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.3