Skip to main content

Interventional Radiologic Techniques for Screening, Diagnosis and Treatment of Patients with Renal Artery Stenosis

Abstract

Renal artery stenosis resulting in renovascular hypertension or renal ischemia is a potentially treatable condition that results in increased morbidity and mortality, especially among older individuals. Sophisticated imaging techniques are used for screening and identification of affected patients to guide therapy. Treatment guidelines recommend intervention in patients with significant renal artery stenosis, although recent evidence has questioned the benefit of intervention in certain populations. Current research focuses on improving the specificity of imaging techniques and determining which imaging modalities best identify patients who will benefit from intervention.

This is a preview of subscription content, access via your institution.

Fig. 1

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Zierler RE et al. Natural history of atherosclerotic renal artery stenosis: a prospective study with duplex ultrasonography. J Vasc Surg. 1994;19(2):250–7. discussion 257-8.

    CAS  PubMed  Article  Google Scholar 

  2. Schreiber MJ, Pohl MA, Novick AC. The natural history of atherosclerotic and fibrous renal artery disease. Urol Clin N Am. 1984;11(3):383–92.

    CAS  Google Scholar 

  3. Wollenweber J, Sheps SG, Davis GD. Clinical course of atherosclerotic renovascular disease. Am J Cardiol. 1968;21(1):60–71.

    CAS  PubMed  Article  Google Scholar 

  4. Piecha G, Wiecek A, Januszewicz A. Epidemiology and optimal management in patients with renal artery stenosis. J Nephrol. 2012;25(6):872–8.

    CAS  PubMed  Article  Google Scholar 

  5. Edwards MS et al. Renovascular disease and the risk of adverse coronary events in the elderly: a prospective, population-based study. Arch Intern Med. 2005;165(2):207–13.

    PubMed  Article  Google Scholar 

  6. Fried LF et al. Renal insufficiency as a predictor of cardiovascular outcomes and mortality in elderly individuals. J Am Coll Cardiol. 2003;41(8):1364–72.

    PubMed  Article  Google Scholar 

  7. Johansson M et al. Increased cardiovascular mortality in hypertensive patients with renal artery stenosis. Relation to sympathetic activation, renal function and treatment regimens. J Hypertens. 1999;17(12 Pt 1):1743–50.

    CAS  PubMed  Article  Google Scholar 

  8. Chobanian AV et al. Seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure. Hypertension. 2003;42(6):1206–52.

    CAS  PubMed  Article  Google Scholar 

  9. Hirsch AT et al. ACC/AHA Guidelines for the Management of Patients with Peripheral Arterial Disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Associations for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (writing committee to develop guidelines for the management of patients with peripheral arterial disease)--summary of recommendation. J Vasc Interv Radiol. 2006;17(9):1383–97. quiz 1398.

    PubMed  Article  Google Scholar 

  10. Martin LG et al. Quality improvement guidelines for angiography, angioplasty, and stent placement for the diagnosis and treatment of renal artery stenosis in adults. J Vasc Interv Radiol. 2010;21(4):421–30.

    PubMed  Article  Google Scholar 

  11. Anderson JL et al. 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. J Am Coll Cardiol. 2013;61(14):1555–70.

    Article  Google Scholar 

  12. Rountas C et al. Imaging modalities for renal artery stenosis in suspected renovascular hypertension: prospective intraindividual comparison of color Doppler US, CT angiography, GD-enhanced MR angiography, and digital substraction angiography. Ren Fail. 2007;29(3):295–302.

    CAS  PubMed  Article  Google Scholar 

  13. Hansen EF et al. Endoscopic ultrasound duplex scanning for measurement of portal venous flow. Validation against transit time ultrasound flowmetry in pigs. Scand J Gastroenterol. 1999;34(3):325–30.

    CAS  PubMed  Article  Google Scholar 

  14. Olin JW et al. The utility of duplex ultrasound scanning of the renal arteries for diagnosing significant renal artery stenosis. Ann Intern Med. 1995;122(11):833–8.

    CAS  PubMed  Article  Google Scholar 

  15. Helenon O et al. Color Doppler US of renovascular disease in native kidneys. Radiographics. 1995;15(4):833–54. discussion 854-65.

    CAS  PubMed  Article  Google Scholar 

  16. Taylor DC et al. Duplex ultrasound scanning in the diagnosis of renal artery stenosis: a prospective evaluation. J Vasc Surg. 1988;7(2):363–9.

