Timing and selection for renal revascularization in an era of negative trials: what to do?

Management of atherosclerotic renal artery stenosis has become more complex with advances in both medical therapy and endovascular procedures. Results from recent trials fail to demonstrate major benefits of endovascular stenting in addition to optimal medical therapy. The general applicability of these results to many patients is limited by short-term follow-up and selection biases in recruitment. Many patients at highest risk were excluded from these studies and some were included with trivial lesions. Identification of patients with hemodynamically significant lesions remains a challenge and has led to more stringent criteria for Doppler ultrasound, measurement of translesional gradients and quantitative angiography. Although many patients can now be managed with medical therapy, it should be recognized that long-term reduction in antihypertensive drug requirements and recovery of kidney function are limited to those undergoing renal revascularization. As with any major vascular lesion, follow-up for disease stability and/or progression is essential. The ambiguity of present trial data may lead some to overlook selected subgroups that would benefit from restoring renal blood supply through revascularization. Further studies to more precisely identify kidneys that can recover function and/or are beyond meaningful recovery are essential. Considering the comorbid risks for the atherosclerotic population, it will remain imperative for clinicians to consider the hazards, costs and benefits carefully for each patient to determine the role and timing for both medical therapy and revascularization.