0
Reviews |

Effectiveness of Management Strategies for Renal Artery Stenosis: A Systematic Review FREE

Ethan Balk, MD, MPH; Gowri Raman, MD; Mei Chung, MPH; Stanley Ip, MD; Athina Tatsioni, MD; Alvaro Alonso, MD; Priscilla Chew, MPH; Scott J. Gilbert, MD; and Joseph Lau, MD
[+] Article and Author Information

From Tufts-New England Medical Center, Boston, Massachusetts


Note: The full report is Available at http://www.effectivehealthcare.ahrq.gov/reports/final.cfm.

Disclaimer: The authors of this report are responsible for its content. Statements in the report should not be construed as endorsement by the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

Grant Support: This project was funded under contract no. 290-02-0023 from the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Ethan Balk, MD, MPH, Tufts-New England Medical Center, Box 63, 750 Washington Street, Boston, MA 02111; e-mail, ebalk@tufts-nemc.org.

Current Author Addresses: Drs. Balk, Raman, Chung, Ip, Tatsioni, and Lau and Ms. Chew: Tufts-New England Medical Center, Box 63, 750 Washington Street, Boston, MA 02111.

Dr. Alonso: Tufts-New England Medical Center, Box 235, 750 Washington Street, Boston, MA 02111.

Dr. Gilbert: Tufts-New England Medical Center, Box 391, 750 Washington Street, Boston, MA 02111.


Ann Intern Med. 2006;145(12):901-912. doi:10.7326/0003-4819-145-12-200612190-00143
Text Size: A A A

Background: Atherosclerotic renal artery stenosis is increasingly common in an aging population. Therapeutic options include medical treatment only or revascularization procedures.

Purpose: To compare the effects of medical treatment and revascularization on clinically important outcomes in adults with atherosclerotic renal artery stenosis.

Data Sources: The MEDLINE database (inception to 6 September 2005) and selected reference lists were searched for English-language articles.

Study Selection: The authors selected prospective studies of renal artery revascularization or medical treatment of patients with atherosclerotic renal artery stenosis that reported mortality rates, kidney function, blood pressure, cardiovascular events, or adverse events at 6 months or later after study entry.

Data Extraction: A standardized protocol with predefined criteria was used to extract details on study design, interventions, outcomes, study quality, and applicability. The overall body of evidence was then graded as robust, acceptable, or weak.

Data Synthesis: No study directly compared aggressive medical therapy with angioplasty and stent placement. Two randomized trials compared angioplasty without stent and medical treatments. Eight other comparative studies and 46 cohort studies met criteria for analysis. Studies generally had poor methodologic quality and limited applicability to current practice. Overall, there was no robust evidence. Weak evidence suggested no large differences in mortality rates or cardiovascular events between medical and revascularization treatments. Acceptable evidence suggested similar kidney-related outcomes but better blood pressure outcomes with angioplasty, particularly in patients with bilateral disease. Improvements in kidney function and cure of hypertension were reported among some patients only in cohort studies of angioplasty. Available evidence did not adequately assess adverse events or baseline characteristics that could predict which intervention would result in better outcomes.

Limitations: The evidence from direct comparisons of interventions is sparse and inadequate to draw robust conclusions.

Conclusions: Available evidence does not clearly support one treatment approach over another for atherosclerotic renal artery stenosis.

Context

  • Is medical therapy as effective as revascularization for atherosclerotic renal artery stenosis?

Contribution

  • This systematic review found no trials that compared aggressive medical therapy and angioplasty with stent in adults with atherosclerotic renal artery stenosis. Some evidence suggested similar kidney outcomes but better blood pressure outcomes with angioplasty, particularly in patients with bilateral renal disease. Weak evidence suggested no large differences in mortality or cardiovascular events between medical and revascularization treatments. No evidence directly compared adverse event rates between treatments.

Implications

  • Available evidence comparing benefits and harms of modern treatments for atherosclerotic renal artery stenosis is sparse and inconclusive.

—The Editors

Renal artery stenosis is defined as narrowing of the renal artery lumen. Atherosclerosis, which usually involves the ostium and proximal third of the main renal artery and the perirenal aorta, accounts for 90% of cases of renal artery stenosis (1). Atherosclerotic renal artery stenosis is increasingly common in aging populations, particularly elderly people with diabetes, hyperlipidemia, aortoiliac occlusive disease, coronary artery disease, or hypertension. Atherosclerotic renal artery stenosis is a progressive disease that may occur alone or in combination with hypertension and ischemic kidney disease (1). Although the prevalence of atherosclerotic renal artery stenosis is poorly defined, it may vary from 30% among patients with coronary artery disease identified by angiography (2) to 50% among elderly people or those with diffuse atherosclerotic vascular diseases (3). In the United States, 12% to 14% of patients in whom dialysis is initiated have been found to have atherosclerotic renal artery stenosis (4).

Most authorities consider blood pressure control, preservation or salvage of kidney function, and prevention of flash pulmonary edema to be important treatment goals for patients with atherosclerotic renal stenosis. Treatment options include medication alone or revascularization of the stenosed artery or arteries. Combination therapy with multiple antihypertensive agents, often including angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers, calcium-channel blockers, and β-blockers, is frequently prescribed. Some clinicians also use statins to decrease low-density lipoprotein cholesterol levels and antiplatelet agents, such as aspirin or clopidogrel, to reduce the risk for thrombosis. The current standard for revascularization in most patients is percutaneous transluminal angioplasty with stent placement across the stenosis. Angioplasty without stent placement is less commonly used. Revascularization by surgical reconstruction is generally done only in patients with complicated renal artery anatomy or in those who require pararenal aortic reconstructions for aortic aneurysms or severe aortoiliac occlusive disease.

The American College of Cardiology and the American Heart Association recently published guidelines for management of patients with peripheral arterial disease, including renal artery stenosis (56). Although these guidelines provide recommendations about which patients should be considered for revascularization, considerable uncertainty remains about which intervention provides the best clinical outcomes. Among patients treated with medical therapy alone, experts are concerned about the risk for deterioration of kidney function and worsening cardiovascular morbidity and mortality. Revascularization procedures may provide immediate improvement in kidney function and blood pressure, but they are invasive interventions that could result in substantial morbidity or death, and because of the risk for restenosis the durability of their benefits is questioned.

Although evidence regarding the optimal management of atherosclerotic renal artery stenosis appears uncertain, a Medicare claims analysis found that the rate of percutaneous renal artery revascularization has rapidly increased between 1996 and 2000, with the number of interventions increasing from 7660 to 18 520 (7). To determine which patients, if any, with atherosclerotic renal artery stenosis would most benefit from angioplasty with stent placement, as opposed to continued aggressive medical treatment, the National Institutes of Health has sponsored the large, multicenter Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL) trial. Participants are currently being enrolled in the trial, and results should be reported in 2010. Meanwhile, the Agency for Healthcare Research and Quality, under Section 1013 of the Medicare Modernization Act, commissioned a review asking key questions related to the effectiveness of aggressive medical therapy compared with renal artery angioplasty with stent placement. However, because no published evidence directly compared angioplasty with stent placement and aggressive medical treatment with currently available drugs, the review covered direct comparisons of revascularization, including angioplasty with or without stent placement and surgery, and various medical regimens and indirect comparisons of angioplasty (with stent placement) and surgical interventions, various medical therapies, and natural history (8).

