Renovascular disease: Difference between revisions

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==Pathophysiology==
== [[Renovascular disease overview|Overview]] ==


'''Causes of Ischemic Renal Disease''' 
== [[Renovascular disease historical perspective|Historical Perspective]] ==
*Atherosclerotic Renal Artery Stenosis (ARAS) 
**Atherosclerosis accounts for approximately 90% of the cases of RAS and is the predominant lesion detected in patients >50 years of age
**The presence and number of diseased coronary arteries predicts the likelihood of ARAS
**RAS resulting from atherosclerotic disease is common in (18% to 20%) individuals undergoing coronary angiography (1)
**RAS resulting from atherosclerotic disease is even more common (35% to 50%) in individuals undergoing peripheral vascular angiography for occlusive disease of the aorta and legs (2)
*Fibromuscular dysplasia
**Unknown etiology
**Second most common cause of RAS
**Affects middle-aged women
**More common in first-degree relatives and in the presence of the ACE-I allele.
**Renal artery involvement is seen in 60% of cases - frequently bilateral compromise.
**Progressive renal stenosis is seen in 37% of cases and loss of renal mass in 63%
*Nephroangiosclerosis (HTN injury)
*[[Diabetic Nephropathy]] (small vessels)
*Renal thromboembolic disease
*Atheroembolic renal disease
*Aortorenal dissection
*Post renal transplant RAS
*Renal artery vasculitis
*Trauma
*[[Neurofibromatosis]]
*Thromboangiitis obliterans
*[[Scleroderma]]


==Incidence==  
== [[Renovascular disease pathophysiology|Pathophysiology]] ==


*Prevalence of Renal Artery Stenosis
== [[Renovascular disease causes|Causes]] ==
**Most Common Cause of HTN
*Incidence of Renal Artery Stenosis at Cardiac Catheterization


==Diagnosis==
== [[Renovascular disease differential diagnosis|Differentiating Renovascular disease from other Diseases]] ==
*Manifestations of Renovascular Disease (3)
**Asymptomatic "Incidental RAS"
**Renovascular Hypertension
**Ischemic Nephropathy
**Accelerated CV Disease
***Congestive Heart Failure
***Stroke
***Secondary Aldosteronism


===Clinical Clues to the Diagnosis of Renal Artery Stenosis-ACC/AHA Guidelines ===
== [[Renovascular disease epidemiology and demographics|Epidemiology and Demographics]] ==


*'''CLASS I'''
== [[Renovascular disease risk factors|Risk Factors]] ==
**Onset of hypertension before the age of 30 years or severe hypertension after age 55; level of evidence B
**Accelerated, resistant, or malignant hypertension; level of evidence C
**Development of new azotemia or worsening renal function after administration of an ACE inhibitor or ARB agent; level of evidence B
**Uneaplained atrophic kidney or sizse discrepancy between kidnyes of >1.5cm; level of evidence B
**Sudden, unexplained pulmonary edema; level of evidence B
*'''CLASS IIa'''
**Unexplained renal dysfunction, including individuals starting renal replacement therapy; level of evidence B
*'''CLASS IIb'''
**Multivessel coronary artery disease; level of evidence B
**Unexplained congestive heart failure; level of evidence C
**Refractory angina; level of evidence C


===Diagnostic Methods to Detect Renal Artery Stenosis - ACC/AHA Guidelines===
== [[Renovascular disease screening|Screening]] ==


*'''CLASS I'''
== [[Renovascular disease natural history, complications and prognosis|Natural History, Complications and Prognosis]] ==
**Duplex ultrasound sonography is recommended as a screening test to establish the diagnosis of renal artery stenosis; Level of eveidence: B
**Computed tomographic angiography(in individuals with normal renal function) is recommended as a screnning test to establish the diagnosis of renal artery stenosis; Level of eveidence: B
**Magnetic resonance angiography is recommended as a screening test to establish the diagnosis of renal artery stenosis;  Level of eveidence: B
**When the clinical index of suspicion is high and the results of noninvasive tests are inconclusive, cathether angiography is recommended as a diagnostic test to establish teh diagnosis of renal aretry stenosis;  Level of eveidence: B
*'''CLASS III'''
**Captopril renal scintigraphy is not recommended as a screening test to establish the diagnosis of renal artery stenosis;  Level of eveidence: C
**Selective renal vein measurements are not recommended as a useful screening test to establish the diagnosis of RAS;  Level of eveidence: B
**The plasma renin activity is not recommended as a useful screening test to establish the diagnosis of RAS;  Level of eveidence: B
**The captopril test (measurements of plasma renin activity following captopril administration) is not recommended as a useful screening test to establish the diagnosis of renal artery stenosis;  Level of eveidence: B


<div align="left">
== Diagnosis ==
<gallery heights="175" widths="175">
Image:Renal artery stenosis.jpg|Renal artery stenosis
Image:Fibromuscular dysplasia.jpg|Fibromscular dysplasia
</gallery>
</div>


