Treatment of unilateral atherosclerotic renal artery stenosis
- Stephen Textor, MD
Stephen Textor, MD
- Professor of Medicine
- Division of Nephrology and Hypertension
- Mayo Clinic College of Medicine
- Rochester, Minnesota
- Section Editors
- George L Bakris, MD
George L Bakris, MD
- Editor-in-Chief — Nephrology
- Section Editor — Hypertension
- Professor of Medicine
- The University of Chicago
- Norman M Kaplan, MD
Norman M Kaplan, MD
- Editor-in-Chief — Nephrology
- Section Editor — Hypertension
- Clinical Professor of Internal Medicine
- University of Texas Southwestern Medical Center
Renal artery stenosis is a relatively common finding in older patients with hypertension. However, renal artery stenosis is the primary cause of hypertension (ie, renovascular hypertension) only in certain settings.
In most cases of renal artery stenosis, one kidney is affected, with the main vessels to the second kidney being essentially normal, hence the designation, "unilateral" disease. Individuals with high-grade stenosis to both kidneys, or to a solitary functioning kidney thereby affecting the entire functioning renal mass, are considered to have "bilateral" disease.
The treatment of unilateral atherosclerotic renal artery stenosis will be reviewed here. Clinical clues suggesting the presence of renovascular hypertension and establishing the diagnosis of renal artery stenosis, treatment of bilateral atherosclerotic renal artery stenosis, issues related to chronic kidney disease associated with atherosclerotic renovascular disease, and diagnosis and treatment of fibromuscular disease are presented in detail elsewhere. (See "Evaluation of secondary hypertension" and "Establishing the diagnosis of renovascular hypertension" and "Treatment of bilateral atherosclerotic renal artery stenosis or stenosis to a solitary functioning kidney" and "Clinical manifestations and diagnosis of chronic kidney disease resulting from atherosclerotic renal artery stenosis" and "Clinical manifestations and diagnosis of fibromuscular dysplasia" and "Treatment of fibromuscular dysplasia of the renal arteries".)
BRIEF REVIEW OF PRESENTATION AND DIAGNOSIS
Epidemiology — The prevalence of renovascular hypertension is probably less than 1 percent in patients with mild hypertension but may be as high as 10 to 40 percent in patients with acute (even if superimposed on a preexisting elevation in blood pressure), severe, or refractory hypertension . (See "Evaluation of secondary hypertension", section on 'Clinical clues for renovascular hypertension'.)
In three prospective treatment trials of patients with renal artery stenosis, the prevalence of unilateral disease (compared with bilateral disease) ranged from 53 to 80 percent [2-4]. Most patients with unilateral renal artery stenosis can achieve goal blood pressures with antihypertensive drug therapy.
- Safian RD, Textor SC. Renal-artery stenosis. N Engl J Med 2001; 344:431.
- Cooper CJ, Murphy TP, Cutlip DE, et al. Stenting and medical therapy for atherosclerotic renal-artery stenosis. N Engl J Med 2014; 370:13.
- ASTRAL Investigators, Wheatley K, Ives N, et al. Revascularization versus medical therapy for renal-artery stenosis. N Engl J Med 2009; 361:1953.
- 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.
- 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.
- Leertouwer TC, Pattynama PM, van den Berg-Huysmans A. Incidental renal artery stenosis in peripheral vascular disease: a case for treatment? Kidney Int 2001; 59:1480.
- 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.
- 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.
- Parikh SA, Shishehbor MH, Gray BH, et al. SCAI expert consensus statement for renal artery stenting appropriate use. Catheter Cardiovasc Interv 2014; 84:1163.
- 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.
- 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.
- Plouin PF, Chatellier G, Darné B, Raynaud A. 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.
- Webster J, Marshall F, Abdalla M, et al. Randomised comparison of percutaneous angioplasty vs continued medical therapy for hypertensive patients with atheromatous renal artery stenosis. Scottish and Newcastle Renal Artery Stenosis Collaborative Group. J Hum Hypertens 1998; 12:329.
- Jenks S, Yeoh SE, Conway BR. Balloon angioplasty, with and without stenting, versus medical therapy for hypertensive patients with renal artery stenosis. Cochrane Database Syst Rev 2014; :CD002944.
- Raman G, Adam GP, Halladay CW, et al. Comparative Effectiveness of Management Strategies for Renal Artery Stenosis: An Updated Systematic Review. Ann Intern Med 2016; 165:635.
- Mann SJ, Sos TA. Misleading results of randomized trials: the example of renal artery stenting. J Clin Hypertens (Greenwich) 2010; 12:1.
