Dr Bijilesh u

Revascularisation in Renal artery stenosis

Atherosclerosis accounts for about 90% of cases of renal artery stenosis in people over age 40

Fibromuscular dysplasia - the other major cause

Percutaneous intervention has become very popular for treating atherosclerotic renal artery stenosis

use of stents has boosted the rate of technical success more cases are being discovered incidentally during

angiography of other arteries

Number of angioplasty-stenting procedures performed every year is on the rise

Yet there is no overwhelming evidence that intervention yields clinical benefits—ie, better blood pressure control or renal function— than does medical therapy

Renal angioplasty began replacing surgical revascularization in the 1990s

Less-invasive , more readily available, similar clinical outcomes

Last decade, stent placement during angioplasty has become standard - improving the rates of technical success

RENAL INTERVENTIONS ON THE RISE

Prevalence of RAS depends on the definition used and the population screened.

More common in older patients who have risk factors for other vascular diseases than in the general population

Affect between 1% and 5% of patients with hypertension Derkx FH, Schalekamp MA. Renal artery stenosis and hypertension. Lancet. 1994; 344: 237–239

Renal artery stenosis is found in 11% to 28% of patients undergoing diagnostic cardiac catheterization

White CJ, Olin JW .Diagnosis and management of atherosclerotic renal artery stenosis: improving patient selection and outcomes. Nat Clin Pract Cardiovasc Med 2009; 6:176–190.

HOW COMMON IS RENAL ARTERY STENOSIS

No studies of the prevalence of renal artery stenosis have been performed in the general population

Holley et al in an autopsy series, found renal artery stenosis of greater than 50% in 27% of patients over age 50 and in 56.4% of hypertensive patients

Prevalence was 10% in normotensive patients

Renal Doppler ultrasonography can detect stenosis only if the artery is narrowed by more than 60%

Hansen et al used ultrasonography to screen 870 people over age 65 and found a lesion (a narrowing of more than 60%) in 6.8%.

Angiography can detect less-severe stenosis define RAS as a narrowing > 50% severe disease - narrowing > 70%Unilateral stenosis needs to be more than 70% to

pose a risk to the kidney Cohen MG, et al. A simple prediction rule for significant renal artery stenosis in patients

undergoing cardiac catheterization. Am Heart J 2005; 150:1204–1211

Factors associated with a higher risk of finding RAS on a radiographic study

Older age , Female sexHypertension , Three-vessel CADPeripheral artery diseaseChronic kidney diseaseDiabetes , Tobacco useLow HDL

Cohen MG, et al. A simple prediction rule for significant renal artery stenosis in patients undergoing cardiac catheterization. Am Heart J 2005; 150:1204–1211

WHO IS AT RISK?

In studies that used duplex ultrasonography, roughly half of lesions smaller than 60% grew to greater than 60% over 3 years

Risk of total occlusion of an artery was relatively low and depended on the severity of stenosis: 0.7% if the baseline stenosis was less than 60% and 2.3% to 7% if it was greater

Caps MT, Perissinotto C, Zierler RE, et al . Prospective study of atherosclerotic disease progression in the renal artery. Circulation 1998; 98:2866–2872

HOW OFTEN DOES STENOSIS PROGRESS

Schreiber and colleagues _ compared serial angiograms obtained a mean of 52 months apart in 85 patients who did not undergo intervention

Stenosis had progressed in 37 (44%), and to the point of total occlusion in 14 (16%)

Schreiber MJ, Pohl MA, Novick AC .The natural history of atherosclerotic and fibrous renal artery disease

1998 study found progression in 11.1% over 2.6 years

Crowley JJ, et al.Progression of renal artery stenosis in patients undergoing cardiac catheterization

Rates of progression differed because – Indications for screening were different (clinical

suspicion vs routine screening during CAG) Severity of stenosis at the time of diagnosis-

differentFewer people were taking statins.

