What are the indications for intervention in renal artery stenosis (RAS)?

From the Guidelines

Intervention in renal artery stenosis is primarily indicated for patients with hemodynamically significant stenosis (typically >70% narrowing) who have refractory hypertension despite optimal medical therapy with multiple antihypertensive medications, recurrent flash pulmonary edema, or progressive renal insufficiency, as supported by the most recent guidelines and studies 1.

Key Indications for Intervention

• Hemodynamically significant stenosis (>70% narrowing) with refractory hypertension despite optimal medical therapy
• Recurrent flash pulmonary edema
• Progressive renal insufficiency
• Bilateral renal artery stenosis or stenosis in a solitary functioning kidney with declining renal function

Considerations for Intervention

• Medical therapy should be optimized first, including angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (unless contraindicated by significant bilateral stenosis), along with other antihypertensive agents
• Comprehensive imaging with duplex ultrasound, CT angiography, or magnetic resonance angiography should be performed to confirm the diagnosis and assess the severity of stenosis
• Endovascular stenting is the preferred intervention, though surgical revascularization may be considered in specific cases such as complex lesions or those involving the aorta
• Patient selection is crucial to ensure benefits outweigh risks, including contrast-induced nephropathy, arterial dissection, and restenosis

Rationale for Intervention

• Restore renal perfusion to improve blood pressure control, preserve renal function, and reduce cardiovascular complications associated with renovascular hypertension
• Careful consideration of individual patient circumstances, including clinical and anatomic lesion criteria, to determine the most appropriate treatment strategy 1

Recent Guidelines and Studies

• The 2021 guideline-driven management of hypertension update suggests that intervention may be considered for patients with significant ASCVD renal artery stenosis, particularly those who are younger, have sudden onset of hypertension, or have radiologic features that suggest fibromuscular dysplasia (FMD) 1
• The 2019 ACC/AHA/SCAI/SIR/SVM appropriate use criteria for peripheral artery intervention provide guidance on the use of revascularization for renal artery stenosis, including the importance of optimizing medical therapy and considering individual patient circumstances 1

From the Research

Indications for Intervention in Renal Artery Stenosis (RAS)

The indications for intervention in RAS include:

• Poorly controlled hypertension 2, 3, 4, 5, 6
• Ischemic nephropathy (preservation of renal function) 2, 3, 4, 5
• Recurrent episodes of "flash" pulmonary edema and congestive heart failure 2, 3, 4, 5
• Dialysis-dependent renal failure resulting from renal artery stenosis 2
• Chronic renal insufficiency and bilateral renal artery stenosis 2
• Renal artery stenosis to a solitary functioning kidney 2
• Significant RAS with progressive or acute deterioration of renal function and/or severe uncontrollable hypertension 4
• Renal function decline with the use of agents blocking the renin-angiotensin system 4
• Recurrent flash pulmonary edema 4

Revascularization Procedures

Revascularization procedures for RAS include:

• Percutaneous transluminal angioplasty (PTA) 2, 3, 6
• PTA with stent implantation 2, 3, 5, 6
• Surgical revascularization 2, 5
• Ex vivo surgical repair of the renal artery 2

Patient Selection

Careful patient selection is essential to maximize the potential clinical benefit of intervention in RAS 3, 4, 5. Patients with significant RAS and clinical sequelae, such as pulmonary flash edema and progressive renal failure, are likely to benefit from revascularization 3, 4, 5.