The prevalence and associated risk factors of renal artery stenosis in patients undergoing cardiac catheterization

Atherosclerotic renovascular disease - epidemiology, treatment and current challenges

The neutral results of recent large randomized controlled trials comparing renal revascularization with optimal medical therapy in patients with atherosclerotic renovascular disease (ARVD) have cast doubt on the role of revascularization in the management of unselected patients with this condition. However, these studies have strengthened the evidence base for the role of contemporary intensive medical vascular protection therapy and aggressive risk factor control in improving clinical outcomes in ARVD. Patients presenting with ‘high-risk’ clinical features such as uncontrolled hypertension, rapidly declining renal function or flash pulmonary oedema are underrepresented in these studies; hence these results may not be applicable to all patients with ARVD. In this ‘high-risk’ subgroup, conservative management may not be sufficient in preventing adverse events, and indeed, observational evidence suggests that this specific patient subgroup may gain benefit from timely renal revascularization. Current challenges include the development of novel diagnostic techniques to establish haemodynamic significance of a stenosis, patient risk stratification and prediction of post-revascularization outcomes to ultimately facilitate patient selection for revascularization. In this paper we describe the epidemiology of this condition and discuss treatment recommendations for this condition in light of the results of recent randomized controlled trials while highlighting important clinical unmet needs and challenges faced by clinicians managing this condition.

Correlation of dental pulp stones, carotid artery and renal calcifications using digital panoramic radiography and ultrasonography

Background:

The human tissues continuously undergo modification as deposition of calcium (CA) salts either in an organized or disorganized pattern. The latter pattern usually occurs in the soft tissues such as in arteries, brain, kidneys, lungs, and dental pulp. The purpose of this study is to evaluate the presence of pulp calcification and carotid artery calcification (CDC) as a marker for renal calcification and altered serum biomarkers such as serum CA, phosphorus (P), and alkaline phosphatase (ALP).

Materials and Methods:

Digital panoramic radiographs of 50 patients with the presence of pulp stones and suspected CAC were subjected to carotid artery and renal ultrasonography (USG) examination for the presence of vascular calcification and also to evaluate the alterations in serum CA, P, and ALP levels. Data were analyzed statistically using Chi-square test.

Results:

Panoramic radiographs of 50 patients showed 88.28% of teeth with the presence of pulp stones stones and 91% carotid arteries with calcification. The sensitivity of panoramic radiograph was greater than that of USG (93.67%), but the specificity of USG was more than the panoramic radiograph (44.44%) in detecting CAC. The prevalence rate of renal calcification on USG was 92%. The statistical difference between the patients with or without alteration in serum Ca levels was not significant (χ² = 0.581 and P = 0.446). On comparison of serum P and ALP, the difference was found to be statistically significant.

Conclusion:

Presence of pulp stones and CAC's on panoramic radiograph have remarkably proved to establish the chances of renal artery calcification associated with alterations in serum CA levels.

Effect of baseline glomerular filtration rate on renal function following stenting for atherosclerotic renal artery stenosis

OBJECTIVE

Percutaneous transluminal renal artery angioplasty and stenting (PTRAS) is one treatment option for atherosclerotic renal artery stenosis (ARAS). However, factors predicting the outcome remain controversial. This study investigated the effect of the baseline glomerular filtration rate (GFR) on renal function after PTRAS in patients with ARAS.

MATERIAL AND METHODS

Patients who underwent PTRAS due to significant ARAS (luminal narrowing > or = 60%) were enrolled. The patients were divided into control (n = 57; estimated GFR (eGFR) > or = 60 ml/min/1.73 m(2)) and chronic renal failure (CRF) groups (n = 53; eGFR < 60 ml/min/1.73 m(2)), according to the baseline eGFR.

RESULTS

The mean age at the time of PTRAS was 62 +/- 9 years, and the mean duration of follow-up was 50 +/- 26 months. There was a significant decrease in eGFR after PTRAS in the control group, whereas the CRF group showed no significant change in eGFR. The percentage change in eGFR was negatively correlated with the baseline eGFR (r = -0.274, p = 0.004). Multivariate linear regression revealed that only baseline eGFR predicted the change in eGFR (p = 0.032).

CONCLUSIONS

PTRAS was more effective at preserving renal function in patients with moderately impaired renal function. Thus, baseline GFR may indicate the expected renal function outcome after PTRAS.

