Renal Artery Stenosis: Prevalence and Associated Risk Factors in Patients Undergoing Routine Cardiac

Michael B. Harding, L. Richard Smith, Stevan I. Himmelstein, Kevin Harrison, Harry R. Phillips, Steve J. Schwab,2 James B. Hermiller, Charles J. Davidson, and Thomas M. Bashore

sociated variable. These data reveal the previously MB. Harding, L.R. Smith, SI. Himmelstein, K. Harrison, undetected high prevalence of renal artery disease H.P. Phillips. S.J. Schwab, J.B. Hermiller. C.J. Davidson, in patients undergoing cardiac catheterization and J.M. Bashore, Duke University Medical Center, Dur- provide clinical and angiographic features that as- ham, NC sist in predicting its presence. (J. Am. Soc. Nephrol. 1992; 2:1608-1616) Key Words: Renal artery stenosis, cardiac catheterization, renovascular disease

ABSTRACT The purposes of this study were to determine the R enal artery stenosis may be a cause of hyperten- prevalence of angiographically significant renal or- sion and may result in renal ischemia and loss tery stenosis in a patient population referred for di- of renal mass. Stenosis of the renal arteries usually agnostic cardiac catheterization and to develop a results from atheromatous lesions that can bead to model that predicts the highest-risk subset of patients progressive arterial occlusion in many patients ( 1 - 3). Atherosclerotic renovascubar disease is a fre- who have significant renal artery narrowing. A pros- quently overbooked clinical entity and may be a com- pective validation cohort study was undertaken in a mon cause of progressive renal insufficiency (4.5). referral-based university hospital. After left ventricu- Renal artery stenosis is a potentially correctable lography, abdominal aortography was performed problem because revascularization techniques in- to screen for the presence of renal artery disease. A cluding surgery and percutaneous renal artery angio- convenience sample of 1,302 of 1,651 consecutive plasty have been shown to be effective in treating patients undergoing diagnostic cardiac catheteri- renal artery stenosis and preserving renal function zatlon were enrolled In the study. Of the 1,302 ab- (6-11). dominal aortograms performed, I .235 (95%) were The prevalence of renal arterial disease in the gen- deemed of adequate quality for the evaluation of eral population is poorly defined. Necropsy studies suggest a frequency of “severe” stenosis to be 25% in renal artery anatomy. Renal artery disease was iden- subjects 40 yr of age or older (12). Renovascular tlfled In 30% of the patients. Insignificant renal artery hypertension is present in 5 to 1 0% of the total stenosis was found in 187 (15%) and significant hypertensive population, but renal artery stenosis (50% diameter narrowing) stenosis was found in I 88 can be demonstrated in 35 to 43% of patients evalu- (15%). Significant unilateral disease was present in ated for renovascular hypertension ( 1 3. 1 4). The oc- I 1%, and bilateral disease was present in 4%. By currence of renal artery stenosis in patients with unlvariable and multivariable logistic regression atherosclerosis elsewhere, especially in patients with analysis, the association of both clinically and cath- abdominal aortic and aortoiliac disease, is as high as eterlzatlon-derived variables with renal artery dis- 39% (1 5). Small series have also noted significant ease was assessed. Multivariable predictors in- renal artery stenosis in 29% of patients with coronary artery disease (16). cluded age, severity of coronary artery disease, The population of patients referred for cardiac congestive heart failure, female gender, and periph- catheterization often exhibits many clinical features eral vascular disease. Hypertension was not an as- that one might anticipate would be associated with atherosclerotic renal artery disease, such as advanced age. evidence of diffuse atherosclerosis, hy- I Rceived September 20. 1991. Accepted January 4. 1992. 2 Correspondenceto Dr. 5.J. Schwab, Duke University MedicalCenter, Box 3014. pertension, renal insufficiency, and the presence of Durham, NC 27710. coronary artery disease (1 2. 1 5- 1 8). Thus, abdominal f046-6673/021 1-1608303.00/0 aortography at the time of cardiac catheterization Journal of the American 5ociety of Nephrology Copyri9ht C 1992 by the American Society of Nephrology provides a low-risk, readily performed means of

