Renovascular hypertension

(RVH)
DEFINITION

The presence of systemic

hypertension due to a stenotic or
obstructive lesion within the renal
artery
Form of secondary hypertension,
accounting for an estimated 0.5% to
4% of cases in unselected

RVH: Introduction
The simultaneous presence of Renal Artery Stenosis
(RAS) and systemic hypertension does not establish
Renovascular Hypertension
Strictly speaking, the definitive diagnosis of RVH
can only be made retrospectively :
Hypertension responds to correction of the
stenosis

RVH: Introduction

(Contd)

In practice, obtaining complete

reversal or cure" of hypertension is
rarely seen
Important to recognize that
renovascular disease:

Often accelerates preexisting

hypertension
Can ultimately threaten the viability of
the post-stenotic kidney

Etiology of Renal Artery

Stenosis
Atherosclerosis
Fibromuscular
dysplasia
Takayasus arteritis
Polyarteritis Nodosa
Radiation-induced

ARAS
Most common and problematic cause
of RVH
70% of cases of RVH due to ARAS

Mainly in older men

Lesion at the ostium or proximal third
of the renal artery as an extension of
an aortic plaque
Bilateral in approx. 1/3 of cases

ARAS

(Contd)

Risk factors
Identical to those associated with
systemic atherosclerosis, i.e.,
Advanced age, male sex, smoking,
Diabetes mellitus, hypertension,
Positive family history, and
Dyslipidemia

ARAS

(Contd)

Generally believed that

ARAS slowly progresses over time, but
the rate of progression is variable (40%50%)
Atherosclerotic renovascular disease is
associated with accelerated and more
severe target organ injury than essential
HT

. Fibromuscular dysplasia
(FMD)

10% -20% of cases of RVH are due to

FMD
Mainly in younger women
Harmonal factors believed to have role
Commonly involves carotid and vertebral
arteries
Renal artery involvement may be
bilateral with extension into the distal
portion of the artery and its branches is
common

Fibromuscular dysplasia
(FMD)
Four histologic variants
recognized:

Intimal fibroplasia
True fibromuscular hyperplasia
Medial fibroplasia
Perimedial (subadventitial)
fibroplasia

They differ in natural history

Renin Angiotensin System

A Renal corpuscle
B Proximal tubule
C Distal convoluted
tb.
D Juxtaglomerular
app.
1. Basal lamina
2. Bowman's capsule
parietal layer
3. Bowman's capsule
visceral layer
3a. Pedicels
(podocytes)
3b. Podocyte
4. Bowman's space
5a. Mesangium
iIntraglomerular
cell
5b. Mesangium
extraglomerular
cell
6. Juxtaglomerular
cells
7. Macula densa

PATHOPHYSIOLOGY
The classical experiments of Goldblatt
Clamping of renal arteries in dogs can
produce hypertension
Two models described:
One clip two kidney
hypertension
One clip one kidney
hypertension

Goldblatt Dog Models

ARB/ACE inhibitors help

Only help when Na depleted

Pathophysiology of RVH
Basic event is renal hypoperfusion
Triggers release of Rennin from the
Juxtaglomerular cells
Rennin release is mediated by:
Macula Densa (decreased del. Of Cl)
Tubuloglomerular feed back

Baroreceptors in afferent arteriole

Neural mechanismAdrenergic
Stimulation
Endocrine, Paracrine and Autocrine
pathways

RVH: Pathophysiology

(Contd)

Pathophysiology of RVH
Phases of Renovascular Hypertension
Renin dependent hypertension
vs
Volume dependent
hypertension

Ultimately culminates as ESRD

RVH: Diagnosis
Mere presence of RAS and
hypertension does not establish the
diagnosis of RVH
Three-step approach to the diagnosis
of RVH has been suggested

RVH: Diagnosis

(Contd)

First step:
An appropriate selection of patients who
are more likely to have RVH

Second step:
The patients renal arteries are imaged to
demonstrate RAS

Third step:
Resolution or improvement in blood
pressure control occurs with reversion of
the stenosis

DIAGNOSIS
Clinical pointers for renovascular
disease in the hypertensive
patient:
Systolic and diastolic upper
abdominal bruits
Diastolic hypertension of >115
mmhg
Rapid onset of hypertension
after the age of 50 years
A sudden worsening of mild to

Clinical pointers (contd.)

