Renal Artery Stenosis

Causes​

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• Atherosclerosis: plaque build-up in the renal artery (most common, typically in older patients)

• Fibromuscular dysplasia (FMD): abnormal thickening of the artery wall (more common in younger patients, often women)

• Less common causes include vasculitis, prior surgery or radiation, or external compression.

 

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Symptoms and clinical clues

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• High blood pressure that is new, worsening, or difficult to control despite multiple medications (refractory hypertension)

• A decline in kidney function (especially if it worsens after starting blood pressure medications such as ACE inhibitors or ARBs)

• Recurrent episodes of sudden pulmonary oedema ("flash" pulmonary oedema) or unexplained recurrent heart failure

• Asymmetric kidney size on imaging

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What is renal artery angioplasty and stenting?​

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Renal artery angioplasty is a minimally invasive procedure performed by an Interventional Radiologist (IR). A small tube (catheter) is inserted into an artery in the groin or wrist and guided to the renal artery under X-ray guidance. A balloon is used to widen the narrowed segment. In many cases (particularly for atherosclerotic disease), a small metal mesh tube (stent) is placed to help keep the artery open.

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Treatment options

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The best treatment depends on the underlying cause and your clinical situation:
Contemporary guidelines and expert consensus (including the 2022 American Heart Association Scientific Statement on renal revascularisation) support optimal medical therapy as first-line for most people with atherosclerotic renal artery stenosis, and reserve revascularisation for carefully selected patients where the likely benefits outweigh risks.

• Atherosclerotic RAS: most patients are managed with optimal medical therapy (blood pressure medications, cholesterol treatment, and lifestyle measures). Randomised trials showed that routine stenting does not usually add benefit beyond contemporary medical therapy for stable disease.

• Revascularisation may be considered in selected high-risk presentations, particularly when stenosis is severe or haemodynamically significant (for example recurrent flash pulmonary oedema or otherwise unexplained recurrent heart failure, rapidly progressive or refractory hypertension, or rapidly declining kidney function with severe bilateral disease or a solitary functioning kidney).

• Fibromuscular dysplasia (FMD): balloon angioplasty (typically without stenting) is frequently effective and is commonly recommended when there is significant stenosis causing renovascular hypertension. This condition is most commonly seen in younger to middle aged women. 

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Procedure

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1. Consultation:
   An interventional radiologist will review your symptoms, blood pressure history, kidney function, and imaging (ultrasound/CT/MR). Your case may be discussed with a nephrologist or cardiologist to confirm the best individualised treatment plan.
    

2. Preparation:
   You may need blood tests (including kidney function) and guidance on medications (e.g., anticoagulants, diabetes medications). You will usually need to fast for several hours before the procedure.
    

3. Angioplasty / Stenting:
   The procedure is performed in an angiography suite under local anaesthetic and sedation (general anaesthesia is occasionally used). A catheter is guided to the renal artery. The narrowing is treated with a balloon, and a stent may be placed if needed. The procedure typically takes around 1 – 2 hours.  
    

4. Post-operative care:
   You are monitored for several hours. Patients often stay overnight for observation and blood pressure monitoring; especially if kidney function is reduced, though same day discharge may be appropriate in some cases. Most people return to light activities within 24 to 48 hours.

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Risks and considerations

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While renal artery angioplasty and stenting are generally safe, potential risks include:
•    Bruising, bleeding, or a pseudoaneurysm at the access site (groin or wrist); rarely major <1%.
•    Injury to the renal artery (spasm, dissection, perforation) or blockage from clot/embolisation <5%.
•    Restenosis (re-narrowing) over time, which may require repeat treatment.
•    Rarely, worsening kidney function from contrast dye (risk is higher in patients with moderate to severe chronic kidney disease).
•    Rarely, allergic reaction to contrast dye or medications.
•    Very rarely, need for emergency surgery or loss of kidney function

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Aftercare

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You may be prescribed antiplatelet medication after a stent (for example aspirin with or without another blood thinner) for a period of time. Follow your doctor's instructions closely and attend follow-up appointments. Follow-up imaging (e.g., ultrasound) may be arranged to monitor the treated artery.

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Specialist expertise

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Interventional Radiologists (IRs) are specialty trained in the assessment and treatment of renovascular disease, including renal angiography, angioplasty, and stenting. We use real-time imaging and modern endovascular devices to perform these procedures with a focus on safety, patient comfort, and durable outcomes.

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Multidisciplinary care

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​Renal artery stenosis is often associated with broader cardiovascular and kidney disease. We commonly coordinate care with your GP and relevant specialists (nephrology, cardiology, hypertension specialists & surgeons) to ensure that medical therapy is optimised and that a procedure is recommended only when the likely benefits outweigh the risks.​​

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Preparation and referral

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If you would like to consult with an Interventional Radiologist about renal artery stenosis, please send a referral for consultation, including:

• Recent blood tests (kidney function and full blood count).

• Previous imaging (renal artery ultrasound, CT angiography, MR angiography, or relevant reports).

• A current medication list (including blood pressure medications and anticoagulants).

• Clinic letters from your GP, nephrologist or cardiologist (if available).

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Public eligible patients can typically undergo the treatment with no out-of-pocket expense in the public system. Renal artery angioplasty and stenting are performed at most of our public and private hospital locations in Melbourne, Victoria, Australia.

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Renal Artery Stenosis content by Dr James Lisik.