From the Guidelines
Percutaneous transluminal renal angioplasty (PTRA) without stenting is the treatment of choice for fibromuscular dysplasia, as it can restore renal perfusion pressure and lower blood pressure. Fibromuscular dysplasia (FMD) is a non-inflammatory, non-atherosclerotic vascular disease that affects multiple vascular beds, including the renal and carotid arteries 1. The management of FMD depends on the affected vessels and symptoms, and medical therapy to reduce blood pressure is the first line of treatment for patients with renovascular hypertension due to FMD.
Key Considerations
- Patients with FMD should receive medical therapy to reduce blood pressure in the first instance, with PTRA without stenting considered for those with significant disease 1.
- RAS blockers, such as ACE inhibitors or ARBs, are the drugs of choice for treatment, but they require careful monitoring of renal function over time, as they can cause acute renal failure in those with tight bilateral stenoses or a stenosed solitary functioning kidney 1.
- Possible involvement of the carotid, coronary, and other major arteries, possibly leading to dissection if blood pressure is not controlled, should also be considered, as FMD is now recognized as a systemic disease affecting multiple vascular beds 1.
Treatment Approach
- PTRA without stenting is the preferred treatment for FMD, as it can restore renal perfusion pressure and lower blood pressure, and should be performed in experienced centers due to the high risk of restenosis 1.
- Lifestyle modifications, such as smoking cessation and regular exercise, are also important for managing FMD, though high-intensity activities that cause sudden blood pressure spikes should be avoided.
- Regular imaging surveillance, typically with CTA or MRA every 1-2 years, is essential to monitor for aneurysms and disease progression 1.
From the Research
Definition and Prevalence of Fibromuscular Dysplasia
- Fibromuscular dysplasia (FMD) is a noninflammatory, nonatherosclerotic disease that affects the arteries, primarily in women aged 15-50 years 2.
- The true prevalence of FMD is unknown due to underdiagnosis, but it is estimated to be more common than previously thought 2.
- FMD can affect almost every arterial bed, with the most common presentations in the renal and extracranial cerebrovascular arteries 2, 3.
Clinical Manifestations and Complications
- FMD can manifest as hypertension, transient ischemic attack, or stroke, and some patients may be asymptomatic 2, 3.
- Dissection or aneurysm may also occur in patients with FMD 2.
- Other complications of FMD include headaches, dissections, aneurysms, myocardial infarctions, and cerebrovascular accidents 3.
Diagnosis and Management
- Diagnosis of FMD is often made through imaging studies, such as catheter-based angiography 4.
- Treatment of FMD consists of antiplatelet therapy for asymptomatic individuals and percutaneous balloon angioplasty for patients with indications for intervention 2, 4.
- Patients with macroaneurysms should be treated with either a covered stent or surgery 2.
- A comprehensive multidisciplinary care model and patient input are essential for managing FMD due to its complexity and systemic presence 3.
Medication Use in FMD
- Anti-platelet agents are commonly used in patients with FMD, particularly in those with cerebrovascular artery involvement or a history of previous intervention 5.
- Anti-hypertension medications are also frequently used in FMD patients, with a greater number of medications used in patients with isolated renal FMD 5.
- ACE inhibitors are commonly prescribed medications for the management of hypertension, including in patients with FMD, although their use may be associated with side effects such as angioedema and cough 6.