Bilateral Atherosclerotic Renal Artery Stenosis Research Articles

A 63–year–old female with bilateral renal artery stenosis – highlights on diagnosis and optimal medical treatment

Renal artery stenosis is responsible for approximately 75% of secondary hypertensive cases. A 63-year-old female patient with uncontrolled hypertension and other comorbidities including type 2 diabetes mellitus and knee osteoarthritis presented with drastically raised systolic blood pressure in this case report (220 mmHg). Bilateral abdominal bruits were detected upon of physical examination. Imaging investigation showed significant bilateral atherosclerotic renal artery stenosis. An optimal combination of antihypertensive agents mainly with an angiotensin converting enzyme inhibitor, other than interventional revascularization, was applied and resulted in controlled blood pressure.

Exaggerated natriuresis after renal artery balloon angioplasty for flash pulmonary oedema: a potential complication in one-kidney renovascular hypertension.

Flash pulmonary oedema is a life-threatening complication of renal artery stenosis. We report a very rare complication in a patient with bilateral atherosclerotic renal artery stenosis who underwent unilateral renal artery angioplasty because of recurrent flash pulmonary oedema. Shortly after the procedure, she developed extreme polyuria (over 201 in the first 48 h) with massive natriuresis (>1000 mmol urinary sodium excretion in the first 24 h). Most likely, the occurrence of this phenomenon is related to the fact that her contralateral kidney was atrophic and no longer functioning due to total renal artery occlusion. We provide an overview of the literature and discuss several mechanisms that may contribute to the occurrence of this exaggerated natriuretic response in patients with one-kidney renovascular hypertension who undergo renovascular revascularization. We recommend close monitoring of natriuresis in such patients and - if needed - administration of intravenous isotonic saline (0.9% NaCl) to prevent hypovolemia.

SAT-185 FEATURES OF ATHEROSCLEROTIC RENAL ARTERY STENOSIS: AN AUTOPSY BASED STUDY

Atherosclerotic renal artery stenosis (ARAS) is a common condition, affecting up to 7% of individuals over 65 years of age. The diagnosis, management (medical vs. surgical), and outcome of ARAS represent issues of considerable controversy. In particular, the risks and benefits of angiotensin enzyme inhibitors (ACEI) in unilateral and bilateral ARAS has been a topic of much discussion. We identified 51 patients with an autopsy diagnosis of ARAS between 1994 and 2013. We classified patients with a stenotic kidney/contralateral kidney weight ratio of <0.8 to have unilateral ARAS and patients with a ratio >0.8 to have bilateral ARAS. 40 patients received medical therapy for hypertension, 11 patients received a stent. Results are summarized below:Tabled 1Received ACE InhibitorsDid not receive ACE InhibitorsDiagnosed with ARAS prior to deathMedical Therapy: bilateral ARAS7114Medical Therapy: unilateral ARAS1394Stent: bilateral ARAS325Stent: unilateral ARAS426 Open table in a new tab For both patients with unilateral and bilateral ARAS, there were no differences in pre-mortem systolic blood pressure or glomerular filtration rate in patients who received ACEI versus those that did not. For patients with unilateral ARAS, the contralateral kidney weight normalized to body weight was higher in those who did not receive ACEI (6.8 vs 5.2, p=0.04). For patients with bilateral ARAS, the weights of both the smaller and larger kidneys (normalized to body mass index) were higher in those receiving ACEI than those that did not. There were no significant differences in normalized stenotic (ST) or contralateral (CTL) kidney weights between those medically treated or those surgically treated (stent placement). Pre-mortem GFR was lower in patients who underwent surgery compared to those receiving medical therapy (26.8 +/- 5.1 vs. 41.9 +/- 3.4, p=0.0352), perhaps reflecting more severe renovascular disease in those who had surgery. For all patients, there were no significant differences in normalized ST or CTL kidney weights, percent cortical atrophy of the ST kidney, systolic blood pressure, or GFR between those who received ACEI and those that did not. As expected, the normalized ST kidney weight was significantly lower (2.7 +/- 0.3 vs 4.9 +/- 0.4, P<0.0001) and percent cortical atrophy was higher (54+/- 7% vs 25 +/- 5, p=0.0014) in those with unilateral versus bilateral ARAS. The most common cause of death in this group of patients was myocardial infarction. A pre-mortem diagnosis of ARAS was made in only 20% (8 of 40) patients who received medical treatment for hypertension. Half of patients with unilateral or bilateral ARAS received ACEI therapy prior to death. However, there were no differences in pre-mortem systolic blood pressure or glomerular filtration rate between those treated or not treated with ACEI. Based on this autopsy study, ACEI may limit potentially maladaptive compensatory hypertrophy of the CTL kidney in patients with unilateral ARAS and does not appear to decrease kidney size in those with bilateral ARAS. Although ACEI may affect short-term renal function, this autopsy based study indicates that ACEI do not adversely affect long-term renal structure in patients with ARAS.

