Renal Artery Stenosis

  • Thomas A. SosEmail author


As a result of the recent highly publicized but poorly designed randomized trials, renal artery angioplasty and stenting have become underutilized as the treatment of choice even in carefully selected patients with hemodynamically significant renal artery stenosis due to atheroma and/or fibromuscular dysplasia. Such patients are frequently and nihilistically medically managed until they are sometimes unsalvageable by revascularization. Indications for renal artery catheter-based interventions include hemodynamically significant renal artery stenosis, particularly when associated with renal dysfunction, poorly controlled hypertension, or recurrent pulmonary edema. Careful selection of patients as above and expert conduct of intervention are key issues to the clinical proof of benefit of this important treatment option for organ preservation, alleviation of renal failure, and long-term control of secondary hypertension.

There is no evidence, however, that «prophylactic» stenting of mild to moderate, hemodynamically nonsignificant, and clinically asymptomatic renal artery stenosis (especially if not fully clinically evaluated prior to intervention) has any benefit compared to aggressive medical therapy and lifestyle changes to prevent progression and the clinical sequela of renal failure, hypertension, and decreased longevity.

Statins and risk reduction are the new paradigm for the treatment of all atheroma including post-interventional treatment, unless the atheroma is clinically symptomatic and hemodynamically significant.


  1. 1.
    ASTRAL Investigators, Wheatley K, Ives N, Gray R, et al. Revascularization versus medical therapy for renal-artery stenosis. N Engl J Med. 2009;361:1953–62.CrossRefGoogle Scholar
  2. 2.
    Bax L, Woittiez AJ, Kouwenberg HJ, et al. Stent placement in patients with atherosclerotic renal artery stenosis and impaired renal function: a randomized trial. Ann Intern Med. 2009;150(840–848):W150–1.Google Scholar
  3. 3.
    Beinart C, Sos TA, Saddekni S, Weiner MA, Sniderman KW. Arterial spasm during renal angioplasty. Radiology. 1983;149(1):97–100.CrossRefPubMedGoogle Scholar
  4. 4.
    Bersin RM, Ansel G, Rizzo A, Bob Smouse H, Sinha S, Sachar R, Dave R, Weinstock BS, Feldman R, Roubin GS. Nine-month results of the REFORM study: a prospective, single-arm, multicenter clinical study of the safety and effectiveness of the Formula™ balloon-expandable stent for treatment of renal artery stenosis. Catheter Cardiovasc Interv. 2013;82(2):266–73. Scholar
  5. 5.
    Bloch MJ, Trost DA, Whitner J, Pickering TG, Sos TA, August P. Ostial renal artery stent placement in patients 75 years of age or older. Am J Hypertens. 2001;14(10):9.CrossRefGoogle Scholar
  6. 6.
    Border WA, Noble NA. Interactions of transforming growth factor-beta and angiotensin II in renal fibrosis. Hypertension. 1998;31(1 Pt 2):181–8.CrossRefPubMedGoogle Scholar
  7. 7.
    Burket MW, Cooper CJ, Kennedy DJ, Brewster PS, Ansel GM, Moore JA, et al. Renal artery angioplasty and stent placement: predictors of a favorable outcome. Am Heart J. 2000;139(1 Pt 1):64–71.CrossRefPubMedGoogle Scholar
  8. 8.
    Bush RL, Najibi S, MacDonald MJ, Lin PH, Chaikof EL, Martin LG, et al. Endovascular revascularization of renal artery stenosis: technical and clinical results. J Vasc Surg. 2001;33:1041–9.CrossRefPubMedGoogle Scholar
  9. 9.
    Cabili S, Hochman I, Goor Y. Reversal of gangrenous lesions in the blue Toe syndrome with lovastatin a case report. Angiology. 1993;44:821.CrossRefPubMedGoogle Scholar
  10. 10.
    Caps MT, Perissinotto C, Zierler RE, et al. Prospective study of atherosclerotic disease progression in the renal artery. Circulation. 1998;98(25):2866–72.CrossRefPubMedGoogle Scholar
  11. 11.