Data Sources and Selection

To identify articles relevant to several key questions, we searched the MEDLINE database from inception to 6 September 2005 for studies involving adults with atherosclerotic renal artery stenosis. The Figure shows the search and selection process. The full technical report (Available at http://www.effectivehealthcare.ahrq.gov/reports/final.cfm) provides a more detailed description of the study methods. We also reviewed reference lists of related systematic reviews, selected narrative reviews, and primary articles, and we invited domain experts to provide additional citations. We combined search terms for renal artery stenosis, renal hypertension, and renal vascular disease, and we limited the search to English-language articles of studies in adult humans that had relevant research designs. We included peer-reviewed primary studies of adult patients treated for atherosclerotic renal artery stenosis and excluded studies that evaluated patients with renal artery stenosis in the setting of a transplanted kidney, renal artery aneurysm requiring repair, aortic disease requiring invasive intervention, or concurrent cancer or patients who had had previous surgical or angioplasty interventions for renal artery stenosis. We included only studies that reported outcomes of interest (mortality rate, kidney function, blood pressure, and cardiovascular events) at 6 months or more after the initial intervention. We excluded studies in which more than 20% of patients had renal artery stenosis due to other causes. We categorized studies according to whether they evaluated medical treatment, angioplasty, or surgical revascularization or were natural history studies, and by whether they directly compared interventions.

Grahic Jump Location
Figure.
Search and selection of studies for review.

*Prospective study; enrolled 10 or more patients; study duration at least 6 months. †Prospective study; angioplasty included stent placement; enrolled 30 or more patients; study duration at least 6 months; patients recruited in 1993 or later; patients did not have previous angioplasty. ‡One study has data both for direct comparison of medical treatment to angioplasty and for natural history. §Any study design; enrolled 10 or more patients; study duration at least 6 months. Studies with surgical intervention must have recruited patients in 1993 or later. ∥Any study design; enrolled 10 or more patients; study duration at least 6 months; patients recruited in 1993 or later. ¶Any study design; enrolled 100 or more patients (10 or more if the study was prospective); study duration at least 6 months; patients recruited in 1993 or later.

Grahic Jump Location

We used different eligibility criteria for studies of different interventions, based on the varying number of studies available for each intervention and the relevance of the intervention to current practice. We included all direct comparisons of medical treatment with angioplasty and all uncontrolled (cohort) studies of medical treatment that had at least 10 patients in each group, regardless of study design. For angioplasty, surgical, or natural history studies, we included only those in which at least some patients were recruited in 1993 or later, after the publication of the Fifth Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. These guidelines marked a substantial change from previous guidelines in treatment recommendations for hypertension, including more aggressive blood pressure targets (9). In addition, at this time point, angiotensin-converting enzyme inhibitors began to be used more routinely in the treatment of patients with severe hypertension. We included only angioplasty studies that used stent placement, were prospective, and had at least 30 patients and retrospective surgery studies that included at least 100 patients. Any prospective surgery study that otherwise met criteria was eligible.

Data Extraction and Quality and Applicability Assessments

Data from each study were extracted by one of the authors and confirmed by another. The extracted data included information about patient samples, interventions, outcomes, adverse events, study design, quality, and applicability. We used predefined criteria to grade study quality as good, fair, or poor; study applicability as high, moderate, or low; and the strength of the overall body of evidence as robust, acceptable, or weak (Appendix Table). Each included study was graded by at least 2 of the authors.

Data Synthesis

Because the study designs, participants, interventions, and reported outcome measures varied markedly, we focused on describing the studies, their results, their applicability, and their limitations and on qualitative synthesis rather than meta-analysis.

Role of the Funding Source

The Agency for Healthcare Research and Quality formulated the initial study questions but did not participate in the literature search; determination of study eligibility criteria; data analysis or interpretation; or preparation, review, or approval of the manuscript for publication.

What Is the Evidence That Medical Therapy Is More or Less Effective than Revascularization (Angioplasty with or without Stents) for Adults with Atherosclerotic Renal Artery Stenosis? What Adverse Events and Complications Have Been Associated with These Treatments?

Available evidence was neither adequate nor sufficiently applicable to current practice to clearly support one treatment approach over another for the general population with atherosclerotic renal artery stenosis. Only 2 randomized trials directly compared angioplasty and medical treatment alone (Table 1). Weak evidence based on few study participants suggested no large differences in mortality rates or cardiovascular events between patients treated medically only and those receiving angioplasty (Table 2). Randomized, controlled trials; other comparative studies; and cohort studies reported similar overall changes in kidney function after angioplasty as with medical therapy alone. However, improved kidney function over time after the intervention was reported among some patients only in cohort studies of angioplasty. Acceptable evidence showed that combination antihypertensive treatment decreased blood pressure substantively but that angioplasty may result in better blood pressure control, particularly in people with bilateral disease. Cure of hypertension (achievement of blood pressure control without medication) was reported only among several patients treated with angioplasty. Available evidence did not adequately assess net harm due to adverse events and complications of medical treatment or angioplasty, but important complications after revascularization occur in a small percentage of patients and all drugs have associated adverse events.

Almost two thirds of the studies that we reviewed were of poor methodologic quality; none was deemed to be of good quality. More than half of the studies had limited applicability to patients commonly seen in practice or to modern management strategies. All studies implicitly or explicitly included only patients with generally stable blood pressure, kidney function, and cardiovascular status. Thus, they were not applicable to patients with acute decompensation due to progressive atherosclerotic renal artery stenosis. No study directly compared angioplasty with stent placement and “aggressive” medical treatment with currently available antihypertensive, antiplatelet, and lipid-lowering agents.

Characteristics of Reviewed Studies

Overall, we reviewed 55 studies (Table 1). Nine studies (in 11 publications) directly compared medical treatment with revascularization (Table 3) (1020). Of these, 2 randomized trials compared angioplasty without stent placement with medical treatment (1011). A third randomized trial compared angioplasty without stent placement at the start of the trial with angioplasty delayed by 3 months in half of the remaining patients and medical treatment alone in the other patients (1214). The remaining 7 comparative studies (including 1 of a nonrandomized subgroup from a randomized trial [10]) compared multiple types of revascularization with a variety of medical treatment for a wide range of durations (6 months to 7 years).

Twenty-five prospective cohort studies that each included at least 30 patients who received angioplasty primarily after 1993 reported “long-term” outcomes 6 months or more after angioplasty (2145). Four cohort studies evaluated angiotensin-converting enzyme inhibitors or “triple therapy” (treatment with 3 classes of antihypertensive agents) (4649). An additional 8 natural history studies evaluated cohorts of patients who usually received some medical treatment that was not clearly described (18, 5056). Long-term outcomes of interest were reported for 4 surgical cohorts that each included at least 100 patients who received angioplasty mostly after 1993 (5760). Thirty-seven studies reported on adverse events (1014, 1617, 2122, 2425, 27, 2936, 3946, 49, 5765).

Mortality Rate in Studies at Least 6 Months in Duration

One small randomized, controlled trial of angioplasty versus medical treatment (55 patients) (10), 4 other comparative studies (10, 1719), and 30 cohort studies of various interventions reported on mortality (18, 2230, 3236, 39, 4144, 47, 49, 5152, 5560). About half of the studies reported mortality data at 2 years or less. Seven studies (primarily surgical studies) reported mortality data for patients followed for at least 5 years (17, 19, 51, 5760). Studies were generally too small to detect anything but large differences in mortality rates, and no large differences in mortality rates were found. Mortality rates greater than 40% within 6 years occurred mostly in studies of patients with high-grade stenosis (>75%) or bilateral disease.