Effects of Stenting for Atherosclerotic Renal Artery Stenosis on eGFR and Predictors of Clinical Events in the CORAL Trial.

Atherosclerotic renal artery stenosis may cause kidney function loss, but effects of stenting on eGFR and clinical events associated with CKD are uncertain. Our study objectives were to determine effects of stenting on eGFR and predictors of clinical events. Participants (n=931) in the Cardiovascular Outcomes in Renal Artery Stenosis Trial (from May of 2005 to September of 2012) had >60% atherosclerotic renal artery stenosis and systolic hypertension on two or more antihypertensive drugs and/or stage ≥3 CKD. The intervention was stenting versus no stenting on a background of risk factor management: renin-angiotensin system inhibition, statin, antiplatelet therapy, and smoking cessation education. The effect of stenting on eGFR by the serum creatinine-cystatin C Chronic Kidney Disease Epidemiology Collaboration equation was the prespecified analysis of kidney function. Predictors of eGFR and CKD outcomes (≥30% eGFR loss, ESRD, and death) and cardiovascular disease outcomes (stroke, myocardial infarction, heart failure, and death) controlling for eGFR and albuminuria were also determined. eGFR was 59±24 ml/min per 1.73 m(2) (mean±SD) at baseline. Over 3 years, eGFR change, assessed by generalized estimating equations, was -1.5±7.0 ml/min per 1.73 m(2) per year in the stent group versus -2.3±6.3 ml/min per 1.73 m(2) per year in the medical therapy only group (P=0.18). eGFR predictors (multiple variable generalized estimating equations) were age, albuminuria, systolic BP, and diabetes (inverse associations) as well as men, total cholesterol, and HDL cholesterol (positive associations). CKD outcomes events occurred in 19% (175 of 931), and predictors (Cox proportional hazards models) included albuminuria (positive association), systolic BP (positive association), and HDL cholesterol (inverse association). Cardiovascular disease outcomes events occurred in 22% (207 of 931), and predictors included age, albuminuria, total cholesterol, prior cardiovascular disease, and bilateral atherosclerotic renal artery stenosis (positive associations). Stenting did not influence eGFR in participants with atherosclerotic renal artery stenosis receiving renin-angiotensin system inhibition-based therapy. Predictors of clinical events were traditional risk factors for CKD and cardiovascular disease.

Renal artery stenting in patients with uncontrolled hypertension: should we? And to whom?

In this issue of the Journal, Chrysant and colleagues evaluated the longer-term efficacy of renal artery stenting with respect to blood pressure (BP) control by analyzing the results of the Safety and Effectiveness Study of the Herculink Elite Renal Stent to Treat Renal Artery Stenosis (HERCULES) trial after 36 months of follow-up. 1 The HERCULES trial was a multicenter, single-arm trial of 202 patients with uncontrolled hypertension caused by atherosclerotic renovascular disease (ARVD) treated by percutaneous renal artery dilatation and renal stent placement. In the original HERCULES trial, the authors found that the absolute reduction in systolic BP (SBP) after 9 months was related to the severity of the baseline hypertension before intervention. In ARVD patients with preprocedure SBP >180 mm Hg and a postprocedure reduction in SBP, the mean reduction recorded at 9 months was 48 mm Hg, while patients with ARVD with a baseline SBP between 140 mm Hg and 160 mm Hg had a decrease of only 23 mm Hg in SBP at 9 months. In addition, this trial demonstrated excellent procedurerelated safety, with a 30-day composite safety endpoint rate of 1.5%. 2 Chrysant and colleagues further hypothesized that if the renal stent used in the initial HERCULES trial maintained renal artery patency over time, then the clinical benefit confirmed in the initial trial should be sustained over time. Based on this hypothesis, the

