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| ==Pathophysiology== | | == [[Renovascular disease overview|Overview]] == |
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| '''Causes of Ischemic Renal Disease'''
| | == [[Renovascular disease historical perspective|Historical Perspective]] == |
| *Atherosclerotic Renal Artery Stenosis (ARAS)
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| **Atherosclerosis accounts for approximately 90% of the cases of RAS and is the predominant lesion detected in patients >50 years of age
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| **The presence and number of diseased coronary arteries predicts the likelihood of ARAS
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| **RAS resulting from atherosclerotic disease is common in (18% to 20%) individuals undergoing coronary angiography (1)
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| **RAS resulting from atherosclerotic disease is even more common (35% to 50%) in individuals undergoing peripheral vascular angiography for occlusive disease of the aorta and legs (2)
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| *Fibromuscular dysplasia
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| **Unknown etiology
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| **Second most common cause of RAS
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| **Affects middle-aged women
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| **More common in first-degree relatives and in the presence of the ACE-I allele.
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| **Renal artery involvement is seen in 60% of cases - frequently bilateral compromise.
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| **Progressive renal stenosis is seen in 37% of cases and loss of renal mass in 63%
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| *Nephroangiosclerosis (HTN injury)
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| *[[Diabetic Nephropathy]] (small vessels)
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| *Renal thromboembolic disease
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| *Atheroembolic renal disease
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| *Aortorenal dissection
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| *Post renal transplant RAS
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| *Renal artery vasculitis
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| *Trauma
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| *[[Neurofibromatosis]]
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| *Thromboangiitis obliterans
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| *[[Scleroderma]]
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| ==Incidence== | | == [[Renovascular disease pathophysiology|Pathophysiology]] == |
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| *Prevalence of Renal Artery Stenosis
| | == [[Renovascular disease causes|Causes]] == |
| **Most Common Cause of HTN
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| *Incidence of Renal Artery Stenosis at Cardiac Catheterization
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| ==Diagnosis== | | == [[Renovascular disease differential diagnosis|Differentiating Renovascular disease from other Diseases]] == |
| *Manifestations of Renovascular Disease (3)
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| **Asymptomatic "Incidental RAS"
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| **Renovascular Hypertension
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| **Ischemic Nephropathy
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| **Accelerated CV Disease
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| ***Congestive Heart Failure
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| ***Stroke
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| ***Secondary Aldosteronism
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| ===Clinical Clues to the Diagnosis of Renal Artery Stenosis-ACC/AHA Guidelines === | | == [[Renovascular disease epidemiology and demographics|Epidemiology and Demographics]] == |
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| *'''CLASS I'''
| | == [[Renovascular disease risk factors|Risk Factors]] == |
| **Onset of hypertension before the age of 30 years or severe hypertension after age 55; level of evidence B
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| **Accelerated, resistant, or malignant hypertension; level of evidence C
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| **Development of new azotemia or worsening renal function after administration of an ACE inhibitor or ARB agent; level of evidence B
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| **Uneaplained atrophic kidney or sizse discrepancy between kidnyes of >1.5cm; level of evidence B
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| **Sudden, unexplained pulmonary edema; level of evidence B
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| *'''CLASS IIa'''
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| **Unexplained renal dysfunction, including individuals starting renal replacement therapy; level of evidence B
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| *'''CLASS IIb'''
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| **Multivessel coronary artery disease; level of evidence B
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| **Unexplained congestive heart failure; level of evidence C
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| **Refractory angina; level of evidence C
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| ===Diagnostic Methods to Detect Renal Artery Stenosis - ACC/AHA Guidelines=== | | == [[Renovascular disease screening|Screening]] == |
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| *'''CLASS I'''
| | == [[Renovascular disease natural history, complications and prognosis|Natural History, Complications and Prognosis]] == |
| **Duplex ultrasound sonography is recommended as a screening test to establish the diagnosis of renal artery stenosis; Level of eveidence: B
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| **Computed tomographic angiography(in individuals with normal renal function) is recommended as a screnning test to establish the diagnosis of renal artery stenosis; Level of eveidence: B
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| **Magnetic resonance angiography is recommended as a screening test to establish the diagnosis of renal artery stenosis; Level of eveidence: B
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| **When the clinical index of suspicion is high and the results of noninvasive tests are inconclusive, cathether angiography is recommended as a diagnostic test to establish teh diagnosis of renal aretry stenosis; Level of eveidence: B
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| *'''CLASS III'''
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| **Captopril renal scintigraphy is not recommended as a screening test to establish the diagnosis of renal artery stenosis; Level of eveidence: C
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| **Selective renal vein measurements are not recommended as a useful screening test to establish the diagnosis of RAS; Level of eveidence: B
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| **The plasma renin activity is not recommended as a useful screening test to establish the diagnosis of RAS; Level of eveidence: B
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| **The captopril test (measurements of plasma renin activity following captopril administration) is not recommended as a useful screening test to establish the diagnosis of renal artery stenosis; Level of eveidence: B
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| <div align="left">
| | == Diagnosis == |
| <gallery heights="175" widths="175">
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| Image:Renal artery stenosis.jpg|Renal artery stenosis
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| Image:Fibromuscular dysplasia.jpg|Fibromscular dysplasia
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| </gallery>
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| </div>
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| <div align="left">
