DEPARTMENT OF VASCULAR INTERVENTIONAL RADIOLOGY

KEM HOSPITAL
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RENOVASCULAR
HYPERTENSION
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CAUSES

 TWO THIRDS- ATHEROSCLEROSIS

 REST –FIBROMUSCULAR DYSPLASIA-

75%-80% of all- MEDIAL FIBROPLASIA. Less common entities

include intimal fibroplasia, perimedial fibroplasia, medial
hyperplasia, and adventitial hyperplasia.

 RARE- Takayasu arteritis(Asia), neurofibromatosis, irradiation.

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INDICATIONS FOR TESTING FOR RVH

 Clinical findings suggest a cause of secondary hypertension.

 Another cause of secondary hypertension such as primary kidney disease, primary

aldosteronism, or pheochromocytoma absent.

 An intervention is planned if a significant stenotic lesion is found.

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CLINICAL SUSPICION
SECONDARY HYPERTENSION-

1.SEVERE/RESISTANT HYPERTENSION,
2.ACUTE RISE OVER PREVIOUSLY STABLE VALUE
3.AGE OF ONSET BEFORE PUBERTY
4.AGE< 30 YRS WITH NO FAMILY HISTORY

RENOVASCULAR HYPERTENSION-

1.ACUTE ELEVATION OF SERUM CREATININE ATLEAST 30 % AFTER ACE

INHIBITOR
2.UNILATERAL SMALL KIDNEY OR SIZE DISCREPANCY OF >1.5 cm
3. RECURRENT EPISODES OF FLASH PULMONARY EDEMA
4. ONSET OF STAGE II HYPERTENSION AFTER 55 YEARS

RESISTANT HYPERTENSION- Hypertension that persists despite adherence to an adequate

and appropriate triple drug regimen.
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AHA guidelines 2017

(Renovascular
hypertension
publication date-
2013)
SCAI(Society of Cardiovascular Angiography and Intervention)- 2014
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ESC/ESH Arterial Hypertension

Guidelines- 2018
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WHEN IS INTERVENTION PLANNED

 A short duration (weeks or months) of blood pressure elevation

prior to the diagnosis of renovascular disease, even if the blood
pressure can be controlled with drug therapy, since this is the
strongest clinical predictor of a fall in blood pressure after renal
revascularization
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WHEN IS INTERVENTION PLANNED
 Failure of optimal medical therapy to control the blood pressure

 Intolerance to optimal medical therapy, including a clinically

significant rise in serum creatinine after initiation of a renin-
angiotensin system inhibitor.

 Suspected fibromuscular disease in a young person in an attempt

to limit the need for life-long antihypertensive therapy.

 Progressive renal insufficiency that is thought be a consequence of

bilateral renovascular disease or unilateral stenosis affecting a
solitary functioning kidney.

 Recurrent flash pulmonary edema and/or refractory heart failure.

 INTERVENTION FOR PROGRESSIVE RENAL INSUFFICIENCY

 Renal resistive index ABOVE 0.80 measured by duplex ultrasound denote

poor prognosis for renal recovery while a low resistive index is a favorable
sign .

 A recent deterioration of renal function ie, in the prior six to twelve months-
good prognosis.

 Very small kidneys (less than 7 cm in longest diameter) are usually

considered unlikely to recover after revascularization .

 Kidney biopsy – Previous studies suggest that biopsy demonstrating

preexisting atheroembolic changes and interstitial fibrosis indicate a limited
potential for recovery . Biopsies are not usually performed.
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 Comparison of kidney morphology with kidney function – Some

investigators recommend assessing morphologic parameters,
such as renal parenchymal volume and cortical thickness with
MRI, and comparing these parameters with renal function
measured by radionuclide scanning. In a stenotic kidney,
apparently normal morphology combined with reduced function
may indicate a "hibernating kidney" that could be salvaged with
revascularization.
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DIAGNOSTIC TESTS
 Duplex Doppler ultrasonography

 Computed tomographic angiography (CTA)

 Magnetic resonance angiography (MRA)

 Digital Subtraction Angiography

 Carbon dioxide Angiography

 Captopril Renogaphy

 Selective renal vein renin measurements

 Plasma renin activity

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Duplex Doppler ultrasonography

 A peak systolic velocity above 200 cm/sec suggests a stenosis of

greater than 60 percent.

