Atherosclerotic Renal Artery Stenosis Research Articles

Diagnosis and Therapy of Atheroscerotic Renal Artery Stenosis - Update 2024

Abstract Atherosclerotic renal artery stenosis (ARAS), an increasingly recognized disorder, may cause ischemic nephropathy and renovascular hypertension, that may occur separately or together. Patients with chronic kidney disease (CKD) resulting from atherosclerotic renal artery stenosis usually have high-grade stenosis of both renal arteries or stenosis to a solitary functioning kidney. Patients at risk for bilateral renal artery stenosis are also at risk for other disorders that can present with similar clinical findings but cannot be corrected by surgery or angioplasty; these include hypertensive nephrosclerosis and atheroembolic kidney disease. In clinical decision-making about screening for and therapy of ARAS, we balance the chance of improving renal function and blood pressure with the risks of interventional procedures. In this article we provide an overview of the epidemiology, diagnosis, and treatment of ARVD based on consensus recommendations from a panel of physician experts who attended the recent KDIGO (Kidney Disease: Improving Global Outcomes) Controversies Conference on central and peripheral arterial diseases in chronic kidney disease. The rapid progress in this field necessitates an update. Most focus is provided for contentious issues, and we also outline aspects of investigation and management of ARVD that require further research.

Renal artery stenosis increases the risk of incident atrial fibrillation and cardiovascular events incorporating death

Abstract Background Renal artery stenosis (RAS) remains an under-recognized clinical risk factor for cardiovascular complications. Its long-term impact on AF arrhythmogenesis is unclear. Objective To investigate the role of RAS on incident AF and related adverse cardiovascular events Methods We performed a retrospective cohort study that comprised 100 patients with ultrasonographically-confirmed atherosclerotic RAS, and 50 age- and sex-matched controls who were healthy renal transplant donors (age 52.6 ±5.6 vs 50.1 ±10.7years, women 59% vs 70%). Incident AF was ascertained from clinical records. Primary endpoint was defined as the composite of incident AF, myocardial infarction, unstable angina, heart failure, ischemic stroke, peripheral arterial disease, end-stage renal failure, and cardiovascular death. Results Over a follow-up duration of 4818 ± 2751 days, RAS was significantly associated with incident AF (9.4% versus 0%, P=0.025). Kaplan-Meier analyses showed that RAS was associated with reduced incident AF event-free survival (Log-rank Mantel-Cox=4.6 P=0.032, Figure). Multivariable logistic regression showed that after adjustment for potential confounders (including age, sex, smoking, alcohol use, history of hypertension, diabetes mellitus, myocardial infarction, heart failure, ischemic stroke, renal function and serum low-density lipoprotein level), RAS was independently associated with substantially increased risk of the primary endpoint (OR=27.8, 95%CI [2.3 – 333.9], P=0.009), Conclusions RAS is an important and under-recognized independent risk factor for AF and cardiovascular events incorporating death. Its pathophysiological implications with a view to potential interventions need to be further explored.

Mesenchymal Stem Cells Infusion and Renal Revascularization in Atherosclerotic Renal Artery Stenosis - New Modalities in Therapeutic Approach

Mesenchymal Stem Cells Infusion and Renal Revascularization in Atherosclerotic Renal Artery Stenosis - New Modalities in Therapeutic Approach

Improving outcomes in atherosclerotic renovascular disease: importance of clinical presentation and multi-disciplinary review

