Atherosclerotic renal artery stenosis and renovascular hypertension: clinical diagnosis and indications for revascularization

Abstract

Atherosclerotic renal artery stenosis (RAS) is relatively common and often associated with reversible hypertension, progressive renal insufficiency, and/or coronary-independent pulmonary edema. Not all RAS is associated with renovascular hypertension. Historical and physical findings may suggest renovascular hypertension and warrant investigation for RAS. Noninvasive diagnostic imaging options include renal artery duplex ultrasonography, magnetic resonance angiography, computed tomographic angiography, and CO2 angiography, with each method having its own advantages and limitations. Functional tests of renal flow, which characterize RAS significance, include captopril-stimulated plasma renin activity and captopril renography. To date, no single approach has shown clear superiority either in diagnosis or identification of patients most likely to benefit from revascularization. Revascularization of RAS is recommended for severe/drug-refractory hypertension, preservation of renal function, recurrent flash pulmonary edema, or recurrent severe heart failure. Intervention response is variable, but the ongoing Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL) trial, comparing medical therapy with and without stenting, should provide management guidance.

Figure 1

Computed tomographic angiography of a 68‐year‐old woman with progressively difficult‐to‐treat hypertension. A high‐grade proximal right renal artery stenosis (arrow) was found. Although not “curative” of hypertension, balloon dilation and stenting of the lesion resulted in a reduction in blood pressure medications and dosages.

Figure 2

A 74‐year‐old man developed progressive severe hypertension. Despite therapy with three medications, his blood pressure remained elevated.