Renal artery stenosis: prevalence and associated risk factors in patients undergoing routine cardiac catheterization.

The purposes of this study were to determine the prevalence of angiographically significant renal artery stenosis in a patient population referred for diagnostic cardiac catheterization and to develop a model that predicts the highest-risk subset of patients who have significant renal artery narrowing. A prospective validation cohort study was undertaken in a referral-based university hospital. After left ventriculography, abdominal aortography was performed to screen for the presence of renal artery disease. A convenience sample of 1,302 of 1,651 consecutive patients undergoing diagnostic cardiac catheterization were enrolled in the study. Of the 1,302 abdominal aortograms performed, 1,235 (95%) were deemed of adequate quality for the evaluation of renal artery anatomy. Renal artery disease was identified in 30% of the patients. Insignificant renal artery stenosis was found in 187 (15%) and significant (greater than or equal to 50% diameter narrowing) stenosis was found in 188 (15%). Significant unilateral disease was present in 11%, and bilateral disease was present in 4%. By univariable and multivariable logistic regression analysis, the association of both clinically and catheterization-derived variables with renal artery disease was assessed. Multivariable predictors included age, severity of coronary artery disease, congestive heart failure, female gender, and peripheral vascular disease. Hypertension was not an associated variable. These data reveal the previously undetected high prevalence of renal artery disease in patients undergoing cardiac catheterization and provide clinical and angiographic features that assist in predicting its presence.

Comparison of intravascular ultrasound, external ultrasound and digital angiography for evaluation of peripheral artery dimensions and morphology.

Validation of catheter-based intravascular ultrasound imaging has been based on comparisons with histology and digital angiography, each of which may have limitations in the assessment of arterial size and morphology. External, high-frequency ultrasound can accurately determine vessel dimensions and morphology and because, like ultravascular ultrasound, it also provides cross-sectional arterial ultrasound images, it may be a more appropriate technique for the in vivo comparison of arterial dimensions and morphology determined by intravascular ultrasound. Thus, intravascular ultrasound, external 2-dimensional ultrasound, Doppler color-flow imaging and digital angiography were compared for assessment of arterial dimensions and wall morphology at 29 femoral artery sites in 15 patients. Intravascular ultrasound and the other 3 imaging modalities correlated well in determination of lumen diameter (2-dimensional, r = 0.98, standard error of the estimate [SEE] = 0.14; Doppler color flow, r = 0.91, SEE = 1.11; angiography, r = 0.95, SEE = 0.91) and cross-sectional area (2-dimensional, r = 0.97, SEE = 0.04; Doppler color flow, r = 0.92, SEE = 0.14; angiography, r = 0.96, SEE = 0.08). However, lumen size measured by Doppler color flow was consistently smaller than that measured by the other 3 imaging modalities. Intravascular ultrasound detected arterial plaque at 15 sites, 5 of which were hypoechoic (soft) and 10 hyperechoic with distal shadowing (hard). Plaque was identified at 12 of 15 sites by Z-dimensional imaging (p = 0.30 vs intravascular ultrasound), but at only 6 of 15 sites by angiography (p = 0.003 vs intravascular ultrasound), only 1 of which was thought to be calcified plaque.(ABSTRACT TRUNCATED AT 250 WORDS)

Intravascular ultrasonography versus digital subtraction angiography: a human in vivo comparison of vessel size and morphology.

The accuracy of catheter-based intravascular ultrasonography to define luminal size in humans in vivo and its sensitivity to describe lesion morphology have not been previously reported. Vessel diameter, cross-sectional area and lesion characteristics assessed by digital subtraction angiography and intravascular ultrasonography (20 MHz) were compared in 86 human arterial segments. The same arterial segments were imaged and analyzed by digital subtraction angiography and intravascular ultrasonography at 49 femoral, 3 renal, 5 iliac, 7 pulmonary and 22 aortic sites. Digital subtraction angiographic diameter and area were determined geometrically by an automated algorithm. Intravascular ultrasonographic diameter and area were determined by planimetry. Linear correlation for diameter by the two techniques was 0.97, standard error of the estimate (SEE) = 1.83 mm, and for cross-sectional area it was 0.95, SEE = 0.65 cm2. Intravascular ultrasonography identified 24 sites in which plaque was present; 11 (46%) of these segments appeared normal by digital subtraction angiography. Conversely, digital subtraction angiography demonstrated irregularities in 18 segments of which 5 (28%) appeared normal by intravascular ultrasonography. These data indicate an excellent correlation between intravascular ultrasonography and digital subtraction angiography for in vivo assessment of human arterial dimensions in normal and minimally diseased segments. However, intravascular ultrasonography is more likely to identify atherosclerotic plaque that may be angiographically "silent."

Balloon angioplasty of coarctation of the aorta evaluated with intravascular ultrasound imaging.

