Renal artery stenosis resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Karol Gema Hernandez, M.D. [2]

Definition

This section provides a short and straight to the point definition of the disease or symptom in one sentence.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

Common Causes

Clinical Clues to the Diagnosis of RAS

 
 
 
 
 
Determine if one or more of the above is present
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
ScenarioLevel of evidence
1.Onset of hypertension before the age of 30 years or severe hypertension after the age of 55Class I; LOE B
2. Accelerated, resistant, or malignant hypertensionClass I; LOE C
3. Development of new azotemia or worsening renal function after administration of an ACE inhibitor or ARB agentClass I; LOE B
4. Unexplained atrophic kidney or size discrepancy between kidneys of greater than 1.5 cmClass I; LOE B
5. Sudden, unexplained pulmonary edemaClass I; LOE B
6. Unexplained renal dysfunction, including individuals starting renal replacement therapyClass IIa; LOE B
7. Multi-vessel coronary artery diseaseClass IIb; LOE B
8. Unexplained congestive heart failureClass IIb; LOE C
9. Refractory anginaClass IIb; LOE C
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If one or more of the above are present, proceed to further diagnostic testing
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Noninvasive Imaging
 
 
 
Invasive Imaging
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Duplex ultrasound

❑ Gadolinium enhanced MRA

❑ CT angiography
 
 
 
❑ Abdominal aortography to assess the renal arteries during coronary and peripheral angiography
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative noninvasive test but with high clinical suspicion
 
Evidence of RAS
 
Evidence of RAS
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Renal angiography
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Evidence of RAS
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Confirmed RAS, proceed to treatment
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Algorithm based on the 2013 AHA Guidelines Recommendations for Management of Patients with PAD.[1]

Indications for Renal Revascularization

IndicationLevel of evidence
1.Hemodynamically significant RAS with recurrent, unexplained CHF or sudden, unexplained pulmonary edemaClass I; LOE B
2. RAS with:
  • Accelerated, resistant, or malignant hyper tension
  • Hypertension with unilateral small kidney
  • Hypertension with medication intolerance
Class IIa; LOE B
3.RAS and CRI with bilateral RAS or RAS to solitary functioning kidneyClass IIa; LOE B
4. RAS and unstable anginaClass IIa; LOE B
5. Asymptomatic bilateral or solitary viable* kidney with a hemodynamically significant RASClass IIb; LOE C
6. Asymptomatic unilateral hemodynamically significant RAS in a viable* kidneyClass IIb; LOE C
7. RAS and CRI with unilateral RAS (2 kidneys present)Class IIb; LOE C
 
 
 
 
 
Renal Angioplasty/Stent
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Noninvasive Imaging
 
 
 
Invasive Imaging
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Duplex ultrasound

❑ Gadolinium enhanced MRA

❑ CT angiography
 
 
 
❑ Abdominal aortography to assess the renal arteries during coronary and peripheral angiography

References

  1. Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH; et al. (2013). "Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA guideline recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". Circulation. 127 (13): 1425–43. doi:10.1161/CIR.0b013e31828b82aa. PMID 23457117.


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