 Some studies indicate that a peak systolic velocity above 300

cm/sec represents a hemodynamically important threshold.

 Renal-to-aortic PSV ratio greater than 3.5

 AT > .07s

In general, a higher resistive index (>0.8) is associated with a greater

degree of intrinsic renal damage (ie, likely irreversible small vessel
injury) and, therefore, a diminished predicted benefit from
revascularization.
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CT AND MR ANGIOGRAPHY

 A stenosis greater than 75 percent in one or both renal arteries

or a 50 percent stenosis with post-stenotic dilatation suggests
that the patient may have renovascular hypertension.

 Prefer CTA in patients with an eGFR less than 30 mL/min,

despite the risk of radiocontrast nephropathy with preventive
measures .

 MRA with gadolinium in patients with moderate to severe renal

disease is now severely limited because of the risk of
nephrogenic systemic fibrosis, which is often severe.
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DSA

 Gold standard

 Society of Interventional Radiology - Catheter-based angiography ,

(1) RAS previously diagnosed on noninvasive imaging,

(2) Noninvasive imaging unlikely to be diagnostic,

(3) Adequately high clinical suspicion,

(4) Hypertension occurring in patients younger than 30 years old, or

(5) High clinical suspicion for FMD in a patient of any age.

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Atherosclerotic RAS

PROXIMAL STENOSIS,
MOSTLY INVOLVING
THE OSTIUM

MAY BE ECCENTRIC OR
CONCENTRIC

ATHEROSCLEROSIS OF
OTHER ARTERIES
STRONG CLUE

Systolic pressure gradient

greater than 10% of
systolic pressure or 20
mm Hg.
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Fibromuscular dysplasia

MULTIFOCAL UNIFOCAL TUBULAR

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CARBON DIOXIDE ANGIOGRAPHY
 Carbon dioxide (CO2) is an excellent negative contrast agent
which has been used for a variety of vascular interventions .

PROPERTIES OF CO2

 Inexpensive, highly soluble (28 times more than air),

compressible and low viscosity(400 times less than iodinated
contrast) gas.

 Buoyancy causes visualisation of vessels anterior to injection

site better.

 Very low viscosity allows injection via small (22G) needles/3F

catheters even when there is a guidewire in situ and results in
filling of the smallest branches regardless of blood flow rate and
degree of stenosis.
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CO2 Angiography Delivery System
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Indications and Contraindications
Contraindications

Indications  Absolute
 CO2 has potential neurotoxic and cardiotoxic
effects hence it should not be used for
Allergy to iodinated cerebral or coronary artery (above diaphragm
aorta) angiograms.
contrast media  prone position injection should be avoided
due to possible spinal ischaemia
 arterial limb of dialysis AVF

Poor renal function  Relative

 COPD patients
 patients on nitrous oxide anaesthesia: may
increase the volume of the CO2 bubbles
leading to pulmonary artery vapour lock
which may be fatal
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Captopril Renogaphy-

 Expected ACE inhibitor-induced decline in glomerular filtration

rate (GFR) in the stenotic kidney, often accompanied by an
increase in GFR in the contralateral kidney due to removal of
angiotensin II-mediated vasoconstriction.

 Poor sensitivity and specificity of the ACE inhibitor scan and a

poor correlation with the benefit obtained from angioplasty .

 Therapeutic nephrectomy for uncontrolled hypertension when

the affected kidney accounts for less than 15 percent of the total
GFR
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Selective renal vein renin measurements
 Renin secretion increased in the stenotic kidney ≥1.5 times the
value from the contralateral kidney---- physiologically significant
renal artery stenosis.

 Measurements may be enhanced by the prior administration of an

ACE inhibitor

 Many false negative and occasional false positive results .

