RENAL ARTERY

INTERVENTIONS
-VIVEK JAGANATHAN
RENAL ARTERY INTERVENTIONS
1. Renal artery balloon angioplasty
2. Renal artery stenting
3. Renal artery denervation
4. Renal artery embolisation
RENAL ARTERY PATHOLOGIES
• RENAL ARTERY STENOSIS:
SYNDROMES A/S WITH RAS
(1) Renovascular hypertension;
(2) Ischemic nephropathy; and
(3) Cardiac disturbance syndromes (ie,sudden-onset pulmonary edema,
refractory heart failure, or unstable angina).
Does RAS need intervention?
1. Observations about the impact on cardiovascular
physiology
2. End-organ effects
3. Natural history
Natural History
• Atherosclerotic RAD is progressive and the risk of progression is
highest with high-grade stenosis, severe hypertension and diabetes.
• Less than 10% of patients with RAS progress to high grade stenosis or
occlusion within 5 years

• Renal function deterioration is rare with unilateral RAS but more

evident with bilateral RAS or with a single functioning kidney (3%,
18% and 55%, respectively, at 2 years)
END ORGAN EFFECTS
RAS and Cardiovascular Events
• Substantial risk of cardiovascular morbidity and mortality in patients
with RAS

• A significant decrease in 4-year survival was seen in patients with

incidental RAS undergoing CAG
Conlon PJ et al., Severity of renal vascular disease predicts mortality in
patients undergoing coronary angiography. Kidney Int. 2001;60:1490 –
1497
WHEN IS RAS SIGNIFICANT??

SCAI 2014
COMMONLY CITED INDICATION FOR
RAS
GOAL OF REVASCULARIASTION
• Normalization of blood pressure,
• Preservation of renal function, and
• Reduction of the risk of cardiovascular events.
 However,
Atherosclerosis, hypertension and renal
insufficiency exist and co-exist commonly.
When there is renal artery stenosis:

Is it the cause of hypertension?

Is it the cause of renal insufficiency?
Will treatment improve either?
Will treatment prevent deterioration?
TOOLS FOR EVALUATION
WHAT DOES EVIDENCE SAY?
• Early 1980s -- Revascularization of the stenotic atherosclerotic renal
artery will salvage the ischemic kidney and will cure hypertension
• Novick Ac et al., Revascularization for preservation of renal function in
patients with atherosclerotic renovascular disease. J Urol 1983; 129 (5):
• 1990s - the procedure became broadly applied ,mixed results emerged
• Some patients showed major benefit after PTRA, while others
experienced further deterioration of renal function and major morbidity
• Textor SC et al., Renal artery stenosis: a 14. common, treatable cause of
renal failure? Annu Rev Med 2001; 52:
EARLIER TRAILS
METAANALYSIS OF RANDOMISED
STUDIES

