RENOVASCULARRENOVASCULAR HYPERTENSIONHYPERTENSION

42 cases analysis42 cases analysis

Mihai Dan Datcu, Georgeta Datcu, Viviana Aursulesei, Helen Rothinberg

I st Medical Cardiology Clinic “C.I.Negoiţă”I st Medical Cardiology Clinic “C.I.Negoiţă”

““St Spiridon” University Emergency HospitalSt Spiridon” University Emergency Hospital

University of Medicine and Pharmacy “Gr.T.Popa”University of Medicine and Pharmacy “Gr.T.Popa”

IaşiIaşi

1. 1. Renal artery stenosis is recognised as a cause of Renal artery stenosis is recognised as a cause of hypertension and renal dysfunction;hypertension and renal dysfunction;

2. 2. No single test is appropiate for all patients;No single test is appropiate for all patients;

3. 3. Diagnostic modalities require an assesment of the Diagnostic modalities require an assesment of the physiologic effects of renal artery stenosis, and the physiologic effects of renal artery stenosis, and the direct imaging of renal artery;direct imaging of renal artery;

4. 4. We believe that direct or conventional contrastWe believe that direct or conventional contrast angiography answer in the same time both requiresangiography answer in the same time both requires..

Key points and purposeKey points and purpose

Female Female 32 patients 32 patientsMaleMale 10 patients 10 patientsMinim age Minim age 14 year14 year Maxim ageMaxim age 78 year78 year

Clinical findings

EtiologyEtiology

AtherosclerosisAtherosclerosis 77 %77 %ThrombosisThrombosis 8%8%AneurAneuryysmsm 8%8%Fibromuscular dFibromuscular dyysplasiasplasia 3%3%Renal artery hRenal artery hyypoplasiapoplasia 2%2%Systemic vasculitisSystemic vasculitis 2%2%

Zanchetti A

et al, 2001

Zanchetti A

et al, 2001

Conventional contrast angiography :Conventional contrast angiography :

the goldthe gold standardstandard

Clinical index of suspicion of renovascular Clinical index of suspicion of renovascular hypertensionhypertension

High Moderate Low

Severe hypertensionSevere hypertension-SH- with progresive unexplained renal -SH- with progresive unexplained renal insufficiencyinsufficiency

SHSH with refractoriness to agressive treatment with refractoriness to agressive treatment

Accelerated or Accelerated or malignant Hmalignant H – gr III or IV retinopathy – gr III or IV retinopathy

Moderate to Moderate to SHSH with elevation serum creatinine reversibly with elevation serum creatinine reversibly induced by an ACE inhibitor or angiotensin II antagonistinduced by an ACE inhibitor or angiotensin II antagonist

Moderate to Moderate to SHSH with asym with asymmmetretryy of renal size of renal size

Batzenschlager criteriaBatzenschlager criteria

A.Zancheti A.Zancheti 20012001

Zanchetti A et al, 2001Zanchetti A et al, 2001

Search for etiologySearch for etiology

Age of onset under 20 yAge of onset under 20 yeaearsrs 15 c15 cAge of onset over 50 yAge of onset over 50 yeaearsrs 27 c27 cAbdominal bruit – 41 –57 % (H.Abdominal bruit – 41 –57 % (H. Dustan)Dustan) 16 c16 cEleveted serum creatinineEleveted serum creatinine 14 c14 cHypokaliemiaHypokaliemia 4 c4 cHigh renin profileHigh renin profile 18 c18 cNon invasive testsNon invasive tests 42 c42 c

Non invasive testsNon invasive tests

Plasma renin activityPlasma renin activity 19 pts19 pts

The captopril testThe captopril test 23 pts23 pts

Renal vein renin Renal vein renin 19 pts19 pts

Captopril augmented renal scanCaptopril augmented renal scan 10 pts10 pts

Duplex ultrasoundDuplex ultrasound 5 pts5 pts

Magnetic resonance angiographyMagnetic resonance angiography 4 pts4 pts

Helical computerized tomography (Spiral CT)Helical computerized tomography (Spiral CT)

Two Major Questions:

1.Morphologic1.Morphologic – – there is a renal artery stenosisthere is a renal artery stenosis Answer – imaging modalitiesAnswer – imaging modalities

2.Functional2.Functional – assesment of physiological effects – assesment of physiological effects of renal artery stenosisof renal artery stenosis

