Renal artery stenosis angioplasty and stenting: Difference between revisions

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__NOTOC__
__NOTOC__
{{Renal artery stenosis}}
{{Renal artery stenosis}}
{{CMG}}; {{AE}} [[User:YazanDaaboul|Yazan Daaboul]], [[User:Sergekorjian|Serge Korjian]], {{VVS}}
{{CMG}}; '''Associate Editor-In-Chief:''' {{Shivam Singla}}


==Overview==
==Overview==
Randomized controlled trials such as ASTRAL (Angioplasty and Stenting for Renal Artery Lesions)<ref name="pmid19907042">{{cite journal| author=ASTRAL Investigators. Wheatley K, Ives N, Gray R, Kalra PA, Moss JG et al.| title=Revascularization versus medical therapy for renal-artery stenosis. | journal=N Engl J Med | year= 2009 | volume= 361 | issue= 20 | pages= 1953-62 | pmid=19907042 | doi=10.1056/NEJMoa0905368 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19907042 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20157130 Review in: Ann Intern Med. 2010 Feb 16;152(4):JC-26] </ref> and CORAL <ref name="pmid16221898">{{cite journal| author=Murphy TP, Cooper CJ, Dworkin LD, Henrich WL, Rundback JH, Matsumoto AH et al.| title=The Cardiovascular Outcomes with Renal Atherosclerotic Lesions (CORAL) study: rationale and methods. | journal=J Vasc Interv Radiol | year= 2005 | volume= 16 | issue= 10 | pages= 1295-300 | pmid=16221898 | doi=10.1097/01.RVI.0000176301.69756.28 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16221898  }} </ref>have not demonstrated a benefit of percutaneous revascularization over medical therapy among patients with unilateral renal artery stenosis.  These trials have been criticized, however, because they did not enroll those patients who in observational data derived the greatest benefit, namely those patients who have a short duration of hypertension, patients who are resistant to medical therapy for hypertension, and patients who have recurrent flash [[pulmonary edema]].<ref name="pmid24074824">{{cite journal| author=Ritchie J, Green D, Chrysochou C, Chalmers N, Foley RN, Kalra PA| title=High-risk clinical presentations in atherosclerotic renovascular disease: prognosis and response to renal artery revascularization. | journal=Am J Kidney Dis | year= 2014 | volume= 63 | issue= 2 | pages= 186-97 | pmid=24074824 | doi=10.1053/j.ajkd.2013.07.020 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24074824  }} </ref>  For instance, in the ASTRAL trial, patients had hypertension for 5 years.  Likewise, the mean number of antihypertensive agents was only 2.1 in the CORAL trial and patients who were recently hospitalized with [[congestive heart failure]] were excluded from the CORAL trial.<ref name="pmid16221898">{{cite journal| author=Murphy TP, Cooper CJ, Dworkin LD, Henrich WL, Rundback JH, Matsumoto AH et al.| title=The Cardiovascular Outcomes with Renal Atherosclerotic Lesions (CORAL) study: rationale and methods. | journal=J Vasc Interv Radiol | year= 2005 | volume= 16 | issue= 10 | pages= 1295-300 | pmid=16221898 | doi=10.1097/01.RVI.0000176301.69756.28 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16221898  }} </ref>
[[Randomized controlled trials]]  such as [[ASTRAL]] (Angioplasty and Stenting for Renal Artery Lesions) and [[CORAL]] have not demonstrated a benefit of percutaneous [[revascularization]] over medical therapy among [[patients]] with [[unilateral]] [[renal artery stenosis]] (RAS).  These [[trials]] have been criticized, however, because they did not enroll those [[patients]] who in observational data derived the greatest benefit, namely those [[patients]] who have a short duration of [[hypertension]], patients who are resistant to [[medical therapy]] for [[hypertension]], and [[patients]] who have recurrent flash [[pulmonary edema]]. For instance, in the [[ASTRAL]] trial, [[patients]] had [[hypertension]] for 5 years.  Likewise, the mean number of [[antihypertensive]] agents was only 2.1 in the [[CORAL]] trial, and [[patients]] who were recently hospitalized with [[congestive heart failure]] were excluded from the [[CORAL trial]].


