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==Overview==
==Overview==
Patients with Renal artery stenosis require the widespread use of intensive medical therapy. The drugs responsible for the management of renal artery stenosis are ACE inhibitors or ARB's. These drugs inhibit the sympathetic and renin-angiotensin system resulting in controlling hypertension. In patients with bilateral renal artery stenosis, there is an associated decrease in renal function after using the ACE inhibitors and ARB, but it is neither a sensitive nor specific finding. Aggressive statin use, optimal glycemic regulation, and therapy for smoking abstinence are of vital significance. Other modalities used are renal artery revascularization, Percutaneous transluminal renal angioplasty, Renal artery stenting, brachytherapy and cutting balloon atherotomy, and surgery in complicated and nonresponding cases. Although morbidity and mortality are high in surgery vs stenting.
Patients with [[Renal artery stenosis]] require the widespread use of intensive [[medical therapy]]. The [[drugs]] responsible for the management of [[renal artery stenosis]] are [[ACE inhibitors]] or [[ARB's]]. These drugs inhibit the [[sympathetic]] and [[renin-angiotensin system]] resulting in controlling [[hypertension]]. In patients with bilateral [[renal artery stenosis]], there is an associated decrease in [[renal]] function after using the [[ACE inhibitors]] and [[ARB]], but it is neither a sensitive nor specific finding. Aggressive [[statin]] use, optimal [[glycemic]] regulation, and therapy for [[smoking]] abstinence are of vital significance. Other modalities used are [[renal artery]] [[revascularization]], [[Percutaneous transluminal renal angioplasty]], [[Renal artery stenting]], [[brachytherapy]] and cutting [[balloon atherotomy]], and [[surgery]] in complicated and nonresponding cases. Although [[morbidity]] and [[mortality]] are higher associated with [[surgery]] as compared to stenting.


==Treatment==
==Treatment==


=== Medical Therapy ===
===Medical Therapy===
The patients with Renal artery stenosis requires the wide spread use of intensive medical therapy. The drugs responsible for the management of renal artery stenosis are ACE inhibitors or ARB's.  These drugs inhibit the sympathetic and renin-angiotensin system resulting in controlling the hypertension. In patients with bilateral renal artery stenosis there is associated decrease in the renal function after using the ACE inhibitors and ARB, but it is neither sensitive nor specific finding. Aggressive statin use, optimal glycemic regulation, and therapy for smoking abstinence are of vital significance.
Patients with [[Renal artery stenosis]] require the widespread use of [[intensive]] [[medical therapy]]. The [[drugs]] responsible for the management of [[renal artery stenosis]] are [[ACE inhibitors]] or [[ARB's]].  These drugs inhibit the [[sympathetic]] and [[renin-angiotensin system]] resulting in controlling [[hypertension]]. In patients with bilateral [[renal artery stenosis]], there is an associated decrease in the [[renal function]] after using the [[ACE inhibitors]] and [[ARB]], but it is neither sensitive nor specific<ref name="pmid6337327">{{cite journal |vauthors=Hricik DE, Browning PJ, Kopelman R, Goorno WE, Madias NE, Dzau VJ |title=Captopril-induced functional renal insufficiency in patients with bilateral renal-artery stenoses or renal-artery stenosis in a solitary kidney |journal=N Engl J Med |volume=308 |issue=7 |pages=373–6 |date=February 1983 |pmid=6337327 |doi=10.1056/NEJM198302173080706 |url=}}</ref>. Aggressive [[statin]] use, optimal [[glycemic regulation]], and therapy for [[smoking]] abstinence are of vital significance.


Aggressive use of statins, optimal glycemic control, and smoking cessation counseling are of paramount importance. The results of various medical regimens on the treatment of ARAS-related hypertension were not analyzed in a randomized clinical trial because such patients frequently have refractory hypertension and need multiple antihypertensive medicines. Medical therapy is preferred to revascularization in patients with ARAS and progressive renal disease (i.e. chronic renal dysfunction, proteinuria[>1 g/d]), diffuse intrarenal vascular disease, and renal atrophy.
Aggressive use of [[statins]], optimal [[glycemic control]], and [[smoking]] cessation counseling is of paramount importance. The results of various medical regimens on the treatment of [[ARAS]]-related [[hypertension]] were not analyzed in a [[randomized clinical trial]] because such [[patients]] frequently have [[refractory]] [[hypertension]] and need multiple [[antihypertensive]] [[medicines]]. [[Medical therapy]] is preferred for [[revascularization]] in [[patients]] with [[ARAS]] and progressive [[renal disease]] (i.e. chronic renal dysfunction, proteinuria[>1 g/d]), diffuse [[intrarenal vascular disease]], and [[renal atrophy]]<ref name="pmid15580159">{{cite journal |vauthors=Bokhari SW, Faxon DP |title=Current advances in the diagnosis and treatment of renal artery stenosis |journal=Rev Cardiovasc Med |volume=5 |issue=4 |pages=204–15 |date=2004 |pmid=15580159 |doi= |url=}}</ref>.


