Bilateral renovascular disease with cardiorenal failure: intervene early or watch and wait?

Abstract

Although, atherosclerotic renovascular disease (ARVD) is an important cause of acute pulmonary oedema (APO) and congestive heart failure (CHF) it is unclear whether best treatment for ARVD with APO or CHF should be medical therapy only or medical therapy with revascularization.1 The randomized controlled trials do not help here as they exclude heart failure.2 Evidence in favour of revascularization comes from case reports3 and observational studies of patients with APO4–6 and CHF7,8 with impressive improvements reported in heart failure symptoms, blood pressure and renal function following revascularization. The question therefore is how to identify such patients and whether to intervene early or watch and wait. Against this background we report a patient with bilateral renal artery stenoses and APO who declined intervention at presentation, and did well for 4 years before representing with cardiorenal failure requiring dialysis. Intervention even at this late stage led to a significant recovery of renal function. A 73-year-old woman presented in 2002 with pulmonary oedema due to acute coronary syndrome with Troponin I 17.5 ng/ml (normal 0–1). Serum creatinine was raised at 256 µmol/l (eGFR 17 ml/min). There had been no previous measurement of renal function. Both kidneys were 8 cm in bipolar diameter and CT renal angiogram …