What is the management for renal artery stenosis (RAS)?

From the Guidelines

The management of renal artery stenosis should prioritize medical therapy with ACE inhibitors or ARBs, lifestyle modifications, and selective revascularization procedures, as recommended by the most recent guidelines 1. The primary goal of treatment is to control blood pressure, protect kidney function, and reduce cardiovascular risk.

• First-line treatment typically includes antihypertensive medications, particularly ACE inhibitors (like enalapril 5-40 mg daily or lisinopril 10-40 mg daily) or ARBs (such as losartan 25-100 mg daily), which effectively control blood pressure and protect kidney function, as supported by the 2018 American Heart Association scientific statement 1.
• Additional medications often include statins (atorvastatin 20-80 mg daily) to manage dyslipidemia and antiplatelet therapy (aspirin 75-100 mg daily) to reduce cardiovascular risk.
• Lifestyle modifications are essential, including smoking cessation, weight management, regular exercise, and sodium restriction (<2.3 g/day).
• Revascularization through percutaneous transluminal angioplasty with stenting is considered for patients with resistant hypertension despite optimal medical therapy, recurrent flash pulmonary edema, progressive kidney dysfunction, or severe stenosis (>70%), as recommended by the 2024 ESC guidelines 1.
• The management approach should be individualized based on the severity of stenosis, kidney function, blood pressure control, and overall cardiovascular risk profile, with regular follow-up to monitor disease progression and treatment effectiveness. Key considerations in the management of renal artery stenosis include:
• The use of low-dose aspirin may be considered in patients with atherosclerotic renal artery stenosis, as suggested by the 2024 ESC guidelines 1.
• Renal artery revascularization should be considered in patients with atherosclerotic unilateral >70% RAS, concomitant high-risk features, and signs of kidney viability, as well as in patients with bilateral (>70%) RAS or RAS in a solitary kidney, as recommended by the 2024 ESC guidelines 1.
• Revascularization with primary balloon angioplasty and bailout stenting should be considered in patients with hypertension and/or signs of renal dysfunction due to RAS caused by fibromuscular dysplasia, as recommended by the 2024 ESC guidelines 1.

From the Research

Management of Renal Artery Stenosis

The management of renal artery stenosis (RAS) involves a combination of medical therapy and revascularization techniques.

• Medical therapy is the primary approach for managing RAS, with a focus on controlling blood pressure and reducing cardiovascular risk factors 2, 3.
• Revascularization techniques, such as angioplasty and stenting, may be considered for patients with significant anatomic stenosis and clinical indications, such as uncontrolled blood pressure or worsening renal function 2, 4.
• The use of anti-platelet drugs, such as aspirin, and statins to minimize progression of atherosclerosis is also recommended 2.
• In patients with bilateral renal artery stenosis, successful revascularization using renal artery stenting may allow for safe treatment with angiotensin-converting enzyme inhibitors (ACEIs) 5.

Revascularization Techniques

Revascularization techniques, such as angioplasty and stenting, have been shown to be effective in restoring blood flow to the kidney, but their use is not without controversy.

• Randomized trials have failed to demonstrate a clear benefit of revascularization over medical therapy alone 2, 3, 4.
• However, revascularization may be beneficial for patients with significant anatomic stenosis and clinical indications, such as uncontrolled blood pressure or worsening renal function 2.
• The use of stents should not be based solely on the presence of stenosis, but rather on a careful consideration of the patient's clinical indications and anatomic characteristics 2.

Medical Therapy

Medical therapy is the primary approach for managing RAS, with a focus on controlling blood pressure and reducing cardiovascular risk factors.

• The use of ACEIs, angiotensin receptor blockers, and other agents to control blood pressure and reduce cardiovascular risk is recommended 2, 3, 5.
• In patients with bilateral renal artery stenosis, careful consideration should be given to the use of ACEIs, as they may be contraindicated due to the risk of azotemia 5.