Management Of Renovascular Disease Research Articles

Renovascular disease: Is there still a role for revascularization? .

There are substantial doubts pertaining to the clinical usefulness of radiological and surgical interventions in the management of renovascular disease, particularly in patients with diffuse atherosclerotic vascular disease. This article reviews the current knowledge on advantages and limitations of interventional techniques in the management of patients with atherosclerotic renovascular disease. .

Low-Energy Shockwave Therapy Improves Ischemic Kidney Microcirculation.

Microvascular rarefaction distal to renal artery stenosis is linked to renal dysfunction and poor outcomes. Low-energy shockwave therapy stimulates angiogenesis, but the effect on the kidney microvasculature is unknown. We hypothesized that low-energy shockwave therapy would restore the microcirculation and alleviate renal dysfunction in renovascular disease. Normal pigs and pigs subjected to 3 weeks of renal artery stenosis were treated with six sessions of low-energy shockwave (biweekly for 3 consecutive weeks) or left untreated. We assessed BP, urinary protein, stenotic renal blood flow, GFR, microvascular structure, and oxygenation in vivo 4 weeks after completion of treatment, and then, we assessed expression of angiogenic factors and mechanotransducers (focal adhesion kinase and β1-integrin) ex vivo A 3-week low-energy shockwave regimen attenuated renovascular hypertension, normalized stenotic kidney microvascular density and oxygenation, stabilized function, and alleviated fibrosis in pigs subjected to renal artery stenosis. These effects associated with elevated renal expression of angiogenic factors and mechanotransducers, particularly in proximal tubular cells. In additional pigs with prolonged (6 weeks) renal artery stenosis, shockwave therapy also decreased BP and improved GFR, microvascular density, and oxygenation in the stenotic kidney. This shockwave regimen did not cause detectable kidney injury in normal pigs. In conclusion, low-energy shockwave therapy improves stenotic kidney function, likely in part by mechanotransduction-mediated expression of angiogenic factors in proximal tubular cells, and it may ameliorate renovascular hypertension. Low-energy shockwave therapy may serve as a novel noninvasive intervention in the management of renovascular disease.

Endovascular intervention in renovascular disease: a pictorial review.

Teaching pointsInterventional radiologic procedures offer a significant and expanding role in the management of various renovascular diseases including renal artery stenosis, renal artery aneurysm and pseudoaneurysm, renal vascular malformations, renal tumours, trauma, and resistant hypertension. In this article, we discuss these entities in the context of currently accepted definitions, incidence, modes of diagnosis, and management as they pertain to the practice of interventional radiology. Particular emphasis is placed on current interventional procedures for managing and treating these diseases as well as emerging procedures and technologies.• Highlights the literature on renovascular diseases • Reviewing the role of various interventional procedures in the management of renovascular disease • Review of imaging techniques in the identification and characterisation of renovascular disease

Open Procedures for Renovascular Disease

The open procedures most commonly performed to treat renovascular disease are aortorenal bypass, renal artery thromboendarterectomy, and renal artery reimplantation. This review discusses preoperative evaluation, operative planning, and the operative technique of the aforementioned procedures. In addition, outcome evaluation is described, including hypertension response, renal function response, and the relationship of these to dialysis-free survival. A table provides the recommended principles for contemporary surgical management of renovascular disease. Figures show various types of bypass procedures. This review contains 10 references plus additional sources of recommended reading.

The management of renovascular disease: ASTRAL and beyond

This review concentrates on the new findings published in the atheromatous renovascular disease (ARVD) literature since the beginning of 2009, a period in which the results of two randomized control trials have been released. The key advances have arisen with respect to the epidemiology of ARVD, the effects of revascularization as demonstrated by the results of randomized controlled trials, an understanding of the pathophysiology of the ischaemic kidney, and also there have been further insights regarding the selection of patients for revascularization utilizing structural and functional imaging. Optimal medical management (and not revascularization therapy) is the established cornerstone for all patients with ARVD. Future studies should be directed to identifying individuals who will significantly benefit from renal revascularization.

