Semin intervent Radiol 2009; 26(4): 333-344
DOI: 10.1055/s-0029-1242202
© Thieme Medical Publishers

The Current State of Endovascular Therapy in the Evaluation and Management of Renovascular Disease

Praveen R. Anchala1 , Scott A. Resnick1
  • 1Department of Interventional Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
Further Information

Publication History

Publication Date:
17 November 2009 (online)


Hypertension is the most common reason for physician office visits among nonpregnant adults in the United States; up to one-third of Americans over the age of 18 have been diagnosed with hypertension. Patients with physiologically significant renal artery stenosis often go unnoticed because hypertension can often be well controlled with antihypertensive medications. As a result, screening for renovascular causes of hypertension is rarely done. However, the likelihood of renovascular disease increases in patients with acute, severe, or refractory hypertension and should be explored in patients who fall into these categories. Renovascular disease is a crucial consideration in the management of hypertension due to its increasing incidence and its potential for reversibility. Although renovascular disease accounts for less than 1% of patients with mild hypertension, it is estimated that between 10 and 45% of white patients with severe or malignant hypertension have renal artery stenosis (RAS). In this population, diagnosing and treating RAS can have a profound and long-lasting effect on the treatment of hypertension.


  • 1 Cherry D K, Hing E, Woodwell D A et al.. National Ambulatory Medical Care Survey: 2006 Summary. Hyattsville, MD; National Health Statistics 2006
  • 2 Cutler J A, Sorlie P D, Wolz M, Thom T, Fields L E, Roccella E J. Trends in hypertension prevalence, awareness, treatment, and control rates in United States adults between 1988–1994 and 1999–2004.  Hypertension. 2008;  52 818-827
  • 3 Fields L E, Burt V L, Cutler J A, Hughes J, Roccella E J, Sorlie P. The burden of adult hypertension in the United States 1999 to 2000: a rising tide.  Hypertension. 2004;  44 398-404
  • 4 Gifford R W. Evaluation of the hypertensive patient with emphasis on detecting curable causes.  Milbank Mem Fund Q. 1969;  47 170-186
  • 5 Davis B A, Crook J E, Vestal R E, Oates J A. Prevalence of renovascular hypertension in patients with grade III or IV hypertensive retinopathy.  N Engl J Med. 1979;  301 1273-1276
  • 6 Mann S J, Pickering T G. Detection of renovascular hypertension. State of the art: 1992.  Ann Intern Med. 1992;  117 845-853
  • 7 Novick A C. Atherosclerotic renovascular disease.  J Urol. 1981;  126 567-572
  • 8 Lewin A, Blaufox M D, Castle H, Entwisle G, Langford H. Apparent prevalence of curable hypertension in the Hypertension Detection and Follow-up Program.  Arch Intern Med. 1985;  145 424-427
  • 9 Rimmer J M, Gennari F J. Atherosclerotic renovascular disease and progressive renal failure.  Ann Intern Med. 1993;  118 712-719
  • 10 Conlon P J, Little M A, Pieper K, Mark D B. Severity of renal vascular disease predicts mortality in patients undergoing coronary angiography.  Kidney Int. 2001;  60 1490-1497
  • 11 Kalra P A, Guo H, Kausz A T et al.. Atherosclerotic renovascular disease in United States patients aged 67 years or older: risk factors, revascularization, and prognosis.  Kidney Int. 2005;  68 293-301
  • 12 Caps M T, Perissinotto C, Zierler R E et al.. Prospective study of atherosclerotic disease progression in the renal artery.  Circulation. 1998;  98 2866-2872
