Prevalence and clinical characteristics of renovascular hypertension associated with fibromuscular dysplasia in China.

OBJECTIVES: The aim of this study was to investigate the clinical characteristics of renal artery fibromuscular dysplasia (FMD) in patients in China and identify the cure rate of hypertension after angioplasty. METHODS: Consecutive hypertensive patients with renal artery stenosis caused by FMD who underwent catheter-based angiography, and were followed at two Chinese referral centres, were retrospectively analysed. All patients underwent a detailed investigation, including demographic characteristics, clinical characteristics, biochemical sampling, Doppler ultrasonography of carotid arteries, magnetic resonance angiography (MRA) of the intracranial artery, and CTA or MRA of the abdominal artery and catheter-based renal angiography. Patients were routinely followed up at 1 month, 6 months and every year after the procedure. RESULTS: Among 245 study participants, with a mean diagnosed age of 26.9 ±â€Š9.9 years, 137 (55.9%) were women, and 38 (15.5%) were children. All patients were diagnosed with hypertension at a mean age of 23.4 ±â€Š8.4 years. There were 73.5% focal and 15.2% multivessel cases. Aneurysms, arterial dissections and total occlusions were found in 21.6, 4.1 and 12.2% of patients, respectively. Patients with multifocal FMD were older (26.0 vs. 23.7 years, P  = 0.021) and more often female (70.8 vs. 50.6%, P  = 0.004). Among children with renal FMD, 55.2% were men, and 86.8% were focal. After a median follow-up of 7.0 years, multifocal FMD had a higher cure rate of hypertension than focal FMD after revascularization (71.7 vs. 55.8%, P  = 0.032). CONCLUSION: In a cohort of mostly young Chinese patients, the prevalence of hypertension associated with renal FMD is similar in both sexes. Focal FMDs were more frequent than the multifocal ones and, after angioplasty, were associated with a worse blood pressure outcome.

Hypertension crisis as the first symptom of renovascular hypertension in children.

BACKGROUND: Renovascular hypertension (RVH) is one of the main causes of hypertensive crisis (HTN-C). It is characterized by acute onset and severe disease, and early diagnosis and treatment are difficult. The objective was to describe the characteristics of RVH and factors associated with RVH leading to HTN-C in children. At present, there are few clinical studies on RVH in children with large cases in China. METHODS: This study retrospectively analyzed the clinical data of inpatient children with RVH. Patients were divided into non-hypertensive crisis (non-HTN-C) group, and HTN-C group according to the first symptoms and blood pressure. Further, HTN-C were classified as hypertensive urgency (HTN-U) or hypertensive emergency (HTN-E). RESULTS: Fifty-four pediatric cases (41 boys and 13 girls) were included. 83.3% of the RVH cases were ≥ 6 years old. Three cases were classified into the non-HTN-C group. Of the 51 HTN-C cases, 18 cases were grouped as HTN-U and 33 as HTN-E. The HTN-U group were mainly asymptomatic (50.0%, 9/18) while the HTN-E group mainly presented with neurological symptoms (72.7%, 24/33). The number of unknown etiology children was 32 (59.2%). The top three known etiologies were Takayasu's arteritis (50.0%, 11/22), congenital renal dysplasia (27.3%, 6/22) and fibromuscular dysplasia (13.6%, 3/22). As for the target organ damage of RVH, patients had a higher prevalence of left ventricular hypertrophy (71.4%, 35/49) and retinopathy (77.8%, 21/27). CONCLUSIONS: Most RVH patients with HTN-C as the first symptoms, especially for males over 6 years old, should be assessed for RVH even if they were asymptomatic. Most asymptomatic patients with RVH already had target organ damage, and symptomatic patients even developed life-threatening complications. As preventive measures, routine monitoring of BP during children's physical examinations is advised.

Atherosclerotic Renovascular Disease: A KDIGO (Kidney Disease: Improving Global Outcomes) Controversies Conference.

