Treatment of fibromuscular dysplasia of the renal arteries
- Jeffrey W Olin, DO
Jeffrey W Olin, DO
- Professor of Medicine (Cardiology)
- Icahn School of Medicine at Mount Sinai
Fibromuscular dysplasia (FMD) is a noninflammatory, nonatherosclerotic disorder that leads to arterial stenosis, aneurysm, and dissection. It has been observed in nearly every arterial bed. The most often involved arteries are the renal and internal carotid arteries, and less often the vertebral, iliac, subclavian, and visceral arteries. When FMD occurs in the coronary arteries, the patient usually presents with a spontaneous coronary artery dissection.
Disease presentation may vary widely, depending upon the arterial segment involved and the severity of disease. The most common presenting manifestations are hypertension, headaches, pulsatile tinnitus, and dizziness. Less common are transient ischemic attack and stroke.
Treatment options for patients with renal artery FMD include medical therapy alone, or revascularization by either percutaneous transluminal angioplasty (PTA) or surgery . However, independent of angioplasty, hypertension should be treated.
The treatment of renal FMD will be reviewed here. The clinical manifestations and diagnosis of this disorder and the management of atherosclerotic renovascular disease and chronic kidney disease due to renal ischemia are discussed separately. (See "Clinical manifestations and diagnosis of fibromuscular dysplasia" and "Treatment of unilateral atherosclerotic renal artery stenosis" 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".)
TREATMENT OF RENAL ARTERY FIBROMUSCULAR DYSPLASIA
The most common manifestation of renal artery fibromuscular dysplasia (FMD) is hypertension that is due to renal artery stenosis (see "Clinical manifestations and diagnosis of fibromuscular dysplasia", section on 'Clinical manifestations'). Options for management of hypertension in patients with FMD include antihypertensive drug therapy and revascularization.
- Slovut DP, Olin JW. Fibromuscular dysplasia. N Engl J Med 2004; 350:1862.
- Olin JW, Gornik HL, Bacharach JM, et al. Fibromuscular dysplasia: state of the science and critical unanswered questions: a scientific statement from the American Heart Association. Circulation 2014; 129:1048.
- 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.
- 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.
- Hall JE, Guyton AC, Jackson TE, et al. Control of glomerular filtration rate by renin-angiotensin system. Am J Physiol 1977; 233:F366.
- Hricik DE, Dunn MJ. Angiotensin-converting enzyme inhibitor-induced renal failure: causes, consequences, and diagnostic uses. J Am Soc Nephrol 1990; 1:845.
- Savard S, Steichen O, Azarine A, et al. Association between 2 angiographic subtypes of renal artery fibromuscular dysplasia and clinical characteristics. Circulation 2012; 126:3062.
- Lüscher TF, Keller HM, Imhof HG, et al. Fibromuscular hyperplasia: extension of the disease and therapeutic outcome. Results of the University Hospital Zurich Cooperative Study on Fibromuscular Hyperplasia. Nephron 1986; 44 Suppl 1:109.
- 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.
- 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.
- Smit JV, Wierema TK, Kroon AA, de Leeuw PW. Blood pressure and renal function before and after percutaneous transluminal renal angioplasty in fibromuscular dysplasia: a cohort study. J Hypertens 2013; 31:1183.
- Olin JW, Pierce M. Contemporary management of fibromuscular dysplasia. Curr Opin Cardiol 2008; 23:527.
- Olin JW, Froehlich J, Gu X, et al. The United States Registry for Fibromuscular Dysplasia: results in the first 447 patients. Circulation 2012; 125:3182.
- Mounier-Véhier C, Haulon S, Devos P, et al. Renal atrophy outcome after revascularization in fibromuscular dysplasia disease. J Endovasc Ther 2002; 9:605.
- Crutchley TA, Pearce JD, Craven TE, et al. Branch renal artery repair with cold perfusion protection. J Vasc Surg 2007; 46:405.
- Kløw NE, Paulsen D, Vatne K, et al. Percutaneous transluminal renal artery angioplasty using the coaxial technique. Ten years of experience from 591 procedures in 419 patients. Acta Radiol 1998; 39:594.
- Birrer M, Do DD, Mahler F, et al. Treatment of renal artery fibromuscular dysplasia with balloon angioplasty: a prospective follow-up study. Eur J Vasc Endovasc Surg 2002; 23:146.
- Surowiec SM, Sivamurthy N, Rhodes JM, et al. Percutaneous therapy for renal artery fibromuscular dysplasia. Ann Vasc Surg 2003; 17:650.
- Jensen G, Zachrisson BF, Delin K, et al. Treatment of renovascular hypertension: one year results of renal angioplasty. Kidney Int 1995; 48:1936.
- Davidson RA, Barri Y, Wilcox CS. Predictors of cure of hypertension in fibromuscular renovascular disease. Am J Kidney Dis 1996; 28:334.
