CONGRESS ABSTRACT

Clinical Description A 74-year-old female presented to the Emergency Department at Careggi University Hospital in May 2024 with worsening dyspnea and was diagnosed with acute pulmonary edema. Her medical history included ischemic-valvular heart disease, for which she had undergone aortic-coronary bypass surgery and aortic valve replacement with a biological prosthesis in 2014. An echocardiogram revealed degeneration of the aortic prosthesis leading to severe stenosis. Surgical intervention was indicated. The patient then underwent a successful valve-in-valve aortic procedure. The postoperative course was complicated by several episodes of dyspnea and radiographic evidence of pulmonary congestion, which were managed with intravenous diuretics with beneficial outcomes. Concurrently, the patient exhibited a progressive increase in creatinine levels. Renal artery ultrasound revealed bilateral subocclusive renal artery stenosis. The patient subsequently underwent renal angiography and percutaneous transluminal angioplasty of the left renal artery and the right iliac artery, resulting in a favorable angiographic outcome. Creatinine levels normalized, accompanied by a significant polyuric response. Discussion In 1988, Pickering described recurrent episodes of fulminant pulmonary edema and deteriorating renal function in patients with hypertension and bilateral renal artery stenosis, a condition subsequently termed Pickering syndrome. Currently, many affected patients remain at risk of avoidable fatal outcomes because Pickering syndrome is often not suspected, identified, or diagnosed. The 2024 ESC guidelines on hypertension treatment highlight that recent null studies, despite not exclusively involving patients with significant atherosclerotic renal artery stenosis, have reduced enthusiasm for researching this condition. This could result in increased uncontrolled hypertension, recurrent pulmonary edema, worsening of the condition, and progression to end-stage renal failure. Conclusion Our clinical case, in alignment with the 2024 ESC guidelines on hypertension treatment, underscores the critical importance of diagnosing Pickering syndrome as a vital step toward life-saving revascularization. Such intervention is crucial to prevent dialysis and other adverse outcomes. This case highlights the necessity for a multidisciplinary and collaborative approach among healthcare professionals.