The diagnosis and management of atherosclerotic renovascular disease (ARVD) is complex and controversial. Despite evidence from the ASTRAL (2009) and CORAL (2013) randomized controlled trials showing that percutaneous renal artery revascularization did not improve major outcomes compared with best medical therapy alone over 3-5 years, several areas of uncertainty remain. Medical therapy, including statin and antihypertensive medications, has evolved in recent years, and the use of renin-angiotensin-aldosterone system blockers is now considered the primary means to treat hypertension in the setting of ARVD. However, the criteria to identify kidneys with renal artery stenosis that have potentially salvageable function are evolving. There are also data suggesting that certain high-risk populations with specific clinical manifestations may benefit from revascularization. Here, we provide an overview of the epidemiology, diagnosis, and treatment of ARVD based on consensus recommendations from a panel of physician experts who attended the recent KDIGO (Kidney Disease: Improving Global Outcomes) Controversies Conference on central and peripheral arterial diseases in chronic kidney disease. Most focus is provided for contentious issues, and we also outline aspects of investigation and management of ARVD that require further research.

Renovascular hypertension and RNF213 p.R4810K variant in Korean children with Moyamoya disease.

Moyamoya disease (MMD) is the most common underlying disease in Korean pediatric renovascular hypertension (RVH). The ring finger protein 213 (RNF213) p.R4810K variant is reported to be a pathologic variant in East Asian MMD. The purpose of this study was to evaluate hypertension (HTN) prevalence and clinical manifestations as well as RNF213 p.R4810K variant prevalence in Korean pediatric MMD patients. The medical records of pediatric MMD patients from January 2000 to June 2018 were retrospectively reviewed. RVH was confirmed by computer tomography angiography or renal Doppler ultrasonography. The American Academy of Pediatrics 2017 guideline for sex-, age-, and height-related blood pressure standards was used to define HTN. Of 706 patients with MMD, 40 (5.7%) had HTN. Among these patients, 22 had RVH and 12 had HTN with no evidence of renal artery stenosis (non-RVH). Patients with MMD and RVH had an MMD onset at a younger age and lower body mass index compared to those with MMD and non-RVH. Among the patients with MMD and HTN, 4 presented with HTN before developing MMD. Genetic testing for the RNF213 p.R4810K variant was performed in 32 patients with MMD and HTN. When the patient had a homozygous RNF213 p.R4810K variant, the odds ratio of RVH to non-RVH was 8.3. Our study suggests that RVH is more prevalent than non-RVH in pediatric MMD patients. Furthermore, RNF213 p.R4810K may be the cause of RVH in Korean children with MMD.

Renovascular Hypertension: Novel Insights.

Renovascular hypertension (RVH) remains among the most prevalent and important, but also potentially reversible, causes of secondary hypertension. The predominant causes of renal artery stenosis (RAS) are atherosclerotic renovascular arterial stenosis (ARAS) and renal fibromuscular dysplasia. This condition can lead to progressive renal injury, cardiovascular complications and 'flash pulmonary edema'. Duplex Doppler ultrasonography, computed tomographic angiography and magnetic resonance angiography are the most commonly used diagnostic methods. There are three therapeutic options available: medical therapy including renin-angiotensin-aldosterone system antagonists, lipid-lowering agents, and antiplatelet therapy, percutaneous angioplasty with or without stent placement and surgical revascularization. Three large trials failed to demonstrate the superiority of renal artery revascularization over pharmaceutical therapy in controlling blood pressure and preserving renal function. For this reason, today revascularization is only recommended for patients with progressive worsening of renal function, recurrent 'flash pulmonary edema' and rapid increase in antihypertensive requirement in patients with previously well-controlled hypertension. However, more properly designed trials are needed in order to identify which patient populations would probably benefit from renal revascularization.

Endovascular Treatment versus Medical Therapy for Hypertensive Patients with Renal Artery Stenosis: An Updated Systematic Review.

The benefit of balloon angioplasty, with or without stenting, for the treatment of patients with renal artery stenosis remains controversial. A number of randomized controlled trials have attempted to determine its efficacy but the matter remains unclear. A 2014 Cochrane review, which combined data from 8 trials, showed homogeneity among the trials with no significant benefit shown. This systematic review replicates the same research methods and meta-analysis while expanding it to include papers between 2014 and 2018. One of the trials included in the previous review published results in the interim. Additionally, 2 ongoing trials identified in the 2014 review are yet to publish any result. Meta-analysis of the reports showed no heterogeneity between trials and no significant improvement shown by balloon angioplasty, with or without stenting, versus medical therapy. Further studies are recommended in order to assess the benefits of balloon angioplasty for patients with more severe renal artery stenosis.

