Renovascular disease

In Western populations, fibromuscular disease (FMD) accounts for around 10% of all cases of renal artery stenosis (RAS), usually presenting as hypertension in young patients, most often women, and there is often a successful response after angioplasty. Atherosclerotic renovascular disease (ARVD) is very common, and accounts for the remaining 90% of cases of RAS. ARVD is frequently associated with hypertension and renal dysfunction, and is a disease of ageing. It is commonly accompanied by atherosclerotic macrovascular disease in other parts of the body, such as coronary artery disease, peripheral vascular disease, cerebrovascular disease and aortic aneurysms. Clinical presentations include hypertension, chronic or acute kidney disease and heart failure, although many patients with ARVD are identified incidentally when being screened for extra-renal vascular disease. The main treatment options involve general vascular protection with blood pressure control, antiplatelet and statin therapy, and interventional procedures, notably percutaneous renal angioplasty and/or stenting. ASTRAL, the largest randomized controlled trial in ARVD, was published in November 2009. It showed that, in an unselected population with significant anatomical ARVD, renal revascularization does not confer any additional overall clinical value over medical therapy. However, there is no doubt that a minority of patients do benefit from revascularization, and future work is needed to aid their identification.