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Clinical Crossroads | Clinician's Corner

An 82-Year-Old Woman With Worsening Hypertension:  Review of Renal Artery Stenosis

Kenneth Rosenfield, MD; Michael R. Jaff, DO
JAMA. 2008;300(17):2036-2044. doi:10.1001/jama.300.13.jrr80009.
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Renal artery stenosis (RAS) is a common disorder in adults with atherosclerosis and is associated with hypertension, impaired renal function, congestive heart failure, and angina pectoris. The incidence of RAS is increasing because of the aging of the US population and increasing prevalence of atherosclerosis. The case of Mrs S, an 82-year-old woman with long-standing hypertension and unilateral RAS detected by magnetic resonance angiography, illustrates the challenges surrounding indications for revascularization. The discussion reviews the clinical presentation and natural history of RAS and strategies for diagnosis. The role of medical therapy, surgery, and endovascular therapy are reviewed, particularly in the context of guidelines and systematic reviews to help clinicians and patients facing this challenging decision.

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Figure. Magnetic Resonance Angiogram (MRA) of Mrs S’s Renal Arteries
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MRA showing severe stenosis at the origin of the main left renal artery (arrowhead) with a patent accessory renal artery to the lower pole of the left kidney. Both kidneys are normal size, with symmetric excretion of contrast.

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A 82 year women with hypertension and uncomplicated renal stenosis: wait and see
Posted on October 19, 2008
Joel Belmin, MD
Service de Geriatrie, Hopital Charles Foix et Universite UPMC-Paris 6, 94200 Ivry-sur-Seine, France
Conflict of Interest: None Declared
The 82 year old women described by Dr Ship had an atherosclerotic renal stenosis, but no clinical problems related to renovascular disease (RVD), like renal failure, malignant or uncontrolled hypertension, nor heart failure or flash pulmonary edema. Hypertension, which a very common finding in elderly individuals, is well controlled by antihypertensive agents in this patient. She has anatomical RVD, but not a clinical RVD. Stent placement is the best procedure to revascularize kidneys with atherosclerotic renal stenosis (1). This procedure was found to improve the control of hypertension in patients with refractory hypertension (2) and to stabilize or even improve renal function in patients with renal failure related to RVD (3,4). Stenting also seems to improve the symptoms of patients with heart failure related to RVD (5). But is renal artery stenting appropriate in the present case? Since the patient had no clinical problem related to RVD, no immediate benefit can be expected from the procedure. Long term benefits of renal stenting consist of reducing the risk of occlusion or atherosclerotic progression of the vessel. How this results in prevention of clinically relevant issues in uncomplicated RVD is unknown. It should be taken into account that the progression of RVD does not always result in clinical disease. In the population-based Cardiovascular Health Study, 834 participants (mean age 77.2 + 4.9 years) underwent renal duplex sonography (RDS) at entry, and 137 of them had a second RDS 8.0 + 0.8 years later (6). None of the individuals with renal stenosis at entry developed renal artery occlusion. Clinically significant RVD occurred in 4% of the participants, indicating a very low incidence of complications related to RVD.
In the present case, there is a large accessory renal artery vascularizing the lower pole suggesting that a large part of left kidney is protected against ischemia. Overall, that indicates that the expected benefit of kidney revascularisation is minimal in this patient. Stent placement in the renal artery might create immediate complications related to the procedure. Major complications occurred in 2% of cases (0.6% to 4.0% according to studies) (1). In addition, restenosis was found to occur 16% of cases and a second procedure was required in about 12% of cases. Few cases of death or acute renal failure requiring dialysis have been described as complications of stenting (1).
My conclusion is that the risks related to renal stenting overtake the benefits in this patient, and thus the procedure is not appropriate for her. Her medical therapy, which includes aspirin and a statin, is appropriate for atherosclerotic renal artery stenosis. Even though the risk of occurrence of a clinically revelant RVD disease in the future is low (6), I would propose that she have her blood pressure and serum creatinine checked periodically, perhaps every 3 months. Renal artery stenting should discussed again only if RVD appears to be responsible for clinical problems like uncontrolled hypertension, renal function worsening and/or flash pulmonary edema.
REFERENCES
1. White CJ. Catheter-based therapy for atherosclerotic renal artery stenosis. Circulation. 2006;113:1464-73.
2. Leertouwer TC, Gussenhoven EJ, Bosch JL, van Jaarsveld BC, van Dijk LC, Deinum J, et al. Stent placement for renal arterial stenosis: where do we stand? A meta-analysis. Radiology. 2000; 216: 78–85.
3. Zeller T, Frank U, Muller C, Burgelin K, Sinn L, Bestehorn HP, et al. Predictors of improved renal function after percutaneous stent-supported angioplasty of severe atherosclerotic ostial renal artery stenosis. Circulation. 2003; 108: 2244–2249.
4. Muray S, Martin M, Amoedo M, Garcia C, Jornet A, Vera M, et al. Rapid decline in renal function reflects reversibility and predicts the outcome after angioplasty in renal artery stenosis. Am J Kidney Dis. 2002; 39: 60–66.
5. Khosla S, White CJ, Collins TJ, Jenkins JS, Shaw D, Ramee SR. Effects of renal artery stent implantation in patients with renovascular hypertension presenting with unstable angina or congestive heart failure. Am J Cardiol. 1997; 80: 363–366.
6; Pearce JD, Craven BL, Craven TE, Piercy KT, Stafford JM, Edwards MS, et al. Progression of atherosclerotic renovascular disease: A prospective population-based study. J Vasc Surg. 2006 ;44:955-62.
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