    CAS  PubMed  Article  Google Scholar 

  17. Williams GJ et al. Comparative accuracy of renal duplex sonographic parameters in the diagnosis of renal artery stenosis: paired and unpaired analysis. Am J Roentgenol. 2007;188(3):798–811.

    Article  Google Scholar 

  18. Baxter GM et al. Colour Doppler ultrasound in renal transplant artery stenosis: which Doppler index? Clin Radiol. 1995;50(9):618–22.

    CAS  PubMed  Article  Google Scholar 

  19. Kliewer MA et al. Renal artery stenosis: analysis of Doppler waveform parameters and tardus-parvus pattern. Radiology. 1993;189(3):779–87.

    CAS  PubMed  Article  Google Scholar 

  20. Richardson D et al. Parvus tardus waveform suggesting renal artery stenosis-remember the more proximal stenosis. Nephrol Dial Transplant. 2000;15(4):539–43.

    CAS  PubMed  Article  Google Scholar 

  21. Miralles M et al. Value of Doppler parameters in the diagnosis of renal artery stenosis. J Vasc Surg. 1996;23(3):428–35.

    CAS  PubMed  Article  Google Scholar 

  22. Berland LL et al. Renal artery stenosis: prospective evaluation of diagnosis with color duplex US compared with angiography. Work in progress. Radiology. 1990;174(2):421–3.

    CAS  PubMed  Article  Google Scholar 

  23. Desberg AL et al. Renal artery stenosis: evaluation with color Doppler flow imaging. Radiology. 1990;177(3):749–53.

    CAS  PubMed  Article  Google Scholar 

  24. Nchimi A et al. Duplex ultrasound as first-line screening test for patients suspected of renal artery stenosis: prospective evaluation in high-risk group. Eur Radiol. 2003;13(6):1413–9.

    CAS  PubMed  Google Scholar 

  25. Zierler RE. Is duplex scanning the best screening test for renal artery stenosis? Semin Vasc Surg. 2001;14(3):177–85.

    CAS  PubMed  Article  Google Scholar 

  26. Soulez G et al. Imaging of renovascular hypertension: respective values of renal scintigraphy, renal Doppler US, and MR angiography. Radiographics. 2000;20(5):1355–68. discussion 1368-72.

    CAS  PubMed  Article  Google Scholar 

  27. Amis Jr ES et al. Radiologic investigation of patients with renovascular hypertension. American College of Radiology. ACR Appropriateness Criteria. Radiology. 2000;215(Suppl):663–70.

    PubMed  Google Scholar 

  28. Sfakianakis GN et al. Single-dose captopril scintigraphy in the diagnosis of renovascular hypertension. J Nucl Med. 1987;28(9):1383–92.

    CAS  PubMed  Google Scholar 

  29. Rubin GD et al. Assessment of living renal donors with spiral CT. Radiology. 1995;195(2):457–62.

    CAS  PubMed  Article  Google Scholar 

  30. Urban BA, Ratner LE, Fishman EK. Three-dimensional volume-rendered CT angiography of the renal arteries and veins: normal anatomy, variants, and clinical applications. Radiographics. 2001;21(2):373–86. questionnaire 549-55.

    CAS  PubMed  Article  Google Scholar 

  31. Kawashima A et al. CT evaluation of renovascular disease. Radiographics. 2000;20(5):1321–40.

    CAS  PubMed  Article  Google Scholar 

  32. Willmann JK et al. Aortoiliac and renal arteries: prospective intraindividual comparison of contrast-enhanced three-dimensional MR angiography and multi-detector row CT angiography. Radiology. 2003;226(3):798–811.

    PubMed  Article  Google Scholar 

  33. American College of Radiology Committee on Drugs and Contrast Media: ACR Manual on Contrast Media: Version 9. Reston, VA. http://www.acr.org/~/media/ACR/Documents/PDF/QualitySafety/Resources/Contrast%20Manual/2013_Contrast_Media.pdf (2013).

  34. Vasbinder GB et al. Diagnostic tests for renal artery stenosis in patients suspected of having renovascular hypertension: a meta-analysis. Ann Intern Med. 2001;135(6):401–11.

    CAS  PubMed  Article  Google Scholar 

  35. Vasbinder GB et al. Accuracy of computed tomographic angiography and magnetic resonance angiography for diagnosing renal artery stenosis. Ann Intern Med. 2004;141(9):674–82. discussion 682.

    PubMed  Article  Google Scholar 

  36. Schoenberg SO et al. Diagnosis of renal artery stenosis with magnetic resonance angiography: update 2003. Nephrol Dial Transplant. 2003;18(7):1252–6.