Long-Term Outcomes of Pediatric Renovascular Hypertension.

BACKGROUND/AIMS: Renovascular hypertension (RVHT) is an important cause of childhood hypertension. This study evaluated the clinical characteristics and outcomes of Korean children with RVHT. METHODS: Children treated for RVHT between 2000 and 2015 at our center were retrospectively reviewed. RESULTS: Forty-six children were followed for a median of 6.5 (0.66-27.23) years. Forty-five percutaneous transluminal angioplasties (PTAs) were performed in 32 children. At the last visit, clinical benefit was observed in 53.3% of children. Patients with comorbid cerebrovascular disease (CVD) showed less favorable long-term outcomes after PTA (clinical benefit in 41.7% vs. 61.1% in others) and higher restenosis rates (50% vs. 31.6% in others). Surgical procedures (bypass or nephrectomy) were performed in 8 patients. After surgery, blood pressure was normalized in 2 patients, improved in 3 patients, and unchanged in the remaining patients. Between PTA group (n=21) and medication group (n=14), percentage of atrophic kidneys became higher after follow-up period in medication group than in PTA group (60.0% vs. 26.1%, P=0.037). CONCLUSION: Aggressive treatment of pediatric RVHT yielded fair outcomes in our cohort. CVD comorbidity was associated with relatively poor PTA outcomes. To confirm our findings, larger cohort studies with a longer follow-up period are warranted.

Current Status of Renal Artery Angioplasty and Stenting for Resistant Hypertension: A Case Series and Review of the Literature.

BACKGROUND: Renal artery stenosis (RAS) has a high prevalence in older patients, especially in the context of general atherosclerosis. It is frequently associated with resistant hypertension and impaired renal function and their attendant consequences. The issue whether revascularization via percutaneous renal angioplasty and stenting (PRA/S) can benefit these patients remains unsettled. OBJECTIVE: To present a case series of patients with refractory hypertension and RAS undergoing PRA/S and also to provide an extensive review of the literature on the current status of PRA/S for resistant hypertension. METHODS: Data of all consecutive patients undergoing PRA/S by a single operator over 1 year were prospectively collected. These were 9 patients with hypertension refractory to drug therapy who also had other clinical cardiac problems that led to their hospitalization, including flash pulmonary edema and coronary artery disease. They were all receiving ≥3 antihypertensive drugs and renal angiography revealed critical RAS (unilateral in 3 and bilateral in 6). In addition, an extensive literature review of the topic was carried out in PubMed, Scopus and Google Scholar. RESULTS: PRS was successful in all 9 high-risk RAS patients with resistant hypertension (5 men, mean age 71 years) without complications and helped in bringing under control their elevated blood pressure (BP) and in maintaining their renal function over a mean of 21 months. Literature review of this controversial topic indicates that in carefully selected patients, PRA/S may play an important role in controlling BP, alleviating symptoms and perhaps preventing renal failure, albeit without concrete evidence of significantly affecting hard end-points of renal events, major cardiovascular events and death. Randomized controlled studies (RCTs), including a large one (CORAL trial), although heavily criticized, have not provided evidence in favor of revascularization. Although RCTs are rather neutral, a multitude of prospective, observational cohort studies, comparing the outcomes of patients after PRA/S have demonstrated significant improvement in systolic and diastolic BP in about two thirds and improvement and/or stabilization in renal function in 30-40% of patients undergoing PRA/S. Nevertheless, the issue remains unsolved and a subject of future studies for further more definitive settlement. Suggestions have been made to adopt physiological and functional renal lesion assessment that may enhance patient selection, at least for RAS cases of moderate lesion severity. Based on this small case series and on exhaustive literature review, an algorithm for approaching patients with significant RAS is herein proposed. CONCLUSION: In high-risk RAS patients with truly resistant hypertension, flash pulmonary edema, and/or rapid deterioration of renal function, PRA/S, a procedure with currently high technical success, may constitute the only viable option. Importantly, despite the unfavorable results of RCTs, current guidelines have not yet changed and clinicians should continue to abide by them. They recommend PRA/S as a reasonable option for patients with hemodynamically significant (especially ostial) RAS and uncontrolled, resistant or malignant hypertension, recurrent, unexplained congestive heart failure or pulmonary edema or unstable angina.

