Diagnosis and management of atherosclerotic renal artery stenosis: improving patient selection and outcomes

Abstract

Renal artery stenosis (RAS) is common among patients with atherosclerosis, and is found in 20-30% of individuals who undergo diagnostic cardiac catheterization. Renal artery duplex ultrasonography is the diagnostic procedure of choice for screening outpatients for RAS. Percutaneous renal artery stent placement is the preferred method of revascularization for hemodynamically significant RAS, and is favored over balloon angioplasty alone. Stent placement carries a class I recommendation for atherosclerotic RAS according to ACC and AHA guidelines. Discordance exists between the very high (>95%) procedural success rate and the moderate (60-70%) clinical response rate after renal stent placement, which is likely to be a result of poor selection of patients, inadequate angiographic assessment of lesion severity, and the presence of renal parencyhmal disease. Physiologic lesion assessment using translesional pressure gradients, and measurements of biomarkers (e.g. brain natriuretic peptide), or both, could enhance the selection of patients and improve clinical response rates. Long-term patency rates for renal stenting are excellent, with 5-year secondary patency rates greater than 90%. This Review will outline the clinical problem of atherosclerotic RAS and its diagnosis, and will critically assess treatment options and strategies to improve patients' outcomes.

Is Fibromuscular Dysplasia a Single Disease?

“…In multifocal FMD, the only way to accurately assess the degree of stenosis is by measuring the translesional gradient or using intravascular ultrasound. 19,20 This may be one of several possible reasons why 87% of patients with unifocal FMD had renal artery revascularization, whereas only 38% of those with multifocal FMD had revascularization. Additionally, the higher cure rate of hypertension in patients undergoing intervention with unifocal FMD (54%) compared with those with multifocal FMD (26%) may be related to the fact that patients with unifocal disease were younger, had a shorter duration, and more severe hypertension, making a favorable response to balloon angioplasty more likely.…”

Endothelin-A Receptor Antagonism after Renal Angioplasty Enhances Renal Recovery in Renovascular Disease

“…The use of PTRAS in RVD grew significantly during the past 20 years, 2 with tremendous progress in successfully resolving renal stenosis and restoring blood flow (.95% of the cases). 3 However, despite the high technical success of PTRAS, improvement in renal function is still observed in a relatively small portion of the cases. 4 The reasons for the persistent poor outcomes after PTRAS in RVD are still unclear.…”

A computational investigation of the geometric factors affecting the severity of renal arterial stenoses

“…Carotid artery stenosis is a severe example of an arterial constriction; it can cause insufficient perfusion and can give rise to a transient ischemic attack [1]. A second example is renal artery stenosis-the most common cause of secondary hypertension, a leading cause of end-stage renal disease in dialysis patients and an independent predictor of cardiovascular complications such as myocardial infarction [2]. It is thought that one cause of renovascular hypertension due to renal artery stenosis is a malfunction in the reninangiotensin-aldosterone system (RAAS) in which unwarranted vasoconstrictors are released causing systemic hypertension.…”