Background and objectivesAtherosclerotic renal artery stenosis may cause hypertension, chronic kidney disease and heart failure, but large randomized control trials to date have shown no major additional benefit of renal revascularization over optimal medical management. However, these trials did not consider outcomes specifically in relation to clinical presentations. Given that atherosclerotic renal artery stenosis is a heterogenous condition, measures of success likely differ according to the clinical presentation. Our retrospective study objectives were to determine the effects of revascularization when applied to specific clinical presentations and after careful multi-disciplinary team review.MethodsAll patients presenting to our centre and its referring hospitals with radiological findings of at least one renal artery stenosis > 50% between January 2015 and January 2020 were reviewed at the renovascular multi-disciplinary team meeting with revascularization considered in accordance with international guidelines, notably for patients with anatomically significant renal artery stenosis, adequately sized kidney and presentations with any of; deteriorating kidney function, heart failure syndrome, or uncontrollable hypertension. Optimal medical management was recommended for all patients which included lipid lowering agents, anti-platelets and anti-hypertensives targeting blood pressure ≤ 130/80 mmHg. The effect of revascularization was assessed according to the clinical presentation; blood pressure and number of agents in those with renovascular hypertension, delta glomerular filtration rate in those with ischaemic nephropathy and heart failure re-admissions in those with heart failure syndromes.ResultsDuring this 5-year period, 127 patients with stenosis ≥ 50% were considered by the multidisciplinary team, with 57 undergoing revascularization (17 primarily for severe hypertension, 25 deteriorating kidney function, 6 heart failure syndrome and 9 for very severe anatomical stenosis). Seventy-nine percent of all revascularized patients had a positive outcome specific to their clinical presentation, with 82% of those with severe hypertension improving blood pressure control, 72% with progressive ischaemic nephropathy having attenuated GFR decline, and no further heart failure admissions in those with heart failure. Seventy-eight percent of patients revascularized for high grade stenosis alone had better blood pressure control with 55% also manifesting renal functional benefits.ConclusionsMulti-disciplinary team discussion successfully identified a group of patients more likely to benefit from revascularization based on 3 key factors: clinical presentation, severity of the renal artery lesion and the state of the kidney beyond the stenotic lesion. In this way, a large proportion of patients can clinically improve after revascularization if their outcomes are considered according to the nature of their clinical presentation.Graphical

Mesenchymal Stem Cells Infusion and Renal Revascularization in Atherosclerotic Renal Artery Stenosis - New Modalities in Therapeutic Approach

Mesenchymal Stem Cells Infusion and Renal Revascularization in Atherosclerotic Renal Artery Stenosis - New Modalities in Therapeutic Approach

Contrast-enhanced ultrasound evaluation of renal perfusion before angioplasty and its predictive value for hypertension.

Atherosclerotic renal artery stenosis (ARAS) is a common disease in the elderly population. The aim was to develop a contrast-enhanced ultrasound (CEUS)-based model for predicting post-angioplasty improvement in hypertension in patients with severe ARAS. Thirty-five patients with severe ARAS (⩾ 70%) were included in this study, and 42 renal arteries received percutaneous transluminal renal arterial stenting. An optimal integral formula was developed from pre-interventional color-coded duplex sonography (CCDS) and CEUS parameters using least absolute shrinkage and selection operator (LASSO) regression and receiver operating characteristic (ROC) curve analysis. A model for predicting short-term hypertension improvement was established using the integral formula and clinical risk factors. Bootstrapping was used for internal validation. Two integral formulas, LASSO.CCDS and LASSO.CEUS, were established. ROC curves of the two integral formulas showed that LASSO.CEUS was the better formula for predicting hypertension improvement (AUC 0.816, specificity 78.6%). Univariate and multivariate regression analyses showed that duration of hypertension (OR 0.841, P= 0.027), diabetes (OR = 0.019, P= 0.010), and LASSO.CEUS (OR 7.641, P= 0.052) were predictors of short-term hypertension improvement after interventional therapy. Using LASSO.CEUS combined with clinical risk factors, the following prediction model was established: logit (short-term improvement in hypertension) = 1.879-0.173 × hypertension duration - 3.961 × diabetes + 2.034 × LASSO.CEUS (AUC 0.939). The model established using CEUS parameters and clinical risk factors could predict hypertension improvement after interventional therapy, but further research and verification are needed.