The Impact of Renal Artery Stenosis on Outcomes After Open-Heart Surgery

The aim of this study was to assess the impact of atherosclerotic renal artery stenosis (ARAS) on outcomes after open-heart surgery (OHS). Acute kidney injury after OHS portends significant morbidity and mortality. Data from all adult patients undergoing OHS from January 2000 to April 2010 who underwent renal duplex ultrasound were prospectively collected. ARAS was severe (60% to 99% stenosis) if peak systolic velocity was >200cm/s. The associations between ARAS and post-operative reduction in glomerular filtration rate (GFR), need for renal replacement therapy, length of stay, and overall short-term and long-term mortality (up to 8 years) were tested using multivariate time-to-event adjusted analysis. A total of 714 patients were evaluated, with a mean age of 67 ± 12 years (63% men) and a mean GFR of 52±25.9ml/min/1.73 m(2). A total of 206 (29%) had ARAS; of these, 79% (n= 163) had unilateral and 21% (n=43)had bilateral ARAS. ARAS was associated with peripheral artery disease (p= 0.004) and lower high-density lipoprotein levels (p= 0.04). Patients with advanced age (p= 0.01) and descending aorta grafting (p= 0.004) had significant post-operative reductions in GFR. Adjusted models showed a nonsignificant trend between ARAS and reduction inGFR (p= 0.09). ARAS was not associated with need for renal replacement therapy (p= 0.4), longer length of stay(p=0.7), or mortality (p= 0.7), but low pre-operative GFR was a strong predictor of long-term mortality. ARAS does not appear to be associated with post-operative change in GFR, need for hemodialysis, longer length of stay, or mortality in patients undergoing OHS.

Prevalence and predictors of renal artery stenosis in patients undergoing peripheral and coronary angiography

Renal artery stenosis is a potential cause of secondary hypertension, ischemic nephropathy and end-stage renal disease. Atherosclerosis is by far the most common etiology of renal artery stenosis in elderly. We investigated whether the presence of significant atherosclerotic renal artery stenosis (ARAS) with luminal diameter narrowing ≥50 % could be predicted in patients undergoing peripheral and coronary angiography. The records of 3,500 consecutive patients undergoing simultaneous renal angiography along with peripheral and coronary angiography were reviewed. The patients with known renal artery disease were excluded. Prevalence of ARAS was 5.7 %. Significant ARAS (luminal diameter narrowing ≥50 %) was present in 139 patients (3.9 %). Hypertension with altered serum creatinine and triple-vessel CAD were associated with significant renal artery stenosis in multivariate analysis. No significant relationship between the involved coronary arteries like left anterior descending, left circumflex, right coronary artery and ARAS was found. Only hypertension and altered serum creatinine were associated with bilateral ARAS. Extent of CAD or risk factors like diabetes, hyperlipidemia or smoking did not predict the unilateral or bilateral ARAS. Prevalence of ARAS among the patients in routine cardiac catheterization was 5.7 %. Hypertension is closely associated with significant ARAS. Significant CAD in the form of triple-vessel disease and altered renal function tests are closely associated with ARAS. They predict the presence of significant renal artery stenosis in patients undergoing routine peripheral and coronary angiography. Moreover, hypertension and altered renal functions predict bilateral ARAS.

Prevalence and risk factors of atherosclerotic renal artery stenosis

To explore the prevalence and risk factors of atherosclerotic renal artery stenosis (ARAS) in patients undergoing coronary angiography. A total of 2506 patients with suspected and known coronary heart disease (CAD) at our hospital underwent simultaneous coronary and renal angiography. Renal artery stenosis was defined as at least one of renal artery stenosis ≥ 50% narrowing of luminal diameter. The prevalence of ARAS was summarized from the results of angiography. And single- and multi-variable logistic regression analysis was used to assess the relationship between clinical characteristics and ARAS. Among them, there were 1479 males and 1027 females with a mean age of 62.7 ± 11.4 years. ARAS was detected in 409 patients (16.3%), including 214 (8.5%) with significant stenosis (≥ 75%); Bilateral ARAS was detected in 98 patients (3.9%), including 27 (1.1%) with significant stenosis (≥ 75%). Left and right ARAS were detected in 162 patients (6.5%) and 148 patients (5.9%) respectively, including 84 patients (3.4%) with significant stenosis (≥ 75%) in left ARAS and 72 patients (2.9%) in right ARAS. Univariate analysis indicated that age, females, diabetes, hypertension, stroke, peripheral artery disease, coronary heart disease, renal insufficiency, dyslipidemia and hyperuricemia were the predictor for ARAS (P < 0.05 or 0.01). Multivariate regression analysis demonstrated that age ≥ 65 years (P = 0.025, OR = 1.358), females (P < 0.01, OR = 1.678), hypertension (P < 0.01, OR = 1.650), peripheral artery disease (P < 0.01, OR = 14.678), renal insufficiency (P < 0.01, OR = 1.835), coronary heart disease including 3-vessel (P < 0.01, OR = 1.746) and left main coronary (P < 0.01, OR = 3.416)disease were independent risk factors for ARAS. Renal angiography should be routinely performed in female patients aged ≥ 65 years with hypertension, peripheral artery disease, elevated creatinine and coronary heart disease, especially for 3-vessel and left main coronary disease to identify ARAS in time.