The prevalence of atherosclerotic renal artery stenosis in risk groups: a systematic literature review

OBJECTIVE

We performed a literature review and analysis to improve the insight in the prevalence of renal artery stenosis (RAS) in risk groups.

METHODS

Relevant studies were identified by a MEDLINE and EMBASE database search (1966 to December 2007), complemented by hand searching of reference lists. Review was restricted to English language studies, using any form of angiography as diagnostic method. Studies were grouped in risk group categories sharing similar clinical characteristics, and pooled prevalence rates were calculated for each category.

RESULTS

Forty studies, involving a total number of 15 879 patients, were identified. The following pooled prevalence rates (95% confidence interval; sample size risk group) of RAS were found: suspected renovascular hypertension, 14.1% (12.7-15.8%; n = 1931); hypertension and diabetes mellitus, 20% (14.9-25.1%; n = 240); coronary angiography (CAG) in consecutive patients, 10.5% (9.8-11.2%; n = 8011); CAG in hypertensive patients, 17.8% (15.4-20.6%; n = 836); CAG and suspected renovascular disease, 16.6% (14.8-18.5%; n = 1576); congestive heart failure, 54.1% (45.7-62.3%; n = 135); peripheral vascular disease, 25.3% (23.6-27.0%; n = 2632); abdominal aortic aneurysm, 33.1% (27.4-39.2%; n = 239) and end-stage renal failure, 40.8% (27-55.8%; n = 49.) In patients with an incidentally discovered RAS, hypertension and renal failure were present in 65.5 and 27.5%, respectively.

CONCLUSION

RAS has a high prevalence in risk groups, especially in those with extrarenal atherosclerosis, end-stage renal failure and heart failure. These findings are important when screening for RAS or prescription of an angiotensin converting enzyme inhibitor or angiotensin-II receptor blocker is considered.

Combined heart-kidney transplantation: a review of recipient selection and patient outcomes

Elevated serum creatinine is a common finding among patients awaiting heart transplantation because of reduced renal perfusion in the setting of severe heart failure as well as overlapping risk factors for chronic kidney disease and heart disease. Patients with significant renal dysfunction preoperatively have worse outcomes with heart transplantation alone compared with those with normal renal function or those with renal dysfunction who undergo combined heart-kidney transplantation. Optimizing organ distribution and patient outcomes after cardiac transplantation requires appropriate recipient selection, including deciding which patients will benefit from combined heart-kidney transplantation. This review focuses on the evaluation of patients with chronic kidney disease awaiting heart transplantation and the outcomes of combined heart-kidney transplantation.

Renovascular disease imaging: Today more than ever the invasive cardiologist may make the difference

Doppler ultrasound (US), computed tomography (CT) and magnetic resonance imaging (MRI) are gaining wide acceptance as gold standard for diagnosing peripheral artery disease at thoracic and abdominal aorta level and infrainguinal arteries. A different case is that of renal artery stenosis (RAS): noninvasive techniques, CT and MRI in particular, failed to become the new gold standard. Image interpretation and artifacts seems to invalidate MRI and CT sensitivity and specificity that remain quite low. The debacle of noninvasive imaging of renal arteries may have important reflexes on the invasive cardiology practice. In the light of the results of noninvasive tests for renal artery stenosis, the angiography of renal vessels performed at the time of coronary artery angiography may became a new tool for invasive professional to optimize the diagnosis of renal artery stenosis at least in patients scheduled for coronary angiography. The invasive cardiologist, today more than ever, has the chance to really impact the diagnosis and therapy of patients with renovascular disease and the prognosis of patients with both coronary artery and renal artery disease.

Vascular profile of patients with multivessel coronary artery disease

PURPOSE

Early and accurate diagnosis of peripheral atherosclerosis is of paramount importance for global management of patients with known coronary artery disease (CAD). We sought to retrospectively evaluate the clinical relevance of significant subclavian artery stenosis (SAS) and abdominal vessel stenosis or aneurysm (AVA) in patients undergoing coronary angiography.

SUBJECTS AND METHODS

Medical records of consecutive patients underwent coronary angiography at two public institutions over a 12-month period were evaluated. Angiographic results of patients underwent coincident diagnostic abdominal aorta angiography to evaluate abdominal vessels or subclavian angiography on the basis of clinical and angiographic criteria were analyzed.

