Renal artery stenosis

Harding MB, Smith LR, Himmelstein SI, et al.: Renal artery stenosis: prevalence and associated risk factors in patients undergoing routine cardiac catheterization. J Am Soc Nephrol 1992, 2:1608–1616. This is a standard reference regarding the prevalence of renal arterial lesions observed in more than 1200 patients undergoing coronary angiography. Renal artery lesions were present in 30% of the patients (50% or greater stenosis in 15% of patients; unilateral lesions in 11%; and bilateral lesions in 4%). Multivariate prediction indicated age, severity of coronary disease, congestive heart failure, female gender, and other atherosclerotic vascular disease were predictors of renal artery disease.PubMedGoogle Scholar

Grim CE, Weinberger MH: Diagnosis of renovascular hypertension: the case for renin assays. In Controversies in Nephrology and Hypertension. Edited Narins RG. New York: Churchill Livingstone, 1984:109–122.Google Scholar

Caps MT, Perissinotto C, Zierler RE, et al.: Prospective study of atherosclerotic disease progression in the renal artery. Circulation 1998, 98:2866–2872. This is an important study conducted between 1990 and 1997 that followed 220 patients (reduced to 170 patients for analysis), with 295 renal arteries. Severity was classified by peak systolic velocity in the renal artery and renal-to-aortic ratio. They defined a change of 100 cm/s as a significant. Progressive disease was observed in 35% of vessels over 3 years: 18% of vessels initially considered normal, 28% of vessels with less than 60% initial stenosis, and 49% of vessels more than 60% initial stenosis. During the study, nine of 295 arteries progressed to occlusion. Predictors of progression were baseline. Severity in the vessel, presence of disease in the contralateral renal artery, age, systolic blood pressure, diabetes, and low ankle-to-arm index.PubMedGoogle Scholar

Chabova V, Schirger A, Stanson AW, et al.: Outcomes of atherosclerotic renal artery stenosis managed without revascularization. Mayo Clin Proc 2000, 75:437–444. This retrospective cohort study followed 68 patients (mean age of 71.8 years) with atherosclerotic RAS (more than 70% stenosis) for an average of 38.9 months. Nearly all renal artery lesions were identified incidentally during aortography for other reasons, primarily for aortic or lower extremity vascular disease. Mean serum creatinine level rose from 1.4 to 2.0 mg/dL, with no change in blood pressure; mean number of medications required rose from 1.6 to 1.9 drugs per patient. During followup, four patients underwent renal revascularization and five patients developed end-stage renal disease for reasons other than RAS (diabetes mellitus, atheroemboli, contrast nephrotoxicity). The authors conclude that in the current era, incidentally identified RAS can be managed conservatively in some patients with relatively low risk of progressive renal failure or accelerated hypertensive nephropathy.PubMedGoogle Scholar

Textor SC, Wilcox CS: Ischemic nephropathy/azotemic renovascular disease. Semin Nephrol 2000, 20:489–502. A current review of atherosclerosis, renal artery stenosis, and kidney disease. The pathophysiology of parenchymal renal injury beyond vascular stenosis is discussed, including oxidative stress and histopathology. Data regarding management, including tabular summary of angioplasty, stenting, and surgery are presented. The authors argue the case for critical renal artery stenosis as a cause of kidney failure, but emphasize general medical management and realistic goals of revascularizationPubMedGoogle Scholar

Krijnen P, van Jaarsveld BC, Steyerberg EW, et al.: A clinical prediction rule for renal artery stenosis. Ann Int Med 1998, 129:705–711.PubMedGoogle Scholar

Heart Outcomes Prevention Evaluation study investigators: Effects of an angiotensin-converting enzyme inhibitor, ramipril, on cardiovascular events in high risk patients. N Engl J Med 2000, 342:145–153.CrossRefGoogle Scholar

Plouin PF, Chatellier G, Darne B, Raynaud A: Blood pressure outcome of angioplasty in atherosclerotic renal artery stenosis: a randomized trial. Hypertension 1998, 31:822–829.Google Scholar

van Jaarsveld BC, Krijnen P, Pieterman H, et al.: The effect of balloon angioplasty on hypertension in atherosclerotic renal-artery stenosis. N Engl J Med 2000, 342:1007–1014. This is the largest prospective, randomized trial of medical therapy versus PTRA in patients referred to centers in the Netherlands with resistant hypertension. A total of 106 patients with atherosclerotic RAS (more than 50% stenosis) and creatinine clearance less than 2.3 mg/dL were randomized. Blood pressure and drug therapy were recorded at 3 and 12 months: final blood pressures did not differ between groups. However, 22 of 50 subjects in medical group were allowed to cross over to PTRA after 3 months. The authors observed that that slightly fewer daily drug doses were used in the PTRA group at 3 months, but there was no difference in blood pressure at 3 or 12 months. They conclude that PTRA offers little advantage compared with drug therapy.PubMedCrossRefGoogle Scholar

Ritz E, Mann JFE: Renal angioplasty for lowering blood pressure. N Eng J Med 2000, 342:1042–1043.CrossRefGoogle Scholar

Tuttle K: Toward more rational management of ischemic nephropathy: the need for clinical evidence. Am J Kidney Dis 2000, 36:863–865.PubMedGoogle Scholar

Butterly DW, Schwab SJ: Renal artery stenosis: the case for conservative management. Mayo Clin Proc 2000, 75:435–436.PubMedGoogle Scholar

Textor SC: Renal failure related to ACE inhibitors. Semin Nephrol 1997, 17:67–76.PubMedGoogle Scholar

Joint National Committee: Sixth report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure [erratum in Arch Intern Med 1998 158:573]. Arch Intern Med 1997, 157:2413–2446.CrossRefGoogle Scholar

