Renal artery stenosis
Dr.
Dr. Alexander
Alexander Woywodt
Woywodt
Consultant
Consultant Renal
Renal Physician,
Physician, Royal
Royal Preston
Preston Hospital
Hospital
Preston,
Preston, 31.10.2007
31.10.2007
Menu
Menu
•
anatomy of the renal
arteries
•
diseases of the large
renal arteries
•
atherosclerotic renal
artery stenosis
•
diagnostic approaches
•
treatment
•
other diseases of the
large renal arteries
Anatomy
Anatomy of
of the
the renal
renal arteries
arteries
•• two
two main
main arteries
arteries
Anatomy
Anatomy of
of the
the renal
renal arteries
arteries
Right
Right renal
renal artery
artery
Left
Left renal
renal artery
artery
Anatomy
Anatomy of
of the
the renal
renal arteries
arteries
••
variants:
variants: precaval
precaval right
right renal
renal artery
artery
(5%)
(5%)
[Radiology
[Radiology 2004;230:429-433
2004;230:429-433 ].].
••
supernumerary
supernumerary and
and early
early branching
branching
arteries
arteries in
in 16%
16% and
and 21%,
21%, respectively
respectively
(upper
(upper pole
pole or
or lower
lower pole
pole arteries)
arteries)
[AJR
[AJR 2007
2007 188(1):105]
188(1):105]
••
multiple
multiple supernumerary
supernumerary arteries
arteries
••
associated
associated anomalies
anomalies
Anatomy
Anatomy of
of the
the renal
renal arteries
arteries
Diseases
Diseases of
of the
the large
large renal
renal vessels
vessels
•• atherosclerotic
atherosclerotic renal
renal artery
artery stenosis
stenosis
•• fibromuscular
fibromuscular dysplasia
dysplasia (FMD)
(FMD)
•• obstruction
obstruction of
of the
the renal
renal arteries
arteries due
due to
to aortic
aortic dissection
dissection
•• obstruction
obstruction of
of the
the renal
renal arteries
arteries after
after interventional
interventional stenting
stenting of
of
the
the abdominal
abdominal aorta
aorta for
for aneurysm
aneurysm
•• renal
renal artery
artery embolism
embolism
Atherosclerotic
Atherosclerotic renal
renal artery
artery stenosis
stenosis
Natural
Natural history
history of
of atherosclerotic
atherosclerotic renal
renal artery
artery stenosis
stenosis
A
A forefather
forefather of
of nephrology
nephrology and
and hypertension
hypertension
•• Speculated
Speculated that
that „pale“
„pale“
hypertension
hypertension is
is mediated
mediated by
by
factors
factors secreted
secreted by
by the
the kidney
kidney
•• This
This was
was later
later proven
proven by
by Goldblatt
Goldblatt
•• Volhard
Volhard also
also pioneered
pioneered the
the saltsaltfree
free diet
diet
•• A
A man
man of
of varied
varied interests
interests
Franz
Franz Volhard
Volhard
1872
1872 -- 1950
1950
First
First experiments
experiments into
into renovascular
renovascular hypertension
hypertension
Injection
Injection into
into other
other dogs
dogs
Hypertension
Hypertension
Hypertension
Hypertension
Wolf
Wolf G,
G, Franz
Franz Volhard
Volhard and
and his
his students’
students’ tortuous
tortuous road
road to
to hypertension.