Intravascular ultrasound images were employed to evaluate aortic coarctation before and after balloon angioplasty. Measurements obtained with use of an ultrasound imaging catheter correlated well with measurements made with digital aortography, both in the area of coarctation and in areas proximal and distal to it. The intravascular ultrasound images dramatically revealed dissection of the aortic wall and an intimal flap that was not appreciated on cineaortography or digital subtraction angiography. Intravascular ultrasound imaging may yield important morphologic information unavailable by other imaging techniques. Such information may allow more precise definition of the results of intravascular procedures and improve understanding of lesion characteristics predictive of a successful outcome.

Atrial natriuretic peptide-induced changes in renal prostacyclin production in ureteral obstruction.

Ureteral obstruction is characterized by a marked reduction in renal hemodynamic function that is mediated in part by increased production of the vasoconstrictor eicosanoid thromboxane. However, animals with bilateral ureteral obstruction (BUO) sustain less renal functional impairment than unilaterally obstructed (UUO) animals. Recent evidence suggests that atrial natriuretic peptide (ANP) may be important in maintaining these differences. We therefore investigated the possibility that ANP-induced changes in renal arachidonic acid metabolism may be linked to and important in maintaining the differences between BUO and UUO animals. We measured renal function, renal eicosanoid production, and plasma ANP levels in BUO and UUO animals after the release of 24 h of ureteral obstruction. Renal function was reduced in both groups of obstructed animals compared with sham-operated controls. Inulin and p-aminohippurate clearance were significantly increased in BUO compared with UUO animals. Renal 6-ketoprostaglandin F1 alpha production by BUO kidneys was also significantly increased compared with kidneys from the UUO group or the sham-operated controls. In contrast, thromboxane B2 production by BUO kidneys was significantly reduced compared with UUO kidneys and was not significantly different from controls. Plasma ANP levels of BUO animals were significantly greater than those of UUO or sham-operated animals. When ANP was administered to in situ perfused UUO or BUO kidneys, renal vascular resistance fell significantly, and ANP induced a dramatic increase in 6-ketoprostaglandin F1 alpha production without affecting production of thromboxane B2. Indomethacin blunted the reduction in renal vascular resistance to ANP by 35-50%.(ABSTRACT TRUNCATED AT 250 WORDS)

Prospective analysis of strategies for diagnosing renovascular hypertension.

Renovascular hypertension is a potentially curable form of high blood pressure. However, it is unclear how best to select patients who are likely to have renovascular hypertension, what diagnostic strategy to use in these selected patients, and how to predict the hemodynamic significance of a renal artery stenosis. We determined the prevalence of renovascular hypertension in adults who exhibited suggestive clinical features. In these clinically selected patients, we then determined the test characteristics of various diagnostic and potential screening tests. Renovascular hypertension was diagnosed if correction of renal artery stenosis resulted in decreased blood pressure. Of the 66 hypertensive adults evaluated, 11 (16.7%) had renovascular hypertension. Captopril-stimulated peripheral renin activity detected renovascular hypertension with 73% sensitivity, 72% specificity, 38% positive predictive value, and 92% negative predictive value. Less optimal combinations of sensitivity and specificity were found for differential glomerular filtration rate renography, differential effective renal plasma flow renography, and selective renal vein renin ratios, each performed after a single dose of captopril. Intravenous digital subtraction renal angiography detected all patients with renovascular hypertension and was normal in 71% of patients with essential hypertension. To evaluate potential screening tests for renovascular hypertension, we calculated predictive values applied to a low prevalence population. If the observed sensitivities and specificities apply to a population with 5% prevalence of renovascular hypertension, captopril-stimulated peripheral renin would have a positive predictive value of 12% and a negative predictive value of 98%. In 16 patients with known renal artery stenosis, neither the captopril-stimulated renal vein renin ratio nor captopril-stimulated differential renography accurately predicted blood pressure response to correction of the stenosis. We conclude that clinical criteria can identify a subgroup with 16.7% prevalence of renovascular hypertension. In this high prevalence group, intravenous digital subtraction renal angiography will identify virtually all patients with renovascular hypertension, and a normal study will be sufficient to exclude renovascular hypertension. In unselected hypertensive patients, screening with captopril-stimulated peripheral renin activity may be the most useful and efficient procedure for identification of patients with renovascular hypertension. Functional tests do not accurately predict the hemodynamic significance of a renal artery stenosis.

The role of thromboxane in two-kidney, one-clip Goldblatt hypertension in rats.

