Determination of Renal Arterial Stenosis Severity: Comparison of Pressure Gradient and Vessel Diameter

Cm, Gross; Kramer, John; Weingärtner, Otto; Uhlich, F; Fc, Luft; Waigand, J; Dietz, Rainer

doi:10.1148/radiol.2203001444

Cited by 96 publications

(59 citation statements)

References 8 publications

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“…Whether less severe disturbances in flow and sheer stress to the vessel wall predispose to subtle alterations in intrarenal hemodynamics is less understood. Recent studies suggest that alterations of blood flow develop in an exponential manner at less severe occlusion (26). The precise pathways by which alterations in renal vessels induce tissue injury in the kidney are not well understood.…”

Section: Pathophysiology Of "Critical" Ras and "Ischemic Nephropathy"mentioning

confidence: 99%

Ischemic Nephropathy

Textor

2004

Journal of the American Society of Nephrology

148

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Abstract. Identification and reversing the loss of kidney function beyond occlusive disease of the renal arteries poses a major clinical challenge. Recent studies indicate that atherosclerotic renal artery stenosis develops as a function of age and is commonly associated with other microvascular disease, including nephrosclerosis and diabetic nephropathy. The risks of renal artery stenosis are related both to declining kidney function and to accelerated cardiovascular disease, with increased morbidity and mortality. Newer drugs, including agents that block the renin-angiotensin system, have improved the level of BP control for renovascular hypertension. Progressive renovascular disease during medical therapy can produce refractory hypertension, congestive heart failure, and renal failure with tubulointerstitial fibrosis. Recent studies indicate a complex interplay of oxidative stress, endothelial dysfunction, and activation of fibrogenic cytokines as a result of experimental atherosclerosis and renal hypoperfusion. Advances in imaging and interventional devices offer major new opportunities to prevent progressive loss of kidney function. Recent series indicate that although 25 to 30% of patients with impaired renal function can recover glomerular filtration after revascularization, many have no apparent change in kidney function and 19 to 25% experience a significant loss of kidney function, in some cases as a result of atheroemboli. To select patients who are most likely to benefit from vascular intervention, clinicians should understand the pathophysiology of developing ischemic nephropathy and the potential hazards of revascularization in the setting of diffuse atherosclerotic disease. Further research should be directed toward identification of critical disease, regulation of fibrogenesis, and the interaction with other atherosclerotic processes.

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Section: Pathophysiology Of "Critical" Ras and "Ischemic Nephropathy"mentioning

confidence: 99%

Ischemic Nephropathy

Textor

2004

Journal of the American Society of Nephrology

148

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“…However, not all of the ARAS lesions impair renal perfusion, and the lesions that do not impair renal perfusion can be seen in hypertensive patients, especially in the elderly (3)(4)(5). Although angioplasty could improve renal perfusion, the procedure during angioplasty might deteriorate renal function.…”

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confidence: 99%

Hemodynamic Index of Atheromatous Renal Artery Stenosis for Angioplasty

Tanemoto¹,

Suzuki²,

Abe³

et al. 2009

Clinical Journal of the American Society of Nephrology

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Background and objectives: Trans-stenotic pressure gradient across the constriction (PG), a hemodynamic variable of atheromatous renal artery stenosis (ARAS), is a widely used indicator for angioplasty, but its association with the outcome of angioplasty has not been fully investigated.Design, setting, participants & measurements: In 34 hypertensive cases with unilateral ARAS, we evaluated hemodymanic variables of ARAS with reference to the systemic BP reduction after angioplasty as the outcome.Results: In each phase, PG divided by its corresponding prestenotic arterial BP (PG/preBP) had better association with the outcome than PG. The mean phase PG/preBP had the largest area under the curve in the receiver operating characteristic analysis (0.794) with the sensitivity/specificity of 0.957/0.545 for its cut-off >0.15. Although the plasma renin activity, which reflects the perfusion to renal parenchyma, was higher in the angioplasty-efficacious cases than in the angioplasty-inefficacious cases before angioplasty (7.8 ؎ 6.6 versus 3.4 ؎ 3.8 ng/ml/h, P ‫؍‬ 0.049), it was not generally reduced by angioplasty independent of the outcome.Conclusions: As the index to select ARAS for angioplasty, PG/preBP was better than PG and the mean phase PG/preBP could be the best. However, other factors such as the microvascular kidney disease, which affect the perfusion to renal parenchyma, would influence the outcome.

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“…This somewhat rigorous definition of anatomic stenosis was based on the desire to only enroll patients in whom hypertension was likely to be the direct result of atherosclerotic renal artery disease. 49 Obviously, patients with hemodynamically insignificant lesions will fail to benefit from stent placement. Patients with recent myocardial infarction, stroke, admission for congestive heart failure, or a serum creatinine Ͼ3 mg/dL are excluded from entry, but, otherwise, CORAL casts a fairly wide net and, therefore, should be broadly applicable to the spectrum of affected patients seen in clinical practice.…”

Section: The Coral Studymentioning

confidence: 99%

Controversial Treatment of Atherosclerotic Renal Vascular Disease

Dworkin

2006

Hypertension

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A therosclerotic renal artery stenosis (RAS) is a relatively common problem, affecting from 1% to 5% of patients with hypertension. 1,2 Given the high prevalence of hypertension, it follows that there are from 2 million to 4 million individuals with RAS in the United States alone. Autopsy data demonstrate that the incidence of RAS increases with age affecting 18% of individuals between the ages 65 to 74 years and Ͼ40% of those more than age 75. 3 RAS is also common in individuals with vascular disease in other beds and is present in Յ40% of those with overt coronary artery disease, aortoiliac disease, or peripheral vascular disease. 4 -6 At present, the best treatment for RAS is unknown, and, in particular, whether or not revascularization, typically accomplished by angioplasty and stenting, improves clinical outcomes for patients with RAS is unclear. Nevertheless, it is estimated that Ϸ40 000 renal artery angioplasties procedures are performed in the United States each year, which, depending on whether or not the procedure is beneficial, is either far too many or far too few. The purpose of this article is to review current knowledge about atherosclerotic RAS and to discuss the Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL) trial, which is examining the best treatment for this disease.

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Determination of Renal Arterial Stenosis Severity: Comparison of Pressure Gradient and Vessel Diameter

Abstract: Patients with a pressure gradient greater than 20 mm Hg should be good candidates for renal arterial dilatation, and use of the pressure guide wire will facilitate interventional decisions.

Cited by 96 publications

References 8 publications

Ischemic Nephropathy

Ischemic Nephropathy

Hemodynamic Index of Atheromatous Renal Artery Stenosis for Angioplasty

Controversial Treatment of Atherosclerotic Renal Vascular Disease

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