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In Patients with Renovascular Hypertension Is There a Role for Open or Endovascular Revascularization Compared to Medical Management?

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Difficult Decisions in Vascular Surgery

Part of the book series: Difficult Decisions in Surgery: An Evidence-Based Approach ((DDSURGERY))

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Abstract

Renovascular hypertension occurs when an existing renal artery stenosis (RAS) leads to hypoperfusion of the juxtaglomerular apparatus of the kidney resulting in an increase in renin production with subsequent up regulation of the renin-angiotensin-aldosterone system. The most common pathology of RAS is atherosclerosis. Non-atherosclerotic etiologies of RAS include fibromuscular dysplasia (FMD), dissection, trauma, congenital hypoplastic syndromes and arteritis. Both medical management, and endovascular (angioplasty/stenting) or open revascularization strategies have been used to treat the hypertensive diathesis, however comparative data of the competing strategies is limited.

Recent randomized trials have demonstrated that medical management should be the first line therapy for patients with atherosclerotic RAS with revascularization, by either endovascular or open surgical technique, being reserved for patients with resistant hypertension (blood pressure greater than 140/90 despite maximum tolerated doses of three antihypertensive with one being a diuretic), non-cardiac flash pulmonary edema, or bilateral severe RAS (>90 %) associated with renal dysfunction (ischemic nephropathy).

Our recommended initial treatment strategy for atherosclerotic RAS mediated renovascular hypertension is optimal medical management. Renal artery angioplasty/stenting is safe with high degree of technical success, and should be considered as the first line of revascularization therapy. Open surgical revascularization is reserved for patients with renal artery anatomy not amenable to endovascular revascularization such as a renal artery occlusion and renal artery disease associated with extensive aortic occlusive or aneurysm disease requiring open repair.

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Authors and Affiliations

  1. Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA, USA

    Joie C. Dunn MD, Sung Wan Ham MD, MS & Fred A. Weaver MD, MMM

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  1. Joie C. Dunn MD
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  2. Sung Wan Ham MD, MS
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  3. Fred A. Weaver MD, MMM
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Correspondence to Fred A. Weaver MD, MMM .

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Editors and Affiliations

  1. The University of Chicago Medical Center and Biological Science Division, Chicago, Illinois, USA

    Christopher L. Skelly

  2. The University of Chicago Medical Center and Biological Science Division, Chicago, Illinois, USA

    Ross Milner

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Dunn, J.C., Ham, S.W., Weaver, F.A. (2017). In Patients with Renovascular Hypertension Is There a Role for Open or Endovascular Revascularization Compared to Medical Management?. In: Skelly, C., Milner, R. (eds) Difficult Decisions in Vascular Surgery. Difficult Decisions in Surgery: An Evidence-Based Approach. Springer, Cham. https://doi.org/10.1007/978-3-319-33293-2_24

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  • DOI: https://doi.org/10.1007/978-3-319-33293-2_24

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-33291-8

  • Online ISBN: 978-3-319-33293-2

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