The Current State of Endovascular Therapy in the Evaluation and Management of Renovascular Disease

Hypertension is the most common reason for physician office visits among nonpregnant adults in the United States; up to one-third of Americans over the age of 18 have been diagnosed with hypertension. Patients with physiologically significant renal artery stenosis often go unnoticed because hypertension can often be well controlled with antihypertensive medications. As a result, screening for renovascular causes of hypertension is rarely done. However, the likelihood of renovascular disease increases in patients with acute, severe, or refractory hypertension and should be explored in patients who fall into these categories. Renovascular disease is a crucial consideration in the management of hypertension due to its increasing incidence and its potential for reversibility. Although renovascular disease accounts for less than 1% of patients with mild hypertension, it is estimated that between 10 and 45% of white patients with severe or malignant hypertension have renal artery stenosis (RAS). In this population, diagnosing and treating RAS can have a profound and long-lasting effect on the treatment of hypertension.

Angiotensin inhibition in renovascular disease: A population-based cohort study

Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers effectively reduce blood pressure in patients with renovascular disease (RVD); yet, randomized cardiovascular prevention trials of these drugs typically exclude individuals with this condition. We studied the association of renin-angiotensin system inhibition with prognosis in a population-based cohort comprising 3,570 patients with RVD in Ontario, Canada; slightly more than half (n = 1,857, 53%) were prescribed angiotensin inhibitors. The primary outcome was the composite of death, myocardial infarction, or stroke. Secondary outcomes included individual cardiovascular and renal events. Patients receiving angiotensin inhibitors had a significantly lower risk for the primary outcome during follow-up (10.0 vs 13.0 events per 100 patient-years at risk, multivariable adjusted hazard ratio [HR] 0.70, 95% CI 0.59-0.82). In addition, hospitalization for congestive heart failure (HR 0.69, 95% CI 0.53-0.90), chronic dialysis initiation (HR 0.62, 95% CI 0.42-0.92), and mortality (HR 0.56, 95% CI 0.47-0.68) was lower in treated patients. Conversely, patients receiving angiotensin inhibitors were significantly more likely to be hospitalized for acute renal failure during follow-up (HR 1.87, 95% CI 1.05-3.33; 1.2 vs 0.6 events per 100 patient-years at risk). These data emphasize the high vascular risk of RVD and suggest that angiotensin inhibitors may improve prognosis in this setting at the expense of acute renal toxicity. If the latter are selected in the management of RVD, renal function parameters should be assiduously followed.

Diagnosis and Management of Renovascular Disease and Renovascular Hypertension

Renovascular disease is a common but complex disorder, the most common causes of which are fibromuscular dysplasia and atherosclerosis. Clinically, it can present as asymptomatic renal artery stenosis, renovascular hypertension, or ischemic nephropathy. Assessing the clinical index of suspicion remains essential in determining an appropriate diagnostic strategy. For diagnosis in patients with suspected fibromuscular disease, it may be reasonable to proceed directly to renal angiography; however, for most patients with suspected atherosclerotic disease, there are a number of noninvasive tests available that can aid in decision making. The choice of the most appropriate initial test should be based on patient characteristics, clinical presentation, and local expertise. Treatment options include medical, surgical, or percutaneous approaches. Generally, in patients with fibromuscular disease, percutaneous intervention provides durable improvement or cure of hypertension. In patients with atherosclerotic disease, the data are less consistent, and there does appear to be a group of patients who will respond well to medical management alone. As technology advances, the diagnostic and treatment paradigms will continue to evolve.

Percutaneous intervention for renovascular disease: rationale and patient selection

The anatomic diagnosis of renovascular disease is increasing in frequency due to the advent of sophisticated non-invasive imaging modalities such as MRA (Magnetic Resonance Angiography) and renal angiography at the time of cardiac catheterization. Despite this fact, the investigation and appropriate management of renovascular disease has remained a controversial topic. This review addresses the clinical syndromes associated with renal artery stenosis (RAS) and the published data guiding appropriate patient selection for revascularization. There is a growing literature in support of renal revascularization as an aid in improving anti-hypertensive control, preserving renal function, and easing the management of congestive heart failure. Meanwhile, technological advances have allowed intervention in an expanding pool of eligible patients. One such technology is the atheroembolic protection device, which may soon allow renal salvage in patients with significant baseline renal impairment that were previously denied intervention for fear of worsening renal function. The data reviewed herein helps to identify patients that will benefit from renal revascularization. Large-scale, randomized data further defining the role of renal revascularization and optimal patient selection is still needed.

