Bilateral Renal Artery Stenosis Research Articles

To stent or not to stent - a challenging decision in a rare condition

Introduction: In this case we discuss the management of a patient with recurrent acute coronary syndrome due to Takayasu arteritis (TA). Case report description: In 2007, a 13-year-old Caucasian male with angina, electrocardiographic and troponin abnormalities consistent with an acute coronary syndrome, and widespread bruits, was found to have multiple arterial stenoses involving the aorta, renal and carotid arteries. The erythrocyte sedimentation rate was 32mm (0-7), C reactive protein 36 mg/L (0-7) with a mild normocytic anaemia. Coronary angiography showed triple vessel disease and he was diagnosed with TA with coronary artery involvement. Coronary artery bypass graft surgery (free left internal mammary graft to the left anterior descending artery and sequential saphenous vein graft to the intermediate and left posterolateral vessels) was performed. The patient received intensive medical therapy and angioplasty for hypertension due to bilateral renal artery stenosis. His condition continued to progress and angina recurred in 2012 with coronary angiography demonstrating occlusion of the vein graft segment to the posterolateral artery. The patient was managed medically but was diagnosed with a non-ST elevation myocardial infarction in 2013 due to occlusion of the vein graft to the intermediate. He suffered ongoing symptoms of cardiac ischaemia and after discussion with the Cardiosurgical team a decision was made to treat the diseased native right coronary artery by percutaneous coronary artery intervention (PCI) with drug eluting stents. Despite this measure the patient has experienced ongoing angina and further PCI to the ungrafted left coronary artery territories is under consideration. Discussion: TA most commonly presents in 20-30 year-old females of East Asian descent and coronary artery involvement in children is very rare. From a cardiac perspective this case highlights the challenge of managing coronary artery disease in the setting of active large vessel vasculitis. Limited data exist to guide clinicians in this setting. Whether redo cardiac surgery at age 18 would be superior to a percutaneous approach is unclear. Implications to clinical practice: 1. Our case highlights the importance of considering vasculitis in the differential diagnosis of a young patient presenting with chest pain. 2. Rare clinical scenarios can pose a management dilemma for the treating physician due to the paucity of supporting research available to direct the decision making process. Treatment strategies should be decided on a case-by-case basis and consensus opinion from the multidisciplinary team is recommended.

Complex renal angioplasty in a solitary functioning kidney due to fibromuscular dysplasia

33-year-old female with refractory hypertension was found to have severe bilateral renal artery stenosis caused by perimedial fibromuscular dysplasia. Angiography showed near total occlusion of right renal artery with shrunken kidney and complex bifurcation disease of left renal artery. She underwent successful renal angioplasty and stenting of left renal artery following which blood pressure normalized.

An Unusual Presentation of Bilateral Renal Artery Stenosis

An Unusual Presentation of Bilateral Renal Artery Stenosis

Kidney and heart: TGFβ1-mediated cross-talk

Rzeźnik et al. [1] in their recent paper published in ‘Kardiologia Polska’ found that revascularisation of unilateral or bilateral renal artery stenosis (RAS) leads to improvement in several echocardiographic parameters reflecting heart structure and function, as well as impacts on plasma transforming growth factor β1 (TGFβ1) and B-type natriuretic peptide. At least some of the effects on the heart (such as LVMI reduction) did not depend on the degree of blood pressure lowering. As can be concluded from the publication, patients did not suffer from symptomatic heart failure (HF; at least in NYHA class III–IV); however, it has been demonstrated recently that RAS revascularisation may also be associated with improvement in NYHA class and reduction in the risk of hospitalisation for HF in patients with concomitant RAS and HF [2]. The message delivered by this paper is very important for both nephrologists and cardiologists. TGFβ1 remains one of the key profibrotic growth factors in renal pathology. It is produced by damaged mesangial cells in the glomerulus (and is crucial for the development of glomerular sclerosis), injured tubular cells and resident interstitial fibroblasts (resulting in interstitial fibrosis). HF in the course of atherosclerotic RAS may develop according to least three different scenarios: (1) Both HF and RAS are consequences of the same, devastating, pathology, namely advanced atherosclerosis; (2) RAS contributes to heart remodelling and dysfunction due to significantly elevated and difficult-to-control hypertension; (3) Humoral mediators released from injured (ischaemic) renal parenchyma may remotely damage the heart (and this may be the case with TGFβ1). The role of TGFβ1 in the development of several heart diseases resulting in myocardial fibrosis has been well recognised for some years [3]. Experimental data suggest that RAS triggers the synthesis and release of several inflammatory and vasoconstrictive agents from the kidney, in addition to the activation of the renin–angiotensin–aldosterone (RAA) axis. These include, among others, endothelin, interleukin-6, TNFα and TGFβ1. It has been demonstrated that disruption of the Smad3 protein gene (signalling pathway essential for TGFβ1 effects) prevents fibrosis of the kidney supplied by stenotic artery even if stenosis persists [4]. Infusion of endothelial progenitor cells into the artery with stenosis significantly decreases plasma levels of several proinflammatory cytokines, prevents myocardial damage and remodelling, even in stenosis remains uncorrected and there is no change in systemic blood pressure [5]. TGFβ1 is one of the key effector molecules involved in epithelial-to-mesenchymal transition, the process of phenotypic change of epithelial tubular cells into fibroblast-like cells — now considered one of the most important mechanisms that lead to kidney fibrosis. A similar process has also been described for cardiac endothelium and was called ‘endothelial-to-mesenchymal transition’ (Endo-MT) [6]. These and other findings should lead to caution when interpreting apparently ‘negative’ trials published recently on RAS which did not demonstrate any substantial be nefit associated with renal artery revascularisation ± stenting vs. medical therapy — effects on blood pressure and/or kidney function were exactly the same in both types of intervention. Now it is tempting to speculate that successful RAS revascularisation might be a much more definite strategy compared to everyday use of RAA axis blockade in lowering TGFβ1 and thus in limiting the impact of this growth factor on the heart and the kidneys. It seems however plausible to expect some lag time between intervention and expected cardiac benefits, not necessarily apparent in the short time following intervention. The findings of Rzeźnik et al. [1] may hold some promise for more delayed, but possible, benefit following RAS revascularisation for the heart, and possibly for the kidneys.

