Renal artery stenosis causing hypertension: the current status of classical surgical therapy versus percutaneous transluminal dilatation.

Abstract

T HE SAGA of hypertensive renovascular disease traces its origin to Richard Bright who wrote in 1827 of the relationship between hypertension and renal disease. Direction was supplied by Goldblatt's observations in 1934 relating renal artery constriction to chronic experimental hypertension. Reports soon followed demonstrating normalization of blood pressure following nephrectomy (1938) and reconstructive surgery (l954). The optimism with regard to renovascular surgery which prevailed in the 1960s was dampened by subsequent reports of surgical failure and mortality. As a result, cautious pessimism replaced this enthusiasm in the early 70s. From this period of reevaluation, a number of advances have occurred concerning diagnosis and management of renovascular hypertension. These have created a renewed feeling of enthusiasm concerning intervention in renal artery stenosis. Several surgical alternatives such as extracorporeal renal revascularization, aortorenal bypass with saphenous veins or arterial grafts, and shunting operations are now possible. Less invasive alternatives such as medical nephrectomy and percutaneous transluminal dilatation have more recently become available. Additionally, advances in antihypertensive pharmacology have made uncommon the entity of nonpharmacologically controllable hypertension. Despite the fact that almost 50 yr have elapsed since the first patients were cured of their renovascular hypertension, a number of important questions still exist. These include questions such as the frequency of signi ficant renal artery stenosis in the hypertensive population, pharmacologic vs. surgical management, and vascular reconstructive surgical intervention vs. percutaneous transluminal dilatation. In the following articles several distinguished physician investigators address one of the pressing problems encountered by the clinician. In patients in whom correction of renal artery stenosis is to be undertaken, should one use classical surgical intervention or percutaneous transluminal dilatation? Andrew Novick and Ralph Straffon of the Cleveland Clinic Foundation were invited to present their views on the natural history and diagnosis of renovascular hypertension as well as their choices and options with regard to surgical management. Following this C. E. Grimm of the University of Indiana was asked to provide an alternative point with regard to percutaneous transluminal dilatation. The data to resolve this dilemma are not yet available. Despite this lack of information, the physician must help make a choice when both modalities are available. It is hoped that the discussion which follows will assist in the task.