Renovascular disease medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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Medical Therapy

Indications for Revascularization

• Reasons to Revascularize Atherosclerotic Renovascular Disease
  • Treat Symptoms
  • Prevent Future Illness
  • Lower BP
  • Preserve Renal Function
  • “Bystander” Effects
    • Prevent Death
    • Prevent MI
    • Prevent CHF
    • Prevent CVA
• Indications for revascularization of RAS
  • hypertension
    • Failure of medical therapy despite full doses of 3 drugs, including diuretic
    • Compelling need for ACE inhibition/angiotensin blockade with angiotensin-dependent GFR
  • Progressive renal insufficiency with salvagable kidneys
    • Recent rise in serum creatinine
    • Loss of GFR during antihypertensive therapy (e.g., ACEI)
    • Evidence of preserved diastolic blood flow (low resistive index)
  • Circulatory congestion, recurrent “flash” pulmonary edema
  • Refractory congestive heart failure with bilateral renal artery stenosis

Technical Considerations

Brachial Approach

• For renal arteries that are oriented cephalad.
• When the aorta is occluded distally or the renal artery takeoff is severely angulated
• Proximal renal artery segment initially courses inferiorly and posteriorly braquial approach allows more coaxial alignment.
• Greater incidence of vascular site complications

Femoral approach

• Renal artery angioplasty and stenting are usually performed via retrograde femoral approach.
• When the real artery origin is oriented horizontally or caudally with respect to the aorta, femoral approach is preferred.

Complications

Complications of Percutaneous Renal Revascularization

• Atheroembolism into the renal or peripheral vascular bed = cholesterol embolization
• Dissection of renal artery or the wall of the aorta
• Acute or delayed thrombosis
• Infection
• Rupture of renal artery
• Renal perforation

Prognosis

Favorable Predictors

Successful Outcome For Control Of Hypertension

• Rapid acceleration of hypertension over the prior weeks or months
• Presence of “malignant” hypertension
• Hypertension in association with flash pulmonary edema
• Contemporaneous rise in serum creatinine
• Development of azotemia in response to ACE inhibitors administered for control of hypertension.

Successful Salvage Or Preservation Of Renal Function

• Recent rapid rise in creatinine, unexplained by other factors
• Azotemia resulting from ACE inhibitors
• Absence of diabetes or other cause of intrinsic kidney disease
• Presence of global renal ischemia, wherein the entire functioning renal mass is subtended by bilateral critically narrowed renal arteries or a vessel supplying a solitary kidney.

Unfavorable Predictors

• Renal atrophy demonstrated by kidney length <7.5 cm on ultrasound
• High renal resistance index detected by duplex ultrasound
• Proteinuria > 1gm/day
• Hyperuricemia
• Creatinine clearance <40 mL/minute

References

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