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Renovascular Disease

Renovascular Disease. Daniel Shoskes MD, MSc, FRCSC Professor of Surgery/Urology Glickman Urological and Kidney Institute Cleveland Clinic. Overview. Pathophysiology Classification of Lesions Clinical Evaluation Medical and Surgical Management Renal Artery Aneurysm. Goldblatt Dog Models.

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Renovascular Disease

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

  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

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