Can a patient with renal artery stenosis undergo surgery in the renal arteries?

Can Surgery Be Performed on the Renal Arteries?

Yes, patients with renal artery stenosis can undergo surgical revascularization of the renal arteries, though this is now typically reserved as a second-line option when endovascular procedures are not feasible or have failed. 1

Treatment Hierarchy for Renal Artery Stenosis

First-Line: Medical Therapy

Medical management should be initiated first in all patients with renal artery stenosis, regardless of whether revascularization is planned. 1

• ACE inhibitors or ARBs are Class I (Level A) recommendations for unilateral stenosis with a normal contralateral kidney 1, 2
• Calcium channel blockers, beta-blockers, and diuretics are effective alternatives 1, 2
• Caution: ACE inhibitors/ARBs may be considered in bilateral severe stenosis or solitary kidney stenosis only if well-tolerated and under close monitoring, as they can precipitate acute renal failure 1

Second-Line: Endovascular Revascularization

For Fibromuscular Dysplasia:

• Percutaneous transluminal renal angioplasty (PTRA) WITHOUT stenting is the treatment of choice (Class IIa, Level C) 1
• This can restore renal perfusion pressure and lower blood pressure effectively 1

For Atherosclerotic Disease:

• Routine revascularization is NOT recommended (Class III, Level A) based on recent randomized trials showing no benefit over medical therapy alone 1
• However, PTRA with stenting may be considered (Class IIb, Level C) in highly selected patients with: 1
  • Recurrent heart failure, unstable angina, or flash pulmonary edema despite maximal medical therapy
  • Resistant hypertension uncontrolled on multiple medications
  • Bilateral renal artery stenosis or unilateral stenosis in a solitary viable kidney
  • Unexplained progressive renal dysfunction with unilaterally small kidney

Third-Line: Open Surgical Revascularization

Open surgery should be considered when: 1

• Endovascular procedures are technically unfeasible or have failed 1
• Complex renal artery anatomy is present (arterial bifurcation or branch involvement) 1
• Concomitant aortic surgery is required (e.g., abdominal aortic aneurysm repair) 1, 3
• Associated aortic disease necessitates open repair 1

The 2024 ESC guidelines explicitly state that "in patients with an indication to renal artery revascularization and technically unfeasible, or failed, renal artery angioplasty and stenting, open surgical revascularization may be considered." 1

Surgical Techniques

While the guidelines don't detail specific surgical approaches, the evidence indicates that surgical options include: 1, 4

• Transaortic endarterectomy for ostial atherosclerotic lesions 4
• Aortorenal bypass grafting 1
• Ex vivo repair with autotransplantation for complex branch vessel disease in fibromuscular dysplasia 3

Important Caveats

Kidney Viability Assessment:

• A viable kidney is defined as >7 cm in length contributing >10% of total renal function 1, 2
• Kidneys <5 cm indicate irreparable ischemic atrophy and are generally not salvageable 2
• Revascularization should not be attempted in severely atrophic kidneys 1

Hemodynamic Significance:

• Stenosis must be hemodynamically significant: ≥70% luminal narrowing, or 50-69% with post-stenotic dilatation and/or significant trans-stenotic pressure gradient 1
• Angioplasty is NOT recommended without confirmed hemodynamically significant stenosis 1

Procedural Risks:

• Endovascular therapy has lower complication rates (6.3%) compared to open surgery (15.4%) 2
• Surgical revascularization carries increased risk of death or major complications, particularly in patients with significant comorbidities 5
• Restenosis may develop in 15-24% of patients after endovascular treatment 1

Specialized Centers:

• Both endovascular and surgical revascularization should be performed in experienced centers due to the high risk of restenosis and technical complexity 1

Clinical Decision Algorithm

1. Start with aggressive medical therapy in all patients 1
2. Consider revascularization only if:
   • Resistant hypertension despite optimal medical therapy 1
   • Recurrent flash pulmonary edema or heart failure 1
   • Progressive renal dysfunction with bilateral disease or solitary kidney 1
3. Choose endovascular approach first (angioplasty ± stenting) 1
4. Reserve surgery for:
   • Failed endovascular attempts 1
   • Complex anatomy 1
   • Concurrent aortic pathology requiring open repair 1, 3

The shift away from routine surgical revascularization reflects evidence that medical therapy alone achieves similar outcomes in most atherosclerotic cases, with intervention reserved for specific high-risk clinical scenarios. 1