- 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; 86:603.
- Kalra PA, Chrysochou C, Green D, et al. The benefit of renal artery stenting in patients with atheromatous renovascular disease and advanced chronic kidney disease. Catheter Cardiovasc Interv 2010; 75:1.
- Herrmann SM, Saad A, Textor SC. Management of atherosclerotic renovascular disease after Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL). Nephrol Dial Transplant 2015; 30:366.
- Ritchie J, Green D, Chrysochou C, et al. High-risk clinical presentations in atherosclerotic renovascular disease: prognosis and response to renal artery revascularization. Am J Kidney Dis 2014; 63:186.
- 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.
- Tullis MJ, Caps MT, Zierler RE, et al. Blood pressure, antihypertensive medication, and atherosclerotic renal artery stenosis. Am J Kidney Dis 1999; 33:675.
- Dworkin LD, Cooper CJ. Clinical practice. Renal-artery stenosis. N Engl J Med 2009; 361:1972.
- Pohl MA, Novick AC. Natural history of atherosclerotic and fibrous renal artery disease: clinical implications. Am J Kidney Dis 1985; 5:A120.
- Crowley JJ, Santos RM, Peter RH, et al. Progression of renal artery stenosis in patients undergoing cardiac catheterization. Am Heart J 1998; 136:913.
- Caps MT, Perissinotto C, Zierler RE, et al. Prospective study of atherosclerotic disease progression in the renal artery. Circulation 1998; 98:2866.
- Conlon PJ, O'Riordan E, Kalra PA. New insights into the epidemiologic and clinical manifestations of atherosclerotic renovascular disease. Am J Kidney Dis 2000; 35:573.
- Chábová V, Schirger A, Stanson AW, et al. Outcomes of atherosclerotic renal artery stenosis managed without revascularization. Mayo Clin Proc 2000; 75:437.
- 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.
- Schoolwerth AC, Sica DA, Ballermann BJ, et al. Renal considerations in angiotensin converting enzyme inhibitor therapy: a statement for healthcare professionals from the Council on the Kidney in Cardiovascular Disease and the Council for High Blood Pressure Research of the American Heart Association. Circulation 2001; 104:1985.
- Hricik DE, Dunn MJ. Angiotensin-converting enzyme inhibitor-induced renal failure: causes, consequences, and diagnostic uses. J Am Soc Nephrol 1990; 1:845.
- Hollenberg NK. The treatment of renovascular hypertension: surgery, angioplasty, and medical therapy with converting-enzyme inhibitors. Am J Kidney Dis 1987; 10:52.
- Franklin SS, Smith RD. Comparison of effects of enalapril plus hydrochlorothiazide versus standard triple therapy on renal function in renovascular hypertension. Am J Med 1985; 79:14.
- Onuigbo MA, Onuigbo NT. Worsening renal failure in older chronic kidney disease patients with renal artery stenosis concurrently on renin angiotensin aldosterone system blockade: a prospective 50-month Mayo-Health-System clinic analysis. QJM 2008; 101:519.
- 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.
- Jackson B, McGrath BP, Matthews PG, et al. Differential renal function during angiotensin converting enzyme inhibition in renovascular hypertension. Hypertension 1986; 8:650.
- Gloviczki ML, Glockner JF, Lerman LO, et al. Preserved oxygenation despite reduced blood flow in poststenotic kidneys in human atherosclerotic renal artery stenosis. Hypertension 2010; 55:961.
- Véniant M, Heudes D, Clozel JP, et al. Calcium blockade versus ACE inhibition in clipped and unclipped kidneys of 2K-1C rats. Kidney Int 1994; 46:421.
- Keddis MT, Garovic VD, Bailey KR, et al. Ischaemic nephropathy secondary to atherosclerotic renal artery stenosis: clinical and histopathological correlates. Nephrol Dial Transplant 2010; 25:3615.
- Gloviczki ML, Glockner JF, Crane JA, et al. Blood oxygen level-dependent magnetic resonance imaging identifies cortical hypoxia in severe renovascular disease. Hypertension 2011; 58:1066.
- Caps MT, Zierler RE, Polissar NL, et al. Risk of atrophy in kidneys with atherosclerotic renal artery stenosis. Kidney Int 1998; 53:735.
- Strandness DE Jr. Natural history of renal artery stenosis. Am J Kidney Dis 1994; 24:630.
- Bonelli FS, McKusick MA, Textor SC, et al. Renal artery angioplasty: technical results and clinical outcome in 320 patients. Mayo Clin Proc 1995; 70:1041.
