Practice changes in renal artery stenting after the CORAL trial

INTRODUCTION: Renal angioplasty emerged as an alternative for renal artery stenosis (RAS). In 2009 and 2014, two clinical trials (ASTRAL and CORAL) led to a paradigm shift in renovascular disease. Neither showed a clear benefit over best medical treatment, although there were methodological flaws. This study aims to evaluate the impact of these trials in clinical practice. METHODS: We designed a retrospective cross-sectional study from patients submitted to renal artery angioplasty between 1999 and 2021 in a tertiary center. Patients were selected from the center’s surgical records. Diagnostic arteriograms, open interventions and renal graft failures were excluded. Patients were divided in two cohorts: a historical group from 1999 to 2013 and a contemporary cohort, from 2014 to 2021. We compared the number of angioplasties per year and patient comorbidities, preoperative lesion severity, renal function, and the number of antihypertensive drugs. RESULTS: 152 patients were included: 104 patients between 1999-2013 (7 cases per year [5-8]) and 48 patients between 2014-2021 (6.5 cases per year [4.5-7]), with no significant difference between medians (p=0.53). Patients included between 2014-2021 were taking more antihypertensive drugs (3 [2-4] vs. 2 [1-3]; p=0.001) with a worse renal function (eGFR 44,2 ± 25,9 vs. 68,6 ± 29,2; p<0.001). Comparing with the results from the CORAL trial, patients included in the whole cohort had a significantly higher degree of stenosis (84.2 ± 7.52 vs. 72.5 ± 14.6; p < 0.001) and a higher proportion of patients in stage ≥3 chronic kidney disease (56.6% vs. 49.6%; p 0.002). While there was a benefit in renal function improvement, no difference was found in blood pressure control. CONCLUSION: Renal artery angioplasties emerged as a first-choice therapy in hemodynamically significant stenoses in patients with difficult-to-control hypertension with or without renal failure. The CORAL trial in 2014, by showing no clear benefit over best medical treatment, led to a paradigm shift. Although the annual number of procedures remained unchanged, patients treated after 2014 had more severe lesions, worse preoperative renal function and blood pressure control. Further studies should assess who truly benefits from this procedure.