Renal artery stenosis (RAS) is a relatively common manifestation of atherosclerosis, although in a small percentage of cases it is due to fibromuscular dysplasia and less frequently may have other etiologies. RAS may be treated by revascularization, using either percutaneous or open surgical techniques. Currently, technical success with percutaneous revascularization utilizing angioplasty and stenting is achieved in 95% or more of cases in which it is attempted. Despite this, at least one third of patients undergoing renal artery stenting do not receive any measurable benefit. Furthermore, randomized trials of stenting for RAS have failed to demonstrate a benefit over medical management alone. Thus, the clinician is faced with a challenge when determining how to manage an individual patient with RAS. In the current era, all patients with RAS should receive "optimal medical therapy." This approach should use medicines to control blood pressure, and specifically utilize agents proven to reduce cardiovascular morbidity and mortality. Other components of "optimal medical therapy" include the use of anti-platelet drugs such as aspirin and statins to minimize progression of atherosclerosis. In addition to these strategies, consideration should be given to revascularization therapy. When deciding to revascularize RAS, the patient should have an appropriate clinical indication, in addition to a significant anatomic stenosis. Importantly, stents should not be placed due to the "oculostenotic reflex." Specifically, patients who continue to have uncontrolled blood pressure or worsening renal function despite an aggressive approach with medical therapy may be particularly good candidates for renal artery stenting. Despite the lack of benefit in randomized trials to date, there is likely still a role for renal artery stenting in RAS; however, careful patient selection is essential to maximize the potential benefit.