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Revascularization Is Ineffective for Atherosclerotic Renal Artery Stenosis

This procedure conferred substantial risk without clinical benefit.

Revascularization for atherosclerotic renal artery stenosis can improve artery patency, but is it associated with clinical benefit? In a 5-year U.K. study, investigators randomized 806 patients with renal artery stenosis and related clinical findings (such as difficult-to-control hypertension or unexplained renal dysfunction) to medical management alone or to medical management plus angioplasty (with stenting at the discretion of treating physicians). In all cases, treating physicians were uncertain whether revascularization would confer benefit. Median follow-up was 34 months.

Among participants who were assigned to revascularization, 17% did not undergo the procedure, mainly because angiography revealed that their stenoses were less severe than expected. Compared with medical management–only patients, those assigned to revascularization had a borderline significant mean lower rate of disease progression (as measured by the reciprocal of the mean serum creatinine level; P=0.06). However, no significant differences were noted between groups in serum creatinine level, systolic blood pressure, adverse renal events, adverse cardiovascular events, or death. Mean diastolic blood pressure was significantly lower in the medical management–only group. Researchers found no effects of revascularization in subgroups as defined by stenosis or renal dysfunction severity. Twenty-three patients suffered serious complications related to revascularization.

Comment: A small recently published study suggested that revascularization produced no benefit (JW Gen Med Jul 21 2009); now, a much larger study yielded similar findings. The authors note that the main limitation of their study is that they excluded people who required revascularization, in their doctors' opinions: Examples are patients with flash pulmonary edema or acute renal injury (or rapidly progressing disease) that was thought to be caused by renal artery stenosis. Whether such patients benefit from revascularization is unknown. But, for most people, revascularization for renal artery stenosis does not appear to be associated with clinical benefit.

— Richard Saitz, MD, MPH, FACP, FASAM

Published in Journal Watch General Medicine November 12, 2009

Citation(s):

The ASTRAL Investigators. Revascularization versus medical therapy for renal-artery stenosis. N Engl J Med 2009 Nov 12; 361:1953.

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Reader Remarks:

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• Renin
  Joe Reynolds, 13 Nov 2009 7:41 AM EST
  I was wondering if the Renin levels pre and post op were measured
• Fibromuscular dysplasia of renal artery
  Barbara A McFee, 12 Nov 2009 6:26 PM EST
  Have studies been done of patients with FMD and if so are the results published?
• renal revascularization
  Darol Joseff MD, 13 Nov 2009 10:59 AM EST
  The real conclusion seems to be that renal revascularization doesn't help in those cases where the treating physician is 'uncertain'... [more]
• complications
  d t, usa, 15 Nov 2009 2:26 PM EST
  ten percent major complications!! what are they doing... possibly learning angioplasty in us we do it for less than 1... [more]
• Rx RAS
  Newell Falkinburg, 19 Nov 2009 3:32 PM EST
  Were they studying unilateral RAS or Bilat RAS or both.
  
  Looks like sloppy reporting to me .