Efficacy of Revascularization For Renal Artery Stenosis Caused by Fibromuscular Dysplasia

Abstract

In patients with fibromuscular dysplasia and renal artery stenosis, renal artery revascularization has been used to cure hypertension or to improve blood pressure control. To provide an up-to-date assessment of the benefits and risks associated with revascularization in this condition, we performed a systematic review of studies in which hypertensive patients with fibromuscular dysplasia renal artery stenosis underwent percutaneous transluminal renal angioplasty or surgical reconstruction. We assessed how often periprocedural complications and hypertension cure and improvement occurred. We selected 47 angioplasty studies (1616 patients) and 23 surgery studies (1014 patients). Combined rates of hypertension cure, defined according to the criteria in each study, after angioplasty or surgery were estimated to be 46% (95% CI: 40% to 52%) and 58% (95% CI: 53% to 62%), respectively, with substantial variations across studies. The probability of being cured was negatively associated with patient age and time of publication. Cure rates using current definitions of hypertension cure (blood pressure <140/90 mm Hg without treatment) were only 36% and 54% after angioplasty and surgery, respectively. The combined risks of periprocedural complications were 12% and 17% after angioplasty and surgery, respectively, with less major complications after angioplasty than surgery (6% versus 15%). In conclusion, angioplasty or surgical revascularization yielded moderate benefits in patients with fibromuscular dysplasia renal artery stenosis, with substantial variation across studies. The blood pressure outcome was strongly influenced by patient age.

High Prevalence of Multiple Arterial Bed Lesions in Patients With Fibromuscular Dysplasia

“…Such patients should be screened with RA imaging because hypertension could be amenable to RA angioplasty in selected cases. [1][2][3]22 Imaging the eCVA could be considered in patients with a renal presentation in whom the first imaging procedure disclosed bilateral RA FMD lesions because they have a higher probability of having eCVA lesions than those with unilateral RA FMD (OR, 1.88; 95% CI, 0.99-3.57).…”

Revisiting Fibromuscular Dysplasia

“…Exploration of other vascular beds or vascular imaging of family members may also be considered in case of suggestive symptoms. 1 Finally, while renal angioplasty is not the panacea, especially in older patients who might suffer from essential hypertension with incidentally associated FMD lesions, 1,55 it may lead to hypertension cure in a substantial proportion of cases 55 and, thus, deserves to be proposed, especially in young hypertensive patients or in case of severe or difficult-to-treat hypertension. In contrast with atherosclerotic renal artery stenosis, stenting is usually not recommended in patients with FMD because of the risk of stent kinking 56 or fracture, 57 probably due to repeated mechanical stress induced by increased kidney mobility.…”

Telling Tails

“…13 Across all ages, fibromuscular dysplasia (FMD) accounts for a minor proportion of all patients with renovascular disease, but intervention is more likely to achieve sustained cure both of the renal artery stenosis and the resulting hypertension. 10,14 Its management should not be influenced by the neutral outcomes in the large trials of revascularization, Angioplasty and Stent for Renal Artery Lesion (ASTRAL) and Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL), which generally excluded patients with FMD. 15,16 Moreover, the primary outcome of these trials was renal function, and the eligible patients were those in whom clinicians were unsure of management.…”