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
This section provides a short and straight to the point definition of the disease or symptom in one sentence.
Causes
Life Threatening Causes
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.
Common Causes
Clinical Clues to the Diagnosis of RAS
❑ Determine if one or more of the above is present | |||||||||||||||||||||||||||||||||||||
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❑If one or more of the above are present, proceed to further diagnostic testing | |||||||||||||||||||||||||||||||||||||
Noninvasive Imaging
| Invasive Imaging
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❑ Abdominal aortography to assess the renal arteries during coronary and peripheral angiography | |||||||||||||||||||||||||||||||||||||
Negative noninvasive test but with high clinical suspicion | Evidence of RAS | Evidence of RAS | |||||||||||||||||||||||||||||||||||
Renal angiography | |||||||||||||||||||||||||||||||||||||
Evidence of RAS | |||||||||||||||||||||||||||||||||||||
Confirmed RAS, proceed to treatment | |||||||||||||||||||||||||||||||||||||
Algorithm based on the 2013 AHA Guidelines Recommendations for Management of Patients with PAD.[1]
Indications for Renal Revascularization
Indication | Level of evidence |
---|---|
1.Hemodynamically significant RAS with recurrent, unexplained CHF or sudden, unexplained pulmonary edema | Class I; LOE B |
2. RAS with:
| Class IIa; LOE B |
3.RAS and CRI with bilateral RAS or RAS to solitary functioning kidney | Class IIa; LOE B |
4. RAS and unstable angina | Class IIa; LOE B |
5. Asymptomatic bilateral or solitary viableʰ kidney with a hemodynamically significant RAS | Class IIb; LOE C |
6. Asymptomatic unilateral hemodynamically significant RAS in a viable* kidney | Class IIb; LOE C |
7. RAS and CRI with unilateral RAS (2 kidneys present) | Class IIb; LOE C |
ʰViable means kidney linear length greater than 7 cm.
Shown below is a table of the definition of hemodynamically significant RAS.[1]
Hemodynamically significant RAS |
≥70% by visual estimation |
≥70% by intravascular ultrasound measurement≥70% |
50-70% RAS with a systolic gradient of ≥20 mm Hg or a mean gradient of ≥10 mm Hg. |
Shown below there is an algorithm of therapeutic options after any of the indications for revascularization are met.
❑ When any of the indications are met: | |||||||||||||||||||||||||||||||||
❑Renal Angioplasty/Stent | ❑ Renal artery surgery | ||||||||||||||||||||||||||||||||
Atherosclerotic RAS
| Fibromuscular dysplasia RAS
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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]
Stenting efficacy can be defined by clinical or technical end points. Recent studies reveal that even though there are high technical success rates, the clinical end points are inconsistently and modestly modified. [2]
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.
- ↑ Cooper CJ, Murphy TP, Cutlip DE, Jamerson K, Henrich W, Reid DM; et al. (2014). "Stenting and medical therapy for atherosclerotic renal-artery stenosis". N Engl J Med. 370 (1): 13–22. doi:10.1056/NEJMoa1310753. PMID 24245566.