Transcript Slide 1

Dr Bijilesh u
 Atherosclerosis accounts for about 90% of cases of renal
artery stenosis in people over age 40
 Fibromuscular dysplasia - the other major cause
 Percutaneous intervention has become very popular for
treating atherosclerotic renal artery stenosis
 use of stents has boosted the rate of technical success
 more cases are being discovered incidentally during angiography of
other arteries
 Number of angioplasty-stenting procedures performed
every year is on the rise
 Yet there is no overwhelming evidence that intervention
yields clinical benefits—ie, better blood pressure control or
renal function— than does medical therapy
 Renal angioplasty began replacing surgical
revascularization in the 1990s
 Less-invasive , more readily available, similar clinical
outcomes
 Last decade, stent placement during angioplasty has
become standard - improving the rates of technical success
 Prevalence of RAS depends on the definition used and
the population screened.
 More common in older patients who have risk factors
for other vascular diseases than in the general
population
 Affect between 1% and 5% of patients with hypertension

Derkx FH, Schalekamp MA. Renal artery stenosis and hypertension. Lancet. 1994; 344: 237–239
 Renal artery stenosis is found in 11% to 28% of patients
undergoing diagnostic cardiac catheterization

White CJ, Olin JW .Diagnosis and management of atherosclerotic renal artery stenosis:
improving patient selection and outcomes. Nat Clin Pract Cardiovasc Med 2009; 6:176–190.
 No studies of the prevalence of renal artery stenosis have
been performed in the general population
 Holley et al in an autopsy series, found renal artery stenosis
of greater than 50% in 27% of patients over age 50 and in
56.4% of hypertensive patients
 Prevalence was 10% in normotensive patients
 Renal Doppler ultrasonography can detect stenosis only if
the artery is narrowed by more than 60%
 Hansen et al used ultrasonography to screen 870 people
over age 65 and found a lesion (a narrowing of more than
60%) in 6.8%.
 Angiography can detect less-severe stenosis
define RAS as a narrowing > 50%
severe disease - narrowing > 70%
 Unilateral stenosis needs to be more than 70% to pose a
risk to the kidney

Cohen MG, et al. A simple prediction rule for significant renal artery stenosis in patients undergoing cardiac
catheterization. Am Heart J 2005; 150:1204–1211
Factors associated with a higher risk of finding RAS on a
radiographic study
 Older age , Female sex
 Hypertension , Three-vessel CAD
 Peripheral artery disease
 Chronic kidney disease
 Diabetes , Tobacco use
 Low HDL

Cohen MG, et al. A simple prediction rule for significant renal artery stenosis in patients undergoing cardiac
catheterization. Am Heart J 2005; 150:1204–1211
 In studies that used duplex ultrasonography, roughly half
of lesions smaller than 60% grew to greater than 60% over
3 years
 Risk of total occlusion of an artery was relatively low and
depended on the severity of stenosis: 0.7% if the baseline
stenosis was less than 60% and 2.3% to 7% if it was greater

Caps MT, Perissinotto C, Zierler RE, et al . Prospective study of atherosclerotic disease progression in
the renal artery. Circulation 1998; 98:2866–2872
 Schreiber and colleagues _ compared serial angiograms
obtained a mean of 52 months apart in 85 patients who did
not undergo intervention
 Stenosis had progressed in 37 (44%), and to the point of
total occlusion in 14 (16%)

Schreiber MJ, Pohl MA, Novick AC .The natural history of atherosclerotic and fibrous renal artery disease
 1998 study found progression in 11.1% over 2.6 years

Crowley JJ, et al.Progression of renal artery stenosis in patients undergoing cardiac catheterization
Rates of progression differed because –
 Indications for screening were different (clinical suspicion
vs routine screening during CAG)
 Severity of stenosis at the time of diagnosis- different
 Fewer people were taking statins.
 Clinically silent stenosis
 Renovascular hypertension
 Ischemic nephropathy
 Recurrent “flash” pulmonary edema
 Less common presentation
 Occurring in patients with critical bilateral renal artery
stenosis or unilateral stenosis in an artery supplying a
solitary functioning kidney
 Most have severe hypertension (average systolic blood
pressure 174–207 mm Hg) and poor renal function
 Association between pulmonary edema and bilateral renal artery
stenosis was first noted in 1998 by Pickering et al
 Several case series showed that 82% to 92% of patients with
recurrent pulmonary edema and renal artery stenosis had
bilateral stenosis