RESULTS

During the study period, 724 consecutive patients (535 males, mean age 68.1+/-11 years) were enrolled (Table 2): a significant atherosclerotic disease of at least one arterial segments were observed in 198 patients (27.3%). Angiographically significant SAS was observed in 18/220 patients (8.1%) undergoing concomitant subclavian artery angiography and candidates to coronary surgery using the internal mammary artery. Ten patients with subclavian artery stenosis and upper limb ischemia underwent subclavian artery angioplasty and stenting and bypass surgery using LIMA. AVA were reported in 180 (35.7%) of 504 consecutive patients: renal artery stenosis was found in 13.1% of cases (66 patients), aortoiliac artery disease in 13.7 % (69 patients), and aortic aneurismal disease in 8.9% (45 patients). Logistic regression analyses revealed > or =3-vessel CAD (odds ratio [OR] 9.917, p=0.002), age>60 years old (OR 3.817, p=0.036), > or =3 risk factors (OR 2.8, p=0.048) as independent predictors of SAS and AVA.

CONCLUSION

Patients with multivessel CAD are frequently aged, have an high risk profile and multiple vascular atherosclerotic distributions, suggesting the usefulness of a more global and comprehensive cardiovascular approach.

Malpractice in Invasive Cardiology: Is Angiography of Abdominal Aorta or Subclavian Artery Appropriate in Patients Undergoing Coronary Angiography?

BACKGROUND

Identification of peripheral vascular disease by angiography in patients undergoing coronary angiography may be considered as malpractice but sometimes seems to be justified under clear entry criteria. The present mata-analysis is aimed to analyze the appropriateness and results of screening angiography of subclavian or abdominal aorta performed at the time of coronary angiography.

METHODS

A search of published literature for peripheral angiography in patients undergoing coronary angiography over the last 10 years was performed using the MEDLINE database. No language restriction was employed. Only studies enrolling more than 100 patients for abdominal aortography and 50 patients for subclavian/internal mammary artery angiography were considered. Reference lists from identified studies were also reviewed to identify other potentially relevant references.

RESULTS

Twenty-nine studies were retrieved: 8 articles about subclavian artery (SA) and internal mammary (IMA) angiography and 21 about renal (RA) and aortoiliac (AOI) angiography. The total number of patients enrolled was 27,936. Nine studies out of 29 were prospective. Defined entry criteria were reported in 24 out of 29 studies. Significant SA and IMA stenosis were reported in 5.5 and 9% of patients, respectively. RA stenosis >50% was present in 12.7% of patients with CAD. Finally, undetected AOI disease was reported in 35.5% of patients undergoing coronary angiography. Mean complication rate was 0.8 +/- 0.6%. Predictors of SA and IMA stenosis were unclear. Age, multi-risk profile, multi-vessel CAD, history of PVD or carotid disease, severe hypertension, unexplained renal dysfunction or decreased creatinine clearance have been reported most frequently as predictors of RA and AOI disease in patients undergoing coronary angiography.

CONCLUSIONS

Consistent evidence of appropriateness of renal angiography in selected patients undergoing coronary angiography have been produced in literature. IMA and AOI angiography seem to be not justified unless they are part of SA in patients scheduled for arterial conduit with brachial differential pressure, thoracic irradiation or surgery, or of abdominal angiography to detect RA stenosis in laboratories with radiological digital peripheral equipment.

Concomitant peripheral vascular and coronary artery disease: a new dimension for the global endovascular specialist?

BACKGROUND

Early and accurate diagnosis of peripheral atherosclerosis is of paramount importance for global ma agement of patients with known coronary artery disease (CAD).

HYPOTHESIS

We sought to evaluate retrospectively the prevalence and clinical relevance of significant abdominal vessel stenosis or aneurysm (AVA) in patients undergoing coronary angiography.

METHODS

Medical records of consecutive patients who underwent coronary angiography at two public institutions over a 12-month period were evaluated. Angiographic results of patients who underwent diagnostic abdominal aorta angiography, based on clinical criteria, to evaluate abdominal vessels the same time as coronary angiography were analyzed.

