Atherosclerotic Renovascular Disease: A Re-evaluation of Lesion Severity and Intervention

Atherosclerotic renal artery stenosis (ARAS) remains a complex contributor to hypertension and kidney disease. Although randomized trials failed to show benefit of revascularization on top of medical therapy over medical therapy alone, mounting evidence suggests that earlier stages of ARAS may still be clinically relevant. In this review, we will reevaluate assumptions about the relationship between lesion severity and clinical outcomes and highlight the discrepancy between angiographic definitions of significant stenosis and functional renal impairment. We suggest that with all degrees of angiographically identified ARAS, particularly in patients with refractory hypertension, Kidney failure, or flash pulmonary edema, the hemodynamic importance of the stenosis should be estimated. In this regard, a pressure drop of 10% or more across the stenosis is an indication that hypertension may be related to the obstruction. Because the classical definition of a hemodynamically significant stenosis precludes earlier and potentially more adequate opportunities for intervention, it is presently unknown if patients with ARAS of less than 60% stenosis would benefit from mechanical treatment. We suggest reevaluating the thresholds for intervention and call for new trials focused on early-stage atherosclerotic renal vascular disease.