Therapy for Renal Artery Stenosis: A Call for Change

Atherosclerosis is the most common cause of renal artery stenosis (RAS) and exerts its effects through activation of the renin-angiotensin-aldosterone system (RAAS). Clinical manifestations of atherosclerotic renal artery stenosis (ARAS) include renovascular hypertension, cardiac destabilization syndromes, and ischemic nephropathy. Angiography is the gold standard for determining hemodynamically significant stenosis and stenosis >70% is deemed significant, while stenosis of 50%–70% requires further hemodynamic evaluation. Randomized controlled trials have failed to show benefit of renal artery stenting as a treatment modality for ARAS over optimal medical therapy; however, these trials are plagued by design and methodologic flaws and failed to enroll patients most likely to benefit from renal artery stenting. Here, we present a review of ARAS and consensus society guidelines for appropriateness of renal artery stenting, patient selection, procedural characteristics, and follow-up. Clinical Impact We present a brief case description of a patient who benefitted from stenting in ARAS and provide a comprehensive review of ARAS; its prevalence, pathophysiology, clinical manifestations, diagnosis and treatment. We review the evidence for and against stenting in ARAS as well as consensus guidelines for stenting. Our review is valuable as we argue that stenting in ARAS is underutilized and the randomized control data for stenting in those patients who may benefit most is lacking. Our review will provide an important perspective for clinicians faced with decisions of how to treat ARAS.