肾动脉支架植入术所致肾动静脉血管瘘形成1例

One case of renal arteriovenous fistula formation caused by renal artery stent implantation

摘要:

肾动脉狭窄(RAS)是危害人类健康的一种常见疾病,通常由动脉粥样硬化或肌纤维发育不良引起。RAS是继发性高血压的常见原因之一,常常引起顽固性高血压,伴随肾素水平的显著升高,并较早出现进行性肾功能不全。此外,由RAS引发的肾素-血管紧张素-醛固酮系统(RAAS)激活,以及肾小球硬化、萎缩和水钠潴留等病理生理变化,还可能诱发心力衰竭、肺水肿、冠心病和脑梗死等心血管事件。因此,尽早识别RAS并针对严重狭窄的患者进行及时血运重建是治疗RAS的关键。经皮肾动脉内支架术(PRAS)因其有效率高、微创、恢复快和再狭窄率低等优点成为RAS患者血运重建的首选方案。然而,PRAS仍存在一些难以避免的并发症,如主动脉夹层、肾动脉破裂、穿刺部位动脉瘤、造影剂过敏反应以及肾功能损害等。这些并发症的出现可能给患者带来不利影响,严重时甚至可能导致死亡。肾动静脉瘘是一种极为罕见的PRAS并发症,临床上对其诊断和处理的经验相当有限。目前可获得的少数病例报告倾向于推荐再次进行外科手术,然而,外科手术无疑会进一步增加患者的痛苦和死亡风险。因此,对这类并发症进行归纳总结,并为临床医生提供科学的指导建议,显得尤为重要。该文报告了1例顽固性高血压患者,肾动脉造影显示肾血管严重狭窄,行支架植入术后出现肾动静脉瘘,经多学科团队讨论以及积极的内科保守治疗后,患者最终转危为安。因此,PRAS所致的肾动静脉瘘是选择外科干预还是内科保守治疗,值得思考。

Abstract:

Renal artery stenosis (RAS) is a common disease that endangers human health, usually caused by atherosclerosis or fibromuscular dyspalsia. RAS is also one of the most common causes of secondary hypertension, often leading to resistant hypertension with markedly elevated renin levels and early onset of progressive renal insufficiency. In addition, the activation of renin-angiotensin-aldosterone system (RAAS) caused by RAS and pathophysiological changes including glomerular sclerosis and atrophy, water and sodium retention can also lead to cardiovascular events such as heart failure, pulmonary edema, coronary heart disease and cerebral infarction. Therefore, early recognition of RAS and prompt revascularization in patients with severe stenosis are key to the treatment of RAS. Percutaneous renal artery stenting (PRAS) has become the preferred revascularization for patients with RAS due to its high response rate, minimally invasiveness, fast recovery and low restenosis rate. However, there are still some unavoidable complications of PRAS, such as aortic dissection, renal artery rupture, puncture vascular aneurysm, contrast allergy and contrast-induced nephropathy. The occurrence of these complications may have adverse consequences for patients, and even death in severe cases. Renal arteriovenous fistula is a very rare complication of PRAS, and clinical experience in its recognition and management is very limited. Few cases that can be collected tend to favor re-surgical intervention. But surgical intervention undoubtedly increases the risk of patient suffering and mortality again. Thus, it is of great significance to summarize such complications and give a scientific recommendation to clinicians. This article reports a patient with resistant hypertension who underwent renal arteriography showing severe stenosis of renal vessels and developed a renal arteriovenous fistula after stent implantation. Therefore, it is worth considering whether the renal arteriovenous fistula caused by PRAS should be treated with surgical intervention or conservative medical treatment.