Balancing Overscreening and Underdiagnosis in Secondary Hypertension: The Case of Fibromuscular Dysplasia.

Knowledge about fibromuscular dysplasia (FMD) has broadened over the last several decades. It is no longer considered a rare and benign entity limited to renal arteries and causing just hypertension. It affects other parts of the arterial tree nearly as frequently as the renal arteries. Complications of undiagnosed and untreated extrarenal FMD can be debilitating and life threatening. However, this disease, specifically extrarenal FMD, is not well known to many physicians and patients. Combined with the nonspecific symptoms and signs of the disease, this leads to delayed diagnosis and missed opportunity to prevent serious vascular complications.

Associated extrarenal vascular diseases may complicate the treatment and outcome of renovascular hypertension.

AIM: This studied reviewed renovascular hypertension (RVH) due to renal artery stenosis (RAS) in two Serbian paediatric centres from 2001 to 2013. METHODS: The patients' demographic data, underlying syndromes, blood pressure (BP), antihypertensive treatments and outcomes were reviewed. RESULTS: The incidence of RVH was 1.9 per million children per year during the study period, and there were 25 patients with RAS, aged 10.4 ± 5.2 years. At presentation, their mean blood pressure (BP) standard deviation scores were 6.9 ± 3.4 systolic and 5.2 ± 2.6 diastolic. BP loads on 24-hour ambulatory BP were 88 ± 14% systolic and 80 ± 29% diastolic. We found that 72% had fibromuscular dysplasia and 28% had underlying syndromes. RAS was unilateral in 64% and bilateral in 28%, and 8% had RAS of a single kidney. Antihypertensive treatment included antihypertensive drugs (100%), percutaneous transluminal angioplasty (92%), renal auto-transplantation (16%), surgical revascularisation (12%) and nephrectomy (12%). After 4.4 ± 3.6 years of follow-up, high BP was cured in 40% of the patients and 39.4% of the kidneys and improved in 48% (75.7%), with BP decreases of 20.3 ± 3.7% systolic and 16.3 ± 6.2% diastolic. CONCLUSION: Fibromuscular dysplasia was the most common cause of RVH in this study, and hypertension was cured or improved in 88% of the patients.

[Renovascular hypertension]. / Nadcisnienie naczyniowo-nerkowe.

Renovascular hypertension (RVH) is one of the most common causes of secondary hypertension. In about 90% of cases it is due to atherosclerotic renal artery stenosis, often accompanied by severe occlusive disease in the other vessels, and as such carries a bad prognosis. In the remaining 10% patients (usually young women) the underlying vascular lesion is fibromuscular dysplasia. A presence of RVH should be suspected in patients with severe or resistant hypertension, sudden decline of renal function, sudden development or worsening of hypertension, flash pulmonary edema, impairment of renal function after treatment with renal-angiotensin-aldosterone system (RAAS) antagonists. Those patients should be screened with Doppler ultrasound, followed by computer tomography or magnetic resonance angiography. In most cases intensive and well-controlled medical treatment with RAAS blockers, aldosterone and/or calcium antagonists, with an addition of statins and platelet-inhibiting drugs is succesful. However in a selected cases renal revascularization may be necessary.

The contemporary management of renal artery aneurysms.

