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Interventional Urology pp 305–323Cite as

Renal Artery Stenosis

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Abstract

Renal artery stenosis, resulting in renovascular hypertension, is a major cause of secondary hypertension (Fatica et al., Am J Kidney Dis 37(6):1184, 2001). When both kidneys are affected, ischemic nephropathy with diminished renal function also results. The most common cause of renal artery stenosis is atherosclerotic, usually ostial, narrowing of the renal artery. The second most common cause of renal artery stenosis is fibromuscular dysplasia. In most cases, aRAS is treated with stent placement and FMD with angioplasty alone. Nonrandomized single-center series for revascularization for both atherosclerotic Renal Artery Stenosis (aRAS) and fibromuscular dysplasia (FMD) have reported excellent outcomes (Takumi et al., Mayo Clin Proc 86:1165–1172, 2011; White, Circulation 113:1464–1473, 2006). In recent years, however, large prospective randomized trials have disputed these previously reported outcomes in the management of aRAS (Cooper et al., N Engl J Med 370:13–22, 2014; ASTRAL Investigators et al. N Engl J Med 361:1953–1962, 2009). Despite many flaws in these trials, the importance of proper patient selection and performance of appropriate endovascular technique by skilled operators has been emphasized. In this chapter, the authors review patient selection factors, describe standard techniques for renal revascularization, and provide technical “tips” that can be utilized during intervention. In addition, the authors will review reported outcomes, in particular, from several large retrospective studies including the primarily US-based “Cardiovascular Outcomes in Renal Atherosclerotic Lesions” (CORAL) trial.

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References

  1. Fatica RA, Port FK, Young EW. Incidence trends and mortality in end-stage renal disease attributed to renovascular disease in the United States. Am J Kidney Dis. 2001;37(6):1184.

    Article  CAS  PubMed  Google Scholar 

  2. Takumi T, Mathew V, Barsness GW, et al. The association between renal atherosclerotic plaque characteristics and renal function before and after renal artery intervention. Mayo Clin Proc. 2011;86:1165–72.

    Article  PubMed Central  PubMed  Google Scholar 

  3. White CJ. Catheter based therapy for atherosclerotic renal artery stenosis. Circulation. 2006;113:1464–73.

    Article  PubMed  Google Scholar 

  4. Cooper CJ, Murphy TP, Cutlip DE, et al. Stenting and Medical therapy for atherosclerotic renal artery stenosis. N Engl J Med. 2014;370:13–22.

    Article  CAS  PubMed  Google Scholar 

  5. ASTRAL Investigators, Wheatley K, Ives N, Gray R, et al. Revascularization versus medical therapy for renal-artery stenosis. N Engl J Med. 2009;361:1953–62.

    Article  Google Scholar 

  6. Cherry DK, Hing E, Woodwell DA, et al. National ambulatory medical care survey: 2006 summary. Hyatts- ville, MD: National Health Statistics; 2006.

    Google Scholar 

  7. Trost D, Sos T. Renal artery angioplasty and stents. Handbook of interventional radiologic procedures. 2010;20:205–18.

    Google Scholar 

  8. Fields LE, Burt VL, Cutler JA, Hughes J, Roccella EJ, Sorlie P. The burden of adult hypertension in the United States 1999 to 2000: a rising tide. Hypertension. 2004;44:398–404.

    Article  CAS  PubMed  Google Scholar 

  9. Hirsch AT, et al. ACC/AHA guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Associations for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (writing committee to develop guidelines for the management of patients with peripheral arterial disease) – summary of recommendations. J Vasc Intervent Radiol. 2006;17(9):1383–97.

    Article  Google Scholar 

  10. Martin LG, et al. Quality improvement guidelines for angiography, angioplasty, and stent placement for the diagnosis and treatment of renal artery stenosis in adults. J Vasc Intervent Radiol. 2010;21(4):421–30.