<div align="left">
[[Renovascular disease history and symptoms|History and Symptoms]] | [[Renovascular disease physical examination|Physical Examination]] | [[Renovascular disease laboratory findings|Laboratory Findings]] | [[Renovascular disease electrocardiogram|Electrocardiogram]] | [[Renovascular disease chest x ray|Chest X Ray]] | [[Renovascular disease CT|CT]] | [[Renovascular disease MRI|MRI]] | [[Renovascular disease echocardiography or ultrasound|Echocardiography or Ultrasound]] | [[Renovascular disease other imaging findings|Other Imaging Findings]] | [[Renovascular disease other diagnostic studies|Other Diagnostic Studies]]
<gallery heights="175" widths="175">
Image:Prevalence RAS.jpg|Prevalence of Renal Artery Stenosis
Image:Prevalence RAS at Cardiac Cath.jpg|Prevalence RAS at Cardiac Cath
</gallery>
</div>


==Indications for Revascularization==
== Treatment ==
*Reasons to Revascularize Atherosclerotic Renovascular Disease
**Treat Symptoms
**Prevent Future Illness
**Lower BP
**Preserve Renal Function
**“Bystander” Effects
***Prevent Death
***Prevent [[MI]]
***Prevent [[CHF]] 
***Prevent CVA
*Indications for revascularization of RAS
**hypertension
***Failure of medical therapy despite full doses of  3 drugs, including diuretic
***Compelling need for ACE inhibition/angiotensin blockade with angiotensin-dependent GFR
**Progressive renal insufficiency with salvagable kidneys
***Recent rise in serum creatinine
***Loss of GFR during antihypertensive therapy (e.g., ACEI)
***Evidence of preserved diastolic blood flow (low resistive index)
**Circulatory congestion, recurrent “flash” pulmonary edema
**Refractory congestive heart failure with bilateral renal artery stenosis
==Treatment Options==
===Medical Therapy===
===PTA===
===Surgical===
==Technical Considerations==
===Renal Arteriography===
*Abdominal Aortogram: identification of ostia of the renal arteries and accessory renal arteries (25% of population)
*Arteriography should include both the arterial phase and the nephrographic phase
*Disease involving renal bifurcations require cranial or caudal angulation to open out the lesion
*Evidence of aortic atheroma: technique of no-touch angiography  is recommended
====Brachial Approach====
*For renal arteries  that are oriented cephalad.
*When the aorta is occluded distally or the renal artery takeoff is severely angulated
*Proximal renal artery segment initially courses inferiorly and posteriorly braquial approach allows more coaxial alignment.
*Greater incidence of vascular site complications
====Femoral approach====
*Renal artery angioplasty and stenting are usually performed via retrograde femoral approach.
*When the real artery origin is oriented horizontally or caudally with respect to the aorta, femoral approach is preferred.
==Complications==
===Complications of Percutaneous Renal Revascularization===
*Atheroembolism into the renal or peripheral vascular bed = cholesterol embolization
*Dissection of renal artery or the wall of the aorta
*Acute or delayed thrombosis
*Infection
*Rupture of renal artery
*Renal perforation
==Prognosis==
===Favorable Predictors===
'''Successful Outcome For Control Of Hypertension'''
*Rapid acceleration of hypertension over the prior weeks or months
*Presence of “malignant” hypertension
*Hypertension in association with flash pulmonary edema
*Contemporaneous rise in serum creatinine
*Development of azotemia in response to ACE inhibitors administered for control of hypertension.
'''Successful Salvage Or Preservation Of Renal Function'''
*Recent rapid  rise in creatinine, unexplained by other factors
*Azotemia resulting from  ACE inhibitors
*Absence of diabetes or other cause of intrinsic kidney disease
*Presence of global renal ischemia, wherein the entire functioning renal mass is subtended by bilateral critically narrowed renal arteries or a vessel supplying a solitary kidney.
===Unfavorable Predictors===
*Renal atrophy demonstrated by kidney length <7.5 cm on ultrasound
*High renal resistance index detected by duplex ultrasound
*Proteinuria > 1gm/day
*Hyperuricemia
*Creatinine clearance <40 mL/minute


==References==
[[Renovascular disease medical therapy|Medical Therapy]] | [[Renovascular disease surgery|Surgery]] | [[Renovascular disease primary prevention|Primary Prevention]] | [[Renovascular disease secondary prevention|Secondary Prevention]] | [[Renovascular disease cost-effectiveness of therapy| Cost-Effectiveness of Therapy]] | [[Renovascular disease future or investigational therapies|Future or Investigational Therapies]]
# PMID 11936924
# PMID 12472042
# PMID 16129817


==Case Studies==
[[Renovascular disease case study one|Case #1]]


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Latest revision as of 19:20, 28 September 2012

Renovascular disease
Renal artery stenosis

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Overview

Historical Perspective

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Risk Factors

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Historical Perspective

Pathophysiology

Causes

Differentiating Renovascular disease from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

History and Symptoms | Physical Examination | Laboratory Findings | Electrocardiogram | Chest X Ray | CT | MRI | Echocardiography or Ultrasound | Other Imaging Findings | Other Diagnostic Studies

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Medical Therapy | Surgery | Primary Prevention | Secondary Prevention | Cost-Effectiveness of Therapy | Future or Investigational Therapies

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