Renal Artery Stenting in Consecutive High-Risk Patients With Atherosclerotic Renovascular Disease: A Prospective 2-Center Cohort Study

Abstract

Background The aim of this study was to prospectively evaluate the effects of renal artery stenting in consecutive patients with severe atherosclerotic renal artery stenosis and high-risk clinical presentations as defined in a national protocol developed in 2015. Methods and Results Since the protocol was initiated, 102 patients have been referred for revascularization according to the following high-risk criteria: severe renal artery stenosis (≥70%) with true resistant hypertension, rapidly declining kidney function, or recurrent heart failure/sudden pulmonary edema. At baseline, the mean 24-hour ambulatory systolic blood pressure was 166.2 mm Hg (95% CI, 162.0-170.4), the defined daily dose of antihypertensive medication was 6.5 (95% CI, 5.8-7.3), and the estimated glomerular filtration rate was 41.1 mL/min per 1.73m² (95% CI, 36.6-45.6). In 96 patients with available 3-month follow-up data, mean 24-hour ambulatory systolic blood pressure decreased by 19.6 mm Hg (95% CI, 15.4-23.8; P<0.001), the defined daily dose of antihypertensive medication was reduced by 52% (95% CI, 41%-62%; P<0.001), and estimated glomerular filtration rate increased by 7.8 mL/min per 1.73m² (95% CI, 4.5-11.1; P<0.001). All changes persisted after 24 month follow-up. Among 17 patients with a history of hospitalization for acute decompensated heart failure, 14 patients had no new episodes after successful revascularization. Conclusions In this prospective cohort study, we observed a reduction in blood pressure and antihypertensive medication, an increase in estimated glomerular filtration rate, and a decrease in new hospital admissions attributable to heart failure/sudden pulmonary edema after renal artery stenting. Registration URL: https://clinicaltrials.gov. Identifier: NCT02770066.

Keywords: atherosclerotic renal artery stenosis; atherosclerotic renovascular disease; flash pulmonary edema; rapid loss of kidney function; renal revascularization; resistant hypertension.

Figure 1. Flowchart for patients referred for angioplasty.

Figure 2. 24‐h ambulatory blood pressure (BP) and antihypertensive medication.

A, Mean values for 24‐h ambulatory systolic and diastolic BP; and (B) geometric mean values for the Defined Daily Dose of antihypertensive medication with and without loop diuretics included. In (A) the results of prestudy ambulatory blood pressure monitoring for 55 patients are shown as a dotted circle for mean systolic BP and as a dotted square for mean diastolic BP. Error bars are 95% CIs.

Figure 3. Estimated glomerular filtration rate (GFR) and urine albumin‐creatinine ratio.

A, Mean values for estimated GFR for all patients and for the subgroups of patients with rapidly declining kidney function and nonrapidly declining kidney function before renal artery stenting. The mean values for estimated GFR for the subgroups are shown until 24 months because of sparse data thereafter. B, Geometric mean values for the urine albumin‐creatinine ratio. Error bars are 95% CIs.