Renal artery stenosis diagnostic criteria
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Yazan Daaboul,Serge Korjian
Overview
Several clinical clues aid in the suspicion of ARAS and warrant further investigation. To date, imaging is considered the optimal modality to diagnose ARAS. According to the ACC/AHA guidelines in 2013, Doppler ultrasonography, CT angiography, and MR angiography are all non-invasive techniques to diagnose ARAS. Renal angiography remains the gold standard for diagnosis of ARAS. Nonethetheless, it is an invasive procedure that should be reserved to patients who are planning to perform a catheterization procedure and concede to renal angiography or to patients whose non-invasive imaging was equivocal.
Diagnosis
Indications for Work-Up
According to the 2013 ACC/AHA Guidelines for the Management of PAD[1], diagnostic work-up for renal artery stenosis is indicated in the following conditions:
Class I Recommendations[1]
- Hypertension of any stage before the age of 30
- Stage II hypertension in patients older than 55 years
- Accelerated condition of a previously controlled hypertension
- Resistant hypertension
- Malignant hypertension
- New azotemia after administration of ACE-I or ARB
- Unexplained atrophic kidney or asymmetric kidneys that differ by > 1.5 cm
- Sudden unexplained pulmonary edema
Class IIa Recommendations[1]
- Unexplained renal failure including patients starting renal replacement therapy
Class IIb Recommendations[1]
- Presence of multi vessel CAD and no clinical clues of ARAS or PAD
- Unexplained CHF or refractory angina
Diagnostic Methods[1]
The best technique to diagnose ARAS is by imaging. Assessment of both the main and the accessory renal arteries bilaterally is important for diagnostic purposes. Further evaluation should include the anatomic location of the stenosis, severity of stenosis, associated perirenal and perivascular pathologies, such as aneurysms or masses.[1] Duplex ultrasonography, computer tomographic angiography (CTA), magnetic resonance angiography (MRA), and catheter angiography are 4 techniques that are currently recommended for the diagnosis of ARAS.[1] In contrast, neither selective renal vein renin studies and captopril renal scintigraphy nor plasma renin activity and captopril test are still not recommended.[1]
Duplex Ultrasonography
Diagnosis by Duplex ultrasonography is considered class I recommendation. It may be used as an initial screening tool for diagnosis of ARAS. Ultrasonography might not be very accurate in obese patients or those intestinal gas.[1]
Computed Tomographic Angiography
Diagnosis by CT angiography is considered class I recommendation. It provides higher spacial resolution compared to MRA. CT angiography may be used in patients with normal renal function to avoid contrast-induced nephropathy in patients with impaired renal function. Presence of previous stents or metallic objects are considered a contraindication for the use of CTA.[1]
Magnetic Resonance Angiography
Diagnosis by MRA is considered class I recommendation. Gadolinium-based MRA has less nephrotoxic characterstics with good visualization of the renal arteries and perirenal pathologies. Presence of previous stents or metallic objects are considered a contraindication for the use of MRA.[1]
Catheter Angiography
Catheter angiography is considered class I recommendation. It is the gold standard for the diagnosis of ARAS. Renal angiography may be used only if previous tests are equivocal and clinical suspicion is high or if the patient is already undergoing another catheterization process and concedes to renal angiography. Generally, it is associated with a low frequency of adverse events.[1]
2011 ACC/AHA Practice Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic) (DO NOT EDIT)[1]
Clinical Clues to the Diagnosis of RAS (DO NOT EDIT)[1]
| Class I |
| "1.Onset of hypertension before the age of 30 years or severe hypertension after the age of 55. (Level of Evidence: B)" |
| "2.Accelerated, resistant, or malignant hypertension. (Level of Evidence: C)" |
| "3.Development of new azotemia or worsening renal function after administration of an ACE inhibitor or ARB agent . (Level of Evidence: B)" |
| "4.Unexplained atrophic kidney or size discrepancy between kidneys of greater than 1.5 cm. (Level of Evidence: B)" |
| "5.Sudden, unexplained pulmonary edema. (Level of Evidence: B)" |
| Class IIa |
| "1.Unexplained renal dysfunction, including individuals starting renal replacement therapy. (Level of Evidence: B)" |
| Class IIb |
| "1.Multi-vessel coronary artery disease. (Level of Evidence: B)" |
| "2.Unexplained congestive heart failure. (Level of Evidence: C)" |
| "3.Refractory angina. (Level of Evidence: C)" |
Diagnostic Methods (DO NOT EDIT)[1]
| Class I |
| "1. Duplex ultrasonography is recommended as a screening test to establish the diagnosis of RAS. (Level of Evidence: B)" |
| "2. Computed tomographic angiography (in individuals with normal renal function) is recommended as a screening test to establish the diagnosis of RAS. (Level of Evidence: B)" |
| "3. Magnetic resonance angiography is recommended as a screening test to establish the diagnosis of RAS. (Level of Evidence: B)" |
| "4. When the clinical index of suspicion is high and the results of noninvasive tests are inconclusive, catheter angiography is recommended as a diagnostic test to establish the diagnosis of RAS. (Level of Evidence: B)" |
| Class III |
| "1. Captopril renal scintigraphy is not recommended as a screening test to establish the diagnosis of RAS. (Level of Evidence: C)" |
| "2. Selective renal vein renin measurements are not recommended as a useful screening test to establish the diagnosis of RAS. (Level of Evidence: B)" |
| "3. Plasma renin activity is not recommended as a useful screening test to establish the diagnosis of RAS. (Level of Evidence: B)" |
| "4. The captopril test (measurement of plasma renin activity after captopril administration) is not recommended as a useful screening test to establish the diagnosis of RAS. (Level of Evidence: B)" |
References
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 Rooke TW, Hirsch AT, Misra S, Sidawy AN, Beckman JA, Findeiss LK; et al. (2011). "2011 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Peripheral Artery Disease (updating the 2005 guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". J Am Coll Cardiol. 58 (19): 2020–45. doi:10.1016/j.jacc.2011.08.023. PMID 21963765.