The diagnosis and management of renovascular disease: a primary care perspective. Part II. Issues in management.

Renovascular disease is a complex disorder, most commonly caused by fibromuscular dysplasia and atherosclerotic disease. It usually presents in one of three forms: asymptomatic renal artery stenosis, renovascular hypertension, or ischemic nephropathy. This complexity may make diagnostic and management decisions difficult for the primary care physician. In Part I of this review (presented in the May/June 2003 issue of The JCH), the authors discussed when to consider and how to go about making a diagnosis of renovascular disease. In Part II, the authors review the management of this complex condition. There is a debate concerning the optimal treatment of patients with renovascular disease. Management options include medical, surgical, or percutaneous approaches (angioplasty and stenting). Generally in patients with fibromuscular disease, the results of surgery and percutaneous approaches appear superior. In patients with atherosclerotic disease, the data are less consistent, and there does appear to be a group of patients who will respond well to medical management. A potential management algorithm is presented.

Management of renovascular disease: a review of renal artery stenting in ten studies.

To evaluate the efficacy and safety of renal artery stents in renovascular disease, we identified 10 descriptive studies containing sufficient information for systematic evaluation. No randomized comparisons of stenting with angioplasty or with surgery were found. Overall, stents were placed in 416 renal arteries in 379 patients, mean age 64 years (range 27-84), 56% male. Of the stenoses, 97% were atheromatous (inter-study range 71-100%), 80% ostial (22-100%) and 31% bilateral (12-87%). The clinical indication for stenting was usually hypertension with or without mild renal impairment. Radiological indications for stenting were: narrowing of > or = 50% (in 9/10 studies) as a result of elastic recoil (58%) or dissection (2%) at the time of angioplasty; restenosis some time after angioplasty (15%); or as a primary procedure (25%). Technical success was reported in 96-100% of procedures. Restenosis (> or = 50% narrowing), evaluated in 312/416 (75%) arteries, generally between 6 and 12 months, was 16% overall. Hypertension was cured by stenting (DBP < or = 90 mmHg on no treatment) in 34/379 (9%) overall and in 34/207 (16%) of those whose renal function was normal initially. Six of 379 (1.6%) patients died within 30 days of stenting, but in only two (0.5%) was death judged to be procedure-related. Complications, other than those which led to dialysis, occurred in 42/379 (13%) patients, one third requiring intervention, ranging from blood transfusion to a surgical bypass procedure. Renal function as judged by serum creatinine concentration (SCC) improved in 26%, stabilized in 48% and deteriorated in 26% of patients whose renal function was impaired initially (SCC > 133 mumol/l). In one study, with average baseline SCC > 200 mumol/l, successful stenting slowed the rate of progression of renal failure when renal function was deteriorating beforehand. Nine of 379 (2.4%) patients, including 7/14 (50%) whose SCC was > or = 400 mumol/l initially, required dialysis after stenting. Stenting should be offered by specialist centres as a secondary procedure for unsuccessful angioplasty, or restenosis following angioplasty, to patients with renovascular disease and uncontrolled hypertension, advancing renal failure or pulmonary oedema.

Renovascular hypertension.

Renovascular disease, particularly when associated with atherosclerosis, is a common cofactor in accelerating hypertension and deteriorating renal function. With increased longevity and effective antihypertensive medications, the prevalence of vascular lesions affecting renal viability is increasing, possibly accounting for 15% of end-stage renal disease. Renal vascular lesions alter renin release and multiple associated mechanisms related to adrenergic and vascular regulation. Several new diagnostic modalities, including captopril renography, duplex ultrasonography, and magnetic resonance angiography, are being applied for noninvasive diagnosis. Advances in interventional radiologic procedures, including endovascular stents and surgical revascularization, offer the potential for both improved blood pressure management and salvage of renal function. Optimal management of renovascular disease depends on careful assessment of the progression of each patient and associated risk of intervention.

Diagnosis and management of renovascular disease

Diagnosis and management of renovascular disease