    Chrysant SG, Chrysant GS. Treatment of hypertension in patients with renal artery stenosis due to fibromuscular dysplasia of the renal arteries. Cardiovasc Diagn Ther. 2014;4(1):36–43. Scholar
  12. 12.
    Chrysant GS, Bates MC, Sullivan TM, Bachinsky WB, Popma JJ, Peng L, Omran HL, Jaff MR, on behalf of the HERCULES Investigators. Proper patient selection yields significant and sustained reduction in systolic blood pressure following renal artery stenting in patients with uncontrolled hypertension: long-term results from the HERCULES trial. J Clin Hypertens. 2014;16:497–503. Scholar
  13. 13.
    Cicuto KP, McLean GK, Oleaga JA, et al. Renal artery stenosis: anatomic classification for percutaneous transluminal angioplasty. AJR Am J Roentgenol. 1981;137:599.CrossRefPubMedGoogle Scholar
  14. 14.
    Cigarroa RG, Lange RA, Williams RH, Hillis LD. Dosing of contrast material to prevent contrast nephropathy in patients with renal disease. Am J Med. 1989;86(6 Pt 1):649–52.CrossRefPubMedGoogle Scholar
  15. 15.
    Conlon PJ, Athirakul K, Kovalik E, Schwab SJ, et al. Survival in renal vascular disease. J Am Soc Nephrol. 1998;9(2):252–6. An epidemiological approach to describing risk associated with blood pressure levels. Final report of the working group on risk and high blood pressure. Hypertension. 1985;7(4):641–51PubMedGoogle Scholar
  16. 16.
    Cooper CJ, Haller ST, Colyer W, Steffes M, Burket MW, Thomas WJ, Safian R, Reddy B, Brewster P, Ankenbrandt MA, Virmani R, Dippel E, Rocha-Singh K, Murphy TP, Kennedy DJ, Shapiro JI, D’Agostino RD, Pencina MJ, Khuder S. Embolic protection and platelet inhibition during renal artery stenting. Circulation. 2008;117(21):2752–60.CrossRefPubMedGoogle Scholar
  17. 17.
    Cooper CJ, Murphy TP, Cutlip DE, et al. Stenting and medical therapy for atherosclerotic renal-artery stenosis. N Engl J Med. 2014;370:13–22.CrossRefPubMedGoogle Scholar
  18. 18.
    Corriere MA, Pearce JD, Edwards MS, Stafford JM, Hansen KJ. Endovascular management of atherosclerotic renovascular disease: early results following primary intervention. J Vasc Surg. 2008;48:580–7.CrossRefPubMedGoogle Scholar
  19. 19.
    Cragg AH, Smith TP, Thompson BH, et al. Incidental fibromuscular dysplasia in potential renal donors: long term follow-up. Radiology. 1989;172:145–7.CrossRefPubMedGoogle Scholar
  20. 20.
    Davidson CJ, Hlatky M, Morris KG, et al. Cardiovascular and renal toxicity of a nonionic radiographic contrast agent after cardiac catheterization. A prospective trial. Ann Intern Med. 1989;110(2):119–24.CrossRefPubMedGoogle Scholar
  21. 21.
    Edwards MS, Corriere MA. Contemporary management of atherosclerotic renovascular disease. J Vasc Surg. 2009;50(5):1197–210.CrossRefPubMedGoogle Scholar
  22. 22.
    Fabbian F, Catalano C, Lambertini D, Bordin V, DiLandro D. A possible role of corticosteroids in cholesterol crystal embolization. Nephron. 1999;83:189–90.CrossRefPubMedGoogle Scholar
  23. 23.
    Fatica RA, Port FK, Young EW. Incidence trends and mortality in end-stage renal disease attributed to renovascular disease in the United States. Am J Kidney Dis. 2001;37(6):1184.CrossRefPubMedGoogle Scholar
  24. 24.
