Synopsis Renal artery stenosis refers to a narrowing of the renal artery that can result in a restriction of blood flow. Atherosclerotic disease (90%) is by far the most common cause of renal artery stenosis, whereas nonatherosclerotic disease (of which fibro- muscular dysplasia is the most common) is much less prevalent and tends to occur in younger, healthier patients.S5.4.3-3 Renal artery stenosis is a common form of secondary hypertension. Relieving ischemia and the ensuing postischemic release of renin by surgical renal artery reconstruction is an invasive strat- egy with a postoperative mortality as high as 13%.S5.4.3-4 With the advent of endovascular procedures to restore blood flow, several trials were designed to test the efficacy of these pro- cedures against medical therapy, but they suggested no benefit over medical therapy alone.S5.4.3-1,S5.4.3-2 Recommendation-Specific Supportive Text 1. Atherosclerotic disease in the renal arteries represents systemic disease and higher risk of both renal failure and cardiovascular morbidity and mortality. No RCT to date has demonstrated a clinical advantage of renal artery revascularization (with either angioplasty or stenting) over medical therapy.S5.4.3-2 On the basis of the CORAL (Cardiovascular Outcomes in Renal Atherosclerotic Lesions) trial, the recommended medical approach en- compasses optimal management of hypertension with an antihypertensive regimen that includes a renin-angio- tensin system (RAS) blocker, in addition to low-density lipoprotein cholesterol reduction with a high-intensity statin, smoking cessation, hemoglobin A1c reduction in patients with DM, and antiplatelet therapy.S5.4.3-1 2. Revascularization may be considered for those who do not respond to medical therapy and for those who have nonatherosclerotic disease (eg, Takayasu arteritis in Asian populations, fibromuscular dysplasia in other populations). 