==Landmark Studies==
==Landmark Studies==
The 2009 ASTRAL (Angioplasty and Stenting for Renal Artery Lesions) trial was an unblinded trial which randomized 806 patients with RAS for 5 years to either revascularization and medical therapy or medical therapy alone in a 1:1 ratio.  Renal angioplasty was associated with significant risk and very little benefit in ASTRAL.<ref name="pmid19907042">{{cite journal| author=ASTRAL Investigators. Wheatley K, Ives N, Gray R, Kalra PA, Moss JG et al.| title=Revascularization versus medical therapy for renal-artery stenosis. | journal=N Engl J Med | year= 2009 | volume= 361 | issue= 20 | pages= 1953-62 | pmid=19907042 | doi=10.1056/NEJMoa0905368 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19907042 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20157130 Review in: Ann Intern Med. 2010 Feb 16;152(4):JC-26] </ref>  The rate of increase in [[creatinine]] was better among patients who underwent revascularization at -0.07x10<sup>-3</sup> L/mmol/year vs -0.13x10<sup>-3</sup> L/mmol/year among those treated with medical therapy. Similarly, the mean serum creatinine was lower in the revascularization group; but the number of renal events was similar. Nonetheless, the reduction in blood pressure was better with medical therapy.<ref name="pmid19907042">{{cite journal| author=ASTRAL Investigators. Wheatley K, Ives N, Gray R, Kalra PA, Moss JG et al.| title=Revascularization versus medical therapy for renal-artery stenosis. | journal=N Engl J Med | year= 2009 | volume= 361 | issue= 20 | pages= 1953-62 | pmid=19907042 | doi=10.1056/NEJMoa0905368 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19907042 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20157130 Review in: Ann Intern Med. 2010 Feb 16;152(4):JC-26] </ref> Furthermore, cardiovascular events and death were not significantly different; but the rates of serious complications during revascularization were high, involving 23 patients and including 2 deaths and 3 amputations.<ref name="pmid19907042">{{cite journal| author=ASTRAL Investigators. Wheatley K, Ives N, Gray R, Kalra PA, Moss JG et al.| title=Revascularization versus medical therapy for renal-artery stenosis. | journal=N Engl J Med | year= 2009 | volume= 361 | issue= 20 | pages= 1953-62 | pmid=19907042 | doi=10.1056/NEJMoa0905368 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19907042 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20157130 Review in: Ann Intern Med. 2010 Feb 16;152(4):JC-26] </ref>
===ASTRAL Trial===


===Asymptomatic Patients===
*The 2009 [[ASTRAL]] (Angioplasty and Stenting for Renal Artery Lesions) trial was an unblinded trial that randomized 806 patients with [[RAS]] for 5 years to either [[revascularization]] and medical therapy or medical therapy alone in a 1:1 ratio.
The 2013 ACC/AHA guidelines update<ref name="pmid23457117">{{cite journal| author=Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH et al.| title=Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA guideline recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2013 | volume= 127 | issue= 13 | pages= 1425-43 | pmid=23457117 | doi=10.1161/CIR.0b013e31828b82aa | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23457117  }} </ref> showed class C evidence to revascularize asymptomatic patients only with hemodynamically significant RAS or with solitary viable kidney. Nonetheless, the report mentioned no known benefit or risk at the time for such procedure in asymptomatic patients.<ref name="pmid23457117">{{cite journal| author=Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH et al.| title=Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA guideline recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2013 | volume= 127 | issue= 13 | pages= 1425-43 | pmid=23457117 | doi=10.1161/CIR.0b013e31828b82aa | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23457117  }} </ref>


===Hypertension===
*[[Angioplasty|Renal angioplasty]] was associated with significant risk and very little benefit in [[ASTRAL]].<ref name="pmid19907042">{{cite journal| author=ASTRAL Investigators. Wheatley K, Ives N, Gray R, Kalra PA, Moss JG et al.| title=Revascularization versus medical therapy for renal-artery stenosis. | journal=N Engl J Med | year= 2009 | volume= 361 | issue= 20 | pages= 1953-62 | pmid=19907042 | doi=10.1056/NEJMoa0905368 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19907042 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20157130 Review in: Ann Intern Med. 2010 Feb 16;152(4):JC-26] </ref>
Revascularization was recommended by ACC/AHA guidelines, with class B evidence, in hypertensive patients who have hemodynamically significant RAS, malignant, resistant, and/or accelerated hypertension, and among those with unexplained unilateral small kidneys or intolerance to anti-hypertensive medications.<ref name="pmid23457117">{{cite journal| author=Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH et al.| title=Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA guideline recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2013 | volume= 127 | issue= 13 | pages= 1425-43 | pmid=23457117 | doi=10.1161/CIR.0b013e31828b82aa | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23457117  }} </ref>


===Impaired Renal Function===
*The rate of increase in [[creatinine]] was better among patients who underwent revascularization at -0.07x10<sup>-3</sup> L/mmol/year vs -0.13x10<sup>-3</sup> L/mmol/year among those treated with medical therapy.
Revascularization was recommended with level B evidence for patients with RAS and progressive kidney disease, for those with bilateral RAS or one solitary viable kidney. For patients with CKD and unilateral RAS, percutaneous revascularization was still considered reasonable, but with a level C evidence.<ref name="pmid23457117">{{cite journal| author=Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH et al.| title=Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA guideline recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2013 | volume= 127 | issue= 13 | pages= 1425-43 | pmid=23457117 | doi=10.1161/CIR.0b013e31828b82aa | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23457117  }} </ref>


===Congestive Heart Failure===
*Similarly, the mean serum [[creatinine]] was lower in the revascularization group; but the number of renal events was similar. Nonetheless, the reduction in [[blood pressure]] was better with medical therapy.<ref name="pmid19907042">{{cite journal| author=ASTRAL Investigators. Wheatley K, Ives N, Gray R, Kalra PA, Moss JG et al.| title=Revascularization versus medical therapy for renal-artery stenosis. | journal=N Engl J Med | year= 2009 | volume= 361 | issue= 20 | pages= 1953-62 | pmid=19907042 | doi=10.1056/NEJMoa0905368 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19907042 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20157130 Review in: Ann Intern Med. 2010 Feb 16;152(4):JC-26] </ref> Furthermore, cardiovascular events and death were not significantly different; but the rates of serious complications during [[revascularization]] were high, involving 23 patients and including 2 deaths and 3 amputations.<ref name="pmid19907042">{{cite journal| author=ASTRAL Investigators. Wheatley K, Ives N, Gray R, Kalra PA, Moss JG et al.| title=Revascularization versus medical therapy for renal-artery stenosis. | journal=N Engl J Med | year= 2009 | volume= 361 | issue= 20 | pages= 1953-62 | pmid=19907042 | doi=10.1056/NEJMoa0905368 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19907042 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20157130 Review in: Ann Intern Med. 2010 Feb 16;152(4):JC-26] </ref>
Revascularization was indicated at level B evidence in patients with hemodynamically significant RAS and recurrent congestive heart failure of undefined cause or in cases of sudden flash pulmonary edema with unexplained etiology, as well as for unstable angina.<ref name="pmid23457117">{{cite journal| author=Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH et al.| title=Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA guideline recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2013 | volume= 127 | issue= 13 | pages= 1425-43 | pmid=23457117 | doi=10.1161/CIR.0b013e31828b82aa | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23457117  }} </ref>


===Unstable Angina===
===CORAL Trial===
There was level B evidence to recommend revascularization among patients known to have unstable angina with hemodynamically significant RAS.<ref name="pmid23457117">{{cite journal| author=Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH et al.| title=Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA guideline recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2013 | volume= 127 | issue= 13 | pages= 1425-43 | pmid=23457117 | doi=10.1161/CIR.0b013e31828b82aa | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23457117  }} </ref>