1608 Volume 2 - Number II . 1992 Harding et al

screening for the presence of renal artery stenosis in phy was performed in the anterior-posterior projec- a population likely to have renal artery disease. tion with lohexol (Omnipaque 350; Winthrop, Bronx, The purpose of this study is twofold. The first is to NY) power injected at a rate of 20 mL/s to a total determine the prevalence of angiographically signif- volume of 30 mL. The injection was recorded on 35- icant renal artery stenosis in a large, diverse popu- mm cine film at 30 frames per second. lation referred for cardiac catheterization. The second is to develop a model based on clinically and cardiac catheterization-derived parameters that pre- Aortography Analysis dicts the highest-risk subset of patients who have Aortograms were reviewed by a single observer significant renal artery narrowing. thus facilitating blinded to the clinical information. The adequacy of the screening procedure. the study and the presence or absence of renal artery disease were noted. Renal artery percent stenosis METHODS was classified as a minor irregularity (<25% narrowing) or 25, 50, 75. 95, or 100% luminal diameter Patient Population narrowing. By convention. an angiographically sig- During a 5-month period, 1 ,302 of 1 .65 1 consecu- nificant lesion was defined as a 50% luminal tive patients undergoing elective diagnostic cardiac diameter narrowing of a major renal artery catheterization at Duke University Medical Center (12,15,16.22-25). Accessory renal arteries with dis- were screened for the presence of renal artery disease ease were felt to be significant if more than one third through the use of abdominal aortography. Patients of the renal mass was estimated to be supplied by not screened were excluded at the discretion of the the vessel. Lesion location was classified as ostial, angiographers. main artery. or branch vessel. Ostial lesions were Before patients had cardiac catheterization. demo- defined as stenotic if the segment of the renal artery graphic data. medical history. physical findings. and lumen immediately contiguous with the aorta was blood chemistries were recorded and entered into a compromised. Lesions of the main segment of the computerized medical information system (19). Pe- renal artery began at least 2 to 3 mm beyond the ripheral vascular disease was defined as a history of ostial segment. Branch lesions were defined as sten- claudication, previous vascular procedure, a history otic lesions originating beyond the first bifurcation of stroke or transient ischemic attack, or physical of the renal artery. The stenotic lesions were desig- evidence of carotid, femoral, or abdominal bruits. nated as atherosclerotic if they did not demonstrate Symptoms of congestive heart failure were recorded a distinctive string-of-beads appearance character- and classified in accordance with the New York Heart istic of fibromuscular dysplasia (26). No complica- Association criteria (20). Hypercholesterolemia was tions related specifically to the aortogram were ob- defined as evidence of a cholesterol level elevated served. Retroperitoneal bleeding (0.002%). laceration above 200 mg/dL. Hypertension was defined as dia- of the femoral artery (0.002%), contrast nephrotox- icity (increase in serum creatinine >0.5 mg/%, 6%; stolic blood pressure >90 mm Hg when subjects were measured as outpatients during the time before >1 mg/%. 1 .4%). and cholesterol embolization in the study group catheterization. Hypertension was also considered (0.00 1 5%) were not increased present if the patient was taking antihypertensive compared with retrospective controls who received cardiac catheterization only. Patients were followed- medications and if it could be confirmed that the Indication for use was hypertension and not angina. up at 24 h and as outpatients. It is reasonable to Blood pressure was measured several times before assume that the risk of renal arteriography is at least as low as combined coronary and renal arteriograpy. and after catheterization but, because of the anxiety and discomfort surrounding the procedure, was not considered as basal blood pressure. Statistical Analysis

Stepwise univariate and mubtivariate logistic Angiography regression was performed in order to identify clinical Coronary angiography was performed via femoral and angiographic variables predictive of significant artery approach by the Judkins technique (2 1 ). The renal artery stenosis. A binary logistic model (27) was presence and severity of coronary atherosclerotic le- used to identify univariate predictors of significant sions were determined in the routine fashion. Coro- renal artery stenosis. The variables that were signif- nary artery lesions graded as >70% narrowing of the icant in the univarlate model were then entered into luminal diameter were classified as significant. After a stepwise logistic regression model to identify the left ventriculography. the pigtail catheter was with- best set of independent predictors of significant renal drawn into the abdominal aorta and positioned a few artery stenosis. From these data, a model was devel- centimeters superior to the renal arteries. Aortogra- oped to predict the probability of significant renal