Prevalence and Associated Factors of Atherosclerotic Plaque and Stenosis in Renal Arteries: A Community-Based Study.

The epidemiology of renal artery atherosclerosis in community populations is poorly documented. This study aimed to determine the prevalence of renal artery plaque (RAP) and atherosclerotic renal artery stenosis (ARAS), and the association of plaque and stenosis with vascular risk factors and kidney disease markers among community-dwelling adults. We conducted a cross-sectional analysis of the Polyvascular Evaluation for Cognitive Impairment and Vascular Events (PRECISE) study. RAP and ARAS were evaluated by thoracoabdominal computed tomography angiography. A total of 3045 adults aged 50-75years were included. The prevalence of RAP and ARAS was 28.7% and 4.8%, respectively. The prevalence of RAP and ARAS was 41.3% and 7.7% in individuals aged ≥60years, 42.9% and 8.7% in hypertensives, and 45.4% and 8.5% in individuals with chronic kidney disease. Older age, hypertension, higher total cholesterol level, and lower high-density lipoprotein cholesterol level were independently associated with RAP and ARAS. A higher urinary albumin-creatinine ratio was independently associated with RAP, whereas a reduced estimated glomerular filtration rate was independently associated with ARAS. In conclusion, there was a non-negligible prevalence of RAP and ARAS among the older, community population in China.

CT-based radiomics: predicting early outcomes after percutaneous transluminal renal angioplasty in patients with severe atherosclerotic renal artery stenosis

This study aimed to comprehensively evaluate non-contrast computed tomography (CT)-based radiomics for predicting early outcomes in patients with severe atherosclerotic renal artery stenosis (ARAS) after percutaneous transluminal renal angioplasty (PTRA). A total of 52 patients were retrospectively recruited, and their clinical characteristics and pretreatment CT images were collected. During a median follow-up period of 3.7 mo, 18 patients were confirmed to have benefited from the treatment, defined as a 20% improvement from baseline in the estimated glomerular filtration rate. A deep learning network trained via self-supervised learning was used to enhance the imaging phenotype characteristics. Radiomics features, comprising 116 handcrafted features and 78 deep learning features, were extracted from the affected renal and perirenal adipose regions. More features from the latter were correlated with early outcomes, as determined by univariate analysis, and were visually represented in radiomics heatmaps and volcano plots. After using consensus clustering and the least absolute shrinkage and selection operator method for feature selection, five machine learning models were evaluated. Logistic regression yielded the highest leave-one-out cross-validation accuracy of 0.780 (95%CI: 0.660–0.880) for the renal signature, while the support vector machine achieved 0.865 (95%CI: 0.769–0.942) for the perirenal adipose signature. SHapley Additive exPlanations was used to visually interpret the prediction mechanism, and a histogram feature and a deep learning feature were identified as the most influential factors for the renal signature and perirenal adipose signature, respectively. Multivariate analysis revealed that both signatures served as independent predictive factors. When combined, they achieved an area under the receiver operating characteristic curve of 0.888 (95%CI: 0.784–0.992), indicating that the imaging phenotypes from both regions complemented each other. In conclusion, non-contrast CT-based radiomics can be leveraged to predict the early outcomes of PTRA, thereby assisting in identifying patients with ARAS suitable for this treatment, with perirenal adipose tissue providing added predictive value.

Risks and benefits of renal artery stenting in fibromuscular dysplasia: Lessons from the ARCADIA-POL study.

