genitourinary disorders
Renal Artery Stenosis and Occlusion
Treatment of Renal Artery Stenosis and Occlusion
Restoration of vascular patency in acute occlusions and, if patients have refractory hypertension or potential for renal failure, in chronic stenosis Treatment depends on the cause. A renal thromboembolic disorder may be treated with a combination of anticoagulation, fibrinolytics, and surgical or catheter-based embolectomy. Treatment within 3 hours of symptom onset is likely to improve renal function. However, complete recovery is unusual, and early and late mortality rates are high because of extrarenal embolization or underlying atherosclerotic heart disease. Patients presenting within 3 hours may benefit from Fibrinolytics (eg, streptokinase, All patients with a thromboembolic disorder require Treatment with IV Surgery to restore vascular patency has a higher mortality rate than fibrinolytic therapy and has no advantage in recovery of renal function. However, surgery, particularly if done within the first few hours, is preferred for patients with traumatic renal artery thrombosis. If patients with nontraumatic, severe renal failure do not recover function after 4 to 6 weeks of drug therapy, surgical revascularization (embolectomy) can be considered, but it helps only a few. If the cause is thromboemboli, the source should be identified and treated appropriately. Revascularization may be considered for patients who meet one or more of the following criteria: Failure or intolerance of medical therapy for optimal blood pressure A short duration of elevated blood pressure prior to the diagnosis of renovascular disease Recurrent flash Pulmonary Edema None Unexplained rapid progression of renal insufficiency Revascularization is usually achieved by Percutaneous coronary intervention (PCI) with stent placement or with surgical bypass of the stenotic segment. Surgery is usually more effective than PTA for atherosclerotic occlusion; it cures or attenuates hypertension in 60 to 70% of patients. However, surgery is considered only if patients have complex anatomic lesions or if PTA is unsuccessful, particularly with repeated in-stent restenosis. PTA is preferred for patients with fibromuscular dysplasia; risk is minimal, success rate is high, and restenosis rate is low. For patients who do not meet one of the criteria above, medical therapy is recommended based on data from the randomized trials, which showed that renal-artery stenting plus medical therapy had no significant benefit over medical therapy alone for preventing adverse cardiovascular or renal events ( Treatment reference ). Angiotensin-converting enzyme (ACE) inhibitors or 1.Cooper CJ, Murphy TP, Cutlip DE, et al:Stenting and medical therapy for atherosclerotic renal-artery stenosis.N Engl J Med370(1):13-22, 2014. doi: 10.1056/NEJMoa1310753 