    PubMed  Article  Google Scholar 

  37. Fain SB et al. High-spatial-resolution contrast-enhanced MR angiography of the renal arteries: a prospective comparison with digital subtraction angiography. Radiology. 2001;218(2):481–90.

    CAS  PubMed  Article  Google Scholar 

  38. Tan KT et al. Magnetic resonance angiography for the diagnosis of renal artery stenosis: a meta-analysis. Clin Radiol. 2002;57(7):617–24.

    CAS  PubMed  Article  Google Scholar 

  39. Zhang HL et al. Renal artery stenosis: imaging options, pitfalls, and concerns. Prog Cardiovasc Dis. 2009;52(3):209–19.

    PubMed  Article  Google Scholar 

  40. Wilson GJ, Maki JH. Non-contrast-enhanced MR imaging of renal artery stenosis at 1.5 tesla. Magn Reson Imaging Clin N Am. 2009;17(1):13–27.

    PubMed  Article  Google Scholar 

  41. Marcos HB, Choyke PL. Magnetic resonance angiography of the kidney. Semin Nephrol. 2000;20(5):450–5.

    CAS  PubMed  Google Scholar 

  42. Notohamiprodjo M, Reiser MF, Sourbron SP. Diffusion and perfusion of the kidney. Eur J Radiol. 2010;76(3):337–47.

    PubMed  Article  Google Scholar 

  43. Sadowski EA et al. Blood oxygen level-dependent and perfusion magnetic resonance imaging: detecting differences in oxygen bioavailability and blood flow in transplanted kidneys. Magn Reson Imaging. 2010;28(1):56–64.

    PubMed Central  PubMed  Article  Google Scholar 

  44. Lum DP et al. Transstenotic pressure gradients: measurement in swine–retrospectively ECG-gated 3D phase-contrast MR angiography versus endovascular pressure-sensing guidewires. Radiology. 2007;245(3):751–60.

    PubMed  Article  Google Scholar 

  45. Hueper K et al. T2 relaxation time and apparent diffusion coefficient for noninvasive assessment of renal pathology after acute kidney injury in mice: comparison with histopathology. Invest Radiol. 2013;48:834–42.

    CAS  PubMed  Article  Google Scholar 

  46. Kim D et al. Renal artery imaging: a prospective comparison of intra-arterial digital subtraction angiography with conventional angiography. Angiology. 1991;42(5):345–57.

    CAS  PubMed  Article  Google Scholar 

  47. Delin NA, Ekestrom S, Hoglund NO. Arteriographic appearance of renal artery stenosis compared to resistance measured at operation. Effect of artery reconstruction on flow, pressure gradient and resistance. Acta Chir Scand Suppl. 1966;356B:150–62.

    CAS  PubMed  Google Scholar 

  48. Nahman Jr NS et al. Renal artery pressure gradients in patients with angiographic evidence of atherosclerotic renal artery stenosis. Am J Kidney Dis. 1994;24(4):695–9.

    PubMed  Article  Google Scholar 

  49. Leesar MA et al. Prediction of hypertension improvement after stenting of renal artery stenosis: comparative accuracy of translesional pressure gradients, intravascular ultrasound, and angiography. J Am Coll Cardiol. 2009;53(25):2363–71.

    PubMed  Article  Google Scholar 

  50. De Bruyne B et al. Assessment of renal artery stenosis severity by pressure gradient measurements. J Am Coll Cardiol. 2006;48(9):1851–5.

    PubMed  Article  Google Scholar 

  51. Drieghe B et al. Assessment of renal artery stenosis: side-by-side comparison of angiography and duplex ultrasound with pressure gradient measurements. Eur Heart J. 2008;29(4):517–24.

    PubMed  Article  Google Scholar 

  52. Tanemoto M et al. Angiographic index for angioplasty-treatable atheromatous renal artery stenosis. Hypertens Res. 2008;31(5):881–5.

    PubMed  Article  Google Scholar 

  53. Colyer Jr WR et al. Utility of a 0.014″ pressure-sensing guidewire to assess renal artery translesional systolic pressure gradients. Catheter Cardiovasc Interv. 2003;59(3):372–7.

    PubMed  Article  Google Scholar 

  54. Novick AC et al. Trends in surgical revascularization for renal artery disease. Ten years’ experience. JAMA. 1987;257(4):498–501.

    CAS  PubMed  Article  Google Scholar 

  55. Weibull H et al. Percutaneous transluminal renal angioplasty versus surgical reconstruction of atherosclerotic renal artery stenosis: a prospective randomized study. J Vasc Surg. 1993;18(5):841–50. discussion 850-2.

