Renal Artery Stenosis – are there Patients who Benefit from Intervention?

Abstract

Atherosclerotic renal artery stenosis (ARAS) is one of the most relevant long-term complications of atherosclerotic disease. It is associated both with hypertension and increased renal and cardiovascular risk and overall mortality. Diagnostic modalities include non-invasive duplex ultrasound, dynamic magnetic resonance angiography (MRA) and computer tomography angiography (CTA) and are confirmed by using invasive renal angiography. Percutaneous revascularization of renal artery stenosis has been studied in various clinical trials. With regard to hypertension, several case series could show a clinical response to revascularization. However, the majority of randomized clinical trials could not confirm the correlation between intervention and the improvement of hypertension, kidney function, cardiovascular events, and mortality. Based on this predication the crucial tool in the treatment of ARAS is an optimal medical therapy, including statins, antihypertensive agents and platelet inhibition. Today the core point is to select subgroups and appropriate indications for better outcomes and avoiding unnecessary procedures very carefully. Therefore in patients with typical manifestations of ARAS including resistant or malignant hypertension, progressive decline of renal function, flash pulmonary edema or angina, renal artery intervention remains a sensible therapeutic option – after hemodynamic testing prior to revascularization. In the future further trials targeting patients who fulfill rational selection criteria need to be undertaken to confirm the efficacy of revascularization.

Key words

hypertension - peripheral arterial disease - coronary artery disease - oxidative stress

• References

• 1 Stanton RC. Diabetic Kidney Disease and Hypertension. Exp Clin Endocrinol Diabetes Nov 17 2015;
• 2 Bolignano D, Pisano A, Coppolino G. The Dark Side of Blocking RAS in Diabetic Patients with Incipient or Manifested Nephropathy. Exp Clin Endocrinol Diabetes Jun 11 2015;
• 3 Hansen KJ, Cherr GS, Dean RH. Dialysis-free survival after surgical repair of ischemic nephropathy. Cardiovasc Surg 2002; 10: 400-404
• 4 Miralles M, Corominas A, Cotillas J et al. Screening for carotid and renal artery stenoses in patients with aortoiliac disease. Ann Vasc Surg 1998; 12: 17-22
• 5 Swartbol P, Parsson H, Thorvinger B et al. To what extent does peripheral vascular disease and hypertension predict renal artery stenosis?. Int Angiol 1994; 13: 109-114
• 6 Iglesias JI, Hamburger RJ, Feldman L. The natural history of incidental renal artery stenosis in patients with aortoiliac vascular disease. Am J Med 2000; 109: 642-647
• 7 Conlon PJ, Little MA, Pieper K et al. Severity of renal vascular disease predicts mortality in patients undergoing coronary angiography. Kidney Int 2001; 60: 1490-1497
• 8 Crowley JJ, Santos RM, Peter RH et al. Progression of renal artery stenosis in patients undergoing cardiac catheterization. Am Heart J 1998; 136: 913-918
• 9 Jean WJ, al-Bitar I, Zwicke DL et al. High incidence of renal artery stenosis in patients with coronary artery disease. Cathet Cardiovasc Diagn 1994; 32: 8-10
• 10 Rihal CS, Textor SC, Breen JF et al. Incidental renal artery stenosis among a prospective cohort of hypertensive patients undergoing coronary angiography. Mayo Clin Proc 2002; 77: 309-316
• 11 Olin JW, Melia M, Young JR et al. Prevalence of atherosclerotic renal artery stenosis in patients with atherosclerosis elsewhere. Am J Med 1990; 88: 46N-51N