Clinically silent stenosisRenovascular hypertension Ischemic nephropathy Recurrent “flash” pulmonary edema

FOUR CLINICAL PRESENTATIONS OF RENAL ARTERY STENOSIS

Less common presentationOccurring in patients with critical bilateral renal

artery stenosis or unilateral stenosis in an artery supplying a solitary functioning kidney

Most have severe hypertension (average systolic blood pressure 174–207 mm Hg) and poor renal function

Recurrent “flash” pulmonary edema

Association between pulmonary edema and bilateral renal artery stenosis was first noted in 1998 by Pickering et al

Several case series showed that 82% to 92% of patients with recurrent pulmonary edema and renal artery stenosis had bilateral stenosis

Pickering TG, et al. Recurrent pulmonary oedema in hypertension due to bilateral renal artery stenosis: treatment by angioplasty or surgical revascularisation. Lancet 1988; 2:551–552

Later case series corroborated this finding: 85% to 100% of patients with renal artery stenosis and pulmonary edema had bilateral stenosis

Messina LM, Zelenock GB, Yao KA, Stanley JC. Renal revascularization for recurrent pulmonary edema in patients with poorly controlled hypertension and renal insufficiency: a distinct subgroup of patients with arteriosclerotic renal artery occlusive disease. J Vasc Surg 1992; 15:73–80

Gray BH, et al. Clinical benefit of renal artery angioplasty with stenting for the control of recurrent and refractory congestive heart failure. Vasc Med 2002; 7:275–279.

Stenting has become standard in the endovascular treatment of renal artery stenosis

Most atherosclerotic renal artery lesions are located in the ostium and many are extensions of calcified aortic plaque

Textor SC. Ischemic nephropathy: where are we now? J Am Soc Nephrol 2004; 15:1974–1982

These hard lesions tend to rebound to their original shape more often with balloon angioplasty alone

Stenting provides the additional force needed to permanently disrupt the lesion- longer-lasting result

STENTING IS NOW STANDARD

Rates of technical success are higher with stents than without them (98% vs 46%– 77%)

Beutler JJ, et al. Long-term effects of arterial stenting on kidney function for patients with ostial atherosclerotic renal artery stenosis and renal insufficiency. J Am Soc Nephrol 2001; 12:1475–1481

If the lesion is ostial, this difference is even more impressive (75% vs 29%)

Restenosis rates at 6 months are lower with stents (14% vs 26%–48%)

Van de Ven PJ, et al. Arterial stenting and balloon angioplasty in ostial atherosclerotic renovascular disease: a randomized trial. Lancet 1999; 353:282–286

Endovascular procedures pose some risk to the patient -critical to intervene only in patients most likely to respond clinically

In renovascular HTN - improve blood pressure control

In ischemic nephropathy- slow the decline in renal function or to improve it

GOALS: LOWER THE BLOOD PRESSURE, SAVE THE KIDNEY

INDICATIONSUPPORT IN THE LITERATURE

Hypertension resistant to three drugs, including a diuretic

Subgroup analysis of a randomized controlled trial

Recurrent flash pulmonary edema Retrospective

Acute kidney injury after introduction of a renin-angiotensin system inhibitor

Retrospective

Rapidly declining renal functionNot supported by subgroup analysis from randomized controlled trials

New onset or worsening control of hypertension in older patients Retrospective

Commonly cited indications for intervention in renal artery stenosis

Coincidental RAS in a patient with unrelated CKD is very hard to differentiate from true ischemic nephropathy

Most patients with ischemic nephropathy do not benefit from revascularization, making it challenging to identify those few whose renal function may respond

Stenting may not improve renal function

In a prospective cohort study in 304 patients with CKD & RAS who underwent surgical revascularization, Textor reported that serum creatinine

improved - in 28%worsened in 19.7%remained unchanged in 160 - 52.6%

Textor SC. Revascularization in atherosclerotic renal artery disease. Kidney Int 1998; 53:799–811

Davies et al found that 20% of patients who underwent renal stenting had a persistent increase in serum creatinine of 0.5 mg/dL or more

