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Renovascular Disease: Diagnosis and EndovascularTherapy
Majdi Aschi, DO, FACC, FCCP
Richard Bright was first to demonstrate an association between hypertension and thekidney. Goldblatt, et al
1
were the first to elucidate the pathogenesis of renovascular hypertension, based on animal studies with mechanical renal artery constriction. There isno agreement on how common is renovascular disease and renovascular hypertension.However, the prevalence of renovascular hypertension varies between 0.2% and 32%,
2, 3
and it has been reported that less than 0.5% of an entire hypertensive population hasrenovascular hypertension.
4
Dustan, et al, has shown that only 50% of the patients withsignificant RAS, in fact, had hypertension.
7
The only true way to diagnose renovascular hypertension is to correct the renal artery stenosis (RAS) surgically or by endovascular therapy and demonstrate cure of the hypertension. There is a high prevalence (35%-40%)of atherosclerotic renal artery stenosis (ARAS) in patients who have concomitant peripheral vascular disease and/or coronary artery disease.
5, 6
High grade bilateral renalartery disease is present in approximately 13% of patients with peripheral and/or coronary artery disease.
5
ARAS has been estimated to be the cause of 10%-15% of newonset end-stage renal disease in individuals over 50 years of age.
8, 9
 
Causes of Renovascular Disease:
1.Atherosclerosis. Atherosclerosis is involved in about 60%-70% of all renovascular lesions. It usually occurs in the proximal 2 cm of the renal artery. A follow-uphypertension is not a useful marker for the progressive nature of this disease, butserial kidney function and kidney size are.
10
 2.Fibrous Dysplasia. Fibrous dysplasia comprises approximately 40% of allrenovascular disease. Medial fibrous dysplasia is the most common of the fibrouslesions. Angiographically, medial fibrodysplasia demonstrates a typical "string of  beads" in appearance involving the distal two-thirds of the main renal artery and branches.3.Renal Artery Aneurysm. There are four types of which saccular aneurysmsaccount for 75% of the aneurysms.
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These aneurysms are specifically of concernwhen they are greater than 2 cm in diameter, noncalcified and occur in perimenopausal women due to the predisposition to rupture during pregnancy.
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4.Extrinsic compression by cysts or tumors.5.Radiation injury.6.Neurofibromatosis.7.Vasculitis, i.e., Takayasu's arteritis.8.Dissection.9.Retroperitoneal fibrosis.10.Thromboembolic disease, which may occur as a complication of rheumatic heartdisease, infective endocarditis, cardiac operations, renal artery catheterization, etc.
 
Clinical Clues That Suggest Renovascular Disease or RenovascularHypertension:
A. High Probability
1.Malignant or accelerated hypertension. Usually it is greater than 180/100 mmHgand/or resistant to two or more drugs.2.Unexplained azotemia, especially after receiving angiotensin converting enzymeinhibitors or angiotensin-II antagonist.3.Atrophic kidney or discrepancy in size between the two kidneys (greater than 1.5cm difference).4.Epigastric bruit (systolic/diastolic or prolonged bruit in the flank area).5.Unexplained pulmonary edema with or without left ventricular systolicdysfunction.
B. Moderate Probability
1.Abrupt onset of hypertension before age of 30 or after age 55.2.Patients with vascular disease elsewhere (generalized atherosclerosis).3.Heavy or prolonged use of tobacco.4.Low body mass index.
C. Low Probability
 1.Presentation typical of mild - moderate essential hypertension.
Diagnosis of Renovascular Diseas
e:
Again, the only true way to diagnose renovascular hypertension is to correct renal arterystenosis surgically or by endovascular therapy and demonstrate a cure of thehypertension. Screening tests with the sensitivity below 75% are not recommended. Highsensitivity is recommended so those patients with potentially curable forms of hypertension or progressive azotemia are not denied the benefit of an intervention. Inadults, there is no usefulness in evaluating renal artery stenosis with intravenous urogram, plasma renin activity, Captopril test, renal vein renin sampling or renal scintigraphy.Renal ultrasound with duplex, spiral CT scanning, magnetic resonance angiography(MRA), intravascular ultrasound(IVUS), conventionalangiography, or carbon dioxideangiography (CO
2
angiography)are more sensitive and specificand deserve brief review.Duplex Ultrasonography.Combining B-mode ultrasoundwith Doppler examinations has
 
 proven useful in the diagnosis of RAS. The sensitivity and specificity has been estimatedat 89% and 97%, respectively.
13, 14
It provides information about the anatomic location of stenosis, an accurate estimate of the kidney size, non-nephrotoxic, nonaltered by placing patients or taking them off of antihypertensive medication, and relatively less expensivethan spiral CT, MRA or angiography. Measuring peak systolic velocity (PSV), end-diastolic velocity and the ratio of the PSV in the renal artery to PSV in the aorta, gives itits high sensitivity and specificity. The criticism, however, has been that larger centersresults cannot be duplicated. This is true since the technique has a steep learning curve. Inour office, we have been able to closely duplicate the Cleveland Clinic results.Magnetic Resonance Angiography (MRA). It has a sensitivity and specificity for detecting stenosis > than 60% in the range of about 73%-100% and 76%-100%,respectively.
16-20
Thornton, et al
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has reported improved MRA sensitivity (100%),specificity (98%) and accuracy (99%) when using a gadolinium-enhanced breath holdmethod. MRA is limited by its availability, high cost of gadolinium and limitedevaluation of the distal main, segmental and accessory renal arteries. MRA is dependentupon the equipment, software and the technical expertise of the specialist performing theMRA examination.CT Angiography. Depending on many factors, including technique used, the sensitivityfor diagnosing renal artery stenosis is 59% to 92% and specificity 82% to 98%.
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Some of its limitations include a large load of dye, especially in patient with pre-existingrenal insufficiency, availability of the software and limited evaluation of distal main renalartery and segmental branches.CO
2
Angiography. It has a sensitivity of 83% and a specificity of 99%.
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CO
2
or carbondioxide angiography provides an alternative to conventional angiography of iodinatedcontrast and its nephrotoxicity. However, it is cumbersome to use and its disadvantagesare related to the buoyancy, compressibility and solubility of the gas. The major drawback of CO
2
as a contrast agent is that it does not really have the resolution andclarity that are seen with contrast dye.Intravascular Ultrasound (IVUS
 
). It is not an ideal screening or diagnostic test for RAS.However it is very useful peri-intervention in determining the significance of the lesion,discriminating among atherosclerotic, fibromuscular disease or other causes of RAS.
27, 28
 Angiography. It is the gold standard for the diagnosis of RAS. It should be done if someform of intervention is warranted. It is more costly than all of the noninvasive tests and ithas very small risk due to its invasive nature.In our practice we follow and recommend this algorithm for the diagnosis and evaluationof RAS.
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