Outcomes and effectiveness of bilateral percutaneous transluminal renal artery stenting in patients with critical bilateral renal artery stenosis

The aim of this study was to assess the effects of percutaneous bilateral renal artery stenting in patients with atherosclerotic renal artery stenosis and in-hospital and 4 month outcome of the procedure, focusing on the changes in renal function and blood pressure. Five consecutive patients (mean age: 64.8 ± 9.7 years, 1 women) with bilateral renal artery stenoses underwent percutaneous interventions. We compared blood pressure, number of oral antihypertensive medications, and renal function changes preprocedure and postprocedure at 4 months follow-up. A total of 5 bilateral atherosclerotic renal artery stenosis patients underwent percutaneous transluminal renal angioplasty and 10 stents were placed. Although systolic and diastolic blood pressures were significantly decreased in follow-up period, glomerular filtration rates were not significantly changed as compared with baseline data (p = 0.009, p = 0.008, p = 1.00, respectively). Also, the number of oral antihypertensive medications were significantly decreased at follow-up period (p = 0.03). Bilateral renal artery stenting provides a beneficial outcome such as stabilization of renal functions, significant improvement in blood pressure control and reduction in the number of oral antihypertensive medications at follow-up.

Critical Appraisal of the Major Randomized Controlled Trails on the Management of Atherosclerotic Renovascular Disease (ARVD)

Background: In this article, the author discusses critical appraisals of the major randomized controlled trials on the management of Atherosclerotic Renovascular Disease (ARVD). The article will also discuss the limitations of the published trials, while highlighting the crucial aspect of appropriate patient selection, the serious flaws noted, and the quality of the main studies. Also included are the six major randomized controlled trials that compared the difference between revascularization, either surgical or PTRA (Percutaneous Renal Angioplasty), with or without stent versus conservative management (medication).The author also discusses the recommended research for the management of atherosclerotic renovascular disease. Methodology and search strategies to identify studies: A comprehensive search of PUBMED including Medical Subject Headings (MeSH) data base from 1990 to may 2012 and The Cochrane library was completed. Searching was only for relevant English papers related to the management of Atherosclerotic renovascular disease.. CASP questionnaire, Jadad scaling and (Oxford Centre for Evidence-based Medicine) levelling of evidence are used for the purpose of the critical appraisal. Criteria for considering studies for this article: To be considered, clinical studies had to be randomized trials comparing intervention; balloon angioplasty or stenting or both or surgical revascularization versus medical treatment, or surgical versus balloon angioplasty with or without stenting in hypertensive patients who had atherosclerotic renal artery stenosis with a minimum of three months of follow up after treatment Only those studies included with adult patients (age >18 years) who had uncontrolled hypertension (diastolic blood pressure ≥ 95mmHg, treated or untreated) and moderate-to-severe (≥50%) unilateral or bilateral atherosclerotic renal artery stenosis. Studies which were not randomized or those related to fibromuscular dysplasia, meta-analysis, and diagnostic studies were excluded. Objectives: Explaining a critical appraisal of six major randomized clinical trials which compared Revascularization (intervention) to medication (conservative treatment) which includes Angioplasty and Stenting for Renal Artery Lesions Trial (ASTRAL), Stent Placement in Patients With Atherosclerotic Renal Artery Stenosis and Impaired Renal Function Trial (STAR), Dutch Renal Artery Stenosis Intervention Cooperative (DRASTIC), Essai Multicentrique Medicaments vs. Angioplastie trial (EMMA), Scottish and Newcastle Renal Artery Stenosis Collaborative Group trial (SNRASCG), and Prospective randomized trial of operative vs. interventional treatment for renal artery ostial occlusive disease (RAOOD) trials. We also highlighted some points about the ongoing CORAL (Cardiovascular Outcomes in Renal Atherosclerotic Lesions) trial. Conclusions: Correction of Astherosclerotic Renal Artery Stenosis (ARAS), either by surgical revascularization or percutaneous methods, including stenting, has not been shown to be beneficial in treating Atherosclerotic RAS over conservative treatment, although some of the studies showed blood pressure control benefit in intervention groups like EMMA, SNRASCG and post hoc analysis of DRASTIC studies. Consequently, it seems reasonable to consider interventional procedures to correct Renal artery stenosis in patients who do not respond to medical therapy or with poorly-controlled or resistant hypertension; recurrent flash pulmonary edema; dialysis dependent renal failure resulting from atherosclerotic renal artery stenosis; chronic kidney disease and bilateral renal artery stenosis; or Renal artery stenosis to a solitary functioning kidney and waiting for the next available research with less flaws and biases.