Although renal stenting is the standard revascularization method for atherosclerotic renal artery stenosis (RAS) (FMD-RAS), stenting in fibromuscular dysplasia (FMD) RAS is usually limited to periprocedural complications of angioplasty and primary arterial dissection. The main aim of the study was to retrospectively analyze the immediate and long-term results of renal stenting versus angioplasty in patients with FMD. Of 343 patients in the ARCADIA-POL registry, 58 patients underwent percutaneous treatment due to FMD-RAS (in 70 arteries). Percutaneous transluminal renal angioplasty (PTRA) was performed as an initial treatment in 61 arteries (PTRA-group), whereas primary stenting was undertaken in nine arteries (stent-group). Stent-related complications were defined as: in-stent restenosis > 50% (ISR); stent fracture; under-expansion; or migration. In the PTRA-group, the initial restenosis rate was 50.8%. A second procedure was then performed in 22 arteries: re-PTRA (12 arteries) or stenting (10 arteries). The incidence of recurrent restenosis after re-PTRA was 41.7%. Complications occurred in seven of 10 (70%) arteries secondarily treated by stenting: two with under-expansion and five with ISR. In the stent-group, stent under-expansion occurred in one case (11.1%) and ISR in three of nine stents (33.3%). In combined analysis of stented arteries, either primarily or secondarily, stent-related complications occurred in 11/19 stenting procedures (57.9%): three due to under-expansion and eight due to ISRs. Finally, despite several revascularization attempts, four of 19 (21%) stented arteries were totally occluded and one was significantly stenosed at follow-up imaging. Our study indicates that renal stenting in FMD-RAS may carry a high risk of late complications, including stent occlusion. Further observational data from large-scale registries are required.

Pickering Syndrome: An Overlooked Renovascular Cause of Recurrent Heart Failure.

ABSTRACTRecurring and rapidly developing (flash) pulmonary edema is the hallmark of Pickering syndrome, affecting patients with hypertension and atherosclerotic renal artery stenosis (either bilateral or unilateral) in a solitary functioning kidney, and impaired renal function. We herein report on a series of consecutive patients with recurrent hospital admissions for pulmonary edema, impaired renal function (chronic kidney disease class 4-5), and atherosclerotic bilateral renal artery stenosis, in whom Pickering syndrome had been long neglected. We also describe a streamlined diagnostic strategy entailing little or no need for contrast medium, thus carrying no risks of further worsening of renal function. This allowed us to make the correct diagnosis and opened the way to revascularization by percutaneous transluminal renal angioplasty with stent, which provided swift recovery of kidney function with resolution of pulmonary congestion and long-term pulmonary edema- and dialysis-free survival in all cases. In summary, these findings support the following key messages: (1) considering the diagnosis of Pickering syndrome, followed by searching atherosclerotic renal artery stenosis, is an essential step toward a life-saving revascularization that avoids dialysis and an otherwise poor outcome; and (2) a simplified strategy entailing little or no need for contrast medium, carrying no associated risks of deteriorating renal function, permits the diagnosis of Pickering syndrome.

Renal perfusion improvement in the perioperative period after unilateral endovascular revascularization in patients with atherosclerotic renal artery stenosis.

The clinical benefits of endovascular treatment in renal artery stenosis (RAS) remain controversial. This study used an intraoperative renal perfusion imaging technique, called flat-panel detector parenchymal blood volume imaging (FD-PBV), to observe the change in renal perfusion after endovascular treatment in RAS. In a prospective, single-center study, we assigned 30 patients with atherosclerotic RAS who underwent endovascular treatment between March 2016 and March 2021. The preoperative and postoperative results of renal perfusion, blood pressure, and renal function, were compared. Both median kidney volume (p < 0.001) and median preoperative mean density of contrast medium (MDCM) (p = 0.028) increased significantly after endovascular treatment. The ratio of postoperative and preoperative MDCM differed greatly among the patients. For patients with preoperative MDCM <304.0 HU (Subgroup A, 15 cases), MDCM significantly increased after treatment (p = 0.001) and 12 (80.0%) patients had more than 10% increase in renal perfusion. For patients who had relatively high preoperative renal perfusion (MDCM ≥304.0 HU, Subgroup B, 15 cases), preoperative and postoperative MDCM were similar (p = 0.776). On the other hand, the serum creatinine levels significantly decreased in Subgroup A (p = 0.033) and fewer antihypertensive drugs were used after endovascular revascularization (p = 0.041). The preoperative and postoperative creatinine levels and number of antihypertensive drugs were similar in Subgroup B. During the perioperative period, RAS patients with relatively low preoperative renal perfusion levels had greater improvement in renal perfusion, renal function, and blood pressure control after endovascular treatment. The improvement of renal function needs to be confirmed by long-term follow-up.