RESULTS

During the study period, AVA was reported in 180 (35.7%) of 504 consecutive patients (335 men, mean age 68 +/- 13.8 years): renal artery stenosis was found in 13.1% of cases (66 patients), aortoiliac artery disease in 13.7% (69 patients and aortic aneurysmal disease in 8.9% (45 patients). Logistic regression analyses revealed > or = 3-vessel CAD (odds ratio [OR] 9.917, p = 0.002), age >65 years (OR 3.817, p = 0.036), > or =3 risk factors (OR 2.8, p = 0.048) as independent predictors of AVA.

CONCLUSION

Multiple vascular atherosclerotic distributions are frequent in elderly patients who have multivessel CAD and a high-risk profile, suggesting the usefulness of a more global and comprehensive cardiovascular approach.

Prevalence of renal artery stenosis in high-risk veterans referred to cardiac catheterization

OBJECTIVE

The prevalence of atherosclerotic renal artery stenosis (RAS) varies depending on patient selection with no specific guidelines on indications for selective renal angiography in patients referred for coronary angiography. The goal of this study is to determine the prevalence and predictors of renal artery stenosis in hypertensive veterans referred for coronary angiography.

DESIGN

Prospective study.

SETTING

Tertiary care veterans' administration facility in the USA.

PATIENTS, PARTICIPANTS

A total of 90 veterans referred for coronary angiography with an initial ascending aortic pressure > 135 mmHg.

INTERVENTIONS

Selective renal angiography was performed following coronary angiography.

RESULTS

We found that 28% of the patients had single RAS (> or = 50% stenosis), while 16% had single RAS > or = 70% stenosis, 10% had bilateral RAS >or = 50% and 6% had bilateral RAS > or = 70%. Significant positive univariate predictors of RAS (> or = 50%) were age, peripheral vascular disease (PVD), creatinine level (Cr) and myocardial infarction. Significant multivariate predictors of RAS (> or = 50%) were age > 65 years [relative risk (RR), 3.6; 95% confidence interval (CI), (1.2-10.6)], PVD [RR 3.2, 95% CI (1.1-9.1)] and Cr > 1 mg/dl [RR 4.9, 95% CI (1.53-15.9)]. No complications related to renal angiography were noted.

CONCLUSIONS

Selective renal angiography during routine coronary angiography in hypertensive veterans with coronary artery disease is safe and uncovers RAS in many older patients with PVD and renal insufficiency.

Prevalence of renal artery stenosis requiring revascularization in patients initially referred for coronary angiography

To evaluate the prevalence of clinically significant renal artery stenosis (RAS) in patients referred for coronary angiography, we analyzed data on 2,439 consecutive patients. Patients underwent selective renal angiography in conjunction with coronary angiography if refractory hypertension (blood pressure > 140/90 on two drugs) or flash pulmonary edema was present. A total of 1,089 renal arteries of 534 patients were evaluated. Twelve percent (137/1,089) of the renal arteries in 19% (101/534) of patients had > 70% diameter stenosis in at least one vessel. Bilateral renal artery stenosis was present in 26% (26/101) of patients. One hundred and thirty-two of the 137 vessels underwent stent revascularization due to clinical renovascular hypertension. Acute clinical success (< 20% diameter stenosis without death or urgent surgery) was 98% (99/101). Due to high prevalence and effective available treatment, we recommend routine screening for RAS in all patients with refractory hypertension referred for coronary angiography.

Chronic renal ischemia: implications for cardiovascular disease risk

Chronic renal ischemia caused by atherosclerotic renal artery stenosis (RAS) is gaining recognition as a potentially important risk factor for cardiovascular (CV) morbidity and mortality. The etiology of increased risk of CV events is multifaceted and includes direct physiologic changes that increase risk as well as intermediate clinical effects that are associated with worse outcome. Physiologic changes associated with increased CV risk in patients with RAS include increased production of fibrogenic and vasoactive peptides such as renin, angiotensin, endothelin, and catecholamines, as well as endothelial cell dysfunction. Clinical intermediate conditions associated with higher incidences of CV events seen in patients with renal ischemia include hypertension, systemic atherosclerosis, chronic renal failure, and left ventricular hypertrophy and dysfunction. More thorough understanding of the myriad physiologic changes seen in patients with RAS will likely improve patient selection for renal artery revascularization. Clinical trials should examine a full range of CV and renal outcomes, not just blood pressure, to adequately assess the merits of revascularization.