Nearly three times more likely (19% vs 7%) to eventually require dialysis

Lower 5-year survival rate (41% vs 71%)

Davies MG, et al. Implications of acute functional injury following percutaneous renal artery intervention. Ann Vasc Surg 2008; 22:783–789

Zeller et al found that renal function improved slightly in 52% of patients who received stents

Mean decrease in serum creatinine in this group was 0.22 mg/Dl

However, the other 48% had a mean increase in serum creatinine of 1.1 mg/dL

.Zeller T, et al. Predictors of improved renal function after percutaneous stent-supported angioplasty of severe atherosclerotic ostial renal artery stenosis. Circulation 2003; 108;2244–2249.

Acute pulmonary edema in the setting of bilateral RAS - improvement in clinical status can be expected in most patients after intervention

Blood pressure improves in 94% to 100%

Messina LM, Zelenock GB, Yao KA, Stanley JC. Renal revascularization for recurrent pulmonary edema in patients with poorly controlled hypertension and renal insufficiency: a distinct subgroup of patients with arteriosclerotic renal artery occlusive disease. J Vasc Surg 1992; 15:73–80

Renal function either improves or stabilizes in 77% to 91%Pulmonary edema resolves without recurrence in 77% to

100%

Gray BH, et al. Clinical benefit of renal artery angioplasty with stenting for the control of recurrent and refractory congestive heart failure. Vasc Med 2002; 7:275–279.

Stenting usually improves flash pulmonary edema

Scottish and Newcastle Renal Artery Stenosis Collaborative Group

Essai Multicentrique Medicaments vs Angioplastie (EMMA) Study Group

Dutch Renal Artery Stenosis Intervention Cooperative (DRASTIC) study

STAR TRIALASTRAL TRIALCORAL TRIAL

Major randomized trials

Before stents came into use, several randomized controlled trials found that blood pressure was no better controlled after angioplasty except in cases of bilateral stenosis

This may be because stenosis tended to recur after angioplasty without stents

Randomised comparison of percutaneous angioplasty vs continued medical therapy for hypertensive patients with atheromatous renal artery stenosis

Methods Out of 135 eligible patients 55 (44%) were

randomisedEligible patients had sustained hypertension, with a

minimum diastolic BP of 95 mm Hg on at least two anti-hypertensive drugs

RAS was defined by renal angiography as at least 50% stenosis in the affected vessel

Scottish and Newcastle Renal Artery Stenosis Collaborative Group study

Results: BP fell in angioplasty and medical groupsBilateral RAS - a statistically significant (P < 0.05)

fall in bpMean fall in bp - 26/10 mm hgIn unilateral RAS, no statistically significant

differences in outcome were observedNo significant differences or trends in serum

creatinine were observed between the two groupsMajor outcome events (death, MI , heart failure,

stroke, dialysis) were similar

Scottish and Newcastle Renal Artery Stenosis Collaborative Group

Conclusions In hypertensive patients with atheromatous RAS

percutaneous renal angioplasty results in a modest improvement in systolic BP compared with medical therapy alone

This benefit was confined to patients with bilateral disease. No patient was 'cured', renal function did not improve, and

intervention was accompanied by a significant complication rate.

J Webster, F Marshall, M Abdalla, A Dominiczak, R Edwards, C G Isles, H Loose, J Main, P Padfield, I T Russell, B Walker, M Watson and R Wilkinson on behalf of the Scottish and Newcastle Renal Artery Stenosis Collaborative Group J Hum Hypertens 1998; 12:329–335

Scottish and Newcastle Renal Artery Stenosis Collaborative Group

Aim - document the efficacy and safety of angioplasty for lowering BP in patients with atherosclerotic RAS

Randomly assigned to antihypertensive drug treatment (control group, n=26) or angioplasty (n=23)

Primary end point - 24 hour ambulatory BP - measured at baseline and at termination(6 months after randomization)

Secondary end points were the incidence of complications

Blood Pressure Outcome of Angioplasty in Atherosclerotic Renal Artery Stenosis Essai Multicentrique Medicaments vs Angioplastie (EMMA) Study Group

Early termination was required for refractory hypertension in 7 patients in the control group.

