Precision medicine meets vascular disease: innovations in atherosclerotic renal artery stenosis management

Ahnaf J. Ahmed¹, Austin J. Marrah², Trenton G. Mayberry², Braydon C. Cowan², Mark R. Wakefield^2,3, Yujiang Fang^1,2,3,*
1 Department of Microbiology, Immunology & Pathology, Des Moines University, West Des Moines, IA, USA
2 Department of Surgery, University of Missouri School of Medicine, Columbia, MO, USA
3 Ellis Fischel Cancer Center, University of Missouri School of Medicine, Columbia, MO, USA
* Corresponding Author: Yujiang Fang. Email: email

Canadian Journal of Urology https://doi.org/10.32604/cju.2026.077527

Received 11 December 2025; Accepted 03 April 2026; Published online 29 April 2026

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Abstract

Atherosclerotic renal artery stenosis (ARAS) is a significant cause of secondary hypertension and kidney injury with important cardiovascular consequences. This review briefly discusses the pathophysiology of ARAS, evaluates in-depth the diagnostic performance of duplex ultrasound, computed tomography angiography, and magnetic resonance angiography, and synthesizes results from major randomized trials and observational studies to explore current treatment options. The objective is to define the current diagnostic and therapeutic landscape of ARAS in a manner that supports evidence-based clinical decision making, and identify which treatment modality may be appropriate based on clinical presentation. The preference for optimized medical therapy as the initial standard of care is largely based on multiple randomized controlled trials (RCTs), which found no overall benefit from invasive endovascular treatments in conjunction with medical therapy. However, the limitations in trial design indicate that these results do not rule out the benefit in carefully selected patients. Evidence from subgroup analyses and non-randomized studies supports invasive endovascular revascularization in presentations such as recurrent flash pulmonary edema, progressive decline in renal function, and hypertension resistant to pharmacologic medical therapy. Endovascular stenting is preferred when anatomy is favorable, while open surgical reconstruction, including aortorenal bypass or endarterectomy, is reserved for complex lesions, failed prior endovascular intervention, or concomitant aortic surgery. The review also discusses emerging strategies, including novel stent platforms and drug-eluting technology, which may improve outcomes if validated in targeted high-risk cohorts.