Bilateral renal artery stenosis impacts postoperative complications after major vascular surgery

BackgroundIncidental atherosclerotic renal artery stenosis (RAS) is common in patients undergoing vascular surgery and has been shown to be associated with postoperative AKI among patients undergoing major non-vascular surgeries. We hypothesized that patients with RAS undergoing major vascular procedures would have a higher incidence of AKI and postoperative complications than those without RAS. MethodsA single-center retrospective cohort study of 200 patients who underwent elective open aortic or visceral bypass surgery (100 with postoperative AKI; 100 without AKI) were identified. RAS was then evaluated by review of pre-surgery CTAs with readers blinded to AKI status. RAS was defined as ≥50 % stenosis. Univariate and multivariable logistic regression was used to assess association of unilateral and bilateral RAS with postoperative outcomes. Results17.4 % (n = 28) of patients had unilateral RAS while 6.2 % (n = 10) of patients had bilateral RAS. Patients with bilateral RAS had similar preadmission creatinine and GFR as compared to unilateral RAS or no RAS. 100 % (n = 10) of patients with bilateral RAS had postoperative AKI compared with 45 % (n = 68) of patients with unilateral or no RAS (p < 0.05). In adjusted logistic regression models, bilateral RAS predicted severe AKI (OR 5.82; CI 1.33, 25.53; p = 0.02), in-hospital mortality (OR 5.71; CI 1.03, 31.53; p = 0.05), 30-day mortality (OR 10.56; CI 2.03, 54.05; p = 0.005) and 90-day mortality (OR 6.88; CI 1.40, 33.87; p = 0.02). ConclusionsBilateral RAS is associated with increased incidence of AKI as well as in-hospital, 30-day, and 90-day mortality suggesting it is a marker of poor outcomes and should be considered in preoperative risk stratification.

Attempting to define a role for renal artery stenting: Another analysis of the CORAL trial

Modrall et al 1 Modrall G.J. Zhu H. Prasad T. Moe O. Dworkin L.D. Cutlip D.E. et al. Retrieval of renal function after renal artery stenting improves event-free survival in a subgroup analysis of the cardiovascular outcomes in renal atherosclerotic lesions trial.. J Vasc Surg. 2023; 77: 1685-1692 Abstract Full Text Full Text PDF Scopus (1) Google Scholar have reanalyzed data from the CORAL trial 2 Cooper C.J. Murphy T.P. Cutlip D.E. Jamerson K. Henrich W. Reid D.M. et al. Stenting and medical therapy for atherosclerotic renal-artery stenosis. N Engl J Med. 2014; 370: 13-22 Crossref PubMed Scopus (666) Google Scholar to identify a role for renal artery stenting (RAS) in the subset of patients with chronic kidney disease (CKD). They demonstrated, again, that stenting does not provide a benefit compared with optimal medical therapy in terms of event-free survival, the primary end point of their analysis and the parent trial. The blood pressure response was similar between their groups, although the change in serum creatinine and the percentage of change in the estimated glomerular filtration rate (eGFR) were better in the stented group, albeit modest. A larger percentage of the stented patients had had a ≥20% increase in their eGFR (responders) vs the medical group (25.6% vs 17.1%), although the percentage of those with a ≥20% decrease in the eGFR was similar. These responders had had improved event-free, non–renal event-free, and overall survival compared with the nonresponders. However, the presence of diabetes (negative) was the only predictor of a good response. Retrieval of renal function after renal artery stenting improves event-free survival in a subgroup analysis of the Cardiovascular Outcomes in Renal Atherosclerotic Lesions trialJournal of Vascular SurgeryVol. 77Issue 6PreviewThe Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL) trial, a multicenter randomized controlled trial with 947 patients, concluded that there was no benefit of renal artery stenting (RAS) over medical therapy. However, patients with chronic kidney disease (CKD) were not analyzed separately in the CORAL trial. CKD is a risk factor for cardiovascular and renal morbidity. We hypothesized that improved renal function after RAS would be associated with increased long-term survival and a lower risk of cardiovascular and renal events in patients with CKD. Full-Text PDF

