Published online before print October 9, 2006, doi: 10.1161/CIRCULATIONAHA.106.178777
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(Circulation. 2006;114:1892-1895.)
© 2006 American Heart Association, Inc.
AHA Science Advisory |
Indications for Renal Arteriography at the Time of Coronary Arteriography
A Science Advisory From the American Heart Association Committee on Diagnostic and Interventional Cardiac Catheterization, Council on Clinical Cardiology, and the Councils on Cardiovascular Radiology and Intervention and on Kidney in Cardiovascular Disease
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Abstract |
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Atherosclerotic renal artery stenosis is commonly present in patients with clinically manifest atherosclerosis in other vascular beds and is independently associated with increased cardiovascular morbidity and mortality. Screening tests such as renal angiography should be selectively applied to patients at high risk for renal artery stenosis who are potential candidates for revascularization. This multispecialty consensus document describes the rationale for patient selection for screening renal angiography at the time of cardiac catheterization.
Key Words: AHA Scientific Statements • arteriography • atherosclerotic renal artery stenosis • atherosclerosishypertension, renal
Atherosclerotic renal artery stenosis (ARAS) is a common anatomic finding in patients with atherosclerosis in other arterial circulations.1 This science advisory will address the appropriate use of diagnostic screening arteriography for ARAS at the time of coronary arteriography, pejoratively called "drive-by renal arteriography," in patients at increased risk for ARAS (Tables 1 and 2
) who have clinical indications for renal artery revascularization as defined in the recently published American College of Cardiology/American Heart Association (ACC/AHA) guidelines for management of peripheral vascular disease.3
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The association between ARAS and peripheral arterial atherosclerosis is well established, occurring in 22% to 59% of cases.5,6 This frequency of concomitant disease explains why abdominal aortography with run-off for lower-extremity ischemic disease routinely includes imaging of the renal arteries. There is also a marked increase in the prevalence of ARAS in patients with known or suspected coronary artery disease7–9 (Table 3). In the largest series of screening renal arteriography, 1235 unselected, consecutive patients had both coronary arteriography and abdominal aortography.9 Thirty percent of patients were found to have some evidence of ARAS, and 15% had lesions 
50% diameter stenosis. In a selected population of 297 hypertensive patients referred for coronary arteriography who also had concurrent abdominal aortography during the same procedure, 34% had evidence of renal artery stenosis, and 19% had ARAS lesions 50% diameter stenosis.11 Bilateral ARAS was noted in 19% to 29% of patients with 50% ARAS (Table 3).
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The diagnosis of ARAS, even if not hemodynamically significant, provides information that affects patient management. ARAS is associated with premature cardiovascular events (myocardial infarction, stroke, and death), and the presence of ARAS in patients with coronary disease independently doubles a patient’s risk of mortality even when coronary revascularization is performed.12 The increase in mortality is directly related to the severity of ARAS: The more severe the stenosis, the higher the mortality risk. The presence of bilateral ARAS significantly reduced 4-year survival in affected patients to 47% compared with 59% (P<0.001) in patients with unilateral ARAS.12
Progression or worsening of ARAS occurs commonly, with occlusion and loss of renal function more likely with more severe renal stenoses.13,14 Sequential coronary and abdominal aortography performed in 1189 patients, with an average of 2.6±1.6 years between studies, demonstrated progression of ARAS in 11.1% of patients.13 Patients with normal renal arteries at baseline who demonstrated progression to severe ARAS (75%) had significant deterioration in their renal function compared with those without progression of ARAS.13 Serial ultrasound studies in patients with ARAS confirmed that lesion progression occurred in about one third of 295 arteries serially imaged over 3 years, but that progression to occlusion only occurred if baseline ARAS was >60%.14 A randomized trial of hypertensive patients with ARAS lesions 50% demonstrated that 16% of the medical treatment group had progressed to occlusion at 1 year.15
The cost or risk versus the benefit of performing screening renal arteriography at the time of diagnostic coronary arteriography in patients with indications for renal revascularization must be considered. Although aortography does add cost to the coronary angiographic procedure, it is comparable to the cost of the noninvasive imaging test that it replaces. There is good evidence that the addition of abdominal aortography to coronary arteriography in patients with a baseline serum creatinine 
2.0 mg/dL is not associated with an increase in procedure-related morbidity or mortality.11 In a series of 297 patients with hypertension undergoing coronary arteriography and concurrent abdominal aortography, no patients experienced deterioration in renal function, clinical atheromatous embolization, or prolongation in the length of hospital stay.11 The additional contrast administration is negligible, and the catheter used for nonselective renal arteriography is atraumatic. Patients at increased risk for contrast-induced nephropathy should be pretreated with N-acetylcysteine and receive vigorous hydration before the administration of low-osmolar contrast.3
Ideally, patients with a clinical indication for investigation of renal artery patency will undergo a noninvasive diagnostic test (duplex ultrasonography, magnetic resonance arteriography, or computer-assisted tomographic arteriography) before diagnostic coronary arteriography. However, some patients at "high risk" for ARAS (Table 1) who are potential candidates for renal revascularization will present for urgent coronary arteriography without having had the opportunity for noninvasive screening for ARAS.
