Abstract

Atherosclerotic renal artery stenosis is an important cause of resistant hypertension and ischemic nephropathy, particularly in older patients with atherosclerosis involving multiple vascular beds. A 79-year-old man with known coronary artery disease, a history of coronary artery bypass grafting in 1990, carotid artery disease, and lower-extremity peripheral artery disease presented to the cardiology outpatient clinic with progressive fatigue and weakness accompanied by uncontrolled hypertension. Despite treatment with four antihypertensive drug classes, including hydrochlorothiazide, home and office blood pressure ranged from 190-220/90-100 mmHg. Serum creatinine increased progressively from 1.27 mg/dL in August 2024 to a pre-stenting peak of 2.60 mg/dL. Renal Doppler ultrasonography demonstrated severe stenosis at the ostium of the left renal artery, prompting invasive evaluation. Selective renal angiography revealed a 99% calcified ostial lesion. Following sequential balloon predilatation, a 7.0×15 mm renal stent was deployed with optimal distal flow. No periprocedural complication occurred. During follow-up, serum creatinine decreased from 1.70 mg/dL to a stable range of 1.10-1.24 mg/dL; blood pressure was controlled with two preparations containing three active antihypertensive agents, and fatigue and weakness markedly improved. In carefully selected patients with critical ostial renal artery stenosis, rapid deterioration of renal function, and resistant hypertension, percutaneous renal artery stenting may be a beneficial treatment option after integrated clinical and anatomical assessment.