Atherosclerotic Renal Artery Stenosis, the Oculostenotic Reflex, and Therapeutic Nihilism

Fifteen years ago, Topol and Nissen1 described the oculostenotic reflex as an “irresistible temptation … to perform angioplasty on any significant residual stenosis,” highlighting a widely held misperception that an angiographically severe stenosis must cause ischemia and that revascularization results in clinical benefit. Although quantitative angiography improves the accuracy of stenosis severity, it does not improve the accuracy of diagnosing ischemia. In fact, more than one third of angiographically severe coronary stenoses are hemodynamically insignificant by fractional flow reserve (FFR), and FFR results are highly correlated with findings of ischemia by myocardial perfusion imaging.2 Similarly, angiographic renal artery stenosis (RAS) severity correlates poorly with hemodynamic significance.3Article see p 537Five randomized trials4–8 demonstrated that a strategy of renal revascularization based on the oculostenotic reflex was not associated with improvement in blood pressure or renal function or reduction in clinical events compared to medical therapy alone. These results lead some to recommend a nihilistic approach …