How is renal artery stenosis caused by atherosclerosis treated
What treatment options exist for renal artery stenosis caused by atherosclerosis?
Atherosclerotic renal artery stenosis may be treated by medical management, angioplasty/stent placement, or surgery.
Medical management is based on blood pressure control with appropriate antihypertensive medications along with lifestyle modifications and other medical interventions aimed at reducing the high cardiovascular risk associated with atherosclerotic renal artery stenosis.
This includes aspirin, statins, smoking cessation, and good glycemic control in patients with diabetes. In addition to this approach, revascularization, now mainly done with percutaneous interventions (angioplasty and stenting) rather than surgery, can be used to treat renovascular hypertension and ischemic nephropathy. However, multiple randomized trials suggest that revascularization does not significantly improve blood pressure control, kidney outcomes, cardiovascular outcomes, or mortality compared with medical management alone.
The two largest and most recently published studies that randomized participants to either medical management with revascularization or medical management alone:
- 1. Angioplasty and STenting for Renal Artery Lesions (ASTRAL) trial in 2009 included more than 800 patients
- 2. Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL) study in 2014 included approximately 950 subjects
Both trials failed to demonstrate a benefit for revascularization toward kidney outcomes, cardiovascular outcomes, and mortality compared with medical management alone. Moreover, in the ASTRAL study, no difference in blood pressure control was observed between the revascularization group and the medical management group. The CORAL trial did find a statistically significant difference in blood pressure between participants who underwent revascularization compared with those receiving only medical management. However, this difference was only 2.3 mm Hg and did not lead to any improvement in clinical outcomes. Of note, periprocedural complications occurred in approximately 9% of patients who underwent revascularization in ASTRAL and in approximately 5% of vessels treated in CORAL.
