Renal vascular disease: medical management, angioplasty, and stenting

In the absence of large, prospective, quality randomized trials, there remains tremendous debate concerning the optimal management of patients with renal vascular disease. This debate is compounded by the fact these patients do not represent a homogeneous group; different causes and presentations each carry a different prognosis and potential response to therapy. Therapeutic options include medical management, surgery, or percutaneous approaches (angioplasty or stenting). This review examines the results of observational studies of medical and percutaneous therapies for blood pressure control and preservation of renal function. Generally, in patients with fibromuscular disease, the results of percutaneous management are superior to medical therapy. Although these observational studies are difficult to compare, in patients with atheromatous disease, the results with interventional and medical therapy appear roughly similar. There have been three randomized prospective trials of routine angioplasty versus medical management. These trials show little advantage to interventional therapies in those patients whose blood pressure is well controlled with medication who do not show progression of renal insufficiency during medical management. Based on these data, this review outlines a potential management strategy that relies on an individualized risk benefit assessment.