Endovascular Management of Atherosclerotic Renal Artery Stenosis: Post-Cardiovascular Outcomes in Renal Atherosclerotic Lesions Era Winner or False Alarm?

Abstract

Renal artery stenosis (RAS) is frequently associated with severe comorbidities such as reduced renal perfusion, hypertension, and end-stage renal failure. In approximately 90% of patients, renal artery atherosclerosis is the main cause for RAS, and it is associated with an increased risk for fatal and non-fatal cardiovascular and renal complications. Endovascular management of atherosclerotic RAS (ARAS) has been recently evaluated by several randomized controlled trials that failed to demonstrate benefit of stenting. Furthermore, the Cardiovascular Outcomes in Renal Atherosclerotic Lesions study did not demonstrate any benefit over the revascularization approach. In this review, we summarized the available data from retrospective, prospective and randomized trials on ARAS to provide clinicians with sufficient data in order to produce useful conclusions for everyday clinical practice.

Effects of percutaneous angioplasty on kidney function and blood pressure in patients with atherosclerotic renal artery stenosis

“…Optimal medical treatment without revascularization has been the ‘gold standard’ for low-risk and stable ARAS, according to a previously reported RCT and meta-analysis [10]. Recently, the two largest RCTs evaluating percutaneous renal artery intervention for RAS, the CORAL trial and the Angioplasty and Stenting for Renal Artery Lesions (ASTRAL) trial, demonstrated that revascularization did not offer significant benefits over medical therapy in patients with ARAS and stable chronic kidney disease [3,4].…”

Renovascular Hypertension in Chronic Hemodialytic Patient

“…The decision to manage an RAS patient should be highly individualized. However, patient selection is sometimes challenging, due to limited data on the specific phenotypes of patients who would benefit from the procedure [27], [39]. In certain cases, the decision on which therapeutic strategy to pursue remains difficult, but clinicians must evaluate patients carefully individually, to determine whether only optimize medical therapy alone or add PTRA.…”

Diagnostic use of contrast medium and the kidney: A challenge or a ghost?

“…CM administration for interventional procedures, such as percutaneous transluminal angioplasty, is weighed by a higher CIAKI incidence, prolonged hospitalization, non-reversible deterioration of renal function, need for renal replacement therapy (RRT), and in-hospital mortality. [22][23][24][25][26][27][28] Indeed, AKI incidence in interventional procedures ranges from 20% to 70%, depending on AKI definition, the characteristics of the population, and the degree of urgency. For a long time, the arterial injection was supposed to play a nephrotoxic effect for the immediate delivery of CM to renal vessels.…”

“…However, two considerations contradict this hypothesis: renal artery angiography and angioplasty are not burdened by the greatest incidence of AKI, and during coronary angiography, CM is drained by coronary veins and flows through pulmonary circulation before reaching the kidney. 22 Among the intra-arterial injection procedures, only those using femoral access are associated with a greater risk of AKI, due to a higher incidence of catheter-induced atheroembolic disease. 29 A large prospective study on inpatients 23 points out the impact of the comorbidities on the diagnosis and prognosis of CIAKI.…”