Kidney Function Outcomes

The 2 randomized, controlled trials of angioplasty versus medical treatment (1011) and the 7 other studies that directly compared revascularization and medical treatment (10, 1218, 20) mostly found no clinically or statistically significant differences in kidney-related outcomes. Among 22 cohort studies of angioplasty (18 with stent placement, 4 with or without stent placement), 2 reported statistically significant improvements in kidney function (25, 37), 2 reported statistically significant deterioration (34, 39), and 18 reported no statistically significant changes (2124, 2628, 30, 3233, 3536, 38, 4042, 4445). Within these studies, 8% to 51% of patients were categorized as having improved kidney function and up to 31% had worsened kidney function. Mean changes in kidney function were generally small; the largest improvement found was a mean increase in glomerular filtration rate from baseline (0.9 mL/s [54 mL/min]) of 0.13 mL/s (8 mL/min) over 3 to 23 months (37). Among 3 surgical cohort studies, kidney function improved in 43% of patients in 1 study and worsened in 10% to 28% across the studies (5860). In comparison, 2 cohort studies of medical treatment (47, 49) and 7 cohort studies of natural history (18, 5055) reported progressive decreases in kidney function.

Blood Pressure Outcomes

The 2 randomized trials of angioplasty versus medical treatment (1011), the 8 other comparative studies (10, 1220), all 25 angioplasty cohort studies (2145), all 4 medical cohort studies (4649), 3 natural history cohort studies (18, 53, 56), and 2 surgical cohort studies (5859) reported blood pressure outcomes. Both trials of angioplasty versus medical treatment and most of the other comparative studies found some evidence of greater improvement in blood pressure after angioplasty than medical treatment. Plouin and colleagues (11) found that both systolic and diastolic blood pressures were reduced by 6 mm Hg more after angioplasty than medical treatment alone, but only the change in diastolic blood pressure was statistically significant. In addition, after angioplasty, patients required almost half as many antihypertensive drugs. Webster and associates (10) found that among patients with bilateral disease, a substantially greater, statistically significant reduction in blood pressure occurred after angioplasty than with medical treatment alone (net decrease, 26/10 mm Hg); however, no statistically significant difference was found in blood pressure among patients with unilateral disease. Among the cohort studies, medical treatment or natural history (mostly medical treatment alone) resulted in decreases of 20 to 50 mm Hg in systolic blood pressure and 8 to 42 mm Hg in diastolic blood pressure, whereas in studies of angioplasty with stent placement, patients had decreases of 6 to 32 mm Hg in systolic blood pressure and 0 to 17 mm Hg in diastolic blood pressure after revascularization. Almost all studies of angioplasty with stent placement reported that some patients (up to 18%) were cured of hypertension.

Cardiovascular Outcomes

In a trial of 55 patients randomly assigned to angioplasty without stent or antihypertensive treatment alone, Webster and associates (10) found no differences in event rates for congestive heart failure, stroke, or myocardial infarction across 54 months of follow-up. Similarly, in a trial of 52 patients receiving surgical revascularization or medical treatment alone, near-identical percentages of participants had a stop point event that included cardiovascular events (20). The reporting of cardiovascular outcomes in cohort studies (47, 56, 58) was inadequate to allow cross-study comparisons. No study of medical interventions reported cardiovascular outcomes.

Adverse Events and Restenosis Rates

Adverse events were reported in 37 studies, including the 2 randomized trials of angioplasty and medical treatment and 1 retrospective comparative trial (1014, 1617, 2122, 2425, 27, 2936, 3946, 49, 5765). Rates of adverse events between interventions were not directly compared. Adverse events reported in angioplasty studies included death by 30 days in up to 3% of patients, transient deterioration of kidney function in 1% to 13%, renal artery or parenchymal injury in up to 5%, and periprocedural cardiovascular events in up to 3%. Other adverse events reported were hemorrhage, hematomas, and renal artery occlusion. Seventeen studies of angioplasty with stent placement showed restenosis rates that ranged from 10% to 21% during follow-up of 3 to 40 months (2223, 2631, 3335, 3741, 43). Only Ramos and colleagues (37) noted a statistically significantly higher rate of restenosis among patients who had undergone stent placement for ostial lesions compared with those with nonostial lesions (27% vs. 8%). Adverse events related to blood pressure medications (angiotensin-converting enzyme inhibitors, β-blockers, and hydralazine) included orthostatic hypotension, central nervous system symptoms, digestive symptoms, the Raynaud phenomenon, and various other symptoms.

What Baseline Characteristics, Including Diagnostic Tests, Are Associated with Improved or Worse Outcomes When Treating with Either Medical Therapy Alone or Angioplasty?

The studies of diagnostic tests were inadequate to determine whether any such tests may predict long-term outcomes or guide best treatment approaches (Table 4). Weak evidence suggests that patients with bilateral disease may preferentially benefit from angioplasty over medical treatment alone. A variety of other clinical factors may be predictive of poorer outcomes with angioplasty or medical treatment alone; however, evidence is insufficient to suggest whether other factors can assist in decisions about preferred treatment.

Webster and associates (10) found different relative effects of angioplasty and medical treatment according to whether patients had unilateral or bilateral disease. Patients with bilateral stenosis had much larger, statistically significant decreases in blood pressure after angioplasty than with medical treatment, in contrast to patients with unilateral stenosis, who had similar changes in blood pressure regardless of the type of intervention (Table 3). The Dutch Renal Artery Stenosis Intervention Cooperative Study, which compared early revascularization with delayed or no revascularization, found a similar difference in diastolic blood pressure reduction but not in creatinine clearance (1214). A single trial comparing surgical revascularization with medical treatment reported that among patients with an elevated serum creatinine concentration (177 to 354 µmol/L [2 to 4 mg/dL]), those who had surgical procedures were less likely to die or have uncontrollable hypertension than were those treated medically (P = 0.01; no other data reported) (20). This was in contrast to their overall finding of no difference in outcomes between interventions. No other associations were reported between baseline factors and relative difference in outcomes based on treatment choice.

Among the reviewed studies, 4 diagnostic tests have been evaluated to determine their value in predicting outcomes in patients with atherosclerotic renal artery stenosis; however, each test was evaluated in only 1 study. The Dutch Renal Artery Stenosis Intervention Cooperative Study found that neither the captopril test nor renography (scintigraphy) predicted kidney function, blood pressure, or dose of antihypertensive drugs after angioplasty or medical treatment (1214). Two cohort studies disagreed on the predictive value of baseline resistance index greater than 80%. In one study, patients with an elevated resistance index were most likely to benefit in terms of kidney function and blood pressure control after angioplasty with stent placement (44), whereas in another study, patients with an elevated resistance index were more likely to have worsening kidney function and less likely to have improved blood pressure or reduced use of antihypertensive medication after surgery or angioplasty with or without stenting (36). One natural history study reported that nonspiral flow on magnetic resonance angiography predicted statistically significantly worse kidney function outcomes (54).

Acceptable evidence, primarily from cohort studies, showed that poorer kidney function (17, 19, 26, 30, 3438, 41, 44, 5860) or concomitant cardiovascular disease (17, 19, 28, 3435, 44, 58) predicted higher mortality rates and poorer clinical outcomes among patients who had angioplasty (with or without stent placement). Evidence was weak owing to sparseness of data or disagreement among studies on other baseline factors and outcomes (Table 4), including the presence of bilateral disease among patients having revascularization (25, 27, 34, 37, 3940, 45) or among those enrolled in natural history studies (5556); the degree of kidney function (20, 51) and cardiovascular disease (17, 19, 52) in patients enrolled in medical treatment studies; and percentage of artery stenosis (17, 19, 28, 3435, 44, 52, 58), age, and sex (10, 17, 19, 3435, 52), regardless of intervention or type of study.

