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[Renovascular hypertension: diagnostic and therapeutic strategy]
1Département d'Hypertension, Hôpital Broussais, Paris.
Insights
Advances in imaging aid renal artery stenosis diagnosis. Identifying renovascular hypertension requires assessing reversibility through specific tests before considering revascularization options like angioplasty.
Area of Science:
- Cardiology
- Nephrology
- Vascular Medicine
Context:
- Renal artery stenosis (RAS) diagnosis is enhanced by modern imaging techniques.
- Intravenous digital subtraction angiography is crucial for patients with drug-resistant hypertension and aorto-iliac lesions or renal impairment from ACE inhibitors.
Purpose:
- To differentiate hypertension with RAS from true renovascular hypertension, which is defined by reversibility after revascularization.
- To outline diagnostic strategies for selecting patients who will benefit from revascularization.
Summary:
- Accurate diagnosis of renovascular hypertension involves urography, scintigraphy, and renal vein renin measurements (pre- and post-captopril).
- Vascular exploration assesses target organ damage and disease extent, guiding revascularization decisions.
- Percutaneous transluminal angioplasty is the primary treatment; surgery is reserved for complex cases.
Impact:
- Improved patient selection for revascularization procedures.
- Optimized treatment strategies for renovascular hypertension.
- Enhanced understanding of diagnostic and therapeutic pathways for renal artery stenosis.
Abstract:
Investigations for renal artery stenosis have been greatly facilitated by advances in imaging techniques. Intravenous digital subtraction angiography is now performed in all patients with progressive, drug-resistant hypertension associated with aorto-iliac lesions or with renal impairment induced by angiotensin-converting enzyme inhibitors. Yet the finding of hypertension with renal artery stenosis is not enough to make the diagnosis of renovascular hypertension, this term being reserved to hypertension reversible by revascularization. The selection of patients who may benefit from revascularization rests on urography to explore the excretory and endocrine functions of the ischaemic kidney, as well as on scintigraphy and measurement of renin levels in renal veins before and after administration of captopril. The functional data are completed by vascular exploration which helps in evaluating the usefulness and safety of revascularization: repercussions of hypertension on target organs and extension of the vascular disease to other territories. Revascularization as first-line treatment consists of percutaneous transluminal dilatation; surgery must be reserved to difficult cases, such as arterial obliteration or failed dilatation.