Current management of atherosclerotic renovascular disease--what have we learned from ASTRAL?

With an increasingly ageing and atherosclerotic-prone population, clinical encounters with patients with atheromatous renovascular disease (ARVD) are commonplace. ARVD is frequently associated with chronic kidney disease (CKD) and hypertension, but evidence suggests that causality only occurs in the minority and it is likely that many atherosclerotic renal artery stenosis (RAS) lesions are incidental. Its association with extensive cardiovascular co-morbidity predisposes to a high patient mortality. The availability of renal angioplasty and stenting, which are generally safe techniques for dilating RAS lesions, has led to widespread use of these endovascular therapies in ARVD, but the outcomes after treatment have been inconsistent, with no clear evidence of benefit in many patients. There has been a great need for a large and appropriately powered randomised control trial to help guide clinical practice. In this review, we present an interpretation of the results of the recently reported Angioplasty and Stenting for Renal Artery Lesions (ASTRAL) trial as well as a brief review of the latest literature, so as to provide the latest guidance regarding the management of this common condition.