- de Fraissinette B, Garcier JM, Dieu V, et al. Percutaneous transluminal angioplasty of dysplastic stenoses of the renal artery: results on 70 adults. Cardiovasc Intervent Radiol 2003; 26:46.
- Reiher L, Pfeiffer T, Sandmann W. Long-term results after surgical reconstruction for renal artery fibromuscular dysplasia. Eur J Vasc Endovasc Surg 2000; 20:556.
- Marekovic Z, Mokos I, Krhen I, et al. Long-term outcome after surgical kidney revascularization for fibromuscular dysplasia and atherosclerotic renal artery stenosis. J Urol 2004; 171:1043.
- Lüscher TF, Lie JT, Stanson AW, et al. Arterial fibromuscular dysplasia. Mayo Clin Proc 1987; 62:931.
- Novick AC, Ziegelbaum M, Vidt DG, et al. Trends in surgical revascularization for renal artery disease. Ten years' experience. JAMA 1987; 257:498.
- Barrier P, Julien A, Guillaume C, et al. Technical and clinical results after percutaneous angioplasty in nonmedial fibromuscular dysplasia: outcome after endovascular management of unifocal renal artery stenoses in 30 patients. Cardiovasc Intervent Radiol 2010; 33:270.
- Oertle M, Do DD, Baumgartner I, et al. Discrepancy of clinical and angiographic results in the follow-up of percutaneous transluminal renal angioplasty (PTRA). Vasa 1998; 27:154.
- Alhadad A, Mattiasson I, Ivancev K, et al. Revascularisation of renal artery stenosis caused by fibromuscular dysplasia: effects on blood pressure during 7-year follow-up are influenced by duration of hypertension and branch artery stenosis. J Hum Hypertens 2005; 19:761.
- Carmo M, Bower TC, Mozes G, et al. Surgical management of renal fibromuscular dysplasia: challenges in the endovascular era. Ann Vasc Surg 2005; 19:208.
- Olin JW. Misconceptions about the diagnosis and treatment of fibromuscular dysplasia. Catheter Cardiovasc Interv 2009; 74:265.
- Olin JW, Sealove BA. Diagnosis, management, and future developments of fibromuscular dysplasia. J Vasc Surg 2011; 53:826.
- Gross CM, Krämer J, Weingärtner O, et al. Determination of renal arterial stenosis severity: comparison of pressure gradient and vessel diameter. Radiology 2001; 220:751.
- Gowda MS, Loeb AL, Crouse LJ, Kramer PH. Complementary roles of color-flow duplex imaging and intravascular ultrasound in the diagnosis of renal artery fibromuscular dysplasia: should renal arteriography serve as the "gold standard"? J Am Coll Cardiol 2003; 41:1305.
- White, CJ, Olin, JW. Renal artery revascularization in patients with atherosclerotic renal artery stenosis:Improving patient selection and outcomes. Nature Clin Practice 2009; 6:1763.
- Zeller T, Frank U, Müller C, et al. Technological advances in the design of catheters and devices used in renal artery interventions: impact on complications. J Endovasc Ther 2003; 10:1006.
- Bisschops RH, Popma JJ, Meyerovitz MF. Treatment of fibromuscular dysplasia and renal artery aneurysm with use of a stent-graft. J Vasc Interv Radiol 2001; 12:757.
- English WP, Pearce JD, Craven TE, et al. Surgical management of renal artery aneurysms. J Vasc Surg 2004; 40:53.
- Pfeiffer T, Reiher L, Grabitz K, et al. Reconstruction for renal artery aneurysm: operative techniques and long-term results. J Vasc Surg 2003; 37:293.
- Mackrell PJ, Langan EM 3rd, Sullivan TM, et al. Management of renal artery stenosis: effects of a shift from surgical to percutaneous therapy on indications and outcomes. Ann Vasc Surg 2003; 17:54.
- 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.
- Bolen MA, Brinza E, Renapurkar RD, et al. Screening CT Angiography of the Aorta, Visceral Branch Vessels, and Pelvic Arteries in Fibromuscular Dysplasia. JACC Cardiovasc Imaging 2017; 10:554.
- Kadian-Dodov D, Gornik HL, Gu X, et al. Dissection and Aneurysm in Patients With Fibromuscular Dysplasia: Findings From the U.S. Registry for FMD. J Am Coll Cardiol 2016; 68:176.
- Carman TL, Olin JW, Czum J. Noninvasive imaging of the renal arteries. Urol Clin North Am 2001; 28:815.
- Olin JW. Atherosclerotic renal artery disease. Cardiol Clin 2002; 20:547.
- TREATMENT OF RENAL ARTERY FIBROMUSCULAR DYSPLASIA
- Antihypertensive therapy
- - Choice of drug
- - Blood pressure goal
- Indications for revascularization
- - Rationale
- - Angioplasty versus surgery
- Percutaneous transluminal angioplasty
- Monitoring and follow-up
- TREATMENT OF NONRENAL LESIONS
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS