Angioplasty and Stenting for Renal Stenosis: Evidence Still Limited

Available evidence shows no consistent benefit of percutaneous angioplasty with stent replacement over medical therapy for patients with atherosclerotic renal artery stenosis (ARAS), concludes an updated systematic review in the Annals of Internal Medicine.

A comprehensive literature review identified 83 studies providing evidence on the benefits and harms of PTRAS versus medical therapy for ARAS. Thirty-three studies were newly identified since a 2007 review. The review was funded and followed a standard protocol by the Agency for Healthcare Research and Quality.

The review identified 15 comparative studies including a total of 4006 patients. Of these, 7 were randomized controlled trials (RCTs) including 2178 patients, most enrolled in two large trials (ASTRAL and CORAL). Five of the RCTs reported similar blood pressure control with ARAS versus medical therapy. None found significant differences in kidney function, mortality, need for renal replacement therapy (RRT), cardiovascular events, or pulmonary edema.

There were 8 nonrandomized comparative studies including 1828 patients. The findings were variable, especially in terms of kidney function and blood pressure. Most of the studies reported no differences in mortality, RRT, or cardiovascular events.

There were few procedure-related adverse events, and no medication-related adverse events. Two RCTs reported no patient factors affecting clinical outcomes with either PTRAS or medical treatment. Some relevant patient characteristics were reported in single-group studies, but these were inconsistent. Some case reports suggested clinical benefits of PTRAS in patients with acute decompensation.

The updated review does not find strong evidence that PTRAS is superior to medical therapy alone for most patients with ARAS. Some observational studies suggest improvements in kidney function or blood pressure for certain groups of “high-risk” patients. The researchers write, “Future studies should focus on patients who are putatively most likely to benefit from PTRAS, namely those with proven hemodynamically significant ARAS or those who have signs of decompensation” [Raman G, et al. Comparative effectiveness of management strategies for renal artery stenosis: an updated systematic review. Ann Intern Med 2016; 165:635–649].

December 2016 (Vol 8, Issue 12)