===Renal Artery Revascularization===
===Renal Artery Revascularization===
It is less obvious and much more contentious whether patients with ARAS and hypertension would undergo surgical revascularization. According to studies patients with extreme ostial renal artery stenosis  who have been successfully revascularized percutaneously do not necessarily have therapeutic benefits.  
It is less obvious and much more contentious whether [[patients]] with [[ARAS]] and [[hypertension]] would undergo [[surgical revascularization]]. According to studies [[patients]] with extreme [[ostial]] [[renal artery stenosis]] who have been successfully [[revascularized]] [[percutaneously]] do not necessarily have therapeutic benefits.  


The ACC/AHA description of RAS is as follows:
The ACC/AHA description of [[RAS]] is as follows:


(1) visually approximate stenosis of 50 percent to 70 percent diameter with a translational peak gradient of at least 20 mm Hg or a mean gradient of at least 10 mm Hg  
(1) visually approximate [[stenosis]] of 50 percent to 70 percent diameter with a translational peak gradient of at least 20 mm Hg or a mean gradient of at least 10 mm Hg  


(2) angiographic stenosis of at least 70 percent diameter  
(2) [[angiographic stenosis]] of at least 70 percent diameter  


(3) greater than 70% stenosis according to the measurement by intravascular ultrasounds.  
(3) greater than 70% stenosis according to the measurement by [[intravascular ultrasounds]]<ref name="pmid8178389">{{cite journal |vauthors=Olin JW |title=Role of duplex ultrasonography in screening for significant renal artery disease |journal=Urol Clin North Am |volume=21 |issue=2 |pages=215–26 |date=May 1994 |pmid=8178389 |doi= |url=}}</ref>.  


Present ACC/AHA recommendations do not however, include these steps and prescribe revascularization of ARAS only when it is associated with certain medical conditions mentioned as follows:
Present ACC/AHA recommendations do not, however, include these steps and prescribe [[revascularization]] of [[ARAS]] only when it is associated with certain [[medical conditions]] mentioned as follows:


1) Asymptomatic stenosis:  Percutaneous revascularization can be considered for the treatment of:
1) Asymptomatic [[stenosis]]:  [[Percutaneous revascularization]] can be considered for the treatment of:


*An asymptomatic bilateral
*An asymptomatic bilateral


*Solitary viable kidney with hemodynamically significant ARAS (class Jib, degree of proof II.OF.I C),.
*Solitary viable [[kidney]] with [[thermodynamically]] significant [[ARAS]] (class Jib, degree of proof II.OF.I C),.


*The efficacy of percutaneous or asymptomatic unilateral hemodynamically significant ARAS in a viable kidney is not well known and clinically unrecognized (class 11b, LOE C)
*The efficacy of [[percutaneous]] or asymptomatic unilateral hemodynamically significant [[ARAS]] in a viable kidney is not well known and clinically unrecognized (class 11b, LOE C)


2) Hypertension
2) [[Hypertension]]


*Percutaneous revascularization is used for the patients with
*[[Percutaneous revascularization]] is used for patients with
*Hemodynamically significant renal artery stenosis along with accelerated hypertension
*Hemodynamically significant [[renal artery stenosis]] along with accelerated [[hypertension]]
*Malignant hypertension
*[[Malignant hypertension]]
*Resistant hypertension
*[[Resistant hypertension]]
*In cases with hypertension and associated unilateral small kidney.
*In cases with [[hypertension]] and associated [[unilateral small kidney]].




