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Atherosclerotic Renal Artery Stenosis: Medical Therapy Alone or in Combination With Revascularization?

Renovascular hypertension (RVH) is one of the most common causes of secondary hypertension. Atherosclerosis accounts for 90% of cases of renal artery stenosis (RAS). Atherosclerotic RAS (ARAS) is associated with a high vascular morbidity and mortality. In patients older than 67 years with ARAS, the annual incidence of coronary events, stroke, heart failure, and death was 30%, 18%, 19%, and 17%, respectively. Atherosclerotic RAS usually reflects atherosclerotic disease in other vascular beds and is a frequent incidental finding in patients undergoing routine angiography for peripheral artery disease (PAD) or coronary heart disease (CHD), with an estimated prevalence between 5% to 40% and 5% to 20%, respectively. In addition, in a large cohort of patients with ARAS, PAD coexisted in 67.5% of the cases, CHD in 44.8%, heart failure in 32.6%, and stroke in 27.3%. Among patients with ARAS, progressive stenosis was reported in 35% and 51% at 3 and 5 years after diagnosis, respectively. The 2-year cumulative incidence of renal atrophy, defined as a reduction in renal length of greater than 1 cm, was 5.5%, 11.7%, and 20.8% in kidneys with baseline renal artery classified as normal, <60% stenotic, and 60% stenotic, respectively. Therefore, ARAS is a progressive disease, particularly in patients with other manifestations of atherosclerosis or diabetes mellitus. It is estimated that approximately 5% of patients who reach end-stage renal disease may have RAS as the underlying cause. The established risk factors for the development of ARAS include hypertension, diabetes mellitus, dyslipidemia, obesity, smoking, old age, and family history. Deterioration of renal function (as defined by rising serum creatinine levels) and elevated C-reactive protein levels seem to be the most important emerging risk factors in predicting ARAS, whereas the evidence regarding homocysteine, lipoprotein (a) and fibrinogen is more limited. Patients with ARAS also manifest increased activity of the sympathetic nervous system, platelet activation, oxidative stress and endothelial dysfunction. In addition, these patients exhibit a higher prevalence of target organ damage (left ventricular hypertrophy, renal injury, and retinopathy) than those with essential hypertension. In 1937, nephrectomy was reported to reverse hypertension in some patients with unilateral renal disease, including patients with RAS. In 1973, a prospective study in 214 patients with RVH, followed-up for 7 to 14 years, showed that surgical management was more effective than medical treatment. For many years, patients with severe or refractory hypertension were evaluated for the presence of RVH to remove the offending kidney or perform surgical revascularization.