Enliven: Journal of Anesthesiology and Critical Care Medicine

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Renal Artery Stenosis in Patients Undergoing Major Surgery or otherwise Critically Ill: The Short-Circuit between Association and Causality

Alessia Azzano MD1*, Sara Izzo2, Giacomo Frati MD2, and Giuseppe Biondi-Zoccai MD2

1Department of Cardiovascular, Respiratory, Nephrologic and Geriatric Sciences, Umberto I Hospital, Sapienza University of Rome, Rome, Italy

2Department of Medico-Surgical Science and Biotechnologies, Sapienza University of Rome, Latina, Italy

Corresponding author

Alessia Azzano, MD, Department of Cardiovascular, Respiratory, Nephrologic and Geriatric Sciences, Umberto I Hospital, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy, E-mail: alessia.azzano@libero.it

Received Date: 04 Mar 2014

Accepted Date: 04 Mar 2014

Published Date: 10 Mar 2014


Azzano A, Izzo S, Frati G, Biondi-Zoccai G (2014) Renal Artery Stenosis in Patients Undergoing Major Surgery or otherwise Critically Ill: The Short-Circuit between Association and Causality. Enliven: J Anesthesiol Crit Care Med 1(2): 003.


@ 2014 Dr. Alessia Azzano. This is an Open Access article published and distributed under the terms of the Creative Commons Attribution License, that permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited.


Non-cardiac surgery; Prognosis; Renal artery stenosis; Risk prediction; Surgery

Risk prediction is an intense field of research and there is an increasing need for an interest in being able to empirically estimate customized, patient-specific risks for virtually all surgical operations in a user friendly format. Surgical risk evaluation before major surgery should offer an opportunity to improve shared decision making and patient care [1]. Yet, there is ongoing debate on how to better identify patients at risk in several important clinical scenarios and when weighing a given risk factor for decision making or when trying to amend it [2,3].

Acute renal failure (ARF) occurs in approximately 1-5% of all hospitalized patients, yet there are no large studies addressing renal dysfunction after non-cardiac or non-vascular surgery [4]. Severe acute kidney injury (AKI) after a major surgical operation is associated with a high risk of morbidity and mortality [5]. Particular attention should be paid to postoperative patients that require renal replacement therapy (RRT), because this subgroup of patients, defined to be the most critical ones, need careful attention and have poor prognosis [6]. In addition, ARF without the need for RRT remains associated with increased mortality in critically ill patients and postoperative cardiac surgery patients. Similarly, there is a clinically important relation between ARF and increased postoperative mortality in non-cardiac surgery.

Several preoperative predictors, such as age, emergent surgery, liver disease, body mass index, high-risk surgery, peripheral vascular occlusive disease, and chronic obstructive pulmonary disease necessitating chronic bronchodilator therapy appear associated with ARF after cardiac surgery as well as after non-cardiac surgery [4,7-14]. There is also some evidence suggesting that renal artery stenosis could be associated with an increased risk for renal injury and ensuing clinical complications [15].

Renal artery stenosis is most commonly due to atherosclerosis and much more rarely fibromuscular dysplasia or inflammatory disease such as Takayasu arteritis [16,17]. Renal artery stenosis, which is present in 1 to 5% of people with hypertension, often occurs in combination with peripheral or coronary artery disease and its prevalence among persons older than 65 years of age may be as high as 7%. Thus, this condition is an important public health issue [18]. Renal artery narrowing is usually focal but can be more diffuse and is of great importance because of its consequent renal ischemia, which can in turn results in disturbance of renal function, blood pressure control, fluid and salt retention, and renal endocrine functions [19]. Philip et al. have recently reported that atherosclerotic renal artery stenosis (ARAS) is rather common, recognized in 29% of patients undergoing cardiac surgery at the renowned Cleveland Clinic, with an even higher prevalence in those with old age, low body mass index, peripheral artery disease and low level of high-density lipoprotein [20]. An additional important piece of the puzzle is that patients with atherosclerotic renal vascular disease have an high mortality, presumably partly conferred by their extensive vascular comorbidities [21,22].