3) Preservation of renal function
3) Preservation of [[renal function]]


*Percutaneous revascularization is helpful in patients with ARAS + Chronic progressive kidney disease with bilateral renal artery stenosis or solitary functioning kidney. (Class IIa, LOE B)
*[[Percutaneous revascularization]] is helpful in patients with [[ARAS]] + [[Chronic progressive kidney disease]] with [[bilateral renal artery stenosis]] or solitary functioning [[kidney]]. (Class IIa, LOE B)


*Also considered significant in patients with RAS and chronic renal insufficiency with unilateral renal artery stenosis. (Class IIb, LOE C)
*Also considered significant in [[patients]] with [[RAS]] and [[chronic renal insufficiency]] with [[unilateral renal artery stenosis]]. (Class IIb, LOE C)




4) Effects of renal artery stenosis on Congestive heart failure and unstable angina: Percutaneous revascularization is considered in patients with  
4) Effects of [[renal artery stenosis]] on [[Congestive heart failure]] and [[unstable angina]]: [[Percutaneous revascularization]] is considered in [[patients]] with  


*RAS + Recurrent congestive heart failure or sudden unexplained pulmonary edema. (Class I, LOE B)
*[[RAS]] + Recurrent [[congestive heart failure]] or sudden unexplained [[pulmonary edema]]. (Class I, LOE B)
*Patients with hemodynamically significant RAS along with unstable angina (Class IIa, LOE B)
*[[Patients]] with hemodynamically significant [[RAS]] along with [[unstable angina]] (Class IIa, LOE B)


=== Percutaneous Transluminal Renal Angioplasty ===
<br />
The largest randomized trial that compared drug treatment and PTRA was the Dutch Renal Artery Stenosis Intervention Cooperative (DRASTIC) study.66 In that study, 106 patients were randomly assigned to PTRA or medical therapy. The study design was such that patients in the drug treatment group whose condition was refractory to medical therapy were allowed to undergo balloon angioplasty if their blood pressure control was inadequate. Major limitations of that study included enrollment of patients with insignificant ARAS, a 44% crossover from medical therapy to PTRA, and low use of stents (20%). Despite the authors' assertion that PTRA in addition to drug therapy provided “little benefit,” patients in the PTRA group were less likely to have deterioration of their blood pressure control or renal artery occlusion during 12 months of follow-up.


=== Renal Artery Stenting ===
===Percutaneous Transluminal Renal Angioplasty===
Results from observational studies have demonstrated that renal stenting is safe and effective in reducing blood pressure.67,68 The problem of elastic recoil is alleviated by using stents, which provide mechanical scaffolding. In a meta-analysis of 1322 patients, stent placement had a significantly higher technical success rate and lower restenosis rate than did PTRA (98% vs 77% and 17% vs 26%, respectively) and higher cure rates for hypertension.69
*Dutch [[Renal Artery Stenosis]] Intervention Cooperative (DRASTIC)<ref name="pmid10749962">{{cite journal |vauthors=van Jaarsveld BC, Krijnen P, Pieterman H, Derkx FH, Deinum J, Postma CT, Dees A, Woittiez AJ, Bartelink AK, Man in 't Veld AJ, Schalekamp MA |title=The effect of balloon angioplasty on hypertension in atherosclerotic renal-artery stenosis. Dutch Renal Artery Stenosis Intervention Cooperative Study Group |journal=N Engl J Med |volume=342 |issue=14 |pages=1007–14 |date=April 2000 |pmid=10749962 |doi=10.1056/NEJM200004063421403 |url=}}</ref> did a study to compare the effects of [[drug treatment]] and [[PTRA]].  


A randomized trial demonstrated the superiority of renal stenting vs PTRA for immediate procedural success (88% vs 57%, respectively) and lower restenosis rates (14% vs 48%, respectively).70 The limitation of that study appears to be the complication rates, although no significant differences in complications were noted between either study arm. The authors identified bleeding as a complication in 19% of patients in both arms (although the definition of bleeding was unclear) and cholesterol embolism as a complication in 10% of both arms. Other studies have demonstrated improvement or stabilization of renal function after unilateral or bilateral renal stenting in patients with ARAS and progressive renal insufficiency.71,72 In patients with ARAS and hypertension (blood pressure >140/90 mm Hg) despite treatment with at least 2 antihypertensive medications, renal stenting resulted in systolic blood pressure reduction of 20 mm Hg and use of 1 less antihypertensive medication.73
*Despite the authors' claim that [[PTRA]] offered "little benefit" in comparison to [[pharmacological treatments]], [[patients]] in the [[PTRA]] community were less likely over 12 months of follow-up to experience regression in their [[blood pressure]] regulation or [[renal artery occlusion]].


