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Renal Arteries: Revascularization
Keith B. Quencer, MD; T. Gregory Walker, MD, FSIR
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KEY FACTS

  • Preprocedure

    • Procedure

      • Post Procedure

        • Outcomes

          TERMINOLOGY

          • Definitions

            • Renal artery stenosis (RAS): Fixed narrowing of renal artery (main or branch vessels)
              • May lead to refractory hypertension (HTN), ischemic nephropathy, &/or pulmonary edema
            • Renal vascular HTN: HTN due to RAS
              • Accelerated HTN: Previously controlled HTN now poorly controlled despite multiple additional medications
              • Malignant HTN: Uncontrolled HTN associated with acute end-organ damage
              • Refractory HTN: Continued HTN despite optimal doses of 3 drugs of different classes
            • Ischemic nephropathy: Declining renal function and atrophy caused by poor renal perfusion
          • Epidemiology/Pathophysiology of Renal Artery Stenosis

            • Epidemiology
              • Major cause of secondary HTN
                • Causative in 0.5-10.0% of all patients with HTN, ~ 30% of patients with accelerated HTN
              • Ischemic nephropathy contributory in ~ 25% of patients requiring hemodialysis
              • High prevalence in patients with atherosclerosis
                • 15-30% in coronary artery disease
                • 22-59% in peripheral artery disease
            • Pathophysiology
              • Stenosis causes decreased renal perfusion
                • Renin released by juxtaglomerular cells
                • Renin activates angiotensin II production
                • Angiotensin II production causes efferent arteriole constriction
                  • ↑ angiotensin II increases glomerular hydrostatic pressure in order to maintain glomerular filtration rate (eGFR)
                  • ↑ angiotensin II leads to diastolic dysfunction
                  • ↑ angiotensin II causes systemic HTN
                  • ↑ angiotensin II causes aldosterone elevation leading to sodium/water retention
            • Causes
              • Atherosclerosis
                • Most common (90%)
                  • M > F
                  • > 50 years old
                • Affects ostium/proximal 1/3 of renal artery
                • Risk factors similar to atherosclerosis elsewhere
                • Often associated with renal impairment
                • Stenting definitively better than percutaneous transluminal angioplasty (PTA) for ostial atherosclerotic lesions
              • Fibromuscular dysplasia (FMD)
                • 2nd most common cause of RAS (10%)
                  • F > M (3-4:1)
                  • Typically < 30 years old
                • Noninflammatory vasculitis
                  • Involves mid and distal main renal artery
                  • Also may involve segmental renal arteries
                • Medial fibroplasia most common subtype (80%)
                  • Alternating areas of aneurysmal dilation give beaded appearance
                • Rarely leads to ischemic nephropathy or complete renal artery occlusion
                • Angioplasty alone effective
                  • Stent reserved for PTA failure/restenosis/complications (i.e., dissection, rupture)
              • Renal transplant arterial stenosis
                • Affects 5-10% of transplants
                • Causes
                  • External compression by peritransplant fibrosis
                  • Kink points at anastomosis
                  • Injury from vascular clamp used during surgery
              • Other causes
                • Takayasu arteritis, neurofibromatosis, mid aorta syndrome
                • Iatrogenic or traumatic injury
                  • Vessel injury damages intima; causes thrombosis
                • Retroperitoneal tumor encasement/compression
              • Acute renal ischemia
                • Embolism from proximal source (e.g., atrial fibrillation or aortic plaque)
                • In situ thrombosis of stenotic renal artery
                • Iatrogenic from endovascular intervention
            • Clinical reasons to suspect RAS
              • Drug-resistant HTN
              • Systolic readings in 170s-190s
              • HTN onset under 30 or after 50 years of age
              • Abrupt worsening of HTN or renal function
              • Concurrent known systemic atherosclerosis
              • Creatinine rise > 20% on angiotensin-converting enzyme inhibitor (ACE inhibitor)
            • RAS and prognosis
              • RAS associated with increased cardiovascular events/mortality
                • Marker of/contributor to atherosclerotic disease
                  • Likely from renin-angiotensin aldosterone system activation
                  • 2-3x increase in coronary artery disease; 3x increase in stroke
                  • Poor survival (27 months) for end-stage renal disease from ischemic nephropathy
                  • 57% 4-year survival in patient with RAS undergoing cardiac catheterization vs. 89% without RAS

