0521779407-18 CUNY1086/Karliner 0 521 77940 7 June 13, 2007 8:1
Renal Artery Stenosis 1279management
■Goals of therapy are reduction of morbidity/mortality of hyperten-
sion and preservation of renal function.
■Initial therapy is reduction of blood pressure using medical means
consistent with recommendations of JNC VI.specific therapy
■Medical Therapy: This is often undertaken before the diagnosis of
renal artery stenosis is considered or established. Unilateral renal
artery disease often responds to blockade of renin angiotensin sys-
tem (e.g., ACE inhibitors and angiotensin receptor blockers) in com-
bination with other agents.
■CAUTION: these agents have potential to reduce glomerular filtra-
tion in post-stenotic kidneys due to loss of efferent arteriolar tone.
■Renal Revascularization: Percutaneous angioplasty (PTRA) with or
without stenting. FMD often responds to PTRA alone if location is
favorable.
■Atherosclerotic disease is more commonly located at ostium; pri-
mary patency is better with stents (>75%) as compared to PTRA alone
(29%) after 6 months.
■Side effects include atheroemboli, vessel dissection, hematoma and
small vessel occlusion (incidence of major events: 4–9%).
■Contraindications (relative): active atheroemboli, diffuse aortic dis-
ease, pre-existing vessel occlusion
■Surgical reconstruction usually part of aortic surgery: endarterec-
tomy or renal artery bypass grafting: Morbidity dependent upon
surgical expertise and support, co-existing cardiac and carotid dis-
ease. Proven long-term durability and patency in most cases, but
higher early morbidity and surgical risk than endovascular techni-
ques.follow-up
■Recheck blood pressure, medications and renal function at regu-
lar intervals – e.g., 1 month and 3 months thereafter. Blood pres-
sure response to revascularization may develop over several months.
Usually recheck vessel patency between 3–6 months (Doppler ultra-
sound).
■Goal is reduction in medication requirement and improved blood
pressure control after successful renal revascularization. Renal func-
tion may improve in patients with pre-existing renal dysfunction
(25–30%), remain unchanged 45–50%) and deteriorate in 20%.