hypertension. KI
KI 57:
57: 2156
2156 92000)
92000)
Renin
Renin angiotensin
angiotensin aldosterone
aldosterone system
system
Uptodate
Uptodate
Pathophysiology
Pathophysiology of
of atherosclerotic
atherosclerotic renal
renal artery
artery stenosis
stenosis
Renal
Renal artery
artery stenosis
stenosis –– prevalence
prevalence and
and diagnostic
diagnostic clues
clues
••
cause
cause of
of end-stage
end-stage renal
renal failure
failure in
in 88 to
to 55%
55% of
of patients
patients
•• 14-29%
14-29% of
of patients
patients with
with ischemic
ischemic heart
heart disease
disease
•• 38%
38% of
of patients
patients with
with abdominal
abdominal aortic
aortic aneurysm
aneurysm
•• 39%
39% of
of patients
patients with
with peripheral
peripheral vascular
vascular disease
disease
•• clinically
clinically evident
evident vascular
vascular disease
disease elsewhere
elsewhere
•• blood
blood pressure
pressure not
not controlled
controlled with
with three
three or
or more
more drugs
drugs
•• abdominal
abdominal bruit
bruit (maybe
(maybe worthwhile
worthwhile to
to check
check lumbar
lumbar area)
area)
•• kidneys
kidneys of
of different
different size
size
•• rise
rise in
in creatinine
creatinine and/or
and/or hyperkalemia
hyperkalemia after
after ACE
ACE inhibitor
inhibitor
•• „flash
„flash pulmonary
pulmonary edema“
edema“
Diagnostic
Diagnostic approaches
approaches
clinical index
index of
of suspicion
suspicion
•• clinical
ultrasound
•• ultrasound
angiography
•• angiography
CT angiography
angiography
•• CT
magnetic resonance
resonance
•• magnetic
angiography
angiography
Ultrasound
Ultrasound diagnosis
diagnosis of
of renal
renal artery
artery stenosis
stenosis
Hieronymus Bosch: The impostor. Copy in Saint-Germain-en-Laye (original lost)
Ultrasound
Ultrasound diagnosis
diagnosis of
of renal
renal artery
artery stenosis
stenosis
Direct signs:
signs:
Direct
Increased velocity
velocity at
at site
site of
of stenosis,
stenosis,
Increased
at least
least in
in excess
excess of
of 180
180 cm/sec
cm/sec
at
x
R ight
Aorta
Kidney
L-RA
X
V -400/96 cm/sec
within stenosis
Indirect signs:
signs:
Indirect
Delayed acceleration
acceleration time,
time,
Delayed
Low renal
renal resistive
resistive index
index
Low
In sonation
Angle
Insonation
Angle
R-RA
V 100/27 cm/sec
distal renal artery
Renal
Renal resistive
resistive index
index
RI=([1
RI=([1 -- end-diastolic
end-diastolic velocity
velocity divided
divided by
by peak
peak systolic
systolic velocity])
velocity])
Depends
Depends on
on skilled
skilled operator
operator
Also
Also affected
affected by
by atrial
atrial fibrillation,
fibrillation, fever,
fever, aortic
aortic stenosis
stenosis etc.
etc.
Renal
Renal resistive
resistive index
index
RI = 72
No microvascular disease
RI = 86
Advanced microvascular disease
RI=([1
RI=([1 -- end-diastolic
end-diastolic velocity
velocity divided
divided by
by peak
peak systolic
systolic velocity])
velocity])
Hypertensive/vascular
Hypertensive/vascular nephropathy
nephropathy
Issues
Issues with
with ultrasound
ultrasound diagnosis
diagnosis of
of renal
renal artery
artery stenosis
stenosis
non-invasive,no
noradiocontrast
radiocontrast
non-invasive,
highlydependent
dependenton
onexperience
experienceand
andskills
skills
highly
onaverage,
average,absorbs
absorbshighly
highlyskilled
skilleddoctor
doctorfor
for45
45min.
min.
on
30
30 min
min
45
45 min
min
60
60 min
min
∞
∞
Angiography
Angiography and
and magnetic
magnetic resonance
resonance angiography
angiography
From
From UpToDate
UpToDate
(MR
(MR scanning
scanning currently
currently not
not recommended
recommended with
with GFR
GFR << 30
30 ml/min)
ml/min)
Medical
Medical treatment
treatment
risk factors
factors should
should be
be addressed
addressed
•• risk
diabetes management,
management, smoking
smoking cessation
cessation
•• diabetes
ASS, LDL
LDL <100
<100 mg/dl
mg/dl
•• ASS,
antihypertensive therapy
therapy including
including ARB
ARB // ACE
ACE inhibitor
inhibitor
•• antihypertensive
these were
were once
once regarded
regarded as
as contraindicated
contraindicated -- no
no longer
longer the
the case
case
•• these
great care
care must
must be
be taken
taken (hyperkalemia)
(hyperkalemia)
•• great
particularly dangerous:
dangerous: combination
combination with
with spironolactone
spironolactone and
and NSAIDS
NSAIDS
•• particularly
bilateral renal
renal atery
atery stenosis
stenosis possibly
possibly contraindication
contraindication
•• bilateral
ARBs possibly
possibly preferable
preferable (no
(no evidence)
evidence)
•• ARBs
Renal
Renal artery
artery intervention
intervention
Gruentzig
Gruentzig A.
A. et
et al.,
al.,
Treatment
Treatment of
of renovascular
renovascular
hypertension
hypertension with
with percutaneous
percutaneous transluminal
transluminal dilatation
dilatation
of
of aa renal-artery
renal-artery stenosis.
stenosis.
Lancet
Lancet 1:
1: 801-802
801-802 (1978)
(1978)
Renal
Renal artery
artery intervention
intervention is
is not
not risk-free
risk-free
Fatal
Fatal bleed
bleed
after
after
perforation
perforation
with
with guide
guide
wire
wire
Journal
Journal of
of Vascular
Vascular and
and Interventional
Interventional Radiology
Radiology 15:985-987
15:985-987 (2004)
(2004)
Intervention
Intervention or
or medical
medical treatment
treatment
Radermacher
Radermacher et
et al.,
al., N
N Engl
Engl JJ Med,
Med, Vol.
