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  • Review Article
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Diagnosis and management of atherosclerotic renal artery stenosis: improving patient selection and outcomes

Nature Reviews Cardiology volume 6, pages 176–190 (2009)Cite this article

Abstract

Renal artery stenosis (RAS) is common among patients with atherosclerosis, and is found in 20–30% of individuals who undergo diagnostic cardiac catheterization. Renal artery duplex ultrasonography is the diagnostic procedure of choice for screening outpatients for RAS. Percutaneous renal artery stent placement is the preferred method of revascularization for hemodynamically significant RAS, and is favored over balloon angioplasty alone. Stent placement carries a class I recommendation for atherosclerotic RAS according to ACC and AHA guidelines. Discordance exists between the very high (>95%) procedural success rate and the moderate (60–70%) clinical response rate after renal stent placement, which is likely to be a result of poor selection of patients, inadequate angiographic assessment of lesion severity, and the presence of renal parencyhmal disease. Physiologic lesion assessment using translesional pressure gradients, and measurements of biomarkers (e.g. brain natriuretic peptide), or both, could enhance the selection of patients and improve clinical response rates. Long-term patency rates for renal stenting are excellent, with 5-year secondary patency rates greater than 90%. This Review will outline the clinical problem of atherosclerotic RAS and its diagnosis, and will critically assess treatment options and strategies to improve patients' outcomes.

Key Points

  • Renal artery stenosis is the most common (2–5%) secondary cause of hypertension

  • Among patients entering dialysis treatment, 10–15% have renal artery stenosis, which is a potentially preventable cause of end-stage renal disease

  • Renal artery stenosis is an independent predictor of adverse cardiovascular events such as myocardial infarction, stroke, and cardiovascular death

  • Duplex ultrasonography—an excellent test to detect renal artery stenosis—is the least expensive of the imaging modalities, is dependent on technician skill, and provides useful information about the degree of stenosis, kidney size, and other associated disease processes such as obstruction

  • Percutaneous catheter-based therapy is the preferred method of revascularization for symptomatic, hemodynamically significant renal artery stenosis

  • The discordance between the high (>95%) procedural success and the moderate (60–70%) clinical response rates is likely to be a result of poor selection of patients, poor discrimination of lesion severity by angiography, and the concomitant presence of parencyhmal renal disease

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Figure 1: Renal duplex ultrasonography.
Figure 2: Abdominal vascular images obtained by noninvasive techniques.
Figure 3: (A) Quantitative angiographic stenosis (Medis, Leiden, Netherlands) compared with visual estimation of peripheral arterial stenosis.
Figure 4: Treatment of renal artery stenosis with balloon angioplasty and stenting.
Figure 5: Superiority of renal stenting compared with balloon angioplasty in a randomized trial.
Figure 6: Results of a meta-analysis showing procedural success rates for balloon angioplasty compared with renal artery stent placement.
Figure 7: Cure and response rates for renal stent treatment of hypertension.
Figure 8: Relationship between changes in slope values of reciprocal serum creatinine plot versus time before and after percutaneous transluminal renal angioplasty.
Figure 9: Improvement in renal function with interaction between use of an EPD and a glycoprotein IIb/IIIa inhibitor during renal stent placement.

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Acknowledgements

Charles P Vega, University of California, Irvine, CA, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the Medscape-accredited continuing medical education activity associated with this article.

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  1. CJ White is Chairman of the Department of Cardiology, Ochsner Clinic Foundation, New Orleans, LA

    Christopher J White

  2. JW Olin is Professor of Medicine (Cardiology) and Director of Vascular Medicine in the Zena and Michael A Wiener Cardiovascular Institute and the Marie-Josée and Henry R Kravis Center for Cardiovascular Health at the Mount Sinai Medical Center, New York, NY, USA

    Jeffrey W Olin

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White, C., Olin, J. Diagnosis and management of atherosclerotic renal artery stenosis: improving patient selection and outcomes. Nat Rev Cardiol 6, 176–190 (2009). https://doi.org/10.1038/ncpcardio1448

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