Renovaskularna hipertenzija

Renovascular hypertension is one of possible causes of refractory hypertension. Patients with refractory hypertension have higher risk of stroke, renal failure, heart attack and other cardiovascular events, than patients with well regulated blood pressure. Furthermore, patients with refractory hypertension and poorly regulated blood pressure suffer constant damage of target organs, which may become cause of further resistance to treatment. We present a patient with severe form of hypertension and ischemic heart disease who developed hypertensive crisis complicated with acute pulmonary edema. This patient had refractory hypertension, which was caused by bilateral atherosclerotic renal artery stenosis, that caused kidney damage with renal failure and anemia.

Hypertension-induced posterior reversible encephalopathy syndrome as the presentation of progressive bilateral renal artery stenosis

Posterior reversible encephalopathy syndrome (PRES) is characterized clinically by headache, altered mental status, visual loss, and seizures. PRES is associated with neuroradiological findings characterized by white matter abnormalities, predominantly in the parieto-occipital regions of the brain. PRES is most often described in cases of hypertensive encephalopathy, eclampsia, renal failure, and immunosuppressive or anticancer therapy. We report a case of PRES associated with severe hypertension in the setting of a progressive renovascular hypertension from bilateral atherosclerotic renal artery stenosis. The pathogenesis of PRES is discussed and the importance of a prompt diagnosis and treatment is emphasized.

Flash pulmonary edema in an orthotopic heart transplant recipient

Flash pulmonary edema (FPE) is a severe renovascular disease that leads to acute recurring pulmonary edema and acute systemic hypertension. Though rarely reported in the literature, its incidence is probably underestimated secondary to misdiagnosis, especially in patients with normal left ventricular function. We report the case of an orthotopic heart transplant recipient who presented with FPE despite having normal left ventricular function and no signs or symptoms of transplant rejection. Discovery of severe bilateral atherosclerotic renal artery stenosis in this patient led to emergency hepatorenal bypass surgery and a favorable postoperative course.

Coronary-like revascularization for atherosclerotic renal artery stenosis

The aim of this study was to document the early outcome of coronary-like revascularization for atherosclerotic renal artery stenosis (ARAS). A total of 181 consecutive patient, 102 men, mean age 66.1 (+/- 9.2) years and 79 females, mean age 68.4 (+/- 9.2) years and 198 lesions were treated between February 1999 and May 2004 for ARAS and retrospectively analyzed. At least one major cardiovascular risk factor was present in 179 (98.9%) patients. Pre-dilatation ARAS was 81.3+/-9.6%, 27 ARAS were 50-70% and no ARAS was <50%. 135 (68.2%) of the ARAS lesions were ostial and 63 (31.8%) were non-ostial. In 17 (9.4%) patients bilateral ARAS were present. Technical success defined as residual stenosis < or =30% was achieved in 178 (98.3%) of patients and 195 (98.5%) of lesions. In one patient (0.5%) the target ARAS could not be crossed, in two (1.1%) patients residual stenosis was >30%. No major adverse cardiac or cerebral effects were observed. In 3.9% of patients minor local complications of the access site occurred; 4 (2.2%) inguinal hematoma, 3 (1.7%) pseudoaneurysm were documented. Serum creatinine concentrations and systolic and diastolic blood pressure before and after the intervention were not statistically different. Coronary-like approach to ARAS revascularization is technically feasible and associated with a very low complication rate.

