Renovascular disease medical therapy

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

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Overview

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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