November 22, 2009

Revascularization versus Medical Therapy for Renal-Artery Stenosis

ASTRAL Investigators, Wheatley K, Ives N, Gray R, Kalra PA, Moss JG, Baigent C, Carr S, Chalmers N, Eadington D, Hamilton G, Lipkin G, Nicholson A, Scoble J.   N Engl J Med.   2009 Nov 12;361(20):1953-62

This randomized, non-blinded study of patients with renovascular disease compared renal artery revascularization plus medical therapy vs medical therapy alone.  Those in the revascularization arm experience an increased rate of serious complications with no reduction in pre-defined clinical endpoints.

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Renal Artery Stenosis, Vascular Disease/Calcification
  • Mario T. Parise M.D.

    There are many problems with this paper. To start,the follow up of this study is only 34 months. How is one able to acertain a deterioration curve for Scr in the medical group in only 34 months? For example; a 70 yo 8o Kg male has a 95% osteal leison. If his GRF is 70% at age 70 and that lesion is allowed to close his GRF would be in the neighborhood of 35% when it closes as he lost 50% of his existing frnal function. I would agree that this would be unlikely to happen in 34 months however, I would expect him to loose function in ten years undoubtedly. Simply, this study shows no difference between groups in 34 months which in my opinion is to short to tell anything.
    With regard to the complications cited, my first questions are; how many different M.D.’s were involved in the stenting and what was there level of training? I am a nephrologist and have referred over 500 cases to a single skilled cardiology collegue since 1993. On one occasion we had a mottled toe which resolved quickly. I can not for the life of me fathom limb loss and death as complications with this relatively simple procedure.
    We are aware that our experience is anectdotal however, we have attempted to participate in the “CORAL” study to no avail and have approached two professors to assist us in publishing our experience. I am hopefull that we will be able to publish these data soon. M.T.Parise M.D.