What is the best approach to treatment of atherosclerotic renal artery stenosis (RAS)?

Updated: Nov 02, 2020
  • Author: Bruce S Spinowitz, MD, FACP; Chief Editor: Vecihi Batuman, MD, FASN  more...
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Answer

However, controversy still surrounds the best approach to patients with atherosclerotic renovascular disease, as reviewed by Ives et al, Textor,  Plouin, and Manaktala et al. [39, 40, 41, 42] In a study of patients with atherosclerotic renal artery stenosis, Bax et al found that renal artery stenting had no clear effect on kidney function impairment in the patients and led to significant complications in some of them. [43] The multicenter trial included 140 patients with creatinine clearance of less than 80 mL/min per 1.73 m2 and renal artery stenosis of 50% or greater. All patients received medical treatment with antihypertensive agents, a statin, and aspirin. Although 64 patients were randomized to stent placement, only 46 had the procedure; in many patients, assessment of renal artery stenosis by noninvasive imaging was inaccurate and stenting was in fact not indicated.

In the study, progression of kidney dysfunction, as indicated by a decrease in creatinine clearance of 20% or greater, occurred in 16% of patients in the stent placement group and in 22% of patients in the medication group (hazard ratio, 0.73 [95% confidence interval [CI], 0.33-1.61]). Serious complications in the stent group included two procedure-related deaths.

The results of the 2009 ASTRAL trial included 806 patients with at least one stenotic renal artery who were randomized to revascularization (ie, interventional radiology) or medical therapy. [44] The estimated GFR was approximately 40 mL/min in each group. No difference was observed in the primary outcome, decline of renal function, between the two groups. Although both studies have some design flaws, they suggest that medical therapy is appropriate for the single, stenotic renal artery. Two review articles, one conducted by Simon and the other conducted by Lao et al, discuss this subject in significant detail. [45, 46]


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