Two important randomized trials of renal artery stenting vs medical therapy have recently been reported. In the Stent Placement in Patients with Atherosclerotic Renal Artery Stenosis and Impaired Renal Function (STAR) trial,74 140 patients with a creatinine clearance of less than 80 mL/min/m2, RAS greater than 50%, and well-controlled hypertension were randomized to either renal artery stenting plus medical therapy or medical therapy alone. The primary end point was a 20% or greater decrease in creatinine clearance, and secondary end points included safety and cardiovascular morbidity and mortality. The authors concluded that stent placement with medical treatment did not clearly affect progression of impaired renal function but led to a few serious procedure-related complications.75 However, this study had a number of important limitations. Foremost, as noted by the editors of Annals of Internal Medicine, the study was “underpowered to provide a definitive estimate of efficacy.”75 Several patients were incorrectly identified as having ARAS greater than 50% by noninvasive imaging and did not require stenting, yet they were analyzed by intention to treat in the stent group. Also, 33% of the study participants had only mild RAS (50%-70%), and more than half of the patients had unilateral disease. Because the primary end point was a change in renal function, it is not surprising that patients with unilateral disease and stenosis of less than 70% had no benefit from revascularization.
===Renal Artery Stenting===


In the Angioplasty and Stenting for Renal Artery Lesions (ASTRAL) trial, 806 patients with ARAS were randomized to undergo stent-based renal revascularization plus medical therapy or medical therapy alone. The primary outcome was renal function, as measured by the reciprocal of the serum creatinine level, and secondary outcomes were blood pressure, time to renal and major cardiovascular events, and mortality. After a median follow-up of 34 months, the authors found “substantial risks but no evidence of a worthwhile clinical benefit from revascularization in patients with ARAS.”74 This study had a number of limitations that might affect interpretation of the results. By limiting study participation to patients in whom the treating physicians had to be undecided about the appropriate treatment strategy (ie, patients were excluded if physicians were sure stenting was necessary), selection bias was introduced into the trial design. Of course, this selection bias is also reflective of clinical practice because many physicians will often refer patients for renal revascularization if they are unsure of the appropriate course of management. In addition, 25% of patients had normal renal function, a significant number had unilateral disease, and 41% had a stenosis of less than 70%. A subgroup analysis of the cohort with bilateral disease also failed to show clinical benefit, downplaying the notion that the negative results were largely affected by the high enrollment of patients with unilateral disease who would benefit less from renal revascularization. Importantly, there was no core laboratory to adjudicate the imaging studies and ensure their accurate and unbiased interpretation. During the 7 years of recruitment, more than half of the centers enrolled fewer than 1 patient per year, perhaps explaining the high adverse event rate. In summary, as the authors of the trial have stated, the results of ASTRAL appear to indicate that renal stenting does not provide a significant net clinical benefit for patients with RAS and may inflict harm because 2 deaths and 3 amputations were attributed to complications of the procedure.
*[[Renal artery stenting]] is considered to be safe<ref name="pmid9715856">{{cite journal |vauthors=Dorros G, Jaff M, Mathiak L, Dorros II, Lowe A, Murphy K, He T |title=Four-year follow-up of Palmaz-Schatz stent revascularization as treatment for atherosclerotic renal artery stenosis |journal=Circulation |volume=98 |issue=7 |pages=642–7 |date=August 1998 |pmid=9715856 |doi=10.1161/01.cir.98.7.642 |url=}}</ref> and one of the effective<ref name="pmid9017938">{{cite journal |vauthors=Blum U, Krumme B, Flügel P, Gabelmann A, Lehnert T, Buitrago-Tellez C, Schollmeyer P, Langer M |title=Treatment of ostial renal-artery stenoses with vascular endoprostheses after unsuccessful balloon angioplasty |journal=N Engl J Med |volume=336 |issue=7 |pages=459–65 |date=February 1997 |pmid=9017938 |doi=10.1056/NEJM199702133360702 |url=}}</ref> procedures involved in the management of [[renal artery stenosis]].
