Endovascular revascularization in treatment of atherosclerotic renal-artery stenosis (aRAS) is controversial since 3 large and multicentric randomised trials failed to prove the superiority of percutaneous transluminal renal-artery stenting (PTRAS) over medical treatment only (MT). However, considering the multiple bias of these trials, the extrapolation of these results in clinical practice is controversial.Design and method:
All aRAS diagnosed cases were discussed during bi-monthly multidisciplinary meetings gathering nephrologists, radiologists and vascular surgeons experienced in ischemic nephropathy in our center. We compiled initial clinical, biological and radiological data, and considered therapeutic option collectively taken on. We recorded blood pressure (BP), serum creatinin and antihypertensive drug therapy after a one-year follow-up.Results:
52 cases were discussed during 23 months. Mean age was 69 years. Prevalence of cardiovascular risk factors was high. Mean initial BP was 146/80 mmHg, despite the use of 2.5 ± 1.1 anti-hypertensive agents. CKD-epi-estimated GFR was 44 ± 28 mL/min/1,73 m2. One third (31%) of patients had a history of pulmonary edema. Collective therapeutic decisions were: PTRAS for 20 patients (40%), MT for 29 patients (54%) and surgery for 3 patients (6%). PTRAS and MT groups were initially comparable on a clinical view (blood pressure, renal function, treatment, comorbidities) except for age (younger in PTRAS group). In multivariate analysis, PTRAS treatment orientation was favored in younger patients (RR = 0.88/extra year, 95%CI 0.78–0.99, p = 0.040), reduced eGFR (RR = 0.95/ml/min/1.73m2, 95%CI 0.91–1.00, p = 0.048) and/or with high ultrasound peak systolic velocity (RR = 4.3/extrameter/second, 95%CI 1.34–13.52, p = 0.014). In the PTRAS group, significant one-year improvement was observed for BP control (systolic −22.6 ± 29.3 mmHg, p = 0.006; diastolic −10.1 ± 12.9 mmHg, p = 0.030), antihypertensive drug number (−0.8 ± 0,94, p = 0.015) and serum creatinin (−18.3 ± 35.4 μmol/L, p = 0.037) versus MT group. Multivariate analysis revealed renal revascularization as an independent factor of BP improvement (RR = 84.7, 95% CI 3.11–2306.74, p = 0.008).Conclusions:
Multidisciplinary identification of PTRAS indications leads to better BP control, reduction in anti-hypertensive drugs and improvement in renal function. This significant improvement could be explained by a better selection of patients who will benefit from PTRAS, based on an individualized clinical and radiological data analysis. This interdisciplinary management of aRAS needs further prospective evaluation.