Hemodynamic Measurements for Renal Artery Stenosis

van Brussel PM, van de Hoef TP, de Winter RJ, Vogt L, van den Born BJ.
Hemodynamic Measurements for the Selection of Patients With Renal Artery Stenosis: A Systematic Review. JACC Cardiovasc Interv 2017;10:973-985.

The following are key points to remember about hemodynamic measurements for the selection of patients with renal artery stenosis:

  1. Interventions targeting renal artery stenoses have been shown to lower blood pressure and preserve renal function. However, recent studies have questioned the efficacy of catheter-based percutaneous transluminal renal angioplasty with stent placement (PTRAS).
  2. The selection of renal arteries suitable for intervention is currently on the basis of anatomic grading of the stenosis by angiography rather than functional assessment under hyperemia.
  3. Studies included in this review show that evidence for outcome improvement using intrarenal functional assessment of renal artery stenosis severity is still insufficient, at least partly related to the heterogeneity in methodology and subjects’ characteristics.
  4. There are distinct differences between myocardial and renal physiology, which implies that successful physiological indexes in coronary interventions may not be fully transferable to the setting of renal artery stenosis.
  5. At this time, determining treatment strategy for renal artery stenosis on the basis of intrarenal physiological measurements faces many challenges.
  6. Available studies indicate that dopamine and fenoldopam, infused intrarenally, are the hyperemic agents of choice for renal hemodynamic measurements.
  7. Post hoc analyses suggest that mean hyperemic gradient (MHG), hyperemic systolic gradient (HSG), and renal fractional flow reserve (rFFR) seem to be able to discriminate responders from nonresponders.
  8. However, studies that aimed to validate cutoff values for MHG, HSG, and rFFR showed variable results, whereas for renal flow reserve (RFR), data are scarce.
  9. Future studies on intrarenal functional measurements should aim for further improvement in techniques that may serve as a benchmark for prospective clinical studies that evaluate the value of PTRAS.
  10. It is possible that in the future, functional testing may help evolve the treatment of renal artery stenosis, similar to the evolution of elective percutaneous coronary intervention, by improving patient selection and clinical outcomes of PTRAS.

Clinical Topics: Invasive Cardiovascular Angiography and Intervention, Vascular Medicine, Interventions and Imaging, Interventions and Vascular Medicine, Angiography, Nuclear Imaging

Keywords: Angiography, Angioplasty, Blood Pressure, Blood Pressure Determination, Constriction, Pathologic, Dopamine, Fenoldopam, Hyperemia, Percutaneous Coronary Intervention, Renal Artery Obstruction, Stents, Vascular Diseases

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