Elsevier

Progress in Cardiovascular Diseases

Volume 52, Issue 3, November–December 2009, Pages 229-237
Progress in Cardiovascular Diseases

Management of Renal Artery Stenosis: The Case for Intervention, Defending Current Guidelines, and Screening (Drive-By) Renal Angiography at the Time of Catheterization

https://doi.org/10.1016/j.pcad.2009.09.006Get rights and content

Abstract

There is little debate that an untreated significant obstruction of blood flow to the kidney, most often due to atherosclerosis, is potentially hazardous to the health of patients. The treatment of atherosclerotic renovascular disease has evolved over the past 20 years from open surgery with its inherent morbidity and risk of mortality to percutaneous endovascular treatment with stents. The current debate is on the question of which patients are offered any additional advantage by revascularization for renal artery stenosis over medications alone. The primary issue is patient selection, including the most appropriate screening strategies for renal artery stenosis, which must be balanced against the risk of procedure-related complications. The goal of this paper is to explore the most appropriate utilization of revascularization with renal stent placement.

Section snippets

Screening strategies for RAS

Incidental, unsuspected, RAS occurs more commonly than previously thought, particularly in patients with known or suspected atherosclerotic vascular disease.4 Incidental RAS may be found in 15% to 34% of patients at the time of cardiac catheterization (Table 1).6, 7, 8, 9,15 In patients with lower extremity atherosclerotic peripheral arterial disease, the prevalence of RAS is 25% or higher.12, 13, 14,16

Screening for RAS is appropriate in patients at increased risk for this disease (Table 2).17

Renovascular hypertension

The Goldblatt kidney is the classic description of renin-dependent (renovascular) hypertension.18 In an attempt to define a hemodynamically significant gradient, DeBruyne et al19 incrementally inflated an angioplasty balloon in a deployed renal stent to obstruct blood flow. They measured ipsilateral renal vein renin release and confirmed that the threshold for renin release, and therefore a hemodynamically significant translesional gradient, was a ratio (Pd/Pa) of renal artery pressure to aorta

Screening angiography at cardiac catheterization

A science advisory from the American Heart Association addressed the issue of screening angiography at the time of coronary arteriography. It was recognized by the writing group that a diagnosis of RAS, even if not hemodynamically significant, provided valuable information for the future management of that patient. There is no additional risk for performing diagnostic renal angiography over and above the risk with coronary angiography alone.9 Given the increased prevalence of RAS in patients

Summary

Renal artery revascularization is indicated in symptomatic patients with a significant RAS, in patients who have failed best medical therapy, or in patients who do not tolerate medical therapy. Specific indications include (1) refractory heart failure or “flash” pulmonary edema (Class I); (2) renovascular hypertension (Class IIa); and (3) ischemic nephropathy (Class IIa).53 The threshold for anatomic and functional severity includes patients with RAS of 50% or higher and less than 70% and a

Statement of Conflict of Interest

The author declares that there are no conflicts of interest.

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