    Feldman RL, Wargovich TJ, Bittl JA. No-touch technique for reducing aortic wall trauma during renal artery stenting. Catheter Cardiovasc Interv. 1999;46(2):245–8.CrossRefPubMedGoogle Scholar
  25. 25.
    Giles H, Lesar C, Erdoes L, Sprouse R, Myers S. Balloon-expandable covered stent therapy of complex endovascular pathology. Ann Vasc Surg. 2008;22(6):762–8.CrossRefPubMedGoogle Scholar
  26. 26.
    Gill KS, Fowler RC. Atherosclerotic renal arterial stenosis: clinical outcomes of stent placement for hypertension and renal failure. Radiology. 2003;226:821–6.CrossRefPubMedGoogle Scholar
  27. 27.
    Gross CM, Krämer J, Weingärtner O, et al. Determination of renal arterial stenosis severity: comparison of pressure gradient and vessel diameter. Radiology. 2001;220(3):751.CrossRefPubMedGoogle Scholar
  28. 28.
    Henry M, Henry I, Klonaris C, Polydorou A, Rath P, Lakshmi G, et al. Renal angioplasty and stenting under protection: the way for the future? Catheter Cardiovasc Interv. 2003;60:299–312.CrossRefPubMedGoogle Scholar
  29. 29.
    Hiramoto J, Hansen KJ, Pan XM, Edwards MS, Sawhney R, Rapp JH. Atheroemboli during renal artery angioplasty: an ex vivo study. J Vasc Surg. 2005;41(6):1026–30.CrossRefPubMedGoogle Scholar
  30. 30.
    Holden A, Hill A, Jaff MR, Pilmore H. Renal artery stent revascularization with embolic protection in patients with ischemic nephropathy. Kidney Int. 2006;70:948–55.CrossRefPubMedGoogle Scholar
  31. 31.
    Imanishi M, Akabane S, Takamiya M, et al. Critical degree of renal arterial stenosis that causes hypertension in dogs. Angiology. 1992;43:833–42.CrossRefPubMedGoogle Scholar
  32. 32.
    Jackson B, Franze L, Sumithran E, Johnston CI. Pharmacologic nephrectomy with chronic angiotensin converting enzyme inhibitor treatment in renovascular hypertension in the rat. J Lab Clin Med. 1990;115(1):21–7.PubMedGoogle Scholar
  33. 33.
    Kashyap VS, Sepulveda RN, Bena JF, Nally JV, Poggio ED, Greenberg RK, et al. The management of renal artery atherosclerosis for renal salvage: does stenting help? J Vasc Surg. 2007;45:101–8.CrossRefPubMedGoogle Scholar
  34. 34.
    Kay J, Chow WH, Chan TM, et al. Acetylcysteine for prevention of acute deterioration of renal function following elective coronary angiography and intervention: a randomized controlled trial. JAMA. 2003;289(5):553–8.CrossRefPubMedGoogle Scholar
  35. 35.
    Kennedy DJ, Colyer WR, Brewster PS, Ankenbrandt M, Burket MW, Nemeth AS, et al. Renal insufficiency as a predictor of adverse events and mortality after renal artery stent placement. Am J Kidney Dis. 2003;42:926–35.CrossRefPubMedGoogle Scholar
  36. 36.
    Kerns SR, Hawkins IF. Carbon dioxide administration angiography: expanding applications and technical evolution. AJR Am J Roentgenol. 1995;164:735–41.CrossRefPubMedGoogle Scholar
  37. 37.
    Khilnani NM, Trost D, Jagust MB, Sos TA. Multiple-side-hole catheter technique for selective over-the-wire completion angiography following renal angioplasty. J Vasc Interv Radiol. 1994;5(2):387–9.CrossRefPubMedGoogle Scholar
  38. 38.
    Kim PA, Khilnani NM, Trost DW, Sos TA, Lee L. Fluoroscopic landmarks for optimal visualization of the proximal renal arteries. J Vasc Interv Radiol. 1999;10(1):37–9.CrossRefPubMedGoogle Scholar
  39. 39.