Bilateral renal artery stenosis and primary aldosteronism in a diabetic patient

Sir, The close association between diabetes mellitus and cardiovascular disease is well known, the risk of cardiovascular disease being 2–5 times greater in diabetics than in the background population.1 Renal arteries seem to be widely involved in the macrovascular disease of diabetes, and primary aldosteronism is also a well-recognized cause of secondary hypertension. We report a diabetic woman presenting with refractory hypertension, who had coexisting bilateral atherosclerotic renal artery stenosis and aldosteronism due to bilateral adrenal hyperplasia. A 58-year-old woman was admitted to our Department because of refractory hypertension during the last 4 months, superimposed on pre-existing and poorly controlled hypertension. The patient was completely asymptomatic. There was a 10-year history of hypertension and type 2 diabetes mellitus. Her medications comprised atenolol, irbesartan, hydrochlorothiazide, amlodipine, terazosin, ticlopidine, metformin, and glibenclamide. Blood pressure was 230/100 mmHg, equal in both arms, and the pulse was 80 bpm. On physical examination, renal bruits were heard bilaterally. Twenty-four-hour blood pressure monitoring confirmed marked hypertension and also showed extreme dipping during night-time. On admission, the laboratory values included Ht 31.8%, Hb 10.4 g/dl, MCV 83.0 fl, MCH 27.3 pg, MCHC 32.8 g/dl, potassium 4.3 mmol/l, glucose 288 mg/dl, urea 57 mg/dl, creatinine 1.28 mg/dl, HbA1c 8.6%, total cholesterol 258 mg/dl, LDL cholesterol 169 mg/dl, HDL cholesterol 60 mg/dl, and triglycerides 144 mg/dl. Her urine was positive (++) …

Long-Term Survival After Surgical Revascularization for Atherosclerotic Renal Artery Disease

Purpose We analyzed the long-term clinical outcome and survival after surgical revascularization for atherosclerotic renal artery stenosis. Materials and Methods The study group comprised 222 patients who underwent surgical revascularization for atherosclerotic renal artery stenosis between 1974 and 1987. The indications for performing surgical revascularization were treatment of hypertension in 60 patients, preservation of renal function in 12, and control of hypertension and preservation of renal function in 148. Postoperative blood pressure, renal function and survival data were analyzed during a mean followup of 7.4 years. Results There were 5 operative deaths (2.2%) and postoperative thrombosis or stenosis of the repaired renal artery occurred in 16 patients (7.3%). Long-term cure or improvement of renovascular hypertension was achieved in 72.4% of patients. Preoperative renal function correlated significantly with a favorable blood pressure response to surgical revascularization (p = 0.013). Long-term improvement or stabilization of renal function was achieved in 71.3% of patients. Preoperative renal function (p = 0.034) and bilateral atherosclerotic renal artery stenosis (p = 0.04) correlated significantly with a favorable renal function result after surgical revascularization. Actuarial 5 and 10-year survivals for the entire series from the time of surgical revascularization were 81 and 53%, respectively. The expected 5 and 10-year survivals for a comparable healthy population are 89 and 77%, respectively. Using a multivariate analysis, factors correlating with diminished long-term survival were age older than 60 years (p = 0.002), coronary artery disease (p = 0.031), and previous vascular operations (p = 0.001). Conclusions These data support the long-term therapeutic efficacy of surgical revascularization in patients with atherosclerotic renal artery stenosis. The merits of newer forms of therapy, such as percutaneous transluminal angioplasty and endovascular stenting, must ultimately be weighed against these results.

Captopril Therapy Following Percutaneous Transluminal Angioplasty for Bilateral Renal Artery Stenosis

To establish an optimal approach for the patients with bilateral atherosclerotic renal artery stenosis, combined treatment involving percutaneous transluminal renal angioplasty and oral captopril was applied. Five patients were examined for effects of the combined treatment on blood pressure and renal function. After percutaneous transluminal renal angioplasty on one renal artery, the blood pressure (mean +/- SD) fell from 210/118 +/- 26/8 to 176/104 +/- 11/9 mm Hg without any deterioration of renal function. This reduced blood pressure was further lowered to 155/92 +/- 6/3 mm Hg by adding captopril therapy. This level of blood pressure has been maintained for an average of 37 months. Significant increases in serum creatinine concentration were not observed (124 +/- 27 vs 141 +/- 44 mumol/L), and renal size has been sustained. These results indicate that combined treatment with percutaneous transluminal renal angioplasty and captopril is effective in reducing the blood pressure and preserving renal function as an approach for the patients with bilateral atherosclerotic renal artery stenosis.