==Angioplasty vs Stenting==
*In the 2013 [[CORAL]] trial, 947 patients with [[atherosclerotic]] [[renal-artery stenosis]] who had either [[chronic kidney disease]] or persistent [[systolic hypertension]] on > or = to 2 [[antihypertensive drugs]] were randomized to either [[renal-artery stenting]] + [[medical therapy]] or medical therapy alone.
Aorto-ostial lesions are the most common location for atherosclerosis in RAS and are susceptible to vascular recoil. As a result, aorto-ostial lesion location is more appropriately managed with stenting with superior results being obtained with larger post-procedure diameters<ref name="pmid2890911">{{cite journal| author=Brawn LA, Ramsay LE| title=Is "improvement" real with percutaneous transluminal angioplasty in the management of renovascular hypertension? | journal=Lancet | year= 1987 | volume= 2 | issue= 8571 | pages= 1313-6 | pmid=2890911 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2890911 }} </ref><ref name="pmid6456652">{{cite journal| author=Cicuto KP, McLean GK, Oleaga JA, Freiman DB, Grossman RA, Ring EJ| title=Renal artery stenosis: anatomic classification for percutaneous transluminal angioplasty. | journal=AJR Am J Roentgenol | year= 1981 | volume= 137 | issue= 3 | pages= 599-601 | pmid=6456652 | doi=10.2214/ajr.137.3.599 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6456652 }} </ref><ref name="pmid1446123">{{cite journal| author=Martin LG, Cork RD, Kaufman SL| title=Long-term results of angioplasty in 110 patients with renal artery stenosis. | journal=J Vasc Interv Radiol | year= 1992 | volume= 3 | issue= 4 | pages= 619-26 | pmid=1446123 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1446123 }} </ref><ref name="pmid10376497">{{cite journal| author=Rocha-Singh KJ, Mishkel GJ, Katholi RE, Ligon RA, Armbruster JA, McShane KJ et al.| title=Clinical predictors of improved long-term blood pressure control after successful stenting of hypertensive patients with obstructive renal artery atherosclerosis. | journal=Catheter Cardiovasc Interv | year= 1999| volume= 47 | issue= 2 | pages= 167-72 | pmid=10376497 | doi=10.1002/(SICI)1522-726X(199906)47:2<167::AID-CCD7>3.0.CO;2-R | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10376497 }} </ref><ref name="pmid11172177">{{cite journal| author=Radermacher J, Chavan A, Bleck J, Vitzthum A, Stoess B, Gebel MJ et al.| title=Use of Doppler ultrasonography to predict the outcome of therapy for renal-artery stenosis. | journal=N Engl J Med | year= 2001 | volume= 344 |issue= 6 | pages= 410-7 | pmid=11172177 | doi=10.1056/NEJM200102083440603 | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11172177 }} </ref>.


==2013 ACC/AHA Practice Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic) (DO NOT EDIT)<ref name="pmid23457117">{{cite journal| author=Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH et al.| title=Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA guideline recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2013 | volume= 127 | issue= 13 | pages= 1425-43 | pmid=23457117 | doi=10.1161/CIR.0b013e31828b82aa | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23457117  }} </ref>==
*After a median follow-up of 43 months, the primary endpoint (the composite of either death from cardiovascular or renal causes, [[myocardial infarction]], [[stroke]], hospitalization for [[congestive heart failure]], progressive [[renal insufficiency]], or the need for renal-replacement therapy) did not differ between the strategies: 35.1% and 35.8%; 0.94; 95% confidence interval [CI], 0.76 to 1.17; P=0.58, for stenting + medical therapy vs medical therapy alone); nor did any of the components of the primary endpoint (including mortality).


===Indications for Revascularization of Asymptomatic Stenosis (DO NOT EDIT)<ref name="pmid23457117">{{cite journal| author=Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH et al.| title=Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA guideline recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2013 | volume= 127 | issue= 13 | pages= 1425-43 | pmid=23457117 | doi=10.1161/CIR.0b013e31828b82aa | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23457117  }} </ref>===
*There was a modest benefit in [[systolic blood pressure]] reduction in the stented group (−2.3 mm Hg; 95% CI, −4.4 to −0.2; P=0.03).


