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Semin intervent Radiol 2001; 18(1): 011-022
DOI: 10.1055/s-2001-12840
Copyright © 2001 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel.: +1(212) 584-4662

Diagnosing Renovascular Hypertension

Iftikhar Ahmad1 , Charles E. Ray Jr.2
  • 1Department of Radiology, Indiana University Hospital, Indianapolis, Indiana
  • 2Department of Radiology, Denver Health Medical Center, Denver, Colorado
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Publication History

Publication Date:
31 December 2001 (online)

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ABSTRACT

Diagnosing renovascular hypertension is complex. Definitive diagnosis can only be made in retrospect, when a hypertensive patient with renal artery stenosis improves following correction of the stenotic arterial lesion. Screening for renovascular hypertension in all hypertensive patients is impractical because of the low prevalence of the disease. However, the diagnosis is important because treatment can lead to potential cure. A select group of patients with clinical signs and symptoms suggesting renovascular hypertension need to be investigated further for the cause of their hypertension. A number of clinical tests help in screening patients that require further imaging tests. The tests designed for evaluating renovascular hypertension assess the functional and anatomic abnormalities. This article reviews various clinical and imaging techniques available for evaluating these patients. A description of each technique is followed by a discussion of its advantages and disadvantages. The authors also propose an algorithm for work-up of patients with a high probability of renovascular hypertension.

