Renal Artery Stenosis—When To Screen, What To Stent?

Abstract

Renal artery stensosis (RAS) continues to be a problem for clinicians, with no clear consensus on how to investigate and assess the clinical significance of stenotic lesions and manage the findings. RAS caused by fibromuscular dysplasia is probably commoner than previously appreciated, should be actively looked for in younger hypertensive patients and can be managed successfully with angioplasty. Atheromatous RAS is associated with increased incidence of cardiovascular events and increased cardiovascular mortality, and is likely to be seen with increasing frequency. Evidence from large clinical trials has led clinicians away from recommending interventional revascularisation towards aggressive medical management. There is now interest in looking more closely at patient selection for intervention, with focus on intervening only in patients with the highest-risk presentations such as flash pulmonary oedema, rapidly declining renal function and severe resistant hypertension. The potential benefits in terms of improving hard cardiovascular outcomes may outweigh the risks of intervention in this group, and further research is needed.

2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS)

“…Metodą obrazową pierwszego rzutu w celu przesiewowego wykrywania istotnego zwężenia (≥ 60%) jest DUS [205,207,209,210], choć może ona zawyżać stopień zwężenia. Obrazowanie można powtarzać w celu oceny progresji zwę-żenia i jego następstw hemodynamicznych (np.…”

“…Jest mniej przydatna u pacjentów ze stentami w tętnicach nerkowych ze względu na artefakty. Referencyjną metodą rozpoznawania zwężenia tętnicy nerkowej pozostaje DSA [209,212]. Ponieważ korelacja między angiograficznym stopniem zwężenia a jego znaczeniem hemodynamicznym jest słaba, ważną zaletą DSA pozostaje możliwość zmierzenia gradientu ciśnienia przez zwężenie, co jest szczególnie użyteczne w przypadku umiarkowanych zwężeń.…”

Endovascular Versus Medical Therapy for Atherosclerotic Renovascular Disease

“…Since ARVD is considered a coronary artery disease equivalent [17••], imparting a high risk of cardiovascular disease and related mortality, it is reasonable to keep well-controlled blood pressure in these patients [18••]. The BP goal according to the 2014 guidelines for hypertensive patients with CKD with or without diabetes is less than 140/90 mmHg [19•].…”

“…Some have hypothesized that patients with severe RAS might require higher blood pressures to maintain adequate blood flow across a stenosis; however, very low rates of progression to ESRD in medically managed patients in CORAL and other studies with medically managed study groups have been argued against pursuing such a strategy. Angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB), calcium channel blockers, and beta-blockers are all reasonable options for hypertension therapy in ARVD, with the caveats detailed for ACEI/ARB treatment below [18••, 20]. …”

Renal Artery Stenosis and Acute Pulmonary Edema-A Possible Correlation beyond Pickering Syndrome

“…The most important etiologic conditions leading to RAS are the fibromuscular dysplasia-responsible for almost 10% of cases, and the atherosclerotic disease-prevailing in 90% of them. Other causes, like arteritis or extrinsic compressions, are rare [1]. The pathophysiologic consequences of RAS are variable, but a narrowing of more than 50% in lumen diameter could become hemodynamically significant [2].…”