What factors would lead you to consider revascularization in a patient with bilateral renal artery stenosis between 50-70% who has persistently uncontrolled hypertension despite maximal medical therapy?

Several randomized controlled trials (RCTs) (STAR 2009, ASTRAL 2009, CORAL 2013) have shown that medical therapy has similar outcomes to revascularization (stenting) in patients with 50-70% renal artery stenosis (RAS). In these RCTs, serious complications of the interventional procedures occurred in some patients in the revascularization arm. Based on the observations in these RCTs, my goal would be to control BP and lower cholesterol with medical therapy and lifestyle changes. I would make cert...

This is a clinical judgement. Things I would consider are: effectiveness of medical therapy (is the patient tolerating max doses of the foundation BP meds: long-acting thiazide, ACEi/ARB, amlodipine); symptoms of flash pulmonary edema or abrupt volume overload, signs of end-organ damage like diastolic dysfunction or heart failure, size of the kidneys (not atrophic), rising or unstable serum creatinine levels, effective cholesterol lowering therapies.

If renal artery stenosis is considered to be hemodynamically significant and between 50-70%, I would consider revascularization if there were the following factors:

1. Recurrent, unexplained pulmonary edema (flash pulmonary edema)
2. Accelerating decline in kidney function, particularly if the decline is happening over 6-12 months
3. Intolerance to BP medications
4. Adequate kidney size (likely not helpful if kidney size is <8-9 cm)

In addition to the above, I might have a lower threshold for referral for i...