Renovascular Hypertension with Progressive Atherosclerotic Renal Artery Stenosis in an Elderly Patient with Known Fibromuscular Dysplasia: A Case Report.

BACKGROUND Atherosclerotic renal artery stenosis (ARAS) and renovascular fibromuscular dysplasia (FMD) are 2 of the most common etiologies of renovascular hypertension. They have different pathophysiologies, risk factors, presentations, and treatment options. However, as our population ages, it can become increasingly common to see patients who previously had FMD who develop ARAS at an advanced age, indicated by recurrent renovascular hypertension. CASE REPORT We present a case of a 66-year-old female patient who, in 2007, had presented with uncontrolled hypertension. She underwent magnetic resonance angiography and was found to have bilateral FMD, for which she received balloon angioplasty to a severe lesion on the mid-right renal artery and subsequently had normalization of blood pressures and resolution of symptoms. In 2021 she returned with uncontrolled hypertension while being treated with 3 antihypertensives. Bilateral renal arteriography revealed new severe ostial stenosis of the left renal artery and a patent right renal artery in which balloon angioplasty was performed 14 years ago. Based on the angiographic pattern of this new left RAS, we concluded this lesion was caused by atherosclerosis. The left ostial lesion was treated with a bare-metal stent and the patient was continued on antihypertensive medication and statin; at follow-up 4 months later, her blood pressures had normalized. CONCLUSIONS This case features a patient who developed severe ARAS with underlying history of bilateral renal artery FMD. Clinicians need to be aware that in patients with FMD, worsening renovascular hypertension at an advanced age could indicate the development of new hemodynamically significant ARAS. These patients need repeat diagnostic testing and treatment with medial optimization with or without endovascular revascularization in the appropriate clinical setting.

Renal Stem Cells, Renal Resistive Index, and Neutrophil Gelatinase Associated Lipocalin Changes After Revascularization in Patients With Renovascular Hypertension and Ischemic Nephropathy.

Percutaneous transluminal renal angioplasty (PTRA) with or without stenting is the gold standard therapy in patients with atherosclerotic renal artery stenosis (aRAS). However, therapeutic success depends on the correct timing of revascularization and the reversibility of the renal damage. We report a case series of patients treated with PTRA for renovascular hypertension and ischemic nephropathy. We measured bilateral renal resistive index (RRI), circulating renal stem cells (RSC), and Neutrophil Gelatinase Associated Lipocalin (NGAL) at baseline and after PTRA at different time points to understand their changes in post-revascularization. At baseline, the studied patients (n=5) had different RSC levels. After PTRAs, all patients showed an improvement in blood pressure, while renal function varied differently within the studied subjects. RRI >0.75 at baseline and the absence of NGAL decrease after PTRAs were associated with post-PTRA renal function worsening, despite an increase of RSC in all patients. Although limited to a few patients, our observation allowed the exploration of the behaviour of the studied parameters in different degrees of renal ischemia. This revealed different disease models suggesting the importance of further investigations in larger and homogeneous cohorts to confirm that a greater basal RSC percentage, low RRI values before PTRA, and a post-revascularization NGAL reduction could be related to better renal outcomes in aRAS patients.

