Increasing the diagnostic yield of renal angiography for the diagnosis of atheromatous renovascular disease

Atheromatous renovascular disease (ARVD) is a common cause of hypertension and chronic renal failure (CRF). In this unit, intravenous digital subtract ion angiography (DSA) (or intraarterial DSA if indicated) is used as a scre ening angiographic study when ARVD is suspected. However, increased use of these investigations has resulted in a longer waiting time fur angiography. As the majority of studies are negative for ARVD, clinical features and re sults of investigations of patients undergoing angiography were reviewed to identify those having the greatest likelihood of ARVD. The clinical notes were reviewed for all 249 patients undergoing angiography over an 18-month period. Primary indications for investigation were. hypertension 71 (28.5%) , CRF 156 (62.7%) and CRF with severe hypertension 23 (8.8%). 12 of the CRF patients had end-stage renal failure. 166 (66.7%) patients had no evidence of ARVD, while only 83 (33.3%) patients showed some degree of ARVD, 29 (35 %;,) of which had bilateral renal artery disease. There was no significant difference between the ARVD group and the non-ARVD group for mean age (69.0 years vs 63.3 years), male to female ratio, history of smoking (68.7% vs 5 5.4%), severe hypertension (10.8% vs 9.0%), hypercholesterolaemia (61.4% vs 47.0%), diabetes mellitus (28.6% vs 25.3%) or angiotensin converting enzym e inhibitor-related renal dysfunction (9.6%, vs 6.1%). More patients in the ARVD group were investigated for CRF than in the non-ARVD group, as reflec ted by the higher serum creatinine level and the lower creatinine clearance in the ARVD group. 55 (33.1%) of the non-ARVD patients had no comorbid vas cular disease, vascular bruits or ultrasound discrepancy in the size of the two kidneys, whereas all ARVD patients had at least one of these features (negative predictive value 100%). All three features were present in 19.3% of ARVD patients but in only 3.0% of the non-ARVD patients (positive predic tive value 76.2%, specificity 97%). We plan to rationalize the criteria for angiography in the light of these findings, anticipating an increase in th e diagnostic yield of renal angiography from its current 33.3% to above 42% .