11. renovascular hypertension . renovascular hypertension 22. renovascular disease. renovascular disease

Always remember there is two possibilitiesAlways remember there is two possibilities::

Mc Cormack, 1971Mc Cormack, 1971

Renal artery stenosis both main arteryRenal artery stenosis both main artery

Non selective conventional contrast angiographyNon selective conventional contrast angiography

Vascular dVascular dyysplasia same patient –splasia same patient –thrombosis of left carotithrombosis of left carotidd artery artery

Right renal artery stenosisRight renal artery stenosis Left renal artery stenosisLeft renal artery stenosis

Yellow arow red arows

Left arteryLeft artery thrombosis small thrombosis small arowarow

Right arteryRight artery moderate stenosismoderate stenosis

pannel – renal pannel – renal vein plasma renin vein plasma renin activityactivity

M.C.,M.C., f, 50f, 50

C.M., m, 54Renal vein

renin ratio 1,8

Left renal artery stenosis

G.G., m, 33

Renal vein renin ratio 1,85

Left renal artery stenosis

Conventional contrast renal angiographyConventional contrast renal angiography H.M, H.M, f, f, 6969

Right renal artery thrombosisRight renal artery thrombosis

White arowWhite arow

Left renal artery stenosisLeft renal artery stenosis

Left renal angioplasty with stentLeft renal angioplasty with stentWhite arow indentation of the baloonWhite arow indentation of the baloon

H.MH.M. , . , f,f, 60 60

Left renal angioplasty with stentLeft renal angioplasty with stent

Stent positionStent position Control angiographyControl angiography

H.M.,H.M., f, 60f, 60

Pressure in left renal artery and aortic pressurePressure in left renal artery and aortic pressure

Before dilatationBefore dilatation After dilatationAfter dilatation

Post-stenosisPost-stenosis 34/25/22 mmHg34/25/22 mmHg 100/62/44 mmHg100/62/44 mmHg

Pre-stenosisPre-stenosis 164/104/60 mmHg164/104/60 mmHg 160/104/60 mmHg160/104/60 mmHg

AortaAorta 168/128/68 mmHg168/128/68 mmHg

Right Right polar superiorpolar superior renal artery renal artery thrombosisthrombosis

T.N., m , 48T.N., m , 48

LeftLeft polarpolar inferior inferior renal arteryrenal artery aneurysm aneurysm

Z.P, f, 28Z.P, f, 28

G.M., f, age 60

Small right kidney Left renal artery aneurysm

Normal renal artery

P.G.,m, 60P.G.,m, 60

Infrarenal thrombosis of the abdominal aortaInfrarenal thrombosis of the abdominal aorta

Abdominal coarctation of the aortaAbdominal coarctation of the aorta

Risk of angiography (1 – 3%)Risk of angiography (1 – 3%)

Complications of arterial punctureComplications of arterial puncture 0,5%0,5%Contrast – induced nephropathy Contrast – induced nephropathy 2%2%Cholesterol embolisationCholesterol embolisation 1%1%

presence of presence of - - atherosclerosisatherosclerosis - - hypertensionhypertension - - renal insufficiencyrenal insufficiency - - diabetic patientsdiabetic patients

risk increaserisk increase::

Treatment modalitiesTreatment modalities

Medical treatmentMedical treatment 13 13 Surgical proceduresSurgical procedures

nephrectomie nephrectomie 3 3 conservative treatmentconservative treatment 5 5 reimplantation in the aortareimplantation in the aorta 33 aortoaorto - - renal bypass renal bypass 22

Renal artery PTARenal artery PTA 2121Renal artery PTA plus stentRenal artery PTA plus stent 22

Final remarkFinal remarks:s:

Search for renovascular hypertension Search for renovascular hypertension in moderate and high risk suspicion;in moderate and high risk suspicion;

DoDo nnoot forget: renovascular hypertension is t forget: renovascular hypertension is fortunately fortunately aa curable form of hypertension! curable form of hypertension!

The advantages of conventional angiography areThe advantages of conventional angiography are::

morphological diagnosis – to be or not to bemorphological diagnosis – to be or not to be

functional assesment of physiological effects functional assesment of physiological effects of renal arteryof renal artery stenosisstenosis

direct and immediately treatment with direct and immediately treatment with interventionalinterventional procedure procedure

We are for an early direct contrast We are for an early direct contrast conventional angiographyconventional angiography!!

Thank you!Thank you!