    Article  Google Scholar 

  11. Anderson JL, et al. 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. J Am Coll Cardiol. 2013;61(14):1555–70.

    Article  Google Scholar 

  12. Amis Jr ES, et al. Radiologic investigation of patients with renovascular hypertension. American College of Radiology. ACR appropriateness criteria. Radiology. 2000;215(Suppl):63–70.

    Google Scholar 

  13. Zierler RE. Is duplex scanning the best screening test for renal artery stenosis? Semin Vasc Surg. 2001;14(3):177–85.

    Article  CAS  PubMed  Google Scholar 

  14. Sfakianakis GN, et al. Single-dose captopril scintigraphy in the diagnosis of renovascular hypertension. J Nucl Med. 1987;28(9):1383–92.

    CAS  PubMed  Google Scholar 

  15. Urban BA, et al. Three dimensional volume rendered CT angiography of the renal arteries and veins: normal anatomy, variants, and clinical applications. Radiographics. 2001;21(2):373–86.

    Article  CAS  PubMed  Google Scholar 

  16. Rountas C, et al. Imaging modalities for renal artery stenosis in suspected renovascular hypertension: prospective intraindividual comparison of color Doppler US, CT angiography, GD-enhanced MR angiography, and digital substraction angiography. Ren Fail. 2007;29(3):295–302.

    Article  CAS  PubMed  Google Scholar 

  17. Vasbinder GB, et al. Diagnostic tests for renal artery stenosis in patients suspected of having renovascular hypertension: a meta-analysis. Ann Intern Med. 2001;135(6):401–11.

    Article  CAS  PubMed  Google Scholar 

  18. Vasbinder GB, et al. Accuracy of computed tomographic angiography and magnetic resonance angiography for diagnosing renal artery stenosis. Ann Intern Med. 2004;141(9):674–82.

    Article  PubMed  Google Scholar 

  19. Schoenberg SO, et al. Diagnosis of renal artery stenosis with magnetic resonance angiography: update 2003. Nephrol Dial Transplant. 2003;18(7):1252–6.

    Article  PubMed  Google Scholar 

  20. Fain SB, et al. High-spatial-resolution contrast-enhanced MR angiography of the renal arteries: a prospective comparison with digital subtraction angiography. Radiology. 2001;218(2):481–90.

    Article  CAS  PubMed  Google Scholar 

  21. Tan KT, et al. Magnetic resonance angiography for the diagnosis of renal artery stenosis: a meta-analysis. Clin Radiol. 2002;57(7):617–24.

    Article  CAS  PubMed  Google Scholar 

  22. Notohamiprodjo M, Reiser MF, Sourbron SP. Diffusion and perfusion of the kidney. Eur J Radiol. 2010;76(3):337–47.

    Article  PubMed  Google Scholar 

  23. Kim D, et al. Renal artery imaging: a prospective comparison of intra-arterial digital subtraction angiography with conventional angiography. Angiology. 1991;42(5):345–57.

    Article  CAS  PubMed  Google Scholar 

  24. Imanishi M, Akabane S, Takamiya M, et al. Critical degree of renal arterial stenosis that causes hypertension in dogs. Angiology. 1992;43:833–42.

    Article  CAS  PubMed  Google Scholar 

  25. Simon G. What is critical renal artery stenosis? Am J Hypertens. 2000;13:1189–93.

    Article  CAS  PubMed  Google Scholar 

  26. Leesar MA, Varma J, Shapira A, et al. Prediction of hypertension improvement after stenting of renal artery stenosis: comparative accuracy of translesional pressure gradients, intravascular ultra- sound, and angiography. J Am Coll Cardiol. 2009;53:2363–71.

    Article  PubMed  Google Scholar 

  27. De Bruyne B, Manoharan G, Pijls NH, et al. Assessment of renal artery stenosis severity by pressure gradient measurements. J Am Coll Cardiol. 2006;48:1851–5.

    Article  PubMed  Google Scholar 

  28. Mangiacapra F, Trana C, Sarno G, et al. Translesional pressure gradients to predict blood pressure response after renal artery stenting in patients with renovascular hypertension. Circ Cardiovasc Interv. 2010;3:537–42.

