From the Guidelines
Treatment of bilateral renal artery stenosis should be considered in patients with atherosclerotic bilateral (>70%) RAS or RAS in a solitary kidney, concomitant high-risk features, and signs of kidney viability, as recommended by the 2024 ESC guidelines 1. The primary goal of treatment is to improve blood pressure control, prevent ischemic nephropathy, and restore renal perfusion.
Key Considerations
- Medical management typically involves blood pressure control with antihypertensive medications, antiplatelet therapy, statins, and lifestyle modifications, but may not be sufficient for patients with hemodynamically significant stenosis (>70%) 1.
- Revascularization should be considered for patients with refractory hypertension, recurrent pulmonary edema, or progressive renal dysfunction, with endovascular stenting generally preferred over surgery due to lower procedural risk 1.
- The rationale for intervention is to address the pathophysiologic activation of the renin-angiotensin-aldosterone system that occurs with bilateral stenosis, and to prevent complications such as end-stage renal disease 1.
Treatment Options
- Medical management:
- Antihypertensive medications (avoiding ACE inhibitors and ARBs if they worsen renal function)
- Antiplatelet therapy (aspirin 81-325 mg daily)
- Statins (such as atorvastatin 20-80 mg daily)
- Lifestyle modifications (smoking cessation, diet improvement, and exercise)
- Endovascular revascularization:
- Preferred for patients with hemodynamically significant stenosis (>70%) and high-risk features
- Technical success rates of 98% and patency rates of 80-85% at 5 years
- Surgical revascularization:
- Reserved for patients with complex anatomy unsuitable for endovascular approaches
- Considered for patients with an indication for renal artery revascularization and complex anatomy, or after failed endovascular revascularization 1.
From the FDA Drug Label
In hypertensive patients with unilateral or bilateral renal artery stenosis, increases in blood urea nitrogen and serum creatinine may occur. Experience with another angiotensin-converting enzyme inhibitor suggests that these increases are usually reversible upon discontinuation of lisinopril and/or diuretic therapy In such patients, renal function should be monitored during the first few weeks of therapy.
The treatment of bilateral renal artery stenosis with ACE inhibitors should be approached with caution.
- Monitoring of renal function is recommended during the first few weeks of therapy.
- Discontinuation of the drug and/or diuretic therapy may be required if increases in blood urea nitrogen and serum creatinine occur.
- Treatment with ACE inhibitors should be initiated with caution in patients with evidence of renal dysfunction 2.
From the Research
Treatment of Bilateral Renal Artery Stenosis
When to Treat
The decision to treat bilateral renal artery stenosis depends on various factors, including the patient's clinical condition, renal function, and the presence of other comorbidities.
- Patients with bilateral renal artery stenosis who have a strong clinical indication for long-term ACEI use, such as left ventricular dysfunction or diabetes, may be safely treated with ACEI therapy after successful revascularization using renal artery stenting 3.
- However, in patients with untreated bilateral renal artery stenosis, ACEIs and angiotensin II receptor antagonists should be avoided due to the risk of azotemia and worsening renal function 4, 5, 6.
- Revascularization may be considered in patients with recent deterioration in renal function, those with bilateral renal artery stenosis or stenosis to a single functioning kidney, those with flash pulmonary edema, advanced chronic renal failure, or ESRD, and those whose conditions cannot be managed medically 7.
- The presence of RAS in an azotemic patient can be assessed with noninvasive and risk-free radiologic techniques, including Duplex doppler velocimetry and magnetic resonance angiography 7.
- Functional tests that predict the change in renal function after revascularization are not yet available, but a renal length of greater than 7.5 cm in the absence of renal cysts and a short history of renal functional deterioration indicate a good prognosis 7.