Imaging Renal Artery Stenosis
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Keywords:
Renovascular Hypertension
Secondary hypertension
Renal Artery Obstruction
Essential hypertension
Renovascular Hypertension
Renal Artery Obstruction
Secondary hypertension
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Renovascular hypertension in two sisters, aged 22 and 20, respectively, has been described. Renal artery stenoses were observed unilaterally in the elder patient and bilaterally in the younger one. In both patients, the functional significance of unilateral stenosis of the renal artery was documented by the renal vein renin ratio between the affected side and the contralateral or less affected side. High blood pressure and elevated plasma renin activity have been normalized with a unilateral revascularization in the elder patient, and with the treatment of propranolol in the younger one. The histological examination of the stenotic renal artery in the elder patient showed a finding comparable to the perimedial fibroplasia in Harrison and McCormack's classification of idiopathic fibromuscular stenosis.
Renovascular Hypertension
Renal Artery Obstruction
Plasma renin activity
Renal vein
Right Renal Artery
Fibromuscular Dysplasia
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In Reply.—
We agree with Drs Bush and Kidd thatbilateralrenal artery stenoses are found in approximately 25% of all cases of renovascular hypertension. The largest published series of patients, the Cooperative Study of Renovascular Hypertension, found bilateral renovascular disease in 28% (250 patients) of their patients with renal artery stenosis.1However, many renal artery lesions are functionally insignificant, since unilateral repair often cures or improves hypertension in patients with bilateral stenoses. For example, Schwarten et al2noted that while 14 of their patients had bilateral renal artery stenosis, nine of these patients responded to only unilateral angioplasty. Furthermore, the Cooperative Study of Renovascular Hypertension noted that in patients with bilateral disease who responded to surgery, 83.3% had abnormal rapid-sequence IVPs. Thus, while the sensitivity of the rapid-sequence IVP is lower in detecting bilateral renal artery stenosis, it remains a useful means of uncovering functionally significant renal vascularRenovascular Hypertension
Renal Artery Obstruction
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The accuracy of the angiographic interpretation of the histologic type of renal artery stenosis was assessed using a renal pathologist's diagnosis as the "gold standard." The angiograms of 42 renal artery stenoses were interpreted without other information, except age and gender, independently by six angiographers. This assessment indicated that angiography is not an accurate means by which to distinguish between the individual types of fibromuscular disease of the renal artery. However, it is a fairly accurate means by which to distinguish fibromuscular disease in general from atherosclerosis of the renal artery, 207 (82%) correct interpretations of 252. In addition, in the presence of renal artery stenosis, the absence of abdominal aortic atherosclerosis on angiography is an excellent predictor of fibromuscular renal artery disease, 17 (94%) of 18 specimens. Likewise, in the presence of a renal artery stenosis, angiographically demonstrable abdominal aortic atherosclerosis is a fair predictor of atherosclerotic renal artery disease, 16 (76%) of 21 specimens.
Renal Artery Obstruction
Fibromuscular Dysplasia
Renal pathology
Right Renal Artery
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Following contemporary trends in arterial endovascular therapy of the lower extremities, recent major trials in anti-hypertensive renovascular revascularization have focused on outcomes after primary stenting of the renal artery. Angioplasty-only therapy has not been studied in a major trial since the year 2000. As such, the current study by Saeed et al. presents an updated data set on the technique with one unique aspect: patients underwent post-procedural physiologic scintigraphy to document the effects of unilateral intervention in patients with two kidneys. Although these physiologic changes should not supersede the clinically relevant outcome of blood pressure reduction (which was also accomplished in this study albeit to a modest but statistically significant degree), the physiologic consequences of unilateral intervention are elegantly presented in this short-term follow-up study. Furthermore, while current renovascular intervention is trending towards treatment of global renal ischemia (i.e. bilateral renal artery stenosis or renal artery stenosis in a congenitally or acquired solitary functional kidney scenario), the current study provides a useful data set for reference in guiding future renovascular revascularization studies and treatment algorithms.
Renovascular Hypertension
Renal Artery Obstruction
Renal ischemia
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Renovascular Hypertension
Secondary hypertension
Renal Artery Obstruction
Essential hypertension
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Renovascular Hypertension
Fibromuscular Dysplasia
Secondary hypertension
Takayasu's arteritis
Etiology
Presentation (obstetrics)
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Detection of a renal artery stenosis (RAS) as a cause of arterial hypertension is of great practical importance because dilatation of the stenosis frequently results in an improvement or cure of the hypertension. In recent years, a number of screening procedures aimed at diagnosing renovascular hypertension have been developed, e.g., duplex sonography of the renal arteries, determination of plasma renin activity, or renal scintigraphy following administration of captopril. The possibilities and limitations of these screening procedures are described here. The best method for detecting renal artery stenosis is angiography, which can now be performed on an outpatient basis, using thin catheters.
Renovascular Hypertension
Renal Artery Obstruction
Captopril
Plasma renin activity
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Following the injection of water-soluble contrast medium and urea an increase in area of the renal shadow of less than 5 per cent was demonstrated on the affected side in 14 cases of hypertension due to renal artery stenosis (verified by operation and post-operative follow-up). On the contra-lateral side an increase of 7–20 per cent was observed in all cases. In 20 patients with hypertension and renal artery stenosis, but no surgical intervention, the same phenomenon was observed in six cases. In these patients other diagnostic criteria were also indicative of reno-vascular hypertension. It is concluded that the increase in renal size which is normally seen following the injection of water-soluble contrast medium and certain drugs is impaired in cases of significant renal artery stenosis. The underlying mechanism (also discussed in a previous paper) may in itself be responsible for the hypertension. If this be the case, measurements of variations in renal size during washout urograms would be very valuable in the diagnosis of renovascular hypertension.
Renovascular Hypertension
Renal Artery Obstruction
Washout
Right Renal Artery
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In patients with renovascular hypertension, it is unknown whether the angiotensin converting enzyme-(ACE) inhibited renal scan will identify stenosis of a segmental branch of a single renal artery or of an accessory artery where multiple renal arteries are present. Since multiple renal arteries may be present in approximately 25% of all individuals, it will be important to establish whether the ACE-inhibited renal scan is useful in this population. We report a case of stenosis involving a renal artery in a patient with multiple renal arteries, successfully identified by ACE-inhibited renal scintigraphy.
Renovascular Hypertension
Renal Artery Obstruction
Secondary hypertension
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