Atherosclerotic renal artery stenosis typically occurs in high risk patients with coexistent vascular disease elsewhere. Patients with atherosclerotic renal artery stenosis may develop progressive renal failure but have a much higher risk of dying with a stroke or a myocardial infarction than of progressing to end-stage renal disease.
Recent controlled trials comparing medication to revascularization have shown that only a minority of such patients can expect hypertension cure, whereas trials designed to document the ability of revascularization to prevent progressive renal failure are not yet available. Percutaneous renal artery angioplasty is the first choice because it is simpler than and as effective as surgical reconstruction.
Revascularization should be undertaken in patients with atherosclerotic renal artery stenosis and resistant hypertension or heart failure, and probably in those with rapidly deteriorating renal function or with an increase in plasma creatinine levels during angiotensin-converting enzyme inhibition. Older age, long history of hypertension and a kidney size less than 8 cm are associated with little chance of blood pressure improvement or kidney function recovery.
With or without revascularization, medical therapy using antihypertensive agents, statins and aspirin is necessary in almost all cases. Blood pressure and plasma creatinine concentration should be measured every three months. Kidney size and renal artery patency should be assessed yearly.