Endovascular treatment of renal arteries

Abstract

Significant renal artery stenosis (RAS) may result in deterioration of arterial hypertension and/or renal insufficiency and may contribute to cardiovascular diseases such as diastolic and systolic heart failure. Balloon angioplasty (PTA) is the established therapy for RAS of fibromuscular disease (FMD) and inflammation origin; the role of cutting balloon angioplasty in this indication needs still to be investigated. In atherosclerotic RAS, stenting has shown superior acute and long-term technical outcomes compared to PTA. Technical improvements such as dedicated guiding catheters and the downsizing of devices including wires, balloon catheters and stents made the intervention more successful and safer. Numerous single-centre studies have reported the beneficial effect of percutaneous revascularisation of RAS of different aetiologies. Even if the recently published randomised STAR and ASTRAL trials did not show any benefit of renal artery stenosis revascularisation over medical therapy in selected patient cohorts, there is nonetheless evidence that stenting of haemodynamically relevant atherosclerotic RAS has an impact on blood pressure control, renal function, left ventricular hypertrophy and even patient survival. This chapter introduces the interventional treatment techniques including management of complications and peri-procedural care step by step. Renal artery revascularisation is a feasible and safe procedure in experienced hands provided dedicated equipment is available. However, there remain particular risks such as a ‘hostile aorta’ with a high soft plaque burden and difficult anatomical conditions that can result in a disastrous interventional outcome. Key for a beneficial interventional outcome is an appropriate interventional plan, the appropriate equipment and, most important, the correct patient selection. Having this in mind, renal revascularisation is still indicated in a well-defined subset of patients with obstructive renal artery disease.