Hypertension that is difficult to
control with three or more
antihypertensives
Development of renal insufficiency
after ACE inhibitors
Development of hypertension
during childhood.
Hypertension below 30yrs of age
in absence of family history of

Diagnosis
Overview

There are two groups of diagnostic studies used to

evaluate RAS:

Anatomic studies:
1.
2.
3.
4.

Renal angiography the gold standard

Doppler ultrasonography
Spiral CT angiography
MR angiography

Function studies:
5. Renal-vein-renin measurement
6. Nuclear imaging with I125iothalamate or DTPA to
determine GFR
7. Conventional renography
8. ACEI renography

RVH: Imaging
Intra-arterial angiography
The gold standard
Invasive and carries the risk of contrastinduced nephropathy
Not used routinely unless
Concurrent therapy with angioplasty,
with/without stenting, is being considered

Digital subtraction angiography

CO2 and gadolinium contrasts have
been tried with good results

RVH: Imaging

(Contd)

Digital subtraction angiography (DSA)

Uses less dye than a conventional
arteriogram but is still invasive
The quality of images with DSA is not as
good as with conventional angiogram

RVH: Imaging

(Contd)

Duplex ultrasound imaging

Direct visualization of the renal vascular
tree while assessing blood flow velocity
and pressure wave forms
Limitations include interoperator
variability and the need for expertise in
obtaining and interpreting the images

RVH: Imaging

(Contd)

Based on detecting the altered flow

pattern distal to the stenosis with a
turbulent jet during systole and a
decrease in diastolic flow.
Measurements are obtained at the
proximal main renal artery using a
standardized angle of incidence

RVH: Imaging

(Contd)

Indices used to diagnose stenosis:

Peak systolic velocity (PSV) > 180
cm/sec (normal renal PSV averages 100
25 cm/sec).
Renal Aortic Ratio (RAR)> 3.5..
Acceleration Time, Acceleration Index,
Resistive Index have not proved as
universally reliable
Intraluminal ultrasonography has also
been used to measure flow rate directly

Degree Stenosis

Renal PSV

RAR

Normal

< 180 cm/sec

< 3.5

< 60%

> 180 cm/sec

< 3.5

> 60%

> 180 cm/sec

> 3.5

Occlusion

No signal

No signal

RVH: Imaging

(Contd)

Spiral computed tomography

angiography
Enables a three-dimensional
reconstruction of the vascular tree
Excellent sensitivity and specificity to
visualize RAS
However, requires up to 150 cc of
iodinated contrast, which may be
nephrotoxic

RVH: Imaging

(Contd)

Magnetic resonance angiography

(MRA)
Noninvasive imaging technique and results in excellent
visualization of the renal vasculature
Gadolinium is used as the radio-contrast in the phase
contrast technique
Drawbacks
High cost
Potential for nephrogenic systemic fibrosis in patients
with renal insufficiency

RVH: Imaging

(Contd)

Captopril-enhanced renography
Noninvasive test and the ability to assess
renal functional status
Use is limited in patients with bilateral RAS
and in patients with significant renal
insufficiency
Based on loss of AT II mediated efferent
arteriolar constriction
Provide a basis for functional, not
anatomical, diagnosis of RAS, as there is
no direct visualization of the renal arteries

RVH: Imaging

(Contd

The study is performed in wellhydrated patients with liberal salt

intake.
ACE inhibitors are discontinued for 3
to 5 days before the study, but other
antihypertensives may be continued
Oral captopril (25 to 50 mg) is usually
used, although IV enalapril (0.04
mg/kg) can be used as well.
The captopril renogram is obtained 1
hour after the captopril dose.