What Treatment Variables Are Associated with Improved or Worse Outcomes of Renal Artery Angioplasty with Stent Placement, Including Periprocedural Medications, Type of Stent, Use of Distal Protection Devices, or Other Adjunct Techniques?

No study that met eligibility criteria reported analyses of whether periprocedural interventions, such as different drugs or different approaches, affected complications or long-term outcomes in patients undergoing revascularization. Two prospective cohort studies reported no difference in blood pressure and kidney-related outcomes between patients who had stents placed and those who did not (Table 4) (21, 42).

Overall, the evidence is not sufficiently robust to determine the comparative effectiveness of angioplasty (with or without stenting) and medical treatment alone. Only 2 randomized trials with long-term outcomes and a third randomized trial that allowed substantial crossover of treatment after 3 months directly compared angioplasty and medical treatment. However, no randomized trial evaluated angioplasty with stent placement, the revascularization technique that is currently most commonly used. Furthermore, the randomized trials did not evaluate enough patients or did not follow patients for a sufficient duration to allow definitive conclusions to be made about clinical outcomes, such as mortality and cardiovascular or kidney failure events.

Some acceptable evidence from comparison of medical treatment and angioplasty suggested no difference in long-term kidney function but possibly better blood pressure control after angioplasty, an effect that may be limited to patients with bilateral atherosclerotic renal artery stenosis. The evidence regarding other outcomes is weak. Because the reviewed studies did not explicitly address patients with rapid clinical deterioration who may need acute intervention, our conclusions do not apply to this important subset of patients.

Although use of angioplasty to improve blood flow to the kidneys holds appeal, the treatment of atherosclerotic renal artery stenosis is probably considerably more complicated. The challenge lies in the substantial overlap between etiologic factors of aortorenal vascular disease and parenchymal kidney disease. The disease conditions that result in atherosclerotic narrowing of the renal arteries, namely diabetes mellitus, dyslipidemia, and elevated blood pressure, are also independently associated with direct kidney injury. Thus, in many cases, revascularizing the renal artery fails to improve hypertension or kidney function, which may be mediated not only by macrovascular atherosclerotic renal artery stenosis but also by underlying microvascular kidney disease. Further evaluation of the role of atherosclerotic renal artery stenosis in hypertension and kidney dysfunction is needed to determine whether intervention should be directed toward improving kidney perfusion through angioplasty with stent placement or more aggressively targeting the underlying factors of parenchymal kidney disease with combination medical therapy.

The ongoing CORAL trial is enrolling patients with atherosclerotic renal artery stenosis with at least 60% narrowing and systolic hypertension for which they are receiving 2 or more antihypertensive medications (66). Patients with advanced chronic kidney disease (serum creatinine concentration ≥ 265 µmol/L [≥3.0 mg/dL]), those with very small kidneys, and certain patients with cardiovascular disease are being excluded. This trial, whose results are expected to be reported in 2010, will probably address many of the deficiencies in current evidence about revascularization versus medical treatment alone. It also might provide useful evidence about the value of different diagnostic tests to determine which intervention would be best for individual patients; whether particular baseline characteristics could suggest which intervention would be best; the value of co-interventions at the time of angioplasty; the value of alternative methods of performing angioplasty with stent placement or of using different types of stents; and the effect of different combinations of antihypertensive medications with other interventions, such as lipid-lowering and antiplatelet drugs. However, if no further trials of sufficient size and duration are done, the findings of the CORAL trial may be applied to patients with less or more severe atherosclerotic renal artery stenosis than those included in the trial. This potentially incorrect extrapolation may result in inappropriate treatment of patients, misallocated resources, and worse patient outcomes. Given the limitations in the quality and applicability to current practice of published studies, it is unclear whether the differences between participants in the published studies and those being enrolled in the CORAL trial will help with extrapolation of the results to patients who were not eligible for the CORAL trial.

Another lesson from our review is that researchers should consider how to improve and standardize definitions of atherosclerotic renal artery stenosis and severity of disease. These considerations should be based on how these definitions and classifications might be associated with clinical outcomes. The CORAL trial and other studies of atherosclerotic renal artery stenosis should use the current suggested methods for estimating kidney function, including preferential use of estimated glomerular filtration rate and stage of chronic kidney disease over serum creatinine concentration alone. The community of clinicians and professional organizations involved in performing renal artery angioplasty should also consider how to improve procedural techniques with the goal of improving clinical outcomes. The methods to achieve these goals may require quality improvement and other types of studies.

Safian RD, Textor SC.  Renal-artery stenosis. N Engl J Med. 2001; 344:431-42. PubMed
CrossRef
 
Harding MB, Smith LR, Himmelstein SI, Harrison K, Phillips HR, Schwab SJ. et al.  Renal artery stenosis: prevalence and associated risk factors in patients undergoing routine cardiac catheterization. J Am Soc Nephrol. 1992; 2:1608-16. PubMed
 
Missouris CG, Buckenham T, Cappuccio FP, MacGregor GA.  Renal artery stenosis: a common and important problem in patients with peripheral vascular disease. Am J Med. 1994; 96:10-4. PubMed
 
 United States Renal Data System (USRDS) 1997 Annual Data Report. Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 1997.
 
Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL. et al.  ACC/AHA 2005 guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): executive summary. A collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease) endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. J Am Coll Cardiol. 2006; 47:1239-312. PubMed
 
Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL. et al.  ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation. 2006; 113:463-654. PubMed
 
Murphy TP, Soares G, Kim M.  Increase in utilization of percutaneous renal artery interventions by medicare beneficiaries, 1996-2000. AJR Am J Roentgenol. 2004; 183:561-8. PubMed
 
Balk E, Raman G, Chung M, Ip S, Tatsioni A, Alvarez A, et al.  Comparative Effectiveness of Management Strategies for Renal Artery Stenosis. Rockville, MD: Agency for Healthcare Research and Quality [In press]. Available athttp://www.effectivehealthcare.ahrq.gov/reports/final.cfm
 
 The fifth report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC V). Arch Intern Med. 1993; 153:154-83. PubMed
 
Webster J, Marshall F, Abdalla M, Dominiczak A, Edwards R, Isles CG. et al.  Randomised comparison of percutaneous angioplasty vs continued medical therapy for hypertensive patients with atheromatous renal artery stenosis. Scottish and Newcastle Renal Artery Stenosis Collaborative Group. J Hum Hypertens. 1998; 12:329-35. PubMed
 
Plouin PF, Chatellier G, Darné 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; 31:823-9. PubMed
 
Krijnen P, van Jaarsveld BC, Deinum J, Steyerberg EW, Habbema JD.  Which patients with hypertension and atherosclerotic renal artery stenosis benefit from immediate intervention? J Hum Hypertens. 2004; 18:91-6. PubMed
 
van Jaarsveld BC, Krijnen P, Pieterman H, Derkx FH, Deinum J, Postma CT. 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; 342:1007-14. PubMed
 
van Jaarsveld BC, Krijnen P.  Prospective studies of diagnosis and intervention: the Dutch experience. Semin Nephrol. 2000; 20:463-73. PubMed
 
Taylor DC, Moneta GL, Strandness DE Jr.  Follow-up of renal artery stenosis by duplex ultrasound. J Vasc Surg. 1989; 9:410-5. PubMed
 
Englund R, Brown MA.  Renal angioplasty for renovascular disease: a reappraisal. J Cardiovasc Surg (Torino). 1991; 32:76-80. PubMed
 
Pizzolo F, Mansueto G, Minniti S, Mazzi M, Trabetti E, Girelli D. et al.  Renovascular disease: effect of ACE gene deletion polymorphism and endovascular revascularization. J Vasc Surg. 2004; 39:140-7. PubMed
 