*In a meta-analysis conducted in the past showed promising results with [[stent placement]] along with higher [[success rates]] (98% vs 77%) and less risk of [[restenosis]] (17% vs 26%)<ref name="pmid10887230">{{cite journal |vauthors=Leertouwer TC, Gussenhoven EJ, Bosch JL, van Jaarsveld BC, van Dijk LC, Deinum J, Man In 't Veld AJ |title=Stent placement for renal arterial stenosis: where do we stand? A meta-analysis |journal=Radiology |volume=216 |issue=1 |pages=78–85 |date=July 2000 |pmid=10887230 |doi=10.1148/radiology.216.1.r00jl0778 |url=}}</ref> as compared to what with [[PTRA]].
*A randomized analysis revealed the effectiveness of [[renal stenting]] versus [[PTRA]] for rapid procedural success (88% versus 57%) and lower rates of [[restenosis]] (14 percent vs 48 percent, respectively) 70.
*In patients with [[ARAS]] and progressive [[renal insufficiency]], other studies have indicated recovery or stability of [[renal function]] after unilateral or [[bilateral renal stenting]]..71,72
*After therapy with at least 2 [[antihypertensive drugs]], in patients with [[ARAS]] and [[hypertension]] (blood pressure >140/90 mm Hg), renal stenting resulted in a 20 mm Hg decrease in [[systolic blood pressure]] and 1 less [[antihypertensive drug]].73
*The [[ASTRAL]]<ref name="pmid19907042">{{cite journal |vauthors=Wheatley K, Ives N, Gray R, Kalra PA, Moss JG, Baigent C, Carr S, Chalmers N, Eadington D, Hamilton G, Lipkin G, Nicholson A, Scoble J |title=Revascularization versus medical therapy for renal-artery stenosis |journal=N Engl J Med |volume=361 |issue=20 |pages=1953–62 |date=November 2009 |pmid=19907042 |doi=10.1056/NEJMoa0905368 |url=}}</ref> ( [[Angioplasty]] and [[Stenting]] for [[Renal Artery Lesions]])  and the [[STAR]]<ref name="pmid19907042">{{cite journal |vauthors=Wheatley K, Ives N, Gray R, Kalra PA, Moss JG, Baigent C, Carr S, Chalmers N, Eadington D, Hamilton G, Lipkin G, Nicholson A, Scoble J |title=Revascularization versus medical therapy for renal-artery stenosis |journal=N Engl J Med |volume=361 |issue=20 |pages=1953–62 |date=November 2009 |pmid=19907042 |doi=10.1056/NEJMoa0905368 |url=}}</ref> (Atherosclerotic Renal Artery Stenosis and Impaired Renal Function) trials, CORAL<ref name="pmid16824832">{{cite journal |vauthors=Cooper CJ, Murphy TP, Matsumoto A, Steffes M, Cohen DJ, Jaff M, Kuntz R, Jamerson K, Reid D, Rosenfield K, Rundback J, D'Agostino R, Henrich W, Dworkin L |title=Stent revascularization for the prevention of cardiovascular and renal events among patients with renal artery stenosis and systolic hypertension: rationale and design of the CORAL trial |journal=Am Heart J |volume=152 |issue=1 |pages=59–66 |date=July 2006 |pmid=16824832 |doi=10.1016/j.ahj.2005.09.011 |url=}}</ref> (Cardiovascular Outcomes in [[Renal]] [[Atherosclerotic]] Lesions) are the major trials conducted for analyzing the importance of [[renal artery stenting]] in the management of [[renal artery stenosis]].


Importantly, in both the ASTRAL and the STAR trials, creatinine clearance equations used to estimate glomerular filtration rate have not been validated in patients with ARAS. Patients with advanced nephropathy (who would be less likely to benefit from revascularization) were included in both trials, and neither trial used an adjunctive measurement of renal ischemia, such as translesional pressure gradients, which adds variability to the assessment of lesion severity.
===Additional Interventional Procedures===
*While [[brachytherapy]] and cutting [[balloon atherotomy]]<ref name="pmid15152154">{{cite journal |vauthors=Jahraus CD, Meigooni AS |title=Vascular brachytherapy: a new approach to renal artery in-stent restenosis |journal=J Invasive Cardiol |volume=16 |issue=4 |pages=224–7; quiz (page following) |date=April 2004 |pmid=15152154 |doi= |url=}}</ref><ref name="pmid15553312">{{cite journal |vauthors=Otah KE, Alhaddad IA |title=Intravascular ultrasound-guided cutting [[balloon angioplasty]] for [[renal artery]] [[stent]] [[restenosis]] |journal=Clin Cardiol |volume=27 |issue=10 |pages=581–3 |date=October 2004 |pmid=15553312 |pmc=6654343 |doi=10.1002/clc.4960271012 |url=}}</ref> for [[renal artery]] in-stent restenosis have been used successfully, long-term findings are uncertain.


