Background: Despite the results of some randomized controlled trials in the last 5 years it remains unclear whether revascularization of atherosclerotic renal artery stenosis (ARAS) by means of percutaneous renal angioplasty and stenting (PTRAS) is advantageous over optimal medical therapy. Materials and methods: The METRAS study was designed with the primary objective to determine whether PTRAS is superior or equivalent to optimal medical treatment for preserving glomerular filtration rate (GFR) in the ischemic kidney, as assessed by 99mTc-DTPA renal scintigraphy. Secondary objectives were to establish whether the two treatments are equivalent in lowering blood pressure, preserving overall renal function and regressing target organ damage. Results: At 2 years follow-up compared to the medical treatment in the endovascular group GFR in the ischemic kidney was higher (p=0.027). Moreover, 24 hours DBP was lower in PTRAS group compared to medical therapy at 3 years follow-up (p=0.029). Of note, this difference occurred despite borderline significant (p=0.055) lower need for number of antihypertensive drugs. Both serum creatinine and cystatin-c were lower in PTRAS group compared to medical therapy (p=0.035 and p=0.02, respectively). HBA1c was also lower in PTRAS group compared to medical therapy (p=0.034). Left ventricular mass index, as assessed by echocardiography, was also borderline significant (p=0.058) lower in the PTRAS group. Diastolic dysfunction, as assessed by E/E’ ratio at tissue Doppler, improved in the PTRAS group compared to medical therapy (p=0.011). Conclusions: In the carefully selected patients with atherosclerotic renovascular hypertension of the METRAS study PTRAS on top of optimal medical therapy provided an improvement in GFR in the ischemic kidney and a better DBP control despite a lower need of antihypertensive drugs compared to optimally treated patients receiving medical therapy only.