A 62-year-old male was referred with a diagnosis of renovascular disease. His past history included cervical spondylosis, a transitional carcinoma of the bladder three years previously and resistant hypertension for the last year. He was intolerant of a number of anti-hypertensive agents. An angiotensin converting enzyme inhibitor (ACEI) was added to the treatment regime followed by a decline in renal function to a plasma creatinine of 400 µmol/l. The creatinine fell on withdrawal of the ACEI to 250 µmol/l. Ultrasound demonstrated a left kidney of 8.3 cm and right at 10.8 cm. A MRI scan showed an ostial stenotic lesion to the left kidney. He was referred for evaluation. On referral his blood pressure was 200/104 mm/Hg on three agents not including an ACEI or Angiotensin II (AII) blocker. At angiography the left renal artery was shown to be occluded. Two right renal arteries were demonstrated. There was a stenosis of the upper renal artery with the lower being normal. An attempt was made to angioplasty the upper lesion but the guide wire could not cross the stenosis. No flow could be demonstrated through the upper artery at the end of the procedure. A subsequent single kidney glomerular filtration rate (SKGFR) found 17.3 ml/min from the right kidney and 18.1 ml/min from the left kidney. The radiologist did not feel that it was possible to intervene in either of the two occluded arteries. The patient was referred to a vascular surgeon for assessment. His blood pressure was 170/96 on Indapamide, Labetolol and Methyl Dopa with a plasma creatinine of 249 µmol/l.

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