The role of percutaneous revascularization for renal artery stenosis

Abstract

Renal artery stenosis (RAS) is usually caused by atherosclerosis or fibromuscular dysplasia. RAS leads to activation of the renin-angiotensin-aldosterone system and may result in hypertension, ischemic nephropathy, left ventricular hypertrophy and congestive heart failure. Management options include medical therapy and revascularization procedures. Recent studies have shown angiotensin receptor blockers (ARB) and angiotensin converting enzyme inhibitors (ACE-I) to be highly effective in treating the hypertension associated with RAS and in reducing cardiovascular events; however, they do not correct the underlying RAS and loss of renal mass may continue. Renal artery angioplasty was first performed by Gruntzig in 1978. The routine use of stents has increased technical success rates compared with angioplasty, and surgery is now only rarely performed. Although numerous case series claimed benefit in terms of blood pressure control, no adequately powered randomized, controlled, prospective study of renal artery interventions has reported their effect on cardiovascular morbidity or mortality. The CORAL trial, an ongoing study of renal artery stent placement and optimal medical therapy (OMT) funded by the National Institutes of Health, is the first study to attempt to do so. Until the CORAL trial results are in, physicians will continue to be faced with difficult choices when determining the optimal management for RAS patients and deciding which, if any, patients should be offered revascularization.

Multimarker assessment for the prediction of renal function improvement after percutaneous revascularization for renal artery stenosis

“…This is in line with previous reports of 11 observational studies which showed improvement of renal function after PTRA in 39% (range, 17-60%) (12). Similarly, Zeller et al demonstrated in larger study cohort improvement of renal function after stent-supported angioplasty of severe ostial RAS in 52 % of patients (13).…”

“…In this trial during followup only a minimal though significant decrease was demonstrated with regard to systolic blood pressure when performing renal artery stenting in addition to medical therapy as opposed to medical therapy alone. Observational studies and larger controlled trials have shown that up to 50% of patients may have some benefit from RAS treatment with PTRA (12). As these results showed, selection of the appropriate subgroup is key when considering patients for PTRA and unselected PTRA based on the pure detection of RAS is not recommended (4,5,15).…”

Fibromuscular Dysplasia: State of the Science and Critical Unanswered Questions

“…225 Major complications, including hemorrhage, dissection, stent migration, vessel thrombosis, and emboli, are seen in up to 6.3% (95% CI, 4.1-9.0) of patients with a mortality rate 0.9% (95% CI, 0.3-1.7).…”

Síndrome de Pickering – estenosis de arteria renal y flash edema pulmonar. Nueva denominación de un concepto antiguo

“…Aunque hay dudas sobre la utilidad del tratamiento intervencionista en la patología vasculorrenal en general 7,9-12 , los pacientes con síndrome de Pickering se benefician más de este enfoque terapéutico que los pacientes con estenosis ateromatosa unilateral y riñón contralateral funcionante [4][5][6][7][8][9][10][11][12][13] . La ATP con colocación de un stent endovascular permite el buen control tensional, la mejoría de la función renal y la desaparición de los episodios de EAP 6,9,[11][12][13] .…”

“…La ATP con colocación de un stent endovascular permite el buen control tensional, la mejoría de la función renal y la desaparición de los episodios de EAP 6,9,[11][12][13] . En cuanto al tratamiento médico, hay que tener en cuenta la ya conocida contraindicacción de los bloqueadores del sistema renina-angiotensina en pacientes con estenosis crítica de arteria renal bilateral o estenosis arterial en riñón único.…”