          PREPROCEDURE

          • Indications

            • Contraindications

              • Preprocedure Imaging

                • Getting Started

                  PROCEDURE

                  • Patient Position/Location

                    • Equipment Preparation

                      • Procedure Steps

                        • Findings and Reporting

                          • Alternative Procedures/Therapies

                            POST PROCEDURE

                            • Things to Do

                              OUTCOMES

                              • Problems

                                • Complications

                                  • Expected Outcomes

                                    Selected References

                                    1. ACR Manual on Contrast Media, Version 10.2, 2016
                                    2. Hassani M: Takayasu arteritis associated with severe renovascular hypertension. Saudi J Kidney Dis Transpl. 27(2):402-6, 2016
                                    3. Kawarada O et al: Renovascular heart failure: heart failure in patients with atherosclerotic renal artery disease. Cardiovasc Interv Ther. 31(3):171-82, 2016
                                    4. O'Connor PJ et al: Endovascular Treatment of Renal Artery Stenosis in the Post CORAL Era. Curr Treat Options Cardiovasc Med. 18(8):48, 2016
                                    5. Sanidas EA et al: Renal fibromuscular dysplasia: a not so common entity of secondary hypertension. J Clin Hypertens (Greenwich). 18(3):240-6, 2016
                                    6. Biederman DM et al: Tailoring the endovascular management of transplant renal artery stenosis. Am J Transplant. 15(4):1039-49, 2015
                                    7. Braga AF et al: Endovascular approach to transplant renal artery stenosis. Ann Transplant. 20:698-706, 2015
                                    8. Chen W et al: Transplant renal artery stenosis: clinical manifestations, diagnosis and therapy. Clin Kidney J. 8(1):71-8, 2015
                                    9. Diego-Nieto A et al: Severe renal artery stenosis after renal sympathetic denervation. JACC Cardiovasc Interv. 8(11):e193-4, 2015
                                    10. Koukoulaki M et al: Successful endovascular treatment of transplant intrarenal artery stenosis in renal transplant recipients: Two case reports. World J Transplant. 5(2):68-72, 2015
                                    11. Mohan IV et al: The management of renal artery stenosis: an alternative interpretation of ASTRAL and CORAL. Eur J Vasc Endovasc Surg. 49(4):465-73, 2015
                                    12. Valente ES et al: Takayasu's arteritis with renal artery stenosis diagnosed in a patient with 65 years old. J Bras Nefrol. 37(4):501-4, 2015
                                    13. Varennes L et al: Fibromuscular dysplasia: what the radiologist should know: a pictorial review. Insights Imaging. 6(3):295-307, 2015
                                    14. Vassallo D et al: Progress in the treatment of atherosclerotic renovascular disease: the conceptual journey and the unanswered questions. Nephrol Dial Transplant. ePub, 2015
                                    15. Cooper CJ et al: Stenting and medical therapy for atherosclerotic renal-artery stenosis. N Engl J Med. 370(1):13-22, 2014
                                    16. Konings R et al: Successful reversal of acute kidney failure by ultrasound-accelerated thrombolysis of an occluded renal artery. Case Rep Med. 2014:205646, 2014
                                    17. Peripheral Vascular Interventions: An Illustrated Manual. Author Juergen Schroeder. Thieme Publishing (C) 2013
                                    18. Stone PA et al: Ten-year experience with renal artery in-stent stenosis. J Vasc Surg. 53(4):1026-31, 2011
                                    19. Dworkin LD et al: Is there any reason to stent atherosclerotic renal artery stenosis? Am J Kidney Dis. 56(2):259-63, 2010
                                    20. Patel RA et al: Tips and tricks in renal artery angioplasty and stenting: angiography, stent placement, embolic protection, complications, and contrast induced nephropathy. Minerva Cardioangiol. 58(1):113-26, 2010
                                    21. Dworkin LD et al: Clinical practice. Renal-artery stenosis. N Engl J Med. 361(20):1972-8, 2009
                                    22. Safian RD et al: Refining the approach to renal artery revascularization. JACC Cardiovasc Interv. 2(3):161-74, 2009
                                    23. Davies MG et al: The long-term outcomes of percutaneous therapy for renal artery fibromuscular dysplasia. J Vasc Surg. 48(4):865-71, 2008
                                    24. Textor SC: Atherosclerotic renal artery stenosis: overtreated but underrated? J Am Soc Nephrol. 19(4):656-9, 2008
                                    25. Cooper CJ et al: Stent revascularization for prevention of cardiovascular and renal events among patients with renal artery stenosis and systolic hypertension: rationale and design of the CORAL trial. Am Heart J. 152(1):59-66, 2006
                                    Related Anatomy
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                                    Related Differential Diagnoses
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                                    References
                                    Tables