• 12 Caps MT, Zierler RE, Polissar NL et al. Risk of atrophy in kidneys with atherosclerotic renal artery stenosis. Kidney Int 1998; 53: 735-742
• 13 Chabova V, Schirger A, Stanson AW et al. Outcomes of atherosclerotic renal artery stenosis managed without revascularization. Mayo Clin Proc 2000; 75: 437-444
• 14 Goldblatt H, Lynch J, Hanzal RF et al. Studies on Experimental Hypertension: I. The Production of Persistent Elevation of Systolic Blood Pressure by Means of Renal Ischemia. J Exp Med 1934; 59: 347-379
• 15 Herrmann SM, Textor SC. Diagnostic criteria for renovascular disease: where are we now?. Nephrol Dial Transplant 2012; 27: 2657-2663
• 16 Imanishi M, Akabane S, Takamiya M et al. Critical degree of renal arterial stenosis that causes hypertension in dogs. Angiology 1992; 43: 833-842
• 17 Textor SC, Novick AC, Tarazi RC et al. Critical perfusion pressure for renal function in patients with bilateral atherosclerotic renal vascular disease. Ann Intern Med. 1985; 102: 308-314
• 18 Bianchi G, Campolo L, Vegeto A et al. The value of plasma renin concentration per se, and in relation to plasma and extracellular fluid volume in diagnosis and prognosis of human renovascular hypertension. Clin Sci 1970; 39: 559-576
• 19 Liard JF, Cowley Jr AW, McCaa RE et al. Renin, aldosterone, body fluid volumes, and the baroreceptor reflex in the development and reversal of Goldblatt hypertension in conscious dogs. Circ Res 1974; 34: 549-560
• 20 Trinquart L, Mounier-Vehier C, Sapoval M et al. Efficacy of revascularization for renal artery stenosis caused by fibromuscular dysplasia: a systematic review and meta-analysis. Hypertension 2010; 56: 525-532
• 21 Kumbhani DJ, Bavry AA, Harvey JE et al. Clinical outcomes after percutaneous revascularization versus medical management in patients with significant renal artery stenosis: a meta-analysis of randomized controlled trials. Am Heart J 2011; 161: 622-630 e621
• 22 White CJ, Olin JW. Diagnosis and management of atherosclerotic renal artery stenosis: improving patient selection and outcomes. Nat Clin Pract Cardiovasc Med 2009; 6: 176-190
• 23 Holden A, Hill A, Jaff MR et al. Renal artery stent revascularization with embolic protection in patients with ischemic nephropathy. Kidney Int 2006; 70: 948-955
• 24 Ives NJ, Wheatley K, Stowe RL et al. Continuing uncertainty about the value of percutaneous revascularization in atherosclerotic renovascular disease: a meta-analysis of randomized trials. Nephrol Dial Transplant 2003; 18: 298-304
• 25 Epstein FH. Oxygen and renal metabolism. Kidney Int 1997; 51: 381-385
• 26 Evans RG, Gardiner BS, Smith DW et al. Intrarenal oxygenation: unique challenges and the biophysical basis of homeostasis. Am J Physiol Renal Physiol 2008; 295: F1259-F1270
• 27 Moss J, Kalra P, Chakraverty S. Do kidneys need blood?. Eur J Vasc Endovasc Surg 2014; 47: 459-460
• 28 Scolari F, Tardanico R, Zani R et al. Cholesterol crystal embolism: A recognizable cause of renal disease. Am J Kidney Dis 2000; 36: 1089-1109
• 29 Minuz P, Patrignani P, Gaino S et al. Increased oxidative stress and platelet activation in patients with hypertension and renovascular disease. Circulation 2002; 106: 2800-2805
• 30 Eirin A, Gloviczki ML, Tang H et al. Inflammatory and injury signals released from the post-stenotic human kidney. Eur Heart J 2013; 34: 540-548a
• 31 Eirin A, Gloviczki ML, Tang H et al. Chronic renovascular hypertension is associated with elevated levels of neutrophil gelatinase-associated lipocalin. Nephrol Dial Transplant 2012; 27: 4153-4161