Journal of the American Society of Nephrology 1609 Renal Artery Stenosis Prevalence at Cardiac Catheterization

artery stenosis in patients undergoing cardiac cath- TABLE 1. Demographic data of the 1.235 patients eterization. with adequate abdominal aortograms

Mean age (yr) 60±11 RESULTS White:Nonwhite 1054: 181 Men: Women 736:499 Of the 1 ,302 studies performed, 67 (5%) were Hypertension 581 (49%) deemed technically inadequate because of either poor Congestive Heart Failure I85 (15%) opacification of the renal vessels or the presence of Peripheral Vascular Disease#{176} 210 ( I7%) overlying mesenteric vessels obscuring the renal Smoking 764 (62%) anatomy. The remaining 1 ,235 studies were consid- Diabetes 226 (18%) ered technically adequate for the evaluation of the 599 (49%) renal artery anatomy and form the basis of this Serum Creatinine (Mmol/L) study. A representative cine angiographic visualiza- Mean (range) 93.7 (17.7-937.0) 208 (17%) tion of renal artery obstruction is shown in Figure 1. >106 Significant CADb The demographic data from the study patients are One Vessel 299 (24%) summarized in Table 1 . The mean age of the group Two Vessel 211 (17%) was 60 ± 1 1 yr. Sixty percent were men. and 85% Three Vessel 266 (22%) were white. Many had risk factors for atherosclero- Left Main 41 (3.3%) sis. About half of the patients had a history of hypertension. The serum creatinine ranged from 0.2 to 0 See text for definition. 1 0.6 mg/dL with a mean of 1 .06 mg/dL. Abnormal b CAD, coronary artery disease; see text for definition. lipids were noted in 599 (49%) patients. Congestive heart failure was noted in 185 (15%) patients. The prevalence of renal artery disease in this pop- patients or 1 5.2% of the study group had angiograph- ulation is illustrated in Figure 2. Lesions were desig- ically significant renal artery narrowing observed at nated as being atherosclerotic 97% of the time. All the time of cardiac catheterization. lesions classified as fibromuscular dysplasia ap- More severe stenosis (75% luminal diameter nar- peared angiographically insignificant. Bilaterally rowing) was seen unilaterally in 76 (6%) patients and normal renal arteries were identified in 70% of the bilaterally in 1 7 (1 .4%) patients. Eight patients had patients screened. Insignificant renal artery stenosis in essence one functional kidney either because of (<50% luminal narrowing) of at least one renal artery congenital absence, surgical removal, or total occlu- was seen in 1 87 (1 5%) patients. Significant unilateral sion of one renal artery. Of these eight patients, one renal artery stenosis (50%luminab narrowing) was had significant disease in the renal artery supplying identified in 1 36 (1 1 %) patients. and 52 (4%) had the solitary kidney. significant bilateral renal artery stenosis. Thus. 188 The overwhelming majority of lesions were located in the ostium or the main segment of the renal artery, with even distribution between these two locations (Figure 3). Of the 253 significant lesions observed in the 1 88 patients, 48% were in the ostium, 49% were in the main segment of the renal artery. and only 3% were beyond the first bifurcation of the renal artery in a branch vessel.

Predictors of Renal Artery Stenosis By univariate logistic regression, 14 variables were analyzed to identify associations that were more common in patients with significant renal artery disease. The predictive clinical variables (shown in descend- ing order according to x2 values) are shown in Table 2. Older age was the most important predictor of significant renal artery stenosis. The mean age of the patients with significant renal artery stenosis was 66 ± 1 0 yr compared with 58 ± 1 1 yr for patients with insigificant or no renal artery disease. Next in order of importance were the evidence of peripheral vascular disease and then congestive heart failure. A Figure 1 . Severe bilateral renal artery stenosis. creatinine of > 106 mol/L (1 .2 mg/dL), cigarette

1610 Volume 2 . Number II . 1992 Harding et al

187 ( 15% ) Insignificant RAS 860 ( 70% ) Normal

136 ( 11 % ) Significant Unilateral RAS

52 ( 4% ) Significant Bilateral RAS

Figure 2. The prevalence of renal artery stenosis as determined by cine abdominal aortography at the time of cardiac catheterization (N = I .235). Insignificant renal artery stenosis is defined as <50% luminal narrowing. Significant renal artery stenosis is defined as 5O% luminal narrowing.