                                    Tables

                                    KEY FACTS

                                    • Preprocedure

                                      • Procedure

                                        • Post Procedure

                                          • Outcomes

                                            TERMINOLOGY

                                            • Definitions

                                              • Renal artery stenosis (RAS): Fixed narrowing of renal artery (main or branch vessels)
                                                • May lead to refractory hypertension (HTN), ischemic nephropathy, &/or pulmonary edema
                                              • Renal vascular HTN: HTN due to RAS
                                                • Accelerated HTN: Previously controlled HTN now poorly controlled despite multiple additional medications
                                                • Malignant HTN: Uncontrolled HTN associated with acute end-organ damage
                                                • Refractory HTN: Continued HTN despite optimal doses of 3 drugs of different classes
                                              • Ischemic nephropathy: Declining renal function and atrophy caused by poor renal perfusion
                                            • Epidemiology/Pathophysiology of Renal Artery Stenosis

                                              • Epidemiology
                                                • Major cause of secondary HTN
                                                  • Causative in 0.5-10.0% of all patients with HTN, ~ 30% of patients with accelerated HTN
                                                • Ischemic nephropathy contributory in ~ 25% of patients requiring hemodialysis
                                                • High prevalence in patients with atherosclerosis
                                                  • 15-30% in coronary artery disease
                                                  • 22-59% in peripheral artery disease
                                              • Pathophysiology
                                                • Stenosis causes decreased renal perfusion
                                                  • Renin released by juxtaglomerular cells
                                                  • Renin activates angiotensin II production
                                                  • Angiotensin II production causes efferent arteriole constriction
                                                    • ↑ angiotensin II increases glomerular hydrostatic pressure in order to maintain glomerular filtration rate (eGFR)
                                                    • ↑ angiotensin II leads to diastolic dysfunction
                                                    • ↑ angiotensin II causes systemic HTN
                                                    • ↑ angiotensin II causes aldosterone elevation leading to sodium/water retention
                                              • Causes
                                                • Atherosclerosis
                                                  • Most common (90%)
                                                    • M > F
                                                    • > 50 years old
                                                  • Affects ostium/proximal 1/3 of renal artery
                                                  • Risk factors similar to atherosclerosis elsewhere
                                                  • Often associated with renal impairment
                                                  • Stenting definitively better than percutaneous transluminal angioplasty (PTA) for ostial atherosclerotic lesions
                                                • Fibromuscular dysplasia (FMD)
                                                  • 2nd most common cause of RAS (10%)
                                                    • F > M (3-4:1)
                                                    • Typically < 30 years old
                                                  • Noninflammatory vasculitis
                                                    • Involves mid and distal main renal artery
                                                    • Also may involve segmental renal arteries
                                                  • Medial fibroplasia most common subtype (80%)
                                                    • Alternating areas of aneurysmal dilation give beaded appearance
                                                  • Rarely leads to ischemic nephropathy or complete renal artery occlusion
                                                  • Angioplasty alone effective
                                                    • Stent reserved for PTA failure/restenosis/complications (i.e., dissection, rupture)
                                                • Renal transplant arterial stenosis
                                                  • Affects 5-10% of transplants
                                                  • Causes
                                                    • External compression by peritransplant fibrosis
                                                    • Kink points at anastomosis
                                                    • Injury from vascular clamp used during surgery
                                                • Other causes
                                                  • Takayasu arteritis, neurofibromatosis, mid aorta syndrome
                                                  • Iatrogenic or traumatic injury
                                                    • Vessel injury damages intima; causes thrombosis
                                                  • Retroperitoneal tumor encasement/compression
                                                • Acute renal ischemia
                                                  • Embolism from proximal source (e.g., atrial fibrillation or aortic plaque)
                                                  • In situ thrombosis of stenotic renal artery
                                                  • Iatrogenic from endovascular intervention
                                              • Clinical reasons to suspect RAS
                                                • Drug-resistant HTN
                                                • Systolic readings in 170s-190s
                                                • HTN onset under 30 or after 50 years of age
                                                • Abrupt worsening of HTN or renal function
                                                • Concurrent known systemic atherosclerosis
                                                • Creatinine rise > 20% on angiotensin-converting enzyme inhibitor (ACE inhibitor)
                                              • RAS and prognosis
                                                • RAS associated with increased cardiovascular events/mortality
                                                  • Marker of/contributor to atherosclerotic disease
                                                    • Likely from renin-angiotensin aldosterone system activation
                                                    • 2-3x increase in coronary artery disease; 3x increase in stroke
                                                    • Poor survival (27 months) for end-stage renal disease from ischemic nephropathy
                                                    • 57% 4-year survival in patient with RAS undergoing cardiac catheterization vs. 89% without RAS

