Li Che1*†
Zilong Wang2,†
- 1Department of Cardiology, Central Hospital of Dalian University of Technology, Dalian, China
- 2Department of Neurosurgery, The First People’s Hospital of JinZhou District, Dalian, China
Renovascular hypertension is a form of secondary hypertension caused by renal artery stenosis and often shows a limited response to medical treatment. Over recent years, renal artery interventions, primarily angioplasty and stenting, have been increasingly used as treatment options in selected patients. This narrative review summarizes current techniques, clinical outcomes, and evidence related to renal artery interventions in the management of renovascular disease. It also highlights existing knowledge, challenges, emerging technologies, and future directions for improving patient selection, procedural safety, and long-term effectiveness of intervention strategies. By consolidating recent developments and identifying critical knowledge gaps, this review provides an updated and practical overview for clinicians and offers guidance for future research in the field of renal artery intervention.
1 Introduction
Renovascular hypertension (RVH) refers to hypertension caused by renal artery disease. It occurs in 1%–5% of individuals with hypertension and is the leading cause of secondary hypertension (1). Atherosclerosis and fibromuscular dysplasia (FMD) are the two most common etiologies of RVH. These conditions cause renal artery stenosis (RAS), which results in renal ischemia and activation of the renin–angiotensin–aldosterone system, thereby elevating blood pressure (BP) (2). Because medical treatment is not always effective in these patients, alternative therapeutic options may be required (3). Percutaneous transluminal angioplasty and stent implantation are two such options (4).
The pathophysiology of RVH is complex. RAS results in reduced renal perfusion, leading to increased renin release from juxtaglomerular cells, elevated angiotensin II levels, and subsequent increases in BP (5). Renal ischemia can also lead to deteriorating renal function and chronic kidney disease (6). Therefore, it is important to identify hypertension at an early stage to prevent further renal damage and cardiovascular complications (7).
Recent studies have shown the potential benefits of renal artery interventions in patients with RVH. For instance, percutaneous transluminal angioplasty can improve renal blood flow and reduce BP in patients who have severe stenosis and relatively preserved renal function (8). Stenting may also help control BP in patients with long-term restenosis (9). However, the results of these interventions may vary depending on the etiologies of RAS, existing diseases, and the degree of renal dysfunction (10–12). Despite their potential benefits, renal artery interventions also carry risks. Complications may include renal artery dissection, thrombosis, and contrast-induced nephropathy (6, 13, 14). Therefore, careful patient selection and thorough preoperative assessment are essential. Additional research is also needed to establish clear guidelines for the use of these interventions in different patient populations.
In summary, renal artery intervention is an effective treatment option when medical therapy fails to control BP in RVH. Correcting the underlying vascular pathology can help control BP and preserve renal function. As our understanding of the pathophysiology of RVH advances, our therapeutic approaches will continue to improve. Future studies should focus on patient selection, procedural techniques, and long-term outcomes.
2 Basic concepts of renal artery interventional therapy
2.1 Definition and classification of RAS
RAS is defined as the narrowing of one or both renal arteries. It may lead to secondary hypertension and renal insufficiency. Atherosclerosis is more common in older individuals, whereas FMD typically affects younger women. RAS may be classified according to its cause, the location of the lesion, and the degree of stenosis (1). This classification is important for determining appropriate treatment strategies in clinical practice.
Research shows that atherosclerotic RAS accounts for more than 90% of all cases, and these patients often have hypertension, diabetes, and other cardiovascular risk factors (15, 16). FMD is a nonatherosclerotic and noninflammatory arterial disease that primarily affects the renal and carotid arteries. It is more prevalent in young women and may result in hypertension (17). Therefore, understanding the classification of RAS is essential for determining the most suitable therapeutic approach, as the cause and severity of stenosis influence treatment decisions and outcomes.