NO. OF variable predictors of renal artery stenosis were: LESIONS older age, the severity of coronary artery disease, a history of congestive heart failure, female gender, 250 and the presence of peripheral vascular disease. From these data, a model was developed to predict 200 the probability of significant renal artery stenosis in patients undergoing cardiac catheterization. As an example, the probability of finding significant renal 150 artery stenosis in a 65-yr-old man with three-vessel coronary artery disease, peripheral vascular disease, 100 and congestive heart failure is 0.43, or 1 0 times greater than the probability of 0.040 for a 55-yr-old 50 man without these associated findings.

DISCUSSION Ostial Main Branch The prevalence of renal artery disease in the gen- Figure 3. Location and distribution of renal artery lesions. eral population is unknown ( 1 7). In most cases, the diagnosis of renovascular disease is established during the course of evaluation for systemic hyperten- smoking, and female gender were also more com- sion. More recently. the effect of ischemic renal dis- monly seen in those with significant renal artery ease and the robe of revascularization in preserving stenosis. Hypertension, however, by itself, proved renal function have been debated (5,7). Obstructive unhelpful in identifying patients with renal artery renal artery lesions are potentially treatable by sur- stenosis. Of the 581 patients with hypertension, 481 gical or angioplastic techniques (6- 1 1). The presence (83%) patients had insignificant or no renal artery of renal arterial disease may also complicate the stenosis whereas only 1 00 (1 7%) patients had signif- medical management of patients with hypertension icant renal artery stenosis. and/or congestive heart failure (28). Because athero- Table 3 shows the results of the univariate analysis sclerosis is the primary cause of renal arterial ob- of the data obtained at cardiac catheterization. As struction and considering the diffuse nature of ath- the severity of coronary artery disease increased erosclerotic disease, patients with coronary artery (from no significant disease to left main or three- disease would logically seem to be at an increased vessel coronary artery disease). the likelihood of sig- risk for renal artery disease (7), which was confirmed nificant renal artery stenosis increased. A decreasing in this study. Abdominal aortography at the time of ejection fraction was also more common in patients cardiac catheterization offers a safe and effective with significant renal artery stenosis. means for evaluating the renal vascubature in this Multivariable logistic regression of all variables potentially high-risk group. These data suggtst that identified five risk factors predictive of significant screening for this process can be improved by the renal artery stenosis (Table 4). The strongest multi- use of certain predictors of disease.

Journal of the American Society of Nephrology loll Renal Artery Stenosis Prevalence at Cardiac Catheterization ..,. . . . . . . #{149}

TABLE 2. Clinical variables analyzed by univariate logistic regression to identify predictors of significant renal artery stenosis (N= 1,235)

Significant No RAS#{176} Variable RAS x2 P Value N- I 047 -, (N= 188)

MeanAge(yr) 58±11 00±10 60.43b 0.0001 Peripheral Vascular Disease 156 54 20.24 0.0001 Congestive Heart Failure 138 47 10.80 0.0001 Creatinine >106 Mmol/Lc 160 48 9.63 0.00 19 Smoking 664 100 7.00 0.0081 Female 408 91 5.84 0.0156 Hypertension 481 100 3.35 0.0022 White 886 168 2.82 0.0930 Diabetes Mellitus 184 42 2.41 0.1207 History of CADd 494 83 0.59 0.4429 Hyperlipidemia 510 89 0.12 0.7293

C) No or insignificant RAS (renal artery stenosis).

b Analyzed by 10-yr increments.

, One hundred thirty-six (1 1%) patients had missing data.

ci CAD. coronary artery disease.

