Endovascular Treatment of Renal Artery Stenosis in the Post CORAL Era

Atherosclerotic renal artery stenosis (RAS) is highly associated with hypertension and renal insufficiency. Determining causation and who may benefit from RAS treatment remains difficult. The role of endovascular management of atherosclerotic RAS was challenged by several recent randomized controlled trials (RCT) which failed to demonstrate benefit of stenting. In the largest RCT to date, the Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL) study did not find benefit of revascularization compared to medical therapy alone. While such RCTs represent the highest level of evidence to date, the conclusions drawn from them should be interpreted with caution due to substantial flaws in study design, inclusion, and exclusion criteria. The current AHA/ACC recommendations for RAS management are supported by many level-II evidence cohort studies which consistently found benefit of revascularization in groups with the highest likelihood of clinically significant RAS. Further study of these patient groups are needed to define a clear role for endovascular therapy of renal artery stenosis.