Renal Artery Stenting in Patients With Uncontrolled Hypertension: Should We? And to Whom? (original) (raw)

2014, The Journal of Clinical Hypertension

In this issue of the Journal, Chrysant and colleagues evaluated the longer-term efficacy of renal artery stenting with respect to blood pressure (BP) control by analyzing the results of the Safety and Effectiveness Study of the Herculink Elite Renal Stent to Treat Renal Artery Stenosis (HERCULES) trial after 36 months of follow-up. The HERCULES trial was a multicenter, single-arm trial of 202 patients with uncontrolled hypertension caused by atherosclerotic renovascular disease (ARVD) treated by percutaneous renal artery dilatation and renal stent placement. In the original HERCULES trial, the authors found that the absolute reduction in systolic BP (SBP) after 9 months was related to the severity of the baseline hypertension before intervention. In ARVD patients with preprocedure SBP >180 mm Hg and a postprocedure reduction in SBP, the mean reduction recorded at 9 months was 48 mm Hg, while patients with ARVD with a baseline SBP between 140 mm Hg and 160 mm Hg had a decrease of only 23 mm Hg in SBP at 9 months. In addition, this trial demonstrated excellent procedurerelated safety, with a 30-day composite safety endpoint rate of 1.5%. Chrysant and colleagues further hypothesized that if the renal stent used in the initial HERCULES trial maintained renal artery patency over time, then the clinical benefit confirmed in the initial trial should be sustained over time. Based on this hypothesis, the authors gave 3-year results. The included patients were those with uncontrolled hypertension defined as an SBP ≥140 mm Hg or a diastolic BP (DBP) ≥90 mm Hg despite maximal doses of at least 2 antihypertensive agents in appropriate combinations and with renal artery stenosis ≥60% (angiographic visual estimate). The suboptimal percutaneous transluminal balloon renal angioplasty (PTRA) result was defined as one of the following: ≥50% residual stenosis, a persistent translesional pressure gradient (mean 10 mm Hg, or peak systolic gradient of 20 mm Hg), flow-limiting dissection, or thrombolysis in myocardial infarction flow <3. Patients with either unilateral or bilateral atherosclerotic renal artery stenosis were included. Lesions representing in-stent resteno-sis following a prior endovascular revascularization were not eligible for enrollment. Patients with serum creatinine >2.5 mg/dL, recent myocardial infarction, stroke or transient cerebral ischemia, impaired left ventricular ejection fraction (≤25%), atherosclerotic renal artery stenosis and a solitary functioning kidney, or transplant renal artery stenosis were also ineligible for the study.