Does revascularization in atherosclerotic renovascular disease improve outcomes in comparison to medical therapy alone?
With age, vascular changes, and as part of generalized atherosclerosis, atherosclerotic renovascular disease (ARVD) prevalence is estimated at 6.8% in community-dwelling patients older than age 65. Heightened suspicion for ARVD in older patients should occur when sudden increase in blood pressure or worsening of kidney function is noted.
Screening methodologies including duplex ultrasonography, computed tomographic angiography, or magnetic resonance angiography, in conjunction with functional significance for underlying stenotic lesions, should be utilized based on patient tolerance and test availability. Medical therapy with antihypertensive medications, particularly agents blocking the renin-angiotensin system, is useful, although careful follow-up is necessary in the face of high-grade bilateral stenotic lesions given an associated drop in GFR. Although concern for loss of kidney mass or poorly controlled hypertension with risk for increased cardiovascular events endorses need for a revascularization procedure either percutaneous or surgical, multiple randomized trials show no evidence for increased clinical benefit in the initial years after revascularization in patients with atherosclerotic renal-artery stenosis when compared to medical therapy. No significant improvements in blood pressure or reductions in kidney or cardiovascular events or mortality were seen.
