Revascularization for Renovascular Disease: A Scientific Statement From the American Heart Association

Abstract

Renovascular disease is a major causal factor for secondary hypertension and renal ischemic disease. However, several prospective, randomized trials for atherosclerotic disease failed to demonstrate that renal revascularization is more effective than medical therapy for most patients. These results have greatly reduced the generalized diagnostic workup and use of renal revascularization. Most guidelines and review articles emphasize the limited average improvement and fail to identify those clinical populations that do benefit from revascularization. On the basis of the clinical experience of hypertension centers, specialists have continued selective revascularization, albeit without a summary statement by a major, multidisciplinary, national organization that identifies specific populations that may benefit. In this scientific statement for health care professionals and the public-at-large, we review the strengths and weaknesses of randomized trials in revascularization and highlight (1) when referral for consideration of diagnostic workup and therapy may be warranted, (2) the evidence/rationale for these selective scenarios, (3) interventional and surgical techniques for effective revascularization, and (4) areas of research with unmet need.

Atherosclerotic renovascular disease and cardiovascular risk: new concepts

“…Results of several randomized controlled studies have questioned the value of routine revascularization for ARAS, since the latter was not associated with improved cardiovascular outcomes when compared with medical therapy alone. 27 In the ASTRAL (Angioplasty and Stenting for Renal Artery Lesions) trial, comparing medical therapy with stenting for ARAS in randomly assigned 806 patients, there was no difference in the pre -established outcomes of renal function decline, renal events, cardiovascular events, or death. 27,28 Also, in the CORAL (Cardiovascular Outcomes in Renal Atherosclerotic Lesions) trial, which enrolled 931 patients with ARAS, there were no differences in primary outcomes including major cardiovascular events (myocardial infarction, stroke, hospitalization was more frequent than in the patients with primary hypertension.…”

“…27 In the ASTRAL (Angioplasty and Stenting for Renal Artery Lesions) trial, comparing medical therapy with stenting for ARAS in randomly assigned 806 patients, there was no difference in the pre -established outcomes of renal function decline, renal events, cardiovascular events, or death. 27,28 Also, in the CORAL (Cardiovascular Outcomes in Renal Atherosclerotic Lesions) trial, which enrolled 931 patients with ARAS, there were no differences in primary outcomes including major cardiovascular events (myocardial infarction, stroke, hospitalization was more frequent than in the patients with primary hypertension. 21 The study of Wright et al 19 also showed that the patients with ARAS and CKD were characterized by higher prevalence of LV diastolic dysfunction (40.5% vs 12.0%) than individuals with other causes of CKD (control group).…”

“…Moreover, the patients with ARAS are characterized by more enhanced coronary atherosclerosis, as compared with hypertensive patients without ARAS, which for HF, or cardiovascular death), kidney events, or a composite outcome. 27,29 These negative results of the ASTRAL and COR-AL studies led to the widespread opinion that renal artery intervention in patients with ARAS is not beneficial in the long -term follow -up. However, these data are conflicting with further observational studies demonstrating that successful restoration of blood flow may reverse complications of untreated ARAS, such as resistant hypertension or ischemic nephropathy.…”

“…However, these data are conflicting with further observational studies demonstrating that successful restoration of blood flow may reverse complications of untreated ARAS, such as resistant hypertension or ischemic nephropathy. 27,[30][31][32] In a retrospective, uncontrolled single center study, interventional treatment in patients with ARAS and true resistant hypertension significantly lowered diastolic ambulatory BP and reduced the need for antihypertensive treatment without affecting renal function. 33 Also, a prospective, longitudinal observational study at a single clinical center indicated that revascularization of ARAS in the patients with HF was associated with substantial reduction in all -cause mortality and hospitalization rate.…”

“…FIGURE 2Progression of atherosclerotic renovascular disease resulting both in ischemic nephropathy and cardiovascular changes: current concepts. Adapted from3,18,27 Abbreviations: BP, blood pressure; eGFR, estimated glomerular filtration rate…”