2.2 Basic principles of interventional surgery
Interventional therapies for RAS aim to restore blood flow to the kidneys and lower BP. Common techniques include angioplasty and stenting (18). Angioplasty involves inserting a catheter with a balloon at its tip into the vessel and inflating the balloon at the stenotic area to widen the artery (19). If there is a high risk of re-stenosis, a stent may be implanted to maintain arterial patency. Interventional therapy requires careful RAS patient selection, image guidance (usually fluoroscopy), and sterile technique to minimize risks such as infection or thrombosis (20). Another important consideration is the clinical time of intervention, which is often performed for patients with resistant hypertension or worsening renal function (21).
2.3 Indications and contraindications for surgery
Indications for renal artery revascularization primarily include RVH, particularly when refractory to medical therapy, and significant chronic renal failure due to stenosis. Patients with atherosclerosis, especially those with unilateral RAS and preserved renal function, are frequently considered for revascularization.
Contraindications include comorbidities such as severe heart failure or significant renal insufficiency, which may limit the anticipated benefit of intervention (22, 23). Patients with extensive atherosclerotic disease involving multiple vascular beds are often unlikely to benefit from renal artery intervention because the probability of improving BP or renal function is low (1). As stent and balloon technologies continue to evolve, more favorable outcomes may be expected in the future (24).
In summary, RAS is a significant clinical condition that requires appropriate recognition and management. The main concepts of interventional therapy, including definition, classification, and surgical principles, provide the foundation for managing these patients. Understanding the indications and contraindications helps identify the appropriate patient population for intervention and supports optimal treatment outcomes.
3 Clinical effectiveness of renal artery angioplasty
3.1 Surgical methods and implementation steps
Renal artery angioplasty is a minimally invasive procedure used to treat RAS (25). The procedure typically involves catheterization through the femoral artery, followed by advancement of the catheter into the renal artery under imaging guidance. A balloon at the catheter tip is then inflated at the stenotic segment to widen the artery. This restores adequate renal circulation, which helps control BP and prevents further kidney damage.
The procedure is performed under local anesthesia and sedation. Most patients recover quickly and experience little postoperative pain. Key steps include using preoperative imaging, renal artery catheterization, balloon inflation, and post-procedure imaging. The use of intravascular ultrasound (IVUS) has improved the accuracy of lesion detection, enhancing procedural outcomes (8).
3.2 Postoperative blood pressure changes assessment
Monitoring BP changes is important to evaluate how well the procedure worked after renal artery angioplasty. Many patients experience measurable reductions in BP. One study reported an average decrease of 14/9 mmHg at one month, with the effect sustained for up to one year (26). Patients often require fewer antihypertensive medications following the surgery (27). Assessment involves regular BP monitoring and evaluation of renal function after treatment. While BP may normalize in some individuals, others may simply require fewer medications. The overall goal is to restore normal renal perfusion and reduce long-term cardiovascular risks.
3.3 Complications and management
Renal artery angioplasty is generally safe, but complications can occur. Adverse events may lead to acute kidney injury or necessitate additional interventions, including surgical repair or repeat angioplasty. Management involves close monitoring of renal function and BP, as well as imaging to detect complications. Renal artery occlusion may require urgent treatment, including renal autotransplantation in high-risk cases (6). Post-angioplasty antiplatelet therapy is mandatory to reduce the risk of thrombosis.
Patient education regarding warning signs and symptoms of complications and adherence to follow-up appointments is crucial. While the risk of complications exists, angioplasty offers significant benefits in appropriately selected patients with RVH, and these typically outweigh the associated risks (28).
4 Application of stent implantation in hypertension treatment
4.1 Types of stents and their indications
Stent implantation is widely used to treat RAS-induced hypertension. RAS resulting from atherosclerosis or FMD may lead to secondary hypertension. Two major stent types are available: Bare-metal stents (BMS) and drug-eluting stents (DES). BMS are technically easier to deploy and more cost-effective, whereas DES are designed to reduce restenosis by inhibiting smooth muscle cell proliferation through drug elution (29).