KEYWORD

Renovascular hypertension - renal artery stenosis

REFERENCES

  • 1 Maxwell M H, Bleifer K H, Franklin S S, Varady P O. Demographic analysis of the study.  JAMA . 1972;  220 1195-1204
    CrossrefPubMedGoogle Scholar
  • 2 Zierler R E, Bergelin R O, Davidson R C. A prospective study of disease progression in patients with atherosclerotic renal artery stenosis.  Am J Hypertens . 1995;  8 40A
    PubMedGoogle Scholar
  • 3 Tollefson D FJ, Ernst C B. Natural history of atherosclerotic renal artery stenosis associated with aortic disease.  J Vasc Surg . 1991;  14 327-333
    CrossrefPubMedGoogle Scholar
  • 4 Zierler R E, Bergelin R O, Isaacson J A, Strandness D E. Natural history of atherosclerotic renal artery stenosis: a prospective study with duplex ultrasonography.  J Vasc Surg . 1994;  19 250-258
    PubMedGoogle Scholar
  • 5 Mitty H A, Shapiro R S, Parsons R B, Silberzwieg J E. Renovascular hypertension.  Radiol Clin North Am . 1996;  34 1017-1036
    PubMedGoogle Scholar
  • 6 Blaufox M D, Middleton M L, Bongiovanni J, Davis B R. Cost efficacy of diagnosis and therapy of renovascular hypertension.  J Nucl Med . 1996;  37 171-177
    PubMedGoogle Scholar
  • 7 Eyler W R, Clark M D, Garman J E. Angiography of the renal arteries including a comparative study of renal arterial stenosis in patients with and without hypertension.  Radiology . 1962;  78 879-892
    PubMedGoogle Scholar
  • 8 Harden P N. Effect of renal artery stenting on progression of renovascular renal failure.  Lancet . 1997;  349 1133-1136
    CrossrefPubMedGoogle Scholar
  • 9 Van Jaarsveld B C. The Dutch renal artery stenosis intervention cooperative (DRASTIC) study. Abstract presented at the Interventional Society of Hypertension meeting, Amsterdam, The Netherlands, August 1998
    Google Scholar
  • 10 Schreij G, Ritsema G H, Vreugdenhil G, De Leeuw W P. Stenosis and renographic characteristics in renovascular disease.  J Nucl Med . 1996;  37 594-597
    PubMedGoogle Scholar
  • 11 Kaplan N M. Renal vascular hypertension. In: Kaplan NM, ed. Clinical Hypertension, 6th ed Baltimore, MD: Williams & Wilkins 1994: 319-341
    Google Scholar
  • 12 Simon S, Franklin S S, Bleifer K H, Maxwell M H. Clinical characteristics of renovascular hypertension.  JAMA . 1972;  220 1209-1218
    CrossrefPubMedGoogle Scholar
  • 13 Deal J E, Snell F M, Barratt T M, Dillion M J. Renovascular diseases in childhood.  J Pediatr . 1992;  121 378-384
    PubMedGoogle Scholar
  • 14 Hiner L B, Falknor B. Renovascular hypertension in children.  Pediatr Clin North Am . 1993;  40 123-140
    PubMedGoogle Scholar
  • 15 Wells T G, Belsha C W. Pediatric renovascular hypertension.  Curr Opin Pediatr . 1996;  8 128-134
    PubMedGoogle Scholar
  • 16 Muller F B, Sealey J E, Case D B. The captopril test for identifying renovascular disease in hypertensive patients.  Am J Med . 1986;  80 633-643
    CrossrefPubMedGoogle Scholar
  • 17 Miralles M, Covas M I, Martinez Miralles E. Captopril test and renal duplex scanning for primary screening of renovascular disease.  Am J Hypertens . 1997;  10 1290-1296
    CrossrefPubMedGoogle Scholar
  • 18 Imanishi M, Ohta M, Kawamura M. Aspirin test for differentiation of unilateral renovascular hypertension from hyperreninemic essential hypertension.  Am J Hypertens . 1991;  4 761-768
    PubMedGoogle Scholar
  • 19 Gluszek J, Malaczynska A P, Musialik D P, Gracz M, Perz H K. Acetylsalicylic acid (aspirin) test for diagnosis of renovascular hypertension.  Clin Invest Med . 1997;  20 171-175
    PubMedGoogle Scholar
  • 20 Baumgart P, Walger K, Vorst M. Can secondary hypertension be identified by twenty-four hour ambulatory pressure monitoring?.  J Hypertens . 1989;  7 25-28
    PubMedGoogle Scholar
  • 21 Ansell G. Complications of intravenous iodinated contrast media. In: Ansell G, Bettmann M, Kaufman J, Wilkins R, eds. Complications in Diagnostic Imaging and Interventional Radiology, 3rd ed Cambridge, MA: Blackwell Science, Inc 1996: 245-302
    Google Scholar
  • 22 Ray Jr C, Kaufman J. Complications of diagnostic angiography. In: Ansell G, Bettmann M, Kaufman J, Wilkins R, eds. Complications in Diagnostic Imaging and Interventional Radiology, 3rd ed Cambridge, MA: Blackwell Science, Inc 1996: 303-316
    Google Scholar
