Renal revascularization in resistant hypertension

Renal artery stenosis (RAS) is a common cause of secondary hypertension (HTN) and may lead to resistant (refractory) HTN despite guideline directed medical therapy. Although randomized controlled trials comparing medical therapy to medical therapy and renal artery stenting have shown no benefit with renal artery stenting, according to comparative effectiveness reviews by the Agency for Healthcare Research and Quality, the trials did not enroll patients with the most severe RAS who would be more likely to benefit from renal stenting. Because of limitations of conventional angiography, it is important to assess the hemodynamic severity of moderate (50%-70%) RAS lesions with a hemodynamic measurement. We review techniques to optimize patient selection, to minimize procedural complications, and to facilitate durable patency of renal stenting. We also review the current ACC/AHA Guidelines and SCAI Appropriate Use Criteria as they relate to renal stenting.