CONGRESS ABSTRACT

Here we present a case of a patient with an acute pulmonary edema and refractary hypertensive crisis. The patient was a 56-year-old woman with familial history of polyvascular disease and smoke referred to emergency department for pulmonary edema. Past medical history was suggestive for recurrent and refractory hypertensive attacks. A progressive worsening of renal function was reported. Transthoracic echocardiography showed global hypertrophy of left ventricle with normal segmental and global kinesis (EF:60%). Laboratory showed a stage 3b NFK-CKD. Renal ultrasonography showed that the right kidney was atrophic with CTO of right renal artery. On the other side, left kidney had standard volume and standard cortical / outer medullary thickness; but left renal artery also got a CTO. Multidetector-row computed tomography confirmed CTO of left renal artery with preserved parenchymal perfusion by collateral circulation from lumbar and intercostal arteries. Multidisciplinary team, keeping in mind that the patient was symptomatic for recurring hypertensive crisis despite medical therapy, referred the patient to percutaneous treatment of LRA. We performed a CTO PTA with effective stent implantation of LRA. Renovascular hypertension is an important cause of secondary hypertension. The frequency of RVH occurs in fewer than 1% of patients with mild to moderate hypertension. Atherosclerotic renal artery stenosis and fibromuscular dysplasia account for the large majority. ARAS ranges a prevalence from 25% to 30% in the population of patients undergoing to cardiac catheterization. US imaging is an excellent choice for the diagnosis of ARAS, however, in this case the information getting from US were conflicting. MDCT with non-invasive cross-sectional imaging allowed to recognize the parenchymal perfusion by collateral circulation. There is no consensus about ARAS treatment, randomized clinical trials have consistently failed to show benefit with ARAS stenting compared with medical treatment. The uniqueness of this case is based on the generosity of the collateral circulation which has made it possible to preserve the functionality of the kidney. In this very particular setting, the rule of cardiologists and nephrologists will be to identify patients at risk of progressive ischemic nephropathy and end-organ damage (pulmonary edema, recurrent heart failure, refractory and malignant hypertension) at a time when they still may benefit from revascularization.