Epidermal nevus syndrome with bilateral renal artery stenosis and midaortic syndrome

Epidermal nevus syndrome with bilateral renal artery stenosis and midaortic syndrome

Outcomes and effectiveness of bilateral percutaneous transluminal renal artery stenting in patients with critical bilateral renal artery stenosis

The aim of this study was to assess the effects of percutaneous bilateral renal artery stenting in patients with atherosclerotic renal artery stenosis and in-hospital and 4 month outcome of the procedure, focusing on the changes in renal function and blood pressure. Five consecutive patients (mean age: 64.8 ± 9.7 years, 1 women) with bilateral renal artery stenoses underwent percutaneous interventions. We compared blood pressure, number of oral antihypertensive medications, and renal function changes preprocedure and postprocedure at 4 months follow-up. A total of 5 bilateral atherosclerotic renal artery stenosis patients underwent percutaneous transluminal renal angioplasty and 10 stents were placed. Although systolic and diastolic blood pressures were significantly decreased in follow-up period, glomerular filtration rates were not significantly changed as compared with baseline data (p = 0.009, p = 0.008, p = 1.00, respectively). Also, the number of oral antihypertensive medications were significantly decreased at follow-up period (p = 0.03). Bilateral renal artery stenting provides a beneficial outcome such as stabilization of renal functions, significant improvement in blood pressure control and reduction in the number of oral antihypertensive medications at follow-up.

Aortic intimal sarcoma masquerading as bilateral renal artery stenosis

Aortic intimal sarcoma is a rare tumor with poor prognosis. The most common manifestations are thromboembolic phenomena and vascular obstruction. We present a case of aortic intimal sarcoma causing bilateral renal artery stenosis which manifested as resistant hypertension and acute kidney inury. Multiple attempts to stent the renal arteries were unsuccessful. Eventually the patient developed acute limb ischemia and oliguric kidney failure as complications of the primary tumor.

Anuric Acute Kidney Injury in Neurofibromatosis 1

Neurofibromatosis is one of several genetic disorders characterized by hyperpigmented skin spots (café au lait spots) and multiple neurofibromas. It was first reported by Friedrich Daniel von Recklinghausen in 1882. There are 2 types of neurofibromatosis described in the literature: von Recklinghausen disease, or neurofibromatosis 1 that involves peripheral nerve sheaths, and central, or neurofibromatosis 2. Neurofibromatosis 1 very commonly involves renal arteries, and hypertension commonly is present in these patients due to stenotic ostial lesions resulting in bilateral renal artery stenosis. However, renal artery aneurysms, renal artery thrombosis, or external compression by neurofibromas also may cause hypertension. We present a unique case of a man with neurofibromatosis 1 presenting with anuric acute kidney injury, followed by a brief discussion of neurofibromatosis 1 and its association with renovascular disease.

