Renal artery stenosis
Renal artery stenosis (RAS) is "narrowing or occlusion of the renal artery or arteries. It is due usually to atherosclerosis; fibromuscular dysplasia; thrombosis; embolism, or external pressure. The reduced renal perfusion can lead to renovascular hypertension." Bilateral RAS can lead to chronic kidney disease.
Prevalence and epidemiology
2% of patients underoing coronary angiography in one study had bilateral RAS > 50%. In this study, 11% had at least unilateral RAS. Of these patients one third do not have a history of hypertension; however, the rate of hypertension among those with bilateral disease was not reported.
In a second study of patients patients underoing coronary angiography, 4% has bilateral RAS with both lesions > 50% while 1.5% had both lesions > 75%. Among all the patients with either unilateral or bilateral RAS, half had hypertension.
In an autopsy study, 10 of 15 patients with bilateral RAS (defined as reduction in artery diameter by 50%) were normotensive by history (defined as diastolic pressure < 100 mm Hg). Other autopsy studies are Lisa who obtained similar results and Blackman and Richardson who found lower prevalences.
The clinical relevance of these patients is unclear.
A more recent trial suggests that surgery leads to improved patency rates at 4 years (88% versus 68%); however, angioplasty improved renal function and tended to have less mortality after 4 years (18% vs 25%).
Angioplasty with or without stents
Stenting may be safer than surgical revascularization.
Stenting improves the patency rates after angioplasty This trial found no statistical significance in differences on blood pressure and renal function; however, this study excluded patients with reduced renal function due to their stenoses.
|Randomized controlled trial||947 patients with ≥ 60% stenosis and SBP > 155 mmHg on at least two antihypertensive agents||Stent and aspririn and thienopyridine||43 months||Various cardiovascular and renal outcomes||No statistical significance|
|Randomized controlled trial||806 patients 'unlikely that revascularization will become definitely indicated within the next 6 months'||Stent
77% received antiplatelet agents
|5 years||Renal events||No statistical significance|
|Randomized controlled trial||140 patients with creatinine clearance < 80 mL/min per 1.73 m2||Stent and aspirin||2 years||20% or greater decrease in creatinine clearance|| Stents: 16%|
(No statistical significance)
|Case series||45 patients with hypertension and/or chronic kidney disease||Stent and aspirin, dipyridamole, and warfarin||6 months||> 0.2 mg/dl decrease in serum creatinine||22% of stented patients had a worsening of renal function|
|Case series||76 patients with > 70% stenosis bilaterally or of unilateral kidney and creatinine 1.5 to 4.0 mg/dL||Stent and aspririn and 2 weeks of thienopyridine||20 months||Slope of serum creatinine over time||28% of stented patients had a worsening of renal function|
Surgical revascularization may benefit patients with serum creatinine above 2.0 mg/dl.
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