  • 23 Wilkinson L, Wilkins R. Complications of percutaneous angioplasty. In: Ansell G, Bettmann M, Kaufman J, Wilkins R, eds. Complications in Diagnostic Imaging and Interventional Radiology, 3rd ed Cambridge, MA: Blackwell Science, Inc 1996: 346-361
    Google Scholar
  • 24 Smith C, Winfield R, Harding D. Evaluation of digital venous angiography for diagnosis of renovascular hypertension.  Radiology . 1982;  144 51-54
    PubMedGoogle Scholar
  • 25 Dunnick N, Svetkey R, Cohan R. Intravenous digital subtraction renal angiography: use in screening for renovascular hypertension.  Radiology . 1998;  171 219-222
    PubMedGoogle Scholar
  • 26 Spinosa D, Matsumoto A, Angle F. Renal insufficiency: usefulness of gadodiamide-enhanced renal angiography to supplement CO2-enhanced renal angiography for diagnosis and percutaneous treatment.  Radiology . 1999;  210 633-672
    PubMedGoogle Scholar
  • 27 Caridi J, Stavropoulos S, Hawkins Jr I. Carbon dioxide digital subtraction angiography for renal artery stent placement.  J Vasc Interv Radiol . 1999;  10 635-640
    PubMedGoogle Scholar
  • 28 Caramella N, Bisogni C, Laiolo E. Detection of accessory renal arteries with virtual vascular endoscopy of the aorta.  Cardiovasc Intervent Radiol . 1999;  22 1-6
    CrossrefPubMedGoogle Scholar
  • 29 Nally V, Black R. State of the art review.  captopril renography: pathophysiological consideration and clinical observations. Semin Nucl Med . 1992;  12 85-97
    PubMedGoogle Scholar
  • 30 Fommei E, Ghione S, Hilson W. Captopril radionuclide test in renovascular hypertension: a European multi-center study.  Eur J Nucl Med . 1993;  2 940-948
    PubMedGoogle Scholar
  • 31 Prigent A. The diagnosis of renovascular hypertension: the role of captopril renal scintigraphy and related issues.  Eur J Nucl Med . 1993;  20 625-644
    PubMedGoogle Scholar
  • 32 Setaro F, Saddler C, Chen C. Simplified captopril renography in diagnosis and treatment of renal artery stenosis.  Hypertension . 1991;  18 299-303
    PubMedGoogle Scholar
  • 33 Van Jaarsveld B, Krijnen P, Derkx F. The place of renal scintigraphy in the diagnosis of renal artery stenosis; fifteen years clinical experience.  Arch Intern Med . 1997;  157 1226-1234
    CrossrefPubMedGoogle Scholar
  • 34 Chen C, Hoffer P, Vahjen G. Patients at high risk for renal artery stenosis: a simple method of renal scintigraphic analysis with Tc-99m DTPA and captopril.  Radiology . 1990;  176 365-370
    PubMedGoogle Scholar
  • 35 Gruenewald M, Collins L. Renovascular hypertension: quantitative renography as a screening test.  Radiology . 1983;  149 287-291
    PubMedGoogle Scholar
  • 36 Helenon O, Malki P, Correas J. Renovascular disease: Doppler ultrasound.  Semin Ultrasound CT MR . 1997;  18 136-146
    CrossrefPubMedGoogle Scholar
  • 37 Karasch T, Rubin J. Diagnosis of renal artery stenosis and renovascular hypertension.  Euro J Ultrasound . 1998;  7 S27-39
    PubMedGoogle Scholar
  • 38 Kohler R, Zierler E, Martin L. Non-invasive diagnosis of renal artery stenosis by ultrasound duplex scanning.  J Vasc Surg . 1986;  4 450-456
    PubMedGoogle Scholar
  • 39 Olin W. Role of duplex ultrasonography in screening for significant renal artery disease.  Urol Clin North Am . 1994;  21 215-226
    PubMedGoogle Scholar
  • 40 Halpern J, Needleman L, Nack L. Renal artery stenosis: should we study the main renal artery or segmental vessels?.  Radiology . 1995;  195 799-804
    PubMedGoogle Scholar
  • 41 Schwerk B, Restrepo K, Stellwaag W. Renal artery stenosis grading with image-directed Doppler US evaluation of renal resistive index.  Radiology . 1994;  190 785-790
    PubMedGoogle Scholar
  • 42 Bude O, Rubin M. Detection of renal artery stenosis with Doppler sonography: it is more complicated than originally thought?.  Radiology . 1995;  196 612-613
    PubMedGoogle Scholar
  • 43 Davidson A, Wilcox S. Newer tests for diagnosis of renovascular diseases.  JAMA . 1992;  268 3353-3358
    CrossrefPubMedGoogle Scholar
  • 44 Berland L, Kosiln B, Routh D. Renal artery stenosis: prospective evaluation of diagnosis with color duplex US compared with angiography: work in progress.  Radiology . 1990;  174 421-423
    PubMedGoogle Scholar
  • 45 Lees R. Echo-enhanced renal ultrasound imaging with Levovist.  Angiology . 1996;  47 531-535
    PubMedGoogle Scholar
  • 46 Debatin J, Spritzer C, Grist T. Imaging of the renal arteries: value of MR angiography.  AJR Am J Roentgenol . 1991;  157 981-990