780 Bilateral Renal Artery Stenosis and Epidermal Nevus Syndrome in a Child

Epidermal nevus syndrome is a rare congenital sporadic neuro-ectodermic disorder, characterized by the presence of epidermal nevi in association with various developmental abnormalities of the skin, eyes, nervous, skeletal, cardiovascular...

The effect of revascularization of renal artery stenosis on renal perfusion in patients with atherosclerotic renovascular disease

Only a small fraction of patients with atherosclerotic renovascular disease (ARVD) treated with revascularization have improved renal function after the procedure. It has been suggested that this may be due to effects of renal microvascular disease. Our aim was to measure the effect of renal artery stenosis (RAS) revascularization on renal perfusion in patients with renovascular disease. Seventeen renovascular disease patients were treated by dilatation of unilateral (N = 8) or bilateral (N = 9) RAS (N = 23 kidneys), mainly because of uncontrolled or refractory hypertension. The patients were studied before and after (103 ± 29 days) the procedure. Renal perfusion was measured using quantitative positron emission tomography (PET) perfusion imaging. Although renal perfusion correlated inversely with the degree of RAS in patients with renovascular disease, it did not change after revascularization. Our data support the notion of former clinical trials that angiographic severity of RAS does not determine the response to revascularization. Quantitative PET perfusion imaging is a promising tool to noninvasively measure renal perfusion for the assessment of physiological impact of RAS.

Renal artery stenosis: an innocent bystander or an independent predictor of worse outcome in patients with chronic heart failure? A magnetic resonance imaging study

To investigate the prognostic impact of atherosclerotic renovascular disease in patients with chronic heart failure. Patients with heart failure due to left ventricular systolic dysfunction underwent cardiac magnetic resonance imaging and contrast-enhanced magnetic resonance angiography. Renal artery stenosis (RAS) was defined as a luminal narrowing >50%. Of the 366 patients investigated, 112 (31%) had RAS, of whom 41 had bilateral RAS. Patients with RAS were older (P < 0.001), had higher blood pressure (P < 0.001), and worse renal function (P = 0.001). In addition, these patients had more admissions and more prolonged hospital stays because of vascular events (0.09 ± 0.26 vs. 0.02 ± 0.16 admissions/per patient/year; P < 0.001; and 1.26 ± 5.79 vs. 0.31 ± 2.54 days/per patient/year; P < 0.001, respectively) and worse prognosis (hazard ratio 1.60, 95% confidence interval 1.10-2.34, P = 0.015). However, in multivariable analysis, a history of diabetes mellitus, decreasing haemoglobin, and increasing left ventricular end-systolic volume index, but not age and RAS, were independently related to outcome. RAS is a common finding in patients suffering from heart failure. Although it is associated with an increased vascular morbidity, it is not an independent predictor of mortality.

Hypertoniebehandlung bei Nierenarterienstenose

Renovascular hypertension is due to reduced renal parenchymal perfusion. The correct diagnosis can be difficult. It is important to note that the demonstration of renal artery stenosis in a patient with hypertension does not necessarily constitute renovascular hypertension. Often, clinically nonsignificant and asymptomatic renal artery stenosis are found in patients with essential hypertension, or renal failure of other origin. Renovascular disease is a complex disorder with various clinical presentations. In patients with significant renovascular hypertension plasma renin is increased. For this reason the therapy aims to block the renin-angiotensin-aldosterone system. Bilateral renal artery stenosis causes renal sodium retention. In this situation a diuretic drug has to be added to the therapy. Endovascular or surgical therapy has to be considered in patients with flash pulmonary edema or fibromuscular dysplasia. The control of cardiovascular risk factors is important.

Extensive congenital abdominal aortic aneurysm and renovascular disease in the neonate

Primary congenital abdominal aortic aneurysm is an extremely rare entity, with only 15 patients reported in the literature. Options for repair are often limited secondary to branch vessel size and other anatomic limitations. We present a neonate diagnosed with an abdominal aortic aneurysm on prenatal ultrasound. A postpartum computed tomography angiogram revealed an extensive type IV thoracoabdominal aortic aneurysm extending to the aortic bifurcation and resulting in bilateral renal artery stenosis. The unique features of this patient and challenges in management are discussed.

