renal artery stenosis
DESCRIPTION
Renal artery stenosisTRANSCRIPT
![Page 1: Renal artery stenosis](https://reader035.vdocuments.mx/reader035/viewer/2022062411/5695d40f1a28ab9b02a024ce/html5/thumbnails/1.jpg)
Diagnosis of Renovascular Hypertension
Cholatip Pongskul
![Page 2: Renal artery stenosis](https://reader035.vdocuments.mx/reader035/viewer/2022062411/5695d40f1a28ab9b02a024ce/html5/thumbnails/2.jpg)
![Page 3: Renal artery stenosis](https://reader035.vdocuments.mx/reader035/viewer/2022062411/5695d40f1a28ab9b02a024ce/html5/thumbnails/3.jpg)
Characteristics of atherosclerotic and fibromuscular dysplasia
Variable Atherosclerotic Fibromuscular dysplasia
Age at presentation Older(>50 yr) Usually young(<40 yr)
Sex Either Usually female
Lesion location Ostial, proximal, middle Middle or distal
BP response to revascularization
Unclear Normotensive in most patients
![Page 4: Renal artery stenosis](https://reader035.vdocuments.mx/reader035/viewer/2022062411/5695d40f1a28ab9b02a024ce/html5/thumbnails/4.jpg)
Atherosclerotic Fibromuscular dysplasia
Elderly>50 Younger<40,femaleResponse to correction
![Page 5: Renal artery stenosis](https://reader035.vdocuments.mx/reader035/viewer/2022062411/5695d40f1a28ab9b02a024ce/html5/thumbnails/5.jpg)
Pathophysiology of renal artery stenosis
![Page 6: Renal artery stenosis](https://reader035.vdocuments.mx/reader035/viewer/2022062411/5695d40f1a28ab9b02a024ce/html5/thumbnails/6.jpg)
Who should be tested for renovascular hypertension?
• 45-year-old man, uremia, BP 160/90 mmHg, proteinuria, kidney 8.5, 8 cm
• 70-year-old man, smoker, hypertension, dyslipidemia, presented with pulmonary edema, Cr=1.4 mg/dl
• 60-year-old woman with pulmonary edema, BP 180/100 mmHg, Cr=1.2 mg/dl
![Page 7: Renal artery stenosis](https://reader035.vdocuments.mx/reader035/viewer/2022062411/5695d40f1a28ab9b02a024ce/html5/thumbnails/7.jpg)
Who Should be tested
![Page 8: Renal artery stenosis](https://reader035.vdocuments.mx/reader035/viewer/2022062411/5695d40f1a28ab9b02a024ce/html5/thumbnails/8.jpg)
What testShould be performed
![Page 9: Renal artery stenosis](https://reader035.vdocuments.mx/reader035/viewer/2022062411/5695d40f1a28ab9b02a024ce/html5/thumbnails/9.jpg)
How
to interpret the result
![Page 10: Renal artery stenosis](https://reader035.vdocuments.mx/reader035/viewer/2022062411/5695d40f1a28ab9b02a024ce/html5/thumbnails/10.jpg)
Who
• Onset of severe hypertension after 55• Unexplained deterioration of kidney function
– Rising > 50%, 1 week, ACEI• Severe hypertension in diffuse atherosclerosis• Severe hypertension with asymmetry kidney >
1.5 cm• Severe hypertension with flash pulmonary
edema, refractory CHF• Systolic-diastolic bruit at one side
![Page 11: Renal artery stenosis](https://reader035.vdocuments.mx/reader035/viewer/2022062411/5695d40f1a28ab9b02a024ce/html5/thumbnails/11.jpg)
Test or not test?
• Medication is effective in renovascular hypertension
• Who will benefit from correction?