When the functional evaluation bears out the severity of the stenosis it is necessary to make a clinical decision [23]. The role of and indications for intervention for renal artery stenosis have long been debated (Table 1) [30,31]. Recent evidence has shown that optimal medical treatment, including statins and risk reduction strategies tailoring important prognostic factors should be the preferred option for most patients with atherosclerotic renal artery disease [32]. Only a minority of patients with rapidly progressive hypertension or renal insufficiency and flash pulmonary edema, or with specific lesions such as bilateral severe renal artery stenosis, or solitary kidney, are likely to a benefit from restoring kidney perfusion [32,33]. Ritchie et al. have indeed confirmed that flash pulmonary edema is a risk factor for adverse outcomes in patient with ARAS and have supported revascularization for this presentation [21]. Deterioration of renal function in the presence of ARAS may not reflect however true ischemia under normal conditions as blood flow to the kidney is far in excess of metabolic needs [22]. Moderate reductions in blood flow, as in ARAS, may not be the sole or even the major contributor to reduced renal function. Philip et al. have shown no association between the presence of ARAS and change in glomerular filtration rate (GFR) or lower GFR, need for RRT, length of intensive care unit (ICU) stay or mortality [20,34], in keeping with findings comparing percutaneous revascularization versus best medical therapy for renal artery stenosis [31].

Author Year of publication No. patients Characteristics of the study population Treatment and results

Plouin et al.[24]



Hypertension and unilateral RAS

Balloon angioplasty (with or without stent placement): No significant change in SBP or DBP No significant change in SCr

Webster et al. [25]



Resistant hypertension and bilateral or unilateral RAS

Balloon angioplasty:
1) Bilateral RAS:
Significant improvement in SBP after angioplasty
No significant change in DBP
No significant change in SCr
2) Unilateral RAS:
No significant change in SBP and DBP
No significant change in SCr 1998

Van Jaarsveld et al. [26]



Resistant hypertension with normal or mild chronic renal insufficiency and RAS

Balloon angioplasty:
No significant change in SBP or DBP
No significant change in SCr

Bax et al. [27]



Chronic renal insufficiency and ostial RAS

Renal artery stenting:
No significant effect on progression of renal dysfunction
No significant effect on BP

ASTRAL investigators [28]



Resistant hypertension or unexplained chronic renal insufficiency and RAS

Renal artery stenting:
No significant effect on renal function
No significant effect on BP
No significant effect on mortality

Scarpioni et al. [29]



Resistant hypertension with chronic renal insufficiency and RAS

Renal artery stenting:
No significant effect on renal function
No significant effect on BP
No significant effect on mortality

Cooper et al. [18]



Hypertension or chronic kidney disease and RAS,

Renal artery stenting:
No significant benefit in the prevention of clinical events
No significant difference in all causes mortality
Modest reduction of BP

BP: blood pressure; DBP: diastolic blood pressure; RAS: renal artery stenosis; SBP: systolic blood pressure; SCr: serum creatinine. *Presented

Table 1. Randomized trials comparing to medical therapy for renal artery stenosis.

Most recent results stemming from the Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL) trial have confirmed these prior data, showing that, despite the fact that the treatment of renal-artery stenosis could improve blood pressure and renal function, renal artery stenting did not confer a significant benefit with respect to the prevention of clinical events when added to a comprehensive, multifactorial medical therapy in people with atherosclerotic renal artery stenosis and hypertension or chronic kidney disease [18,35]. Notwithstanding these lukewarm results for the primary and key secondary end-points in the CORAL study, it is also true that stenting yielded a moderate but statistically significant reduction in blood pressure (average of −2.3 mm Hg [95% confidence interval: −4.4 to −0.2], p=0.03).

In conclusion, until new treatments are found to be save and effective, patients who have moderately severe atherosclerotic renovascular disease and are critically ill or awaiting non-cardiac surgery should mainly receive medical therapy to control blood pressure and prevent the progression of atherosclerosis but should not be corralled into getting a renal-artery stent [18]. The best practice for those with critical or subocclusive renal artery stenosis should instead probably be individualized and decision-making shared with several specialists, to minimize the risk of complications but salvage a jeopardized kidney.

