Renal artery disease: diagnosis and management

Renal artery stenosis (RAS) is most commonly due to either fibromuscular dysplasia or atherosclerosis. The former predominates in young women while atherosclerosis is usually encountered in individuals over the age of 55. The most common clinical manifestation of fibromuscular dysplasia is hypertension, which can frequently be cured or significantly improved with percutaneous balloon dilation. Atherosclerotic RAS may present with hypertension, renal failure (ischemic nephropathy), recurrent episodes of congestive heart failure and flash pulmonary edema or may be discovered incidentally during an imaging procedure for some other reason. Screening tests for RAS have improved considerably over the last decade. While captopril renography was utilized almost exclusively in the past, duplex ultrasound of the renal arteries or magnetic resonance angiography have replaced other modalities as the screening test of choice in many centers. Rarely does an arteriogram have to be performed for diagnostic purposes only. Management of RAS consists of three possible strategies: medical management, surgical management or percutaneous therapy with balloon angioplasty and stent implantation. The treatment of choice to control hypertension in patients with fibromuscular disease is percutaneous angioplasty. Renal artery stenting has replaced surgical revascularization for most patients with atherosclerotic disease who meet the criteria for intervention.