Stenting for atherosclerotic renal artery stenosis: Another nail in the coffin

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Despite a lack of strong evidence,
angioplasty and stenting of atherosclerotic renal artery stenosis (RAS) became
a common intervention in the last decade. It was often performed on incidental
lesions discovered  during “drive-by”
angiography in cardiac procedures. In the last few years, enthusiasm has cooled
as two randomized trials; the ASTRAL and STAR trials have failed to show any
benefit of the procedure.The ASTRAL trial received significant
criticism in some corners of the medical press –as headlines like this show! 
The CORAL trial recently reported in the NEJM
has added to the weight of evidence against the procedure. It included 947
patients with either systolic hypertension >155mmHg on two agents or an
eGFR <60ml/min and RAS of >80% or >60% with a pressure gradient
> 20mmHg. All patients received, amlodipine, atorvastatin, and candesartan
+/- hydroclorothiazide.

In short there was no difference in the
primary and composite endpoints of Death, MI, Stroke, heart failure,
progression of CKD and need for RRT. The only exception was for that of BP in
which a significant but minor (2mmHg) drop in the intervention arm.

This is another large, RCT demonstrating a
lack of benefit or renal artery stenting, therefore for the vast majority of
patients with RAS and either hypertension or CKD, management of RAS should be
limited to medical therapy.

There remains uncertainty around patient groups
in which their may still be benefit such as those with severe stenosis to a
single functioning kidney, severe stenosis and AKI and patients flash pulmonary
oedema. It is hard to imagine recruitment of these groups in numbers sufficient
to adequately power a clinical trial.

Posted by Jonathan Dick

2 comments

  1. Likewise, we all remember the patient whose kidney function took a dump after the procedure never to return. We celebrated the successes and tried to forget our failures.

    Long and short, we hurt as many as we helped.

  2. Good riddance. Though, anecdotally, many here can probably relate the N of 1's where stenting rescued a patient in extremis. I recall a case of pt with progressive CKD and bilateral RAS who developed flash plum edema after becoming oliguric, after stenting started pouring urine and blood pressure dropped 20mm Hg in the IR suite!

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