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BR 05-2 ANGIOPLASTY OF ATHEROSCLEROTIC RENAL ARTERY STENOSIS: WHO BENEFITS?

Atherosclerotic renal artery stenosis is an increasingly recognized medical problem especially in elderly patients. It commonly occurs with systemic manifestations including hypertension (HTN), chronic kidney disease (CKD) or atherosclerotic diseases including coronary or peripheral artery disease. Significant renal artery stenosis may result in HTN, ischemic nephropathy, however it is still in debate about the benefit of revascularization. Although several randomized controlled trials including Angioplasty and Stenting for Renal Artery Lesions (ASTRAL) and Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL) study has failed to reveal a significant benefit of angioplasty, angioplasty with medical therapy is increasingly accepted in some patients with certain clinical conditions.For determining appropriate candidates for renal artery angioplasty, anatomical evaluation of renal artery stenosis and atherosclerotic change of abdominal aorta should be preferentially undergone. Angiographic stenosis more than 50% with physiologic significance, or ≥70% stenosis is considered significant. Translesional pressure gradient with or without hyperemia should be routinely assessed in intermediate stenosis (50-70%). Intravascular ultrasound assessment may be used to evaluate luminologic severity or characteristics.Global renal ischemia caused by renal artery stenosis should be an appropriate indication of revascularization, however unilateral and solitary ischemia would be considerable. Patients with cardiac disturbance syndrome or pulmonary edema relevant to renal artery stenosis can be managed with renal artery angioplasty. Several prospective randomized trials have failed to show a significant difference in blood pressure (BP) response after revascularization or medical treatment, nevertheless resistant HTN with global renal ischemia would be a proper indication of revascularization. Both patient groups with revascularization and medication alone in CORAL showed similar BP response about 15 mmHg. Such BP responders with optimal medication may be not appropriate candidates for revascularization for controlling BP. Patients with reduced renal function and global renal ischemia may be also good candidates for renal artery stenting. However, evidences to support revascularization in unilateral renal artery stenosis are limited. Revascularization would be considered if renal artery stenosis is relevant to hemodynamic significance.

CONCLUSION: Although revascularization with stenting have been commonly used for patients with renal artery stenosis, previous results are inconclusive and lacking to support comprehensive indications of current clinical application. Selection of candidates who benefits with angioplasty should be carefully conducted with sufficient diagnostic evaluation.

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