The CORAL (Cardiovascular Outcomes in Renal Atherosclerotic Lesions) study is a large randomized, prospective multicenter trial funded by the National Institutes of Health that is comparing the effects of angioplasty with stenting and optimal medical therapy to medical therapy alone on a composite of adverse cardiovascular and renal events.76 Enrollment ended on January 31, 2010, and study data will not be available for several years. The CORAL investigators realized that previous trials of ARAS have lacked rigorous medical treatment that could prevent the progression of cardiovascular and renal disease pervasive in this population. Thus, this trial focuses on strict antihypertensive therapy, smoking cessation, aggressive treatment of dyslipidemia and diabetes, administration of an antiplatelet agent, and complications of renal insufficiency. The CORAL treatment algorithm is based on current evidence-based practice guidelines even though the effect of these medical interventions on outcomes has not yet been well defined in this population.
*[[Coronary]] [[drug-eluting stent]] usage<ref name="pmid15619320">{{cite journal |vauthors=Granillo GA, van Dijk LC, McFadden EP, Serruys PW |title=Percutaneous radial intervention for complex bilateral renal artery stenosis using paclitaxel eluting stents |journal=Catheter Cardiovasc Interv |volume=64 |issue=1 |pages=23–7 |date=January 2005 |pmid=15619320 |doi=10.1002/ccd.20240 |url=}}</ref> has also been identified for narrow [[renal arteries]], but there is a shortage of well-designed trials to evaluate the adequate eluting drug dosage for this vessel


In the CORAL trial, randomization to the revascularization or medical treatment arm was performed at the time of the invasive assessment. Patients in the stent therapy arm underwent implantation of a Genesis stent (Cordis, Warren, NJ). The study was designed to have more than 80% power to detect a threshold effect size of 25% with a sample of 1080 randomized patients. This is the pivotal study of stent therapy for ARAS, on par with large randomized clinical trials of carotid artery or coronary artery bypass surgery (NASCET [North American Symptomatic Carotid Endarterectomy Trial] and CASS [Coronary Artery Surgery Study], respectively).
*The major [[drug-eluting stent]] is just 3.5 mm in diameter, which is an inappropriate dimension for stenting of a [[renal artery]] (with a normal diameter of 4-7 mm). In order to trap atherosclerotic debris and avoid [[distal embolization]] during [[renal stenting]], 80 distal embolic safety systems have also been used, which may help maintain [[renal function]].


We anticipate that the CORAL study will greatly clarify the controversy regarding renal artery stenting. However, the strict crossover requirements may have led some centers to avoid enrolling patients in whom the indication to treat was weak.
===Surgery===
*[[Surgical revascularization]]<ref name="pmid6700670">{{cite journal |vauthors=White CW, Wright CB, Doty DB, Hiratza LF, Eastham CL, Harrison DG, Marcus ML |title=Does visual interpretation of the coronary arteriogram predict the physiologic importance of a coronary stenosis? |journal=N Engl J Med |volume=310 |issue=13 |pages=819–24 |date=March 1984 |pmid=6700670 |doi=10.1056/NEJM198403293101304 |url=}}</ref> is one of the effective modalities involved in the management of [[Renal artery stenosis]]. But the [[morbidity]] and [[mortality]] are higher with [[surgery]] as compared to [[stenting]].  


=== Additional Interventional Procedures ===
*In one of the few trials comparing ostial [[ARAS]] [[surgical]] [[revascularization]] with [[percutaneous revascularization]], Balzer et al81 observed no substantial difference in long-term [[morbidity]] or [[mortality]] and no significant difference in [[blood pressure]] reduction.
Although brachytherapy and cutting balloon atherotomy have been used successfully for renal artery in-stent restenosis,77,78 long-term outcomes are unknown. Use of coronary drug-eluting stents has also been described for small renal arteries,79 but well-designed studies to determine the adequate dosing of the eluting drug for this vessel are lacking. The largest drug-eluting stent is only 3.5 mm in diameter, an inadequate size for stenting of a renal artery (with a normal diameter of 4-7 mm). Distal embolic protection devices have also been used to capture atherosclerotic debris and prevent it from distal embolization during renal stenting,80 which may help preserve renal function.