Conflicts of interest: None


1. Bilimoria KY, Liu Y, Paruch JL, Zhou L, Kmiecik TE, et al. (2013) Development and evaluation of the universal ACS NSQIP surgical risk calculator: a decision aid and informed consent tool for patients and surgeons. J Am Coll Surg 217: 833-842.

2. D’ascenzo F, Ballocca F, Moretti C, Barbanti M, Gasparetto V, et al. (2011) Inaccurancy of available surgical risk scores to predict outcomes after transcatheter aortic valve replacement. J Cardiovasc Med (Hagerstown) 14: 894-898.

3. Wald NJ, Simmonds M, Morris JK (2011) Screening for future cardiovascular disease using age alone compared with multiple risk factors and age. PLoS One 6: e18742.

4. Kheterpal S, Tremper KK, Englesbe MJ, O'Reilly M, Shanks AM, et al. (2007) Predictors of postoperative acute renal failure after noncardiac surgery in patients with previously normal renal function. Anesthesiology 107: 892-902.

5. Bihorac A, Yavas S, Subbiah S, Hobson CE, Schold JD, et al. (2009) Long-term risk of mortality and acute kidney injury during hospitalization after major surgery. Ann Surg 249: 851-858.

6. Lin YF, Ko WJ, Chu TS, Chen YS, Wu VC, et al. (2009) The 90-day mortality and the subsequent renal recovery in critically ill surgical patients requiring acute renal replacement therapy. Am J Surg 198: 325-332.

7. Kheterpal S, Tremper KK, Heung M, Rosenberg AL, Englesbe M, et al. (2009) Development and validation of an acute kidney injury risk index for patients undergoing general surgery: results from a national data set. Anesthesiology 110: 505-515.

8. Uchino S, Kellum JA, Bellomo R, Doig GS, Morimatsu H, et al. (2005) Beginning and Ending Supportive Therapy for the Kidney (BEST Kidney) Investigators. Acute renal failure in critically ill patients: a multinational, multicenter study. JAMA 294: 813-818.

9. Li WX, Chen HD, Wang XW, Zhao S, Chen XK, et al. (2009) Predictive value of RIFLE classification on prognosis of critically ill patients with acute kidney injury treated with continuous renal replacement therapy. Chin Med J (Engl) 122: 1020-1025.

10. D'Onofrio A, Cruz D, Bolgan I, Auriemma S, Cresce GD, et al. (2010) RIFLE criteria for cardiac surgery-associated acute kidney injury: risk factors and outcomes. Congest Heart Fail 16: S32-36.

11. Wahrhaftig KM, Correia LC, Matias D, De Souza CA (2013) Does the RIFLE Classification Improve Prognostic Value of the APACHE II Score in Critically Ill Patients? Int J Nephrol 2013: 406165.

12. Hoste EA, De Corte W (2013) Implementing the Kidney Disease: Improving Global Outcomes/acute kidney injury guidelines in ICU patients. Curr Opin Crit Care 19: 544-553.

13. Apel M, Maia VP, Zeidan M, Schinkoethe C, Wolf G, et al. (2013) End-stage renal disease and outcome in a surgical intensive care unit. Crit Care 17: R298.

14. Huen SC, Parikh CR (2012) Predicting acute kidney injury after cardiac surgery: a systematic review. Ann Thorac Surg 93: 337–347.

15. Yang J, Lu C, Yan L, Tang X, Li W, et al. (2013) The association between atherosclerotic renal artery stenosis and acute kidney injury in patients undergoing cardiac surgery. PLoS One 8: e64104.

16. Colyer WR, Eltahawy E, Cooper CJ (2011) Renal artery stenosis: optimizing diagnosis and treatment. Prog Cardiovasc Dis 54: 29 - 35.

17. Lao D, Parasher PS, Cho KC, Yeghiazarians Y (2011) Atherosclerotic renal artery stenosis diagnosis and treatment. Mayo Clin Proc 86: 649–657.

18. Cooper CJ, Murphy TP, Cutlip DE, Jamerson K, Henrich W, et al. (2014) Stenting and medical therapy for atherosclerotic renal-artery stenosis. N Engl J Med 370: 13-22.

19. Chrysochou C, Kalra PA (2009) Epidemiology and natural history of atherosclerotic renovascular disease. Prog Cardiovasc Dis 52: 184-195.

