Contemporary management of atherosclerotic renovascular disease: Before and after ASTRAL

Optimal medical management in patients with renovascular hypertension

Renovascular hypertension refers to the rise of arterial pressure due to reduced perfusion of the kidney caused by the stenotic renal artery/ies. The most common cause of stenotic renal artery is atherosclerosis. Atherosclerotic renal stenosis is usually part of a systemic syndrome that involves hypertension, intrinsic renal damage, and cardiovascular morbidity. So far, large trials have not proven the superiority of interventional therapies to medical management. As a result, renal artery stenosis should be treated mainly as a coronary artery disease equivalent focusing on rigorous management of hypertension, hyperglycemia, and hyperlipidemia. Antihypertensive treatment should include renin-angiotensin system blockade medication in most cases, while HMG-CoA reductase inhibitors (statins) can be used even in chronic kidney disease with safety. Lifestyle modifications, such as cessation of smoking, and antiplatelet therapy have reduced the risk of cardiovascular events in high-risk patients.

Influence and critique of the ASTRAL and CORAL Trials

Optimal management of renal artery atherosclerotic occlusive disease has been widely debated and studied. Although the accepted invasive treatment has evolved into favoring balloon angioplasty and stenting, the indications for intervention or medical therapy have not been universally agreed upon. The Angioplasty and Stenting for Renal Artery Lesions (ASTRAL) trial was conducted to answer the question of whether medical therapy or angioplasty and stenting is the best treatment for hemodynamically significant renal artery stenosis. However, the ASTRAL trial's study design was faulty and therefore did not provide conclusive evidence to answer the question. The Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL) trial was designed to answer the same question as to which treatment (medical or angioplasty and stent) is best for renal artery stenosis, and its methodologies took into consideration the weaknesses of the ASTRAL trial. Results are soon to be released.