=== Surgery ===
*These findings show that [[surgical revascularization]] of ostial [[ARAS]] could be at least equal to [[PTRA]].
Surgical revascularization is effective for treating ARAS; however, morbidity and mortality are higher with surgery vs stenting.59 In one of the few studies that compared surgical to percutaneous revascularization for ostial ARAS, Balzer et al81 found no significant difference in long-term morbidity or mortality, a significant improvement in durability of the result in the surgical arm, and no significant difference in blood pressure reduction (although blood pressure improved significantly from baseline in both study arms). These results suggest that surgical revascularization may be at least equivalent to PTRA for ostial ARAS.
 
==References==
 
 
 
 
 
 
 
 
 
<br />

Latest revision as of 20:25, 12 December 2020


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Shivam Singla, M.D.[2]

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Overview

Patients with Renal artery stenosis require the widespread use of intensive medical therapy. The drugs responsible for the management of renal artery stenosis are ACE inhibitors or ARB's. These drugs inhibit the sympathetic and renin-angiotensin system resulting in controlling hypertension. In patients with bilateral renal artery stenosis, there is an associated decrease in renal function after using the ACE inhibitors and ARB, but it is neither a sensitive nor specific finding. Aggressive statin use, optimal glycemic regulation, and therapy for smoking abstinence are of vital significance. Other modalities used are renal artery revascularization, Percutaneous transluminal renal angioplasty, Renal artery stenting, brachytherapy and cutting balloon atherotomy, and surgery in complicated and nonresponding cases. Although morbidity and mortality are higher associated with surgery as compared to stenting.

Treatment

Medical Therapy

Patients with Renal artery stenosis require the widespread use of intensive medical therapy. The drugs responsible for the management of renal artery stenosis are ACE inhibitors or ARB's. These drugs inhibit the sympathetic and renin-angiotensin system resulting in controlling hypertension. In patients with bilateral renal artery stenosis, there is an associated decrease in the renal function after using the ACE inhibitors and ARB, but it is neither sensitive nor specific[1]. Aggressive statin use, optimal glycemic regulation, and therapy for smoking abstinence are of vital significance.

Aggressive use of statins, optimal glycemic control, and smoking cessation counseling is of paramount importance. The results of various medical regimens on the treatment of ARAS-related hypertension were not analyzed in a randomized clinical trial because such patients frequently have refractory hypertension and need multiple antihypertensive medicines. Medical therapy is preferred for revascularization in patients with ARAS and progressive renal disease (i.e. chronic renal dysfunction, proteinuria[>1 g/d]), diffuse intrarenal vascular disease, and renal atrophy[2].

Renal Artery Revascularization

It is less obvious and much more contentious whether patients with ARAS and hypertension would undergo surgical revascularization. According to studies patients with extreme ostial renal artery stenosis who have been successfully revascularized percutaneously do not necessarily have therapeutic benefits.

The ACC/AHA description of RAS is as follows:

(1) visually approximate stenosis of 50 percent to 70 percent diameter with a translational peak gradient of at least 20 mm Hg or a mean gradient of at least 10 mm Hg

(2) angiographic stenosis of at least 70 percent diameter

(3) greater than 70% stenosis according to the measurement by intravascular ultrasounds[3].

Present ACC/AHA recommendations do not, however, include these steps and prescribe revascularization of ARAS only when it is associated with certain medical conditions mentioned as follows:

1) Asymptomatic stenosis: Percutaneous revascularization can be considered for the treatment of:

  • An asymptomatic bilateral
  • The efficacy of percutaneous or asymptomatic unilateral hemodynamically significant ARAS in a viable kidney is not well known and clinically unrecognized (class 11b, LOE C)

2) Hypertension


3) Preservation of renal function


4) Effects of renal artery stenosis on Congestive heart failure and unstable angina: Percutaneous revascularization is considered in patients with


