1. Renovascular Disease Daniel Shoskes MD, MSc, FRCSC
Professor of Surgery/Urology
Glickman Urological and Kidney Institute
Cleveland Clinic

2. Overview Pathophysiology Classification of Lesions Clinical Evaluation
Medical and Surgical Management
Renal Artery Aneurysm

3. Goldblatt Dog Models ARB/ACE inhibitors help
Only help when Na depleted

4. Ischemic Nephropathy Does not correlate with hypertension
Progressive azotemia in pt with risk factors for atherosclerotic disease
Progresses through nephrosclerosis and atheroemboli
Treatment of hypertension will not improve renal function, may actually exacerbate

5. Diameter and Blood Flow

6. Classification
Atherosclerotic (70%)
Fibromuscular Disease (30%)

7. Fibromuscular Disease
Medial Fibroplasia: 77%
Perimedial Fibroplasia: 10%
Intimal Fibroplasia: 10%
Fibromuscular Hyperplasia: 3%

8. Atherosclerosis typically a systemic disease
involves proximal 2 cm of artery
may only be seen on oblique views
progression common, at least 50% in 2 years
10-15% progress to occlusion
can cause hypertension and Renal Failure

9. Medial Fibroplasia most common fibrous women 25-50 commonly bilateral
"string of beads"
involves distal 2/3 and branches
progression less common

10. Clinical Clues to RVH HTN onset < 30 yrs or > 55
sudden onset, short duration
lack of family history
difficult to control
malignant crisis
bruits
disseminated atherosclerotic disease
renal size disparity

11. Key Diagnostic Points Captopril provocation
reduction of GFR detected by nuclear scan
best predictor of surgical cure (spec 93-98%)
increased PRA (off most drugs)
Renal Vein Renins
ipsilateral hypersecretion, contralateral suppression
best for bilateral disease
Ultrasound
operator dependent, independent of renal function
MRA
poor images beyond main renal artery

12. Investigation of Ischemic Nephropathy
High suspicion
straight to angiography
Mild to Moderate suspicion
non-invasive imaging (local preference)
if significant azotemia, US rather than MRA or spiral CT

13. Investigation of RVH High suspicion
angiography and Renal Vein Renins if bilateral
Moderate suspicion
captopril nuclear renography (can do "post" study first)
positive -> angio
equivocal -> non-invasive imaging
negative -> stop

14. Treatment of RVH
Select medical management based on risk of ischemic nephropathy and lesion progression
medial fibroplasia and atherosclerotic (without ischemic nephropathy) best for medical
angioplasty +/- stents usually procedure of choice unless
branch vessel disease
renal artery aneurysm
Nephrectomy if small and non-functioning

15. Treatment of Ischemic Nephropathy
No benefit with unilateral disease
Signs of reversibility
progressive occlusion
collaterals
retrograde arterial filling
size > 9 cm
Cr < 4.0
preservation of glomeruli on biopsy

16. Surgical Approaches Hepatorenal Splenorenal Ileorenal Autotransplant
Arteriotomy
Aortorenal
Thoracic aorta - renal

17. Renal Artery Aneurysms
most small and asymptomatic
pathology
saccular (most common), fusiform, dissecting, intrarenal
risk of rupture
absent/incomplete calcification, >2cm diameter, expanding, hypertension, pregnancy
other complications
pain, hematuria, dissection, emboli