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Renovascular Disease

Understand the pathophysiology, clinical evaluation, and treatment of renovascular disease, including renal artery aneurysm and ischemic nephropathy. Learn about lesion classification, diagnostic points, and surgical approaches for optimal management.

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Renovascular Disease

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  1. Renovascular Disease Daniel Shoskes MD, MSc, FRCSC Professor of Surgery/Urology Glickman Urological and Kidney Institute Cleveland Clinic

  2. Overview • Pathophysiology • Classification of Lesions • Clinical Evaluation • Medical and Surgical Management • Renal Artery Aneurysm

  3. Goldblatt Dog Models ARB/ACE inhibitors help Only help when Na depleted

  4. Ischemic Nephropathy • Does not correlate with hypertension • Progressive azotemia in pt with risk factors for atherosclerotic disease • Progresses through nephrosclerosis and atheroemboli • Treatment of hypertension will not improve renal function, may actually exacerbate

  5. Diameter and Blood Flow

  6. Classification • Atherosclerotic (70%) • Fibromuscular Disease (30%)

  7. Fibromuscular Disease Medial Fibroplasia: 77% Perimedial Fibroplasia: 10% Intimal Fibroplasia: 10% Fibromuscular Hyperplasia: 3%

  8. Atherosclerosis • typically a systemic disease • involves proximal 2 cm of artery • may only be seen on oblique views • progression common, at least 50% in 2 years • 10-15% progress to occlusion • can cause hypertension and Renal Failure

  9. Medial Fibroplasia • most common fibrous • women 25-50 • commonly bilateral • "string of beads" • involves distal 2/3 and branches • progression less common

  10. Clinical Clues to RVH • HTN onset < 30 yrs or > 55 • sudden onset, short duration • lack of family history • difficult to control • malignant crisis • bruits • disseminated atherosclerotic disease • renal size disparity

  11. Key Diagnostic Points • Captopril provocation • reduction of GFR detected by nuclear scan • best predictor of surgical cure (spec 93-98%) • increased PRA (off most drugs) • Renal Vein Renins • ipsilateral hypersecretion, contralateral suppression • best for bilateral disease • Ultrasound • operator dependent, independent of renal function • MRA • poor images beyond main renal artery

  12. Investigation of Ischemic Nephropathy • High suspicion • straight to angiography • Mild to Moderate suspicion • non-invasive imaging (local preference) • if significant azotemia, US rather than MRA or spiral CT

  13. Investigation of RVH • High suspicion • angiography and Renal Vein Renins if bilateral • Moderate suspicion • captopril nuclear renography (can do "post" study first) • positive -> angio • equivocal -> non-invasive imaging • negative -> stop

  14. Treatment of RVH • Select medical management based on risk of ischemic nephropathy and lesion progression • medial fibroplasia and atherosclerotic (without ischemic nephropathy) best for medical • angioplasty +/- stents usually procedure of choice unless • branch vessel disease • renal artery aneurysm • Nephrectomy if small and non-functioning

  15. Treatment of Ischemic Nephropathy • No benefit with unilateral disease • Signs of reversibility • progressive occlusion • collaterals • retrograde arterial filling • size > 9 cm • Cr < 4.0 • preservation of glomeruli on biopsy

  16. Hepatorenal Splenorenal Ileorenal Autotransplant Arteriotomy Aortorenal Thoracic aorta - renal Surgical Approaches

  17. Renal Artery Aneurysms • most small and asymptomatic • pathology • saccular (most common), fusiform, dissecting, intrarenal • risk of rupture • absent/incomplete calcification, >2cm diameter, expanding, hypertension, pregnancy • other complications • pain, hematuria, dissection, emboli

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