Antihypertensive treatment was resumed in 17 patients in the angioplasty group

Mean ambulatory BP at termination did not differ between control (141±15/84±11 mm Hg) and angioplasty (140±15/81±9 mm Hg) groups

Two patients in the control group and 6 in the angioplasty group suffered procedural complications (RR 3.4; 95% confidence interval, 0.8 to 15.1)

EMMA

Angioplasty allowed easier BP control than medication alone

Antihypertensive agents - required at termination for all control patients but not for 6 of the 23 allocated to angioplasty (26%)

Moreover, 7 of 25 patients in the control group (28%) developed refractory hypertension leading to secondary angioplasty within 6 Months

Angioplasty madeBP control easier in the short term but was more frequently associated with complications than conservative management in patients with unilateral atherosclerotic RAS

Plouin PF, Chatellier G, Darne B, Raynaud A Blood pressure outcome of angioplasty in atherosclerotic renal artery stenosis: a randomized trial. Essai Multicentrique Medicaments

vs Angioplastie (EMMA) Study Group. Hypertension 1998; 31:823–829.

Conclusion EMMA

Draw backs EMMA

Only unilateral renal artery disease was enrolledGroups were not well balanced - 23 patients for

angioplasty and 26 for control Cross-over - seven of the control-group crossed

over to intervention groupHigh complication rate in angioplasty group

which was about (6 of 23, or 26%)

Examined the effect of angioplasty on BP control in RAS

Overall, intervention (balloon angioplasty without stents in 54 of 56 patients, with stents in the other 2) carried no benefit

However, in subgroup analysis, the patients who crossed over because of resistant hypertension were more likely to benefit from angioplasty

van Jaarsveld BC, et al.The effect of balloon angioplasty on hypertension in atherosclerotic renal-artery stenosis. Dutch Renal Artery Stenosis Intervention Cooperative Study Group. N Engl J Med 2000; 342:1007–1014

Dutch Renal Artery Stenosis Intervention Cooperative (DRASTIC) study

Randomly assigned 106 patients with HTN who had atherosclerotic RAS (luminal diameter < 50 %) and a serum creatinine 2.3 mg/dl or less to undergo PTRA or to receive drug therapy

Also had to have a diastolic BP > 95 mm Hg or higher despite treatment with two antihypertensive drugs

Blood pressure, doses of antihypertensive drugs, and renal function were assessed at 3 and 12 months, and patency of the renal artery was assessed at 12 months

No significant differences between the angioplasty and drug-therapy groups in systolic and diastolic blood pressures, daily drug doses, or renal function

In the treatment of patients with hypertension and renal-artery stenosis, angioplasty has little advantage over antihypertensive-drug therapy

CONCLUSION

Sample size was not sufficient to detect a significant difference between treatment groups

Renal artery stenosis was defined as greater than 50% stenosis

High rate of cross over - Twenty-two of 50 patients randomized to medical therapy crossed over to the angioplasty group

LIMITATIONS

50 patients (female 18, male 32, mean age 64.4 years) with RAOOD of at least 70% stenosis in one or both renal arteries

Randomized to either OSRP (n = 25 patients, 49 arteries) or PTRA + stent (n = 25 patients, 28 arteries)

Operative vs interventional treatment for renal artery ostial occlusive disease (RAOOD)

Patients were followed on a regular basis for 4 years and longer

Endpoints were re-occurrence of RAOOD and impairment of either kidney function or RVH

ResultsDirectly procedure-related morbidity was 13% in

the interventional group and 4% in the surgical group

Four-year follow-up mortality was 18% vs 25%

Both groups showed significant improvement of RVH (P < .001) as well as improvement or stabilization of renal function

Both treatment modalities showed good early results concerning RVH, kidney function, and renal perfusion

