POS-405 SINGLE KIDNEY WITH RENAL ARTERY STENOSIS CAUSING PICKERING SYNDROME

Abstract

Pickering syndrome, defined as recurrent 'flash' pulmonary oedema in patients with renal artery stenosis (RAS), is associated with a high mortality. Our case highlights the importance of careful patient selection for percutaneous renal artery stenting (PRAS) to ensure the benefits of revascularisation. A 51-year-old female, with a single functioning kidney secondary to reflux nephropathy, known hypertension, ischaemic heart disease, and a 10 pack-year smoking history, presented to the emergency department with a two week history of dyspnoea, 'flash' pulmonary oedema, a progressive pericardial effusion, acute kidney injury and severe hypertension despite treatment with frusemide and four anti-hypertensive agents. Her blood pressure (BP) remained poorly controlled with systolic readings between 170 and 190 mmHg and diastolic levels between 90 and 110 mmHg. She subsequently developed acute respiratory failure requiring ventilator support. Computed tomographic (CT) angiography revealed severe ostial left RAS and near-occlusive distal aortic atheromatous disease (Figure 1). Following extensive multidisciplinary discussion, a catheter-based selective renal angiogram and stenting were performed, with access from the brachial artery. This resulted in marked improvement in renal perfusion, BP control and diuresis (5-6 litres per day for a week). She was extubated within 48 hours and her kidney function normalised. Percutaneous stenting for the treatment of atherosclerotic RAS continues to be a controversial topic because of variable results from several randomised clinical trials (including ASTRAL, DRASTIC, STAR and CORAL). The primary patency of an optimally sized and deployed bare-metal renal stent exceeds 80% at 5 years. Once placed, periodic kidney function and BP monitoring are required, as is annual renal artery Doppler ultrasonography for surveillance of in-stent restenosis (ISR). There is no consensus on the optimal treatment for ISR; however, drug-coated balloon angioplasty, which delivers anti-proliferative drugs such as paclitaxel directly to the endothelial surface, has recently emerged as a promising therapeutic option.