TABLE 3. Cardiac catheterization-derived variables TABLE 4. Multivariate logistic regression analysis of analyzed by univariate logistic regression to identify both clinically and catheterization-derived predictors of significant renal artery stenosis variables

Variable No RAS#{176}Significa nt RAS x2 P Value . 2 Risk Odds Variable 1 x P Value . Ratio

No. of vessels 5345C 0.0001 with signifi- Age#{176} 0.0529 33.4 0.0001 1.70 cant CADb ExtentofCADb 0.4408 33.4 0.0001 1.55 0 418 39 CHFC 0.6062 8.5 0.0036 1.83 I 267 32 Sex -0.4374 6.1 0.0138 0.65 2 172 39 PVDd 0.4237 4.6 0.0327 1.52 3 189 77 LeftMainDisease 25 16 16.32 0.0001 0 Analyzed by 10-yr increments. Ejection Fraction 55 ± 12 51 ± 13 17.Old 0.0001 b Analyzed by one-vessel disease increments. CAD, coronary artery disease.

C CHF, congestive heart failure. () No or insignificant PAS (renal artery stenosis).

b CAD, coronary artery disease. d PVD, peripheral vascular disease; see text for definition.

Analyzed by one-vessel disease increments.

d Analyzed by 10% change. plasia were found in patients investigated for renovascular hypertension (1 8). This discrepancy is likely Our finding of a 1 5% prevalence of significant because of the vastly different patient populations renal artery narrowing in a cardiac catheterization being studied. Renovascular hypertension was not population is consistent with findings from previous suspected in this population referred for the evalua- smaller studies, which have demonstrated a preva- tion of cardiac disease. Other studies have confirmed lence between 5 and 29% (1 6, 24). However, the the overwhelming preponderance of atherosclerotic discovery of the angiographic presence of renal artery rather than fibrodysplastic renovascular disease in stenosis does not necessarily imply functional signif- similar subsets of patients with advanced age and icance. evidence of multiorgan atherosclerosis (15,16). The lesion type was presumed to be atherosclerotic The location of the renal artery narrowing has 97% of the time on the basis of angiographic appear- important clinical implications in regard to the ap- ance. This is in contrast to findings from other re- proach toward potential revascularization. Ostial be- ports of renovascubar disease where roughly 60% sions are generally the result of atherosclerotic aortic atherosclerotic lesions and 40% fibromuscubar dys- plaques that overhang the orifice of the renal artery,

