Pickering syndrome in a patient with a single kidney: role of renal artery stenting

Renal artery stenosis (RAS) is associated with hypertension and high mortality rates. With its prevalence and associated risk of death, it is important to screen for patients displaying symptoms of RAS. RAS has a wide spectrum of clinical manifestations and is usually resistant to medical therapy. Of these clinical manifestations is Pickering syndrome which is characterized by bilateral renal arterial occlusion inflow lesions, flash pulmonary edema, acute kidney injury, and hypertensive emergencies in the setting of a preserved left ventricle function. Stenting techniques have been used extensively to treat symptomatic renal artery stenosis with excellent primary patency rate, however have failed to demonstrate a long-term benefit over the optimal medical management alone in randomized trials. However, accumulating evidence suggests that stenting is justified in specific patient subgroups that have severe occlusive renal artery stenoses with significant clinical sequelae, including flash pulmonary edema, acute ischemic kidney injury, and uncontrolled hypertension. In this report we discuss the case of a 32-year-old male who presented to our center with recurrent flash pulmonary edema and hypertensive emergency and was found to have RAS, which responded well to renal artery stenting. In conclusion, correcting the renal arterial inflow stenosis is beneficial and warranted in selective clinical scenarios.