The choice of stent depends on the underlying cause of RAS, renal artery anatomy, and comorbidities. In nonatherosclerotic disease such as FMD, balloon angioplasty alone is often effective, though stent placement may be required in selected cases (30, 31). In atherosclerotic RAS, the more complex vascular anatomy and higher complication rates often necessitate stenting as a preferred option (32).
Stent placement aims not only to control hypertension but also to prevent renal ischemia and preserve renal function. Even in patients with resistant hypertension, successful stenting may result in BP reduction, particularly in those with severe but asymptomatic stenosis (33). Hence, the type of stent selected and the decision to stent are important contributors to optimal hypertension management.
4.2 Postoperative outcomes and long-term follow-up
Stent implantation generally yields favorable outcomes; many studies show significant reductions in BP and improvements in renal function. Initial technical success rates often exceed 90%, and most patients report relief of hypertensive symptoms (16). Long-term follow-up is necessary to evaluate the intervention's durability and to detect the occurrence of late complications such as restenosis.
In one cohort, long-term BP control was maintained in some patients, although a subset developed recurrent hypertension (34). The rate of in-stent restenosis varies by stent type. For example, among 398 patients with chronic heart disease who underwent percutaneous coronary intervention with sirolimus-eluting stents (SES), the overall one-year restenosis rate was 9.3% (35). Factors such as age, hypertension, diabetes, increased low-density lipoprotein cholesterol, and lesions targeting left circumflex arteries affect the restenosis risk associated with the use of SES. Regular imaging and clinical follow-up can facilitate early detection of such a possible event (35).
Studies also show that long-term survival among patients undergoing renal artery stenting is comparable to that of medically treated individuals, especially in high-risk groups (36). This suggests that stenting may improve both BP control and overall cardiovascular health. However, patient selection is important as patients with high comorbidities or advanced renal disease may not benefit from the intervention (8).
In conclusion, stent implantation is a valuable treatment option for hypertension related to RAS. Its long-term effectiveness depends on careful patient selection and continuous clinical follow-up.
4.3 Analysis of stent-related complications
Although stenting is effective, it can be associated with complications. These can be classified as immediate or delayed and often relate to technical aspects of the procedure. Immediate complications include access-site bleeding, vascular complications, and acute renal failure, particularly in patients with pre-existing renal insufficiency (23, 37, 38). Minimizing these risks requires careful procedural planning and skilled operators.
Chronic complications have important implications for long-term outcomes. Restenosis is the most common delayed complication, usually caused by neointimal hyperplasia or, less frequently, late stent thrombosis (39). Factors affecting restenosis include stent type, patient vascular biology, and characteristics of the renal artery disease (11, 40, 41).
Other complications include stent migration, fracture, and in-stent thrombosis development (13, 42, 43). These complications may require further interventions such as repeat angioplasty or surgical revision, which increase both clinical complexity and healthcare costs. Although stent implantation is an effective treatment, vigilance for complications remains essential. Continued research on device development and refinement of patient selection criteria is necessary to maximize safety and clinical benefit.
5 Latest research findings and progress
Recent renal interventions have been affected by numerous clinical trials. These data show that percutaneous renal artery revascularization is performed mainly for hypertension and impaired renal function (44). One study reported that acute anatomic renal injury may occur after renal artery interventions and is associated with negative long-term outcomes, including reduced survival and increased renal-related morbidity (23). These findings emphasize the need for careful preprocedural planning and patient selection. Guideline-directed medical therapy is essential, especially for patients with refractory symptoms (45). Evidence suggests that patients with significant stenosis are more likely to benefit from stenting. Overall, clinical trials on renal interventions have expanded our understanding of procedural risks and support the refinement of treatment protocols.