• Testing associated with potential risk• Correction procedure associated with
morbidity/mortality
![Page 12: Renal artery stenosis](https://reader035.vdocuments.mx/reader035/viewer/2022062411/5695d40f1a28ab9b02a024ce/html5/thumbnails/12.jpg)
Test should be performed in patient with high likelihood of benefit
from procedure
![Page 13: Renal artery stenosis](https://reader035.vdocuments.mx/reader035/viewer/2022062411/5695d40f1a28ab9b02a024ce/html5/thumbnails/13.jpg)
High likelihood of benefit from procedure
• Short duration• Failure of medical Rx, in patient with high
likelihood of renovascular hypertension• Intolerance to optimal medical therapy• Progressive renal failure• Suspected fibromuscular dysplasia• Recurrent flash pulmonary edema
![Page 14: Renal artery stenosis](https://reader035.vdocuments.mx/reader035/viewer/2022062411/5695d40f1a28ab9b02a024ce/html5/thumbnails/14.jpg)
Gold Renal angiography
More than 50% stenosis
![Page 15: Renal artery stenosis](https://reader035.vdocuments.mx/reader035/viewer/2022062411/5695d40f1a28ab9b02a024ce/html5/thumbnails/15.jpg)
Other tests• Duplex sonography• CT angiogram• MRA
![Page 16: Renal artery stenosis](https://reader035.vdocuments.mx/reader035/viewer/2022062411/5695d40f1a28ab9b02a024ce/html5/thumbnails/16.jpg)
Duplex doppler sonography
Functional and anatomical
Peak200 cm/sec
![Page 17: Renal artery stenosis](https://reader035.vdocuments.mx/reader035/viewer/2022062411/5695d40f1a28ab9b02a024ce/html5/thumbnails/17.jpg)
Peak systolic velocitySensitivity 85, specificity 92%Positive predictive value 84%
Positive test: more informative than negative test
![Page 18: Renal artery stenosis](https://reader035.vdocuments.mx/reader035/viewer/2022062411/5695d40f1a28ab9b02a024ce/html5/thumbnails/18.jpg)
Resistive index(1-end diastolic velocity)/PSV
Predict outcome after revascularization
![Page 19: Renal artery stenosis](https://reader035.vdocuments.mx/reader035/viewer/2022062411/5695d40f1a28ab9b02a024ce/html5/thumbnails/19.jpg)
Limitation
Time consuming operator dependent
![Page 20: Renal artery stenosis](https://reader035.vdocuments.mx/reader035/viewer/2022062411/5695d40f1a28ab9b02a024ce/html5/thumbnails/20.jpg)
Obese patient
![Page 21: Renal artery stenosis](https://reader035.vdocuments.mx/reader035/viewer/2022062411/5695d40f1a28ab9b02a024ce/html5/thumbnails/21.jpg)
CT angiography
![Page 22: Renal artery stenosis](https://reader035.vdocuments.mx/reader035/viewer/2022062411/5695d40f1a28ab9b02a024ce/html5/thumbnails/22.jpg)
Excellent sensitivity and specificityLimitation in distal stenosis (FMD)
![Page 23: Renal artery stenosis](https://reader035.vdocuments.mx/reader035/viewer/2022062411/5695d40f1a28ab9b02a024ce/html5/thumbnails/23.jpg)
Magnetic resonance angiography
![Page 24: Renal artery stenosis](https://reader035.vdocuments.mx/reader035/viewer/2022062411/5695d40f1a28ab9b02a024ce/html5/thumbnails/24.jpg)
MRA• Almost 100% sensitivity!• Nephrogenic systemic
fibrosis?
![Page 25: Renal artery stenosis](https://reader035.vdocuments.mx/reader035/viewer/2022062411/5695d40f1a28ab9b02a024ce/html5/thumbnails/25.jpg)
Functional assessment
![Page 26: Renal artery stenosis](https://reader035.vdocuments.mx/reader035/viewer/2022062411/5695d40f1a28ab9b02a024ce/html5/thumbnails/26.jpg)
Captopril renography: less commonly usedLittle predictive value
Not for screening test!
![Page 27: Renal artery stenosis](https://reader035.vdocuments.mx/reader035/viewer/2022062411/5695d40f1a28ab9b02a024ce/html5/thumbnails/27.jpg)
Selecting a diagnostic test
• Local availability• Expertise with each technique• Renal insufficiency?
![Page 28: Renal artery stenosis](https://reader035.vdocuments.mx/reader035/viewer/2022062411/5695d40f1a28ab9b02a024ce/html5/thumbnails/28.jpg)
Who
New onset HT>55 yrDeterioration GFRAsymmetry kidneyFlash pulmonary edema
Test
Failure medicalFMD?Progressive renalfailure
Benefit fromcorrection
![Page 29: Renal artery stenosis](https://reader035.vdocuments.mx/reader035/viewer/2022062411/5695d40f1a28ab9b02a024ce/html5/thumbnails/29.jpg)