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Endovascular Renal Denervation

Endovascular renal denervation has emerged as a promising therapy for resistant hypertension. Phase III randomized trials have not been completed, but the emerging data suggest that this procedure may be highly effective at improving hypertension control in this population. The procedure is also being evaluated for a variety of other clinical indications characterized by increased sympathetic activity. The pathophysiologic rationale for this approach, the early experience…

Renal Arteriovenous Malformations And Arteriovenous Fistulas

Renal arteriovenous malformations (AVMs) and arteriovenous fistulas (AVFs) have the common characteristic of one or more abnormal channels between an intrarenal artery and vein, allowing the blood to bypass the glomerular capillaries. A communication between the renal artery and the renal vein can be demonstrated by color Doppler sonography, computed tomography (CT), or magnetic resonance angiography (MRA), and the diagnosis is confirmed by renal arteriography. The…

Treatment of Renal Artery Aneurysms

Renal artery aneurysms represent an unusual vascular disease that has been encountered with increasing regularity in clinical practice. In part, this reflects their frequent incidental recognition as a consequence of the proliferation of noninvasive imaging for nonvascular diseases. The incidence of true renal artery aneurysms approaches 0.1%, a figure derived from the 0.09% incidence of these lesions in approximately 8500 patients subjected to arteriographic studies for…

Renal Vein Thrombosis

Renal vein thrombosis is an uncommon clinical condition that typically occurs in association with or as a consequence of the nephrotic syndrome, renal cell carcinoma, extrinsic compression, or a hypercoagulable condition. It is also a distinct entity recognized in the pediatric population, specifically in neonates who have severe dehydration or sepsis. Traditional management for renal vein thrombosis has been systemic anticoagulation followed by long-term warfarin administration.…

Renal Artery Atheroembolism

Atheroembolic renal disease (AERD) occurs following occlusion of the renal vasculature by cholesterol crystals originating from the aorta or other large arteries spontaneously (primary disease) or following vascular intervention (secondary disease). Cardiac and cerebrovascular cases of atheroembolic disease were the first to be described, with initial reports dating back to the 1870s. Flory, in 1946, was the first to prove that atheromatous aortic plaque is the…

Renal Artery Dissection

Renal artery dissection is most commonly associated with dissection of the aorta. Less than one fourth of all dissections involving the renal vessels are isolated to the renal artery alone. Nonetheless, the renal artery is the most common site of isolated dissection of an aortic branch vessel. The causes of isolated renal artery dissection fall into two distinct categories: those that are primary and associated with…

Surgical Treatment of Renovascular Hypertension in Children

Renal artery occlusive disease affecting pediatric patients is an important but very uncommon cause of hypertension in children. Renal artery stenoses in this age group represent a wide spectrum of heterogeneous diseases, although developmental anomalies with concomitant narrowings of the splanchnic arteries and the abdominal aorta itself are most common. Inflammatory aortoarteritis is the second most common cause of renal artery stenoses in children, and in…

Ex Vivo Arterial Repair for Renovascular Hypertension Secondary to Fibrodysplasia

Fibrodysplastic disease of the renal arteries is bilateral in more than half of the patients, and involvement of the primary branches of the renal artery has been reported in as many as 40%. In most patients the fibrodysplastic lesions are located in the distal renal artery, but many lesions affect multiple smaller renal arteries or extend into the primary and secondary branches of the renal artery.…

Alternative Renal Artery Reconstruction Techniques: Hepatorenal, Splenorenal, Iliorenal, and Mesorenal Bypass Procedures

Open renal revascularization for renovascular hypertension is being performed less often given advances in endovascular therapy. In fact, currently most renal artery bypass procedures are undertaken as part of hybrid operations accompanying endovascular interventions for aortic aneurysmal disease. Alternatives to conventional renal revascularizations may be very important when an open procedure is needed. Marginal cardiac function or a hostile aorta because of coexistent aortic disease or…

Aortorenal Bypass for Renovascular Hypertension in Adults

The introduction of new, highly potent antihypertensive agents and percutaneous intervention has changed many attitudes regarding open surgical treatment for renovascular disease. Many physicians recommend surgical intervention for severe hypertension despite maximal medical therapy, for failures or disease patterns not amenable to percutaneous dilation, or for renovascular disease associated with excretory renal insufficiency (ischemic nephropathy). Preoperative Preparation Antihypertensive medications are reduced during the preoperative period to…

Transaortic Renal Artery Endarterectomy for Renal Artery Atherosclerosis

Renal revascularization is indicated for renin-mediated hypertension and for progressive renal insufficiency secondary to renal artery arteriosclerosis. Renal artery atherosclerotic lesions account for 90% of all renal artery stenoses and are most often a manifestation of generalized atherosclerosis. Operative options in carefully selected patients include percutaneous angioplasty with or without a stent, a bypass, or an endarterectomy. Endarterectomy is the most technically challenging. Three specific patterns…

Percutaneous Arterial Dilation and Stenting for Arteriosclerotic Renovascular Hypertension and Ischemic Nephropathy

Anecdotal experience and many retrospective studies support the utility of renal artery stenting in carefully selected patients, yet Level 1 evidence has been lacking. Several multicenter prospective randomized studies have been conducted to determine whether renal artery stenting was superior to medical therapy for treatment of ischemic nephropathy. The negative conclusions of the widely quoted Angioplasty and STenting for Renal Artery Lesions (ASTRAL) trial, a large…

Selection of Patients for Open Surgical or Endovascular Treatment of Renal Artery Arteriosclerotic Disease

Two questions arise when an arteriosclerotic renal artery stenosis is identified. First, is it a contributing factor to the patient’s hypertension or renal insufficiency? Second, if stenosis is a contributing factor and an operative intervention is deemed appropriate, is an open surgical procedure or endovascular procedure preferred? Historically, when open surgical procedures were the only means available to revascularize a kidney, considerable time and resources were…

Renal Insufficiency and Renal Artery Occlusive Disease

Until the early 1960s, the pathophysiology and management of atherosclerotic renovascular disease focused solely on hypertension. However, current management of renal artery atherosclerosis considers the relationship between renal artery occlusive disease and renal insufficiency, a relationship recognized by the term ischemic nephropathy. In 1962, Morris and associates reported on eight azotemic patients with global renal ischemia who had improved blood pressure and kidney function after renal…

Duplex Scanning in the Evaluation of Renal Arterial Occlusive Disease

Duplex ultrasound scanning was developed in the 1970s as a direct noninvasive method for evaluating the extracranial carotid arteries. Subsequent advances in ultrasound technology, particularly the improved B-mode imaging systems, color-flow Doppler imaging, and lower-frequency ultrasound transducers, have extended the applications of duplex scanning to the more complex and deeply located vessels of the abdomen including the renal vasculature. Duplex scanning is currently the only noninvasive…