• 32 Bohlke M, Barcellos FC. From the 1990s to CORAL (Cardiovascular Outcomes in Renal Atherosclerotic Lesions) trial results and beyond: does stenting have a role in ischemic nephropathy?. Am J Kidney Dis 2015 65: 611-622
• 33 Brito R, Castillo G, Gonzalez J et al. Oxidative stress in hypertension: mechanisms and therapeutic opportunities. Exp Clin Endocrinol Diabetes 2015; 123: 325-335
• 34 Hirsch AT, Haskal ZJ, Hertzer NR et al. ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association 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): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation 2006; 113: e463-e654
• 35 Parikh SA, Shishehbor MH, Gray BH et al. SCAI expert consensus statement for renal artery stenting appropriate use. Catheter Cardiovasc Interv 2014; 84: 1163-1171
• 36 Taylor DC, Kettler MD, Moneta GL et al. Duplex ultrasound scanning in the diagnosis of renal artery stenosis: a prospective evaluation. J Vasc Surg 1988; 7: 363-369
• 37 Hansen KJ, Tribble RW, Reavis SW et al. Renal duplex sonography: evaluation of clinical utility. J Vasc Surg 1990; 12: 227-236
• 38 Olin JW, Piedmonte MR, Young JR et al. The utility of duplex ultrasound scanning of the renal arteries for diagnosing significant renal artery stenosis. Ann Intern Med 1995; 122: 833-838
• 39 Willmann JK, Wildermuth S, Pfammatter T et al. Aortoiliac and renal arteries: prospective intraindividual comparison of contrast-enhanced three-dimensional MR angiography and multi-detector row CT angiography. Radiology 2003; 226: 798-811
• 40 Hahn U, Konig CW, Miller S et al. Multidetector CT Angiography – is it a valuable screening tool to detect significant renal artery stenosis?. Rofo 2001; 173: 1086-1092
• 41 Snidow JJ, Johnson MS, Harris VJ et al. Three-dimensional gadolinium-enhanced MR angiography for aortoiliac inflow assessment plus renal artery screening in a single breath hold. Radiology 1996; 198: 725-732
• 42 Rieumont MJ, Kaufman JA, Geller SC et al. Evaluation of renal artery stenosis with dynamic gadolinium-enhanced MR angiography. AJR Am J Roentgenol 1997; 169: 39-44
• 43 Fain SB, King BF, Breen JF et al. High-spatial-resolution contrast-enhanced MR angiography of the renal arteries: a prospective comparison with digital subtraction angiography. Radiology 2001; 218: 481-490
• 44 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 ultrasound, and angiography. J Am Coll Cardiol 2009; 53: 2363-2371
• 45 Shammas NW, Kapalis MJ, Dippel EJ et al. Clinical and angiographic predictors of restenosis following renal artery stenting. J Invasive Cardiol 2004; 16: 10-13
• 46 White CJ. Catheter-based therapy for atherosclerotic renal artery stenosis. Circulation 2006; 113: 1464-1473
• 47 Kalra PA, Guo H, Kausz AT et al. Atherosclerotic renovascular disease in United States patients aged 67 years or older: risk factors, revascularization, and prognosis. Kidney Int 2005; 68: 293-301
• 48 Caps MT, Perissinotto C, Zierler RE et al. Prospective study of atherosclerotic disease progression in the renal artery. Circulation 1998; 98: 2866-2872
• 49 Schreiber MJ, Pohl MA, Novick AC. The natural history of atherosclerotic and fibrous renal artery disease. Urol Clin North Am 1984; 11: 383-392
• 50 van Jaarsveld BC, Krijnen P, Pieterman H et al. The effect of balloon angioplasty on hypertension in atherosclerotic renal-artery stenosis. Dutch Renal Artery Stenosis Intervention Cooperative Study Group. N Engl J Med 2000; 342: 1007-1014