Pickering TG, et al. Recurrent pulmonary oedema in hypertension due to bilateral renal artery stenosis: treatment by
angioplasty or surgical revascularisation. Lancet 1988; 2:551–552
 Later case series corroborated this finding: 85% to 100% of
patients with renal artery stenosis and pulmonary edema had
bilateral stenosis

Messina LM, Zelenock GB, Yao KA, Stanley JC. Renal revascularization for recurrent pulmonary edema in
patients with poorly controlled hypertension and renal insufficiency: a distinct subgroup of patients with
arteriosclerotic renal artery occlusive disease. J Vasc Surg 1992; 15:73–80

Gray BH, et al. Clinical benefit of renal artery angioplasty with stenting for the control of recurrent and
refractory congestive heart failure. Vasc Med 2002; 7:275–279.
 Stenting has become standard in the endovascular
treatment of renal artery stenosis
 Most atherosclerotic renal artery lesions are located in
the ostium and many are extensions of calcified aortic
plaque

Textor SC. Ischemic nephropathy: where are we now? J Am Soc Nephrol 2004; 15:1974–1982
 These hard lesions tend to rebound to their original
shape more often with balloon angioplasty alone
 Stenting provides the additional force needed to
permanently disrupt the lesion- longer-lasting result
 Rates of technical success are higher with stents than
without them (98% vs 46%– 77%)

Beutler JJ, et al. Long-term effects of arterial stenting on kidney function for patients with ostial
atherosclerotic renal artery stenosis and renal insufficiency. J Am Soc Nephrol 2001; 12:1475–1481
 If the lesion is ostial, this difference is even more
impressive (75% vs 29%)
 Restenosis rates at 6 months are lower with stents (14%
vs 26%–48%)

Van de Ven PJ, et al. Arterial stenting and balloon angioplasty in ostial atherosclerotic renovascular
disease: a randomized trial. Lancet 1999; 353:282–286
 Endovascular procedures pose some risk to the patient -
critical to intervene only in patients most likely to respond
clinically
 In renovascular HTN - improve blood pressure control
 In ischemic nephropathy- slow the decline in renal
function or to improve it
INDICATION
SUPPORT IN THE LITERATURE
Hypertension resistant to three drugs,
including a diuretic
Subgroup analysis of a randomized
controlled trial
Recurrent flash pulmonary edema
Retrospective
Acute kidney injury after introduction
of a renin-angiotensin system inhibitor
Retrospective
Rapidly declining renal function
Not supported by subgroup analysis
from randomized controlled trials
New onset or worsening control of
hypertension in older patients
Retrospective
 Coincidental RAS in a patient with unrelated CKD is very
hard to differentiate from true ischemic nephropathy
 Most patients with ischemic nephropathy do not benefit
from revascularization, making it challenging to identify
those few whose renal function may respond
 In a prospective cohort study in 304 patients with CKD
& RAS who underwent surgical revascularization,
Textor reported that serum creatinine
improved - in 28%
worsened in 19.7%
remained unchanged in 160 - 52.6%

Textor SC. Revascularization in atherosclerotic renal artery disease. Kidney Int 1998; 53:799–811
 Davies et al found that 20% of patients who underwent
renal stenting had a persistent increase in serum creatinine
of 0.5 mg/dL or more
 Nearly three times more likely (19% vs 7%) to eventually
require dialysis
 Lower 5-year survival rate (41% vs 71%)

Davies MG, et al. Implications of acute functional injury following percutaneous renal artery
intervention. Ann Vasc Surg 2008; 22:783–789
 Zeller et al found that renal function improved slightly in 52% of
patients who received stents
 Mean decrease in serum creatinine in this group was 0.22 mg/Dl
 However, the other 48% had a mean increase in serum creatinine
of 1.1 mg/dL
.Zeller T, et al. Predictors of improved renal function after percutaneous stent-supported angioplasty of
severe atherosclerotic ostial renal artery stenosis. Circulation 2003; 108;2244–2249.
 Acute pulmonary edema in the setting of bilateral RAS -
improvement in clinical status can be expected in most
patients after intervention
 Blood pressure improves in 94% to 100%

Messina LM, Zelenock GB, Yao KA, Stanley JC. Renal revascularization for recurrent pulmonary
edema in patients with poorly controlled hypertension and renal insufficiency: a distinct subgroup of
patients with arteriosclerotic renal artery occlusive disease. J Vasc Surg 1992; 15:73–80
 Renal function either improves or stabilizes in 77% to 91%
 Pulmonary edema resolves without recurrence in 77% to
100%

