Late Outcomes of Endovascular and Open Revascularization for Nonatherosclerotic Renal Artery Disease

Abstract

Conclusion: In patients with nonatherosclerotic renal artery disease (NARAD), open revascularization results in superior 1- and 5-year outcomes compared with endovascular management. Summary: Fibromuscular dysplasia and Takayasu arteritis are the most common etiologies of NARAD leading to hypertension. Open or endovascular revascularization is preferred over medical management alone in patients with severe hypertension associated with NARAD. Percutaneous transluminal angioplasty (PTA) is generally considered first-line therapy for fibromuscular disease, whereas open revascularization is generally thought to be the best treatment for patients with Takayasu arteritis. The purpose of this report was to evaluate long-term outcomes of endovascular and open treatment of NARAD. This was a retrospective review of 55 patients (47 women), with a mean age of 40 years. Underlying disease processes included Takayasu arteritis in 31 patients and fibromuscular dysplasia in 24. Open revascularization was compared with renal artery PTA, with and without stenting, for primary, primary assisted, and secondary patency rates as well as blood pressure, antihypertensive medication requirements, renal function, and mortality. Among the 79 renal artery interventions performed were 59 aortorenal bypasses (16 ex vivo), 3 visceral-to-renal artery bypasses, 5 nephrectomies, and 12 endovascular percutaneous revascularizations, 4 of which included stent placement. There were no procedural deaths. Mean follow-up was 75 months. Rates of primary patency at 1, 3, and 5 years for any intervention were 87%, 75% and 75%, respectively. Primary, primary assisted, and secondary patency rates were 92%, 86%, and 86%, respectively. Primary patency rates for endovascular interventions at 1, 3, and 5 years were 73%, 49%, and 49%. Primary assisted/secondary patency rates for endovascular interventions were 83%, 83%, and 83% at 1, 3, and 5 years. At 1, 3, and 5 years, primary patency rates for open revascularization were 91%, 80%, and 80%. Primary assisted/secondary patency rates for open interventions at 1, 3 and 5 years were 94%, 87%, and 87%, respectively. Open and endovascular interventions both resulted in improvements in blood pressure and the number of antihypertensive medications compared with preintervention values (all P < .05). Revascularization also improved serum creatinine levels and estimated glomerular filtration rate (both P < .05). The 5- and 10-year actuarial survival rates were 94% and 78%, respectively. Comment: The authors demonstrated open and endovascular intervention can be safe and effective in management of renal artery-mediated hypertension and renal dysfunction associated with NARAD. The patients are not randomized, and any conclusions are somewhat weakened by the study design, but in general, the data indicate primary open revascularization, when compared with endovascular intervention, results in superior outcome with respect to patency with equivalent safety. The authors' conclusion is that open revascularization should be considered selectively as first-line of therapy for NARAD in the young patient with moderate to complex renal artery disease. This conclusion is clearly suggested but not confirmed by the data.