  • 13 Crowley J J, Santos R M, Peter R H et al.. Progression of renal artery stenosis in patients undergoing cardiac catheterization.  Am Heart J. 1998;  136 913-918
  • 14 Pohl M A, Novick A C. Natural history of atherosclerotic and fibrous renal artery disease: clinical implications.  Am J Kidney Dis. 1985;  5 A120-A130
  • 15 Leertouwer T C, Pattynama P M, van den Berg-Huysmans A. Incidental renal artery stenosis in peripheral vascular disease: a case for treatment?.  Kidney Int. 2001;  59 1480-1483
  • 16 Slovut D P, Olin J W. Fibromuscular dysplasia.  N Engl J Med. 2004;  350 1862-1871
  • 17 Nabel E G, Gibbons G H, Dzau V J. Pathophysiology of experimental renovascular hypertension.  Am J Kidney Dis. 1985;  5 A111-A119
  • 18 Schreiber Jr M J, Pohl M A, Novick A C. Preserving renal function by revascularization.  Annu Rev Med. 1990;  41 423-429
  • 19 White C J, Jaff M R, Haskal Z J American Heart Association Committee on Diagnostic and Interventional Cardiac Catheterization, Council on Clinical Cardiology et al. Indications for renal arteriography at the time of coronary arteriography: a science advisory from the American Heart Association Committee on Diagnostic and Interventional Cardiac Catheterization, Council on Clinical Cardiology, and the Councils on Cardiovascular Radiology and Intervention and on Kidney in Cardiovascular Disease.  Circulation. 2006;  114 1892-1895
  • 20 Hirsch A T, Haskal Z J, Hertzer N R American Association for Vascular Surgery et al. ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation.  Circulation. 2006;  113 e463-e654
  • 21 Safian R D, Textor S C. Renal-artery stenosis.  N Engl J Med. 2001;  344 431-442
  • 22 Vasbinder G B, Nelemans P J, Kessels A G, Kroon A A, de Leeuw P W, van Engelshoven J M. Diagnostic tests for renal artery stenosis in patients suspected of having renovascular hypertension: a meta-analysis.  Ann Intern Med. 2001;  135 401-411
  • 23 Roubidoux M A, Dunnick N R, Klotman P E et al.. Renal vein renins: inability to predict response to revascularization in patients with hypertension.  Radiology. 1991;  178 819-822
  • 24 Derkx F H, Schalekamp M A. Renal artery stenosis and hypertension.  Lancet. 1994;  344 237-239
  • 25 Williams G J, Macaskill P, Chan S F et al.. Comparative accuracy of renal duplex sonographic parameters in the diagnosis of renal artery stenosis: paired and unpaired analysis.  AJR Am J Roentgenol. 2007;  188 798-811
  • 26 Strandness Jr D E. Duplex imaging for the detection of renal artery stenosis.  Am J Kidney Dis. 1994;  24 674-678
  • 27 Hoffmann U, Edwards J M, Carter S et al.. Role of duplex scanning for the detection of atherosclerotic renal artery disease.  Kidney Int. 1991;  39 1232-1239
  • 28 Olin J W, Piedmonte M R, Young J R, DeAnna S, Grubb M, Childs M B. The utility of duplex ultrasound scanning of the renal arteries for diagnosing significant renal artery stenosis.  Ann Intern Med. 1995;  122 833-838
  • 29 René P C, Oliva V L, Bui B T et al.. Renal artery stenosis: evaluation of Doppler US after inhibition of angiotensin-converting enzyme with captopril.  Radiology. 1995;  196 675-679
  • 30 Spies K P, Fobbe F, El-Bedewi M, Wolf K J, Distler A, Schulte K L. Color-coded duplex sonography for noninvasive diagnosis and grading of renal artery stenosis.  Am J Hypertens. 1995;  8(12 Pt 1) 1222-1231
  • 31 Zeman R K, Silverman P M, Vieco P T, Costello P. CT angiography.  AJR Am J Roentgenol. 1995;  165 1079-1088