Nordman et al
WHAT DOES EARLIER TRIALS SAY?
• The EMMA study group looked at 49 total patients, but was not
able to find any improvements with angioplasty at six months.
• Scottish and Newcastle collaborative group in the same year did
not find any difference with angioplasty in a total cohort of 135
patients with the longest follow up of 54 months.
• A Dutch group as well looked at 106 patients showed no difference
at 12 months in systolic pressure, medication use, or decreased
kidney function.  
• Limitations : short time frames, high (29% average) crossover rate,
and small cohorts that may have lacked power to adequately
determine differentiation.
CONCLUSION OF STAR, ASTRAL ,
CORAL
• When examining the three randomized trials of STAR,
ASTRAL and CORAL, there was no significant evidence of
benefit in revascularization with stenting in those with
ARAS.
• All three trials have been criticized for not including
enough high-risk patients.
MULTISOCIETAL GUIDELINES
RECOMMENDATION
WHAT DOES AHA 2017 SAY?
• If a patient has failed medical management and
continues to have clinical evidence of refractory
hypertension, worsening renal function or intractable
heart failure, revascularization should be considered.  
• ACC/AHA do not fully endorse any specific procedure or
evidence of outcome benefit.
WHAT DOES ESC2017 SAY?
• Routine revascularization is not recommended in RAS secondary to
atherosclerosis III A
• Balloon angioplasty, with or without stenting, may be considered in
selected patients with RAS and unexplained recurrent congestive
heart failure or sudden pulmonary oedema IIb C
• In cases of hypertension and/or signs of renal impairment related to
renal arterial fibromuscular dysplasia, balloon angioplasty with
bailout stenting should be considered. IIa C
RENAL ARTERY ANGIOGRAPHY
• The renal arteries arise from the lateral aspect of the aorta at the L 1-
L2 level.
• Accessory renal arteries may occur in 25% to 35% of cases and usually
supply the lower pole of the kidney. These may originate anywhere
from the suprarenal aorta down to the iliac arteries.
• Access for renal angiography is most commonly achieved via the
femoral approach.
ABDOMINAL AOROTGRAM
• The first stage of renal angiography is an abdominal aortogram,
allowing identification of ostia of the renal arteries and location of any
accessory renal arteries,
• 4F to SF multiholed catheter placed at the Ll-L2 interspace for power
injection of a total of 15 to 30 mL of 50% diluted contrast at 15
ml/second using DSA at 4 frames per second is generally sufficient to
provide adequate opacification
SELECTIVE RENAL ARTERIOGRAPHY
• Commonly used catheters include SF internal mammary, hockey stick,
or renal double-curve catheters .
• For downward angulated renal arteries, a reverse-curve catheter such
as an Omni selective catheter may be more appropriate from the
femoral approach or a SF multipurpose catheter, from a brachial
approach
• Contrast should be injected at a rate of 5 ml/second for a total of 5 to
8 mL using DSA at 4 frames per second.
• Angiography should include both the arterial phase and the
nephrographic phase
• No-touch angiography- a 0.014 inch wire is left in the catheter, sitting
in the abdominal aorta, to prevent the catheter from dislodging
atheroma as its tip is manipulated toward the renal artery
• Trans-stenotic gradient -hemodynamic significance of a stenosis .
Pressure measurement is most accurately done using a 0.014 inch
pressure wire , / or by measuring the differential pressure between a
4F catheter placed beyond the lesion and a 5F or 6F sheath or guide
placed in the aorta .
• Gradients higher than 10 mmHg mean or 20 mmHg systolic are
considered significant
RENAL FRAME COUNT
• Number of cine frames required for contrast to reach the smallest
visible distal branch in renal parenchyma
• For assessing the severity of RAS and predicts the likelihood of clinical
response after stenting
• RFC>30 predictive of clinical response
NO TOUCH TECHNIQUE
ANGIOPLASTY AND STENTING
• It is not necessary to perform angioplasty prior to every stenting;
however, if there is any doubt as to whether the lesion is expandable
or not, angioplasty should be undertaken
FDA approved STENTS;
1. Boston Scientific's Express SD,
2. Cook's Formula, and
3. Abbott Vascular's RX Herculink Elite
• IVUS imaging is used identify the location of the ostial renal artery
• The position of the IVUS catheter is then used to place a stent in order
to cover the ostium
• IVUS is used to select appropriate stent size, evaluate stent apposition
and edge dissection
• ATHEROEMBOLISM REDUCTION: EPDs as well as the no-touch
technique during intervention, glycoproteinIIb/IIIa inhibitors
TECHNICAL CONSIDERATION
• Selective renal angiography should be preceded by non selective
abdominal aortography
• The catheter in catheter technique or no touch technique- to be used
to minimise aortic wall injury
• Agrresive hydration and limiting contrast volume
• Prevention of atheroembolism
COMPLICATIONS
• Renal and aortic dissection
• Embolization
• Perforation
• Death
TAKE HOME POINT
• Patients with hemodynamically significant RAS causing
Resistant (refractory) HTN despite GDMT,
Declining renal function,and
Cardiac destabilization syndromes are reasonable candidates for
renal artery stenting
OTHER SCENARIOS
• FMD- Balloon angioplasty is the Treatment of choice
• In Fibromuscular dysplasia, balloon angioplasty with bailout stenting
should be considered. IIa C ESC 2017

• Takayasu aorto arteritis- Balloon angioplasty- cutting ballon

stenting is avoided
RENAL ARTERY DENERVATION
Hope for patients with severe resistant hypertension ?

Endovascular renal denervation- catheter-based ablation techniques in

the main renal arteries in both kidneys to reducing localized renal
sympathetic activity.
Staged Clinical Evaluation
First-in-Man 
Symplicity HTN-1
Series of Pilot studies 

Symplicity HTN-2 
EU/AU Randomized Clinical Trial

USA EU/AU

Symplicity HTN-3 Other Areas of Research:

US Randomized Clinical Trial Insulin Resistance, HF/Cardiorenal,
(upcoming) Sleep Apnea, More

16
TRIALS
• SYMPLICITY-HTN 2 - promising and relatively safe procedure
• SYMPLICITY-HTN 3 - no difference in BP reduction with renal
denervation
• SPYRAL HTN OFFMED, SPYRAL HTN ON-MED, and A Study of the
ReCor Medical Paradise System in Clinical Hypertension (RADIANCE-
HTN SOLO)- consistent reductions in ambulatory and office BP in the
short (2–3 months) and medium term (6 months)
• RADIOSOUND trial observed lower BP with ultrasound-based ablation
compared with two methods of radiofrequency ablation
TAKE HOME POINT
• Renal denervation is a safe and efficacious procedure in lowering BP
in the short term to a similar degree as that afforded by a single
antihypertensive medication.
• Denervation does not seem to affect kidney function