Abstract No. 142: Renal function following angioplasty of renal artery for fibromuscular dysplasia (FMD)

Abstract No. 142: Renal function following angioplasty of renal artery for fibromuscular dysplasia (FMD)

Reverse cardiac remodelling and renal functional improvement following bilateral renal artery stenting for flash pulmonary oedema

Acute flash pulmonary oedema (AFPO) is a life-threatening syndrome almost unique to patients with atheromatous renovascular disease (ARVD). Although recurrent AFPO is a widely accepted indication to consider renal revascularization, this is based on a number of case reports/series describing a successful outcome post-procedure. There is limited literature on the pathophysiological mechanisms and treatment effects of revascularization to support this clinical decision making. We report the case of a 65-year-old lady who presented with three episodes of AFPO. Investigations revealed severe bilateral renal artery stenosis. Post-revascularization, she experienced substantial improvement in energy levels and New York Heart Association class, with improvement in her blood pressure and renal function. Post-procedure, there were dramatic improvements in her cardiac morphology and function that were sustained at 1 year (ejection fraction improved from 39 to 65%, left ventricular mass decreased from 161 to 116 g) as well as renal function (isotopic glomerular filtration rate increased from 22.4 to 34.2 mL/min). This report provides new insights into the pathophysiological relationships between renal and cardiac changes in AFPO; the extent of the cardiac morphological changes was striking and unexpected.

The Incidence of Renal Artery Stenosis in Patients with Significant Stenosis of Lower Extremity Arteries

The purpose of this study is to evaluate the unity of renal artery stenosis and peripheral vascular disease and to find the fre quency of incidental renal artery stenosis in the patients with peripheral vascular disease. In this study,it was included 1502 patients that were sent from cardiovascular surgery department to radiology department to do lower extremity digital substraction angiography and found on at least one segment 50% stenosis and more. The arteries of lower extremity were evaluated by dividing into three segments as aortoiliac, femoropopliteal and infrapopliteal. Segments were classified as unisegment and mul tisegment. Multisegments were named aortoiliac+femoropopliteal, aortoiliac+infrapopliteal, femoropopliteal+infrapopliteal and aortoiliac+femoropopliteal+ infrapopliteal. Patients with 50% stenosis and more of renal artery are decided. The unity of renal artery stenosis and the segmental disease of peripheral artery were compared by using Chi-Square test. It was found evident renal artery stenosis in 228 (15.2%) of 1502 patients with peripheral vascular disease. The frequency of renal artery stenosis was found lesser at unisegment disease than multisegment disease (p=0.03). The renal artery stenosis was found 11.9% unisegment and %16.4 at multisegment disease. The frequency of renal artery stenosis was appeared less at infrapopliteal (6%) disease compared to the others (p=0.027). It was not found any difference between groups when the segmental groups of peripheral vascular disease was compared with right, left and bilateral renal artery stenosis (p=0.086, p=0.219). It was found higher rate of renal artery stenosis at women (23.6%, p=0.01). The frequency of renal artery stenosis is %15,2 in the patients with peripheral vascular disease. Renal artery stenosis is less at infrapopliteal segment disease. Renal artery stenosis in women is more than men at multisegment disease compared to unisegment disease.

Critical Appraisal of the Major Randomized Controlled Trails on the Management of Atherosclerotic Renovascular Disease (ARVD)

Background: In this article, the author discusses critical appraisals of the major randomized controlled trials on the management of Atherosclerotic Renovascular Disease (ARVD). The article will also discuss the limitations of the published trials, while highlighting the crucial aspect of appropriate patient selection, the serious flaws noted, and the quality of the main studies. Also included are the six major randomized controlled trials that compared the difference between revascularization, either surgical or PTRA (Percutaneous Renal Angioplasty), with or without stent versus conservative management (medication).The author also discusses the recommended research for the management of atherosclerotic renovascular disease. Methodology and search strategies to identify studies: A comprehensive search of PUBMED including Medical Subject Headings (MeSH) data base from 1990 to may 2012 and The Cochrane library was completed. Searching was only for relevant English papers related to the management of Atherosclerotic renovascular disease.. CASP questionnaire, Jadad scaling and (Oxford Centre for Evidence-based Medicine) levelling of evidence are used for the purpose of the critical appraisal. Criteria for considering studies for this article: To be considered, clinical studies had to be randomized trials comparing intervention; balloon angioplasty or stenting or both or surgical revascularization versus medical treatment, or surgical versus balloon angioplasty with or without stenting in hypertensive patients who had atherosclerotic renal artery stenosis with a minimum of three months of follow up after treatment Only those studies included with adult patients (age >18 years) who had uncontrolled hypertension (diastolic blood pressure ≥ 95mmHg, treated or untreated) and moderate-to-severe (≥50%) unilateral or bilateral atherosclerotic renal artery stenosis. Studies which were not randomized or those related to fibromuscular dysplasia, meta-analysis, and diagnostic studies were excluded. Objectives: Explaining a critical appraisal of six major randomized clinical trials which compared Revascularization (intervention) to medication (conservative treatment) which includes Angioplasty and Stenting for Renal Artery Lesions Trial (ASTRAL), Stent Placement in Patients With Atherosclerotic Renal Artery Stenosis and Impaired Renal Function Trial (STAR), Dutch Renal Artery Stenosis Intervention Cooperative (DRASTIC), Essai Multicentrique Medicaments vs. Angioplastie trial (EMMA), Scottish and Newcastle Renal Artery Stenosis Collaborative Group trial (SNRASCG), and Prospective randomized trial of operative vs. interventional treatment for renal artery ostial occlusive disease (RAOOD) trials. We also highlighted some points about the ongoing CORAL (Cardiovascular Outcomes in Renal Atherosclerotic Lesions) trial. Conclusions: Correction of Astherosclerotic Renal Artery Stenosis (ARAS), either by surgical revascularization or percutaneous methods, including stenting, has not been shown to be beneficial in treating Atherosclerotic RAS over conservative treatment, although some of the studies showed blood pressure control benefit in intervention groups like EMMA, SNRASCG and post hoc analysis of DRASTIC studies. Consequently, it seems reasonable to consider interventional procedures to correct Renal artery stenosis in patients who do not respond to medical therapy or with poorly-controlled or resistant hypertension; recurrent flash pulmonary edema; dialysis dependent renal failure resulting from atherosclerotic renal artery stenosis; chronic kidney disease and bilateral renal artery stenosis; or Renal artery stenosis to a solitary functioning kidney and waiting for the next available research with less flaws and biases.