1612 Volume 2 . Number I I - 1992 . . .. Harding et al .,, ..,..,. . . .... . -.A’ . ‘

producing inflow obstruction. These are difficult to multivessel coronary artery disease and/or symp- treat effectively by current percutaneous translumi- toms of congestive heart failure and significant renal nal angioplasty techniques (29,30). Almost one half artery stenosis. The presence of peripheral vascular of the patients who had significant renal artery ste- disease was a predictor of significant renal artery nosis in this study had ostiab lesions. Renal artery stenosis and is a known marker for renal artery disease was clearly more likely to be present in those disease. Patients with atherosclerosis elsewhere, es- with coronary and peripheral vascular disease. These pecially with abdominal aortic aneurysms (22 to findings confirm other observations that atheroscbe- 28%), aorto-occlusive disease (33%), or bower-extrem- rotic renovascular disease is often a manifestation of ity occlusive disease ( 1 8 to 39%), have previously generalized atherosclerosis involving the abdominal been shown to have a high prevalence of significant aorta and the coronary. cerebral. and bower-extrem- renal artery stenosis, even in the absence of the other ity arteries (12,15,16). clinical clues to suspect renal artery stenosis Both multivariate and univariate analyses of din- (15,22,32). In this study. only 29 of the 188 patients ically and cardiac catheterization-derived variables with significant renal artery stenosis had no evidence showed that older age, multivessel coronary artery of significant coronary artery disease or peripheral disease, and the presence of congestive heart failure vascular disease. symptoms are the most important markers for an Female gender as a predictor of significant renal increased risk of coexistent angiographlcably signifi- artery stenosis is of interest because women are com- cant renal artery stenosis. It is not surprising that monly not felt to have a high association with ath- advancing age is the strongest predictor because it is erosclerotic disease. In other series. male gender, commonly accepted that atherosclerosis in general, along with advanced age, have been cited as as well as atherosclerotic renovascular disease, most predictors of atherosclerotic renal artery lesions often occurs late in life (4,8,26,29,3 1). It follows that (3, 1 8,26,33). It Is well established, though, that patients with coronary artery disease would also be women have a higher incidence of fibromuscular more likely to have renal artery stenosis. Moreover, disease than do men (2,26). Furthermore, atheroma- the data reveal that the greater the number of coro- tous lesions can develop in patients with hyperten- nary arteries involved. the greater the likelihood of sion and fibromuscular dysplasia within the proxi- significant renal artery stenosis. Vetrovec et al. have mal segment of the renal artery (14). It is speculative previously shown that significant coronary artery that fibromuscular renovascular disease could have disease correlates with the presence of renal artery accelerated coexistent atherosclerotic disease as the stenosis, but these authors did not relate this finding women became more elderly. to the number of coronary artery vessels involved ( 1 6). Smaller series have not demonstrated a relationship between the number of coronary arteries and The Role of Renal Artery Disease in Clinical renal artery stenosis (24). Syndromes Patients with heart failure symptoms were signifi- Although an elevated creatinine was not found to cantly older, had a higher incidence of multivessel be an Important predictor of significant renal artery coronary artery disease and significant renal artery stenosis, it deserves special attention. This issue is stenosis, and were more likely to have a history of important in light of arguments promoting renal re- hypertension compared with patients without symp- vascularization for the preservation of renal function toms of congestive heart failure (Table 5). There may rather than for the control of hypertension. Up to be pathologic significance to the association between 14% of patients on dialysis have renal failure sec- ondary to ischemic renal disease (4,7). Unilateral TABLE 5. Comparison of patients with and without renal artery stenosis should not result In an elevated congestive heart failure symptoms creatinine if the contralateral kidney functions prop- erby. Instead, an elevated creatinine should be a CHF#{176} No CHF PValue marker for renal artery disease only if the stenosis is (N= 185) (N= 1,050) functionally significant in a solitary kidney or causes bilateral hemodynamic compromise of both kidneys Mean age (yr) 62 ± 12 59 ± I I 0.02 (5). In this study. we found no significant difference Hypertension 101 (55%) 480 (46%) 0.03 in the mean serum creatinine between these patients Significant RASb 47 (25%) 141 (13%) 0.001 with significant unilateral or bilateral renal artery Multivessel CADC 81 (44%) 396 (38%) 0.05 stenosis (88.4 and 95.5 mol/L, respectively). A history of hypertension also did not predict the 0 CHF. congestive heart failure. presence of renal artery stenosis. However, it is b RAS, renal artery stenosis. known that all renal artery obstructions do not cause C Two-vessel or left main CAD (coronary artery disease). hypertension and both hypertensive and normoten-

Journal of the American Society of Nephrology 1613 Renal Artery Stenosis Prevalence at Cardiac Catheterization