    PubMedGoogle Scholar
  • 47 Vock P, Terrier F, Wegmuller H. Magnetic resonance angiography of the abdominal vessels: Early experience using the three-dimensional phase contrast technique.  Br J Radiol . 1991;  64 10-16
    PubMedGoogle Scholar
  • 48 Kent K, Edelman R, Kim D. Magnetic resonance imaging: a reliable test for the evaluation of proximal atherosclerotic renal artery stenosis.  J Vasc Surg . 1991;  13 311-318
    PubMedGoogle Scholar
  • 49 Kim D, Edelman R, Kent K. Abdominal aorta and renal artery stenosis: Evaluation with MR angiography.  Radiology . 1990;  174 727-731
    PubMedGoogle Scholar
  • 50 Kaufman J, Prince M, Yucel K. Magnetic resonance angiography of the renal and visceral arteries. In: Yucel K, ed. Magnetic Resonance Angiography: A Practical Approach New York: McGraw Hill 1995: 212-220
    Google Scholar
  • 51 Yucel K. Magnetic resonance angiography of the lower extremity and renal arteries.  Semin Ultrasound CT MR . 1992;  13 291-302
    PubMedGoogle Scholar
  • 52 Evans J, Richardson B, Tien R. Poststenotic signal loss in MR angiography: effects of echo time, flow compensation, and fractional echo.  AJNR Am J Neuroradiol . 1993;  14 721-729
    PubMedGoogle Scholar
  • 53 Silverman J, Friedman M, Van Allan R. Detection of main renal artery stenosis using phase contrast cine MR angiography.  AJR Am J Roentgenol . 1996;  166 1131-1137
    PubMedGoogle Scholar
  • 54 Grenier N, Trillaud H, Combe C. Diagnosis of renovascular hypertension: feasibility of captopril-sensitized dynamic MR imaging and comparison with captopril scintigraphy.  AJR Am J Roentgenol . 1996;  166 835-843
    PubMedGoogle Scholar
  • 55 Olbricht C J, Paul K, Prokop M. Minimally invasive diagnosis of renal artery stenosis by spiral computed tomography angiography.  Kidney Int . 1995;  48 1332-1337
    PubMedGoogle Scholar
  • 56 Ray Jr C, Kaufman J A. Computed tomographic arteriography: overview of technique.  Seminars in Interventional Radiology . 1998;  15 123-133
    PubMedGoogle Scholar
  • 57 Galanski M, Prokop M, Chavan A. Renal artery stenosis: spiral CT angiography.  Radiology . 1993;  189 185-192
    PubMedGoogle Scholar
  • 58 Rubin G D, Dake M D, Napels S. Spiral CT of renal artery stenosis: comparison of three dimensional rendering technique.  Radiology . 1994;  190 181-189
    PubMedGoogle Scholar
  • 59 Kaatee R, Beek F, Lange E. Renal artery stenosis: detection and quantification with spiral CT angiography versus optimized digital subtraction angiography.  Radiology . 1997;  205 121-127
    PubMedGoogle Scholar
  • 60 Verschuyl E J, Kaatee R, Beek F JA. Location of the renal artery origins in the transverse plane.  Radiology . 1997;  203 71-75
    PubMedGoogle Scholar
  • 61 Gellens M, Matrin K. Renovascular hypertension: a clinical overview. In: Kadir S, ed. Teaching atlas of Interventional Radiology New York: Thieme Medical Publishers 1999: 21-28
    Google Scholar
  • 62 Korobkin M, Glickman G, Schambelan M. Segmental renal vein sampling for renin.  Radiology . 1976;  118 307-313
    PubMedGoogle Scholar
  • 63 Harrington P, Whelton K, Mackenzie J. Renal venous sampling: Prospective study of technique and methods.  Radiology . 1981;  138 571-575
    PubMedGoogle Scholar
  • 64 Vaughn E D, Buhler F R, Laragh J H. Renovascular hypertension: Renin measurements to indicate hypersecretion and contralateral suppression, estimate renal plasma flow, and score for surgical curability.  Am J Med . 1973;  55 402-413
    CrossrefPubMedGoogle Scholar
  • 65 Kutkuhn B, Godehardt E, Kunert J. Acute blockage of renin system and differential renal vein renin determination is diagnostic of renovascular hypertension.  Scand J Urol Nephrol . 1996;  30 69-72
    PubMedGoogle Scholar
  • 66 Roubidoux A, Dunnick N, Klotman P. Renal vein renins: Inability to predict response to revascularization in patients with hypertension.  Radiology . 1991;  178 819-822
    PubMedGoogle Scholar
  • 67 Strandness D E. Duplex imaging for the detection of renal artery stenosis.  Am J Kidney Dis . 1994;  24 674-678
    PubMedGoogle Scholar
  • 68 Nelemans P J, Kessels A GH, Leeuw P D, Hann M D, Engelshoven J. The cost-effectiveness of diagnosis of renal artery stenosis.  Eur J Radiol . 1998;  27 95-107
    CrossrefPubMedGoogle Scholar
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