{|class="wikitable"
<br />
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|Class IIb]]


|-
== Indications for Renal Angioplasty or Stenting ==
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Percutaneous revascularization may be considered for treatment of an asymptomatic bilateral or a solitary viable kidney with a hemodynamically significant RAS. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
Based upon the modest data observed in the above [[observational]] studies, the following are considered reasonable indications for [[percutaneous intervention]]:<ref name="pmid24074824">{{cite journal| author=Ritchie J, Green D, Chrysochou C, Chalmers N, Foley RN, Kalra PA| title=High-risk clinical presentations in atherosclerotic renovascular disease: prognosis and response to renal artery revascularization. | journal=Am J Kidney Dis | year= 2014 | volume= 63 | issue= 2 | pages= 186-97 | pmid=24074824 | doi=10.1053/j.ajkd.2013.07.020 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24074824  }} </ref><ref name="pmid19937777">{{cite journal| author=Kalra PA, Chrysochou C, Green D, Cheung CM, Khavandi K, Sixt S et al.| title=The benefit of renal artery stenting in patients with atheromatous renovascular disease and advanced chronic kidney disease. | journal=Catheter Cardiovasc Interv | year= 2010 | volume= 75 | issue= 1 | pages= 1-10 | pmid=19937777 | doi=10.1002/ccd.22290 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19937777 }} </ref> <ref name="pmid12710843">{{cite journal| author=Gray BH, Olin JW, Childs MB, Sullivan TM, Bacharach JM| title=Clinical benefit of renal artery angioplasty with stenting for the control of recurrent and refractory congestive heart failure. | journal=Vasc Med | year= 2002 | volume= 7 | issue= 4 | pages= 275-9 | pmid=12710843 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12710843  }} </ref>
 
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' The usefulness of percutaneous revascularization of an asymptomatic unilateral hemodynamically significant RAS in a viable kidney is not well established and is presently clinically unproven. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
 
=== Hypertension (DO NOT EDIT)<ref name="pmid23457117">{{cite journal| author=Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH et al.| title=Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA guideline recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2013 | volume= 127 | issue= 13 | pages= 1425-43 | pmid=23457117 | doi=10.1161/CIR.0b013e31828b82aa | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23457117 }} </ref>===
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|Class IIa]]
 
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Percutaneous revascularization is reasonable for patients with hemodynamically significant RAS and accelerated hypertension, [[resistant hypertension]], [[malignant hypertension]], [[hypertension]] with an unexplained unilateral small kidney, and hypertension with intolerance to medication. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}


=== Preservation of Renal Function (DO NOT EDIT)<ref name="pmid23457117">{{cite journal| author=Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH et al.| title=Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA guideline recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2013 | volume= 127 | issue= 13 | pages= 1425-43 | pmid=23457117 | doi=10.1161/CIR.0b013e31828b82aa | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23457117  }} </ref>===
*<u>Failure of [[medical therapy]] with [[persistent hypertension]] or a decline in [[renal]] function while on medical therapy</u>
**[[Revascularization]] was recommended by ACC/AHA guidelines, with class B evidence, in [[hypertensive]] [[patients]] who have hemodynamically significant [[RAS]], [[malignant hypertension]], [[resistant hypertension]], and/or accelerated [[hypertension]], and among those with unexplained [[unilateral]] [[small kidneys]] or intolerance to anti-[[hypertensive]] [[medications]].<ref name="pmid23457117">{{cite journal| author=Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH et al.| title=Management of [[patients]] with [[peripheral artery disease]] (compilation of 2005 and 2011 ACCF/AHA guideline recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2013 | volume= 127 | issue= 13 | pages= 1425-43 | pmid=23457117 | doi=10.1161/CIR.0b013e31828b82aa | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23457117  }} </ref>