Vol. 344,
344, No.
No. 6,
6, February
February 8,
8, 2001
2001
Treatment
Treatment of
of renal
renal artery
artery stenosis:
stenosis: Medical
Medical treatment
treatment vs.
vs. stent
stent
medical
old
old age
age
very
very calcified
calcified atherosclerosis
atherosclerosis
advanced
advanced renal
renal failure
failure
(GFR
(GFR << 30,
30, changes
changes on
on ultrasound)
ultrasound)
high
high renal
renal resistive
resistive index?
index?
stenting
bilateral
bilateral stenosis
stenosis
flash
flash pulmonary
pulmonary edema
edema
stenosis
stenosis >> 65%
65% with
with RI<0.8
RI<0.8
BP
BP uncontrolled
uncontrolled on
on 33 drugs
drugs
low
low renal
renal resistive
resistive index?
index?
Treatment
Treatment of
of renal
renal artery
artery stenosis
stenosis
Renal
Renal artery
artery intervention
intervention -- current
current dilemma
dilemma
„Available
„Available evidence
evidence does
does not
not
clearly
clearly support
support one
one treatment
treatment
approach
approach over
over another
another for
for
atherosclerotic
atherosclerotic renal
renal artery
artery
stenosis.“
stenosis.“
Balk
Balk E
E et
et al.
al. Ann
Ann Intern
Intern Med.
Med. 2006
2006
145(12):901-12.
145(12):901-12.
Hieronymus Bosch: The ship of fools.
Louvre, Paris
Renal
Renal artery
artery intervention
intervention -- current
current dilemma
dilemma
Srivastava
Srivastava and
and Beevers,
Beevers, JJ Hum
Hum Hypertens
Hypertens 2007:
2007: 21:
21: 507
507
Treatment
Treatment of
of renal
renal artery
artery stenosis:
stenosis: ASTRAL
ASTRAL study
study
750-1000 patients
patients with
with renovascular
renovascular disease
disease
•• 750-1000
500 medical
medical treatment
treatment // 500
500 intervention
intervention
•• 500
Progression of
of renal
renal failure
failure as
as endpoint
endpoint
•• Progression
Fibromuscular
Fibromuscular dysplasia
dysplasia (FMD)
(FMD)
inborn error
error of
of vascular
vascular
•• inborn
structure
structure
usually younger
younger female
female
•• usually
patients with
with positive
positive family
family
patients
history
history
often bilateral
bilateral and
and other
other large
large
•• often
arteries affected
affected
arteries
no occlusion
occlusion
•• no
string of
of beads
beads appearance
appearance
•• string
amenable to
to stenting
stenting (very)
(very)
•• amenable
From
From UpToDate
UpToDate
Obstruction
Obstruction of
of the
the renal
renal arteries
arteries due
due to
to aortic
aortic dissection
dissection
rarely
rarely the
the leading
leading
symptom
symptom of
of aortic
aortic
dissection
dissection
often
often found
found on
on
angiography
angiography
flank
flank pain,
pain, acute
acute
renal
renal failure,
failure,
haematuria
haematuria
Woywodt
Woywodt et
et al.,
al., Nephrology,
Nephrology, Dialysis,
Dialysis, Transplantation
Transplantation
15(4):
15(4): 544-546
544-546 (2000)
(2000)
Obstruction
Obstruction of
of the
the renal
renal arteries
arteries after
after aortic
aortic stenting
stenting
Cotroneo
Cotroneo et
et al.,
al., Radiol
Radiol Med
Med (2007)
(2007) 112:252–263
112:252–263
Embolic
Embolic renal
renal artery
artery occlusion
occlusion
sudden
sudden onset
onset of
of flank
flank pain,
pain,
often
often in
in atrial
atrial fibrillation
fibrillation
fever
fever
nausea,
nausea, vomiting
vomiting
LDH
LDH and
and D-Dimer
D-Dimer
abnormal
abnormal
ultrasound
ultrasound with
with colour
colour
duplex,
duplex, CT
CT
thrombolysis
thrombolysis // surgery
surgery //
heparin
heparin
Fort
Fort et
et al.,
al., Nephrol
Nephrol Dial
Dial Transplant
Transplant
(1996)
(1996) 11:
11: 1843-1845
1843-1845
Messages
Messages
Renal artery
artery stenosis
stenosis is
is not
not rare
rare
•• Renal
Older vascular
vascular patients
patients vs.
vs. young
young
•• Older
females with
with aa family
family history
history of
of
females
hypertension
hypertension
Differences in
in renal
renal size,
size,
•• Differences
abdominal bruit
bruit and
and clinical
clinical
abdominal
vascular disease
disease
vascular
Controversies in
in diagnostic
diagnostic
•• Controversies
approach and
and management
management
approach