5.1 Application of new technologies in interventional therapy
New technologies are being incorporated into the interventional therapy of renal artery disease. Three-dimensional (3D) printing technology is among the most promising innovations for renal artery interventions. One study demonstrated that 3D-printed renal artery models help clinicians better understand complex anatomy (46). This technology may minimize the need to use contrast agents and fluoroscopy during procedures. This also improves the efficiency and safety of endovascular treatment. IVUS has been recognized as a valuable tool for optimizing stent placement and assessing vascular lesions (47). Incorporating these imaging techniques represents a significant advancement in the precision of renal interventions.
5.2 Exploration of multidisciplinary collaborative models
Multidisciplinary teamwork has become increasingly preferred in the management of complex disease conditions. Evidence indicates that effective communication and collaboration lead to more appropriate treatment strategies and higher levels of patient satisfaction (48). Pharmacists make important contributions within these teams by reducing adverse drug events in older adults with multiple comorbidities and improving overall medication management (49).
In summary, clinical research, advanced technologies, and multidisciplinary collaboration are essential components of modern renal interventions. These factors will continue to influence the development of new care strategies and improvements in patient outcomes.
6 Future directions of renal artery interventional therapy
6.1 Technological innovations and development trends
The field of renal artery intervention is evolving rapidly. Advances are occurring across multiple domains, including imaging, minimally invasive approaches, and biomaterials. Improvements in imaging techniques provide clearer vascular visualization, enabling more precise treatment planning, particularly for RAS caused by FMD (50).
Treatment strategies are also shifting. For instance, robot-assisted interventions have been shown to improve surgical precision and control during procedures, potentially reducing complications and facilitating faster patient recovery (51). Robotic systems also make the surgeon's job physically easier, helping them stay sharp and avoid fatigue during those long procedures (52). Furthermore, emerging technologies such as bioresorbable stents and drug-coated balloons are gaining attention for their ability to minimize the risk of restenosis by delivering localized medication effectively (53).
Artificial intelligence (AI) and machine learning are proving indispensable in analyzing patient data and medical imaging. These tools predict patient responses to treatments by identifying patterns in patient data and medical imaging from historical information, enabling physicians to develop more personalized care strategies. Such AI-assisted analysis has been recently shown to enhance patient outcomes while optimizing resource allocation (54).
Overall, renal artery intervention is undergoing a significant transformation. Emerging technologies are enabling more accurate diagnostics and safer procedural techniques, leading to better patient outcomes. As these innovations continue to advance and integrate, treatments are expected to become more effective and less invasive.
6.2 Research prospects for personalized treatment
There is a growing shift toward personalized medicine in renal artery interventions. Recent findings suggest that tailoring treatment strategies to individual patient characteristics, such as age, sex, and comorbidities, can significantly enhance treatment efficacy (55). This emphasizes the importance of developing patient-specific treatment plans (1).
Research on genetic and molecular markers related to renal artery disease is expanding. Understanding genetic factors may lead to more targeted therapeutic options. For instance, identifying mutations in genes regulating vascular smooth muscle cell activity could assist in identifying patients at high risk for severe disease. This would allow clinicians to deliver more personalized treatments.
Pharmacogenomics also offers opportunities for personalized treatment. Clinicians may eventually tailor antihypertensive therapy based on genetic variations that influence drug metabolism and response. This is particularly relevant for RVH, as responses to standard antihypertensive medications vary among patients.
The development of personalized therapy in renal artery intervention also depends on advanced intraprocedural imaging. Techniques such as IVUS and optical coherence tomography provide real-time, high-resolution visualization of vessel anatomy and functional status. These tools allow clinicians to adapt and optimize the treatment plan based on an individual's immediate response during the procedure itself (56).
Future research in personalized renal artery intervention is promising. Investigations focused on genetic profiling, response prediction, pharmacogenomics, patient-oriented models of care, and advanced imaging are anticipated. Personalized approaches are expected to increase treatment precision, reduce complications, and improve outcomes for patients with renal artery disease.