BACKGROUND: Renal artery aneurysms (RAAs) are rare, with little known about their natural history and growth rate or their optimal management. The specific objectives of this study were to (1) define the clinical features of RAAs, including the precise growth rate and risk of rupture, (2) examine the current management and outcomes of RAA treatment using existing guidelines, and (3) examine the appropriateness of current criteria for repair of asymptomatic RAAs. METHODS: A standardized, multi-institutional approach was used to evaluate patients with RAAs at institutions from all regions of the United States. Patient demographics, aneurysm characteristics, aneurysm imaging, conservative and operative management, postoperative complications, and follow-up data were collected. RESULTS: A total of 865 RAAs in 760 patients were identified at 16 institutions. Of these, 75% were asymptomatic; symptomatic patients had difficult-to-control hypertension (10%), flank pain (6%), hematuria (4%), and abdominal pain (2%). The RAAs had a mean maximum diameter of 1.5 ± 0.1 cm. Most were unilateral (96%), on the right side (61%), saccular (87%), and calcified (56%). Elective repair was performed in 213 patients with 241 RAAs, usually for symptoms or size >2 cm; the remaining 547 patients with 624 RAAs were observed. Major operative complications occurred in 10%, including multisystem organ failure, myocardial infarction, and renal failure requiring dialysis. RAA repair for difficult-to-control hypertension cured 32% of patients and improved it in 26%. Three patients had ruptured RAA; all were transferred from other hospitals and underwent emergency repair, with no deaths. Conservatively treated patients were monitored for a mean of 49 months, with no acute complications. Aneurysm growth rate was 0.086 cm/y, with no difference between calcified and noncalcified aneurysms. CONCLUSIONS: This large, contemporary, multi-institutional study demonstrated that asymptomatic RAAs rarely rupture (even when >2 cm), growth rate is 0.086 ± 0.08 cm/y, and calcification does not protect against enlargement. RAA open repair is associated with significant minor morbidity, but rarely a major morbidity or mortality. Aneurysm repair cured or improved hypertension in >50% of patients whose RAA was identified during the workup for difficult-to-control hypertension.

Angioplasty for pediatric renovascular hypertension: a 13-year experience.

PURPOSE: We aimed to evaluate the long-term outcome and efficacy of percutaneous transluminal renal angioplasty (PTRA) for pediatric renal artery stenosis (RAS), which is an important cause of medication-refractory pediatric hypertension. MATERIALS AND METHODS: We retrospectively evaluated 22 hypertensive children (age range, 3-17 years) who underwent PTRA from February 2000 to July 2012. Sixteen patients had Takayasu arteritis and six fibromuscular dysplasia. Five were not included in the statistical analysis due to loss to follow-up. RESULTS: Technical success was achieved in 32 of 34 procedures (94.1%). The stenosis rate decreased from 84.5% before PTRA to 20.1% after PTRA. Treatment was effective in 72.7% (16/22) of patients, including complete cure in 27.3% (6/22) and improvement in 45.5% (10/22). Systolic and diastolic blood pressures decreased from 153 ± 19.1 to 131.7 ± 21.4 mmHg and from 97.9 ± 14.2 to 83.6 ± 19.3 mmHg, respectively (P <0.01). Number of antihypertensive agents decreased from 2.7 to 0.5 per patient. Restenosis was detected in 40.9% (9/22) of patients, with a restenotic interval of 11.8 months (range, 3-47 months). Lesion length was strongly correlated with clinical success (cure and improvement) (independent-sample t test, P <0.001; binary logistic regression, P = 0.040). CONCLUSION: Lesion length is an important determination of clinical success with PTRA for pediatric RAS. PTRA is an appropriate treatment option for pediatric renovascular hypertension due to Takayasu arteritis and fibromuscular dysplasia.

Transplant renal artery stenosis in children: risk factors and outcome after endovascular treatment.

