy. The contemporary approach is based not simply on the angiographic presence of stenosis, but on its clinical and hemodynamic significance. Although trials such as ASTRAL, STAR, and CORAL suggested limited benefit of stenting in the population, these studies are now understood to have underrepresented high-risk patients. Pathophysiologically, reduced renal perfusion pressure activates the renin-angiotensin-aldosterone system, leading to vasoconstriction, volume expansion, and progressive parenchymal injury. Bilateral disease or stenosis in a functioning kidney may result in global renal ischemia and episodes of flash pulmonary edema, classically described as Pickering syndrome. Currently, patients with resistant or malignant hypertension, recurrent flash pulmonary edema or heart failure exacerbations, and rapidly deteriorating yet salvageable renal function are considered candidates for revascularization. Renal Doppler ultrasonography remains the first-line diagnostic modality, and hemodynamic relevance should be confirmed when necessary. In endovascular treatment, access strategy, embolization prevention, and stent selection according to vessel diameter are crucial. Bare-metal stents are standard for larger vessels, whereas drug-eluting stents may be advantageous in small-caliber arteries. In selected patients, renal artery stenting can improve blood pressure control, reduce heart failure admissions, stabilize renal function, and influence long-term outcomes.
Referanslar
Drieghe B, De Buyzere M, Bové T, De Backer T. Interventions for renal artery stenosis: Appraisal of novel physiological insights and procedural techniques to improve clinical outcome. Vol. 104, Catheterization and Cardiovascular Interventions. John Wiley and Sons Inc; 2024. p. 285–99.
Safian RD. Renal artery stenosis. Vol. 65, Progress in Cardiovascular Diseases. W.B. Saunders; 2021. p. 60–70.
Prince M, Gupta A, Bob-Manuel T, Tafur J. Renal revascularization in resistant hypertension. Vol. 63, Progress in Cardiovascular Diseases. W.B. Saunders; 2020. p. 58–63.
Triantis G, Chalikias GK, Ioannidis E, Dagre A, Tziakas DN. Renal artery revascularization is a controversial treatment strategy for renal artery stenosis: A case series and a brief review of the current literature. Hellenic J Cardiol. 2022;65:42-8.
Dreyfus I, Zilinyi R, Radhakrishnann J, Parikh SA. Therapy for Renal Artery Stenosis: A Call for Change. Vol. 31, Journal of Endovascular Therapy. SAGE Publications Inc.; 2024. p. 522–32.
Oktan MA, Sarioglu O, Heybeli C, Ozdemir E, Atay I, Korucu B, et al. Predictors of kidney disease progression after renal artery stenting. BMC Nephrol. 2025;26(1):175.
Modrall JG, Zhu H, Weaver FA. Clinical predictors of blood pressure response after renal artery stenting. In: Journal of Vascular Surgery. Mosby Inc.; 2020. p. 1269–75.
Edgar B, Pearson R, Kasthuri R, Gillis K, Geddes C, Rostron M, et al. The impact of renal artery stenting on therapeutic aims. J Hum Hypertens. 2023;37(4):265-72.
Reinhard M, Schousboe K, Andersen UB, Buus NH, Rantanen JM, Bech JN, et al. Renal Artery Stenting in Consecutive High-Risk Patients With Atherosclerotic Renovascular Disease: A Prospective 2-Center Cohort Study. J Am Heart Assoc. 2022;11(7):e024421.
Modrall JG, Jeon-Slaughter H, Ramanan B, Tsai S, Miller RT, Hastings JL. Predicting renal function response to renal artery stenting. In: Journal of Vascular Surgery. Elsevier Inc.; 2023. p. 102-110.e1.
Arnold S V, Wang K, Kirtane AJ, Magnuson EA, Chinnakondepalli KM, Cooper CJ, et al. Quality of life effects of renal artery stenting versus medical therapy for atherosclerotic renal-artery stenosis: results from the randomized CORAL trial. Eur Heart J Qual Care Clin Outcomes. 2025;11(8):1388-95.
Dregoesc MI, Bolboacǎ SD, Doroltan PM, Istrate M, Marc MC, Iancu AC. Long-term mortality after renal artery stenting in patients with severe atherosclerotic renal artery stenosis and high-risk clinical manifestations. Am J Hypertens. 2021;34(8):880–7.
Referanslar
Drieghe B, De Buyzere M, Bové T, De Backer T. Interventions for renal artery stenosis: Appraisal of novel physiological insights and procedural techniques to improve clinical outcome. Vol. 104, Catheterization and Cardiovascular Interventions. John Wiley and Sons Inc; 2024. p. 285–99.
Safian RD. Renal artery stenosis. Vol. 65, Progress in Cardiovascular Diseases. W.B. Saunders; 2021. p. 60–70.
Prince M, Gupta A, Bob-Manuel T, Tafur J. Renal revascularization in resistant hypertension. Vol. 63, Progress in Cardiovascular Diseases. W.B. Saunders; 2020. p. 58–63.
Triantis G, Chalikias GK, Ioannidis E, Dagre A, Tziakas DN. Renal artery revascularization is a controversial treatment strategy for renal artery stenosis: A case series and a brief review of the current literature. Hellenic J Cardiol. 2022;65:42-8.
Dreyfus I, Zilinyi R, Radhakrishnann J, Parikh SA. Therapy for Renal Artery Stenosis: A Call for Change. Vol. 31, Journal of Endovascular Therapy. SAGE Publications Inc.; 2024. p. 522–32.
Oktan MA, Sarioglu O, Heybeli C, Ozdemir E, Atay I, Korucu B, et al. Predictors of kidney disease progression after renal artery stenting. BMC Nephrol. 2025;26(1):175.
Modrall JG, Zhu H, Weaver FA. Clinical predictors of blood pressure response after renal artery stenting. In: Journal of Vascular Surgery. Mosby Inc.; 2020. p. 1269–75.
Edgar B, Pearson R, Kasthuri R, Gillis K, Geddes C, Rostron M, et al. The impact of renal artery stenting on therapeutic aims. J Hum Hypertens. 2023;37(4):265-72.
Reinhard M, Schousboe K, Andersen UB, Buus NH, Rantanen JM, Bech JN, et al. Renal Artery Stenting in Consecutive High-Risk Patients With Atherosclerotic Renovascular Disease: A Prospective 2-Center Cohort Study. J Am Heart Assoc. 2022;11(7):e024421.
Modrall JG, Jeon-Slaughter H, Ramanan B, Tsai S, Miller RT, Hastings JL. Predicting renal function response to renal artery stenting. In: Journal of Vascular Surgery. Elsevier Inc.; 2023. p. 102-110.e1.
Arnold S V, Wang K, Kirtane AJ, Magnuson EA, Chinnakondepalli KM, Cooper CJ, et al. Quality of life effects of renal artery stenting versus medical therapy for atherosclerotic renal-artery stenosis: results from the randomized CORAL trial. Eur Heart J Qual Care Clin Outcomes. 2025;11(8):1388-95.
Dregoesc MI, Bolboacǎ SD, Doroltan PM, Istrate M, Marc MC, Iancu AC. Long-term mortality after renal artery stenting in patients with severe atherosclerotic renal artery stenosis and high-risk clinical manifestations. Am J Hypertens. 2021;34(8):880–7.