 More than 90 percent of patients with unilateral renal artery

stenosis and lateralizing renin values will have a favorable blood
pressure response to angioplasty or surgery so will approximately
50 percent of patients with nonlateralizing renin values.
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Plasma renin activity

 Transient elevation in RVH, so poor sensitivity.

 Levels of PRA may be suppressed by a-

 High dietary sodium intake,

 Bilateral renal arterial disease,

 Volume expansion related to intrinsic kidney disease,

 Various antihypertensive drugs .

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TREATMENT

 Medical therapy (essentially all patients)

 Percutaneous angioplasty with or without stent placement

 Surgical revascularization or, in some cases, resection of a

"pressor" kidney

In general, the effects of revascularization on blood pressure were

greater in bilateral disease, but effects on renal function and
mortality did not differ in those with bilateral as compared with
unilateral stenosis
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ATHEROSCLEROTIC RAS-PTRA +/-stent in combination
with medical therapy
VS.
Medical therapy alone

 8 RCTS

 CORAL , ASTRAL – LARGEST AMONG THESE

 No benefit from PTRA on mortality, end-stage renal

disease (ESRD), major cardiovascular events, or
blood pressure control
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CORAL
( Cardiovascular Outcomes in Renal
Atherosclerotic Lesions )

 Luminal narrowing >60 %- DSA

 A peak systolic velocity >300 cm/second

 Luminal narrowing >80 percent if diagnosed with MRA OR CTA

 Systolic hypertension despite two or more antihypertensive

medications and/or an estimated glomerular filtration rate
(eGFR) <60 mL/min/1.73 m2 that was presumably due to the
stenosis.
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OUTCOME

 NO EFFECT ON PRIMARY OUTCOMES (Mortality associated

with CVS AND RENAL disease ,myocardial infarction and
progression to ESRD)

 REDUCTION IN MEAN SYSTOLIC BLOOD PRESSURE by 2

mm Hg in combination gp vs Medical therapy alone.

 The most frequent serious complication was renal artery

dissection, which occurred in 2.2 % revascularized patients
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MAJOR SELECTION BIAS

CORAL

 Heart failure within 30 days of screening for the trial

were excluded, thereby limiting the number of trial
participants with recurrent flash pulmonary edema .

 Mean number of antihypertensive medications used

by CORAL participants at baseline was 2.1, indicating
that many had not failed optimal medical therapy.
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Prospective cohort

467 patients with renal artery stenosis were treated with either revascularization or medical
therapy alone according to patient and clinician preferences

Revascularization BENEFITS
RISK OF DEATH in patients with flash pulmonary edema (58 versus 76 percent)

RISK OF DEATH with both resistant hypertension and progressive renal insufficiency
(9 versus 65 percent)

CARDIOVASCULAR EVENTS among patients with both resistant hypertension and

progressive renal insufficiency (27 versus 60 percent).

BY CONTRAST, REVASCULARIZATION WAS NOT ASSOCIATED WITH SUCH BENEFITS

IN PATIENTS WITHOUT THESE RISK FACTORS
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Observational study compared the outcomes of 347 patients

with renal artery stenosis treated with medical therapy alone
with 89 patients treated with PTRA.

The patients who underwent revascularization had more

comorbidity at baseline than patients who received medical
therapy alone. Despite this, patients who had revascularization
had significantly lower rates of mortality and renal disease
progression after multivariable analysis.
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MEDICAL THERAPY

 ACE inhibitors and angiotensin II receptor blockers (ARBs) – 1st

line in U/L RAS .

 Combination therapy with a diuretic plus an angiotensin-

converting enzyme (ACE) inhibitor or angiotensin II receptor
blocker (ARB) for bilateral renal artery stenosis.

 If goal blood pressure is not reached , other antihypertensive

drugs, a long-acting calcium channel blocker, a mineralocorticoid
receptor antagonist, or a beta blocker, should be added as
necessary .
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INTERVENTIONAL THERAPY-
PTRA VS RENAL STENTING
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RESULTS OF RCT OF
PTRA + STENTING vs PTRA
 ●A higher initial primary success rate, defined as less than 50
percent stenosis (88 versus 57 percent).

