Arteriosclerotic renal artery stenosis: conservative versus interventional management.

Renal artery stenosis is the most common cause of secondary hypertension. Over 90% of renal artery stenoses are caused by arteriosclerosis, the remainder resulting from fibromuscular dysplasia which usually does not lead to progressive azotemia and end stage renal disease. Renal angioplasty is the treatment of choice for fibromuscular dysplastic disease and has the potential of curing hypertension if performed early. The situation is quite different for arteriosclerotic renal artery disease which generally occurs in older patients with longstanding hypertension. The stenotic lesions are typically localised at the ostium of the renal artery, respectively in the aortic wall. Reconstructive surgery has been the classical treatment for these lesions, particularly since the initial experience with renal artery angioplasty for arteriosclerotic ostial lesions was disappointing. However, a prospective randomised study has demonstrated that reconstructive surgery offers no definite advantage over interventional treatment of renal artery stenosis. Since most patients with arteriosclerotic renal artery disease have coronary and cerebral atherosclerosis and other significant comorbid conditions which increase the risk of surgery, the interventional treatment of renal artery stenosis has become the preferred method of renal revascularisation in many centres. This development has been reinforced by the more recent introduction of renal arterial stent implantation, which may improve the outcome of renal artery interventions, although there have been no randomised prospective comparisons between renal artery stenting and other forms of treatment. Most reports on renal angioplasty with stent implantation have been based on relatively few patients with only a short follow up period. However, a recently published paper from a multicentre registry of 1058 patients reports a benefit from renal artery stenting on both blood pressure control and renal function after four years of follow up. The treatment of renal artery disease has recently been reviewed. The present paper summarises the arguments and evidence for interventional versus conservative treatment of arteriosclerotic renal artery disease, focusing on the indications for interventional treatment to provide interventional cardiologists with criteria for patient selection.