{|class="wikitable"
*<u>Refractory [[heart failure]] and or recurrent [[flash pulmonary edema]]</u>
|-
**[[Revascularization]] was indicated at level B evidence in [[patients]] with [[thermodynamically]] significant [[RAS]] and [[recurrent]] [[congestive heart failure]] of undefined cause or in cases of sudden [[flash pulmonary edema]] with unexplained etiology, as well as for [[unstable angina]].<ref name="pmid23457117">{{cite journal| author=Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH et al.| title=Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA guideline recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2013 | volume= 127 | issue= 13 | pages= 1425-43 | pmid=23457117 | doi=10.1161/CIR.0b013e31828b82aa | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23457117  }} </ref>
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|Class IIa]]
*<u>Brief duration of [[hypertension]] preceding the diagnosis of [[renal artery stenosis]]</u>


|-
<br />
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Percutaneous revascularization is reasonable for patients with RAS and progressive [[chronic kidney disease]] with bilateral RAS or a RAS to a solitary functioning kidney. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}


{|class="wikitable"
==Management of Patients With Peripheral Artery Disease (Compilation of 2005 and 2011 ACCF/AHA Guideline Recommendations) : A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines<ref name="pmid23473760">{{cite journal| author=Rooke TW, Hirsch AT, Misra S, Sidawy AN, Beckman JA, Findeiss L et al.| title=Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA Guideline Recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=J Am Coll Cardiol | year= 2013 | volume= 61 | issue= 14 | pages= 1555-70 | pmid=23473760 | doi=10.1016/j.jacc.2013.01.004 | pmc=4492473 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23473760  }} </ref>==
|-
{| class="wikitable"
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|Class IIb]]
|+
!Indications for Revascularization of Asymptomatic Stenosis
![[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|Class IIb]]
<nowiki>"</nowiki>'''1.''' Percutaneous revascularization may be considered for the treatment of an asymptomatic bilateral or a solitary viable kidney with a hemodynamically significant RAS. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>


<nowiki>"</nowiki>'''2.''' The usefulness of percutaneous revascularization of an asymptomatic unilateral hemodynamically significant RAS in a viable kidney is not well established and is presently clinically unproven. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
<br />
|-
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Percutaneous revascularization may be considered for patients with RAS and [[chronic renal insufficiency]] with unilateral RAS. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|'''Hypertension'''
|}
|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|'''Class IIa''']]
 
'''"1. Percutaneous revascularization is reasonable for patients with hemodynamically significant RAS and accelerated hypertension, [[resistant hypertension]], [[malignant hypertension]], [[hypertension]] with an unexplained unilateral small kidney, and hypertension with intolerance to medication. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>'''
=== Impact of RAS on Congestive Heart Failure and Unstable Angina (DO NOT EDIT)<ref name="pmid23457117">{{cite journal| author=Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH et al.| title=Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA guideline recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2013 | volume= 127 | issue= 13 | pages= 1425-43 | pmid=23457117 | doi=10.1161/CIR.0b013e31828b82aa | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23457117  }} </ref>===
 
{|class="wikitable"
|-
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|Class I]]
|'''Preservation of Renal'''
'''Function'''
|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|'''Class IIa''']]
'''"1. Percutaneous revascularization is reasonable for patients with RAS and progressive [[chronic kidney disease]] with bilateral RAS or a RAS to a solitary functioning kidney. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>'''


|-
[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|'''Class IIb''']]
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Percutaneous revascularization is indicated for patients with hemodynamically significant RAS and recurrent, unexplained [[congestive heart failure]] or sudden, unexplained [[pulmonary edema]] (see text). ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}


{|class="wikitable"
'''"1. Percutaneous revascularization may be considered for patients with RAS and [[chronic renal insufficiency]] with unilateral RAS. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>'''
|-
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|Class IIa]]
|'''Impact of RAS on'''
'''Congestive Heart'''


|-
'''Failure and Unstable'''
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Percutaneous revascularization is reasonable for patients with hemodynamically significant RAS and [[unstable angina]] (see text). ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}


