From the Guidelines
Bilateral renal artery stenosis should be managed with a comprehensive approach, starting with diagnosis using Computed Tomography Angiography (CTA), followed by medical management with antihypertensive medications, and considering revascularization for patients with resistant hypertension or declining renal function. The diagnosis of bilateral renal artery stenosis depends on clinical suspicion and consideration for arterial imaging for subjects with unexplained progressive hypertension or renal dysfunction, with CTA being a preferred modality due to its high sensitivity and specificity in detecting renal artery narrowing 1.
Medical Management
Medical management typically involves the use of agents that block the renin-angiotensin system, such as ACE inhibitors or Angiotensin II Receptor Blockers (ARBs), as they have been shown to be effective in managing renovascular hypertension 1. However, these medications require careful monitoring of renal function as they can cause acute kidney injury in severe bilateral stenosis.
Revascularization
For patients with resistant hypertension, declining renal function, or recurrent flash pulmonary edema despite optimal medical therapy, revascularization should be considered 1. This may involve percutaneous transluminal angioplasty with stenting or, less commonly, surgical revascularization. Observational series have repeatedly demonstrated that blood pressure control and mortality can be improved substantially after successful revascularization 1.
Ongoing Monitoring
Following intervention, patients require ongoing monitoring of blood pressure, renal function, and periodic imaging to assess for restenosis. The management approach is guided by the pathophysiology of bilateral stenosis, which activates the renin-angiotensin-aldosterone system, leading to systemic hypertension and potential kidney damage through reduced perfusion pressure. Key considerations in the management of bilateral renal artery stenosis include:
- Accurate diagnosis through CTA
- Medical management with antihypertensive medications
- Consideration of revascularization for resistant cases
- Ongoing monitoring to prevent complications and assess treatment efficacy.
From the Research
Diagnosis of Bilateral Renal Artery Stenosis
- Computed Tomography Angiography (CTA) scan is a diagnostic tool used to visualize the renal arteries and detect stenosis 2.
- CTA scan can provide detailed images of the renal arteries, allowing for accurate assessment of stenosis severity and location.
Management Approach
- The management of bilateral renal artery stenosis involves a combination of medical and interventional therapies 3, 4.
- Medical therapy includes the use of antihypertensive medications, such as angiotensin-converting enzyme inhibitors (ACEIs), which can be safely used in patients with bilateral renal artery stenosis after successful revascularization using renal artery stenting 4.
- Interventional therapy includes percutaneous renal artery stenting (PTRAS), which can provide a survival advantage in individuals with significant hemodynamic renal artery stenosis lesions 2.
Considerations for Revascularization
- Revascularization using PTRAS can improve renal function and reduce the risk of cardiovascular events in selected patients with bilateral renal artery stenosis 2, 5.
- However, restenosis can occur after PTRAS, and preoperative statin use and increased preoperative diastolic blood pressure have been associated with reduced risk of restenosis 6.