DR IMRAN JAVED,

MBBS, FCPS.

INTERNATIONAL FELLOW

DR IMRAN JAVED,

MBBS, FCPS.

INTERNATIONAL FELLOW

RENO-VASCULAR HYPERTENSION:

BYPASS VERSUS STENT

RENO-VASCULAR HYPERTENSION:

BYPASS VERSUS STENT

Renovascular hypertension occurs when the artery to one of the kidneys is narrowed (unilateral, or one-sided, stenosis), while renal failure occurs when the arteries to both kidneys are narrowed (bilateral, or two-sided, stenosis). The decreased blood flow to both kidneys increasingly impairs renal function.

ANATOMICAL REVIEWANATOMICAL REVIEW• The renal arteries normally arise off the

side of the abdominal aorta, immediately below the superior mesenteric artery, and supply the kidneys with blood. Each is directed across the crus of the diaphragm, so as to form nearly a right angle with the aorta.

• The renal arteries normally arise off the side of the abdominal aorta, immediately below the superior mesenteric artery, and supply the kidneys with blood. Each is directed across the crus of the diaphragm, so as to form nearly a right angle with the aorta.

ANATOMICAL REVIEWANATOMICAL REVIEW• The renal arteries carry a large portion

of total blood flow to the kidneys. Up to a third of total cardiac output can pass through the renal arteries to be filtered by the kidneys.

• The arterial supply of the kidneys is variable and there may be one or more renal arteries supplying each kidney. It is located above the renal vein.

• The renal arteries carry a large portion of total blood flow to the kidneys. Up to a third of total cardiac output can pass through the renal arteries to be filtered by the kidneys.

• The arterial supply of the kidneys is variable and there may be one or more renal arteries supplying each kidney. It is located above the renal vein.

Causes of renal artery stenosisCauses of renal artery stenosis• Atherosclerosis • high cholesterol levels• high blood pressure• age• cigarette smoking• diabetes

• Fibromuscular dysplasia

• Arteritis

• Dissection

• Atherosclerosis • high cholesterol levels• high blood pressure• age• cigarette smoking• diabetes

• Fibromuscular dysplasia

• Arteritis

• Dissection

Symptoms of renal artery stenosis

Symptoms of renal artery stenosis

• high blood pressure that responds poorly to treatment.

• severe high blood pressure that develops prior to age 30 or greater than age 50.

• an incidental finding (discovered through routine tests or tests performed for another condition) of one small kidney compared to a normal sized one on the other side.

• high blood pressure that responds poorly to treatment.

• severe high blood pressure that develops prior to age 30 or greater than age 50.

• an incidental finding (discovered through routine tests or tests performed for another condition) of one small kidney compared to a normal sized one on the other side.

DIAGNOSTIC TESTSDIAGNOSTIC TESTS

• Duplex Doppler ultra sonography.

• Computed tomographic angiography.

• Magnetic resonance angiography.

• RENAL ANGIOGRAPHY.

• DSA .

• DIFFERENTIAL RENAL FUNCTION TESTS.

• PROVOCATIVE TESTS. (RARE)

• Duplex Doppler ultra sonography.

• Computed tomographic angiography.

• Magnetic resonance angiography.

• RENAL ANGIOGRAPHY.

• DSA .

• DIFFERENTIAL RENAL FUNCTION TESTS.

• PROVOCATIVE TESTS. (RARE)

Medical treatmentsMedical treatments

In bilateral (both-sided) and unilateral (one-sided) renal artery stenosis associated with high blood pressure, controlling the blood pressure with usual blood pressure medications is the first and the safest treatment. ACE inhibitors or ARB medications with or without a diuretic (water pill) may be tried first.

In bilateral (both-sided) and unilateral (one-sided) renal artery stenosis associated with high blood pressure, controlling the blood pressure with usual blood pressure medications is the first and the safest treatment. ACE inhibitors or ARB medications with or without a diuretic (water pill) may be tried first.

ANGIOGRAPHIC LANDMARKSANGIOGRAPHIC LANDMARKS

• The optimal initial angle for angiographic evaluation of the origin of the renal artery and for renal artery stent placement is 30° left anterior oblique (LAO) relative to the L1SP for the right renal artery and 7° LAO for the left renal artery. In some patients, additional views will be necessary to optimally depict the origins of the renal arteries.

• The optimal initial angle for angiographic evaluation of the origin of the renal artery and for renal artery stent placement is 30° left anterior oblique (LAO) relative to the L1SP for the right renal artery and 7° LAO for the left renal artery. In some patients, additional views will be necessary to optimally depict the origins of the renal arteries.

ConclusionConclusion

• Renal artery disease and renovascular hypertension are complex disorders that affect the heart, brain, blood vessels, and kidneys. Prompt diagnosis and timely intervention done by a skilled vascular surgeon can significantly decrease target organ damage and potentially cure high blood pressure due to renal artery disease.

• Renal artery disease and renovascular hypertension are complex disorders that affect the heart, brain, blood vessels, and kidneys. Prompt diagnosis and timely intervention done by a skilled vascular surgeon can significantly decrease target organ damage and potentially cure high blood pressure due to renal artery disease.