Impaired contralateral kidney (CLK) function is important in the maintenance of hypertension in the two-kidney, one-clip (2K, 1C) Goldblatt rat model. Since glomerular filtration rate (GFR) is influenced by the products of arachidonic acid metabolism, we investigated the potential role of eicosanoids as mediators of impaired CLK pressure-volume regulation. At 4 wk following right renal artery clipping, GFR of hypertensive rats was significantly reduced. This decrease was due to the fixed reduction in GFR of the clipped kidney and failure of the CLK to increase its GFR. Thromboxane (Tx) production by isolated perfused CLK was significantly elevated, whereas prostacyclin production remained unchanged. Furthermore, CLK GFR was inversely proportional to Tx production. Treatment of 4-wk hypertensive animals with either the Tx synthase inhibitor UK-38,485 or the Tx receptor antagonist GR 32191 produced a significant increase in CLK GFR. In addition, treatment with either the Tx synthase inhibitor or the Tx receptor antagonist significantly reduced systemic blood pressure. Thus, in this 2K, 1C model of hypertension, increased renal Tx production prevents functional hypertrophy of the contralateral kidney. As a result, CLK pressure-volume regulation is impaired and systemic hypertension is maintained. Furthermore, Tx antagonists restore CLK function and acutely lower systemic blood pressure. Therefore, increased renal Tx production by the CLK appears to be an important mediator of hypertension in the 2K, 1C model.

Intravenous digital subtraction renal angiography: use in screening for renovascular hypertension.

Intravenous digital subtraction renal angiography (DSRA) has been compared with conventional angiography only in small, selected series of hypertensive patients. The authors prospectively examined with intravenous DSRA 94 patients at increased risk for renovascular hypertension and compared these studies with conventional angiography. A stenosis of at least one main renal artery was identified with intravenous DSRA in 22 patients and confirmed in 20 patients. No significant stenoses were seen with conventional angiography in any of the 64 patients in whom lesions were not seen with intravenous DSRA. Since inadequate DSRA studies were considered positive for renal artery stenosis, the sensitivity of intravenous DSRA was 100% (25 of 25); specificity, 93% (64 of 69); positive predictive value, 83% (25 of 30); and negative predictive value, 100% (64 of 64). The authors conclude that intravenous DSRA is a sensitive test for identifying stenosis of the main renal arteries and is appropriate to use as a screening test among patients at increased risk for renovascular hypertension.

Comparison of intravenous digital subtraction angiography and conventional arteriography in defining renal anatomy.

Intravenous digital subtraction renal angiography (IV-DSRA) is frequently used in the preoperative evaluation of living-related (LR) kidney donors. However, the true accuracy of IV-DSRA in the donor population is difficult to assess since abnormalities of the kidney and its circulation are uncommon in this group. Therefore, we evaluated IV-DSRA in a group of patients more likely to have anomalies and abnormalities that would affect LR donor selection, donor nephrectomy, and subsequent transplantation. Hypertensive adults being evaluated for renovascular hypertension had IV-DSRA and conventional renal arteriograms, which were interpreted independently. We determined the accuracy of IV-DSRA, compared with conventional arteriography, in detecting multiple renal arteries, renal artery stenosis, fibromuscular dysplasia, and abnormal renal parenchyma. Technically unsatisfactory studies were excluded from analysis. Of 59 patients evaluated, 37 had abnormalities or anomalies. IV-DSRA failed to detect 28 of 50 findings in these 37 patients. In 21 patients with multiple renal arteries, IV-DSRA underestimated the number of main renal arteries in 8. Significant renal artery stenosis, present in 16 patients, was undetected by IV-DSRA in 3 of these patients. Mild fibromuscular dysplasia was not detected by IV-DSRA in any of the 5 patients with this condition, and abnormalities of renal parenchyma were not detected in 6 of the 8 patients with scarred or cystic kidneys. When compared with conventional renal arteriography in a hypertensive population, the IV-DSRA does not accurately detect abnormalities of the kidney and its circulation. If these data are confirmed in nonhypertensive subjects, preoperative evaluation of LR kidney donors using IV-DSRA alone may fail to detect potentially important anatomic abnormalities.

Effect of atrial natriuretic factor on transmural myocardial blood flow distribution in the dog.

These studies were designed to define the effect of atrial natriuretic peptide (ANP) on coronary flow. ANP was infused as a bolus directly into the left circumflex coronary artery in doses ranging from 0.05 to 5 micrograms in nine open-chest, anesthetized dogs. Coronary flow was measured with an electromagnetic flowmeter. Regional transmural myocardial blood flow and distribution were measured with 11.3 +/- 0.25 micron radionuclide-labeled microspheres. No significant change was noted in systemic hemodynamics (heart rate, arterial pressure, left atrial pressure, or cardiac output) during the course of the studies. ANP produced a transient vasodilatation of coronary resistance vessels and increased flow by 41% after both the 2.5 and 5 micrograms doses. The vasodilatation occurred uniformly throughout the ventricular wall so that the endocardial/epicardial flow ratio remained constant. There was no evidence of coronary vasoconstriction. The peak vasodilatation response occurred 28 +/- 7 sec after the beginning of the infusion of ANP and lasted approximately 3 min. These data support the hypothesis that ANP administration is associated with a vasodilator response in the coronary resistance vessels that may be modulated through either the release of another vasodilator substance or another mechanism.