  • 32 Rubin G D, Walker P J, Dake M D et al.. Three-dimensional spiral computed tomographic angiography: an alternative imaging modality for the abdominal aorta and its branches.  J Vasc Surg. 1993;  18 656-664 discussion 665
  • 33 Galanski M, Prokop M, Chavan A, Schaefer C M, Jandeleit K, Nischelsky J E. Renal arterial stenoses: spiral CT angiography.  Radiology. 1993;  189 185-192
  • 34 Olbricht C J, Galanski M, Chavan A, Prokop M. Spiral CT angiography—can we forget about arteriography to diagnose renal artery stenosis?.  Nephrol Dial Transplant. 1996;  11 1227-1231
  • 35 Beregi J P, Louvegny S, Ceugnart L et al.. [Helical x-ray computed tomography of renal arteries. Apropos of 300 patients].  J Radiol. 1997;  78 549-556
  • 36 Berg M H, Manninen H I, Vanninen R L, Vainio P A, Soimakallio S. Assessment of renal artery stenosis with CT angiography: usefulness of multiplanar reformation, quantitative stenosis measurements, and densitometric analysis of renal parenchymal enhancement as adjuncts to MIP film reading.  J Comput Assist Tomogr. 1998;  22 533-540
  • 37 Brink J A, Lim J T, Wang G, Heiken J P, Deyoe L A, Vannier M W. Technical optimization of spiral CT for depiction of renal artery stenosis: in vitro analysis.  Radiology. 1995;  194 157-163
  • 38 Halpern E J, Deane C R, Needleman L, Merton D A, East S A. Normal renal artery spectral Doppler waveform: a closer look.  Radiology. 1995;  196 667-673
  • 39 Leung D A, Hoffmann U, Pfammatter T et al.. Magnetic resonance angiography versus duplex sonography for diagnosing renovascular disease.  Hypertension. 1999;  33 726-731
  • 40 Rieumont M J, Kaufman J A, Geller S C et al.. Evaluation of renal artery stenosis with dynamic gadolinium-enhanced MR angiography.  AJR Am J Roentgenol. 1997;  169 39-44
  • 41 Postma C T, Joosten F B, Rosenbusch G, Thien T. Magnetic resonance angiography has a high reliability in the detection of renal artery stenosis.  Am J Hypertens. 1997;  10(9 Pt 1) 957-963
  • 42 Schoenberg S O, Knopp M V, Londy F et al.. Morphologic and functional magnetic resonance imaging of renal artery stenosis: a multireader tricenter study.  J Am Soc Nephrol. 2002;  13 158-169
  • 43 Thornton M J, Thornton F, O'Callaghan J et al.. Evaluation of dynamic gadolinium-enhanced breath-hold MR angiography in the diagnosis of renal artery stenosis.  AJR Am J Roentgenol. 1999;  173 1279-1283
  • 44 Leung D A, Pelkonen P, Hany T F, Zimmermann G, Pfammatter T, Debatin J F. Value of image subtraction in 3D gadolinium-enhanced MR angiography of the renal arteries.  J Magn Reson Imaging. 1998;  8 598-602
  • 45 Niendorf H P, Haustein J, Cornelius I, Alhassan A, Clauss W. Safety of gadolinium-DTPA: extended clinical experience.  Magn Reson Med. 1991;  22 222-228 discussion 229-232
  • 46 Prince M R, Arnoldus C, Frisoli J K. Nephrotoxicity of high-dose gadolinium compared with iodinated contrast.  J Magn Reson Imaging. 1996;  6 162-166
  • 47 Marckmann P, Skov L, Rossen K et al.. Nephrogenic systemic fibrosis: suspected causative role of gadodiamide used for contrast-enhanced magnetic resonance imaging.  J Am Soc Nephrol. 2006;  17 2359-2362
  • 48 Grobner T. Gadolinium—a specific trigger for the development of nephrogenic fibrosing dermopathy and nephrogenic systemic fibrosis?.  Nephrol Dial Transplant. 2006;  21 1104-1108
  • 49 Sadowski E A, Bennett L K, Chan M R et al.. Nephrogenic systemic fibrosis: risk factors and incidence estimation.  Radiology. 2007;  243 148-157
  • 50 Kim T S, Chung J W, Park J H, Kim S H, Yeon K M, Han M C. Renal artery evaluation: comparison of spiral CT angiography to intra-arterial DSA.  J Vasc Interv Radiol. 1998;  9 553-559