sive patients may exhibit renal artery stenosis racy of cine abdominal aortography performed in a (22,23,3 1 ,34). Almost half of the patient population single view for determining the absence or presence studied had a history of hypertension, and of the 581 of renal artery stenosis. Previous studies using the hypertensive patients, 1 00 ( 1 7%) had significant anterIor-posterior projection have demonstrated that renal artery stenosis. This is similar to other findings renal arteriography permits excellent visualization of of about an 1 8% incidence of renal artery stenosis in the renal vascular anatomy but point out the diffi- hypertensive patients who undergo cardiac catheter- culties in ruling out ostial lesions (1 2.30). Oblique ization (16). views, however, may be necessary to completely eval- Possibly the most important aspect of our findings uate the ostia and very proximal portions of the renal is the high incidence of renal atherosclerotic lesions artery because these areas may be partially obscured observed. Although a prospective study on the natu- by the aortic silhouette (1 6, 1 8,29). In addition, distal ral history of renal artery stenosis has not been branches of the renal artery may be less well seen. performed. retrospective studies suggest progression Five percent of the studies were deemed inadequate may occur in 36 to 63% of patients examined (1-3). for visualizing both renal arteries. Selective renal Progressive deterioration of renal function has been arteriograms would likely have helped delineate dis- observed to occur in 4 1 % of medically treated pa- ease in the main renal artery or its branches that tients with atherosclerotic renal artery stenosis and were obscured by overlying mesenteric vessels. It is, renovascular hypertension despite the presence of therefore, probable that some renal artery lesions good blood pressure control (35). were missed, particularly in the ostium and distal When the decision is made to treat, there are cur- branches of the renal arteries, and that the true rently three therapeutic options available for patients prevalence of renal artery stenosis Is somewhat with renal artery disease: medical therapy. percuta- greater than the 1 5% reported here. neous transluminal angioplasty, and surgical ther- A second shortcoming is the fact that 2 1 % of the apy. Several factors must be weighed in determining patients undergoing routine cardiac catheterization whether medical or interventional management is did not have abdominal aortography, and this could appropriate for a given patient. These include the cause selection bias. Unfortunately, this was an In- causal relationship of renovascular disease to hyper- herent problem in a study of this magnitude. which tension, the adequacy of blood pressure control with involved up to 1 0 angiographers. A number of pa- medical therapy, the natural history of untreated tients had only right heart studies, right heart biop- renovascular disease. the medical condition of the sies, or “rebook” coronary angiography after percuta- patient, and the known results of surgical therapy neous transluminal coronary angioplasty, and these and percutaneous transluminal angioplasty (36). To patients normally do not have ventricubography per- date no prospective trials have evaluated the outcome formed. In turn, the additional aortograms were not of patients randomized to surgical versus angioplas- available. Although a few patients might have been tic treatments. Revascubarization has been shown to excluded because of an elevated creatinine, these be effective in treating renovascular hypertension numbers were likely small because a previous. pro- and restoring renal function but iiot without consid- spective study of 1 , 1 44 patients undergoing elective erable risk (6,9, 1 3,37-40). Surgical mortality has catheterization from our institution revealed only 6% been reported to be between 2 and 15%, wIth the had a creatinine >106 zmol/L (41). predominant cause of death related to nonaortorenal disease, primarily myocardial infarction (5). The bong-term technical success rate for percutaneous CONCLUSION renal angioplasty is as high as 90% for lesions of the The prevalence of angiographically significant main segment of the renal artery. but ostial lesions renal artery narrowing, primary due to atheroscle- fare much worse with a technical success rate of rotic disease, in a population going to cardiac cathe- <25% (5). Major complications related to angioplasty terization is 1 5%. The yield of screening abdominal occur in 3 to 1 4% of cases, and mortality as high as aortography at the time of cardiac catheterization 2% has been reported (5, 1 1 ,40). can be increased if certain clinically and catheterization-derived variables including age, multivessel coronary artery disease, symptoms of congestive Limitations heart failure, female gender, and evidence of periph- It should be emphasized that this study was de- eral vascular disease are used to select those signed to screen for renal artery disease in a simple screened. and convenient manner in order to maximize the The high incidence of associated renovascular dis- number and percentage of patients studied who ease may contribute to clinical morbidity in this underwent routine cardiac catheterization. The study group of patients over time, and this should be re- was limited because of its dependency on the accu- membered when unexplained renal dysfunction en-

1614 Volume 2 . Number II ‘ 1992 Harding et al

sues in cardiac patients. Because renal vascular dis- 1 4. Horvath JS, Waugh RC, Tiller DJ, Duggin GG: The detection of renovascular hypertension: A ease may result in the loss of renal mass and func- study of 490 patients by renal angiography. Q J tion, further prospective studies are needed to Med 1982;51:139-146. identify the natural history of atherosclerotic renal 15. Olin JW, Meia M, Young JR. Graor RA, Risius artery disease and to define the role of intervention B: Prevalence of atherosclerotic renal artery ste- and correction of these lesions in preventing the loss nosis in patients with atherosclerosis elsewhere. Am J Med 1990;88:146N-151N. of renal function. 16. Vetrovec GW, Landwehr DM, Edwards VL: In- cidence of renal artery stenosis in hypertensive ACKNOWLEDGMENTS patients undergoing coronary angiography. J In- terven Cardiob 989;2:69-76. Supported in part by research grant HLO7 1 01 from the National 1 7. 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Journal of the American Society of Nephrology 1615 Renal Artery Stenosis Prevalence at Cardiac Catheterization

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1616 Volume 2 . Number I I - 1992