Renal artery stenosis resident survival guide
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Karol Gema Hernandez, M.D. [2]
Definition
Renal artery stenosis is defined as a dimished diameter of the lumen of the renal artery. Renal artery of >70% is considered hemodynamically significant.[1]
Causes
Life Threatening Causes
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Renal artery stenosis does not have life threatening causes.
Common Causes
Managment of RAS
Clinical Clues to the Diagnosis of RAS
| Determine if one or more of the following is present: ❑ Onset of hypertension before the age of 30 years ❑ Onset of severe hypertension after the age of 55 ❑ Accelerated, resistant, or malignant hypertension ❑ Development of new azotemia or worsening renal function after administration of an ACE inhibitor or ARB agent ❑ Unexplained atrophic kidney or size discrepancy between kidneys >1.5 cm ❑ Sudden, unexplained pulmonary edema ❑ Unexplained renal dysfunction, including individuals starting renal replacement therapy ❑ Multi-vessel CAD ❑ Unexplained CHF ❑ Refractory angina | |||||||||||||||||||||||||||||||||||||||||||
| If yes: ❑ Proceed with non-invasive imaging [2] | |||||||||||||||||||||||||||||||||||||||||||
Is patient allergic to contrast | |||||||||||||||||||||||||||||||||||||||||||
| If yes: ❑ Proceed with US | If no check for: ❑ Implanted devices: - Pacemakers - Defibrillators - Cochlear implants - Spinal cord stimulators ❑ Claustrophobic patient | ||||||||||||||||||||||||||||||||||||||||||
If none of the above proceed with MRA
| If yes to any of the above, proceed with CT | ||||||||||||||||||||||||||||||||||||||||||
| Inconclusive noninvasive test but with high clinical index of suspicion: ❑ Perform catheter angiography | Confirmed RAS:
❑Proceed to treatment | ||||||||||||||||||||||||||||||||||||||||||
Algorithm based on the 2013 AHA Guidelines Recommendations for Management of Patients with PAD.[1]
Treatment
| Initiate a regimen that combines: | |||||||||||||||||||||||||||||||||
| Determine if the following conditions are met: ❑ Hypertension controlled on <3 drugs ❑ Stable mild/moderate renal insufficiency ❑ Advanced renal atrophy (<7.5 cm) ❑ Doppler ultrasonographic renal resistance index >80 (<7.5 cm) ❑ History or clinical evidence of cholesterol embolisation | |||||||||||||||||||||||||||||||||
| If yes: ❑ Conservative treatment/watchful waiting | If no: ❑ Check if any of the following are present | ||||||||||||||||||||||||||||||||
❑ Hemodynamically significant RAS (see table above) with recurrent, unexplained CHF or sudden, unexplained pulmonary edema ❑ RAS with: - Accelerated, resistant, or malignant hypertension ❑ RAS and CRI with bilateral RAS or RAS to solitary functioning kidney ❑ RAS and unstable angina ❑ Asymptomatic bilateral or solitary viableʰ kidney with a hemodynamically significant RAS ❑ Asymptomatic unilateral hemodynamically significant RAS in a viable kidney (>7cm) ❑ RAS and CRI with unilateral RAS (2 kidneys present) | |||||||||||||||||||||||||||||||||
| ❑ If answered yes to any: | |||||||||||||||||||||||||||||||||
| ❑Renal Angioplasty/Stent | ❑ Renal artery surgery | ||||||||||||||||||||||||||||||||
Atherosclerotic RAS
| Fibromuscular dysplasia RAS
| ||||||||||||||||||||||||||||||||
| Renal stent placement is indicated for ostial atherosclerotic RAS lesions that meet the clinical criteria for intervention | Balloon angioplasty with bailout stent placement if necessary is recommended for fibromuscular dysplasia lesions | ||||||||||||||||||||||||||||||||
Algorithm based on the 2013 AHA Guidelines Recommendations for Management of Patients with PAD.[1] [3]
References
- ↑ 1.0 1.1 1.2 Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH; et al. (2013). "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". Circulation. 127 (13): 1425–43. doi:10.1161/CIR.0b013e31828b82aa. PMID 23457117.
- ↑ Lao D, Parasher PS, Cho KC, Yeghiazarians Y (2011). "Atherosclerotic renal artery stenosis--diagnosis and treatment". Mayo Clin Proc. 86 (7): 649–57. doi:10.4065/mcp.2011.0181. PMC 3127560. PMID 21719621 Check
|pmid=value (help). - ↑ Haller C (2002). "Arteriosclerotic renal artery stenosis: conservative versus interventional management". Heart. 88 (2): 193–7. PMC 1767237. PMID 12117859.