Textor SC, Novick A, Tarazi RC, et al.: Critical perfusion pressure for renal function in patients with bilateral atherosclerotic renal vascular disease. Ann Int Med 1985, 102:309–314.Google Scholar

Bonelli FS, McKusick MA, Textor SC, et al.: Renal artery angioplasty: technical results and clinical outcome in 320 patients. Mayo Clinic Proc 1995, 70:1041–1052.Google Scholar

Canzanello VJ, Millan VG, Spiegel JE, et al.: Percutaneous transluminal renal angioplasty in management of atherosclerotic renovascular hypertension: results in 100 patients. Hypertension 1989, 13:163–172.PubMedGoogle Scholar

Ramsay LE, Waller PC: Blood pressure response to percutaneous transluminal angioplasty for renovascular hypertension: an overview of published series. BMJ 1990, 300:569–572.PubMedCrossRefGoogle Scholar

Webster J, Marshall F, Abdalla M, et al.: Randomised comparison of percutaneous angioplasty vs continued medical therapy for hypertensive patients with atheromatous renal artery stenosis. J Hum Hypertens 1998, 12:329–335.PubMedCrossRefGoogle Scholar

van de Ven PJ, Kaatee R, Beutler JJ, et al.: Arterial stenting and balloon angioplasty in ostial atherosclerotic renovascular disease: a randomised trial. Lancet 1999, 353:282–286. This carefully conducted trial compared 42 patients with ostial atherosclerotic renovascular disease treated with angioplasty alone versus 43 treated with stents. Primary success was 57% for patients treated with PTRA alone versus 88% with stents. The complication rates were similar. Rate of restenosis was 48% for patients who received PTRA only and 14% for patients had stent implanted. The 6-month patency rate was 29% in patients who received PTRA alone, compared wth 75% in stents. This study establishes the value of stenting to restore patency in arteries with ostial atherosclerotic disease compared with angioplasty alone. Remarkably, there was no difference in clinical results was evident regarding blood pressure, medications used, or renal function at 6 months.PubMedCrossRefGoogle Scholar

Dorros G, Jaff M, Mathiak L, et al.: Four-year follow-up of Palmaz-Schatz stent revascularization as treatment for atherosclerotic renal artery stenosis. Circulation 1998, 98:642–647.PubMedGoogle Scholar

Harden PN, Macleod MJ, Rodger RS, et al.: Effect of renal-artery stenting on progression of renovacular renal failure. Lancet 1997, 349:1133–1136. This widely cited study included 32 patients (with 33 stents implanted) with successful arterial patency in all cases. Rate of restenosis detected by angiography at 6 months was 12%. One patient died with procedure-related hemorrhage. Diastolic blood pressure was lower after stenting (median of 95 mm Hg vs 87 mm Hg), but there was no change in the need for antihypertensive medication. Renal function, as defined by reciprocal creatinine plots, improved or stabilized in 69% of patients. It should be emphasized that rates of progression improved only in a subset, with others developing progressive renal insufficiency as others have reported.PubMedCrossRefGoogle Scholar

Henry M, Amor M, Henry I, et al.: Stents in the treatment of renal artery stenosis: long-term follow-up. J Endovasc Surg 1999, 6:42–51. This retrospective review followed 210 patients (mean age: 67.7 years) who received renal stents between 1990 and 1998. Seventeen percent of patients had diabetes; 48 patients had renal insufficiency (creatinine less than 1.4 mg/dL). Patients were on a mean of 2.7 antihypertensive drugs for refractory hypertensive nephropathy. Ninety-six percent of patients had arteriosclerosis obliterans, with 244 arteries more than 70% stenosis (32 patients had bilateral lesions). Palmaz (Cordis; Miami, FL) and renal bridge stents were used. Technical success was defined as less than 20% residual stenosis, a gradient less than 5 mm, and no major complications. The authors report 99% technical success: restenosis developed in 27 patients (11%) by 8 months. Primary patency was 90.9% at 1 year and 78.8% at 5 years; secondary patency was 99.2% at 1 year and 97.8% at 5 years. Over a mean follow-up period of 25.4 months, blood pressure levels fell from 183/108 to 142/84 mm Hg. Overall, no change was observed in renal function (defined by change in creatinine level of more than 20%). For patients with renal failure, 14 (29%) improved, 32 (67%) had no change, and 2 (4%) deteriorated to requirement of dialysis. These authors argue for vigorous endovascular intervention, with excellent long-term patency. It should be noted that French physicians tend not use ACE inhibitors in patients with suspected RAS and may have observed large effects on blood pressure for that reason.PubMedCrossRefGoogle Scholar

Cambria RP, Brewster DC, L’Italien GJ, et al.: The durability of different reconstructive techniques for atherosclerotic renal artery disease. J Vasc Surg 1994, 20:76–87.PubMedGoogle Scholar

Hallett JW, Textor SC, Kos PB, et al.: Advanced renovascular hypertension and renal insufficiency: trends in medical comorbidity and surgical approach from 1970 to 1993. J Vasc Surg 1995, 21:750–759.PubMedCrossRefGoogle Scholar

Steinbach F, Novick AC, Campbell S, et al.: Long-term survival after surgical revascularization for atherosclerotic renal artery disease. J Urol 1997, 158:38–41.PubMedCrossRefGoogle Scholar

White CJ: Open renal arteries are better than closed renal arteries. Cathet Cardiovas Diag 1998, 45:9–10.CrossRefGoogle Scholar

Main J: Atheromatous renal artery stenosis rarely causes renal failure. Nephrol Dial Transplant 2000, 15:924–925.PubMedCrossRefGoogle Scholar