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 Renal Artery Disease

Kimberly J. Hansen, M.D., Robert G. Atnip, Jr., M.D., Gregorio A. Sicard, M.D.

Includes:

  • Renovascular Hypertension
  • Ischemic Nephropathy
  • Renal Artery Surgery
  • Renal Angioplasty
  • Diagnostic Studies to Detect Functionally Significant
  • Renal Artery Stenosis

I. Anatomy and Pathophysiology

1. To define normal renal artery anatomy and collateral pathways important in renal artery disease.

2. To understand the etiology, pathology and natural history of these renal artery lesions:

a. Renal artery atherosclerosis

b. Renal artery fibromuscular dysplasia

c. Renal artery aneurysm

d. Renal arteriovenous malformation

e. Takayasu's arteritis

f. Middle aortic syndrome/congenital hypoplasia

g. Atheroembolic disease

h. Renal artery trauma

i . Embolic occlusion

j. Renal artery dissection

3. To define common co-existing extrarenal diseases associated with the various renal artery lesions.

4. To understand the exocrine and endocrine function of the kidney, and relate these to the structure and function of the nephron unit.

5. To understand the renin-angiotensin axis in the absence and presence of renal artery disease.

6. To describe the mechanisms of renovascular hypertension and renovascular insufficiency (i.e., ischemic nephropathy) and to understand how these differ for unilateral and bilateral renal artery disease.

II. Diagnostic Evaluation

Screening and Imaging

1. To describe the clinical features of renovascular hypertension and renovascular insufficiency, and to contrast these with essential hypertension and parenchymal renal failure.

2. To describe the performance and diagnostic criteria for these screening/imaging studies:

a. Captopril renin test

b. Captopril renography

c. Intravenous urography

d. Ultrasonography

1. Duplex sonography

2. Intravascular sonography

e. Spiral computerized tomography

f. Magnetic resonance imaging

g. Angiography

1. Digital subtraction angiography

a . Intravenous

b. Intra-arterial

2. Cut-film angiography

3. CO 2 angiography

3. To define the applications and limitations of available screening/imaging studies.

Tests of Functional Significance

1. To distinguish between functionally significant and clinically silent renal artery disease.

2. To define the selection and patient preparation for these studies of functional significance:

a. Split renal function test

b. Selective renal vein renin determination

c. Peripheral plasma renin determination

d. Captopril renin test

e. Captopril renography

3. To describe the diagnostic criteria, predictive value and limitations of each study of physiologic significance.

III. Treatment

1. To describe the strategies, options and anticipated results of medical management for the various renal artery lesions.

2. To appreciate the limitations and complications associated with medical management of renovascular hypertension and renovascular insufficiency.

3. To understand the indications, anticipated anatomic results and clinical response associated with catheter-based intervention for the various renal artery lesions:

a. PTA ± intravascular stenting

b. Athrectomy

c. Fibrinolytic therapy

4. To understand the indications for surgical renal artery reconstruction as they relate to the various renal artery lesions.

5. To define the techniques of surgical exposure for renal artery lesions.

6. To understand the selection and performance of direct and indirect reconstruction for the different renal artery lesions:

a. Direct reconstruction

1. Aortorenal bypass

2. Endarterectomy

a. Transaortic

b. Transrenal

3. Reimplantation

4. Ex vivo reconstruction

b. Indirect reconstruction

1. Splanchnorenal bypass

a. Splenorenal

b. Hepatorenal

c. Nephrectomy

7. To describe the anticipated results of reconstruction and nephrectomy as they relate to hypertension response, renal function response, subsequent cardiovascular events and patient survival.

8. To define the management of silent and functionally significant renal artery lesions combined with occlusive or aneurysmal aortic disease.

9. To recognize and develop a plan of management for complications associated with surgical management of renal artery disease and understand how these complications relate to co-existing renal and extrarenal disease.

References

1. Robaczewski , DL, Dean RH. Renovascular hypertension. In: Sidawy AN, Sumpio BE, DePalma RG, eds . The basic science of vascular disease. Armonk , NY :Futura Publishing Company, Inc. (In Press)

2. Martinez-Maldonado M. Pathophysiology or renovascular hypertension. Hypertension 1991 ;17:708 .

3. Gomez RA, Chevalier RL. Carey RL, Peach MJ. Molecular biology of the renal renin-angiotensin system. Kidney Int 1990 ;38 (30):S18.

4. Dean RH, Benjamin ME, Hansen KJ. Surgical management of renovascular hypertension. In: Wells SA, Jr., eds . Current problems in surgery. St. Louis : Mosby -Year Book, Inc. (In Press)

5. Dean RH, Kieffer RW, Smith BM, et al. Renovascular hypertension: anatomic and renal function changes during drug therapy. Arch Surg 1981 ;166:1408 .

6. Dean RH, Tribble RW, Hansen KJ, et al. Evolution of renal insufficiency in ischemic nephropathy. Ann Surg 1991 ;213:446 .

7. Libertino JA, Flam TA, Zinman LN , et al. Changing concepts in surgical management of renovascular hypertension. Arch Intern Med 1988 ;148:357 .

8. Reilly JM, Rubin BG, Thompson RW, Allen BT, Anderson CB, Sicard GA. Long-term effectiveness of extra-anatomic renal artery revascularization. Surgery 1994 ;116 (4):784.

9. Atnip RG, Neumyer MM, Healy DA, et al. Combined aortic and visceral arterial reconstruction: risks and result. J Vasc Surg 1990 ;12:705.

Posted June 2010