Treatment options for the control of hypertension
in patients of RENAL ARTERY STENOSIS(RAS) with atherosclerotic bilateral renal artery includes both medical and interventional therapy. Interventions aimed at preserving renal function in patients with bilateral renal artery stenosis
Antihypertensive drugs — For hypertension control, we recommend an ACE inhibitor
or angiotensin II receptor blocker , often in combination with diuretic . Chlorthalidone
is the preferred thiazide diuretic, but a loop diuretic (eg, furosemide or torsemide), may be required in patients who have chronic kidney disease
with a significantly reduced glomerular filtration rate. Long-acting calcium channel blockers and beta blockers are also effective .
Interventional therapy — Percutaneous transluminal angioplasty
with stenting is the preferred nonsurgical intervention. Three randomized trials, all with serious flaws, found no improvement in blood pressure, renal, or cardiovascular outcomes in patients with atherosclerotic renal artery stenosis who were treated with percutaneous transluminal angioplasty and stent placement.
We agree with the 2005 ACC/AHA guidelines on the management of peripheral artery disease
, which recommended percutaneous transluminal angioplasty with stenting for ostial atherosclerotic lesions in patients who have clinical clues suggesting that the renovascular disease
is likely to be responsible for hypertension that is not well controlled with optimal medical therapy
Based upon the available data, we recommend not performing percutaneous transluminal angioplasty in patients who do not meet these criteria because the likelihood of benefit is small and the risk of procedural complications is relatively high.
We agree with the 2005 ACC/AHA guidelines, which recommended surgery in patients with atherosclerotic renal artery stenosis who have clinical indications for revascularization, particularly if they have multiple small renal arteries, early primary branching of the main renal artery, or require aortic reconstruction near the renal arteries for other indications (eg, aneurysm repair or severe aortoiliac occlusive disease)