Renal Outcome and New-Onset Renal and Extrarenal Dissections in Patients With Nontrauma Renal Artery Dissection Associated With Renal Infarction

Abstract

We aimed to compare the characteristics of the patients with renal infarction related to nontrauma renal artery dissection (RAD) with versus without an underlying vascular disease and report long-term renal and vascular outcomes, as well as new-onset renal and extra-RADs. Data from 72 consecutive patients with RAD referred to our Hypertension Unit between 2000 and 2015 were analyzed. Radiological data, including a systematic brain-to-pelvis computed tomography angiography, were independently reviewed. Three main causes of RAD were identified at the initial work-up: fibromuscular dysplasia (n=16); dissecting or aneurysmal multisite arterial disease (n=21) not linked to any known vascular disease; and isolated RAD (n=24) without any other arterial lesion. At diagnosis, patients (median age 46 [interquartile range, 40–53] years, 70.5% males, 26.2% preexisting hypertension, 65.6% smokers) had a median blood pressure of 138 (125–152)/87 (78–97) mm Hg. Estimated glomerular filtration rate was 81 (66–95) mL/min per 1.73 m 2 and 18% had renal impairment. Patients were treated with antiplatelet drugs (65.6%), anticoagulant (3.3%). A total of 11.5% underwent angioplasty. No clinical or biological difference was observed between the 3 groups. After 51 (19–92) months follow-up, blood pressure was reduced by 13 (0–29)/9 (3–18) mm Hg; 11.5% of patients had estimated glomerular filtration rate <60 mL/min per 1.73 m 2 . RAD evolved toward healing (67.2%), aneurysmal dilation (24.6%), or stenosis (8.2%). New-onset RAD was as frequent in dissecting or aneurysmal multisite arterial disease (23.8%) than in fibromuscular dysplasia (25%) group, whereas de novo extrarenal dissection was 6-fold more frequent in dissecting or aneurysmal multisite arterial disease (38.1%) than in fibromuscular dysplasia (6.3%) group. No new event occurred in patients with an initial diagnosis of isolated RAD. Initial diagnostic accuracy using thorough systematic exhaustive explorations of arterial sites helps to stratify the risk of new-onset dissection and adapt monitoring accordingly.

Baseline Brain-to-Pelvis Imaging Predicts Subsequent Arterial Complications in Patients With Renal Artery Dissection

“…12 Such findings are in sharp contrast with the overwhelming female prevalence of SCAD, 6,7 whether associated with extracoronary FMD or not. As 66% of patients with renal artery dissection reported by Faucon et al 3 were current or former smokers, and smoking is a known factor associated with arterial dissection, it is tempting to speculate that a gender difference in smoking behavior may at least, in part, account for the apparent association of male gender with dissection in this cohort. 3 Notably, however, in the United States 9 and European/International 10 FMD registries, the presence of arterial dissection was not associated with smoking.…”

“…As 66% of patients with renal artery dissection reported by Faucon et al 3 were current or former smokers, and smoking is a known factor associated with arterial dissection, it is tempting to speculate that a gender difference in smoking behavior may at least, in part, account for the apparent association of male gender with dissection in this cohort. 3 Notably, however, in the United States 9 and European/International 10 FMD registries, the presence of arterial dissection was not associated with smoking. As a whole, there appears to be a strong, probably multifactorial, vessel-dependent interaction between gender and the risk of nonatherosclerotic arterial dissection, whether due to FMD or not.…”

“…Another question is to what extent patients with isolated renal artery dissection, FMD, and dissecting or aneurysmal multisite arterial disease belong to a pathophysiological continuum as suggested by similar baseline characteristics, or represent distinct entities, as suggested by their different prognosis. The dissecting or 3 Unexplained implies that dissection was nontraumatic and underlying vascular diseases (atherosclerotic, inflammatory, connective tissue diseases, genetic arteriopathies…) have been carefully excluded. We feel that this differential diagnosis should be considered again based on the results of brain-topelvis arterial scanning and, in case of multiple dissections or aneurysms, systematic screening for genetic arteriopathies should be considered.…”

“…Another potential caveat would be to mis- or overinterpret mild, potentially artifactual arterial irregularities for a string of beads. In summary, assignment of patients to 1 of the 3 categories described by Faucon et al 3 may be tricky, and after the acute phase, it may be preferable to refer patients to a third referral center including both experts of vascular medicine and vascular geneticists.…”

“…In the meantime, both clinicians and researchers are encouraged to consider using the classification proposed by Faucon et al 3 and collect similar information (Figure), also in patients with dissection of other arterial beds. Such a careful clinical characterization will likely lead to a thorough reappraisal not only of renal artery dissection but also of unexplained arterial dissections as a whole.…”