    Article  PubMed  Google Scholar 

  29. Strong CG, Hunt JC, Sheps SG, et al. Renal venous renin activity: enhancement of sensitivity of lateralization by sodium depletion. Am J Cardiol. 1971;27:602–11.

    Article  CAS  PubMed  Google Scholar 

  30. Vaughan ED, Buhler FR, Laragh JH, et al. Renovascular hypertension: renin measurements to indicate hypersecretion and contralateral suppression, estimate renal plasma flow, and score for surgical curability. Am J Med. 1973;55:402–14.

    Article  PubMed  Google Scholar 

  31. Foster JH, Maxwell MH, Franklin SS, et al. Renovascular occlusive disease: results of operative treatment. JAMA. 1975;231:1043–8.

    Article  CAS  PubMed  Google Scholar 

  32. Canzanello VJ, Millan VG, Spiegel JE, et al. Percutaneous transluminal renal angioplasty in management of atherosclerotic renovascular hypertension: results in 100 patients. Hypertension. 1989;13(2):163–72.

    Article  CAS  PubMed  Google Scholar 

  33. Burket MW, Cooper CJ, Kennedy DJ, et al. Renal artery angioplasty and stent placement: predictors of a favorable outcome. Am Heart J. 2000;139(1 Pt 1):64–71.

    Article  CAS  PubMed  Google Scholar 

  34. Sos TA. Upper extremity access for renal artery stenting: radial, brachial and axillary access: how to do them safely and pitfalls to avoid. J Cardiovasc Surg. 2010;51:741–6.

    CAS  Google Scholar 

  35. Colyer Jr WR, et al. Utility of a 0.014" pressure-sensing guidewire to assess renal artery translesional systolic pressure gradients. Catheter Cardiovasc Interv. 2003;59(3):372–7.

    Article  PubMed  Google Scholar 

  36. Eldrup-Jorgensen J, Harvey HR, Sampson LN, Amberson SM, Bredenberg CE. Should percutaneous transluminal renal artery angioplasty be applied to ostial renal artery atherosclerosis? J Vasc Surg. 1995;21:909–14, 914–5.

    Article  CAS  PubMed  Google Scholar 

  37. Funaki B. Renal ostial angioplasty and stenting. The routine procedure. Semin Intervent Radiol. 2009;26:74–81.

    Article  PubMed Central  PubMed  Google Scholar 

  38. Lederman RJ, Mendelsohn FO, Santos R, Phillips HR, Stack RS, Crowley JJ. Primary renal artery stenting: characteristics and outcomes after 363 procedures. Am Heart J. 2001;142:314–23.

    Article  CAS  PubMed  Google Scholar 

  39. Rehan A, Almanaseer Y, Desai DM, Ali A, et al. Complete resolution of acute renal failure after left renal artery angioplasty and stent placement for total renal artery occlusion. Cardiology. 2007;108:51–4.

    Article  PubMed  Google Scholar 

  40. Laird JR, Rundback J, Zierler RE, et al. Safety and efficacy of renal artery stenting following suboptimal renal angioplasty for de novo and restenotic ostial lesions: results from a nonrandomized, prospective multicenter registry. J Vasc Interv Radiol. 2010;21(5):627–37.

    Article  PubMed  Google Scholar 

  41. Bruno S, Remuzzi G, Ruggenenti P. Transplant renal stenosis. J Am Soc Nephrol. 2004;15:134.

    Article  PubMed  Google Scholar 

  42. Fervenza RF, Lafayette RA, Alfrey EJ, Peterson J. Renal artery stenosis in kidney transplantation. Am J Kidney Dis. 1998;31:142–8.

    Article  CAS  PubMed  Google Scholar 

  43. Beecroft JR, Rajan DK, Clark T, Robinette M, Stavropoulos SW. Transplant renal artery stenosis: outcome after percutaneous intervention. J Vasc Interv Radiol. 2004;15:1407–13.

