Diagnosis and Treatment of Renal-artery Stenosis
Authors: J. J. Brown, K. Owen, W. S. Peart, J. I. S. Robertson, D. Sutton
Journal: BMJ (1960)

1960). - This condition in man parallels experimental hypertension produced in animals by clamping the renal artery (Goldblatt et al., 1934).Renal-artery stenosis is now being recognized with increasing frequency in patients with high blood-pressure, and strict diagnostic criteria must be applied if successful surgical treatment is to be achieved.The diagnosis of renal-artery stenosis based upon inadequate data is likely only to lead to therapeutic failure and to bring the surgical methods employed into disrepute.Certain patients with renal- artery lesions and severe hypertension may be greatly improved by appropriate surgical procedures.It is, however, important that overenthusiastic investigation and treatment shall not result in unnecessary morbidity.We therefore wish to define the diagnostic criteria which, in the light of our experience of this condition, we con- sider significant.This is an amplification of points made previously (Peart, 1959; Owen, 1959, 1960; Robertson, 1960).The present paper is based on a study of 22 patients in whom renal-artery disease was proved or strongly suspected.Of these, 11 were judged to be likely to benefit from operation (see Table I).Incidence of Renal-artery Stenosis.-Since 1957we have routinely performed renal arteriography, usually by the selective method, in patients with severe hypertension.Of 160 cases investigatedI in this way, a renal artery lesion was demonstrated in 10.In eight of the other cases reported here, renal artery narrowing was revealed at aortography performed for other reasons (usually iliac or aortic stenosis, or abdominal aneurysm).Though these figures give only an approximate indication of the inci- dence of renal-artery stenosis as a cause of hypertension, they show that it is not rare. Clinical FeaturesAetiology.-Thewide variety of disorders which may lead to renal-artery stenosis has been reviewed by DeCamp and Birchall (1958).The most frequent cause of narrowing, however, is an atheromatous plaque, usually situated close to the origin of the artery.Case 18 of the present series is of particular interest as an example of Takayashu's disease (pulseless syndrome) with renal-artery involvement.Age Incidence.-There is a tendency for renal-artery stenosis to be seen more commonly in the older age- groups, but the disease is found in younger patients, and DeCamp and Birchall (1958) have reported the case of a 9-months-old baby with stricture of the renal artery and severe hypertension.The ages of the patients of the present series ranged from 17 to 65.Evidence of Widespread Arterial Disease.-Renal-artery stenosis is to be suspected particularly in those hypertensive patients with evidence of occlusive arterial disease elsewhere.Of the present series, seven patients gave a history of intermittent claudication, five had ischaemic heart disease, and three had suffered strokes.Narrowing of the renal artery was found in 5 out of 32 cases in which aortography was performed to demon- strate a lower aortic occlusion (Starer and Sutton, 1958).The mouth of the renal artery may be involved in an upward extension of an aortic thrombosis (Case 20 of the present series) ; alternatively, as in Case 6, separate atheromatous renal-artery narrowing may be present in addition to a lower aortic block.Coronary or cerebral arterial occlusion and intermittent claudication are, how- ever, not rare in cases of hypertension in the absence of demonstrable renal-artery stenosis.Conversely, nine cases of the present series (Nos. 1, 3, 4, 9, 10, 11, 17, 19, anl 22) had no evidence of arterial disease elsewhere at the time of presentation.Cases 4, 17, and 22 were free of symptoms and were found to have high blood-pressure on routine examination.Family History.Only occasionally have we elicited any relevant family history.However, the father of Case 19 and a brother of Case 7 had experienced inter- mittent claudication, and the father of Case 9 had had both legs amputated " because of gangrene."Complete Occlusion of Renial Artery.-Inthis event (Case 19; Adams and Newman, 1958) the patient may 5195