OBJECTIVE: Endovascular revascularization in atherosclerotic renal artery stenosis (ARAS) has dominated during the last 15 years with surgery relegated mostly to back-up for failed endovascular procedures. This study examines the available outcome evidence to determine what role open surgery should have in comparison to endovascular treatment in the management of ARAS. METHOD: Of 183 papers listed in PubMed, the USNLM and the Cochrane library, (1975-2004) 47, dealing with outcomes of surgical and endovascular treatments (evidence levels 2b and 3) were selected. Endovascular included 1750 patients in 16 prospective non-randomised (PNRT) and 5 retrospective (RET) studies. Surgical included 2314 patients in 4 PNRTs and 17 RETs. Outcome data were subjected to meta-regression analysis weighted according to the inverse variance method. RESULTS: Mean maximum ages were 79.4 yrs (SD 6.9) for surgical and 83.6 yrs (SD 3.8) for endovascular studies. Primary technical success was similar. Endovascular patency declined by 0.26%/month (95% CI: 0.04-0.48, p=0.03). Surgical studies showed greater improvement for hypertension control by 21% (95% CI: 9-33%, p=0.001) and for renal function by 34% (95% CI: 18-54%, p<0.001), as well as a higher creatinine reduction by 32 micromol/L (95% CI: 7-57 micromol/L, p<0.014). A higher excess surgical mortality, 3.1% (95% CI: 1.8-4.4%, p<0.001) became insignificant, 0.18% (95% CI: 0.7-1.1, p=0.70) when concomitant aortic surgery was excluded. CONCLUSION: This data shows a marked and durable clinical benefit for surgery. These findings question the endovascular predominance in intervention in ARAS and highlight the need for a carefully designed prospective randomised comparison to define the roles of endovascular and surgical renal revascularization.
OBJECTIVE: Endovascular revascularization in atherosclerotic renal artery stenosis (ARAS) has dominated during the last 15 years with surgery relegated mostly to back-up for failed endovascular procedures. This study examines the available outcome evidence to determine what role open surgery should have in comparison to endovascular treatment in the management of ARAS. METHOD: Of 183 papers listed in PubMed, the USNLM and the Cochrane library, (1975-2004) 47, dealing with outcomes of surgical and endovascular treatments (evidence levels 2b and 3) were selected. Endovascular included 1750 patients in 16 prospective non-randomised (PNRT) and 5 retrospective (RET) studies. Surgical included 2314 patients in 4 PNRTs and 17 RETs. Outcome data were subjected to meta-regression analysis weighted according to the inverse variance method. RESULTS: Mean maximum ages were 79.4 yrs (SD 6.9) for surgical and 83.6 yrs (SD 3.8) for endovascular studies. Primary technical success was similar. Endovascular patency declined by 0.26%/month (95% CI: 0.04-0.48, p=0.03). Surgical studies showed greater improvement for hypertension control by 21% (95% CI: 9-33%, p=0.001) and for renal function by 34% (95% CI: 18-54%, p<0.001), as well as a higher creatinine reduction by 32 micromol/L (95% CI: 7-57 micromol/L, p<0.014). A higher excess surgical mortality, 3.1% (95% CI: 1.8-4.4%, p<0.001) became insignificant, 0.18% (95% CI: 0.7-1.1, p=0.70) when concomitant aortic surgery was excluded. CONCLUSION: This data shows a marked and durable clinical benefit for surgery. These findings question the endovascular predominance in intervention in ARAS and highlight the need for a carefully designed prospective randomised comparison to define the roles of endovascular and surgical renal revascularization.