Оценка показателей расчетной скорости клубочковой фильтрации до и после эндоваскулярной коррекции стеноза почечных артерий на фоне резистентной вазоренальной артериальной гипертензии

Atherosclerotic stenosis of the renal arteries is the most common cause of renovascular hypertension (RVHT) among middle-aged and elderly people. In this survey a comparative analysis of the calculated glomerular filtration rate (cGFR) in a patient with resistant renovascular hypertension (RVHT) before and after endovascular correction of atherosclerotic renal artery stenosis is given. The medical records (medical history) of 44 patients (34 men, 10 women) with RVHT were analyzed. The criterion for inclusion in the study was renal artery stenosis of more than 75% of the vessel diameter. The mean age of the patients was 50.7±7.2 years. All patients had unilateral lesion of the renal arteries. Patients were divided into three groups according to the initial level of cGFR. The patients were divided into three groups according to initial cGFR value: Group 1 included 12 patients with cGFR over 90 ml/min/1.73 m2, Group 2 — 19 patients with cGFR from 89 to 60 ml/min/1.73 m2, Group 3 — 13 patients with cGFR from 59 to 45 ml/min/1.73 m2. It was revealed that the level of blood pressure after endovascular correction of stenosis decreased significantly among all patients. At the same time, among the patients with initially preserved cGFR (from 90 ml/min/1.73 m2 and more), there was an improvement in the functional state of the kidneys, a decrease in the number of antihypertensive drugs from 3–5 to a 3-component regimen. Among the patients with initially minimally reduced cGFR (less than 90 ml/min/1.73 m2), the functional state of the kidneys did not change, and among the patients with cGFR less than 60 ml/min/1.73 m2, this state continued to worsen progressively; antihypertensive therapy did not change. During the 2-year follow-up period, restenosis of the renal arteries according to duplex scanning was not observed. When deciding whether to perform endovascular interventions for atherosclerotic stenosis of the renal arteries, it is advisable to take into account the calculated GFR data.

PS-R04-2: A CASE OF SUCCESSFUL PERCUTANEOUS TRANSLUMINAL RENAL ANGIOPLASTY (PTRA) FOR RENAL ARTERY STENOSIS ASSOCIATED WITH TAKAYASU'S ARTERITIS

Introduction: In Japan, renal vascular hypertension based on renal artery stenosis (RAS) accounts for 1% of all hypertensive patients, and RAS is present in approximately 10% of autopsy cases of coronary artery disease and cerebrovascular disease. As ischemic nephropathy and complications of cardiovascular disease (CVD) due to RAS are common, early diagnosis and treatment for RAS is important. However, results of several large clinical trials have not shown the efficacy of percutaneous transluminal renal angioplasty (PTRA) for atherosclerotic RAS. Case: 51-year-old woman who diagnosed as Takayasu's arteritis (TA) 35 years ago, had been treated with 5 mg daily of prednisone. She presented with hypertension and edema in both legs a year before admission. Her examination at that time revealed increased serum creatinine from 1.0 to 1.7 mg/dL, high proteinuria (7.3 g/gCr), high renin activity (47.0 ng/mL/hr) and right RAS. Eight months before admission, she had an operation for ruptured descending aorta. She had recurrent episodes of dyspnea on exertion, worsening leg edema and severe hypertension and was admitted to the hospital for the treatment. Clinical course: In addition to severe hypertension (190/80 mmHg) and progression of RAS, she had pulmonary congestion, high brain natriuretic peptide (BNP) level (1149.5 pg/mL), increasing creatinine levels (Cr 3.1 mg/dL), and left non-functioning kidney on admission. Despite taking 8 types of antihypertensive drugs and diuretics without renin-angiotensin system inhibitors, blood pressure and fluid retention were poorly controlled, and thus we decided to perform PTRA for the right RAS. After the PTRA, edema, hypertension and pleural effusion had been dramatically improved. In addition, we could observe decrease of serum creatinine (Cr 1.6 mg/dL), proteinuria (0.5 g/gCr) and plasma renin activity (1.9 ng/mL/hr). Therefore, we reduced the antihypertensive drugs from 8 to 2. Discussions: Although the benefit of PTRA for RAS associated with TA remains unclear, the clinical course suggests that the success of PTRA in this case may be related to the fact that the RAS was complicated by TA. It also suggests that we should consider PTRA in cases of hypertension and pulmonary congestion associated with RAS which are difficult to control like this case. Conclusion: We have experienced a case of RAS associated with TA that was successfully treated with PTRA.