RVH: Imaging

(Contd

The most commonly used agents are

technetium 99m (99mTc)
diethylenetriaminepentaacetic acid
(DTPA)
These changes on the postcaptopril
renogram include:
a delayed time to maximal activity (>11
minutes)
significant asymmetry of peak activity of
each kidney
marked cortical retention of radionuclide

Diagnosis

Functional studies
Diagnostic Study

Pros

Cons

Renal Vein Renin Measurements

Useful in confirming the functional

significance of a lesion demonstrated
by anatomical studies particularly if
bilateral disease is present

Poor sensitivity
Nonlateralization not predictive of
the failure of HTN to improve with
therapy

Nuclear Imaging with Tc99-MAG or

Tc99-DTPA to estimate fractional flow
to each kidney

Allows calculation of single kidney

GFR and/or RBF

Difficult to differentiate reversible

from intrinsic disease

Conventional Renography

Useful as both a screening test

and functional study

Lower sens/spec compared to

ACEI renography

ACEI Renography

Test of choice for the diagnosis of

RVH in many centers

Reduced sens/spec in patients

with renal insufficiency (Pcr>2.0)
Operator dependent

Diagnosis
Diagnostic Study

Sens.

Spec.

Renal Vein Renins

62%

70-88%

Doppler Ultrasonography

80-98%

Conventional Renography

75%

PPV

NPV

98%

99%

88-97%

85%

33%

ACEI Renography

75 -90% 94%

92%

88%

CT angiography

92%

98%

87%

99%

MRA

100%

93%

90%

100%

RVH: Management
Treatment options include
Pharmacological therapy with various
antihypertensive medications,
Percutaneous angioplasty with or without
stent placement, and
Surgical revision of RAS

RVH: Management

(Contd)

Availability of potent antihypertensive

drugs and the advances in
endovascular techniques, as well as
stents, have made surgical treatment
rarely necessary

RVH: TA Management
Besides management of hypertension and its
complications,
Steroids and immunosuppressive agents like
methotrexate and cyclophosphamide are used to
suppress disease activity

Response to therapy is faster and better in children

with a higher rate of remission
Anti-platelet agents like aspirin and dipyridamole
have been used especially in patients with transient
neurological symptoms

Criteria For Intervention

Angiography criteria
Fibromuscular dysplasia lesion
Pressure gradient >20 mmHg
Affected/unaffected kidney renin ratio >1.5:1

Clinical criteria
Inability to control hypertension despite
appropriate antihypertensive regimen.
Chronic renal insufficiency related to bilateral
renal artery stenosis or to a solitary
functioning kidney.
Dialysis-dependent renal failure without
another definite cause of end-stage renal
disease.

In patients Fibromuscular
Dysplasia intervention is guided
by the specific type of disease as
determined by angiographic
findings

MEDIAL FIBROPLASIA
Progressive obstruction/loss of renal
function is uncommon
MEDICAL MANAGEMENT preferred initial
treatment
Intervention reserved for refractory
hypertension

INTIMAL or PERIMEDIAL
FIBROPLASIA
Generally progressive leading to
ischemic renal atrophy. Tend to occur in
younger patients
Cause hypertension that is extremely

Patients with atherosclerotic RVH are

older and often have extrarenal
vascular disease.
Therefore more vigorous attempts at
medical management are warranted
Multiple-drug regimens that control
the blood pressure are often the
preferred approach.
Indeed, the advent of new and
effective antihypertensive has
enhanced the efficacy of medical

Intervention is best reserved for

patients whose hypertension cannot
be adequately controlled or when
renal function is threatened by
advanced vascular disease

RVH: ARAS Management

(Contd)

One of the largest trials,

The Angioplasty and Stenting for Renal
Artery Lesions (ASTRAL) study,
806 renal failure patients (mean serum
creatinine approximately 2 mg/dL) with
atherosclerotic renal vascular disease
included
Randomized to receive either
revascularization and medical therapy or
medical therapy alone

RVH: ARAS Management

ASTRAL Study

(Contd)

(Contd)

On average, patients had 75% RAS

At 1-year follow-up there were no
differences in the change in serum
creatinine level (it rose by 0.2 mg/dL in
both groups) or in rates of renal events,
including acute renal failure

RVH: ARAS Management

(Contd)

At this time, there is no clear benefit of revascularization for

ARAS,
Especially in patients for whom BP can be controlled easily
and who have no evidence of ischemic nephropathy
The risks of the procedure may outweigh any potential
benefits

Angioplasty with or without stenting may be of benefit in

Patients with HT that is difficult to control in the setting of
decreased renal perfusion, because uncontrolled
hypertension is a major cardiovascular risk factor