Pillay WR, Kan YM, Crinnion JN, Wolfe JH, Joint Vascular Research Group, UK.  Prospective multicentre study of the natural history of atherosclerotic renal artery stenosis in patients with peripheral vascular disease. Br J Surg. 2002; 89:737-40. PubMed
 
Johansson M, Herlitz H, Jensen G, Rundqvist B, Friberg P.  Increased cardiovascular mortality in hypertensive patients with renal artery stenosis. Relation to sympathetic activation, renal function and treatment regimens. J Hypertens. 1999; 17:1743-50. PubMed
 
Uzzo RG, Novick AC, Goormastic M, Mascha E, Pohl M.  Medical versus surgical management of atherosclerotic renal artery stenosis. Transplant Proc. 2002; 34:723-5. PubMed
 
Baumgartner I, von Aesch K, Do DD, Triller J, Birrer M, Mahler F.  Stent placement in ostial and nonostial atherosclerotic renal arterial stenoses: a prospective follow-up study. Radiology. 2000; 216:498-505. PubMed
 
Blum U, Krumme B, Flügel P, Gabelmann A, Lehnert T, Buitrago-Tellez C. et al.  Treatment of ostial renal-artery stenoses with vascular endoprostheses after unsuccessful balloon angioplasty. N Engl J Med. 1997; 336:459-65. PubMed
 
Bucek RA, Puchner S, Reiter M, Dirisamer A, Minar E, Lammer J.  Long-term follow-up after renal artery stenting. Wien Klin Wochenschr. 2003; 115:788-92. PubMed
 
Dangas G, Laird JR Jr, Mehran R, Lansky AJ, Mintz GS, Leon MB.  Intravascular ultrasound-guided renal artery stenting. J Endovasc Ther. 2001; 8:238-47. PubMed
 
Dorros G, Jaff M, Mathiak L, He T, Multicenter Registry Participants.  Multicenter Palmaz stent renal artery stenosis revascularization registry report: four-year follow-up of 1, 058 successful patients. Catheter Cardiovasc Interv. 2002; 55:182-8. PubMed
 
Gill-Leertouwer TC, Gussenhoven EJ, Bosch JL, Deinum J, van Overhagen H, Derkx FH. et al.  Predictors for clinical success at one year following renal artery stent placement. J Endovasc Ther. 2002; 9:495-502. PubMed
 
Gill KS, Fowler RC.  Atherosclerotic renal arterial stenosis: clinical outcomes of stent placement for hypertension and renal failure. Radiology. 2003; 226:821-6. PubMed
 
Gray BH, Olin JW, Childs MB, Sullivan TM, Bacharach JM.  Clinical benefit of renal artery angioplasty with stenting for the control of recurrent and refractory congestive heart failure. Vasc Med. 2002; 7:275-9. PubMed
 
Gross CM, Krämer J, Waigand J, Uhlich F, Olthoff H, Luft FC. et al.  Ostial renal artery stent placement for atherosclerotic renal artery stenosis in patients with coronary artery disease. Cathet Cardiovasc Diagn. 1998; 45:1-8. PubMed
 
Harden PN, MacLeod MJ, Rodger RS, Baxter GM, Connell JM, Dominiczak AF. et al.  Effect of renal-artery stenting on progression of renovascular renal failure. Lancet. 1997; 349:1133-6. PubMed
 
Harjai K, Khosla S, Shaw D, Collins T, Jenkins S, White C. et al.  Effect of gender on outcomes following renal artery stent placement for renovascular hypertension. Cathet Cardiovasc Diagn. 1997; 42:381-6. PubMed
 
Henry M, Henry I, Klonaris C, Polydorou A, Rath P, Lakshmi G. et al.  Renal angioplasty and stenting under protection: the way for the future? Catheter Cardiovasc Interv. 2003; 60:299-312. PubMed
 
Iannone LA, Underwood PL, Nath A, Tannenbaum MA, Ghali MG, Clevenger LD.  Effect of primary balloon expandable renal artery stents on long-term patency, renal function, and blood pressure in hypertensive and renal insufficient patients with renal artery stenosis. Cathet Cardiovasc Diagn. 1996; 37:243-50. PubMed
 
Kennedy DJ, Colyer WR, Brewster PS, Ankenbrandt M, Burket MW, Nemeth AS. et al.  Renal insufficiency as a predictor of adverse events and mortality after renal artery stent placement. Am J Kidney Dis. 2003; 42:926-35. PubMed
 
Lederman RJ, Mendelsohn FO, Santos R, Phillips HR, Stack RS, Crowley JJ.  Primary renal artery stenting: characteristics and outcomes after 363 procedures. Am Heart J. 2001; 142:314-23. PubMed
 
Radermacher J, Chavan A, Bleck J, Vitzthum A, Stoess B, Gebel MJ. et al.  Use of Doppler ultrasonography to predict the outcome of therapy for renal-artery stenosis. N Engl J Med. 2001; 344:410-7. PubMed
 
Ramos F, Kotliar C, Alvarez D, Baglivo H, Rafaelle P, Londero H. et al.  Renal function and outcome of PTRA and stenting for atherosclerotic renal artery stenosis. Kidney Int. 2003; 63:276-82. PubMed
 
Rivolta R, Bazzi C, Stradiotti P, Paparella M.  Stenting of renal artery stenosis: is it beneficial in chronic renal failure? J Nephrol. 2005; 18:749-54. PubMed
 
Rocha-Singh K, Jaff MR, Rosenfield K, ASPIRE-2 Trial Investigators.  Evaluation of the safety and effectiveness of renal artery stenting after unsuccessful balloon angioplasty: the ASPIRE-2 study. J Am Coll Cardiol. 2005; 46:776-83. PubMed
 
Rocha-Singh KJ, Mishkel GJ, Katholi RE, Ligon RA, Armbruster JA, McShane KJ. et al.  Clinical predictors of improved long-term blood pressure control after successful stenting of hypertensive patients with obstructive renal artery atherosclerosis. Catheter Cardiovasc Interv. 1999; 47:167-72. PubMed
 
Tuttle KR, Chouinard RF, Webber JT, Dahlstrom LR, Short RA, Henneberry KJ. et al.  Treatment of atherosclerotic ostial renal artery stenosis with the intravascular stent. Am J Kidney Dis. 1998; 32:611-22. PubMed
 
van de Ven PJ, Kaatee R, Beutler JJ, Beek FJ, Woittiez AJ, Buskens E. et al.  Arterial stenting and balloon angioplasty in ostial atherosclerotic renovascular disease: a randomised trial. Lancet. 1999; 353:282-6. PubMed
 
White CJ, Ramee SR, Collins TJ, Jenkins JS, Escobar A, Shaw D.  Renal artery stent placement: utility in lesions difficult to treat with balloon angioplasty. J Am Coll Cardiol. 1997; 30:1445-50. PubMed
 
Zeller T, Frank U, Müller C, Bürgelin K, Sinn L, Horn B. et al.  Stent-supported angioplasty of severe atherosclerotic renal artery stenosis preserves renal function and improves blood pressure control: long-term results from a prospective registry of 456 lesions. J Endovasc Ther. 2004; 11:95-106. PubMed
 
Ziakka S, Belli AM, Kong TK, MacGregor GA, Missouris CG.  Percutaneous transluminal renal artery angioplasty: who benefits most? Int J Clin Pract. 2002; 56:649-54. PubMed
 
Franklin SS, Smith RD.  Comparison of effects of enalapril plus hydrochlorothiazide versus standard triple therapy on renal function in renovascular hypertension. Am J Med. 1985; 79:14-23. PubMed
 
