AimsRecent randomized controlled trials have reported that angioplasty does not have a beneficial effect compared with pharmacological treatment on blood pressure and renal function in patients with atherosclerotic renal artery stenosis (RAS). We aimed to explore systematically the evidence that angioplasty is effective in subgroups of patients with RAS and either flash pulmonary oedema or congestive heart failure (CHF) and renal insufficiency. Methods and resultsWe searched online databases (PubMed and ClinicalTrials.gov) and references of included articles. We included 25 articles describing 79 patients with RAS and flash oedema and seven articles describing 94 patients with RAS, CHF, and renal insufficiency. According to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system, the quality of the evidence was, at best, low. Seventy-six per cent of patients with flash oedema did not have any recurrence after angioplasty. Recurrence of symptoms was associated with either restenosis of the renal artery or cardiac arrhythmias in all patients. In the patients with CHF and renal insufficiency, the severity of heart failure symptoms, expressed as New York Heart Association (NYHA) functional class, improved after angioplasty in all included articles. ConclusionThe evidence included in this systematic review justifies a weak recommendation in favour of angioplasty in patients with atherosclerotic RAS and either flash pulmonary oedema or CHF and renal insufficiency.--