Clinical practice. Renal-artery stenosis

Abstract

A 73-year-old former smoker with a history of hypertension and dyslipidemia presents to the emergency department with shortness of breath. His blood pressure is 160/75 mm Hg, heart rate 60 beats per minute, and respiratory rate 24 breaths per minute. Chest auscultation reveals diffuse rales, and there is 1+ pitting edema. The serum creatinine level is 1.4 mg per deciliter (124 µmol per liter) (estimated glomerular filtration rate, 52 ml per minute), and urinalysis shows 1+ protein. His condition improves after treatment with intravenous diuretics, but his systolic blood pressure remains elevated, at 170 mm Hg. Magnetic resonance angiography (MRA) reveals a diseased aorta, a high-grade ostial lesion of the left renal artery that is consistent with atherosclerotic stenosis, and a normal right renal artery. How should he be further evaluated and treated?

Figure 1. Duplex Ultrasonography in a Patient with Renal-Artery Stenosis

Panel A shows aliasing of color in the proximal left renal artery indicating high velocity and turbulent flow. Panel B shows the estimated velocity of blood flow in excess of 900 cm per second in the left renal artery near the aortic ostium; 90% stenosis was confirmed angiographically.

Figure 2. Magnetic Resonance Angiography of the Renal Arteries Showing Severe Bilateral Stenosis

The angiographically confirmed 70% ostial stenosis of the right renal artery (arrow) is associated with a systolic pressure gradient of 28 mm Hg, and the 40% ostial stenosis of the left renal artery (arrowhead) is associated with a pressure gradient of 13 mm Hg.