The rise and fall of renal artery angioplasty and stenting in the United States, 1988-2009

Abstract

Objective: Optimal management of renal artery stenosis (RAS) remains unclear. Recent randomized controlled trials have shown no clear benefit with percutaneous transluminal angioplasty with or without stenting (PTRA/S) over medical management. We hypothesize that interventions for RAS are decreasing nationally.

Methods: The Nationwide Inpatient Sample, 1988-2009, was used to identify patients with a diagnosis of renal artery atherosclerosis undergoing open surgical repair (bypass or endarterectomy) or PTRA/S. The rate of interventions, in-hospital death, and perioperative outcomes were analyzed over time. Additionally, we used individual state inpatient and ambulatory databases to better understand the influence of outpatient procedures on current volume and trends.

Results: We identified 308,549 PTRA/S and 33,147 open surgical repairs. PTRA/S increased from 1.9/100K adults in 1988 to 13.7 in 2006 followed by a decrease to 6.7 in 2009. Open surgical repair steadily decreased from 1.3/100K adults in 1988 to 0.3 in 2009. In 2009, PTRA/S procedures (6.4/100K adults) greatly outnumbered procedures done by open repair alone (0.1/100K), combined open renal and aortic repair (0.2/100K), and combined PTRA/S and endovascular aneurysm repair (0.3/100K). From 2005 to 2009 33,953 patients underwent PTRA/S in the states of New Jersey Maryland, Florida, and California combined. The total number of PTRA/S performed in the outpatient setting remained stable from 2005 (3.8/100K) to 2009 (3.7/100K), whereas the total number of inpatient procedures mirrored the national trend, declining from 2006 (7.9/100K) to 2009 (4.2/100K). PTRA/S had lower in-hospital mortality (0.9% vs 4.1%; P < .001) compared with open repair. PTRA/S patients were more likely to be discharged home (86.2% vs 76.3%; P < .001) and had a shorter length of stay (4.4 vs 12.3 days; P < .001). Mortality was higher after combined open renal and open aortic surgery compared to open repair alone (6.5% vs 4.1%; P < .001). Mortality was similar for combined PTRA/S and endovascular aneurysm repair compared with PTRA/S alone (1.2% vs 0.9%; P = .04).

Conclusions: The performance of PTRA/S procedures for the management of RAS has decreased significantly after 2006. An increasing proportion of these procedures are performed in the outpatient setting. PTRA/S remains the dominant revascularization procedure for RAS with lower in-hospital mortality and morbidity than surgery.

Figure 1

Annual number of inpatient procedures per 100K adults for treatment of renal artery atherosclerosis from 1988-2009: percutaneous transluminal angioplasty with or without stenting (PTRA/S) compared with open repair.

Figure 2

Change in mean age of patients undergoing inpatient PTRA/S or open renal artery revascularization for a diagnosis of renal artery atherosclerosis from 1988-2009.

Figure 3

Annual number of PTRA/S procedures per 100K adults performed in NJ, MD, FL, and CA from 2005 to 2009 in patients with a diagnosis of renal atherosclerosis.

Figure 4

Annual number of procedures per 100K adults for treatment of renal fibromuscular dysplasia from 1988 to 2009; PTRA/S compared with open repair.

Figure 5

Annual number of inpatient procedures per 100K adults for treatment of renal atherosclerosis from 1988 to 2009 by PTRA/S alone, open repair alone, open repair combined with open aortic surgery, and PTRA/S combined with endovascular aneurysm repair (EVAR) of the aorta.

Figure 6

PTRA/S procedures per 100K adults performed by vascular surgeons, interventional cardiologist, and interventional radiologists from 2001-2009