Primary stent placement for atherosclerotic renal artery stenosis (ARAS) has become a subject of considerable debate. It even seems that the indication has been cast aside altogether, maybe as a result of prospective trials seeking to define the role of renal revascularisation, which failed to establish a compelling benefit for endovascular stenting when added to effective medical regimens. Various explanations for these disappointing results have been offered. However, it could be that the currently accepted belief, i.e. that only stenoses greater than 50-70% of the luminal surface result in ischaemic changes leading to hypertension and renal insufficiency, needs rethinking. There is ample experimental evidence that ischaemia per se does not fully explain the clinical sequelae accompanying ARAS. Treatment of advanced stenosis and renal derangement might be unsuccessful because the changes resulting from these conditions are already irreversible. Perhaps treatment should be initiated earlier in the disease process when stenosis and renal impairment are less advanced.