=== Catheter-Based Interventions (DO NOT EDIT)<ref name="pmid23457117">{{cite journal| author=Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH et al.| title=Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA guideline recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2013 | volume= 127 | issue= 13 | pages= 1425-43 | pmid=23457117 | doi=10.1161/CIR.0b013e31828b82aa | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23457117  }} </ref>===
'''Angina'''
|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|'''Class I''']]
'''"1. Percutaneous revascularization is indicated for patients with hemodynamically significant RAS and recurrent, unexplained [[congestive heart failure]] or sudden, unexplained [[pulmonary edema]] (see text). ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>'''


{|class="wikitable"
[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|'''Class IIa''']]
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|Class I]]


'''"1. Percutaneous revascularization is reasonable for patients with hemodynamically significant RAS and [[unstable angina]] (see text). ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>'''
<br />
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Renal stent placement is indicated for ostial atherosclerotic RAS lesions that meet the clinical criteria for intervention. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|'''Endovascular'''
'''Treatment for RAS'''
|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|'''Class I''']]
'''"1. Renal stent placement is indicated for ostial atherosclerotic RAS lesions that meet the clinical criteria for intervention. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>'''


|-
'''"2. [[Balloon angioplasty]] with bail-out stent placement if necessary is recommended for [[fibromuscular dysplasia]] lesions. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>'''
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' [[Balloon angioplasty]] with bail-out stent placement if necessary is recommended for [[fibromuscular dysplasia]] lesions. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
|}



Latest revision as of 20:59, 12 December 2020

Renal artery stenosis Microchapters

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Shivam Singla, M.D.[2]

Overview

Randomized controlled trials such as ASTRAL (Angioplasty and Stenting for Renal Artery Lesions) and CORAL have not demonstrated a benefit of percutaneous revascularization over medical therapy among patients with unilateral renal artery stenosis (RAS). These trials have been criticized, however, because they did not enroll those patients who in observational data derived the greatest benefit, namely those patients who have a short duration of hypertension, patients who are resistant to medical therapy for hypertension, and patients who have recurrent flash pulmonary edema. For instance, in the ASTRAL trial, patients had hypertension for 5 years. Likewise, the mean number of antihypertensive agents was only 2.1 in the CORAL trial, and patients who were recently hospitalized with congestive heart failure were excluded from the CORAL trial.

Landmark Studies

ASTRAL Trial

  • The 2009 ASTRAL (Angioplasty and Stenting for Renal Artery Lesions) trial was an unblinded trial that randomized 806 patients with RAS for 5 years to either revascularization and medical therapy or medical therapy alone in a 1:1 ratio.
  • The rate of increase in creatinine was better among patients who underwent revascularization at -0.07x10-3 L/mmol/year vs -0.13x10-3 L/mmol/year among those treated with medical therapy.
  • Similarly, the mean serum creatinine was lower in the revascularization group; but the number of renal events was similar. Nonetheless, the reduction in blood pressure was better with medical therapy.[1] Furthermore, cardiovascular events and death were not significantly different; but the rates of serious complications during revascularization were high, involving 23 patients and including 2 deaths and 3 amputations.[1]

CORAL Trial

  • After a median follow-up of 43 months, the primary endpoint (the composite of either death from cardiovascular or renal causes, myocardial infarction, stroke, hospitalization for congestive heart failure, progressive renal insufficiency, or the need for renal-replacement therapy) did not differ between the strategies: 35.1% and 35.8%; 0.94; 95% confidence interval [CI], 0.76 to 1.17; P=0.58, for stenting + medical therapy vs medical therapy alone); nor did any of the components of the primary endpoint (including mortality).
  • There was a modest benefit in systolic blood pressure reduction in the stented group (−2.3 mm Hg; 95% CI, −4.4 to −0.2; P=0.03).


