Stenting and Medical Therapy for Atherosclerotic Renal-Artery Stenosis

Study Questions:

What is the benefit of renal artery stenting for the prevention of major adverse renal and cardiovascular events in patients with atherosclerotic renal artery stenosis?

Methods:

The CORAL (Cardiovascular Outcomes in Renal Atherosclerotic Lesions) authors randomly assigned 947 participants who had atherosclerotic renal artery stenosis and either systolic hypertension while taking two or more antihypertensive drugs or chronic kidney disease to medical therapy plus renal artery stenting or medical therapy alone. Participants were followed for the occurrence of adverse cardiovascular and renal events (a composite endpoint of death from cardiovascular or renal causes, myocardial infarction, stroke, hospitalization for congestive heart failure, progressive renal insufficiency, or the need for renal replacement therapy).

Results:

There was no difference in the primary composite endpoint between the two arms over a median follow-up period of 43 months (35.1% and 35.8%, respectively; hazard ratio with stenting, 0.94; 95% confidence interval [CI], 0.76-1.17; p = 0.58). There were also no significant differences between the treatment groups in the rates of the individual components of the primary endpoint or in all-cause mortality. During follow-up, there was a modest difference in systolic blood pressure favoring the stent group (-2.3 mm Hg; 95% CI, -4.4 to -0.2; p = 0.03).

Conclusions:

The authors concluded that renal artery stenting was not associated with a major clinical benefit in patients with atherosclerotic renal artery stenosis.

Perspective:

This study adds to the growing data supporting lack of benefit of stenting for renal artery disease in elderly patients. No subgroups were identified in this study or in the ASTRAL trial (N Engl J Med 2009) that benefited from stenting, and stenting cannot be recommended for routine treatment of renal artery stenting.

Clinical Topics: Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Vascular Medicine, Acute Heart Failure, Interventions and Vascular Medicine, Hypertension

Keywords: Stroke, Myocardial Infarction, Follow-Up Studies, Blood Pressure, Constriction, Pathologic, Stents, Renal Artery Obstruction, Heart Failure, Confidence Intervals, Renal Replacement Therapy, Renal Insufficiency, Chronic, Hypertension


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