1. Renovascular Disease Daniel Shoskes MD, MSc, FRCSC Professor of Surgery/Urology Glickman Urological and Kidney Institute Cleveland Clinic

2. Pathophysiology Classification of Lesions Clinical Evaluation Medical and Surgical Management Renal Artery Aneurysm Overview

3. Goldblatt Dog Models ARB/ACE inhibitors help Only help when Na depleted

4. Ischemic Nephropathy Does not correlate with hypertension Progressive azotemia in pt with risk factors for atherosclerotic disease Progresses through nephrosclerosis and atheroemboli Treatment of hypertension will not improve renal function, may actually exacerbate

5. Diameter and Blood Flow

6. Atherosclerotic (70%) Fibromuscular Disease (30%) Classification

7. Fibromuscular Disease Medial Fibroplasia: 77% Perimedial Fibroplasia: 10% Intimal Fibroplasia: 10% Fibromuscular Hyperplasia: 3%

8. Atherosclerosis typically a systemic disease involves proximal 2 cm of artery may only be seen on oblique views progression common, at least 50% in 2 years 10-15% progress to occlusion can cause hypertension and Renal Failure

9. Medial Fibroplasia most common fibrous women 25-50 commonly bilateral "string of beads" involves distal 2/3 and branches progression less common

10. Clinical Clues to RVH HTN onset 55 sudden onset, short duration lack of family history difficult to control malignant crisis bruits disseminated atherosclerotic disease renal size disparity

11. Key Diagnostic Points Captopril provocation –reduction of GFR detected by nuclear scan best predictor of surgical cure (spec 93-98%) –increased PRA (off most drugs) Renal Vein Renins –ipsilateral hypersecretion, contralateral suppression –best for bilateral disease Ultrasound –operator dependent, independent of renal function MRA –poor images beyond main renal artery

12. Investigation of Ischemic Nephropathy High suspicion –straight to angiography Mild to Moderate suspicion –non-invasive imaging (local preference) –if significant azotemia, US rather than MRA or spiral CT

13. Investigation of RVH High suspicion –angiography and Renal Vein Renins if bilateral Moderate suspicion –captopril nuclear renography (can do "post" study first) –positive -> angio –equivocal -> non-invasive imaging –negative -> stop

14. Treatment of RVH Select medical management based on risk of ischemic nephropathy and lesion progression –medial fibroplasia and atherosclerotic (without ischemic nephropathy) best for medical angioplasty +/- stents usually procedure of choice unless –branch vessel disease –renal artery aneurysm Nephrectomy if small and non-functioning

15. Treatment of Ischemic Nephropathy No benefit with unilateral disease Signs of reversibility –progressive occlusion –collaterals –retrograde arterial filling –size > 9 cm –Cr < 4.0 –preservation of glomeruli on biopsy

16. Surgical Approaches Hepatorenal Splenorenal Ileorenal Autotransplant Arteriotomy Aortorenal Thoracic aorta - renal

17. Renal Artery Aneurysms most small and asymptomatic pathology –saccular (most common), fusiform, dissecting, intrarenal risk of rupture –absent/incomplete calcification, >2cm diameter, expanding, hypertension, pregnancy other complications –pain, hematuria, dissection, emboli