Gray BH, et al. Clinical benefit of renal artery angioplasty with stenting for the control of
recurrent and refractory congestive heart failure. Vasc Med 2002; 7:275–279.
 Scottish and Newcastle Renal Artery Stenosis
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Collaborative Group
Essai Multicentrique Medicaments vs Angioplastie
(EMMA) Study Group
Dutch Renal Artery Stenosis Intervention Cooperative
(DRASTIC) study
STAR TRIAL
ASTRAL TRIAL
CORAL TRIAL
 Before stents came into use, several randomized controlled
trials found that blood pressure was no better controlled
after angioplasty except in cases of bilateral stenosis
 This may be because stenosis tended to recur after
angioplasty without stents
 Randomised comparison of percutaneous angioplasty vs
continued medical therapy for hypertensive patients with
atheromatous renal artery stenosis
 Methods
 Out of 135 eligible patients 55 (44%) were randomised
 Eligible patients had sustained hypertension, with a
minimum diastolic BP of 95 mm Hg on at least two antihypertensive drugs
 RAS was defined by renal angiography as at least 50%
stenosis in the affected vessel
Scottish and Newcastle Renal Artery
Stenosis Collaborative Group
Results:
 BP fell in angioplasty and medical groups
 Bilateral RAS - a statistically significant (P < 0.05) fall in
bp
 Mean fall in bp - 26/10 mm hg
 In unilateral RAS, no statistically significant differences in
outcome were observed
 No significant differences or trends in serum creatinine
were observed between the two groups
 Major outcome events (death, MI , heart failure, stroke,
dialysis) were similar
Conclusions
 In hypertensive patients with atheromatous RAS percutaneous
renal angioplasty results in a modest improvement in systolic BP
compared with medical therapy alone
 This benefit was confined to patients with bilateral disease.
 No patient was 'cured', renal function did not improve, and
intervention was accompanied by a significant complication rate.

J Webster, F Marshall, M Abdalla, A Dominiczak, R Edwards, C G Isles, H Loose, J Main, P Padfield, I T Russell, B Walker, M Watson
and R Wilkinson on behalf of the Scottish and Newcastle Renal Artery Stenosis Collaborative Group J Hum Hypertens 1998; 12:329–
335
 Aim - document the efficacy and safety of angioplasty for
lowering BP in patients with atherosclerotic RAS
 Randomly assigned to antihypertensive drug treatment
(control group, n=26) or angioplasty (n=23)
 Primary end point - 24 hour ambulatory BP - measured at
baseline and at termination(6 months after randomization)
 Secondary end points were the incidence of complications
 Early termination was required for refractory hypertension
in 7 patients in the control group.
 Antihypertensive treatment was resumed in 17 patients in
the angioplasty group
 Mean ambulatory BP at termination did not differ between
control (141±15/84±11 mm Hg) and angioplasty (140±15/81±9
mm Hg) groups
 Two patients in the control group and 6 in the angioplasty
group suffered procedural complications (RR 3.4; 95%
confidence interval, 0.8 to 15.1)
 Angioplasty allowed easier BP control than medication
alone
 Antihypertensive agents - required at termination for all
control patients but not for 6 of the 23 allocated to
angioplasty (26%)
 Moreover, 7 of 25 patients in the control group (28%)
developed refractory hypertension leading to secondary
angioplasty within 6 Months
 Angioplasty madeBP control easier in the short term but
was more frequently associated with complications than
conservative management in patients with unilateral
atherosclerotic RAS

