Renovascular hypertension (RVH) is high blood pressure caused by reduced kidney perfusion. The most common causes are renal artery stenosis from fibromuscular dysplasia or atherosclerosis. Fibromuscular dysplasia typically affects younger women and causes smooth muscle cell proliferation in artery walls. Atherosclerotic renal artery stenosis usually occurs in older patients with generalized atherosclerosis. RVH results from activation of the renin-angiotensin-aldosterone system when renal perfusion decreases. Imaging tests can identify renal artery stenosis but angiography remains the gold standard. Treatment depends on the cause, with angioplasty often used for fibromuscular dysplasia and medical management preferred for atherosclerotic

1. Renovascular HTN

2. Anatomy
• The clinical presentations of renovascular disease are
influenced by the acuity, nature, and site of renal vascular
compromise. In most individuals, the kidney has a single renal
artery (RA) with a lumen diameter of 3 to 7 mm.
• The collaterals to the kidney can maintain renal parenchymal
viability in the face of main RA occlusion.

5. • RVH is defined as a syndrome of elevated BP (systolic and/or
diastolic) produced by any condition that leads to reduced perfusion
of the kidneys.
• Pathogenesis:
• of RVH is activation of the renin-angiotensin-aldosterone system
(RAAS) with release of renin from the juxtaglomerular apparatus.
This is mediated in part by stimulation of neuronal nitric oxide (NO)
synthase and cyclooxygenase-2 in the macula densa.
Renovascular Hypertension (RVH)

6. Pathogenesis of RVH in one kidney vs two kidney model

10. RVH Common Causes
The most common causes of RVH is RA Stenosis:
RA Stenosis common causes include
1. RA fibromuscular dysplasia (FMD)
2. Atherosclerotic RA stenosis

11. Fibromuscular Dysplasia
• FMD is a noninflammatory, nonatherosclerotic arteriopathy
characterized by arterial medial smooth muscle cell proliferation and
fibrosis.
• It is the most common cause of RVH in children and young
adults.
• prevalence is estimated at 4 in 1000.
• 90% of FMD cases occur in women
• pathophysiology of FMD is unknown. It is likely that there are
numerous disturbances in vascular collagen.

15. Atherosclerotic Renal Artery Stenosis
• Atherosclerotic RA stenosis is the most common cause of
RVH in patients over the age of 50.
• Atherosclerotic RA stenosis generally occurs in patients with
more generalized atherosclerosis involving the aorta,
peripheral vasculature, and coronary arteries.

16. IMAGING RENOVASCULAR HYPERTENSION
AND RENAL ARTERY STENOSIS
• Duplex scan
• CTA
• MRA
• Angiography remains the gold standard for defining the degree of
stenosis
• In cases of unilateral RA disease, captopril renography provides
functional information regarding the size and excretory capacity of
the kidney and demonstrates the rate of isotope appearance as an
index of renal blood flow and filtration.

19. TREATMENT OF FIBROMUSCULAR DYSPLASIA
• The treatment of choice for FMD is percutaneous renal
artery angioplasty (PTRA) usually without stenting.
• Successful PTRA results in disruption of the abnormal
collagen bands in the lumen of the artery and the vascular
wall leading to larger lumen diameter and less turbulent
RA blood flow.

20. Treatment for Atherosclerotic RA stenosis
• Medical therapy
• ACE ,ARBS ,renin inhibitors
• Diuretics
• Calcium channel blockers
• High-dose statin therapy
• Promote smoking cessation

22. Treatment continued
• The optimal treatment of atherosclerotic RA stenosis has been the
subject of much controversy.
• Primary percutaneous renal artery stenting (PTRS) became standard
treatment in many centers.
• But medical treatment still remains the primary choice.

23. Indications to Consider Renal Revascularization
in Atherosclerotic Renal Artery Stenosis

25. Thank you.