The treatment of renovascular hypertension: surgery, angioplasty, and medical therapy with converting-enzyme inhibitors.

Surgery has been used to treat renal vascular hypertension for almost 50 years. The reason for the many apparent discrepancies in the literature on effectiveness and risk have become clear only in the past decade. The results are poorest and the risk is greater, not surprisingly, in patients with advanced atherosclerosis involving many vascular beds. The results are much better in fibromuscular disease, both in terms of effectiveness and risk. Angioplasty has been available for a much shorter time, but a reasonable picture of the short-term effectiveness and the risk is emerging. The risk is substantially lower than that of surgery. The results are again best in fibromuscular disease. In atherosclerotic disease, the results are especially poor for the most common lesion, that involving the renal artery ostium. Medical therapy before the development of captopril was often difficult and often unsatisfactory. Since the development of converting-enzyme inhibition, medical therapy is an important option. In the early experience, reflecting the severity of the hypertension, the frequency with which azotemia was present, and the high dose of captopril used, the adverse reaction rate was substantial. In one study, none of 133 patients with unilateral renal arterial disease and an intact contralateral kidney developed renal failure. Among 136 patients with bilateral disease or a solitary kidney, renal failure occurred in 15 and led to discontinuation of therapy in 12. If surgery or angioplasty are contraindicated, one can modify the therapeutic goal.(ABSTRACT TRUNCATED AT 250 WORDS)