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N N N N N N Patient with suspicion of RAS Duplex ultrasound Renal artery revascularization (Class III) Diagnostic Kidney viablea Catheter-based angiography >70% RAS or haemodynamically relevant 50–70% RASc Evaluation of high-risk features after confirmed OMTb Presence of high-risk featuresb Kidney viablea Kidney viablea No RAS RAS exclusion RAS exclusion PSV ≥200 cm/s (>50% RAS), RAR >3.5 (≥60%) side-to-side difference of intrarenal resistance index ≥0.5 Morphologically significant RAS Bilateral high-grade atherosclerotic RAS (>70%) Non-atherosclerotic RAS and special populations Unilateral atherosclerotic RAS (>70%) Inconclusive DUS or suspicion of haemodynamically significant RAS MRA/CTA (Class I) OMT (Class I) OMT (Class I) Renal artery revascularization (Class III) Renal artery revascularization (Class IIa) OMT (Class I) Y Y Y Y Y Y Figure 19 Diagnostic and treatment algorithm for renal artery stenosis. CTA, computed tomography angiography; MRA, magnetic resonance angiography; OMT, optimal medical treatment; Pd/Pa, distal coronary pressure to aortic pressure ratio; PSV, peak systolic velocity; RAR, renal-aortic peak flow velocity ratio; RAS, renal artery stenosis. asee table below aKidney viability in RAS Signs of viability Signs of non-viability Renal size >8 cm <7 cm Renal cortex Distinct cortex (>0.5 cm) Loss of corticomedullar differentiation Proteinuria Albumin-creatinine ratio <20 mg/mmol Albumin-creatinine ratio >30 mg/mmol Renal resistance index <0.8 >0.8 © ESC 2024 bRapidly progressive, treatment-resistant arterial hypertension; rapidly declining renal function; flash pulmonary oedema; solitary kidney. cResting mean pressure gradient >10 mmHg; systolic hyperaemic pressure gradient >20 mmHg; renal PdPa ≤ 0.9 (or 0.8). ESC Guidelines 3599 Downloaded from academic.oup.com/eurheartj/article/45/36/3538/7738955 by guest on 07 October 2026