Atherosclerotic Renal Artery Stenosis and Hypertension: Pragmatism, Pitfalls, and Perspectives

Abstract

For many years and even decades, a diagnostic work-up to look for a secondary form of hypertension, particularly of renovascular origin, has been a central tenet in medicine. Atherosclerotic renal artery stenosis is considered the most common cause of renovascular hypertension. However, advances in understanding the complex pathophysiology of this condition and the recently documented futility of renal revascularization bring into question whether atherosclerotic renal artery stenosis truly causes "renovascular hypertension." From a clinical point of view, a clear distinction should be made between hypertension associated with atherosclerotic renal artery stenosis and hypertension caused by renal artery stenosis-induced activation of the renin-angiotensin-aldosterone system. Most patients with atherosclerotic renal artery stenosis do not have a form of hypertension that is remediable or improved by angioplasty; to expose them to the cost, inconvenience, and risk of a diagnostic work-up add up to little more than a wild goose chase. However, with very few exceptions, medical therapy with antihypertensives and statins remains the cornerstone for the management of patients with atherosclerotic renal artery stenosis and hypertension.

The renal artery is involved in Chinese Takayasu’s arteritis patients

“…Neither renal function nor hypertension can be improved by endovascular or surgical interventions in ARVD patients with RAS. 19 However, the mean blood pressure decreased and GFR increased after renal revascularization in TA patients with RAS in a report by Weaver et al, implying that ARVD and TA are different. 25 In the present study, we found that renal function was negatively correlated with the severity of RAS.…”

“…18 In fact, not all patients with RAS experience hypertension. 19 Dysfunction of the carotid sinus, aortic body, and medulla oblongata near the obex may also contribute to renin secretion. 20,21 In addition, hypertension may be due to coarctation of the aorta, loss of elasticity in the involved vessels, increased activity of the sympathetic nervous system, and endothelial dysfunction.…”

“…20,21 In addition, hypertension may be due to coarctation of the aorta, loss of elasticity in the involved vessels, increased activity of the sympathetic nervous system, and endothelial dysfunction. 17,19 The kidney may adapt to moderate reduction in blood flow and may even maintain homeostasis with less than 10% blood flow. 22,23 Previous studies have demonstrated that TA patients with RAI usually have normal renal function, and progressive renal failure is extremely rare.…”

Long-Term Renal and Cardiac Outcomes after Stenting in Patients with Resistant Hypertension and Atherosclerotic Renal Artery Stenosis

“…However, while a multiplicity of observational studies on revascularization of stenotic renal arteries reported a significant reduction in blood pressure and plasma creatinine, randomized controlled trials that compared renal artery angioplasty with stenting to conservative treatment did not meet the expectations as they could not demonstrate any benefit on renal and cardiovascular outcomes [10]. These randomized trials have been criticized on several grounds and principally for inadequate selection of patients [11]. Indeed, the majority of these studies enrolled patients with a relatively mild degree of renal arterial narrowing or excluded patients at higher cardiovascular risk such as those with resistant hypertension.…”

Atherosclerotic renal artery stenosis

“…These patients should also be treated with an antiplatelet drug, statins, smoking cessation, control of diabetes mellitus, and weight loss if obese to reduce progression of atherosclerosis. However, it should be pointed out that there are no randomized controlled clinical trial data showing the efficacy on outcomes of different medical regimens in treating patients with atherosclerotic RAS (5).…”