[Stent or not in the case of renal artery stenosis? No clear-cut answer yet]

Area of Science:

• Cardiology
• Nephrology
• Vascular Medicine

Context:

• Atherosclerotic renal artery stenosis (RAS) affects numerous patients, often leading to renal events.
• Recent trials like STAR and ASTRAL evaluated revascularization versus medical therapy for moderate-to-severe RAS.
• Complications from interventions in these patients are often linked to widespread atherosclerosis.

Purpose:

• To analyze the efficacy of stenting versus medical treatment for atherosclerotic renal artery stenosis.
• To discuss the implications of recent trial findings on clinical practice for RAS management.
• To propose future research directions for optimizing treatment strategies.

Summary:

• Recent trials (STAR, ASTRAL) suggest medical therapy alone is non-inferior to stenting plus medical therapy for preventing renal events in patients with 50-70% atherosclerotic renal artery stenosis.
• High complication rates in catheter interventions are attributed to generalized atherosclerosis in this patient population.
• Intervention may be too late to prevent renal events in advanced cases; stenting for lower-grade RAS could be an option for hypertension and RAS, requiring prospective trials.

Impact:

• Findings challenge the routine use of stenting in moderate-to-severe atherosclerotic renal artery stenosis.
• Highlights the need for careful patient selection for revascularization procedures.
• Suggests a potential role for stenting in specific subgroups, such as those with lower-grade stenosis and hypertension, necessitating further investigation through randomized controlled trials.