20. Philip F, Gornik HL, Rajeswaran J, Blackstone EH, Shishehbor MH (2014) The impact of renal artery stenosis on outcomes after open-heart surgery. J Am Coll Cardiology 63: 310-316.

21. Ritchie J, Green D, Chrysochou C, Chalmers N, Foley RN, et al. (2014) High-Risk Clinical Presentations in Atherosclerotic Renovascular Disease: Prognosis and Response to Renal Artery Revascularization. Am J Kidney Dis 63: 186-197.

22. Keddis MT, Garovic VD, Bailey KR, Wood CM, Raissian Y, et al. (2010) Ischaemic nephropathy secondary to atherosclerotic renal artery stenosis: Clinical and histopathological correlates. Nephrol Dial Transplant 25: 3615-3622.

23. Drieghe B, Madaric J, Sarno G, Manoharan G, Bartunek J, et al. (2008) Assessment of renal artery stenosis: side-by-side comparison of angiography and duplex ultrasound with pressure gradient measurements. Eur Heart J 29: 517–524.

24. Plouin PF, Chatellier G, Darné B, Raynaud A (1998) Blood pressure outcome of angioplasty in atherosclerotic renal artery stenosis: a randomized trial. Essai Multicentrique Medicaments vs Angioplastie (EMMA) Study Group. Hypertension 31: 823-829.

25. Webster J, Marshall F, Abdalla M, Dominiczak A, Edwards R, et al. (1998) Wilkinson R. Randomized comparison of percutaneous angioplasty vs continued medical therapy for hypertensive patients with atheromatous renal artery stenosis. Scottish and Newcastle Renal Artery Stenosis Collaborative Group. J Hum Hypertens12: 329-335.

26. Van Jaarsveld BC, Krijnen P, Pieterman H, Derkx FH, Deinum J, et al. (2000) The effect of balloon angioplasty on hypertension in atherosclerotic renal-artery stenosis. Dutch Renal Artery Stenosis Intervention Cooperative Study Group. N Engl J Med 342: 1007-1014.

27. Bax L, Mali WP, Buskens E, Beutler JJ, Braam B, et al. (2003) STAR Study Group. The benefit of STent placement and blood pressure and lipid-lowering for the prevention of progression of renal dysfunction caused by Atherosclerotic ostial stenosis of the Renal artery. The STAR-study: rationale and study design. J Nephrol 16: 807-812.

28. ASTRAL Investigators, Wheatley K, Ives N, Gray R, Kalra PA, et al. (2009) Revascularization versus medical therapy for renal-artery stenosis. N Engl J Med 361: 1953-1962.

29. Scarpioni R, Michieletti E, Cristinelli L, Ugolotti U, Scolari F, et al. (2005) Atherosclerotic renovascular disease: medical therapy versus medical therapy plus renal artery stenting in preventing renal failure progression: the rationale and study design of a prospective, multicenter and randomized trial (NITER). J Nephrol 18: 423-428.

30. Kumbhani DJ, Bavry AA, Harvey JE, de Souza R, Scarpioni R, et al. (2011) Clinical outcomes after percutaneous revascularization versus medical management in patients with significant renal artery stenosis: a meta-analysis of randomized controlled trials. Am Heart J 161: 622-630.

31. Shetty R, Biondi-Zoccai GG, Abbate A, Amin MS, Jovin IS (2011) Percutaneous renal artery intervention versus medical therapy in patients with renal artery stenosis: a meta-analysis. EuroIntervention 7: 844-851.

32. Kashyap VS, Schneider F, Ricco JB (2011) Role of interventions for atherosclerotic renal artery stenoses. J Vasc Surg 54: 563-570.

33. Textor SC, Lerman LO (2013) Renal artery stenosis: medical versus interventional therapy. Curr Cardiol Rep 15: 409.

34. Biondi-Zoccai G, Mancone M, Frati G (2014) Our preoccupation with renal artery disease in patients undergoing cardiac surgery: Much Ado About Nothing? J Am Coll Cardiol 63: 317-320.

35. Bittl JA (2014) Treatment of atherosclerotic renovascular disease N Engl J Med 370: 78-79. s