Renal Vascular Disease

Key points

• Renal artery stenosis (RAS) is most commonly atherosclerotic, accounting for >90% of cases in the 2024 ESC guideline; fibromuscular dysplasia (FMD) is an important non-atherosclerotic cause, particularly in younger women.
• MR angiography is not the universal investigation of choice. Current ESC guidance recommends duplex ultrasound as first-line imaging when RAS is suspected; CTA or MRA are appropriate non-invasive alternatives depending on circumstances.
• CT angiography (CTA) is an accurate non-invasive anatomical test and can be used after or instead of duplex ultrasound when appropriate, but iodinated contrast and renal function must be considered.
• Catheter renal angiography remains the invasive gold-standard anatomical test and allows haemodynamic assessment/intervention, but because of procedural risk it is generally reserved for selected cases and intervention planning.
• MRCP discriminator: young woman with resistant hypertension → consider FMD; older patient with atherosclerosis → atherosclerotic RAS.
• Current ESC 2024: duplex ultrasound is first-line; CTA/MRA are non-invasive alternatives; catheter angiography is invasive gold standard.