Treatment of Unilateral Atherosclerotic Renal Artery Stenosis

Purpose: To explain the clinical workup of renovascular hypertension. To summarize the current literature on the treatment of renal artery stenosis. To list the criteria for percutaneous transluminal angioplasty (PTRA) with stenting with medical therapy versus medical therapy alone.

Materials and Methods: Although atherosclerotic renal artery stenosis is quite common in patients with hypertension, it may be the primary cause of hypertension in certain settings, such as severe, acute, and refractory cases of hypertension. When hypertension is directly related to renal artery stenosis, it is known as renovascular hypertension. In this educational exhibit, we review the current literature on the treatment of unilateral atherosclerotic renal artery stenosis, the clinical workup of patients with renovascular hypertension, and the criteria for intervention.

Results: Renovascular hypertension is defined as secondary hypertension caused by renal artery stenosis and subsequent activation of the renin–angiotensin–aldosterone-system. Several large, randomized trials (including CORAL, STAR, and ASTRAL) that have compared PTRA (with or without stenting) and medical therapy have largely concluded that PTRA provides no additional benefit to medical therapy. However, patients with certain clinical features may still benefit from PTRA, including those with refractory heart failure, recurrent flash pulmonary edema, failure of or intolerance to optimal antihypertensive medical therapy, and a short duration of hypertension before diagnosis.

Conclusions: Renovascular hypertension is found in up to 40% of patients with severe and refractory hypertension. It is important for clinicians and interventionalists to understand the diagnosis of renovascular hypertension. More important, clinicians and interventionalists must understand when to intervene in patients with renal artery stenosis.