RENOVASCULAR HYPERTENSION

42 cases analysis


Mihai Dan Datcu, Georgeta Datcu, Viviana Aursulesei, Helen Rothinberg
I st Medical Cardiology Clinic C.I.Negoi
St Spiridon University Emergency Hospital
University of Medicine and Pharmacy Gr.T.Popa
Iai

1. Renal artery stenosis is recognised as a cause of
hypertension and renal dysfunction;

2. No single test is appropiate for all patients;

3. Diagnostic modalities require an assesment of the
physiologic effects of renal artery stenosis, and the
direct imaging of renal artery;

4. We believe that direct or conventional contrast
angiography answer in the same time both requires.

Key points and purpose

Female 32 patients
Male 10 patients
Minim age 14 year Maxim age 78 year

Clinical findings

Etiology

Atherosclerosis 77 %
Thrombosis 8%
Aneurysm 8%
Fibromuscular dysplasia 3%
Renal artery hypoplasia 2%
Systemic vasculitis 2%


Zanchetti A
et al, 2001
Conventional contrast angiography :

the gold
standard
Clinical index of suspicion of renovascular
hypertension
High Moderate Low
Severe hypertension-SH- with progresive unexplained renal
insufficiency
SH with refractoriness to agressive treatment
Accelerated or malignant H gr III or IV retinopathy
Moderate to SH with elevation serum creatinine reversibly
induced by an ACE inhibitor or angiotensin II antagonist
Moderate to SH with asymmetry of renal size
Batzenschlager criteria
A.Zancheti 2001
Zanchetti A et al, 2001
Search for etiology
Age of onset under 20 years 15 c
Age of onset over 50 years 27 c
Abdominal bruit 41 57 % (H. Dustan) 16 c
Eleveted serum creatinine 14 c
Hypokaliemia 4 c
High renin profile 18 c
Non invasive tests 42 c

Non invasive tests

Plasma renin activity 19 pts
The captopril test 23 pts
Renal vein renin 19 pts
Captopril augmented renal scan 10 pts
Duplex ultrasound 5 pts
Magnetic resonance angiography 4 pts
Helical computerized tomography (Spiral CT)
Two Major Questions:




1.Morphologic there is a renal artery stenosis
Answer imaging modalities

2.Functional assesment of physiological effects
of renal artery stenosis






1. renovascular hypertension
2. renovascular disease


Always remember there is two possibilities:
Mc Cormack, 1971
Renal artery stenosis both main artery
Non selective conventional contrast angiography

Vascular dysplasia same patient
thrombosis of left carotid artery
Right renal artery stenosis Left renal artery stenosis
Yellow arow red arows
Left artery
thrombosis small
arow
Right artery
moderate stenosis

pannel renal
vein plasma renin
activity

M.C., f, 50

C.M., m, 54
Renal vein
renin ratio 1,8



Left renal artery stenosis


G.G., m, 33
Renal vein renin ratio 1,85
Left renal artery stenosis
Conventional contrast renal angiography
H.M, f, 69








Right renal artery thrombosis
White arow
Left renal artery stenosis
Left renal angioplasty with stent
White arow indentation of the baloon
H.M. , f, 60
Left renal angioplasty with stent
Stent position
Control angiography
H.M., f, 60
Pressure in left renal artery and aortic pressure
Before dilatation After dilatation
Post-stenosis 34/25/22 mmHg 100/62/44 mmHg
Pre-stenosis 164/104/60 mmHg 160/104/60 mmHg
Aorta 168/128/68 mmHg
Right polar superior renal artery thrombosis
T.N., m , 48
Left polar inferior renal artery aneurysm
Z.P, f, 28
G.M., f, age 60
Small right kidney Left renal artery aneurysm
Normal renal artery

P.G.,m, 60
Infrarenal thrombosis of the abdominal aorta
Abdominal coarctation of the aorta
Risk of angiography (1 3%)


Complications of arterial puncture 0,5%
Contrast induced nephropathy 2%
Cholesterol embolisation 1%
presence of - atherosclerosis
- hypertension
- renal insufficiency
- diabetic patients

risk increase:

Treatment modalities
Medical treatment 13
Surgical procedures
nephrectomie 3
conservative treatment 5
reimplantation in the aorta 3
aorto - renal bypass 2
Renal artery PTA 21
Renal artery PTA plus stent 2

Final remarks:
Search for renovascular hypertension
in moderate and high risk suspicion;

Do not forget: renovascular hypertension is
fortunately a curable form of hypertension!

The advantages of conventional angiography are:
morphological diagnosis to be or not to be

functional assesment of physiological effects
of renal artery stenosis

direct and immediately treatment with
interventional procedure
We are for an early direct contrast
conventional angiography!

Thank you!