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Among the indications for renal artery revascularization, either surgical or endovascular, in patients with renal artery stenosis are poorly controlled hypertension, ischemic nephropathy (preservation of renal function), or recurrent episodes of "flash" pulmonary edema and congestive heart failure. Pharmacologic treatment is the first-line therapy to control blood pressure. If the disease is unilateral, the blood pressure regimen should include an angiotensin-converting enzyme inhibitor. Guidelines published in the Sixth Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of high blood pressure should be followed. Revascularization is recommended if patients have at least 75% stenosis of one or both renal arteries, combined with resistant or poorly controlled hypertension; recurrent flash pulmonary edema; dialysis-dependent renal failure resulting from renal artery stenosis; chronic renal insufficiency and bilateral renal artery stenosis; or renal artery stenosis to a solitary functioning kidney. To treat fibromuscular disease of the renal arteries, percutaneous transluminal angioplasty is the revascularization procedure of choice. Ex vivo surgical repair of the renal artery may be required if there is significant branch renal artery stenosis. To treat atherosclerotic renal artery stenosis, the revascularization procedure of choice is percutaneous transluminal angioplasty and stent implantation, especially if there is concomitant ostial or proximal renal artery disease. Surgical revascularization is performed if concomitant aortic surgery is required, such as for abdominal aortic aneurysm.
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PMID:Renal Artery Stenosis. 1109 69

Although revascularization of renal artery stenosis (RAS) from fibromuscular dysplasia (FMD) generally yields satisfying outcomes, traditional approaches to revascularization for atherosclerotic renal artery stenosis (ARAS) have been suboptimal because of the invasiveness, relatively high perioperative morbidity and mortality rates of surgery, and the low rates of technical success and long-term patency with percutaneous renal balloon angioplasty (PTA). Endovascular stents have been deployed for failed PTA (unsatisfactory results or complications) and treatment of restenotic lesions. Compared to PTA, primary stenting of ostial ARAS gives superior technical success rates greater than 95% and improved long-term patency. Curing hypertension after RAS revascularization is rare (< 10%). Improved control with fewer medications is a more realistic goal. Renal function as judged by serum creatinine improves in 20% to 30%, stabilizes in 40% to 60%, and deteriorates in 20% to 30% of patients whose renal function is impaired initially. One study demonstrated successful stenting slowed the rate of progression of renal failure in 89% of patients whose serum creatinine was less than 400 mol/L. Complications of renal artery stenting may be substantial, though procedure-related mortality is low. Patient selection for renal revascularization remains controversial. Those with renovascular disease and uncontrolled hypertension, progressive renal failure, or recurrent flash pulmonary edema should be carefully considered for renal artery stenting in experienced centers.
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PMID:Renal Artery Stent Placement: Indications and Results. 1109 60

Chronic azotemic renovascular disease is common in patients with atherosclerosis. Its prevalence appears to be increasing in the aging population. How often it is the primary cause of end-stage renal disease (ESRD) is not yet certain. Some studies suggest that 10%-40% of elderly hypertensive patients with newly documented ESRD and no demonstrable primary renal disease have significant renal artery stenosis (RAS). Atherosclerotic vascular occlusive disease of the renal arteries does progress, but current rates of progression and occlusion are lower than those reported a decade ago. Methods of identifying patients whose renal function is at true risk from vascular occlusive disease and determining who will benefit from intervention remain elusive. The presence of RAS in an azotemic patient can be assessed with noninvasive and risk-free radiologic techniques, including Duplex doppler velicometry and magnetic resonance angiography. Functional tests that predict the change in renal function after revascularization are not yet available. However, a renal length of greater than 7.5 cm in the absence of renal cysts and a short history of renal functional deterioration indicate a good prognosis. Patients with recent deterioration in renal function, those with bilateral renal artery stenosis or stenosis to a single functioning kidney, those with flash pulmonary edema, advanced chronic renal failure, or ESRD (who have much to gain), those with reversible azotemia during angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor antagonist (ARB) therapy, and those whose conditions cannot be managed medically should be considered for revascularization. Results from recent controlled clinical trials of the response to percutaneous transluminal renal artery angioplasty (PTRA) and stenting indicate that improvement in blood pressure control or renal function is not a predictable outcome of renal revascularization. In azotemic groups, 25%-30% of patients achieve important recovery of renal function. Thus, significant progress has been made recently in determining whether RAS is a frequent, treatable cause of renal failure. The decision to recommend revascularization remains a difficult balance between the risks and expense of the procedure and the undoubted benefits that accrue if renal function is successfully stabilized.
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PMID:Renal artery stenosis: a common, treatable cause of renal failure? 1116 Jul 87

We report the case of a 70-year-old hypertensive man with a solitary kidney and chronic renal insufficiency who developed two episodes of transient anuria after losartan administration. He was hospitalized for a myocardial infarction with pulmonary edema, treated with high-dose diuretics. Due to severe systolic dysfunction losartan was prescribed. Surprisingly, the first dose of 50 mg of losartan resulted in a sudden anuria, which lasted eight hours despite high-dose furosemide and amine infusion. One week later, by mistake, losartan was prescribed again and after the second dose of 50 mg, the patient developed a second episode of transient anuria lasting 10 hours. During these two episodes, his blood pressure diminished but no severe hypotension was noted. Ultimately, an arteriography showed a 70-80% renal artery stenosis. In this patient, renal artery stenosis combined with heart failure and diuretic therapy certainly resulted in a strong activation of the renin-angiotensin system (RAS). Under such conditions, angiotensin II receptor blockade by losartan probably induced a critical fall in glomerular filtration pressure. This case report highlights the fact that the angiotensin II receptor antagonist losartan can cause serious unexpected complications in patients with renovascular disease and should be used with extreme caution in this setting.
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PMID:Repeated transient anuria following losartan administration in a patient with a solitary kidney. 1125 25

