Q J Med 1999; 92: 159-167
© 1999 Association of Physicians
Management of renovascular disease: a review of renal artery stenting in ten studies
From the Renal Unit and 1 Department of Radiology, Dumfries and Galloway Royal Infirmary, Dumfries, UK
Received 27 October 1998
Dr C.G. Isles, Renal Unit, Dumfries and Galloway Royal Infirmary, Dumfries DG1 4AP
To evaluate the efficacy and safety of renal artery stents in renovascular disease, we identified 10 descriptive studies containing sufficient information for systematic evaluation. No randomized comparisons of stenting with angioplasty or with surgery were found. Overall, stents were placed in 416 renal arteries in 379 patients, mean age 64 years (range 27–84), 56% male. Of the stenoses, 97% were atheromatous (inter-study range 71–100%), 80% ostial (22–100%) and 31% bilateral (12–87%). The clinical indication for stenting was usually hypertension with or without mild renal impairment. Radiological indications for stenting were: narrowing of 
50% (in 9/10 studies) as a result of elastic recoil (58%) or dissection (2%) at the time of angioplasty; restenosis some time after angioplasty (15%); or as a primary procedure (25%). Technical success was reported in 96–100% of procedures. Restenosis (50% narrowing), evaluated in 312/416 (75%) arteries, generally between 6 and 12 months, was 16% overall. Hypertension was cured by stenting (DBP 
90 mmHg on no treatment) in 34/379 (9%) overall and in 34/207 (16%) of those whose renal function was normal initially. Six of 379 (1.6%) patients died within 30 days of stenting, but in only two (0.5%) was death judged to be procedure-related. Complications, other than those which led to dialysis, occurred in 42/379 (13%) patients, one third requiring intervention, ranging from blood transfusion to a surgical bypass procedure. Renal function as judged by serum creatinine concentration (SCC) improved in 26%, stabilized in 48% and deteriorated in 26% of patients whose renal function was impaired initially (SCC >133 µmol/l). In one study, with average baseline SCC >200 µmol/l, successful stenting slowed the rate of progression of renal failure when renal function was deteriorating beforehand. Nine of 379 (2.4%) patients, including 7/14 (50%) whose SCC was 400 µmol/l initially, required dialysis after stenting. Stenting should be offered by specialist centres as a secondary procedure for unsuccessful angioplasty, or restenosis following angioplasty, to patients with renovascular disease and uncontrolled hypertension, advancing renal failure or pulmonary oedema.
Author note: Since this paper was accepted, a randomized comparison of angioplasty with stent (n=40) versus angioplasty alone (n=41) in ostial atherosclerotic renovascular disease has been published (van de Ven, Lancet 1999; 353:282–6). Primary patency rates at six months were 75% for stent and 29% for angioplasty. The corresponding secondary patency rates were 80% and 51%. Despite the better angiographic result there were no differences in blood pressure and renal function between the two groups at six months. The authors concluded that primary stenting should be the preferred procedure for ostial atherosclerotic renovascular disease.
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