Percutaneous Transluminal Renal Angioplasty

Renal Artery Stenting

Additional Interventional Procedures

Surgery

References


  1. ↑ Hricik DE, Browning PJ, Kopelman R, Goorno WE, Madias NE, Dzau VJ (February 1983). "Captopril-induced functional renal insufficiency in patients with bilateral renal-artery stenoses or renal-artery stenosis in a solitary kidney". N Engl J Med. 308 (7): 373–6. doi:10.1056/NEJM198302173080706. PMID 6337327.
  2. ↑ Bokhari SW, Faxon DP (2004). "Current advances in the diagnosis and treatment of renal artery stenosis". Rev Cardiovasc Med. 5 (4): 204–15. PMID 15580159.
  3. ↑ Olin JW (May 1994). "Role of duplex ultrasonography in screening for significant renal artery disease". Urol Clin North Am. 21 (2): 215–26. PMID 8178389.
  4. ↑ van Jaarsveld BC, Krijnen P, Pieterman H, Derkx FH, Deinum J, Postma CT, Dees A, Woittiez AJ, Bartelink AK, Man in 't Veld AJ, Schalekamp MA (April 2000). "The effect of balloon angioplasty on hypertension in atherosclerotic renal-artery stenosis. Dutch Renal Artery Stenosis Intervention Cooperative Study Group". N Engl J Med. 342 (14): 1007–14. doi:10.1056/NEJM200004063421403. PMID 10749962.
  5. ↑ Dorros G, Jaff M, Mathiak L, Dorros II, Lowe A, Murphy K, He T (August 1998). "Four-year follow-up of Palmaz-Schatz stent revascularization as treatment for atherosclerotic renal artery stenosis". Circulation. 98 (7): 642–7. doi:10.1161/01.cir.98.7.642. PMID 9715856.
  6. ↑ Blum U, Krumme B, Flügel P, Gabelmann A, Lehnert T, Buitrago-Tellez C, Schollmeyer P, Langer M (February 1997). "Treatment of ostial renal-artery stenoses with vascular endoprostheses after unsuccessful balloon angioplasty". N Engl J Med. 336 (7): 459–65. doi:10.1056/NEJM199702133360702. PMID 9017938.
  7. ↑ Leertouwer TC, Gussenhoven EJ, Bosch JL, van Jaarsveld BC, van Dijk LC, Deinum J, Man In 't Veld AJ (July 2000). "Stent placement for renal arterial stenosis: where do we stand? A meta-analysis". Radiology. 216 (1): 78–85. doi:10.1148/radiology.216.1.r00jl0778. PMID 10887230.
  8. ↑ 8.0 8.1 Wheatley K, Ives N, Gray R, Kalra PA, Moss JG, Baigent C, Carr S, Chalmers N, Eadington D, Hamilton G, Lipkin G, Nicholson A, Scoble J (November 2009). "Revascularization versus medical therapy for renal-artery stenosis". N Engl J Med. 361 (20): 1953–62. doi:10.1056/NEJMoa0905368. PMID 19907042.
  9. ↑ Cooper CJ, Murphy TP, Matsumoto A, Steffes M, Cohen DJ, Jaff M, Kuntz R, Jamerson K, Reid D, Rosenfield K, Rundback J, D'Agostino R, Henrich W, Dworkin L (July 2006). "Stent revascularization for the prevention of cardiovascular and renal events among patients with renal artery stenosis and systolic hypertension: rationale and design of the CORAL trial". Am Heart J. 152 (1): 59–66. doi:10.1016/j.ahj.2005.09.011. PMID 16824832.
  10. ↑ Jahraus CD, Meigooni AS (April 2004). "Vascular brachytherapy: a new approach to renal artery in-stent restenosis". J Invasive Cardiol. 16 (4): 224–7, quiz (page following). PMID 15152154.
  11. ↑ Otah KE, Alhaddad IA (October 2004). "Intravascular ultrasound-guided cutting [[balloon angioplasty]] for [[renal artery]] [[stent]] [[restenosis]]". Clin Cardiol. 27 (10): 581–3. doi:10.1002/clc.4960271012. PMC 6654343 Check |pmc= value (help). PMID 15553312. URL–wikilink conflict (help)
  12. ↑ Granillo GA, van Dijk LC, McFadden EP, Serruys PW (January 2005). "Percutaneous radial intervention for complex bilateral renal artery stenosis using paclitaxel eluting stents". Catheter Cardiovasc Interv. 64 (1): 23–7. doi:10.1002/ccd.20240. PMID 15619320.
  13. ↑ White CW, Wright CB, Doty DB, Hiratza LF, Eastham CL, Harrison DG, Marcus ML (March 1984). "Does visual interpretation of the coronary arteriogram predict the physiologic importance of a coronary stenosis?". N Engl J Med. 310 (13): 819–24. doi:10.1056/NEJM198403293101304. PMID 6700670.
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