                                            PREPROCEDURE

                                            • Indications

                                              • Contraindications

                                                • Preprocedure Imaging

                                                  • Getting Started

                                                    PROCEDURE

                                                    • Patient Position/Location

                                                      • Equipment Preparation

                                                        • Procedure Steps

                                                          • Findings and Reporting

                                                            • Alternative Procedures/Therapies

                                                              POST PROCEDURE

                                                              • Things to Do

                                                                OUTCOMES

                                                                • Problems

                                                                  • Complications

                                                                    • Expected Outcomes

                                                                      Selected References

                                                                      1. ACR Manual on Contrast Media, Version 10.2, 2016
                                                                      2. Hassani M: Takayasu arteritis associated with severe renovascular hypertension. Saudi J Kidney Dis Transpl. 27(2):402-6, 2016
                                                                      3. Kawarada O et al: Renovascular heart failure: heart failure in patients with atherosclerotic renal artery disease. Cardiovasc Interv Ther. 31(3):171-82, 2016
                                                                      4. O'Connor PJ et al: Endovascular Treatment of Renal Artery Stenosis in the Post CORAL Era. Curr Treat Options Cardiovasc Med. 18(8):48, 2016
                                                                      5. Sanidas EA et al: Renal fibromuscular dysplasia: a not so common entity of secondary hypertension. J Clin Hypertens (Greenwich). 18(3):240-6, 2016
                                                                      6. Biederman DM et al: Tailoring the endovascular management of transplant renal artery stenosis. Am J Transplant. 15(4):1039-49, 2015
                                                                      7. Braga AF et al: Endovascular approach to transplant renal artery stenosis. Ann Transplant. 20:698-706, 2015
                                                                      8. Chen W et al: Transplant renal artery stenosis: clinical manifestations, diagnosis and therapy. Clin Kidney J. 8(1):71-8, 2015
                                                                      9. Diego-Nieto A et al: Severe renal artery stenosis after renal sympathetic denervation. JACC Cardiovasc Interv. 8(11):e193-4, 2015
                                                                      10. Koukoulaki M et al: Successful endovascular treatment of transplant intrarenal artery stenosis in renal transplant recipients: Two case reports. World J Transplant. 5(2):68-72, 2015
                                                                      11. Mohan IV et al: The management of renal artery stenosis: an alternative interpretation of ASTRAL and CORAL. Eur J Vasc Endovasc Surg. 49(4):465-73, 2015
                                                                      12. Valente ES et al: Takayasu's arteritis with renal artery stenosis diagnosed in a patient with 65 years old. J Bras Nefrol. 37(4):501-4, 2015
                                                                      13. Varennes L et al: Fibromuscular dysplasia: what the radiologist should know: a pictorial review. Insights Imaging. 6(3):295-307, 2015
                                                                      14. Vassallo D et al: Progress in the treatment of atherosclerotic renovascular disease: the conceptual journey and the unanswered questions. Nephrol Dial Transplant. ePub, 2015
                                                                      15. Cooper CJ et al: Stenting and medical therapy for atherosclerotic renal-artery stenosis. N Engl J Med. 370(1):13-22, 2014
                                                                      16. Konings R et al: Successful reversal of acute kidney failure by ultrasound-accelerated thrombolysis of an occluded renal artery. Case Rep Med. 2014:205646, 2014
                                                                      17. Peripheral Vascular Interventions: An Illustrated Manual. Author Juergen Schroeder. Thieme Publishing (C) 2013
                                                                      18. Stone PA et al: Ten-year experience with renal artery in-stent stenosis. J Vasc Surg. 53(4):1026-31, 2011
                                                                      19. Dworkin LD et al: Is there any reason to stent atherosclerotic renal artery stenosis? Am J Kidney Dis. 56(2):259-63, 2010
                                                                      20. Patel RA et al: Tips and tricks in renal artery angioplasty and stenting: angiography, stent placement, embolic protection, complications, and contrast induced nephropathy. Minerva Cardioangiol. 58(1):113-26, 2010
                                                                      21. Dworkin LD et al: Clinical practice. Renal-artery stenosis. N Engl J Med. 361(20):1972-8, 2009
                                                                      22. Safian RD et al: Refining the approach to renal artery revascularization. JACC Cardiovasc Interv. 2(3):161-74, 2009
                                                                      23. Davies MG et al: The long-term outcomes of percutaneous therapy for renal artery fibromuscular dysplasia. J Vasc Surg. 48(4):865-71, 2008
                                                                      24. Textor SC: Atherosclerotic renal artery stenosis: overtreated but underrated? J Am Soc Nephrol. 19(4):656-9, 2008
                                                                      25. Cooper CJ et al: Stent revascularization for prevention of cardiovascular and renal events among patients with renal artery stenosis and systolic hypertension: rationale and design of the CORAL trial. Am Heart J. 152(1):59-66, 2006