Accordingly, aggressive treatment of hypertension with

medications is recommended

Modalities Available With

The Surgeon
Surgical revascularization procedures
Endovascular interventions
PERCUTANEOUS TRANSLUMINAL
ANGIOPLASTY
ENDOVASCULAR STENTING

SURGICAL
REVASCULARIZATION

Preoperative Preparation
General medical condition of the patient is
the main determinant of the risk
Operative risk is minimal in young patients
with FMD
In atherosclerotic renovascular disease
ACUTE CORONARY EVENTS are the leading
cause of PERIOPERATIVE MORTALITY
A thorough evaluation for of coronary
artery disease is indicated
Myocardial revascularization if indicated
should precede renal revascularization.
Cerebrovascular accident has also been a

Operative Techniques
AORTORENAL BYPASS
Patients with a healthy abdominal aorta
With a free graft of autogenous
hypogastric artery or saphenous vein
Polytetrafluoroethylene aortorenal
bypass grafts
RENAL ENDARTERECTOMY utilized

occasionally to treat atherosclerotic

renal artery disease..

Operative Techniques
In older patients severe
atherosclerosis of the abdominal aorta
Alternative surgical procedures are
used:
Splenorenal bypass for left renal
revascularization
Hepatorenal bypass for right renal
revascularization.

Celiac axis ostial occlusion must be

excluded
Importance of obtaining preoperative

Operative Techniques
Use of the supraceliac or lower
thoracic aorta more recent surgical
alternative
Reconstruction with an interposition
saphenous vein graft.

Limited role of total or partial

nephrectomy
Severe arteriolar
nephrosclerosis

Endovascular interventions
PERCUTANEOUS TRANSLUMINAL
ANGIOPLASTY
ENDOVASCULAR STENTING

PERCUTANEOUS TRANSLUMINAL
ANGIOPLASTY
First introduced by Grntzig in
Germany
Dilatation a renal artery stenosis using
a balloon catheter technique
Access is typically via a femoral artery
Brachial approach can be considered
in
Aortoiliac occlusive/aneurysmal disease,
Caudal renal artery angulation.

PERCUTANEOUS TRANSLUMINAL
ANGIOPLASTY

Starts with an aortogram

Orifice of the stenosed renal artery
visualized
Assess the presence of accessory
renal arteries.
Noniodinated contrast agents:

Carbon dioxide
Gadolinium

PERCUTANEOUS TRANSLUMINAL
ANGIOPLASTY
Systemic heparinization
Catheterization of the renal artery
using angled catheters
A selective renal angiogram performed
Lesion crossed with a 0.035-in or a
0.018- to 0.014-in guidewire.
Distal wire position maintained in
tertiary renal branches
A guiding sheath advanced to secure
access for balloon and stent
deployment.

PERCUTANEOUS TRANSLUMINAL
ANGIOPLASTY
Balloon is sized to the diameter of the
normal renal artery.
Balloon with a 4-mm diameter is a
reasonable first choice.
Baloon is inflated for 1 min and
deflated twice
Once completed an angiogram is
performed to document result

ENDOVASCULAR STENTING
Endovascular stent placement is the
treatment of choice for high-grade renal
artery stenosis
High incidence of restenosis with balloon
angioplasty, especially in ostial stenosis.
Stenting is also indicated for renal artery
dissection caused by balloon angioplasty
Studies have clearly demonstrated the
clinical efficacy of renal artery stenting
when compared to balloon angioplasty
alone in high-grade renal artery stenosis

ENDOVASCULAR STENTING
Arterial stents are radiopaque,
expandable metallic wire mesh tubes
Expand either spontaneously on
extrusion from a delivery catheter
(Self-expandable)
Expand on inflation of a balloon on
which the stent is preloaded (Balloon
Expandable).

ENDOVASCULAR STENTING
Assess balloon and stent length and
diameter.
(High Quality
Angiogram)
The stent used should be long enough
to traverse the entire lesion
Excessive length beyond the lesion is
undesirable
In ostial lesions, the stent protrude 1
to 2 mm into the aortic lumen to
prevent restenosis

Indications Of Stenting
Current indications for stent
placement are:
Poor immediate results during PTA
Restenosis after PTA
To treat angioplasty complications (artery
dissection and intimal flaps
Primary stent placement is becoming
increasingly popular esp. In (ostial
lesions).