  • 51 Bartholomew B A, Harjai K J, Dukkipati S et al.. Impact of nephropathy after percutaneous coronary intervention and a method for risk stratification.  Am J Cardiol. 2004;  93 1515-1519
  • 52 Levy E M, Viscoli C M, Horwitz R I. The effect of acute renal failure on mortality. A cohort analysis.  JAMA. 1996;  275 1489-1494
  • 53 Chábová V, Schirger A, Stanson A W, McKusick M A, Textor S C. Outcomes of atherosclerotic renal artery stenosis managed without revascularization.  Mayo Clin Proc. 2000;  75 437-444
  • 54 Grüntzig A, Kuhlmann U, Vetter W, Lütolf U, Meier B, Siegenthaler W. Treatment of renovascular hypertension with percutaneous transluminal dilatation of a renal-artery stenosis.  Lancet. 1978;  1 801-802
  • 55 Libertino J A, Bosco P J, Ying C Y et al.. Renal revascularization to preserve and restore renal function.  J Urol. 1992;  147 1485-1487
  • 56 Kidney D D, Deutsch L S. The indications and results of percutaneous transluminal angioplasty and stenting in renal artery stenosis.  Semin Vasc Surg. 1996;  9 188-197
  • 57 Martin L G, Casarella W J, Alspaugh J P, Chuang V P. Renal artery angioplasty: increased technical success and decreased complications in the second 100 patients.  Radiology. 1986;  159 631-634
  • 58 Martin L G, Cork R D, Kaufman S L. Long-term results of angioplasty in 110 patients with renal artery stenosis.  J Vasc Interv Radiol. 1992;  3 619-626
  • 59 van Jaarsveld B C, Krijnen P, Pieterman H Dutch Renal Artery Stenosis Intervention Cooperative Study Group et al. The effect of balloon angioplasty on hypertension in atherosclerotic renal-artery stenosis.  N Engl J Med. 2000;  342 1007-1014
  • 60 Plouin P F, Chatellier G, Darné B, Raynaud A. Blood pressure outcome of angioplasty in atherosclerotic renal artery stenosis: a randomized trial. Essai Multicentrique Medicaments vs Angioplastie (EMMA) Study Group.  Hypertension. 1998;  31 823-829
  • 61 Weibull H, Bergqvist D, Bergentz S E, Jonsson K, Hulthén L, Manhem P. Percutaneous transluminal renal angioplasty versus surgical reconstruction of atherosclerotic renal artery stenosis: a prospective randomized study.  J Vasc Surg. 1993;  18 841-850 discussion 850-852
  • 62 Canzanello V J, Millan V G, Spiegel J E, Ponce P S, Kopelman R I, Madias N E. Percutaneous transluminal renal angioplasty in management of atherosclerotic renovascular hypertension: results in 100 patients.  Hypertension. 1989;  13 163-172
  • 63 Eldrup-Jorgensen J, Harvey H R, Sampson L N, Amberson S M, Bredenberg C E. Should percutaneous transluminal renal artery angioplasty be applied to ostial renal artery atherosclerosis?.  J Vasc Surg. 1995;  21 909-914 discussion 914-915
  • 64 Cicuto K P, McLean G K, Oleaga J A, Freiman D B, Grossman R A, Ring E J. Renal artery stenosis: anatomic classification for percutaneous transluminal angioplasty.  AJR Am J Roentgenol. 1981;  137 599-601
  • 65 Bonelli F S, McKusick M A, Textor S C et al.. Renal artery angioplasty: technical results and clinical outcome in 320 patients.  Mayo Clin Proc. 1995;  70 1041-1052
  • 66 Hendricks D E, Hagspiel K D. Cryoplasty for the treatment of in-stent renal artery stenosis?.  Tex Heart Inst J. 2008;  35 489-491 author reply 491
  • 67 van de Ven P J, Kaatee R, Beutler J J et al.. Arterial stenting and balloon angioplasty in ostial atherosclerotic renovascular disease: a randomised trial.  Lancet. 1999;  353 282-286