• 51 Mailloux LU, Napolitano B, Bellucci AG et al. Renal vascular disease causing end-stage renal disease, incidence, clinical correlates, and outcomes: a 20-year clinical experience. Am J Kidney Dis 1994; 24: 622-629
• 52 Mailloux LU, Bellucci AG, Mossey RT et al. Predictors of survival in patients undergoing dialysis. Am J Med 1988; 84: 855-862
• 53 Hackam DG, Spence JD, Garg AX et al. Role of renin-angiotensin system blockade in atherosclerotic renal artery stenosis and renovascular hypertension. Hypertension 2007; 50: 998-1003
• 54 Tullis MJ, Caps MT, Zierler RE et al. Blood pressure, antihypertensive medication, and atherosclerotic renal artery stenosis. Am J Kidney Dis 1999; 33: 675-681
• 55 Tendera M, Aboyans V, Bartelink ML et al. ESC Guidelines on the diagnosis and treatment of peripheral artery diseases: Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries: the Task Force on the Diagnosis and Treatment of Peripheral Artery Diseases of the European Society of Cardiology (ESC). Eur Heart J 2011; 32: 2851-2906
• 56 Silva VS, Martin LC, Franco RJ et al. Pleiotropic effects of statins may improve outcomes in atherosclerotic renovascular disease. Am J Hypertens 2008; 21: 1163-1168
• 57 Simone TA, Brooke BS, Goodney PP et al. Clinical effectiveness of secondary interventions for restenosis after renal artery stenting. J Vasc Surg 2013; 58: 687-694
• 58 Gruntzig A, Kuhlmann U, Vetter W et al. Treatment of renovascular hypertension with percutaneous transluminal dilatation of a renal-artery stenosis. Lancet 1978; 1: 801-802
• 59 Hansen KJ, Starr SM, Sands RE et al. Contemporary surgical management of renovascular disease. J Vasc Surg 1992; 16: 319-330 discussion 330–311
• 60 Lawrie GM, Morris Jr GC, Glaeser DH et al. Renovascular reconstruction: factors affecting long-term prognosis in 919 patients followed up to 31 years. Am J Cardiol 1989; 63: 1085-1092
• 61 Modrall JG, Rosero EB, Smith ST et al. Operative mortality for renal artery bypass in the United States: Results from the National Inpatient Sample. J Vasc Surg 2008; 48: 317-322
• 62 Stanley JC, David M. Hume memorial lecture. Surgical treatment of renovascular hypertension. Am J Surg 1997; 174: 102-110
• 63 Isles CG, Robertson S, Hill D. Management of renovascular disease: a review of renal artery stenting in ten studies. QJM 1999; 92: 159-167
• 64 Patel SM, Li J, Parikh SA. Renal artery stenosis: optimal therapy and indications for revascularization. Curr Cardiol Rep 2015; 17: 623
• 65 van de Ven PJ, Kaatee R, Beutler JJ et al. Arterial stenting and balloon angioplasty in ostial atherosclerotic renovascular disease: a randomised trial. Lancet 1999; 353: 282-286
• 66 Wollenweber J, Sheps SG, Davis GD. Clinical course of atherosclerotic renovascular disease. Am J Cardiol 1968; 21: 60-71
• 67 Pearce JD, Craven BL, Craven TE et al. Progression of atherosclerotic renovascular disease: A prospective population-based study. J Vasc Surg 2006; 44: 955-962 discussion 962-953
• 68 Wheatley K, Ives N, Gray R et al. Revascularization versus medical therapy for renal-artery stenosis. N Engl J Med 2009; 361: 1953-1962
• 69 Marcantoni C, Zanoli L, Rastelli S et al. Effect of renal artery stenting on left ventricular mass: a randomized clinical trial. Am J Kidney Dis 2012; 60: 39-46
• 70 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