BACKGROUND: Transplant renal artery stenosis (TRAS) is an increasingly recognised cause of post-transplant hypertension. METHODS: We retrospectively analysed 216 paediatric renal recipients transplanted between 2001 and 2011 to assess TRAS prevalence and percutaneous transluminal angioplasty (PTA) efficacy. To assess risk factors, we compared children with TRAS with a propensity score-matched cohort of recipients without TRAS. RESULTS: Of the 216 paediatric patients who were transplanted in the study period, 44 were hypertensive (prevalence 20.3 %) and ten presented with TRAS (prevalence 4.6 %, median age at transplantation 14 years, range 6.78-17.36 years). Hypertensive patients without TRAS were prescribed one to two anti-hypertensive agents, whereas patients with TRAS required one to five medications. In the TRAS group, one recipient presented with vascular complications during surgery, and in three patients the graft had vascular abnormalities. TRAS was detected by Doppler ultrasonography (US) performed due to hypertension in nine of the patients with TRAS, but in the tenth case the TRAS was clinically silent and detected by routine Doppler-US screening. TRAS diagnosis was refined using angio-computed tomography or angio-magnetic resonance imaging. All patients underwent PTA without complications. Significant improvement after PTA was observed in the standard deviation scores for blood pressure [3.2 ± 1.4 (pre-PTA) vs. 1.04 ± 0.8 (post-PTA); p = 0.0006) and graft function [creatinine clearance: 69 ± 17.08 (pre-PTA) vs. 80.7 ± 21.5 ml/min/1.73 m(2) (post-PTA); p = 0.006] We observed no significant differences between the two cohorts for cold ischaemia time, recipient/donor weight ratio, delayed graft function, cytomegalovirus infections and acute rejection episodes. CONCLUSIONS: Our study reports a low but significant TRAS prevalence among the paediatric patients who were transplanted at our centre in the study period and confirms that PTA is an effective and safe therapeutic option in paediatric renal transplant recipients. Known risk factors do not appear to be related to the development of TRAS.

Clinical management of renovascular hypertension: practical recommendations from the Italian Society of Hypertension (SIIA).

Renovascular hypertension (RVH) is one of the most frequent forms of secondary hypertension but this diagnosis is often missed because of insufficient care taken in collecting patient's history and clinical signs. Herein we summarize the clinical, instrumental and laboratory clues which should raise the suspicion of RVH. In addition we briefly discuss the available evidence in favour and against the revascularization therapy and, at the light of the uncertain benefit of this procedure, the alternative approach with pharmacological treatment.

Renovascular hypertension--is it fibromuscular dysplasia or Takayasu arteritis.

Renovascular hypertension (RVH) can be caused by many different diseases, with the most common being fibromuscular dysplasia (FMD) and Takayasu arteritis (TA). A strikingly different diagnostic pattern is seen in children with RVH from different parts of the world. In Europe and North America, these children are mainly diagnosed as having FMD while in Asia and South Africa they will most often get a diagnosis of TA. When comparing the clinical diagnosis for FMD and TA, it becomes obvious that there is a great deal of overlap between the definitions of these two conditions. Different ways to come to the most accurate diagnosis using imaging of the blood vessel wall and positron emission tomography (PET) will be discussed. How an accurate diagnosis should influence the treatment of the children with these conditions will also be addressed.

Epidemiology and optimal management in patients with renal artery stenosis.

Renovascular hypertension (hypertension induced by renal artery stenosis) is a form of secondary hypertension caused by overactivation of the renin-angiotensin system by the ischemic kidney. Prevalence of renal artery stenosis (RAS) is estimated to be between 2% (unselected hypertensives) and 40% (older patients with other atherosclerotic comorbidities). Most cases of RAS are caused by atherosclerosis; other causes, including fibromuscular dysplasia, vasculitis, thromboembolism and aneurysms, are less frequent. The most frequent clinical presentation of RAS is hypertension. Acute kidney injury, rapid loss of kidney function and episodes of flash pulmonary edema are other symptoms of RAS, especially in bilateral disease. In current practice, RAS therapy includes antiplatelet (aspirin) and lipid-lowering (statin) therapy as well as angiotensin II receptor blockers or angiotensin-converting enzyme inhibitors as a first choice of antihypertensive agents. Angiotensin blockade, however, is contraindicated in bilateral RAS and in RAS of the solitary kidney. This review summarizes the current status and perspectives on the epidemiology and management of renovascular hypertension.

[Role of angioplasty in the treatment of renal artery stenosis]. / Place de l'angioplastie des artères rénales.