7 Conclusion
Interventional therapy to treat RAS has become an important option for patients with secondary hypertension who do not respond to medical therapy. This article reviewed recent advancements in this field, including both accomplishments and remaining challenges.
The management of RVH has transformed significantly due to the advancements in interventional techniques. The progression from percutaneous transluminal renal angioplasty to stenting has been widely studied. Many studies report that these interventions can effectively reduce BP and improve renal function in selected patients. However, several randomized trials report conflicting results. For example, one study found that the BP improvement after stent implantation diminished after six months (57). In the ASTRAL randomized trial, revascularization plus medical therapy showed no significant benefit in systolic BP compared with medical therapy alone, while 23 patients experienced serious procedural complications, including two deaths and three amputations (58). In the STAR trial, 10 of 64 patients in the stenting plus medical treatment group (46 completed stenting) and 16 of 76 patients in the medical treatment alone group reached the primary end point of a decrease of ≥20% in creatinine clearance. However, no significant differences were seen between the two groups in the primary or most secondary endpoints, despite the occurrence of complications in the stent group (59). Similarly, the CORAL trial reported no statistically significant differences in primary endpoint outcomes between the stent plus medical therapy group and the medical therapy-only group (60). These findings demonstrate the need for careful patient selection and adherence to rigorous follow-up protocols.
Given the diversity and complexity of patient presentations, defining optimal treatment strategies can be challenging. Clinicians and researchers must proceed cautiously, with a clear understanding of RVH pathophysiology and strong evidence from well-designed clinical trials. Continued collaborative efforts are needed to establish best practices and consensus guidelines.
The future of renal artery intervention lies in personalized care. Tailoring treatment to individual characteristics, comorbidities, and preferences will be essential. Integration of advanced imaging technologies and biomarkers will be critical for identifying the most suitable treatment options. Emphasis on long-term follow-up is necessary to assess the durability and safety of interventions.
Innovations such as drug-coated stents and bioresorbable scaffolds hold significant promise for improving long-term results. Integration of these advancements with treatment strategies may reduce restenosis and improve safety. Although emerging approaches such as bioresorbable stents show promise in reducing restenosis rates, their long-term effectiveness remains under investigation.
Renal artery angioplasty and stenting remain promising therapeutic options, but they are underused in clinical practice. A coordinated movement toward personalized medicine will be essential to address the complex interactions between disease mechanisms and treatment responses. Ensuring that each patient receives the safest and most effective therapy remains the guiding goal, and progress in technology and research continues to bring this goal closer.
Author contributions
LC: Conceptualization, Funding acquisition, Project administration, Supervision, Visualization, Writing – review & editing. ZW: Data curation, Formal analysis, Methodology, Software, Supervision, Validation, Writing – original draft.
Funding
The author(s) declared that financial support was received for this work and/or its publication. This research was supported by the “Dengfeng Program” of Dalian University of Technology Affiliated Central Hospital (Dalian Central Hospital), Project Number: 2024ZZ052.
Acknowledgments
We thank all participants included in our present study.
Conflict of interest
The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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Keywords: angioplasty, hypertension, renal artery obstruction, renovascular, treatment outcome
Citation: Che L and Wang Z (2025) A narrative review of the role of renal artery intervention in renovascular hypertension. Front. Surg. 12:1712028. doi: 10.3389/fsurg.2025.1712028
Received: 24 September 2025; Revised: 26 November 2025;
Accepted: 1 December 2025;
Published: 15 December 2025.
Edited by:
Ahmed Zaky, University of Alabama at Birmingham, Birmingham, United StatesReviewed by:
Eugenio Martelli, University of Rome Tor Vergata, ItalyMehmet Ali Yesiltas, Sisli Kolan International Hospitaş, Türkiye
Copyright: © 2025 Che and Wang. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Li Che, Y2xsNTI4NTI4QDE2My5jb20=
†These authors share first authorship