    Article  PubMed  Google Scholar 

  44. Chow K, Szeto CC, Lee PSF, et al. Revascularization for post transplant renal artery stenosis. Nephrology. 2007;12:406–12.

    Article  PubMed  Google Scholar 

  45. Seratnahaei A, Shah A, Bodiwala K, Mukherjee D. Management of transplant renal artery stenosis. Angiology. 2010;62:219–24.

    Article  PubMed  Google Scholar 

  46. Rundback JH, Weintraub JL. Renovascular interventions. Image guided interventions. 2014;58:404–10.

    Google Scholar 

  47. Daniels SR, Loggie JM, McEnery PT, Towbin RB. Clinical spectrum of intrinsic renovascular hypertension in children. Pediatrics. 1987;19:698–704.

    Google Scholar 

  48. Tullus K, Brennan E, Hamilton G, Lord R, McLaren CA, Marks SD, Roebuck DJ. Renovascular hypertension in children. Lancet. 2008;19:1453–63.

    Article  Google Scholar 

  49. Radanovic B, Cacic Z, Perkov D, Smiljanic R, Coric SR, Ilakovac K. Endovascular therapy of renovascular hypertension in children: single center analysis. Pediatr Surg. 2009;19(3):135–40.

    Article  CAS  Google Scholar 

  50. Waybill MM, Waybill PN. Contrast media-induced nephrotoxicity: identification of patients at risk and algorithms for prevention. J Vasc Interv Radiol. 2001;12(1):3–9.

    Article  CAS  PubMed  Google Scholar 

  51. Kerns SR, Hawkins IF. Carbon dioxide administration angiography: expanding applications and technical evolution. AJR. 1995;164:735–41.

    Article  CAS  PubMed  Google Scholar 

  52. Lautin EM, Freeman NJ, Schoenfeld AH, et al. Radiocontrast-associated renal dysfunction: incidence and risk factors. AJR Am J Roentgenol. 1991;157(1):49–58.

    Article  CAS  PubMed  Google Scholar 

  53. Merten GJ, Burgess WP, Gray LV, et al. Prevention of contrast-induced nephropathy with sodium bicarbonate: a randomized controlled trial. JAMA. 2004;291(19):2328–34.

    Article  CAS  PubMed  Google Scholar 

  54. Zeller T, Frank U, Müller C, et al. Predictors of improved renal function after percutaneous stent-supported angioplasty of severe atherosclerotic ostial renal artery stenosis. Circulation. 2003;108:2244–9.

    Article  PubMed  Google Scholar 

  55. Edwards MS, Corriere MA, Craven TE, et al. Atheroembolism during percutaneous renal revascularization. J Vasc Surg. 2007;46:55–61.

    Article  PubMed  Google Scholar 

  56. Edwards MS, Craven BL, Stafford J, et al. Distal embolic protection during renal artery angioplasty and stenting. J Vasc Surg. 2006;44:128–35.

    Article  PubMed  Google Scholar 

  57. Kawarda O, Yokoi Y, Takemoto K. The characteristics of dissemination of embolic materials during renal artery stenting. Catheter Cardiovasc Interv. 2007;70:784–8.

    Article  Google Scholar 

  58. Talenfeld AD, Schope RB, Alper HJ, Cohen E. MDCT angiography of the renal arteries in patients with atherosclerotic renal artery stenosis: implications for renal artery stenting with distal protection. Am J Roentgenol. 2007;188(6):1652–8.

    Article  Google Scholar 

  59. Arthurs Z, Starnes B, Cuadrado D, et al. Renal artery stenting slows the rate of renal function decline. J Vasc Surg. 2007;45:726–31.

    Article  PubMed  Google Scholar 

  60. Chryssant SS, et al. Treatment of hypertension in patients with renal artery stenosis due to fibromuscular dysplasia of the renal arteries. Diagn Ther. 2014;4(1):36–43.

    Google Scholar 

  61. Cluzel P, Raynaud A, Beyssen B, Pagny JY, Gaux JC. Stenoses of renal branch arteries in fibromuscular dysplasia: results of percutaneous transluminal angioplasty. Radiology. 1994;193(1):227–32.

