© 2015 John Wiley & Sons, Ltd. Severe atherosclerotic renovascular disease is a common pathological condition associated with major deleterious clinical effects. Patients with severe renal artery stenosis frequently develop uncontrolled hypertension and progressive deterioration of kidney excretory function with expected development of chronic kidney disease stage 5 requiring renal replacement therapy. The patients can also present with severe congestive heart failure, flash pulmonary edema, and unstable angina. Left untreated, severe-critical renal artery stenosis can rapidly progress and cause clinical catastrophe. In addition, these patients have a high risk for cardiovascular events including myocardial infarction, stroke, chronic heart failure, and sudden cardiac death. Acute endovascular revascularization targeting the stenosis is indicated in order to either avoid or treat this ominous scenario.Preintervention physiological assessment of the target lesion is of paramount importance even during urgent endovascular renal procedures. The urgent renal intervention should focus on an expedient management of the stenosed vessel's minimal luminal diameter and the abnormal renal artery flow velocities. Successful interventions are judged by correction of baseline translesional gradient, stabilization of related hemodynamic parameters, and clinical manifestations. In selected patients who require urgent renal intervention, especially those exhibiting tight, eccentric lesions deemed nonideal for standard intervention, plaque debulking is a valid option for facilitation of stenting. Adjunct stenting should be performed in consideration with the morphological features of the obstructive plaque and the anatomical curve of the vessel. When safe interventional techniques are applied, the challenge of urgent endovascular renal intervention can be met with considerable success.