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Refining the Approach to Renal Artery Revascularization

Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, Michigan

^_* Reprint requests and correspondence: Dr. Robert D. Safian, Director, Cardiac and Vascular Intervention, Department of Cardiovascular Medicine, William Beaumont Hospital, Heart Center-3rd Floor, 3601 W. Thirteen Mile Road, Royal Oak, Michigan 48073 (Email: rsafian{at}beaumont.edu).

Renal artery stenosis (RAS) is caused by a heterogenous group of diseases with different pathophysiology, clinical manifestations, treatment approaches, and outcomes. The 2 most common forms of RAS are fibromuscular dysplasia (FMD) and atherosclerosis (ARAS). Renovascular syndromes are broadly classified into renovascular hypertension and ischemic nephropathy, but these terms are misleading, because they imply a causal relationship between RAS, hypertension, and renal dysfunction, which is difficult to prove in humans. Data supporting renal revascularization are limited by heterogeneous causes of hypertension and renal dysfunction, insufficient understanding of the relationship between RAS and nephropathy, inconsistent techniques for revascularization, ambiguous terminology and end points to assess benefit, and lack of large-scale randomized trials. The purpose of this review is to enhance understanding of the epidemiology, clinical markers, and diagnosis of RAS; the relationship between RAS and important disease states; the distinction between renal ischemia and nephropathy; optimal revascularization techniques; and avoidance of renal injury.

Key Words: renal angioplasty and stenting • renal artery stenosis

Abbreviations and Acronyms   ACC = American College of Cardiology   AHA = American Heart Association   ARAS = atherosclerotic renal artery stenosis   CTA = computerized tomography angiography   FMD = fibromuscular dysplasia   GFR = glomerular filtration rate   MRA = magnetic resonance angiography   RAS = renal artery stenosis   RRI = renal resistive index   TLG = translesional pressure gradient   99MTc-DTPA = technetium-labeled pentetic acid

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