Single centerGroups were not well balanced (PTRA+ stent

group number= 22, Surgical group = 27)Power calculation was not mentioned

limitations

NEW RANDOMIZED TRIALS

Despite the lack of evidence supporting revascularization of renal artery stenosis, many interventionalists practice under the assumption that the radiographic finding of renal artery stenosis alone is an indication for renal revascularization

Only three randomized controlled trials in the modern era attempt to examine this hypothesis: STAR, ASTRAL, and CORAL

Randomized trial - medical treatment of renal artery stenosis was compared with medical treatment plus stenting

140 Patients with RAS and renal insufficiency were randomized to revascularization with stenting (n = 64) versus continued medical management (n = 76)

Renal artery stenosis >50% luminal narrowingRenal insufficiency - creatinine clearance <80

ml/min/1.73 m2 Patients could crossover from medical therapy to

stent placement if necessary for refractory HTN

STAR TRIAL

June 2000 and December 2005

Patients Screened: 185Patients Enrolled: 140Mean Follow Up: 2 yearsMean Patient Age: 66 yearsFemale: 33%

Study Design

From: Stent Placement in Patients With Atherosclerotic Renal Artery Stenosis and Impaired Renal Function:

Hypertension was treated to <140/90 mm Hg with the use of diuretics, CCB , beta blockers

All patients received atorvastatin 10 mg & aspirin 75-100 mg daily

No difference in baseline characteristics between the groups

Stent group – Mean age was 66 years33% were womenmean creatinine was 1.7 mg/dlmean systolic blood pressure was 160 mm Hg, mean number of antihypertensive drugs was 2.8, >90% stenosis was present in 34%.

Participant Characteristics at Baseline – STAR TRIAL

Primary Endpoint 20% or more decrease in creatinine

clearanceSecondary Endpoints:

Procedural complications Hypertension Mortality

Primary outcome - occurred in 16% of the stent group versus 22% of the medical therapy group (p = NS)Unilateral stenoses - 9% versus 20% (p = NS)With only bilateral stenoses, 22% vs 23% (p =

NS).

RESULTS

All-cause mortality was 8% vs 8% and cardiovascular mortality was 3% vs 5%

3/5 deaths in the stent group were due to procedure-related deaths and one late death was due to infected hematoma

With RAS and renal insufficiency strategy of revascularization with stenting was not superior to continued medical therapy

Renal artery stenting was not able to preserve creatinine clearance at 2 years of follow-up

No difference based on the presence of unilateral or bilateral stenoses

Interpretation

Stent placement with medical treatment had no clear effect on progression of impaired renal function but led to a small number of significant procedure-related complications

Study was under-poweredMoreover, four patients lost in follow up and 3% drop

out

Included patients with mild RAS 33% of the patients - RAS 50%-70% 12 (19%) intervention group RAS < 50%

Limitations

Not all “stent” group patients received stentsOnly 46 (72%) of the 64 patients subjected to

stenting infact received a stent, while 18 (28%) did not

More than half of the patients had unilateral disease

Complication rates were high

Limitations

Aim - To evaluate percutaneous renal artery revascularization compared with medical therapy in patients with significant renal artery stenosis

Hypothesis - Percutaneous revascularization of stenotic renal arteries would be more effective at decreasing the rate of decline in renal function

ASTRAL TRIAL Angioplasty and Stenting for Renal Artery Lesions

Patients Enrolled: 806Mean Follow Up: 27 monthsMean Patient Age: 70 yearsFemale: 37

Study Design

Primary Endpoint Change in renal functionSecondary Endpoints:

Blood pressure control Time to first renal event Time to first cardiovascular event Mortality

Clinical suspicion for atherosclerotic renal disease, with substantial anatomical atherosclerotic stenosis in at least one renal artery

Patient Population

Need for surgical revascularization High likelihood of needing revascularization

within 6 months Nonatheromatous cardiovascular disease History of prior revascularization for renal

artery stenosis

Exclusions

Patients with significant RAS were randomized to PTRA (angioplasty and/or stenting) plus medical therapy (n = 403) or medical therapy alone (n = 403).