| | [[Renovascular disease history and symptoms|History and Symptoms]] | [[Renovascular disease physical examination|Physical Examination]] | [[Renovascular disease laboratory findings|Laboratory Findings]] | [[Renovascular disease electrocardiogram|Electrocardiogram]] | [[Renovascular disease chest x ray|Chest X Ray]] | [[Renovascular disease CT|CT]] | [[Renovascular disease MRI|MRI]] | [[Renovascular disease echocardiography or ultrasound|Echocardiography or Ultrasound]] | [[Renovascular disease other imaging findings|Other Imaging Findings]] | [[Renovascular disease other diagnostic studies|Other Diagnostic Studies]] |
| <gallery heights="175" widths="175">
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| Image:Prevalence RAS.jpg|Prevalence of Renal Artery Stenosis
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| Image:Prevalence RAS at Cardiac Cath.jpg|Prevalence RAS at Cardiac Cath
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| </gallery>
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| </div>
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| ==Indications for Revascularization==
| | == Treatment == |
| *Reasons to Revascularize Atherosclerotic Renovascular Disease
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| **Treat Symptoms
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| **Prevent Future Illness
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| **Lower BP
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| **Preserve Renal Function
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| **“Bystander” Effects
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| ***Prevent Death
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| ***Prevent [[MI]]
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| ***Prevent [[CHF]]
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| ***Prevent CVA
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| *Indications for revascularization of RAS
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| **hypertension
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| ***Failure of medical therapy despite full doses of 3 drugs, including diuretic
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| ***Compelling need for ACE inhibition/angiotensin blockade with angiotensin-dependent GFR
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| **Progressive renal insufficiency with salvagable kidneys
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| ***Recent rise in serum creatinine
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| ***Loss of GFR during antihypertensive therapy (e.g., ACEI)
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| ***Evidence of preserved diastolic blood flow (low resistive index)
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| **Circulatory congestion, recurrent “flash” pulmonary edema
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| **Refractory congestive heart failure with bilateral renal artery stenosis
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| ==Treatment Options== | |
| ===Medical Therapy===
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| ===PTA===
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| ===Surgical===
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| ==Technical Considerations==
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| ===Renal Arteriography===
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| *Abdominal Aortogram: identification of ostia of the renal arteries and accessory renal arteries (25% of population)
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| *Arteriography should include both the arterial phase and the nephrographic phase
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| *Disease involving renal bifurcations require cranial or caudal angulation to open out the lesion
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| *Evidence of aortic atheroma: technique of no-touch angiography is recommended
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| ====Brachial Approach====
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| *For renal arteries that are oriented cephalad.
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| *When the aorta is occluded distally or the renal artery takeoff is severely angulated
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| *Proximal renal artery segment initially courses inferiorly and posteriorly braquial approach allows more coaxial alignment.
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| *Greater incidence of vascular site complications
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| ====Femoral approach====
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| *Renal artery angioplasty and stenting are usually performed via retrograde femoral approach.
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| *When the real artery origin is oriented horizontally or caudally with respect to the aorta, femoral approach is preferred.
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| ==Complications==
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| ===Complications of Percutaneous Renal Revascularization===
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| *Atheroembolism into the renal or peripheral vascular bed = cholesterol embolization
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| *Dissection of renal artery or the wall of the aorta
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| *Acute or delayed thrombosis
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| *Infection
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| *Rupture of renal artery
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| *Renal perforation
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| ==Prognosis==
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| ===Favorable Predictors===
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| '''Successful Outcome For Control Of Hypertension'''
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| *Rapid acceleration of hypertension over the prior weeks or months
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| *Presence of “malignant” hypertension
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| *Hypertension in association with flash pulmonary edema
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| *Contemporaneous rise in serum creatinine
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| *Development of azotemia in response to ACE inhibitors administered for control of hypertension.
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| '''Successful Salvage Or Preservation Of Renal Function'''
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| *Recent rapid rise in creatinine, unexplained by other factors
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| *Azotemia resulting from ACE inhibitors
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| *Absence of diabetes or other cause of intrinsic kidney disease
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| *Presence of global renal ischemia, wherein the entire functioning renal mass is subtended by bilateral critically narrowed renal arteries or a vessel supplying a solitary kidney.
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| ===Unfavorable Predictors===
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| *Renal atrophy demonstrated by kidney length <7.5 cm on ultrasound
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| *High renal resistance index detected by duplex ultrasound
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| *Proteinuria > 1gm/day
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| *Hyperuricemia
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| *Creatinine clearance <40 mL/minute
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| ==References==
| | [[Renovascular disease medical therapy|Medical Therapy]] | [[Renovascular disease surgery|Surgery]] | [[Renovascular disease primary prevention|Primary Prevention]] | [[Renovascular disease secondary prevention|Secondary Prevention]] | [[Renovascular disease cost-effectiveness of therapy| Cost-Effectiveness of Therapy]] | [[Renovascular disease future or investigational therapies|Future or Investigational Therapies]] |
| # PMID 11936924
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| # PMID 12472042
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| # PMID 16129817
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| | ==Case Studies== |
| | [[Renovascular disease case study one|Case #1]] |
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