Atherosclerotic renal artery stenosis is frequent and is associated with a high incidence of morbidity and mortality, with a strong correlation with coronary artery disease, (Kalra et al., 2005; Cheung et al., 2002; Guo et al., 2007 [1-3]). The atherosclerotic renal artery stenosis is an independent predictive factor of death (Conlon et al., 1998 [4]). The treatment of this lesion does not have strong evidence. A lot of studies in this area suggest the angioplasty is superior in a big majority between surgery, and angioplasty with stent is superior between balloon angioplasty, but some studies fail to prove the superiority of angioplasty versus medical treatment. These studies have sadly a lot of mistakes and nowadays we don't know what is the treatment for our patients in a lot of cases. The angioplasty is indicated when there is a failure of antihypertensive medications for control of blood pressure, when it is associated with a renal insufficiency quickly progressive or when there is a lesion on each renal artery. Other studies must be organized for prove the superiority of angioplasty when there is a real stenosis, maybe with the use of fractional flow reserve.

Endovascular intervention for renal artery stenosis.

Renovascular diseases are common conditions with important implications on cardiovascular morbidity and mortality. Renal artery stenosis (RAS) is present in 1-5% of patients with hypertension (HTN) in the US with the vast majority of caused by atherosclerosis. Atherosclerotic RAS is related not only to uncontrolled HTN, but also to renal dysfunction. Atherosclerotic RAS in the USA has been reported to account for approximately 14-16% of new patients requiring dialysis each year. Hence a concerted effort was made in the last decade to treat renovascular stenosis using newly developed endovascular therapies to improve cardiovascular morbidity and renal function. A review on new advances in the endovascular management of renal artery stenosis with low profile stents, embolic protection devices, and drug eluting stents is presented.

Atherosclerotic renovascular disease among hypertensive adults.

PURPOSE: This report describes the change in atherosclerotic renovascular disease (AS-RVD) among hypertensive adults referred for renal duplex sonography (RDS) scan. METHODS: From Oct 1993 through July 2008, 20,994 patients had RDS at our center. A total of 434 hypertensive patients with two or more RDS exams without intervention comprised the study cohort. Patient demographics (blood pressures, medications, serum creatinine levels, and data from RDS) were collected. Analyses of longitudinal changes in Doppler scan parameters, blood pressures, and renal function were performed by fitting linear growth-curve models. After confirming the linearity of change in Doppler scan parameters among patients with variable number of studies, estimates of mean slopes were calculated using maximum likelihood techniques. For changes in renal function, quadratic growth curves were required to describe longitudinal change. RESULTS: A total of 434 subjects (212 men [49%] and 222 women [51%]; mean age, 64.6 +/- 12.2 years) provided 1351 studies (mean, 3.2 +/- 2.4; range, 2 to 18) for 863 kidneys over a mean follow-up of 34.4 +/- 25.1 months. At baseline, 20.6% of kidneys demonstrated hemodynamically significant stenosis. On follow-up, 72 kidneys (9.1%) demonstrated anatomic progression of disease. A total of 54 kidneys (6.9%) progressed to significant stenosis and 18 (2.3%) progressed to occlusion. Controlling for progression of disease, baseline renal artery status demonstrated a strong association with baseline kidney length (P = .0006). Significant annualized change in renal length was observed (cm change/year +/- standard error of the mean [SEM]: 0.042 +/- 0.011; P = .0002) among both kidneys with and without critical disease at baseline, however, decline in length was significantly greater among kidneys exhibiting progression of renovascular disease (-0.152 +/- 0.028 cm/year; comparison of slopes between groups P = .0005). In the absence of progression, the presence or absence of critical renal artery stenosis at baseline did not affect the rate of decline in renal length. Fitted models for the natural log transform of serum creatinine demonstrated a significant increase during follow-up (P < .0001). No association was observed between change in serum creatinine and baseline renovascular disease status, or its progression. CONCLUSION: A total of 32% of hypertensive adults referred for RDS demonstrated hemodynamically significant renal artery stenosis. Regardless of the presence or absence of baseline disease, a small percentage of patients demonstrated anatomic progression of AS-RVD. A total of 9.1% demonstrated anatomic progression and 2.3% progressed to occlusion. Although anatomic progression of AS-RVD was associated with an increased rate of decline in renal length, progression did not predict a decline in excretory renal function. Intervention for AS-RVD should be selective and reserved for strict indications.