Plouin PF, Chatellier G, Darne B, Raynaud A Blood pressure outcome of angioplasty in atherosclerotic renal
artery stenosis: a randomized trial. Essai Multicentrique Medicaments vs Angioplastie (EMMA) Study Group.
Hypertension 1998; 31:823–829.
 Only unilateral renal artery disease was enrolled
 Groups were not well balanced - 23 patients for angioplasty
and 26 for control
 Cross-over - seven of the control-group crossed over to
intervention group
 High complication rate in angioplasty group which was
about (6 of 23, or 26%)
 Examined the effect of angioplasty on BP control in RAS
 Overall, intervention (balloon angioplasty without stents
in 54 of 56 patients, with stents in the other 2) carried no
benefit
 However, in subgroup analysis, the patients who crossed
over because of resistant hypertension were more likely to
benefit from angioplasty
 van Jaarsveld BC, et al.The effect of balloon angioplasty on
hypertension in atherosclerotic renal-artery stenosis. Dutch Renal
Artery Stenosis Intervention Cooperative Study Group. N Engl J Med
2000; 342:1007–1014
 Randomly assigned 106 patients with HTN who had
atherosclerotic RAS (luminal diameter < 50 %) and a serum
creatinine 2.3 mg/dl or less to undergo PTRA or to receive
drug therapy
 Also had to have a diastolic BP > 95 mm Hg or higher
despite treatment with two antihypertensive drugs
 Blood pressure, doses of antihypertensive drugs, and renal
function were assessed at 3 and 12 months, and patency of
the renal artery was assessed at 12 months
 No significant differences between the angioplasty and
drug-therapy groups in systolic and diastolic blood
pressures, daily drug doses, or renal function
 In the treatment of patients with hypertension and renal-
artery stenosis, angioplasty has little advantage over
antihypertensive-drug therapy
 Sample size was not sufficient to detect a significant
difference between treatment groups
 Renal artery stenosis was defined as greater than 50%
stenosis
 High rate of cross over - Twenty-two of 50 patients
randomized to medical therapy crossed over to the
angioplasty group
 50 patients (female 18, male 32, mean age 64.4 years) with
RAOOD of at least 70% stenosis in one or both renal
arteries
 Randomized to either OSRP (n = 25 patients, 49 arteries) or
PTRA + stent (n = 25 patients, 28 arteries)
 Patients were followed on a regular basis for 4 years and
longer
 Endpoints were re-occurrence of RAOOD and impairment
of either kidney function or RVH
Results
 Directly procedure-related morbidity was 13% in the
interventional group and 4% in the surgical group
 Four-year follow-up mortality was 18% vs 25%
 Both groups showed significant improvement of RVH (P <
.001) as well as improvement or stabilization of renal
function
 Both treatment modalities showed good early results
concerning RVH, kidney function, and renal perfusion
 Single center
 Groups were not well balanced (PTRA+ stent group
number= 22, Surgical group = 27)
 Power calculation was not mentioned
 NEW RANDOMIZED TRIALS
 Despite the lack of evidence supporting revascularization
of renal artery stenosis, many interventionalists practice
under the assumption that the radiographic finding of
renal artery stenosis alone is an indication for renal
revascularization
 Only three randomized controlled trials in the modern era
attempt to examine this hypothesis: STAR, ASTRAL, and
CORAL
 Randomized trial - medical treatment of renal artery
stenosis was compared with medical treatment plus
stenting
 140 Patients with RAS and renal insufficiency were
randomized to revascularization with stenting (n = 64)
versus continued medical management (n = 76)
 Renal artery stenosis >50% luminal narrowing
 Renal insufficiency - creatinine clearance <80 ml/min/1.73
m2
 Patients could crossover from medical therapy to stent
placement if necessary for refractory HTN
 Patients Screened: 185
 Patients Enrolled: 140
 Mean Follow Up: 2 years
 Mean Patient Age: 66 years
 Female: 33%
From: Stent Placement in Patients With Atherosclerotic Renal Artery Stenosis and
Impaired Renal Function:
 Hypertension was treated to <140/90 mm Hg with the
use of diuretics, CCB , beta blockers
 All patients received atorvastatin 10 mg & aspirin 75100 mg daily
 No difference in baseline characteristics between the
groups
Stent group –
 Mean age was 66 years
 33% were women
 mean creatinine was 1.7 mg/dl
 mean systolic blood pressure was 160 mm Hg,
 mean number of antihypertensive drugs was 2.8,
 >90% stenosis was present in 34%.
Participant
Characteristics
at Baseline – STAR
TRIAL
 Primary Endpoint
20% or more decrease in creatinine clearance
 Secondary Endpoints:
Procedural complications
Hypertension
Mortality
 Primary outcome - occurred in
16% of the stent group versus
22% of the medical therapy group (p = NS)
 Unilateral stenoses - 9% versus 20% (p = NS)
 With only bilateral stenoses, 22% vs 23% (p = NS).
 All-cause mortality was 8% vs 8% and cardiovascular
mortality was 3% vs 5%
 3/5 deaths in the stent group were due to procedurerelated deaths and one late death was due to infected
hematoma