Indications for Renal Angioplasty or Stenting

Based upon the modest data observed in the above observational studies, the following are considered reasonable indications for percutaneous intervention:[2][3] [4]


Management of Patients With Peripheral Artery Disease (Compilation of 2005 and 2011 ACCF/AHA Guideline Recommendations) : A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines[6]

Indications for Revascularization of Asymptomatic Stenosis Class IIb

"1. Percutaneous revascularization may be considered for the treatment of an asymptomatic bilateral or a solitary viable kidney with a hemodynamically significant RAS. (Level of Evidence: C)"

"2. The usefulness of percutaneous revascularization of an asymptomatic unilateral hemodynamically significant RAS in a viable kidney is not well established and is presently clinically unproven. (Level of Evidence: C)"

Hypertension Class IIa

"1. Percutaneous revascularization is reasonable for patients with hemodynamically significant RAS and accelerated hypertension, resistant hypertension, malignant hypertension, hypertension with an unexplained unilateral small kidney, and hypertension with intolerance to medication. (Level of Evidence: B)"

Preservation of Renal

Function

Class IIa

"1. Percutaneous revascularization is reasonable for patients with RAS and progressive chronic kidney disease with bilateral RAS or a RAS to a solitary functioning kidney. (Level of Evidence: B)"

Class IIb

"1. Percutaneous revascularization may be considered for patients with RAS and chronic renal insufficiency with unilateral RAS. (Level of Evidence: C)"

Impact of RAS on

Congestive Heart

Failure and Unstable

Angina

Class I

"1. Percutaneous revascularization is indicated for patients with hemodynamically significant RAS and recurrent, unexplained congestive heart failure or sudden, unexplained pulmonary edema (see text). (Level of Evidence: B)"

Class IIa

"1. Percutaneous revascularization is reasonable for patients with hemodynamically significant RAS and unstable angina (see text). (Level of Evidence: B)"

Endovascular

Treatment for RAS

Class I

"1. Renal stent placement is indicated for ostial atherosclerotic RAS lesions that meet the clinical criteria for intervention. (Level of Evidence: B)"

"2. Balloon angioplasty with bail-out stent placement if necessary is recommended for fibromuscular dysplasia lesions. (Level of Evidence: B)"

References

  1. 1.0 1.1 1.2 ASTRAL Investigators. Wheatley K, Ives N, Gray R, Kalra PA, Moss JG; et al. (2009). "Revascularization versus medical therapy for renal-artery stenosis". N Engl J Med. 361 (20): 1953–62. doi:10.1056/NEJMoa0905368. PMID 19907042. Review in: Ann Intern Med. 2010 Feb 16;152(4):JC-26
  2. Ritchie J, Green D, Chrysochou C, Chalmers N, Foley RN, Kalra PA (2014). "High-risk clinical presentations in atherosclerotic renovascular disease: prognosis and response to renal artery revascularization". Am J Kidney Dis. 63 (2): 186–97. doi:10.1053/j.ajkd.2013.07.020. PMID 24074824.
  3. Kalra PA, Chrysochou C, Green D, Cheung CM, Khavandi K, Sixt S; et al. (2010). "The benefit of renal artery stenting in patients with atheromatous renovascular disease and advanced chronic kidney disease". Catheter Cardiovasc Interv. 75 (1): 1–10. doi:10.1002/ccd.22290. PMID 19937777.
  4. Gray BH, Olin JW, Childs MB, Sullivan TM, Bacharach JM (2002). "Clinical benefit of renal artery angioplasty with stenting for the control of recurrent and refractory congestive heart failure". Vasc Med. 7 (4): 275–9. PMID 12710843.
  5. 5.0 5.1 Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH; et al. (2013). "Management of [[patients]] with [[peripheral artery disease]] (compilation of 2005 and 2011 ACCF/AHA guideline recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". Circulation. 127 (13): 1425–43. doi:10.1161/CIR.0b013e31828b82aa. PMID 23457117. URL–wikilink conflict (help)
  6. Rooke TW, Hirsch AT, Misra S, Sidawy AN, Beckman JA, Findeiss L; et al. (2013). "Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA Guideline Recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". J Am Coll Cardiol. 61 (14): 1555–70. doi:10.1016/j.jacc.2013.01.004. PMC 4492473. PMID 23473760.

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