What is the management of severe stenosis of the renal artery?

From the Guidelines

The management of severe stenosis of the renal artery should prioritize medical therapy with angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin-receptor blockers (ARBs) as the first line of treatment, with revascularization considered in selected cases with resistant hypertension or signs of renal impairment. The initial approach to managing severe renal artery stenosis involves aggressive blood pressure control using antihypertensive medications, particularly ACEIs or ARBs such as lisinopril 10-40 mg daily or losartan 50-100 mg daily 1. These medications must be used cautiously with close monitoring of renal function, as they can precipitate acute kidney injury in bilateral stenosis or stenosis of a solitary functioning kidney.

Medical Therapy

Additional medications often include:

• Calcium channel blockers (amlodipine 5-10 mg daily)
• Diuretics (hydrochlorothiazide 12.5-25 mg daily)
• Statins (atorvastatin 20-80 mg daily) to manage cardiovascular risk factors 1. Antiplatelet therapy with aspirin 75-100 mg daily is also recommended.

Revascularization

For patients with progressive renal dysfunction, uncontrolled hypertension despite optimal medical therapy, or recurrent flash pulmonary edema, revascularization should be considered 1. Percutaneous transluminal renal angioplasty with stenting is the preferred intervention, while surgical revascularization is reserved for complex lesions or failed endovascular procedures. The rationale for this approach is that renal artery stenosis activates the renin-angiotensin-aldosterone system, leading to hypertension and potential kidney damage, while revascularization aims to restore renal perfusion and preserve kidney function.

Key Considerations

• Routine revascularization is not recommended in renal artery stenosis secondary to atherosclerosis 1.
• In cases of hypertension and/or signs of renal impairment related to renal arterial fibromuscular dysplasia, balloon angioplasty with bailout stenting should be considered 1.
• Balloon angioplasty, with or without stenting, may be considered in selected patients with renal artery stenosis and unexplained recurrent congestive heart failure or sudden pulmonary edema 1. The management strategy should be individualized based on the patient's clinical presentation, renal function, and overall cardiovascular risk profile, with the goal of improving morbidity, mortality, and quality of life.

From the Research

Management of Severe Stenosis of the Renal Artery

• Severe renal artery stenosis can cause renovascular hypertension, renal insufficiency, and pulmonary flash edema 2, 3.
• The management of renal artery stenosis includes medical therapy and revascularization using percutaneous angioplasty or open surgical procedures 4, 2, 3, 5.
• Medical therapy should include optimal medical therapy with agents to control blood pressure, anti-platelet drugs, and statins to minimize progression of atherosclerosis 4, 5.
• Revascularization therapy should be considered in patients with significant anatomic stenosis and clinical indications such as uncontrolled blood pressure or worsening renal function despite medical therapy 4, 2, 3, 5.
• Careful patient selection is essential to maximize the potential benefit of revascularization, and patients with refractory hypertension or progressive renal failure may be good candidates for renal artery stenting 4, 2, 3, 5.
• The use of angiotensin receptor blockers (ARBs) and angiotensin-converting enzyme inhibitors (ACE-is) in combination with medical therapy may improve renal outcome and decrease restenosis rate in patients with renal artery stenosis 6.
• Screening for renal artery stenosis can be done with Doppler ultrasonography, computed tomographic angiography, and magnetic resonance angiography, and invasive physiologic measurements can confirm the severity of renal hypoperfusion 5.