Management of renovascular disease

Fibromuscular dysplasia responds well to balloon dilatation, often resulting in a normal blood pressure.

Atherosclerosis may respond to balloon dilatation but the effect on blood pressure is unpredictable. If renal artery stenosis is bilateral, balloon dilatation often leads to improved renal function.

It is important for renal artery stenosis to be recognised before aortic reconstructive surgery, whether for aneurysmal or occlusive disease, as transient hypotension during surgery may initiate thrombotic occlusion at the site of renal artery stenosis and cause post-operative renal failure. Renal artery stenosis, therefore, if combined with the need for aortic arterial reconstruction, should be treated before, or in combination, with the aortic surgery.

Notes:

• a systematic review investigating the management strategies for renal artery stenosis has been undertaken (1):
  • weak evidence suggested no large differences in mortality rates or cardiovascular events between medical and revascularization treatments. Acceptable evidence suggested similar kidney-related outcomes but better blood pressure outcomes with angioplasty, particularly in patients with bilateral disease. Improvements in kidney function and cure of hypertension were reported among some patients only in cohort studies of angioplasty. Evidence from direct comparisons of interventions is sparse and inadequate to draw robust conclusions
  • evidence does not clearly support one treatment approach over another for atherosclerotic renal artery stenosis

Reference:

1. Balk E et al. Effectiveness of management strategies for renal artery stenosis: a systematic review. Ann Intern Med. 2006 Dec 19;145(12):901-12