Renal Artery Stenosis As Etiology of Recurrent Flash Pulmonary Edema and Role of Imaging in Timely Diagnosis and Management.

Pradnya Brijmohan Bhattad,Vinay Jain

doi:10.7759/cureus.7609

Abstract

Renal hypoperfusion from renal artery stenosis (RAS) activates the renin-angiotensin system, which in turn causes volume overload and hypertension. Atherosclerosis and fibromuscular dysplasia are the most common causes of renal artery stenosis. Recurrent flash pulmonary edema, also known as Pickering syndrome, is commonly associated with bilateral renal artery stenosis. There should be a high index of clinical suspicion for renal artery stenosis in the setting of recurrent flash pulmonary edema and severe hypertension in patients with atherosclerotic disease. Duplex ultrasonography is commonly recommended as the best initial test for the detection of renal artery stenosis. Computed tomography (CT) angiography (CTA) or magnetic resonance (MR) angiography (MRA) are useful diagnostic imaging studies for the detection of renal artery stenosis in patients where duplex ultrasonography is difficult. If duplex ultrasound, CTA, and MRA are indeterminate or pose a risk of significant renal impairment, renal angiography is useful for a definitive diagnosis of RAS. The focus of medical management for RAS relies on controlling renovascular hypertension and aggressive lifestyle modification with control of atherosclerotic disease risk factors. The restoration of renal artery patency by revascularization in the setting of RAS due to atherosclerosis may help in the management of hypertension and minimize renal dysfunction.

Highlights

BackgroundRenal artery stenosis (RAS) is often associated with hypertension and ischemic nephropathy
Duplex ultrasonography is commonly recommended as the best initial test for the detection of renal artery stenosis
The focus of medical management for renal artery stenosis (RAS) relies on controlling renovascular hypertension and aggressive lifestyle modification with control of atherosclerotic disease risk factors

Summary

Introduction

Renal artery stenosis (RAS) is often associated with hypertension and ischemic nephropathy. Angiography commonly demonstrates the classic ‘string of beads’ appearance and the location within the renal artery in fibromuscular dysplasia, which helps differentiate it from atherosclerotic renovascular lesions. According to the American College of Cardiology (ACC)/American Heart Association (AHA) peripheral artery disease guidelines, hemodynamically significant RAS in patients with recurrent unexplained pulmonary edema or congestive heart failure is the only class I indication for percutaneous renal artery revascularization. Percutaneous renal artery revascularization for hemodynamically significant RAS may be considered in the setting of unstable angina (class IIa), accelerated/malignant/resistant hypertension or hypertension with medication intolerance or in the unexplained unilateral atrophic kidney (class IIa), solitary functioning kidney or chronic kidney disease with bilateral RAS [21,22,32,33,34]. In patients with RAS due to fibromuscular dysplasia, balloon angioplasty alone without stent placement is often performed with outcomes comparable to those of stent placement [1012,34]

Conclusions

Findings

Disclosures