 ●At six months, a higher patency rate (75 versus 29 percent)

and a lower restenosis rate (14 versus 48 percent).

 ●Twelve patients assigned to PTRA alone underwent stenting

because of treatment failure within six months. These patients
had a similar blood pressure response as those initially treated
with stenting.

 ●Most patients had stable renal function.

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SURGERY- 2006 ACC/AHA guidelines-
Performed only when
•Multiple small renal arteries

•Early primary branching of the main renal artery

•Requirement for aortic reconstruction near the renal arteries for

other indications, such as aneurysm repair or severe aortoiliac
occlusive disease

•In order to avoid manipulation of a highly diseased aorta or failed

endovascular stents (using specific surgical techniques, including
splenorenal, ileorenal, or hepatorenal bypass procedures)
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FIBROMUSCULAR DYSPLASIA

 MEDICAL THERAPY- SAME AS ATHEROSCLEROTIC RAS.

Majority of patients with focal FMD have their blood pressure
cured (normal blood pressure, no antihypertensive medications)
after angioplasty.

 Children with FMD may be at higher risk than adults for

progressive renal parenchymal loss, and therefore could benefit
from revascularization even if their hypertension can be well-
controlled with one or two antihypertensive medications .
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PTRA VS STENTING FOR FMD

 Patients do very well with angioplasty alone, so there is no reason

to place a stent. If the lesion is so fibrotic that the pressure gradient
cannot be obliterated with an angioplasty, a stent will not correct
this problem (and stent deformation will likely occur). Such patients
should be referred for surgery.

 ●Patients with renal FMD usually have stenoses in the mid and
distal portions of the artery rather than at the ostium or proximal
portion (as occurs with atherosclerosis). Should surgical
revascularization become necessary due, for example, to in-stent
restenosis, patients may require more complex branch repair to
bypass the occluded stent since the stent often covers the renal
artery up to the point of the first intrarenal branch.
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Meta-analysis of 70 observational studies that included 47 PTA series and

13 surgery series .

●Improvement in blood pressure (including those with and without cure) was
similar with PTA as compared with surgery (86 versus 88 percent).

●Cure rates were higher with surgery (54 versus 36 percent).

●Major adverse events were more frequent with surgery (15 versus 6
percent).

●Older age and longer duration of hypertension prior to revascularization

were significantly associated with a lower cure rate.
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COMPLICATIONS OF PTRA+/-
STENTING
 The technical complication rate with percutaneous transluminal renal
angioplasty with or without stenting is between 5 and 15 percent

 Most of the complications are relatively minor - Puncture site hematoma

and renal artery dissection.

MAJOR-

 Renal artery thrombosis or perforation (often requiring surgery)

 Acute kidney injury due to atheroembolic disease (which may be

irreversible)

 Reaction to the radiocontrast agent (which is usually reversible)

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Case 1- 18 year old girl with refractory
hypertension

Angiogram shows
unifocal stenosis
in mid segment of
renal artery-
Likely etiology-
FMD
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PTRA with post procedure angiogram
shows good revascularisation
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Case 2- 66 yr old gentleman with Rt renal
ostial stenosis and deranged renal functions

A.CARBON
DIOXIDE
ANGIOGRAPHY
SHOWS OSTIAL
STENOSIS.

B.POSITIONING
OF A BALOON
MOUNTED STENT

A B
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POST STENTING ANGIOGRAM-SUCCESSFUL REVASCULARISATION
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Case 3- 63 yr old gentleman with Rt renal
ostial stenosis and deranged renal functions

A.CARBON
DIOXIDE
ANGIOGRAPHY
SHOWS OSTIAL
STENOSIS.

B.POSITIONING OF
A BALOON
MOUNTED STENT

A B
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POST STENTING ANGIOGRAM-SUCCESSFUL REVASCULARISATION
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