    Laird JR, Rundback J, Zierler RE, et al. Safety and efficacy of renal artery stenting following suboptimal renal angioplasty for de novo and restenotic ostial lesions: results from a nonrandomized, prospective multicenter registry. J Vasc Interv Radiol. 2010;21(5):627–37.CrossRefPubMedGoogle Scholar
  40. 40.
    Lautin EM, Freeman NJ, Schoenfeld AH, et al. Radiocontrast-associated renal dysfunction: incidence and risk factors. AJR Am J Roentgenol. 1991;157(1):49–58.CrossRefPubMedGoogle Scholar
  41. 41.
    Lederman RJ, Mendelsohn FO, Santos R, Phillips HR, Stack RS, Crowley JJ. Primary renal artery stenting: characteristics and outcomes after 363 procedures. Am Heart J. 2001;142:314–23.CrossRefPubMedGoogle Scholar
  42. 42.
    Mailloux LU, Bellucci AG, Mossey RT, et al. Predictors of survival in patients undergoing dialysis. Am J Med. 1988;84:855.CrossRefPubMedGoogle Scholar
  43. 43.
    Mailloux LU, Napolitano B, Bellucci AG, Vernace M, Wilkes BM, Mossey RT. Renal vascular disease causing end-stage renal disease, incidence, clinical correlates, and outcomes: a 20-year clinical experience. Am J Kidney Dis. 1994;24(4):622–9.CrossRefPubMedGoogle Scholar
  44. 44.
    Mann SJ, Sos TA. Treatment of atheroembolization with corticosteroids. Am J Hypertens. 2001;14(8 Pt 1):831–4.CrossRefPubMedGoogle Scholar
  45. 45.
    Manske CL, Sprafka JM, Strony JT, Wang Y. Contrast nephropathy in azotemic diabetic patients undergoing coronary angiography. Am J Med. 1990;89(5):615–20.CrossRefPubMedGoogle Scholar
  46. 46.
    Merten GJ, Burgess WP, Gray LV, et al. Prevention of contrast-induced nephropathy with sodium bicarbonate: a randomized controlled trial. JAMA. 2004;291(19):2328–49.CrossRefPubMedGoogle Scholar
  47. 47.
    Murphy TP, Cooper CJ, Cutlip DE, et al. Roll-in experience from the Cardiovascular Outcomes with Renal Atherosclerotic Lesions (CORAL) study. J Vasc Interv Radiol. 2014;25:511–20.CrossRefPubMedGoogle Scholar
  48. 48.
    Nash K, Hafeez A, Hou S. Hospital-acquired renal insufficiency. Am J Kidney Dis. 2002;39(5):930–6.CrossRefPubMedGoogle Scholar
  49. 49.
    Nolan BW, Schermerhorn ML, Rowell E, Powell RJ, Fillinger MF, Rzucidlo EM, et al. Outcomes of renal artery angioplasty and stenting using low-profile systems. J Vasc Surg. 2005;41:46–52.CrossRefPubMedGoogle Scholar
  50. 50.
    Pasternak RC, Criqui MH, Benjamin EJ, et al. American Heart Association. Atherosclerotic Vascular Disease Conference: Writing Group I: epidemiology. Circulation. 2004;109(21):2605–12.CrossRefPubMedGoogle Scholar
  51. 51.
    Paul JF, Cherrak I, Jaulent MC, et al. Interobserver variability in the interpretation of renal digital subtraction angiography. Am J Roentgenol. 1999;173(5):1285–8.CrossRefGoogle Scholar
  52. 52.
    Pickering TG. Renovascular hypertension: medical evaluation and non-surgical treatment. In: Laragh JH, Brenner BM, editors. Hypertension. New York: Raven; 1990. p. 1539.Google Scholar
  53. 53.