Hanzel G, Balon H, Wong O, Soffer D, Lee DT, Safian RD.  Prospective evaluation of aggressive medical therapy for atherosclerotic renal artery stenosis, with renal artery stenting reserved for previously injured heart, brain, or kidney. Am J Cardiol. 2005; 96:1322-7. PubMed
 
Ogihara T, Kaneko Y, Ikeda M, Yamada K, Omae T, Arakawa K. et al.  Clinical evaluation of delapril in Japan. Report from the Japan Study Group on Delapril. Am J Hypertens. 1991; 4:42S-45S. PubMed
 
Tillman DM, Malatino LS, Cumming AM, Hodsman GP, Leckie BJ, Lever AF. et al.  Enalapril in hypertension with renal artery stenosis: long-term follow-up and effects on renal function. J Hypertens Suppl. 1984; 2:S93-100. PubMed
 
Caps MT, Zierler RE, Polissar NL, Bergelin RO, Beach KW, Cantwell-Gab K. et al.  Risk of atrophy in kidneys with atherosclerotic renal artery stenosis. Kidney Int. 1998; 53:735-42. PubMed
 
Cheung CM, Wright JR, Shurrab AE, Mamtora H, Foley RN, O'Donoghue DJ. et al.  Epidemiology of renal dysfunction and patient outcome in atherosclerotic renal artery occlusion. J Am Soc Nephrol. 2002; 13:149-57. PubMed
 
Conlon PJ, Little MA, Pieper K, Mark DB.  Severity of renal vascular disease predicts mortality in patients undergoing coronary angiography. Kidney Int. 2001; 60:1490-7. PubMed
 
Fergany A, Novick AC, Goldfarb DA.  Management of atherosclerotic renal artery disease in younger patients. J Urol. 1994; 151:10-2. PubMed
 
Houston JG, Gandy SJ, Milne W, Dick JB, Belch JJ, Stonebridge PA.  Spiral laminar flow in the abdominal aorta: a predictor of renal impairment deterioration in patients with renal artery stenosis? Nephrol Dial Transplant. 2004; 19:1786-91. PubMed
 
Iglesias JI, Hamburger RJ, Feldman L, Kaufman JS.  The natural history of incidental renal artery stenosis in patients with aortoiliac vascular disease. Am J Med. 2000; 109:642-7. PubMed
 
Uzu T, Takeji M, Yamada N, Fujii T, Yamauchi A, Takishita S. et al.  Prevalence and outcome of renal artery stenosis in atherosclerotic patients with renal dysfunction. Hypertens Res. 2002; 25:537-42. PubMed
 
Alhadad A, Ahle M, Ivancev K, Gottsater A, Lindblad B.  Percutaneous transluminal renal angioplasty (PTRA) and surgical revascularisation in renovascular disease—a retrospective comparison of results, complications, and mortality. Eur J Vasc Endovasc Surg. 2004; 27:151-6. PubMed
 
Cherr GS, Hansen KJ, Craven TE, Edwards MS, Ligush J Jr, Levy PJ. et al.  Surgical management of atherosclerotic renovascular disease. J Vasc Surg. 2002; 35:236-45. PubMed
 
Galaria II, Surowiec SM, Rhodes JM, Illig KA, Shortell CK, Sternbach Y. et al.  Percutaneous and open renal revascularizations have equivalent long-term functional outcomes. Ann Vasc Surg. 2005; 19:218-28. PubMed
 
Marone LK, Cambria RP.  Revascularization for renal function retrieval: which patients will benefit? Perspect Vasc Surg Endovasc Ther. 2004; 16:249-58.
 
Hricik DE, Browning PJ, Kopelman R, Goorno WE, Madias NE, Dzau VJ.  Captopril-induced functional renal insufficiency in patients with bilateral renal-artery stenoses or renal-artery stenosis in a solitary kidney. N Engl J Med. 1983; 308:373-6. PubMed
 
Jackson B, Murphy BF, Johnston CI, Kincaid-Smith P, Whitworth JA.  Renovascular hypertension: treatment with the oral angiotensin-converting enzyme inhibitor enalapril. Am J Nephrol. 1986; 6:182-6. PubMed
 
Spinosa DJ, Matsumoto AH, Angle JF, Hagspiel KD, Cage D, Bissonette EA. et al.  Safety of CO(2)- and gadodiamide-enhanced angiography for the evaluation and percutaneous treatment of renal artery stenosis in patients with chronic renal insufficiency. AJR Am J Roentgenol. 2001; 176:1305-11. PubMed
 
Takabatake T, Ohta H, Yamamoto Y, Ishida Y, Hara H, Ushiogi Y. et al.  Effect of angiotensin blockade and converting enzyme inhibition on renovascular hypertension: comparison between unilateral and bilateral renal artery stenosis. Angiology. 1987; 38:434-9. PubMed
 
Gross CM, Krämer J, Weingärtner O, Uhlich F, Luft FC, Waigand J. et al.  Determination of renal arterial stenosis severity: comparison of pressure gradient and vessel diameter. Radiology. 2001; 220:751-6. PubMed
 
Cooper CJ, Murphy TP, Matsumoto A, Steffes M, Cohen DJ, Jaff M. et al.  Stent revascularization for the prevention of cardiovascular and renal events among patients with renal artery stenosis and systolic hypertension: rationale and design of the CORAL trial. Am Heart J. 2006; 152:59-66. PubMed
 

Figures

Grahic Jump Location
Figure.
Search and selection of studies for review.

*Prospective study; enrolled 10 or more patients; study duration at least 6 months. †Prospective study; angioplasty included stent placement; enrolled 30 or more patients; study duration at least 6 months; patients recruited in 1993 or later; patients did not have previous angioplasty. ‡One study has data both for direct comparison of medical treatment to angioplasty and for natural history. §Any study design; enrolled 10 or more patients; study duration at least 6 months. Studies with surgical intervention must have recruited patients in 1993 or later. ∥Any study design; enrolled 10 or more patients; study duration at least 6 months; patients recruited in 1993 or later. ¶Any study design; enrolled 100 or more patients (10 or more if the study was prospective); study duration at least 6 months; patients recruited in 1993 or later.

Grahic Jump Location

Tables

References

Safian RD, Textor SC.  Renal-artery stenosis. N Engl J Med. 2001; 344:431-42. PubMed
CrossRef
 
Harding MB, Smith LR, Himmelstein SI, Harrison K, Phillips HR, Schwab SJ. et al.  Renal artery stenosis: prevalence and associated risk factors in patients undergoing routine cardiac catheterization. J Am Soc Nephrol. 1992; 2:1608-16. PubMed
 
Missouris CG, Buckenham T, Cappuccio FP, MacGregor GA.  Renal artery stenosis: a common and important problem in patients with peripheral vascular disease. Am J Med. 1994; 96:10-4. PubMed
 
 United States Renal Data System (USRDS) 1997 Annual Data Report. Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 1997.
 
Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL. et al.  ACC/AHA 2005 guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): executive summary. A collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease) endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. J Am Coll Cardiol. 2006; 47:1239-312. PubMed
 
Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL. et al.  ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation. 2006; 113:463-654. PubMed
 
Murphy TP, Soares G, Kim M.  Increase in utilization of percutaneous renal artery interventions by medicare beneficiaries, 1996-2000. AJR Am J Roentgenol. 2004; 183:561-8. PubMed
 
Balk E, Raman G, Chung M, Ip S, Tatsioni A, Alvarez A, et al.  Comparative Effectiveness of Management Strategies for Renal Artery Stenosis. Rockville, MD: Agency for Healthcare Research and Quality [In press]. Available athttp://www.effectivehealthcare.ahrq.gov/reports/final.cfm
 
 The fifth report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC V). Arch Intern Med. 1993; 153:154-83. PubMed
 
Webster J, Marshall F, Abdalla M, Dominiczak A, Edwards R, Isles CG. et al.  Randomised comparison of percutaneous angioplasty vs continued medical therapy for hypertensive patients with atheromatous renal artery stenosis. Scottish and Newcastle Renal Artery Stenosis Collaborative Group. J Hum Hypertens. 1998; 12:329-35. PubMed
 
Plouin PF, Chatellier G, Darné 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; 31:823-9. PubMed
 
Krijnen P, van Jaarsveld BC, Deinum J, Steyerberg EW, Habbema JD.  Which patients with hypertension and atherosclerotic renal artery stenosis benefit from immediate intervention? J Hum Hypertens. 2004; 18:91-6. PubMed
 
van Jaarsveld BC, Krijnen P, Pieterman H, Derkx FH, Deinum J, Postma CT. 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; 342:1007-14. PubMed
 
van Jaarsveld BC, Krijnen P.  Prospective studies of diagnosis and intervention: the Dutch experience. Semin Nephrol. 2000; 20:463-73. PubMed
 
Taylor DC, Moneta GL, Strandness DE Jr.  Follow-up of renal artery stenosis by duplex ultrasound. J Vasc Surg. 1989; 9:410-5. PubMed
 
Englund R, Brown MA.  Renal angioplasty for renovascular disease: a reappraisal. J Cardiovasc Surg (Torino). 1991; 32:76-80. PubMed
 
Pizzolo F, Mansueto G, Minniti S, Mazzi M, Trabetti E, Girelli D. et al.  Renovascular disease: effect of ACE gene deletion polymorphism and endovascular revascularization. J Vasc Surg. 2004; 39:140-7. PubMed
 
Pillay WR, Kan YM, Crinnion JN, Wolfe JH, Joint Vascular Research Group, UK.  Prospective multicentre study of the natural history of atherosclerotic renal artery stenosis in patients with peripheral vascular disease. Br J Surg. 2002; 89:737-40. PubMed
 
Johansson M, Herlitz H, Jensen G, Rundqvist B, Friberg P.  Increased cardiovascular mortality in hypertensive patients with renal artery stenosis. Relation to sympathetic activation, renal function and treatment regimens. J Hypertens. 1999; 17:1743-50. PubMed
 
Uzzo RG, Novick AC, Goormastic M, Mascha E, Pohl M.  Medical versus surgical management of atherosclerotic renal artery stenosis. Transplant Proc. 2002; 34:723-5. PubMed
 
Baumgartner I, von Aesch K, Do DD, Triller J, Birrer M, Mahler F.  Stent placement in ostial and nonostial atherosclerotic renal arterial stenoses: a prospective follow-up study. Radiology. 2000; 216:498-505. PubMed
 
Blum U, Krumme B, Flügel P, Gabelmann A, Lehnert T, Buitrago-Tellez C. et al.  Treatment of ostial renal-artery stenoses with vascular endoprostheses after unsuccessful balloon angioplasty. N Engl J Med. 1997; 336:459-65. PubMed
 
Bucek RA, Puchner S, Reiter M, Dirisamer A, Minar E, Lammer J.  Long-term follow-up after renal artery stenting. Wien Klin Wochenschr. 2003; 115:788-92. PubMed
 
Dangas G, Laird JR Jr, Mehran R, Lansky AJ, Mintz GS, Leon MB.  Intravascular ultrasound-guided renal artery stenting. J Endovasc Ther. 2001; 8:238-47. PubMed
 
Dorros G, Jaff M, Mathiak L, He T, Multicenter Registry Participants.  Multicenter Palmaz stent renal artery stenosis revascularization registry report: four-year follow-up of 1, 058 successful patients. Catheter Cardiovasc Interv. 2002; 55:182-8. PubMed
 
Gill-Leertouwer TC, Gussenhoven EJ, Bosch JL, Deinum J, van Overhagen H, Derkx FH. et al.  Predictors for clinical success at one year following renal artery stent placement. J Endovasc Ther. 2002; 9:495-502. PubMed
 
Gill KS, Fowler RC.  Atherosclerotic renal arterial stenosis: clinical outcomes of stent placement for hypertension and renal failure. Radiology. 2003; 226:821-6. PubMed
 
Gray BH, Olin JW, Childs MB, Sullivan TM, Bacharach JM.  Clinical benefit of renal artery angioplasty with stenting for the control of recurrent and refractory congestive heart failure. Vasc Med. 2002; 7:275-9. PubMed
 
Gross CM, Krämer J, Waigand J, Uhlich F, Olthoff H, Luft FC. et al.  Ostial renal artery stent placement for atherosclerotic renal artery stenosis in patients with coronary artery disease. Cathet Cardiovasc Diagn. 1998; 45:1-8. PubMed
 
Harden PN, MacLeod MJ, Rodger RS, Baxter GM, Connell JM, Dominiczak AF. et al.  Effect of renal-artery stenting on progression of renovascular renal failure. Lancet. 1997; 349:1133-6. PubMed
 
Harjai K, Khosla S, Shaw D, Collins T, Jenkins S, White C. et al.  Effect of gender on outcomes following renal artery stent placement for renovascular hypertension. Cathet Cardiovasc Diagn. 1997; 42:381-6. PubMed
 
Henry M, Henry I, Klonaris C, Polydorou A, Rath P, Lakshmi G. et al.  Renal angioplasty and stenting under protection: the way for the future? Catheter Cardiovasc Interv. 2003; 60:299-312. PubMed
 
Iannone LA, Underwood PL, Nath A, Tannenbaum MA, Ghali MG, Clevenger LD.  Effect of primary balloon expandable renal artery stents on long-term patency, renal function, and blood pressure in hypertensive and renal insufficient patients with renal artery stenosis. Cathet Cardiovasc Diagn. 1996; 37:243-50. PubMed
 
Kennedy DJ, Colyer WR, Brewster PS, Ankenbrandt M, Burket MW, Nemeth AS. et al.  Renal insufficiency as a predictor of adverse events and mortality after renal artery stent placement. Am J Kidney Dis. 2003; 42:926-35. PubMed
 
Lederman RJ, Mendelsohn FO, Santos R, Phillips HR, Stack RS, Crowley JJ.  Primary renal artery stenting: characteristics and outcomes after 363 procedures. Am Heart J. 2001; 142:314-23. PubMed
 
Radermacher J, Chavan A, Bleck J, Vitzthum A, Stoess B, Gebel MJ. et al.  Use of Doppler ultrasonography to predict the outcome of therapy for renal-artery stenosis. N Engl J Med. 2001; 344:410-7. PubMed
 
Ramos F, Kotliar C, Alvarez D, Baglivo H, Rafaelle P, Londero H. et al.  Renal function and outcome of PTRA and stenting for atherosclerotic renal artery stenosis. Kidney Int. 2003; 63:276-82. PubMed
 
Rivolta R, Bazzi C, Stradiotti P, Paparella M.  Stenting of renal artery stenosis: is it beneficial in chronic renal failure? J Nephrol. 2005; 18:749-54. PubMed
 
Rocha-Singh K, Jaff MR, Rosenfield K, ASPIRE-2 Trial Investigators.  Evaluation of the safety and effectiveness of renal artery stenting after unsuccessful balloon angioplasty: the ASPIRE-2 study. J Am Coll Cardiol. 2005; 46:776-83. PubMed
 