The incidence of renal artery stenosis in the patients referred for coronary artery bypass grafting

Multivessel coronary disease or peripheral arterial disease is the clinical clue to diagnosis of renal artery stenosis (RAS). RAS is considered equivalent to coronary artery disease in terms of cardiovascular risk. In this study, we evaluated the incidence of RAS in the patients who were proposed to undergo coronary artery bypass grafting (CABG). Diagnostic evaluations of coronary arteriography and renal artery angiography were performed during the same procedure; the patients who were proposed for CABG in terms of CAD anatomy and clinical manifestation were enrolled. RAS was evaluated and a diameter stenosis of ≥50% was considered as significant RAS; significant RAS patients were divided into five groups. The five groups of RAS were as follows: (1) unilateral RAS ≥50–70%, (2) unilateral RAS ≥70%, (3) bilateral RAS ≥50–70%, (4) one-renal-artery stenosis ≥50–70%, contralateral RAS ≥70%, and (5) bilateral renal artery stenosis ≥70%. A total of 151 patients were enrolled, and RAS (≥50% stenosis in either or both renal arteries) was identified in 47.02% (71/151) patients. Unilateral RAS ≥50–70% was identified in 16.6% (25/151) patients, unilateral RAS ≥70% in 4.6% (7/151) patients, bilateral RAS ≥50–70% in 7.9% (12/151) patients, one-renal-artery stenosis ≥50–70% and contralateral RAS ≥70% in 7.9% (12/151) patients, and bilateral RAS ≥70% was in 9.9%(15/151) patients. The incidence of RAS was 29.03% (18/62) in patients aged ≤60 years, 60% (36/60) in patients aged >60 and ≤70 years, and 58.62% (17/29) in patients aged >70 years. The incidence of RAS was significantly higher in patients aged >60 - ≤70, and >70 years than patients aged ≤60 years (P = 0.001 and P = 0.007, respectively). There was a trend that the incidence of RAS in patients with hypertension [HTN, 50.40% (64/127)] was higher than those without HTN (29.17%, 7/24), with P = 0.056. The incidence of RAS was 47.02% in patients who were proposed for CABG; bilateral RAS of ≥70% was 9.9%. Older age and HTN were associated with RAS in patients who were referred for CABG. This study indicates that the incidence of RAS was high in the patients referred for CABG, and the renal function should be taken care of.

Letters to Editor Hypertension without renovascular stenosis: a rare case of abdominal aorta coarctation treated with percutaneous transluminal angioplasty

Letters to Editor Hypertension without renovascular stenosis: a rare case of abdominal aorta coarctation treated with percutaneous transluminal angioplasty

Bilateral renal artery stenosis in a patient with chronic myeloid leukemia treated with nilotinib

Previously authors have recently described an association between nilotinib therapy for chronic myeloid leukemia (CML) and severe peripheral artery disease, coronary artery disease and sudden death. We present a case report of a male patient with CML who received nilotinib therapy. He developed bilateral renal artery stenosis and renovascular hypertension. He had no history of hypertension, cardiovascular disease, or diabetes, and he was a nonsmoker. Together, these observations indicated that obtaining further understanding of the effects is necessary and that extreme caution is warranted when considering second-generation tyrosine kinase inhibitors for first-line therapy in CML.