Endovascular Versus Medical Management of Atherosclerotic Renovascular Disease: Update and Emerging Concepts

Abstract

Atherosclerotic renovascular disease is the most frequent cause of renovascular hypertension and its prevalence increases with age and in specific subset of patients, such as those with end-stage chronic kidney disease, heart failure, and coronary artery disease. Besides hypertension, atherosclerotic renovascular disease is responsible for several clinical manifestations, including life-threatening conditions, such as recurrent flash pulmonary edema, rapidly progressive chronic kidney disease, or acute kidney injury. Atherosclerotic renovascular disease is usually part of a more diffuse atherosclerotic process and requires a combination therapy including antihypertensive, antiplatelet and lipid-lowering agents, as well as optimization of antidiabetic treatment, if needed. Besides medical therapy, percutaneous renal angioplasty was supposed to be the most effective therapy for atherosclerotic renovascular disease, by leading to blood flow restoration. However, despite an apparently solid rationale, several randomized clinical trials failed to confirm the favorable effects of percutaneous renal angioplasty on blood pressure control, kidney function, cardiovascular and renal outcomes, previously reported in observational, retrospective and single-center cohorts, switching off the enthusiasm for this procedure. Several studies’ limitations may partly account for this failure, including heterogeneity of diagnostic techniques, overestimation of the degree of renal artery stenosis, inappropriate timing of revascularization, multiple protocol revisions, frequent crossovers, and most importantly exclusion of patients at higher likelihood to respond to angioplasty. The purpose of this review is to summarize studies’ potential weaknesses and provide guidance to the clinician for identification of patients who may benefit most from revascularization.

2023 ESH Guidelines for the management of arterial hypertension The Task Force for the management of arterial hypertension of the European Society of Hypertension

“…While revascularization with balloon angioplasty without stenting is the treatment of choice for patients with FMD and hemodynamically significant renal artery stenosis [340], the optimal treatment of atherosclerotic renal vascular disease has been matter of considerable debate for several years [1422,1423]. After some early years of little evidence-based support of revascularization, a few large RCTs attempted to test the effects of standard medical therapy plus percutaneous transluminal renal angioplasty compared with medical therapy alone in patients with atherosclerotic renal vascular disease, and showed no significant differences in BP levels, adverse CV or kidney outcomes between the two groups [1424–1426].…”

“…Several observational studies in patients with well documented severe atherosclerotic renal vascular disease (≥70% stenosis) and high-risk clinical profiles document significant benefits of revascularization in terms of BP control, preservation of kidney function and reductions in the risk of CV events and death [1421,1427]. Thus, the current consensus is to offer revascularization on top of medical therapy in patients with documented secondary hypertension because of atherosclerotic renal vascular disease or high-risk clinical profiles and documented high-grade stenosis (≥ 70%) [1418,1422,1423]. Medical therapy alone could be used for individuals with asymptomatic atherosclerotic renal vascular disease with <70% stenosis, patients with mild or moderate hypertension that is easily controlled with antihypertensive drugs and low-grade stenosis, or patients with nonviable kidney parenchyma, where revascularization has little to offer.…”

A European Renal Association (ERA) synopsis for nephrology practice of the 2023 European Society of Hypertension (ESH) Guidelines for the Management of Arterial Hypertension

“…The 2023 ESH Guidelines also discuss the prevalence [ 122 , 123 ], prognosis [ 124 ] and management [ 125 , 126 ] of the two main causes of renovascular hypertension, atherosclerotic renal vascular disease (ARVD) and fibromuscular dysplasia (FMD) [ 1 ]. Revascularization with balloon angioplasty without stenting is emphasized as the treatment of choice for patients with FMD and critical renal artery stenosis [ 127 ], while for ARVD, the recommendation is to offer revascularization on top of medical therapy in patients with documented secondary hypertension due to ARVD or those with high-risk clinical presentations (flash pulmonary edema, refractory hypertension or rapid loss of kidney function) with documented high-grade stenosis (≥70%) [ 1 ].…”

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“…More properly designed studies are needed to determine which patient populations are likely to benefit from renal revascularization. In addition to medical treatment, PRA or PRA-S was considered the most effective treatment in renovascular diseases because it would lead to the restoration of blood flow [21,27]. In practical terms, angioplasty can also limit overall hospital stays, avoid general anesthesia, and minimize tissue trauma.…”

“…In addition to these, diuretics, beta-blockers, alpha-beta blockers, and calcium channel blockers are frequently used drugs [8]. If the underlying cause is atherosclerosis, a combination therapy that includes antihypertensive, antiplatelet, and lipid lowering agents may be required [27].…”