Rocha-Singh KJ, Mishkel GJ, Katholi RE, Ligon RA, Armbruster JA, McShane KJ. et al.  Clinical predictors of improved long-term blood pressure control after successful stenting of hypertensive patients with obstructive renal artery atherosclerosis. Catheter Cardiovasc Interv. 1999; 47:167-72. PubMed
 
Tuttle KR, Chouinard RF, Webber JT, Dahlstrom LR, Short RA, Henneberry KJ. et al.  Treatment of atherosclerotic ostial renal artery stenosis with the intravascular stent. Am J Kidney Dis. 1998; 32:611-22. PubMed
 
van de Ven PJ, Kaatee R, Beutler JJ, Beek FJ, Woittiez AJ, Buskens E. et al.  Arterial stenting and balloon angioplasty in ostial atherosclerotic renovascular disease: a randomised trial. Lancet. 1999; 353:282-6. PubMed
 
White CJ, Ramee SR, Collins TJ, Jenkins JS, Escobar A, Shaw D.  Renal artery stent placement: utility in lesions difficult to treat with balloon angioplasty. J Am Coll Cardiol. 1997; 30:1445-50. PubMed
 
Zeller T, Frank U, Müller C, Bürgelin K, Sinn L, Horn B. et al.  Stent-supported angioplasty of severe atherosclerotic renal artery stenosis preserves renal function and improves blood pressure control: long-term results from a prospective registry of 456 lesions. J Endovasc Ther. 2004; 11:95-106. PubMed
 
Ziakka S, Belli AM, Kong TK, MacGregor GA, Missouris CG.  Percutaneous transluminal renal artery angioplasty: who benefits most? Int J Clin Pract. 2002; 56:649-54. PubMed
 
Franklin SS, Smith RD.  Comparison of effects of enalapril plus hydrochlorothiazide versus standard triple therapy on renal function in renovascular hypertension. Am J Med. 1985; 79:14-23. PubMed
 
Hanzel G, Balon H, Wong O, Soffer D, Lee DT, Safian RD.  Prospective evaluation of aggressive medical therapy for atherosclerotic renal artery stenosis, with renal artery stenting reserved for previously injured heart, brain, or kidney. Am J Cardiol. 2005; 96:1322-7. PubMed
 
Ogihara T, Kaneko Y, Ikeda M, Yamada K, Omae T, Arakawa K. et al.  Clinical evaluation of delapril in Japan. Report from the Japan Study Group on Delapril. Am J Hypertens. 1991; 4:42S-45S. PubMed
 
Tillman DM, Malatino LS, Cumming AM, Hodsman GP, Leckie BJ, Lever AF. et al.  Enalapril in hypertension with renal artery stenosis: long-term follow-up and effects on renal function. J Hypertens Suppl. 1984; 2:S93-100. PubMed
 
Caps MT, Zierler RE, Polissar NL, Bergelin RO, Beach KW, Cantwell-Gab K. et al.  Risk of atrophy in kidneys with atherosclerotic renal artery stenosis. Kidney Int. 1998; 53:735-42. PubMed
 
Cheung CM, Wright JR, Shurrab AE, Mamtora H, Foley RN, O'Donoghue DJ. et al.  Epidemiology of renal dysfunction and patient outcome in atherosclerotic renal artery occlusion. J Am Soc Nephrol. 2002; 13:149-57. PubMed
 
Conlon PJ, Little MA, Pieper K, Mark DB.  Severity of renal vascular disease predicts mortality in patients undergoing coronary angiography. Kidney Int. 2001; 60:1490-7. PubMed
 
Fergany A, Novick AC, Goldfarb DA.  Management of atherosclerotic renal artery disease in younger patients. J Urol. 1994; 151:10-2. PubMed
 
Houston JG, Gandy SJ, Milne W, Dick JB, Belch JJ, Stonebridge PA.  Spiral laminar flow in the abdominal aorta: a predictor of renal impairment deterioration in patients with renal artery stenosis? Nephrol Dial Transplant. 2004; 19:1786-91. PubMed
 
Iglesias JI, Hamburger RJ, Feldman L, Kaufman JS.  The natural history of incidental renal artery stenosis in patients with aortoiliac vascular disease. Am J Med. 2000; 109:642-7. PubMed
 
Uzu T, Takeji M, Yamada N, Fujii T, Yamauchi A, Takishita S. et al.  Prevalence and outcome of renal artery stenosis in atherosclerotic patients with renal dysfunction. Hypertens Res. 2002; 25:537-42. PubMed
 
Alhadad A, Ahle M, Ivancev K, Gottsater A, Lindblad B.  Percutaneous transluminal renal angioplasty (PTRA) and surgical revascularisation in renovascular disease—a retrospective comparison of results, complications, and mortality. Eur J Vasc Endovasc Surg. 2004; 27:151-6. PubMed
 
Cherr GS, Hansen KJ, Craven TE, Edwards MS, Ligush J Jr, Levy PJ. et al.  Surgical management of atherosclerotic renovascular disease. J Vasc Surg. 2002; 35:236-45. PubMed
 
Galaria II, Surowiec SM, Rhodes JM, Illig KA, Shortell CK, Sternbach Y. et al.  Percutaneous and open renal revascularizations have equivalent long-term functional outcomes. Ann Vasc Surg. 2005; 19:218-28. PubMed
 
Marone LK, Cambria RP.  Revascularization for renal function retrieval: which patients will benefit? Perspect Vasc Surg Endovasc Ther. 2004; 16:249-58.
 
Hricik DE, Browning PJ, Kopelman R, Goorno WE, Madias NE, Dzau VJ.  Captopril-induced functional renal insufficiency in patients with bilateral renal-artery stenoses or renal-artery stenosis in a solitary kidney. N Engl J Med. 1983; 308:373-6. PubMed
 
Jackson B, Murphy BF, Johnston CI, Kincaid-Smith P, Whitworth JA.  Renovascular hypertension: treatment with the oral angiotensin-converting enzyme inhibitor enalapril. Am J Nephrol. 1986; 6:182-6. PubMed
 
Spinosa DJ, Matsumoto AH, Angle JF, Hagspiel KD, Cage D, Bissonette EA. et al.  Safety of CO(2)- and gadodiamide-enhanced angiography for the evaluation and percutaneous treatment of renal artery stenosis in patients with chronic renal insufficiency. AJR Am J Roentgenol. 2001; 176:1305-11. PubMed
 
Takabatake T, Ohta H, Yamamoto Y, Ishida Y, Hara H, Ushiogi Y. et al.  Effect of angiotensin blockade and converting enzyme inhibition on renovascular hypertension: comparison between unilateral and bilateral renal artery stenosis. Angiology. 1987; 38:434-9. PubMed
 
Gross CM, Krämer J, Weingärtner O, Uhlich F, Luft FC, Waigand J. et al.  Determination of renal arterial stenosis severity: comparison of pressure gradient and vessel diameter. Radiology. 2001; 220:751-6. PubMed
 
Cooper CJ, Murphy TP, Matsumoto A, Steffes M, Cohen DJ, Jaff M. et al.  Stent revascularization for the prevention of cardiovascular and renal events among patients with renal artery stenosis and systolic hypertension: rationale and design of the CORAL trial. Am Heart J. 2006; 152:59-66. PubMed
 

Letters

NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Comments

Submit a Comment
Submit a Comment

Supplements

Summary for Patients

Clinical Slide Sets

Terms of Use

The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.

Toolkit

Want to Subscribe?

Learn more about subscription options

Advertisement
Related Articles
Related Point of Care
Topic Collections
PubMed Articles

Want to Subscribe?

Learn more about subscription options

Forgot your password?
Enter your username and email address. We'll send you a reminder to the email address on record.
(Required)
(Required)