The increased prevalence of ARAS in patients with coronary artery disease and the poor prognosis independently associated with the presence of ARAS supports a strategy of increased awareness of this disease process and a need to identify ARAS as early as possible. We conclude that it is reasonable to perform screening renal arteriography at the time of cardiac catheterization in patients at increased risk for ARAS (Table 1) who are candidates for revascularization as defined in the ACC/AHA peripheral arterial disease manage- ment guideline document.3
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Disclosures
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Footnotes |
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The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.
This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on August 23, 2006. A single reprint is available by calling 800-242-8721 (US only) or writing the American Heart Association, Public Information, 7272 Greenville Ave, Dallas, TX 75231-4596. Ask for reprint No. 71-0375. To purchase additional reprints: Up to 999 copies, call 800-611-6083 (US only) or fax 413-665-2671; 1000 or more copies, call 410-528-4121, fax 410-528-4264, or e-mail kelle.ramsay@wolterskluwer.com.
Expert peer review of AHA Scientific Statements is conducted at the AHA National Center. For more on AHA statements and guidelines development, visit http://www.americanheart.org/presenter.jhtml?identifier=3023366.
Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American Heart Association. Instructions for obtaining permission are located at http://www.americanheart.org/presenter.jhtml?identifier=4431. A link to the "Permission Request Form" appears on the right side of the page.
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References |
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1. Scoble JE. The epidemiology and clinical manifestations of atherosclerotic renal disease. In: Novick AC, Scoble JE, Hamilton G, eds. Renal Vascular Disease. London, England: WB Saunders; 1996: 303–314.
2. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, Jones DW, Materson BJ, Oparil S, Wright JT Jr, Rocella EJ; National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; National High Blood Pressure Education Program Coordinating Committee. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report [published correction in JAMA. 2003;290:197]. JAMA. 2003; 289: 2560–2572.
3. Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, Hiratzka LF, Murphy WRC, Olin JW, Puschett JB, Rosenfield KA, Sacks D, Stanley JC, Taylor LM Jr, White CJ, White J, White RA. ACC/AHA 2005 practice guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease). Circulation. 2006; 113: e463–e654.
4. Gibbons RJ, Smith SC Jr, Antman E; American College of Cardiology; American Heart Association. American College of Cardiology/American Heart Association clinical practice guidelines, part II: evolutionary changes in a continuous quality improvement project. Circulation. 2003; 107: 3101–3107.
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8. Weber-Mzell D, Kotanko P, Schumacher M, Klein W, Skrabal F. Coronary anatomy predicts presence or absence of renal artery stenosis: a prospective study in patients undergoing cardiac catheterization for suspected coronary artery disease. Eur Heart J. 2002; 23: 1684–1691.
9. Harding MB, Smith LR, Himmelstein SI, Harrison K, Phillips HR, Schwab SJ, Hermiller JB, Davidson CJ, Bashore TM. Renal artery stenosis: prevalence and associated risk factors in patients undergoing routine cardiac catheterization. J Am Soc Nephrol. 1992; 2: 1608–1616.[Abstract]
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12. Conlon PJ, Little MA, Pieper K, Mark DB. Severity of renal vascular disease predicts mortality in patients undergoing coronary angiography. Kidney Int. 2001; 60: 1490–1497.[CrossRef][Medline] [Order article via Infotrieve]
13. Crowley JJ, Santos RM, Peter RH, Puma JA, Schwab SJ, Phillips HR, Stack RS, Conlon PJ. Progression of renal artery stenosis in patients undergoing cardiac catheterization. Am Heart J. 1998; 136: 913–918.[CrossRef][Medline] [Order article via Infotrieve]
14. Caps MT, Perissinotto C, Zierler RE, Polissar NL, Bergelin RO, Tullis MJ, Cantwell-Gab K, Davidson RC, Strandness DE Jr. Prospective study of atherosclerotic disease progression in the renal artery. Circulation. 1998; 98: 2866–2872.
15. van Jaarsveld BC, Krijnen P, Pieterman H, Derkx FH, Deinum J, Postma CT, Dees A, Woittiez AJ, Bartelink AK, Man in ’t Veld AJ, Schalekamp MA. The effect of balloon angioplasty on hypertension in atherosclerotic renal artery stenosis. Dutch Renal Artery Stenosis Intervention Cooperative Study Group. N Engl J Med. 2000; 342: 1007–1014.
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