Top Things to Know: Revascularization for Renovascular Disease
Published: June 16, 2022
Prepared by Anne Leonard MPH, RN, Senior Science and Medicine Advisor - Lead
- This scientific statement outlines future directions for basic, translational and clinical research in this area.
- Renovascular hypertension is one manifestation in a spectrum of clinical syndromes associated with renovascular disease. This syndrome is primarily caused by atherosclerosis or fibromuscular dysplasia (FMD). Renovascular disease remains the prototype of “secondary” hypertension first noted in the 1930’s when experimental renal artery occlusion revealed raised systemic arterial pressure.
- Early surgical studies of revascularization of the kidney have shown to reverse hypertension (HTN), occasionally leading to a “cure”.
- Activation of pressor pathways associated with renovascular hypertension can occur with reduced perfusion pressure and with low levels of blood flow to the kidney, tissue hypoxia and tissue injury within the kidney occurs. This can lead to ischemic nephropathy.
- Atherosclerotic renovascular disease or ARVD, is the most common etiology of renovascular disease, with luminal obstruction usually in the large arteries. ARVD can be identified in 6.8% of persons over 65 years. Although HTN more prevalent and more severe in Non-Hispanic Blacks than Whites, rates of ARVD are not higher in Blacks than Whites.
- The second most common etiology is fibromuscular dysplasia (FMD), which is in a group of non-inflammatory, non-atherosclerotic arterial diseases, predominately affecting middle aged women. About 1/3 of patients with multifocal FMD (most common) and 90% of patients with focal FMD warrant renovascular intervention.
- Randomized clinical trials for renal revascularization have demonstrated that routine use of renal artery revascularization for ARVD is not warranted for moderate renal artery disease. However, there are limitations noted for this trial group.
- Patients with FMD, refractory hypertension, progressive kidney function decline, congestive heart failure, are all populations where revascularization might be considered.
- Characteristics of patients who may benefit from revascularization include recent onset or exacerbation (<1 year) of HTN, absence of proteinuria, and identifiable activation of renin-angiotensin system such as hyperreninemia, and in the case of unilateral renal artery stenosis, lateralization of renal vein renin. Additional characteristics are described within this paper.
- Possible interventions for revascularization of the renal arteries include percutaneous angioplasty and stenting, renovascular surgery, and extrarenal reconstructions.
- Because blood supply to the kidneys is essential for renal function, revascularization is an important component of care for individuals for whom vascular occlusion threatens kidney function or is accelerating clinical hypertensive syndromes.
Bhalla V, Textor SC, Beckman JA, Casanegra AI, Cooper CJ, Kim ESH, Luther JM, Misra S, Oderich GS; on behalf of the American Heart Association Council on the Kidney in Cardiovascular Disease; Council on Hypertension; Council on Peripheral Vascular Disease; and Council on Cardiovascular Radiology and Intervention. Revascularization for renovascular disease: a scientific statement from the American Heart Association [published online ahead of print June 16, 2022]. Hypertension. doi: 10.1161/HYP.0000000000000217