    Radermacher J, Chavan A, Bleck J, et al. Use of Doppler ultrasonography to predict the outcome of therapy for renal-artery stenosis. N Engl J Med. 2001;344:410–7.CrossRefPubMedGoogle Scholar
  54. 54.
    Rocha-Singh KJ, Ahuja RK, Sung CH, Rutherford J. Long-term renal function preservation after renal artery stenting in patients with progressive ischemic nephropathy. Catheter Cardiovasc Interv. 2002;57:135–41.CrossRefPubMedGoogle Scholar
  55. 55.
    Rocha-Singh K, Jaff MR, Rosenfield K. Evaluation of the safety and effectiveness of renal artery stenting after unsuccessful balloon angioplasty: the ASPIRE-2 study. J Am Coll Cardiol. 2005;46(5):776–83.CrossRefPubMedGoogle Scholar
  56. 56.
    Rocha-Singh K, Jaff MR, Kelley EL. Renal artery stenting with noninvasive duplex ultrasound follow-up: 3-year results from the RENAIS¬SANCE renal stent trial. Catheter Cardiovasc Interv. 2008;72(6):853–62.CrossRefPubMedGoogle Scholar
  57. 57.
    Simon G. What is critical renal artery stenosis? Am J Hypertens. 2000;13:1189–93.CrossRefPubMedGoogle Scholar
  58. 58.
    Sniderman KW, Sos TA. Percutaneous transluminal recanalization and dilatation of totally occluded renal arteries. Radiology. 1982;142(3):607–10.CrossRefPubMedGoogle Scholar
  59. 59.
    Sos TA, Trost DW. Renal angioplasty and stenting. In: Kandarpa K, editor. Peripheral vascular interventions. Philadelphia: Lippincot Williams & Wilkins; 2008. p. 287–314.Google Scholar
  60. 60.
    Sos TA. The renal stenting debate: is this procedure underused or overused? Yes. Endovasc Today. 2006;5:64–8.Google Scholar
  61. 61.
    Sos TA, Mann SJ. Did renal artery stent placement fail in the Cardiovascular Outcomes with Renal Atherosclerotic Lesions (CORAL) study or did the CORAL Study Fail Renal Artery Stent Placement? The CORAL roll-in experience and the CORAL trials. J Vasc Interv Radiol. 2014;25(4):520–523.; quiz 524. Scholar
  62. 62.
    Srur MF, Sos TA, Saddekni S, Cohn DJ, Rozenblit G, Wetter EB. Intimal fibromuscular dysplasia and Takayasu arteritis: delayed response to percutaneous transluminal renal angioplasty. Radiology. 1985;157(3):657–60.CrossRefPubMedGoogle Scholar
  63. 63.
    Stone GW, McCullough PA, Tumlin JA, Investigators CONTRAST. Fenoldopam mesylate for the prevention of contrast-induced nephropathy: a randomized controlled trial. JAMA. 2003;290(17):2284–91.CrossRefPubMedGoogle Scholar
  64. 64.
    Subramanian R, White CJ, Rosenfield K, et al. Renal fractional flow reserve: a hemodynamic evaluation of moderate renal artery stenoses. Catheter Cardiovasc Interv. 2005;64(4):480–6.CrossRefPubMedGoogle Scholar
  65. 65.
    Tegtmeyer CJ, Sos TA. Techniques of renal angioplasty. Radiology. 1986;161(3):577–86.CrossRefPubMedGoogle Scholar
  66. 66.
    Tepel M, van der Giet M, Schwarzfeld C, Laufer U, Liermann D, Zidek W. Prevention of radiographic-contrast-agent-induced reductions in renal function by acetylcysteine. N Engl J Med. 2000;343(3):180–4.CrossRefPubMedGoogle Scholar
  67. 67.
    Trinquart L, Mounier-Vehier C, Sapoval M, Gagnon N, Plouin PF. Efficacy of revascularization for renal artery stenosis caused by fibromuscular dysplasia: a systematic review and meta-analysis. Hypertension. 2010;56(3):525–32. Epub 2010 Jul 12CrossRefPubMedGoogle Scholar
  68. 68.