    CAS  PubMed  Article  Google Scholar 

  56. Cambria RP. Surgery: indications and variables that affect procedural outcome, as well as morbidity and mortality. J Invasive Cardiol. 1998;10(1):55–8.

    PubMed  Google Scholar 

  57. van de Ven PJ et al. Transluminal vascular stent for ostial atherosclerotic renal artery stenosis. Lancet. 1995;346(8976):672–4.

    PubMed  Article  Google Scholar 

  58. van de Ven PJ et al. Arterial stenting and balloon angioplasty in ostial atherosclerotic renovascular disease: a randomised trial. Lancet. 1999;353(9149):282–6.

    PubMed  Article  Google Scholar 

  59. Henry M et al. Stent placement in the renal artery: three-year experience with the Palmaz stent. J Vasc Interv Radiol. 1996;7(3):343–50.

    CAS  PubMed  Article  Google Scholar 

  60. Henry M et al. Stents in the treatment of renal artery stenosis: long-term follow-up. J Endovasc Surg. 1999;6(1):42–51.

    CAS  PubMed  Article  Google Scholar 

  61. Blum U et al. Treatment of ostial renal-artery stenoses with vascular endoprostheses after unsuccessful balloon angioplasty. N Engl J Med. 1997;336(7):459–65.

    CAS  PubMed  Article  Google Scholar 

  62. Ives NJ et al. Continuing uncertainty about the value of percutaneous revascularization in atherosclerotic renovascular disease: a meta-analysis of randomized trials. Nephrol Dial Transplant. 2003;18(2):298–304.

    PubMed  Article  Google Scholar 

  63. Nordmann AJ et al. Balloon angioplasty or medical therapy for hypertensive patients with atherosclerotic renal artery stenosis? A meta-analysis of randomized controlled trials. Am J Med. 2003;114(1):44–50.

    PubMed  Article  Google Scholar 

  64. Bax L et al. Stent placement in patients with atherosclerotic renal artery stenosis and impaired renal function: a randomized trial. Ann Intern Med. 2009;150(12):840–8. w150-1. This randomized trial evaluated renal artery stenting compared to medical therapy, however, its patient population and flawed techniques result in inaccurate conclusions.

  65. Investigators, A. et al. Revascularization versus medical therapy for renal-artery stenosis. N Engl J Med. 2009;361(20):1953–62. In this investigation, medical therapy was compared to renal artery stenting and, like other publications at a similar time, included suboptimal patient populations and intervention techniques resulting in misleading conclusions.

    Article  Google Scholar 

  66. Cooper CJ et al. Stenting and medical therapy for atherosclerotic renal-artery stenosis. N Engl J Med. 2014;370(1):13–22. This publication is the largest randomized trial comparing renal stenting to medical therapy. As with prior similar studies, its design and techniques make its results and conclusions misleading.

    CAS  PubMed  Article  Google Scholar 

  67. Mann SJ, Sos TA. Stent placement in patients with atherosclerotic renal artery stenosis and impaired renal function. Ann Intern Med. 2010;152(3):197. author reply 198.

    PubMed  Article  Google Scholar 

  68. White CJ. The need for randomized trials to prove the safety and efficacy of parachutes, bulletproof vests, and percutaneous renal intervention. Mayo Clin Proc. 2011;86(7):603–5.

    PubMed Central  PubMed  Article  Google Scholar 

  69. White CJ, Olin JW. Diagnosis and management of atherosclerotic renal artery stenosis: improving patient selection and outcomes. Nat Clin Pract Cardiovasc Med. 2009;6(3):176–90.

    PubMed  Article  Google Scholar 

  70. Mann SJ, Sos TA. Misleading results of randomized trials: the example of renal artery stenting. J Clin Hypertens (Greenwich). 2010;12(1):1–2.

    Article  Google Scholar 

  71. White CJ. Kiss my astral: one seriously flawed study of renal stenting after another. Catheter Cardiovasc Interv. 2010;75(2):305–7.

    PubMed  Article  Google Scholar 

  72. Rees CR. Stents for atherosclerotic renovascular disease. J Vasc Interv Radiol. 1999;10(6):689–705. In this review of previously published data on renal artery stenting for atherosclerosis, the author evaluated 815 patients and showed the procedure is effective in reducing hypertension, improving and preserving renal function.

    CAS  PubMed  Article  Google Scholar 

  73. Tegtmeyer CJ, Kellum CD, Ayers C. Percutaneous transluminal angioplasty of the renal artery. Results and long-term follow-up. Radiology. 1984;153(1):77–84.