Serum creatinine - 2.02 mg/dlEstimated GFR - 40 ml/minMean stenosis - 76%Mean number of antihypertensive - 2.8 per patientBP - 151/76 mm Hg

53% ex-smokers, 30% diabetics, and 41% PVD6% of the medically treated patients crossed over to

revascularization

82% of the revascularization group that were successfully revascularized (95% of revascularized patients ) received a stent

At baseline for the entire group

Overall mortality - 25.6% in the revascularization group

26.3% in the medical groups (p = 0.46)

Cardiovascular mortality - 7.4% of the revascularization gp

8.2% of medically treated gp (p=NS)

Any CV event - 35% in revascularization gp 36% in the medically treated

group (p = 0.96)Hospitalization for fluid overload or heart failure 12% of the revascularization group 14% of the medically treated group (p = NS)No difference in serum creatinine, SBP, time to first

renal event, or overall vascular event during follow-up (p = NS for all outcomes).

FINDINGS

Currently - no evidence of benefit for renal artery revascularization

Renal revascularization did not improve serum creatinine, SBP, renal events mortality, or overall vascular events

Interpretation

It remains to be determined if renal revascularization would benefit certain subgroups –

Acute renal failure with a critical RAS Flash pulmonary edema

Normal renal function at baseline - 25% of patients in each group had normal renal function (eGFR > 50 ml/min/1.73 m2) at the entry of the trial

No core laboratory were found - some patients in the 50%–70% stenosis group actually had a stenosis of < 50%

Major drawbacks of ASTRAL

Possible selection bias - physicians were aware that which patients would benefit from either revascularization or medications

High complication rate - major complication rate in first 24 hrs - 9%

Measurement of GFR - by the Cockcroft–Gault not MDRD

Non-blinding - observer and selection bias - highRate of cross-over - 6% from medication to intervention

gp

ASTRAL

• Baseline creatinine, 2.02 mg/dl; glomerular filtration rate, 40 ml/min; mean stenosis, 76%; antihypertensive medications, 2.8 per patient

• 93% of revascularized patients received a stent

• At follow-up, no difference in creatinine, blood pressure, time to first renal event, or mortality (p = NS for all outcomes)

Trial design: Patients with significant renal artery stenosis were randomized to angioplasty and/or stenting plus medical therapy (n = 403) or medical therapy alone (n = 403) and followed for 27 months.

Results

Conclusions

• Renal artery revascularization is not superior to medical therapy alone

• Renal artery stenting does not reduce creatinine, blood pressure, time to first renal event, adverse cardiac events, or mortality

(p = 0.46) (p = 0.96)

The ASTRAL Investigators. NEJM 2009;361:1953-62

0

8

16

24

32

40

Renal stenting (n = 403)

Medical therapy(n = 403)

%

All-cause mortality CV event

25.6 26.335.0 36.0

Ongoing multicenter randomized controlled trialContrasting optimum medical therapy alone to

stenting with optimum medical therapy Composite cardiovascular and renal end point:

o Cardiovascular or renal deatho MI & hospitalization for CHF o Strokeo Doubling of serum creatinineo need for renal replacement therapy.

CORAL TRIAL Cardiovascular Outcomes in RenalArtherosclerotic Lesions

Secondary end points - evaluate effectiveness of revascularization in important subgroups

o All-cause mortalityo Kidney functiono Renal artery patencyo Microvascular renal functiono Blood pressure control

CORAL is using a standardized medical protocol to control blood pressure

Use of embolic protection devices during stenting is encouraged

Randomization will occur in 1080 subjects

1. An atherosclerotic renal stenosis of > or = 60% with a 20 mm Hg systolic pressure

gradient or > or = 80% with no gradient necessary

2. Systolic hypertension of > or = 155 mm Hg on > or = 2 antihypertensive medications

Primary entry criteria

CORAL represents a unique opportunity to determine the incremental value of stent revascularization, for the treatment of atherosclerotic RAS

