Renovascular hypertension: Lesion detection, patient selection, treatment options and results

Renal artery stenosis (RAS) causing either renovascular hypertension (RVH) or ischemic nephropathy (IN) is a complicated pathophysiologic entity. The diagnosis may remain uncertain in many cases and is frequently obscured by other overlapping sources of hypertension. Improved sensitivities of non-invasive diagnostic imaging modalities has led to an increase in the detection of RAS without necessarily guiding treatment recommendations. Simultaneously, widespread, multidisciplinary competence with minimally-invasive, catheter-based therapies has led to frequent treatment of RAS without clearcut benefit. Establishing a causal relationship between the renal artery lesion and hypertension, when feasible, is of paramount importance in recommending therapy and achieving expected results. Broad lesion classification and location is also helpful in guiding therapies when indicated. Developmental lesions of the renal arteries typical of RVH affecting children behave differently than typical fibromuscular dysplastic (FMD) lesions or atherosclerotic renal artery disease (ASO-RAS). Unilaterality versus bilaterality, ostial versus branch vessel, focal versus diffuse and renal functional status are equally important in recommending therapy. Renovascular surgery and results of renal artery angioplasty/stenting (RAA) are discussed in the context of outcomes and durability. Ongoing investigations examining results of catheter-based treatments of RAS utilizing embolic protection devices (EPD) are presently in the forefront of the current literature and discussed in this review.