    CAS  PubMed  Article  Google Scholar 

  74. Sos TA et al. Percutaneous transluminal renal angioplasty in renovascular hypertension due to atheroma or fibromuscular dysplasia. N Engl J Med. 1983;309(5):274–9.

    CAS  PubMed  Article  Google Scholar 

  75. Muller FB et al. The captopril test for identifying renovascular disease in hypertensive patients. Am J Med. 1986;80(4):633–44.

    CAS  PubMed  Article  Google Scholar 

  76. Miller GA et al. Percutaneous transluminal angioplasty vs. surgery for renovascular hypertension. AJR Am J Roentgenol. 1985;144(3):447–50.

    CAS  PubMed  Article  Google Scholar 

  77. Sos TA. Angioplasty for the treatment of azotemia and renovascular hypertension in atherosclerotic renal artery disease. Circulation. 1991;83(2 Suppl):I162–6.

    CAS  PubMed  Google Scholar 

  78. Gerlock Jr AJ et al. Renal transplant arterial stenosis: percutaneous transluminal angioplasty. AJR Am J Roentgenol. 1983;140(2):325–31.

    PubMed  Article  Google Scholar 

  79. Cooper CJ et al. Embolic protection and platelet inhibition during renal artery stenting. Circulation. 2008;117(21):2752–60.

    CAS  PubMed  Article  Google Scholar 

  80. Edwards MS et al. Distal embolic protection during renal artery angioplasty and stenting. J Vasc Surg. 2006;44(1):128–35.

    PubMed  Article  Google Scholar 

  81. Holden A, Hill A. Renal angioplasty and stenting with distal protection of the main renal artery in ischemic nephropathy: early experience. J Vasc Surg. 2003;38(5):962–8.

    PubMed  Article  Google Scholar 

  82. Hagspiel KD, Stone JR, Leung DA. Renal angioplasty and stent placement with distal protection: preliminary experience with the FilterWire EX. J Vasc Interv Radiol. 2005;16(1):125–31.

    PubMed  Article  Google Scholar 

  83. Martin LG et al. Quality improvement guidelines for angiography, angioplasty, and stent placement for the diagnosis and treatment of renal artery stenosis in adults. J Vasc Interv Radiol. 2010;21(4):421–30. quiz 230.

    PubMed  Article  Google Scholar 

  84. Hoobler SW et al. The effects of splanchnicectomy on the blood pressure in hypertension; a controlled study. Circulation. 1951;4(2):173–83.

    CAS  PubMed  Article  Google Scholar 

  85. Investigators, S.H. Catheter-based renal sympathetic denervation for resistant hypertension: durability of blood pressure reduction out to 24 months. Hypertension. 2011;57(5):911–7.

    Article  Google Scholar 

  86. Esler MD et al. Renal sympathetic denervation in patients with treatment-resistant hypertension (The Symplicity HTN-2 Trial): a randomised controlled trial. Lancet. 2010;376(9756):1903–9.

    PubMed  Article  Google Scholar 

  87. Kandzari DE et al. Catheter-based renal denervation for resistant hypertension: rationale and design of the SYMPLICITY HTN-3 Trial. Clin Cardiol. 2012;35(9):528–35.

    PubMed  Article  Google Scholar 

  88. http://www.clinicaltrials.gov, NCT01418261. 29 May 2013 [cited 2013 October 29].

Download references

Compliance with Ethics Guidelines

Conflict of Interest

Dr. Richard H. Marshall, Dr. Marc H. Schiffman, Dr. Ronald S. Winokur, Dr. Adam D. Talenfeld, and Dr. David N. Siegel each declare no potential conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Author information

Affiliations

Authors

Corresponding author

Correspondence to Marc H. Schiffman.

Additional information

This article is part of the Topical Collection on New Imaging Techniques

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Marshall, R.H., Schiffman, M.H., Winokur, R.S. et al. Interventional Radiologic Techniques for Screening, Diagnosis and Treatment of Patients with Renal Artery Stenosis. Curr Urol Rep 15, 414 (2014). https://doi.org/10.1007/s11934-014-0414-5

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11934-014-0414-5

Keywords

  • Renal artery stenosis
  • Magnetic resonance angiography
  • Magnetic resonance imaging
  • CORAL
  • ASTRAL
  • STAR
  • Renal artery stent
  • Angioplasty
  • Atheromatous renal artery stenosis
  • Fibromuscular dysplasis
  • Kidney
  • BOLD
  • Iron-oxide