 With RAS and renal insufficiency strategy of
revascularization with stenting was not superior to
continued medical therapy
 Renal artery stenting was not able to preserve
creatinine clearance at 2 years of follow-up
 No difference based on the presence of unilateral or
bilateral stenoses
 Stent placement with medical treatment had no clear
effect on progression of impaired renal function but
led to a small number of significant procedure-related
complications
 Study was under-powered
Moreover, four patients lost in follow up and 3% drop out
 Included patients with mild RAS
33% of the patients - RAS 50%-70%
12 (19%) intervention group RAS < 50%
 Not all “stent” group patients received stents
 Only 46 (72%) of the 64 patients subjected to stenting
infact received a stent, while 18 (28%) did not
 More than half of the patients had unilateral disease
 Complication rates were high
 Aim - To evaluate percutaneous renal artery
revascularization compared with medical therapy in
patients with significant renal artery stenosis
 Hypothesis - Percutaneous revascularization of stenotic
renal arteries would be more effective at decreasing the rate
of decline in renal function
Patients Enrolled: 806
Mean Follow Up: 27 months
Mean Patient Age: 70 years
Female: 37
 Primary Endpoint
Change in renal function
 Secondary Endpoints:
Blood pressure control
Time to first renal event
Time to first cardiovascular event
Mortality
 Clinical suspicion for atherosclerotic renal disease,
with substantial anatomical atherosclerotic stenosis in
at least one renal artery
 Need for surgical revascularization
 High likelihood of needing revascularization within 6
months
 Nonatheromatous cardiovascular disease
 History of prior revascularization for renal artery
stenosis
 Patients with significant RAS were randomized to
PTRA (angioplasty and/or stenting) plus medical
therapy (n = 403) or medical therapy alone (n = 403).
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Serum creatinine - 2.02 mg/dl
Estimated GFR - 40 ml/min
Mean stenosis - 76%
Mean number of antihypertensive - 2.8 per patient
BP - 151/76 mm Hg
 53% ex-smokers, 30% diabetics, and 41% PVD
 6% of the medically treated patients crossed over to
revascularization
 82% of the revascularization group that were
successfully revascularized (95% of revascularized
patients ) received a stent
 Overall mortality - 25.6% in the revascularization group
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26.3% in the medical groups (p = 0.46)
Cardiovascular mortality - 7.4% of the revascularization gp
8.2% of medically treated gp (p=NS)
Any CV event - 35% in revascularization gp
36% in the medically treated group (p = 0.96)
Hospitalization for fluid overload or heart failure
12% of the revascularization group
14% of the medically treated group (p = NS)
No difference in serum creatinine, SBP, time to first renal
event, or overall vascular event during follow-up (p = NS for all
outcomes).
 Currently - no evidence of benefit for renal artery
revascularization
 Renal revascularization did not improve serum
creatinine, SBP, renal events mortality, or overall
vascular events
 It remains to be determined if renal revascularization
would benefit certain subgroups –
Acute renal failure with a critical RAS
Flash pulmonary edema
 Normal renal function at baseline - 25% of patients in each
group had normal renal function (eGFR > 50 ml/min/1.73
m2) at the entry of the trial
 No core laboratory were found - some patients in the 50%–
70% stenosis group actually had a stenosis of < 50%
 Possible selection bias - physicians were aware that which
patients would benefit from either revascularization or
medications
 High complication rate - major complication rate in first 24 hrs
- 9%
 Measurement of GFR - by the Cockcroft–Gault not MDRD
 Non-blinding - observer and selection bias - high
 Rate of cross-over - 6% from medication to intervention gp
ASTRAL
Trial design: Patients with significant renal artery stenosis were randomized to angioplasty
and/or stenting plus medical therapy (n = 403) or medical therapy alone (n = 403) and
followed for 27 months.
Results
(p = 0.46)
35.0
40
32
(p = 0.96)
25.6
36.0
26.3
24
% 16
• Baseline creatinine, 2.02 mg/dl; glomerular
filtration rate, 40 ml/min; mean stenosis, 76%;
antihypertensive medications, 2.8 per patient
• 93% of revascularized patients received a
stent
• At follow-up, no difference in creatinine, blood
pressure, time to first renal event, or mortality
(p = NS for all outcomes)
8
0
All-cause mortality
CV event
Conclusions
• Renal artery revascularization is not superior
to medical therapy alone
Renal
stenting
(n = 403)
Medical
therapy
(n = 403)
• Renal artery stenting does not reduce
creatinine, blood pressure, time to first renal
event, adverse cardiac events, or mortality
The ASTRAL Investigators. NEJM 2009;361:1953-62
 Ongoing multicenter randomized controlled trial
 Contrasting optimum medical therapy alone to stenting
with optimum medical therapy
 Composite cardiovascular and renal end point:
o Cardiovascular or renal death
