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Approach to atherosclerotic renovascular disease: 2016

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ABSTRACT

The management of atherosclerotic renal artery stenosis in patients with hypertension or impaired renal function remains a clinical dilemma. The current general consensus, supported by the results of the Angioplasty and Stenting for Renal Atherosclerotic Lesions and Cardiovascular Outcomes for Renal Artery Lesions trials, argues strongly against endovascular intervention in favor of optimal medical management. We discuss the limitations and implications of the contemporary clinical trials and present our approach and formulate clear recommendations to help with the management of patients with atherosclerotic narrowing of the renal artery.

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Timeline of the clinical approaches to atherosclerotic renovascular disease.
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SFW079F1: Timeline of the clinical approaches to atherosclerotic renovascular disease.

Mentions: Atherosclerotic renal artery stenosis (ARAS) accounts for >90% of cases of renal artery stenosis [1]. It is most commonly seen in older patients (>65 years) and is usually associated with atheromatous disease in other vascular beds. The incidence and prevalence are hard to estimate given the asymptomatic nature of the majority of cases. A study in the US Medicare population estimated an incidence of 3.7/1000 patient-years in patients ≥65 years of age [2]. Another population-based study by Hansen et al. [3] showed a prevalence of 6.8% in elderly patients. The clinical significance of ARAS and its optimal management have been topics of great controversy. Early studies reported that renal artery stenosis is a progressive problem that can lead to resistant hypertension (HTN) and gradual loss of functional renal mass resulting in chronic kidney disease (CKD) [4–8]. Its presence has been linked to increased rates of cardiovascular events and mortality in patients with atherosclerotic cardiovascular disease [9–11]. This triggered an increasing interest in the treatment of ARAS by surgical or intravascular intervention. In 1996, the number of endovascular stent procedures done in the USA tables was estimated to be ∼7600. Over the next decade this number ballooned to ≥35 000 by the year of 2005 [12]. Interventional cardiologists may have contributed to the rapid increase in renal artery revascularization via convenient renal intervention during cardiac catheterization. However, enthusiasm for renal revascularization diminished in the era of statin therapy and renin–angiotensin system (RAS) blockade, which are believed to slow the rate of atherosclerosis progression. Major contemporary clinical trials, such as the Cardiovascular Outcomes for Renal Artery Lesions (CORAL) [13] and the Angioplasty and Stenting for Renal Atherosclerotic Lesions (ASTRAL) [14] trials, have failed to show statistically significant benefit of revascularization over optimal medical management in controlling blood pressure (BP) or preserving kidney function. These two trials have influenced medical decision making away from vascular intervention. A timeline of the clinical approaches to atherosclerotic renovascular disease is shown in Figure 1 and reflects the introduction of new technical and therapeutic advances used in addressing this clinical problem.Fig. 1.


Approach to atherosclerotic renovascular disease: 2016
Timeline of the clinical approaches to atherosclerotic renovascular disease.
© Copyright Policy - creative-commons
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC5036906&req=5

SFW079F1: Timeline of the clinical approaches to atherosclerotic renovascular disease.
Mentions: Atherosclerotic renal artery stenosis (ARAS) accounts for >90% of cases of renal artery stenosis [1]. It is most commonly seen in older patients (>65 years) and is usually associated with atheromatous disease in other vascular beds. The incidence and prevalence are hard to estimate given the asymptomatic nature of the majority of cases. A study in the US Medicare population estimated an incidence of 3.7/1000 patient-years in patients ≥65 years of age [2]. Another population-based study by Hansen et al. [3] showed a prevalence of 6.8% in elderly patients. The clinical significance of ARAS and its optimal management have been topics of great controversy. Early studies reported that renal artery stenosis is a progressive problem that can lead to resistant hypertension (HTN) and gradual loss of functional renal mass resulting in chronic kidney disease (CKD) [4–8]. Its presence has been linked to increased rates of cardiovascular events and mortality in patients with atherosclerotic cardiovascular disease [9–11]. This triggered an increasing interest in the treatment of ARAS by surgical or intravascular intervention. In 1996, the number of endovascular stent procedures done in the USA tables was estimated to be ∼7600. Over the next decade this number ballooned to ≥35 000 by the year of 2005 [12]. Interventional cardiologists may have contributed to the rapid increase in renal artery revascularization via convenient renal intervention during cardiac catheterization. However, enthusiasm for renal revascularization diminished in the era of statin therapy and renin–angiotensin system (RAS) blockade, which are believed to slow the rate of atherosclerosis progression. Major contemporary clinical trials, such as the Cardiovascular Outcomes for Renal Artery Lesions (CORAL) [13] and the Angioplasty and Stenting for Renal Atherosclerotic Lesions (ASTRAL) [14] trials, have failed to show statistically significant benefit of revascularization over optimal medical management in controlling blood pressure (BP) or preserving kidney function. These two trials have influenced medical decision making away from vascular intervention. A timeline of the clinical approaches to atherosclerotic renovascular disease is shown in Figure 1 and reflects the introduction of new technical and therapeutic advances used in addressing this clinical problem.Fig. 1.

View Article: PubMed Central - PubMed

ABSTRACT

The management of atherosclerotic renal artery stenosis in patients with hypertension or impaired renal function remains a clinical dilemma. The current general consensus, supported by the results of the Angioplasty and Stenting for Renal Atherosclerotic Lesions and Cardiovascular Outcomes for Renal Artery Lesions trials, argues strongly against endovascular intervention in favor of optimal medical management. We discuss the limitations and implications of the contemporary clinical trials and present our approach and formulate clear recommendations to help with the management of patients with atherosclerotic narrowing of the renal artery.

No MeSH data available.


Related in: MedlinePlus