Page 8 - Carotid and peripheral vascular interventions textbook
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                      A                                          B

                                                A                                         B

                    Figure  10-6.  Comparison imaging resolution between computerized tomography angiography (A) and magnetic resonance angiography
                    (B) of renal arteries.

                    INDICATION FOR REVASCULARIZATION                and ESC also recommended balloon angioplasty together

                                                                    with bailout stenting in case of FMD with hypertension
      A                 The  following  organizations  have  published     and/or indications of renal impairment (Class IIa) (23,34).
                    guidelines for the treatment of RAS: 2013 American        In 2018, ACC/AHA/SCAI/SIR/SVM produced
                    College of Cardiology (ACC)/American Heart Association   an appropriate use criteria (AUC) statement for PTRAS
                    (AHA) (34), 2014 Society of Cardiovascular Angiography   (36). Using an expert panel to scientif cally review data,
                    and Interventions (SCAI) (35), and 2017 European Society   they concluded that patients with the following were
                    of Cardiology (23). There are some discrepancies among   most likely to gain advantage from PTRAS (36,37).
                    these guidelines, but all guidelines favor medical therapy   1. Cardiac destabilization syndromes: f ash pulmonary
                    for the primary management of RAS.                    edema with severe hypertension
                        The 2013 ACC/AHA guidelines recommend PTRAS     2. Resistant (refractory) hypertension
                    in patients who have hemodynamically signif cant RAS   3. Rapidly progressive ischemic nephropathy, CKD
                    together with any of the following (34) :             with eGFR less than 45 cc/min/m , and global
                        •  Recurrent CHF or sudden unexplained pulmonary   renal ischemia.
                          edema (Class I, LOE B)                        Table 10-3 summarizes the AUC for treatment of ARAS
         256            •  Unstable angina (Class IIa, LOE B)       in different indications (36). Both clinical and anatomical
                        •  Accelerated, resistant, or malignant hypertension   lesion criteria have to be met. Severe RAS is def ned as
                          or hypertension with unexplained unilateral small   a stenosis diameter ≥70-99% or a stenosis 50-69% with
                          kidney and hypertension with medication intolerance   a translesional peak pressure gradient (measured with
                          (Class IIa, LOE B)                        a ≤ 5-Fr catheter or pressure wire) ≥20 mmHg or a resting
                        •  RAS and chronic renal insuff ciency (CRI) with   mean pressure gradient ≥10 mmHg, a hyperemic mean
                          bilateral RAS or RAS to solitary functioning kidney   gradient ≥10mmHg or FFR performed with dopamine
                          (Class IIa, LOE B)                        (50 µg/kg) or papaverine (32 mg) of <0.8 or any stenosis
                        •  Asymptomatic bilateral or solitary viable kidney   ≥70% diameter by intravascular ultrasound (36).
                          with a hemodynamically signif cant RAS (Class IIb,
                          LOE C)                                    SURGICAL REVASCULARIZATION
                        •  Asymptomatic  unilateral  hemodynamically
                          signif cant RAS in a viable kidney (Class IIb, LOE C)     Although surgical renal revascularization is associated
                        •  RAS and CRI with unilateral RAS (2 kidneys   with more durable long-term results, the high surgical risk
                          present) (Class IIb, LOE C)               limits its use. Surgical revascularization should be appraised
                        The 2017 ESC guidelines recommended balloon   only for patients who have complex renal arteries’ anatomy,
                    angioplasty, without or with stenting, only selected RAS   following a failed endovascular procedure, or during
                    patients and unexplained repeated congestive heart failure or   open aortic surgery (i.e., presence of abdominal aortic
                    sudden pulmonary edema (Class IIb) (23). Both ACC/AHA   aneurysm, renal artery dissection or aneurysm) (23,34).
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