An Analysis Comparing Open Surgical and Endovascular Treatment of Atherosclerotic Renal Artery Stenosis

Abstract 

Objective

Endovascular revascularization in atherosclerotic renal artery stenosis (ARAS) has dominated during the last 15 years with surgery relegated mostly to back-up for failed endovascular procedures. This study examines the available outcome evidence to determine what role open surgery should have in comparison to endovascular treatment in the management of ARAS.

Method

Of 183 papers listed in PubMed, the USNLM and the Cochrane library, (1975–2004) 47, dealing with outcomes of surgical and endovascular treatments (evidence levels 2b and 3) were selected. Endovascular included 1750 patients in 16 prospective non-randomised (PNRT) and 5 retrospective (RET) studies. Surgical included 2314 patients in 4 PNRTs and 17 RETs. Outcome data were subjected to meta-regression analysis weighted according to the inverse variance method.

Results

Mean maximum ages were 79.4 yrs (SD 6.9) for surgical and 83.6 yrs (SD 3.8) for endovascular studies. Primary technical success was similar. Endovascular patency declined by 0.26%/month (95% CI: 0.04–0.48, p=0.03). Surgical studies showed greater improvement for hypertension control by 21% (95% CI: 9–33%, p=0.001) and for renal function by 34% (95% CI: 18–54%, p<0.001), as well as a higher creatinine reduction by 32μmol/L (95% CI: 7–57μmol/L, p<0.014). A higher excess surgical mortality, 3.1% (95% CI: 1.8–4.4%, p<0.001) became insignificant, 0.18% (95% CI: 0.7–1.1, p=0.70) when concomitant aortic surgery was excluded.

Conclusion

This data shows a marked and durable clinical benefit for surgery. These findings question the endovascular predominance in intervention in ARAS and highlight the need for a carefully designed prospective randomised comparison to define the roles of endovascular and surgical renal revascularization.

Keywords: Atherosclerotic renal artery stenosis, Surgical revascularization, Stent revascularization, Hypertension, Renal function