• 71 Plouin PF, Chatellier G, Darne B et al. Blood pressure outcome of angioplasty in atherosclerotic renal artery stenosis: a randomized trial. Essai Multicentrique Medicaments vs Angioplastie (EMMA) Study Group. Hypertension 1998; 31: 823-829
• 72 Bax L, Woittiez AJ, Kouwenberg HJ et al. Stent placement in patients with atherosclerotic renal artery stenosis and impaired renal function: a randomized trial. Ann Intern Med 2009; 150: 840-848 W150–841
• 73 Riaz IB, Husnain M, Riaz H et al. Meta-analysis of revascularization versus medical therapy for atherosclerotic renal artery stenosis. Am J Cardiol 114: 1116-1123
• 74 Balk E, Raman G, Chung M et al. Effectiveness of management strategies for renal artery stenosis: a systematic review. Ann Intern Med 2006; 145: 901-912
• 75 Leertouwer TC, Gussenhoven EJ, Bosch JL et al. Stent placement for renal arterial stenosis: where do we stand? A meta-analysis. Radiology 2000; 216: 78-85
• 76 Radermacher J, Chavan A, Bleck J et al. Use of Doppler ultrasonography to predict the outcome of therapy for renal-artery stenosis. N Engl J Med 2001; 344: 410-417
• 77 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: 1851-1855
• 78 Derkx FH, Schalekamp MA. Renal artery stenosis and hypertension. Lancet 1994; 344: 237-239
• 79 Edwards MS, Craven TE, Burke GL et al. Renovascular disease and the risk of adverse coronary events in the elderly: a prospective, population-based study. Arch Intern Med 2005; 165: 207-213
• 80 Lewin A, Blaufox MD, Castle H et al. Apparent prevalence of curable hypertension in the Hypertension Detection and Follow-up Program. Arch Intern Med 1985; 145: 424-427
• 81 Lederman RJ, Mendelsohn FO, Santos R et al. Primary renal artery stenting: characteristics and outcomes after 363 procedures. Am Heart J 2001; 142: 314-323
• 82 Scoble JE. Do protection devices have a role in renal angioplasty and stent placement?. Nephrol Dial Transplant 2003; 18: 1700-1703
• 83 Farmer CK, Cook GJ, Blake GM et al. Individual kidney function in atherosclerotic nephropathy is not related to the presence of renal artery stenosis. Nephrol Dial Transplant 1999; 14: 2880-2884
• 84 Suresh M, Laboi P, Mamtora H et al. Relationship of renal dysfunction to proximal arterial disease severity in atherosclerotic renovascular disease. Nephrol Dial Transplant 2000; 15: 631-636
• 85 Cheung CM, Wright JR, Shurrab AE et al. Epidemiology of renal dysfunction and patient outcome in atherosclerotic renal artery occlusion. J Am Soc Nephrol 2002; 13: 149-157
• 86 Wright JR, Shurrab AE, Cheung C et al. A prospective study of the determinants of renal functional outcome and mortality in atherosclerotic renovascular disease. Am J Kidney Dis 2002; 39: 1153-1161
• 87 Leertouwer TC, Derkx FH, Pattynama PM et al. Functional effects of renal artery stent placement on treated and contralateral kidneys. Kidney Int 2002; 62: 574-579
• 88 Missouris CG, Buckenham T, Vallance PJ et al. Renal artery stenosis masquerading as congestive heart failure. Lancet 1993; 341: 1521-1522
• 89 Khosla S, White CJ, Collins TJ et al. Effects of renal artery stent implantation in patients with renovascular hypertension presenting with unstable angina or congestive heart failure. Am J Cardiol 1997; 80: 363-366
• 90 Gray BH, Olin JW, Childs MB et al. Clinical benefit of renal artery angioplasty with stenting for the control of recurrent and refractory congestive heart failure. Vasc Med 2002; 7: 275-279
• 91 Green D, Ritchie JP, Chrysochou C et al. Revascularisation of renal artery stenosis as a therapy for heart failure: an observational cohort study. Lancet 2015; 385 (Suppl. 01) S11