Divisions of Nephrology, Cardiology and Nuclear medicine, Kantonsspital St Gallen, Switzerland
Keywords: coronary angiography; non-stenosing atherosclerotic plaques; renal artery stenosis
Case history
In 1990, a 49-year-old woman with unstable angina was admitted for coronary angiography, which showed two-vessel disease. She had a 33-year history of hypertension and so renal angiography was also performed which revealed a non-stenosing atherosclerotic plaque in the proximal left renal artery (Figure 1A). Blood pressure was controlled with two antihypertensive drugs. The calculated creatinine clearance was 61 ml/min, and was unchanged since 1974.
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Discussion
Atherosclerotic renal artery disease causes renovascular hypertension and progressive kidney failure. Progression from a non-stenosing plaque to renal artery stenosis (>60% of diameter) occurs in 60% of patients over 5 years. Renal artery occlusion happens in less than 10% of patients within the same period [1]. Treatment options are aggressive antihypertensive and lipid-lowering therapy, percutaneous transluminal angioplasty with or without stent implantation, and surgical reconstruction. Revascularisation may prevent disease progression by restoration of arterial patency, but can cause renal infarction, contrast nephropathy or cholesterol embolism. Therefore the benefit of revascularisation and the optimal time of intervention is still a matter of debate [2,3], since no long-term follow up investigations are available.
Our patient illustrates: (i) the slow progression of atherosclerotic renal artery disease over 11 years with stable renal function for 25 years, after 35 years of well controlled hypertension; (ii) a different progression rate of atherosclerosis in coronary compared with renal arteries; (iii) the normalisation of angiographic and scintigraphic findings and reduction of antihypertensive treatment after angioplasty with stent implantation. We suggest careful follow-up of such patients with aggressive medical treatment of hypertension and hyperlipidaemia and with intervention only when renal artery occlusion is impending according to scintigraphic and angiographic findings.
Notes
Correspondence and offprint requests to: Dr. T. Fehr, Division of Nephrology, Kantonsspital, CH-9007 St. Gallen, Switzerland. E-mail: thomas.fehr{at}kssg.ch
References