Treating RAS: To Stent or Not to Stent?

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This colored angiogram shows a stent in a patient's right renal artery.
This colored angiogram shows a stent in a patient's right renal artery.
ORLANDO—More than 30,000 Americans with atherosclerotic renovascular disease (ARVD) undergo revascularization for renal artery stenosis (RAS) each year. Nephrologists contend that many of these patients could do just as well with medical therapy.

The issue—to stent or not to stent the renal artery—was debated by two nephrologists and an interventional cardiologist, who squared off at a “Great Debates in Hypertension” session at the 58th annual meeting of the American College of Cardiology.

Increasing recognition of ARVD has resulted in a fourfold increase in this diagnosis over the past decade, said Philip A. Kalra, MD, Consultant and Reader in Nephrology, Salford Royal Hospital and the University of Manchester, United Kingdom.  

Revascularizations are performed on 16% of new detected ARVD patients, and 98% of those procedures use percutaneous techniques, not surgery. The primary indications for revascularization are to prevent progression from severe RAS to renal artery occlusion, to prevent rapid deterioration in renal function, and to control severe hypertension, he said.

Christopher J. White, MD, Chairman of the Department of Cardiology at Ochsner Heart and Vascular Institute, in New Orleans, contended that these patients are being optimally treated. Renal artery stenting can help prevent progression to end-stage renal disease (ESRD).

Stenting beats drugs

“RAS from atherosclerotic causes is significantly underreported in patients with ESRD entering dialysis, according to a Medicare database,” he observed. “I am concerned about the natural history of this disease. Clearly, ESRD is worth impacting.”

“Do patients get better with revascularization? Definitely,” Dr. White maintained. Studies have shown that open arteries are better than closed ones and that stenting improves renal function (Catheter Cardiovasc Interv. 2002;57:135-141 and Circulation. 2000;102:1671-1677).

“Standing by and watching nephrons die is probably not the best way to treat these patients,” he said. “Renal artery stenosis is not benign. Even incidental RAS has been significantly associated with reduced survival. Patients with the most rapid decline in renal function have the most to gain.”

Dr. White maintained that the optimal way to address RAS is with renal revascularization, especially renal stenting. The American Heart Association has given a class IIA recommendation to renal revascularization for patients with RAS and accelerated, resistant, or malignant hypertension, he said.

“The evidence strongly supports renal stents for renovascular hypertension. Balloon angioplasty alone is better than medical treatment, and stents are better than angioplasty,” Dr. White concluded.
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