Renovascular Disease

1
Renovascular Disease

• Clinical manifestations refractory HTN, renal
  insufficiency, bump in creatinine after ACE
  inhibition, hypokalemia due to hyperrenin/hyperald
  o state induced by decreased renal perfusion
• Suspect this in patients with cardiovascular risk
  factors, other manifestations of PAD, bruits
  (exception fibromuscular dysplasia can occur
  in otherwise healthy young women)
• Diagnosis captopril renogram, duplex U/S (10-20
  rate of failure to visualize needed
  structures) conventional angiography or CT
  angio/MR angio

2
Therapy

• Why investigate or treat? In theory better
  control of HTN, preservation of renal mass and
  renal function
• Once diagnosis is established, choice of medical
  therapy, surgical therapy, interventional therapy
• Fibromuscular dysplasia pts usually renal
  function is preserved HTN very renin-dependent
  and respond well to ACEI do not tend to progress
  over time
• For atherosclerotic types will tend to progress
  over time. Medical management (smoking
  cessation, cholesterol lowering agents, ASA)
  essential.
• What about percutaneous interventions?

3
Percutaneous intervention

• Fibromuscular dysplasia has overall better
  outcomes with angioplasty.
• Success rates 82-100
• Restenosis rates lt10.
• Cure of HTN (off meds) occurs in 60.
• Atherosclerotic not so good.

4
The data

• Largest RCCT of 106 pts randomized to medical
  therapy vs. renal angioplasty. 1 outcomes
  systolic and diastolic BP 2 outcomes, number
  and doses of anti-HTN drugs, and renal function
  (creatinine, creatinine clearance, renal
  scintigraphy) Results
• Systolic and diastolic BP no significant
  difference
• Mean serum creatinine in the angioplasty group
  was slightly lower at 3 months but at 12 months
  there was no statistical significance.
  (Restenosis?)

5
More data 10 studies total

• Scottish study 56 pts systolic BP slightly
  better, renal function the same
• French 49 pts no sig difference in the two
  treatment arms (ambulatory 24h BP monitoring),
  but a medication sparing effect was noted ( of
  pts needing 2 or more drugs was less in the
  plasty group)
• Restenosis rates one study of 50 pts had a
  restenosis rate of 25 at two years. Other
  studies report 8-30 restenosis rate. Surgical
  management 4.

6
Other considerations

• What about stents?
• First nonrandomized study of 120 pts success
  rate (cure or improvement of HTN) 65 restenosis
  rates (11-13)
• Prospective study of plasty alone vs plasty plus
  stent for ostial lesions
• --success rate 88, 57
• --patency at 6mo 75, 29
• --restenosis 1 year 14, 48
• --improvement of BP average 180/105 to 160/90
• --did not look at renal function
• Need more studies and longer follow up

7
Current recommendations

• Work up renovascular disease only in patients who
  would consider surgical or percutaneous
  intervention.
• Fibromuscular dysplasia can be successfully
  treated with angioplasty.
• Older patients (not good operative candidates)
  should be treated conservatively, starting with
  ACEI and diuretic, and watched carefully over
  time.
• Surgery is treatment of choice for pts under
  60yo, with refractory HTN, renal insufficiency,
  or severe bilateral stenosis.
• Angioplasty need more data.