  • 68 Blum U, Krumme B, Flügel P et al.. Treatment of ostial renal-artery stenoses with vascular endoprostheses after unsuccessful balloon angioplasty.  N Engl J Med. 1997;  336 459-465
  • 69 Rocha-Singh K, Jaff M R, Rosenfield K. ASPIRE-2 Trial Investigators . Evaluation of the safety and effectiveness of renal artery stenting after unsuccessful balloon angioplasty: the ASPIRE-2 study.  J Am Coll Cardiol. 2005;  46 776-783
  • 70 van de Ven P J, Beutler J J, Kaatee R et al.. Transluminal vascular stent for ostial atherosclerotic renal artery stenosis.  Lancet. 1995;  346 672-674
  • 71 Tuttle K R, Chouinard R F, Webber J T et al.. Treatment of atherosclerotic ostial renal artery stenosis with the intravascular stent.  Am J Kidney Dis. 1998;  32 611-622
  • 72 Rees C R, Palmaz J C, Becker G J et al.. Palmaz stent in atherosclerotic stenoses involving the ostia of the renal arteries: preliminary report of a multicenter study.  Radiology. 1991;  181 507-514
  • 73 Bakker J, Goffette P P, Henry M et al.. The Erasme study: a multicenter study on the safety and technical results of the Palmaz stent used for the treatment of atherosclerotic ostial renal artery stenosis.  Cardiovasc Intervent Radiol. 1999;  22 468-474
  • 74 Leertouwer T C, Gussenhoven E J, Bosch J L et al.. Stent placement for renal arterial stenosis: where do we stand? A meta-analysis.  Radiology. 2000;  216 78-85
  • 75 DeMaioribus C A, Anderson C A, Popham S S, Yeager T D, Cordts P R. Mycotic renal artery degeneration and systemic sepsis caused by infected renal artery stent.  J Vasc Surg. 1998;  28 547-550
  • 76 Deiparine M K, Ballard J L, Taylor F C, Chase D R. Endovascular stent infection.  J Vasc Surg. 1996;  23 529-533
  • 77 Martin L G. Renal vascularization using percutaneous balloon angioplasty for fibromuscular dysplasia and atherosclerotic disease. In: Calligaro KD, Dougherty MJ Modern Management of Renovascular Hypertension and Renal Salvage. Philadelphia; Williams and Wilkins 1996: 125-144
  • 78 Martin L G, Rundback J H, Sacks D Society of Interventional Radiology. Standards of Practice Committee et al. Quality improvement guidelines for angiography, angioplasty, and stent placement in the diagnosis and treatment of renal artery stenosis in adults.  J Vasc Interv Radiol. 2002;  13 1069-1083
  • 79 Beek F J, Kaatee R, Beutler J J, van der Ven P J, Mali W P. Complications during renal artery stent placement for atherosclerotic ostial stenosis.  Cardiovasc Intervent Radiol. 1997;  20 184-190
  • 80 Rudnick M R, Berns J S, Cohen R M, Goldfarb S. Nephrotoxic risks of renal angiography: contrast media-associated nephrotoxicity and atheroembolism—a critical review.  Am J Kidney Dis. 1994;  24 713-727
  • 81 Holden A, Hill A, Jaff M R, Pilmore H. Renal artery stent revascularization with embolic protection in patients with ischemic nephropathy.  Kidney Int. 2006;  70 948-955
  • 82 Edwards M S, Craven B L, Stafford J et al.. Distal embolic protection during renal artery angioplasty and stenting.  J Vasc Surg. 2006;  44 128-135
  • 83 Dorros G, Jaff M, Mathiak L et al.. Renal function and survival after renal artery stent revascularization may be influenced by embolic debris.  J Invasive Cardiol. 2004;  16 189-195
  • 84 Zeller T, Sixt S, Rastan A et al.. Treatment of reoccurring instent restenosis following reintervention after stent-supported renal artery angioplasty.  Catheter Cardiovasc Interv. 2007;  70 296-300
  • 85 N'Dandu Z M, Badawi R A, White C J et al.. Optimal treatment of renal artery in-stent restenosis: repeat stent placement versus angioplasty alone.  Catheter Cardiovasc Interv. 2008;  71 701-705
