New Research on ARAS Management: FFR-Guided Stenting Significantly Reduces Unnecessary Procedures for Renovascular Hypertension

A recent pilot randomized controlled trial (RCT), the FAIR trial, led by investigators at Beijing University First Hospital and involving 24 centers across China, presents a significant development for the management of atherosclerotic renal artery stenosis (ARAS) and renovascular hypertension. The FAIR trial provides critical evidence that using Fractional Flow Reserve (FFR) can help clinicians select which patients with ARAS are most likely to benefit from a stent, thus supporting the integration of advanced functional diagnostics into percutaneous intervention decision-making, directly addressing a critical gap in global clinical guidelines. The results were published on October 7, 2025 on European Heart Journal.

Key Findings of the FAIR Trial:

The FAIR trial was designed to address the controversy over renal artery stenting by comparing the traditional angiography-guided stenting strategy with a FFR-guided strategy. In the study, 101 patients with ARAS and hypertension were randomized. Crucially, stenting in the FFR-guided group was only performed if the renal FFR was less than 0.80, indicating a functionally significant blockage.

This selective FFR-guided approach significantly reduced the rate of stenting to 46.0% compared to a 100.0% rate in the traditional angiography-guided group. Despite performing fewer procedures, the FFR-guided strategy achieved the same overall level of blood pressure control as the angiography-guided strategy at the three-month follow-up. This was because the benefit was highly concentrated: stenting was only beneficial in the subset of patients with an FFR < 0.80. In this functionally significant group, stenting led to a substantial improvement, including an adjusted mean reduction of 6.2 mmHg in Daytime Mean Systolic Blood Pressure (DMSBP) and a reduction of 3.1 in the Composite Index of Antihypertensive Medicines (CIAHM). Finally, the study determined that the optimal FFR cut-off for predicting blood pressure improvement was 0.78.

The Take-Home Message

The functional evaluation of ARAS with FFR is feasible, safe, and significantly reduces the number of renal stents performed without compromising the positive effect of stenting on blood pressure. This research supports a major shift in clinical practice: using renal FFR to precisely identify which atherosclerotic renal artery lesions are truly pressure-limiting is key to ensuring that revascularization is only performed on patients who stand to gain substantial clinical benefit.

Source: Eur Heart J. 2025 Oct 7:ehaf746. doi: 10.1093/eurheartj/ehaf746.

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