o MI & hospitalization for CHF
o Stroke
o Doubling of serum creatinine
o need for renal replacement therapy.
 Secondary end points - evaluate effectiveness of
o
o
o
o
o
revascularization in important subgroups
All-cause mortality
Kidney function
Renal artery patency
Microvascular renal function
Blood pressure control
 CORAL is using a standardized medical protocol to control
blood pressure
 Use of embolic protection devices during stenting is
encouraged
 Randomization will occur in 1080 subjects
1. An atherosclerotic renal stenosis of
> or = 60% with a 20 mm Hg systolic pressure gradient or
> or = 80% with no gradient necessary
2. Systolic hypertension of > or = 155 mm Hg on > or = 2
antihypertensive medications
 CORAL represents a unique opportunity to determine the
incremental value of stent revascularization, for the
treatment of atherosclerotic RAS
 Hopefully, the large size and inclusion of patients with
more marked HTN will address the utility of intervention
in higher-risk populations with RAS
 Renal stenting carries an increasingly common risk to kidney
function: atheroembolism
 Stent crushes the plaque against vessel wall
 Leads to obstruction of the renal microvasculature, increasing
the risk of irreversible damage to renal function
 Embolic protection devices - inserted downstream of the lesion
before stenting
 Catch any debris that may break loos
 Holden et al prospectively studied 63 patients with renal
artery stenosis and deteriorating renal function who
underwent stenting with an embolic protection device
 At 6 months renal function had either improved or
stabilized in 97% of patients
 Suggesting that many of the deleterious effects of stenting
are related to atheroembolism
 Prospective Randomized Study Comparing Renal Artery
Stenting With or Without Distal Protection
 In patients with mild renal dysfunction and GFR was not
declining (average estimated GFR 59.3 mL/min), found
contrary results
Recommendations for intervention in renal artery stenosis
Intervention is not recommended:
In patients whose renal function has remained stable over the past 6 to 12 months
and whose hypertension can be controlled medically
Intervention should be considered:
In patients with recurrent episodes of congestive heart failure without an obvious
cardiac cause and with bilateral renal artery stenosis or stenosis to a single
functioning kidney
In patients whose renal function has been rapidly declining over the past 3 to 6
months with bilateral renal artery stenosis or stenosis to a single functioning
kidney, without another obvious cause
In patients in whom it is impossible to control hypertension with intense medical
management (at least three maximally dosed antihypertensive medications, one
of which is a diuretic)
 Attention should now be focusing on clinical,
rather than radiographic, indications for
intervening on renal artery stenosis
 Multidisciplinary approach - includes the input of
a nephrologist well versed in renal artery stenosis
 Two large randomized trials of intervention vs medical
therapy showed negative results for intervention. A third
trial is under way
 Intervention is not recommended if renal function has
remained stable over the past 6 to 12 months and if
hypertension can be controlled medically
 The best evidence supporting intervention is for bilateral
stenosis with flash pulmonary edema, but the evidence is
from retrospective studies
 Stenosis by itself, even if bilateral, is not an indication for
renal artery stenting
 Results of STAR and ASTRAL confirm the growing
suspicion that the surge seen in the last decade in renal
artery stenting should be coming to an end
 Results either from CORAL or possibly a post hoc analysis
of ASTRAL might identify potential high-risk groups that
will benefit from renal intervention
 As embolic protection devices become more agile and
suitable to different renal lesions, there remains the
possibility that, due to lower rates of unidentified
atheroembolic kidney disease, CORAL may demonstrate
improved renal outcomes after stenting
 If not, the search for the best means to predict who
should have renal intervention will continue
 The clinical problem is too intriguing, and too
profitable, to die altogether
 Thank you
 Evaluate short and long-term outcomes of PTRA renal
artery stenosis due to RAFMD
 Technical success was 100%
Short-term outcomes
 Majority (69%) had an immediate clinical benefit for
hypertension
 6% were cured without BP medications, and 63% improved
with less than or equal to preoperative BP medications.
 For the entire cohort, renal function (mean eGFR)
significantly increased from 71.9 mL/minute to 80.8
mL/minute (P = .007
 Long-term outcomes:
 freedom from recurrent or worsening hypertension (>140
systolic blood pressure [SBP] and >90 diastolic blood
pressure [DBP]) was (93%, 75%, and 41%)
 freedom from reduced renal function (eGFR <30
mL/minute) was (100%, 95%, and 64%)
 at 1, 5, and 8 years, respectively
 Renal angioplasty is a safe and durable modality for
treating RAFMD with favorable short and long-term
clinical outcomes