  • 86 Zähringer M, Sapoval M, Pattynama P M et al.. Sirolimus-eluting versus bare-metal low-profile stent for renal artery treatment (GREAT Trial): angiographic follow-up after 6 months and clinical outcome up to 2 years.  J Endovasc Ther. 2007;  14 460-468
  • 87 Tanaka R, Higashi M, Naito H. Angioplasty for non-arteriosclerotic renal artery stenosis: the efficacy of cutting balloon angioplasty versus conventional angioplasty.  Cardiovasc Intervent Radiol. 2007;  30 601-606
  • 88 Munneke G J, Engelke C, Morgan R A, Belli A M. Cutting balloon angioplasty for resistant renal artery in-stent restenosis.  J Vasc Interv Radiol. 2002;  13 327-331
  • 89 Karthik S, Tuite D J, Nicholson A A et al.. Cryoplasty for arterial restenosis.  Eur J Vasc Endovasc Surg. 2007;  33 40-43
  • 90 Samson R H, Showalter D P, Lepore Jr M, Nair D G, Merigliano K. CryoPlasty therapy of the superficial femoral and popliteal arteries: a reappraisal after 44 months' experience.  J Vasc Surg. 2008;  48 634-637
  • 91 Yan B P, Kiernan T J, Rosenfield K. Covered stent for the treatment of recurrent bilateral renal artery in-stent restenosis.  J Invasive Cardiol. 2008;  20 E288-E292
  • 92 Giles H, Lesar C, Erdoes L, Sprouse R, Myers S. Balloon-expandable covered stent therapy of complex endovascular pathology.  Ann Vasc Surg. 2008;  22 762-768
  • 93 Patel N H, Jindal R M, Wilkin T et al.. Renal arterial stenosis in renal allografts: retrospective study of predisposing factors and outcome after percutaneous transluminal angioplasty.  Radiology. 2001;  219 663-667
  • 94 Fervenza F C, Lafayette R A, Alfrey E J, Petersen J. Renal artery stenosis in kidney transplants.  Am J Kidney Dis. 1998;  31 142-148
  • 95 Roberts J P, Ascher N L, Fryd D S et al.. Transplant renal artery stenosis.  Transplantation. 1989;  48 580-583
  • 96 Bruno S, Remuzzi G, Ruggenenti P. Transplant renal artery stenosis.  J Am Soc Nephrol. 2004;  15 134-141
  • 97 Benoit G, Moukarzel M, Hiesse C, Verdelli G, Charpentier B, Fries D. Transplant renal artery stenosis: experience and comparative results between surgery and angioplasty.  Transpl Int. 1990;  3 137-140
  • 98 Curry N S, Cochran S, Barbaric Z L et al.. Interventional radiologic procedures in the renal transplant.  Radiology. 1984;  152 647-653
  • 99 Raynaud A, Bedrossian J, Remy P, Brisset J M, Angel C Y, Gaux J C. Percutaneous transluminal angioplasty of renal transplant arterial stenoses.  AJR Am J Roentgenol. 1986;  146 853-857
  • 100 Aliabadi H, McLorie G A, Churchill B M, McMullin N. Percutaneous transluminal angioplasty for transplant renal artery stenosis in children.  J Urol. 1990;  143 569-572 discussion 572-573
  • 101 King III S B, Smith Jr S C, Hirshfeld Jr J W 2005 Writing Committee Members et al. 2007 focused update of the ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association task force on practice guidelines: 2007 writing group to review new evidence and update the ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention, writing on behalf of the 2005 writing committee.  Circulation. 2008;  117 261-295
  • 102 Collet J P, Silvain J, Landivier A et al.. Dose effect of clopidogrel reloading in patients already on 75-mg maintenance dose: the Reload with Clopidogrel Before Coronary Angioplasty in Subjects Treated Long Term with Dual Antiplatelet Therapy (RELOAD) study.  Circulation. 2008;  118 1225-1233

Scott A ResnickM.D. 

Northwestern University Feinberg School of Medicine

251 East Huron Street, Feinberg 4-710X, Chicago, IL 60611