Patients with atherosclerotic renal artery stenosis may develop hypertension, recurrent pulmonary edema and chronic renal failure, but have a much higher risk of dying from stroke or myocardial infarction than of progressing to end-stage renal disease. Indeed, atherosclerotic renal artery stenosis typically occurs in high risk patients with coexistent vascular disease elsewhere. Recent controlled trials comparing medication to revascularization have shown that only a minority of such patients can expect hypertension cure, whereas the results of trials designed to document the ability of revascularization to prevent progressive renal failure are not yet available. Revascularization should be undertaken in patients with atherosclerotic renal artery stenosis and resistant hypertension or heart failure, and probably in those with rapidly deteriorating renal function or with an increase in plasma creatinine levels during angiotensin-converting enzyme inhibition, especially if their renal resistance--index before revascularization is less than 80. With or without revascularization, medical therapy using antihypertensive agents, statins and aspirin is necessary in almost all cases.
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PMID:[Management of atherosclerotic renal artery stenoses]. 1207 Aug 43

The attitude to treatment of renal artery stenosis has recently been modified from an active to a more expectant strategy based on informations from randomised studies. The primary treatment should be antihypertensive agents. Revascularisation should be considered in patients with refractory hypertension, recurrent pulmonary oedema, bilateral renal artery stenosis or progressive azotaemia, and in patients with a narrow stenosis to a single kidney. The treatment, i.e. surgery or PTA with or without stent, should be selected on an overall view of the patients' health using a combination of clinical, pathophysiological, and angiographic investigations.
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PMID:[Treatment of renal artery stenosis]. 1208 59

An 83-year-old female who had previously (32 years ago) donated a kidney to her husband presented with loin pain, confusion and oliguria. Acute renal failure and pulmonary edema necessitated emergency hemodialysis. The history and findings were thought to be consistent with acute renal artery occlusion on a background of atherosclerosis and severe renal artery stenosis. We present this case, not to imply that renal donation is a hazardous procedure, but rather as an illustration of a complication of donor nephrectomy that in a very large series has proved to be extremely rare. This case illustrates the point that even very rare events become more likely as the period of follow-up increases.
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PMID:A late complication of spousal kidney donation. 1214 8

Among the different causes of pulmonary edema, there are all the clinical situations with hydrosaline overload. A significant (> 70%) bilateral renal artery stenosis or a unilateral stenosis in the presence of a solitary kidney is one possibility. Recurrent acute pulmonary edema not fully explained on a cardiac basis is rather typical for such a disease in a cardiac patient with moderate renal failure aggravated when angiotensin converting enzyme inhibitors are used.
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PMID:[Renal artery stenosis: acute congestive heart failure as a possible cause]. 1214 63

Flash pulmonary edema is a paroxismal pulmonary edema associated to a hypertensive crisis, that subsides in hours with the usual therapeutic measures. It occurs in patients with renal artery stenosis. We report two male patients aged 71 and 74 years old, presenting with acute dyspnea and high blood pressure. Diffuse rales were auscultated and arterial blood pressure was high in both. Dyspnea subsided in few hours with diuretics and oxygen. In both, a critical renal arterial stenosis was found and an angioplasty with stent placement was performed. After 5 and 6 months of follow up, the patients remain asymptomatic.
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PMID:[Flash pulmonary edema: when the kidney causes decompensation of the heart]. 1243 52

Atherosclerotic renal artery stenosis is the most common primary disease of the renal arteries, and it is associated with two major clinical syndromes, ischemic renal disease and hypertension. The prevalence of this disease in the population is undefined because there is no simple and reliable test that can be applied on a large scale. Renal artery involvement in patients with coronary heart disease and/or heart failure is frequent, and it may influence cardiovascular outcomes and survival in these patients. Suspecting renal arterial stenosis in patients with recurrent episodes of pulmonary edema is justified by observations showing that about one third of elderly patients with heart failure display atherosclerotic renal disease. Whether interventions aimed at restoring arterial patency may reduce the high mortality in patients with heart failure is still unclear because, to date, no prospective study has been carried out in these patients. Increased awareness of the need for cost containment has renewed the interest in clinical cues for suspecting renovascular hypertension. In this regard, the DRASTIC study constitutes an important attempt at validating clinical prediction rules. In this study, a clinical rule was derived that predicted renal artery stenosis as efficiently as renal scintigraphy (sensitivity: clinical rule, 65% versus scintigraphy, 72%; specificity: 87% versus 92%). When tested in a systematic and quantitative manner, clinical findings can perform as accurately as more complex tests in the detection of renal artery stenosis.
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PMID:Atherosclerotic renal artery stenosis: epidemiology, cardiovascular outcomes, and clinical prediction rules. 1246 10


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