Renal artery stenting in consecutive high-risk patients with atherosclerotic renovascular disease: Five-year follow-up results from the DAN-PTRA-I study

Background Severe atherosclerotic renal artery stenosis (ARAS) often leads to resistant hypertension, progressive decline in renal function, and recurrent episodes of acute heart failure. However, the clinical benefit of renal artery stenting in patients with ARAS remains controversial. Purpose To evaluate the long-term (5-year) effects of renal artery stenting on blood pressure, antihypertensive treatment burden, renal function, and heart-failure-related hospitalisations in consecutive high-risk patients treated according to a standardized national protocol between January 2015 and July 2023. Methods After initiation of the national protocol in 2015, patients with ARAS were offered revascularization only if they met at least one predefined high-risk criterion: severe renal artery stenosis (≥70% lumen reduction) in combination with either (1) resistant hypertension, defined as an average 24-hour ambulatory systolic blood pressure ≥130 mmHg (typically ≥150 mmHg) despite ≥3 antihypertensive agents, including a diuretic if tolerated, all prescribed at optimal doses; (2) rapidly declining kidney function, defined as a reduction in estimated glomerular filtration rate (eGFR) >5 mL/min/1.73 m² per year; or (3) hospital admissions for acute decompensated heart failure (≥2 admissions for heart failure or ≥1 episode of sudden “flash” pulmonary oedema). Patients were followed for up to 5 years after stent implantation. Follow-up evaluations included 24-hour ambulatory blood pressure monitoring after nurse-administered medication, antihypertensive defined daily dose (DDD), total number of antihypertensive agents, estimated glomerular filtration rate (eGFR), and clinical outcomes. Results A total of 133 consecutive patients were included (median age 69.9 years; 56% female). At baseline, mean 24-hour systolic blood pressure was 166.2 mmHg (95% CI 162.5-170.0), mean antihypertensive DDD was 7.0 (95% CI 6.3-7.8), the mean number of antihypertensives was 4.0 (95% CI 3.8-4.2), and mean eGFR was 38.2 mL/min/1.73 m² (95% CI 34.5-41.9). In 122 patients with 3-month follow-up, systolic blood pressure decreased by 20.5 mmHg (95% CI 16.4-24.6; P<0.001), antihypertensive DDD was reduced by 54% (95% CI 44-61%; P<0.001), the number of antihypertensives decreased by 1.0 (95% CI 0.7-1.2; P<0.001), and eGFR increased by 8.6 mL/min/1.73 m² (95% CI 5.6-11.5; P<0.001). Improvements persisted through 60 months. Among 29 patients with prior hospitalisation for acute decompensated heart failure, 23 experienced no further episodes after successful revascularisation. Conclusions In this prospective high-risk cohort, renal artery stenting was associated with sustained 5-year reductions in blood pressure and antihypertensive medication use, improved renal function, and fewer heart failure-related hospitalisations. These findings support the role of renal revascularisation in carefully selected high-risk ARAS patients.24-hour ABPM and antihypertensive medicationFor image description, please refer to the figure legend and surrounding text.