OBJECTIVE To examine long-term survival after angioplasty and stenting of atherosclerotic renal artery stenosis (RAS). METHODS Over a 5-year period, 241 consecutive patients (153 men; mean age 67+/-9 years, range 44-84) were treated with angioplasty and stent implantation for 355 ostial renal stenoses >70%. The procedures were performed in standard fashion using a variety of stents. For survival analysis, the patients were divided into 3 groups based on baseline creatinine levels: group 1: 115 (48%) patients with normal renal function (creatinine <1.2 mg/dL); group 2: 93 (39%) patients with moderately impaired renal function (creatinine 1.2 to 2.5 mg/dL); and group 3: 33 (13%) patients with severely impaired renal function (creatinine >2.5 mg/dL). RESULTS All patients were treated successfully without any procedure-related mortality. The 30-day mortality was 0.4% (1/241). Twenty-two patients died during a follow-up of 27+/-15 months (range 1-60) (overall survival 91%). The causes of death were cardiac (congestive heart failure or myocardial infarction, 73%), stroke (13.5%), and malignant disease (13.5%). The survival rate was significantly lower (29.6%) in patients with a baseline serum creatinine >2.5 mg/dL (p<0.0001) than in groups 2 (89.1%) or 1 (95.4%). Long-term survival without hemodialysis or restenosis was 66.6% at 48 months. Independent predictors for a reduced survival were left ventricle function (HR 2.59, 95% CI 1.45 to 4.63, p=0.001 for each 15% incremental decrease), age (HR 1.13, 95% CI 1.03 to 1.25, p=0.011), and baseline renal function (HR 1.58, 95% CI 1.10 to 2.29, p=0.014). CONCLUSIONS Survival after successful stenting for severe ostial RAS depends on baseline serum creatinine and left ventricle function. Efforts must be made to avoid the development of advanced ischemic nephropathy and congestive heart failure.