Reengineering US Health Care

Abstract

Despite substantial improvement in imaging techniques over the past decade, clinicians have become increasingly reluctant to search for renal artery stenosis in patients with hypertension. A reason for refraining from a diagnostic trajectory is doubt as to whether treatment of atherosclerotic renal artery stenosis with angioplasty, with or without stent placement, confers any benefit to the patient. A meta-analysis of 3 small randomized trials showed only a modest effect of balloon angioplasty on blood pressure among patients with atherosclerotic renal artery stenosis and 50% or more luminal reduction.1 Although not designed for that purpose, the trials did not show any benefit of angioplasty for preservation of renal function. This observation was reinforced by a large randomized trial2 demonstrating that rates of renal events, major cardiovascular events, and death were similar in the group assigned to undergo revascularization in addition to optimal medical treatment compared with the control group that received medical treatment only. In addition, no significant between-group differences in systolic blood pressure were apparent, and revascularization was associated with 31 serious complications in 23 patients. According to many investigators, therefore, this trial indicates that curing renovascular hypertension is not currently possible.