The unending saga of renal artery stenting: A “slam-dunk” intervention that turned out not to be

Consider the following:

– Renal artery stenosis (RAS) is a frequent finding on patients with severe atherosclerotic disease;
– RAS is well documented to be an important treatable cause of severe hypertension;
- It can also lead to significant or even critical renal dysfunction when the entire renal-parenchyma mass is affected, most typically in the setting of severe bilateral RAS;
- Other potential but less common complications of RAS are well known as well, particularly cardiac dysfunction leading to flash pulmonary edema and aggravated angina symptoms;
- Renal artery revascularization can reverse and/or prevent the above-described when performed on well-selected patients, but the surgical approach (in use for many years) proved technically complex and is accompanied by significant morbidity and mortality;
- Thus, the development of percutaneous catheter-based RA intervention was viewed widely as a most significant advancement since the procedure can be performed relatively easily and safely, and (mostly) on an outpatient basis.

When put all together as I did above, one could not help but be almost sure that RA stenting would rapidly become widely used and prove to be of enormous benefit to countless patients: a good example of a “slam-dunk” intervention!

Well, in reality, RA stenting has been shown to be anything but a slam-dunk, with trial after trial failing to show a clear-cut benefit. The much-awaited ASTRAL trial proved to be no different.

We are left in a place of doubt and equivocation vis-à-vis the selection of patients for renal revascularization and RA stenting. And while many interventionists (myself included) continue to treat many renal RAS cases when the resultant stenosis appears very tight, and especially when present bilaterally and with mildly impaired renal function, it is extremely difficult to ascertain the wisdom or even appropriateness of continuing such pursuits. I’d love to hear voices — pro and con — across the spectrum of vascular and interventional physicians on this difficult matter.

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Dr. Frank J Criado is a Board-Certified Vascular Surgeon and Endovascular Specialist at the Union Memorial Hospital-MedStar Health in Baltimore, Maryland – USA.

Dr. Criado is widely acknowledged to be a pioneer in endovascular therapy, with a 20-year + interventional experience. He has contributed extensively to the literature with more than 100 peer-reviewed published articles – mostly on various vascular and endovascular subjects, and Editor-in-Chief of Vascular Disease Management (VDM). He has also been active in clinical research, with a major focus on aortic stent-graft and carotid interventions, and endovascular technologies in general. He was the National Principal Investigator (P.I.) for the Medtronic Talent AAA clinical trials in the U.S., and a member of the Executive Committee for the Medtronic Valor Thoracic trial.

He is a founding member and immediate past President of the International Society of Endovascular Specialists (ISES), founder and current President of the endovascular surgery society of Latinamerica (CELA), and a member of all major U.S. and international vascular and endovascular societies. He is a Fellow of the American College of Surgeons (FACS) and of the Society of Vascular Medicine (FSVM), and a member of the Board of Directors of the Society for Vascular Surgery (SVS).