Renal artery stenosis resident survival guide
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Karol Gema Hernandez, M.D. [2]
Definition
This section provides a short and straight to the point definition of the disease or symptom in one sentence.
Causes
Life Threatening Causes
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.
Common Causes
Clinical Clues to the Diagnosis of RAS
| ❑ Determine if one or more of the above is present | |||||||||||||||||||||||||||||||||
| <table class="wikitable" | |||||||||||||||||||||||||||||||||
| ❑If one or more of the above are present, proceed to further diagnostic testing | |||||||||||||||||||||||||||||||||
Noninvasive Imaging
| Invasive Imaging
| ||||||||||||||||||||||||||||||||
❑ Duplex ultrasound
❑ Gadolinium enhanced MRA ❑ CT angiography | ❑ Abdominal aortography to assess the renal arteries during coronary and peripheral angiography | ||||||||||||||||||||||||||||||||
Negative noninvasive test but with high clinical suspicion | Evidence of RAS | Evidence of RAS | |||||||||||||||||||||||||||||||
Renal angiography | |||||||||||||||||||||||||||||||||
Evidence of RAS | |||||||||||||||||||||||||||||||||
Confirmed RAS, proceed to treatment | |||||||||||||||||||||||||||||||||
Algorithm based on the 2013 AHA Guidelines Recommendations for Management of Patients with PAD.[1]
Indications for Renal Revascularization
| Indication | Level of evidence |
|---|---|
| 1.Hemodynamically significant RAS with recurrent, unexplained CHF or sudden, unexplained pulmonary edema | Class I; LOE B |
2. RAS with:
| Class IIa; LOE B |
| 3.RAS and CRI with bilateral RAS or RAS to solitary functioning kidney | Class IIa; LOE B |
| 4. RAS and unstable angina | Class IIa; LOE B |
| 5. Asymptomatic bilateral or solitary viableʰ kidney with a hemodynamically significant RAS | Class IIb; LOE C |
| 6. Asymptomatic unilateral hemodynamically significant RAS in a viable* kidney | Class IIb; LOE C |
| 7. RAS and CRI with unilateral RAS (2 kidneys present) | Class IIb; LOE C |
ʰViable means kidney linear length greater than 7 cm
| ❑ When any of the indications are met: | |||||||||||||||||||||||||||||||||
| ❑Renal Angioplasty/Stent | ❑ Renal artery surgery | ||||||||||||||||||||||||||||||||
Atherosclerotic RAS
| Fibromuscular dysplasia RAS
| ||||||||||||||||||||||||||||||||
| Renal stent placement is indicated for ostial atherosclerotic RAS lesions that meet the clinical criteria for intervention | Balloon angioplasty with bailout stent placement if necessary is recommended for fibromuscular dysplasia lesions | ||||||||||||||||||||||||||||||||
References
- ↑ Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH; et al. (2013). "Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA guideline recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". Circulation. 127 (13): 1425–43. doi:10.1161/CIR.0b013e31828b82aa. PMID 23457117.