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Treating Renal-Artery Stenosis: Skip the Stent

November 18, 2013

Treating Renal-Artery Stenosis: Skip the Stent

  1. Harlan M. Krumholz, MD, SM

In patients with atherosclerotic renal-artery stenoses and hypertension, clinical outcomes were no better with stenting than with medical therapy alone.

  1. Harlan M. Krumholz, MD, SM

Despite findings from prior studies that failed to show a benefit of renal-artery stenting in patients with atherosclerotic stenoses and hypertension (NEJM JW Gen Med Nov 12 2009), enthusiasm for the procedure has remained unabated in many quarters. The refrain from some doctors I know was that they were waiting for the results of the CORAL trial before considering practice change. Those results have now arrived.

The CORAL investigators randomized 947 patients with resistant hypertension or stage ≥3 chronic kidney disease and atherosclerotic renal-artery stenosis (mean stenosis, 73%) to medical therapy either with or without stenting. At a median follow-up of 43 months, the primary endpoint (a composite of death from cardiovascular or renal causes, acute myocardial infarction, stroke, hospitalization for heart failure, renal insufficiency, and the need for permanent renal replacement therapy) was 35.1% in the stenting group and 35.8% in the medical-therapy group (P=0.58). Systolic blood pressure was lower in the stenting group than in the medical-therapy group by 2.3 mm Hg (P=0.03). No subgroup derived a benefit from stenting, including patients with more-severe stenoses.

Comment

An editorialist makes clear the strength of this evidence and states that this study “establishes beyond a reasonable doubt that renal-artery stenting is futile” in this patient population. The only question now is, how long will it take for us to stop doing it?

To join an online discussion of these findings, go to CardioExchange, an online community hosted by the New England Journal of Medicine and NEJM Journal Watch and dedicated to improving cardiac patient care. Membership is free for medical professionals.

  • Disclosures for Harlan M. Krumholz, MD, SM at time of publication Consultant / Advisory board United Healthcare Equity ImageCor Speaker's bureau Centrix Grant / research support FDA; NIH-NHLBI; Commonwealth Fund; The Catherine and Patrick Weldon Donaghue Medical Research Foundation; Robert Wood Johnson Foundation; Medtronic Editorial boards BMJ.com/us; American Journal of Managed Care; American Journal of Medicine; Archives of Medical Science; Central European Journal of Medicine; Congestive Heart Failure; Critical Pathways in Cardiology; Current Cardiovascular Risk Reports; JACC: Cardiovascular Imaging; Journal of Cardiovascular Medicine; Circulation: Cardiovascular Quality and Outcomes Leadership positions in professional societies American Board of Internal Medicine (Chair, Assessment 2020 Task Force); American College of Cardiology (CV Research and Scholarly Activity, and Lifelong Learning Oversight Committee); American College of Physicians (CV Research and Scholarly Activity); American Heart Association (CV Research and Scholarly Activity); Centers for Medicare & Medicaid Services (Heart Care Technical Expert Panel); Oklahoma Foundation for Medical Quality (Heart Care Technical Expert Panel); VHA, Inc. (Center of Applied Healthcare Studies External Advisory Board)

Citation(s):

Reader Comments (6)

Lorick Fox, PA-C, AACC Other Healthcare Professional, Cardiology

I tend to agree with Dr. Reddy, that I have rarely seen lack of benefit in setting of high grade stenosis. I also agree that using 60% as a definition of hemodynamically significant stenosis does not appear to be evidence based.
The other point not addressed is quantity/cost of medication required, ADR's and general QOL. In 2013, it strikes me as unacceptable to fail to study these issues.

Howard McCarthy retired general surgeon Other, Surgery, Specialized, Retired

Personal question - I have 90% L renal artery stenosis with gradual atrophy of the cortex of L kidney (current 1 cm)). One nephrologist "get stent", another said no. BP is well controlled with Ca channel blocker plus labetolol and Lasix. Stage 3 CKD and feel Ok. Would stent give better eGFR re Kidney disease.

CHRISTOPHER WHITE Physician, Cardiology, Ochsner Clinic

Depending on the degree of atrophy, in general, revascularization will restore renal function. If atrophy is severe, pole to pole sizes <7cm, they generally do not improve.

Reddy Physician, Cardiology

Study is poorly designed. I have yet to see failure of benefit for critical renal artery stenosis . Especially b/l. They are sure to end in dialysis >90%

Ischemic death of kidneys cannot be allowed with poorly designed studies like this

homz

As pointed out in the NEJM editorial as well, perfusion of the kidneys far outweighs their metabolic demand, and a "stringer" inclusion criteria of > 60% stenosis may not be stringent enough to note a benefit in the primary outcome; Average stenosis in this trial was 73%. Animal studies have indicated only stenoses of > 80% to be of "significant" magnitude. For obvious reasons, conduction of such trial wold hampered by slow enrollment, and would be nearly impossible. Not sure if CORAL demonstrates lack of potential efficacy of stenting in a patient with 90% stenosis, recalcitrant hypertension on optimal medical therapy and CKD.

Gabriel-Levon Physician, Cardiology, Retired in Iran-Shiraz

I like this comment.How long will take for us to stop doing it.
I hope one day to see stoping to put stent in stable coronary artery as well.

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