Atherosclerotic renovascular disease and cardiovascular risk: new concepts.

Renal vascular hypertension (RVHT) is one of the most common secondary forms of hypertension. It is estimated that 1% to 5% of all cases of hypertension can be attributed to RVHT. RVHT is generally caused by progressive stenosis of the renal artery most often due to atherosclerosis, and less often caused by fibromuscular dysplasia. Atherosclerotic renal artery stenosis (ARAS) can lead to the development of resistant hypertension and can also cause progressive impairment of renal function. ARAS can also result in serious cardiac complications, such as flash pulmonary edema or congestive heart failure. Most patients with ARAS are characterized by the presence of left ventricular hypertrophy and diastolic dysfunction. The disease progression is associated with an increase in left ventricular mass index and cardiac dilatation. Atherosclerotic renovascular disease is recognized as a relevant risk factor for cardiovascular morbidity and mortality. Studies published so far documented ARAS as a predictor of higher cardiovascular risk and showed that mortality after incidental ARAS diagnosis is much higher than that observed in the general population. Proper recognition of the patients with ARAS who would benefit from interventional treatment is crucial, particularly for identification of patients with true resistant hypertension, flash pulmonary edema, and progressive impairment of renal function.

Ultra-Low-Dose Contrast Using Transluminal Renal Angioplasty: The ULTRA Study.

Although severe atherosclerotic renal artery stenosis (ARAS) is a predictor of future cardiovascular events, large trials have not shown the benefits of percutaneous transluminal renal angioplasty (PTRA). This study aimed to validate the safety and efficacy of PTRA using low-concentration digital subtraction angiography (LC-DSA) in patients with severe ARAS and advanced chronic kidney disease (CKD). This prospective study was conducted between August 2018 and October 2021. Eighteen patients with 20 lesions, CKD stage 3b or worse, and significant renal artery stenosis were included and underwent PTRA using ultra-low-dose contrast medium. The primary endpoint was a change in renal function based on serum creatinine (sCr) level. The mean sCr level significantly improved from 3.34 ± 1.8mg/dL pre-PTRA to 2.48 ± 1.19mg/dL at 1 month post-PTRA (P = .02). The mean amount of contrast used was 8.3 ± 3.9mL per vessel. More severe stenosis and rapid deterioration of renal function before treatment were associated with improved kidney function. No cardiovascular or renal complications such as stroke or contrast-induced nephropathy were observed during the 30-day period. PTRA using an ultra-low-dose contrast medium is safe and provides acceptable results.

Current trends in the use of the renin-angiotensin system blocking drugs in renovascular arterial hypertension

Renovascular hypertension (RH) is one of the most common secondary forms of arterial hypertension, in most cases caused by atherosclerotic renal artery stenosis (ARAS). The development of a course of hypertension resistant to antihypertensive therapy with an unfavorable prognosis of deterioration of kidney function and cardiovascular complications is characteristic. The review discusses the pathophysiological mechanisms of RH development in ARAS, draws attention to the important role of the renin-angiotensin system (RAS) activation, which determines the nature of the course of the disease, the high frequency of target organ damage. Modern approaches to the drug treatment of this form of hypertension, the validity and benefits of the use of drugs that block the effects of RAS in patients with RH of atherosclerotic genesis, constituting a category of high risk of cardiovascular complications, are The issues of the effectiveness of the use of these drugs in order to reduce the risk of cardiovascular complications and improve the long-term prognosis of the course of this form of hypertension are discussed.