    Article  CAS  PubMed  Google Scholar 

  62. Meuse MA, Turba UC, Sabri SS, Park AW, Saad WEA, Angle JF, Matsumoto AH. Treatment of renal artery fibromuscular dysplasia. Tech Vasc Interv Radiol. 2010;13(2):126–33.

    Article  PubMed  Google Scholar 

  63. Bonelli FS, McKusick MA, Textor SC, et al. Renal artery angioplasty: technical results and clinical outcome in 320 patients. Mayo Clin Proc. 1995;70(11):1041–52.

    Article  CAS  PubMed  Google Scholar 

  64. Gottsater A, Lindblad B. Optimal management of renal artery fibromuscular dysplasia. Ther Clin Risk Manag. 2014;10:583–95.

    Article  PubMed Central  PubMed  Google Scholar 

  65. Tegtmeyer CJ, Kellum CD, Ayers C. Percutaneous transluminal angioplasty of the renal artery. Results and long-term follow-up. Radiology. 1984;153(1):77–84.

    Article  CAS  PubMed  Google Scholar 

  66. Sos TA, et al. Percutaneous transluminal renal angioplasty in renovascular hypertension due to atheroma or fibromuscular dysplasia. N Engl J Med. 1983;309(5):274–9.

    Article  CAS  PubMed  Google Scholar 

  67. Miller GA, et al. Percutaneous transluminal angioplasty vs. surgery for renovascular hypertension. AJR Am J Roentgenol. 1985;144(3):447–50.

    Article  CAS  PubMed  Google Scholar 

  68. Sos TA. Angioplasty for the treatment of azotemia and renovascular hypertension in atherosclerotic renal artery disease. Circulation. 1991;83(2 Suppl):I162–6.

    CAS  PubMed  Google Scholar 

  69. White CJ. The need for randomized trials to prove the safety and efficacy of parachutes, bulletproof vests, and percutaneous renal intervention. Mayo Clin Proc. 2011;86(7):603–5.

    Article  PubMed Central  PubMed  Google Scholar 

  70. White CJ, Olin JW. Diagnosis and management of atherosclerotic renal artery stenosis: improving patient selection and outcomes. Nat Clin Pract Cardiovasc Med. 2009;6(3):176–90.

    Article  PubMed  Google Scholar 

  71. Mann SJ, Sos TA. Misleading results of randomized trials: the example of renal artery stenting. J Clin Hypertens (Greenwich). 2010;12(1):1–2.

    Article  Google Scholar 

  72. White CJ. Kiss my astral: one seriously flawed study of renal stenting after another. Catheter Cardiovasc Interv. 2010;75(2):305–7.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Division of Interventional Radiology, Department of Radiology, New York Presbyterian Hospital/Weill Cornell Medical College, New York, NY, USA

    Noor Ahmad MD, Marc H. Schiffman MD & Thomas A. Sos MD

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  1. Noor Ahmad MD
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  2. Marc H. Schiffman MD
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  3. Thomas A. Sos MD
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Correspondence to Thomas A. Sos MD .

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Editors and Affiliations

  1. Focal Therapy and Interventional Urologic Oncology, Icahn School of Medicine at Mount Sinai, New York, New York, USA

    Ardeshir R. Rastinehad

  2. Department of Radiology, Hofstra North Shore LIJ School of Medici Department of Radiology, New Hyde Park, New York, USA

    David N. Siegel

  3. National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA

    Peter A. Pinto

  4. National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA

    Bradford J. Wood

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Ahmad, N., Schiffman, M.H., Sos, T.A. (2016). Renal Artery Stenosis. In: Rastinehad, A., Siegel, D., Pinto, P., Wood, B. (eds) Interventional Urology. Springer, Cham. https://doi.org/10.1007/978-3-319-23464-9_23

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  • DOI: https://doi.org/10.1007/978-3-319-23464-9_23

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