    Trost DW, Sos TA. Complications of renal angioplasty and stenting. Semin Interv Radiol. 1994;11(2):150–60.CrossRefGoogle Scholar
  69. 69.
    Tunick PA, Nayar AC, Goodkin GM, Mirchandani S, Francescone S, Rosenzweig BP, Freedberg RS, Katz ES, Applebaum RM, Kronzon I. Effect of treatment on the incidence of stroke and other emboli in 519 patients with severe thoracic aortic plaque. Am J Cardiol. 2002;90:1320–5.CrossRefPubMedGoogle Scholar
  70. 70.
    van Jaarsveld BC, Pieterman H, van Dijk LC, van Seijen AJ, Krijnen P, Derkx FH, Man in’t Veld AJ, Schalekamp MA. Inter-observer variability in the angiographic assessment of renal artery stenosis DRASTIC study group. Dutch Renal Artery Stenosis Intervention Cooperative. J Hypertens. 1999;17(12 Pt 1):1731–6.CrossRefPubMedGoogle Scholar
  71. 71.
    van Jaarsveld BC, Pieterman H, van Dijk LC. Inter-observer variability in the angiographic assessment of renal artery stenosis. DRASTIC study group. Dutch Renal Artery Stenosis Intervention Cooperative. J Hypertens. 1999;17:1731–6.CrossRefPubMedGoogle Scholar
  72. 72.
    Waybill MM, Waybill PN. Contrast media-induced nephrotoxicity: identification of patients at risk and algorithms for prevention. J Vasc Interv Radiol. 2001;12(1):3–9.CrossRefPubMedGoogle Scholar
  73. 73.
    Weisberg LS, Kurnik PB, Kurnik BR. Risk of radiocontrast nephropathy in patients with and without diabetes mellitus. Kidney Int. 1994;45(1):259–65.CrossRefPubMedGoogle Scholar
  74. 74.
    Wright JR, Shurrab AE, Cooper A, Kalra PR, Foley RN, Kalra PA. Left ventricular morphology and function in patients with atherosclerotic renovascular disease. J Am Soc Nephrol. 2005;16(9):2746–53.CrossRefPubMedGoogle Scholar
  75. 75.
    Zambetis-Bellesis M, Dusting GJ, Mendelsohn FA, Richardson K. Autoradiographic localization of angiotensin-converting enzyme and angiotensin II binding sites in early atheroma-like lesions in rabbit arteries. Clin Exp Pharmacol Physiol. 1991;18(5):337–40.CrossRefPubMedGoogle Scholar
  76. 76.
    Zeller T, Frank U, Muller C, Burgelin K, Sinn L, Bestehorn HP, et al. Predictors of improved renal function after percutaneous stent-supported angioplasty of severe atherosclerotic ostial renal artery stenosis. Circulation. 2003;108:2244–9.CrossRefPubMedGoogle Scholar
  77. 77.
    Zeller T, Frank U, Muller C, Burgelin K, Sinn L, Horn B, et al. Stent-supported angioplasty of severe atherosclerotic renal artery stenosis preserves renal function and improves blood pressure control: long-term results from a prospective registry of 456 lesions. J Endovasc Ther. 2004;11:95–106.CrossRefPubMedGoogle Scholar
  78. 78.
    Zeller T, Rastan A, Schwarzwälder U, et al. Treatment of instent restenosis following stent-supported renal artery angioplasty. Catheter Cardiovasc Interv. 2007;70(3):454–9.CrossRefPubMedGoogle Scholar
  79. 79.
    Zeller T, Sixt S, Rastan A, et al. Treatment of reoccurring instent restenosis following reintervention after stent-supported renal artery angioplasty. Catheter Cardiovasc Interv. 2007;70(2):296–300.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Peripheral Arterial Disease, Weill Cornell Interventional, New York Presbyterian Hospital-Weill CornellNew YorkUSA

Personalised recommendations