Hopefully, the large size and inclusion of patients with more marked HTN will address the utility of intervention in higher-risk populations with RAS

CONCLUSIONS

Renal stenting carries an increasingly common risk to kidney function: atheroembolism

Stent crushes the plaque against vessel wall

Leads to obstruction of the renal microvasculature, increasing the risk of irreversible damage to renal function

Embolic protection devices - inserted downstream of the lesion before stenting

Catch any debris that may break loos

RISK OF ATHEROEMBOLISM

Holden et al prospectively studied 63 patients with renal artery stenosis and deteriorating renal function who underwent stenting with an embolic protection device

At 6 months renal function had either improved or stabilized in 97% of patients

Suggesting that many of the deleterious effects of stenting are related to atheroembolism

Prospective Randomized Study Comparing Renal Artery Stenting With or Without Distal Protection

In patients with mild renal dysfunction and GFR was not declining (average estimated GFR 59.3 mL/min), found contrary results

RESIST trial

Recommendations for intervention in renal artery stenosis

Intervention is not recommended:

In patients whose renal function has remained stable over the past 6 to 12 months and whose hypertension can be controlled medically

Intervention should be considered:

In patients with recurrent episodes of congestive heart failure without an obvious cardiac cause and with bilateral renal artery stenosis or stenosis to a single functioning kidney

In patients whose renal function has been rapidly declining over the past 3 to 6 months with bilateral renal artery stenosis or stenosis to a single functioning kidney, without another obvious cause

In patients in whom it is impossible to control hypertension with intense medical management (at least three maximally dosed antihypertensive medications, one of which is a diuretic)

Attention should now be focusing on clinical, rather than radiographic, indications for intervening on renal artery stenosis

Multidisciplinary approach - includes the input of a nephrologist well versed in renal artery stenosis

Two large randomized trials of intervention vs medical therapy showed negative results for intervention. A third trial is under way

Intervention is not recommended if renal function has remained stable over the past 6 to 12 months and if hypertension can be controlled medically

The best evidence supporting intervention is for bilateral stenosis with flash pulmonary edema, but the evidence is from retrospective studies

Stenosis by itself, even if bilateral, is not an indication for renal artery stenting

Key Points

Results of STAR and ASTRAL confirm the growing suspicion that the surge seen in the last decade in renal artery stenting should be coming to an end

Results either from CORAL or possibly a post hoc analysis of ASTRAL might identify potential high-risk groups that will benefit from renal intervention

FUTURE POSSIBILITIES

As embolic protection devices become more agile and suitable to different renal lesions, there remains the possibility that, due to lower rates of unidentified atheroembolic kidney disease, CORAL may demonstrate improved renal outcomes after stenting

If not, the search for the best means to predict who should have renal intervention will continue

The clinical problem is too intriguing, and too profitable, to die altogether

Thank you

Evaluate short and long-term outcomes of PTRA renal artery stenosis due to RAFMD

Technical success was 100% Short-term outcomesMajority (69%) had an immediate clinical benefit

for hypertension 6% were cured without BP medications, and 63%

improved with less than or equal to preoperative BP medications.

For the entire cohort, renal function (mean eGFR) significantly increased from 71.9 mL/minute to 80.8 mL/minute (P = .007

Short- and long-term outcomes of percutaneous transluminal angioplasty/stenting of renal fibromuscular dysplasia Mousa A Y et al

Long-term outcomes: freedom from recurrent or worsening

hypertension (>140 systolic blood pressure [SBP] and >90 diastolic blood pressure [DBP]) was (93%, 75%, and 41%)

freedom from reduced renal function (eGFR <30 mL/minute) was (100%, 95%, and 64%)

at 1, 5, and 8 years, respectively

Renal angioplasty is a safe and durable modality for treating RAFMD with favorable short and long-term clinical outcomes