- Beck AW, Nolan BW, De Martino R, et al. Predicting blood pressure response after renal artery stenting. J Vasc Surg 2010; 51:380.
- Tuttle KR, Chouinard RF, Webber JT, et al. Treatment of atherosclerotic ostial renal artery stenosis with the intravascular stent. Am J Kidney Dis 1998; 32:611.
- 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.
- 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.
- Blum U, Krumme B, Flügel P, et al. Treatment of ostial renal-artery stenoses with vascular endoprostheses after unsuccessful balloon angioplasty. N Engl J Med 1997; 336:459.
- Rocha-Singh K, Jaff MR, Rosenfield K, ASPIRE-2 Trial Investigators. Evaluation of the safety and effectiveness of renal artery stenting after unsuccessful balloon angioplasty: the ASPIRE-2 study. J Am Coll Cardiol 2005; 46:776.
- van de Ven PJ, Beutler JJ, Kaatee R, et al. Transluminal vascular stent for ostial atherosclerotic renal artery stenosis. Lancet 1995; 346:672.
- Rees CR, Palmaz JC, Becker GJ, et al. Palmaz stent in atherosclerotic stenoses involving the ostia of the renal arteries: preliminary report of a multicenter study. Radiology 1991; 181:507.
- 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.
- Henry M, Amor M, Henry I, et al. Stents in the treatment of renal artery stenosis: long-term follow-up. J Endovasc Surg 1999; 6:42.
- Boateng FK, Greco BA. Renal artery stenosis: prevalence of, risk factors for, and management of in-stent stenosis. Am J Kidney Dis 2013; 61:147.
- Rocha-Singh KJ, Novack V, Pencina M, et al. Objective performance goals of safety and blood pressure efficacy for clinical trials of renal artery bare metal stents in hypertensive patients with atherosclerotic renal artery stenosis. Catheter Cardiovasc Interv 2011; 78:779.
- Stone PA, Campbell JE, Aburahma AF, et al. Ten-year experience with renal artery in-stent stenosis. J Vasc Surg 2011; 53:1026.
- Rocha-Singh K, Jaff MR, Lynne Kelley E, RENAISSANCE Trial Investigators. Renal artery stenting with noninvasive duplex ultrasound follow-up: 3-year results from the RENAISSANCE renal stent trial. Catheter Cardiovasc Interv 2008; 72:853.
- Chi YW, White CJ, Thornton S, Milani RV. Ultrasound velocity criteria for renal in-stent restenosis. J Vasc Surg 2009; 50:119.
- La Batide-Alanore A, Azizi M, Froissart M, et al. Split renal function outcome after renal angioplasty in patients with unilateral renal artery stenosis. J Am Soc Nephrol 2001; 12:1235.
- Murphy TP, Soares G, Kim M. Increase in utilization of percutaneous renal artery interventions by medicare beneficiaries, 1996-2000. AJR Am J Roentgenol 2004; 183:561.
- Stanley JC. David M. Hume memorial lecture. Surgical treatment of renovascular hypertension. Am J Surg 1997; 174:102.
- Novick AC. Long-term results of surgical revascularization for renal artery disease. Urol Clin North Am 2001; 28:827.
- Lawrie GM, Morris GC Jr, Glaeser DH, DeBakey ME. Renovascular reconstruction: factors affecting long-term prognosis in 919 patients followed up to 31 years. Am J Cardiol 1989; 63:1085.
- Hughes JS, Dove HG, Gifford RW Jr, Feinstein AR. Duration of blood pressure elevation in accurately predicting surgical cure of renovascular hypertension. Am Heart J 1981; 101:408.
- Weibull H, Bergqvist D, Bergentz SE, et al. Percutaneous transluminal renal angioplasty versus surgical reconstruction of atherosclerotic renal artery stenosis: a prospective randomized study. J Vasc Surg 1993; 18:841.
- Hansen KJ, Starr SM, Sands RE, et al. Contemporary surgical management of renovascular disease. J Vasc Surg 1992; 16:319.
- Novick AC. Current concepts in the management of renovascular hypertension and ischemic renal failure. Am J Kidney Dis 1989; 13:33.
- BRIEF REVIEW OF PRESENTATION AND DIAGNOSIS
- Clinical clues
- RISK FACTOR REDUCTION
- General approach to therapy
- Revascularization versus medical therapy alone
- Overview of therapeutic options
- - Medical therapy
- Progression of stenosis
- Impaired renal function with angiotensin inhibition
- Loss of functional renal mass in the stenotic kidney
- - Percutaneous transluminal renal angioplasty
- Stent placement
- Procedural complications
- Split kidney function
- - Surgery
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS