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Emergent unilateral renal artery stenting for treatment of flash pulmonary edema: fact or fiction?

Khan AA, McFadden EP - Case Rep Cardiol (2015)

Bottom Line: Acute increase of left ventricular (LV) end diastolic pressure is the usual cause of sudden decompensated cardiac failure in this patient population.Presence of bilateral renal artery stenosis or unilateral stenosis in combination with a single functional kidney in the susceptible cohort is usually blamed for this condition.Percutaneous stent implantation in the affected renal artery resulted in rapid resolution of pulmonary edema.

View Article: PubMed Central - PubMed

Affiliation: Cardiology Department, Massachusetts General Hospital, Boston, MA 02114, USA ; Interventional Cardiology Department, Cork University Hospital, Cork, Ireland.

ABSTRACT
Flash pulmonary edema is characteristically sudden in onset with rapid resolution once appropriate therapy has been instituted (Messerli et al., 2011). Acute increase of left ventricular (LV) end diastolic pressure is the usual cause of sudden decompensated cardiac failure in this patient population. Presence of bilateral renal artery stenosis or unilateral stenosis in combination with a single functional kidney in the susceptible cohort is usually blamed for this condition. We describe a patient who presented with flash pulmonary edema in the setting of normal coronary arteries. Our case is distinct as our patient developed flash pulmonary edema secondary to unilateral renal artery stenosis in the presence of bilateral functioning kidneys. Percutaneous stent implantation in the affected renal artery resulted in rapid resolution of pulmonary edema.

No MeSH data available.


Related in: MedlinePlus

Left renal artery after intervention.
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fig3: Left renal artery after intervention.

Mentions: Coronary angiogram revealed nonobstructive coronary artery disease with severely raised end diastolic pressure. In view of the nature of her presentation, renal angiography was performed which showed a normal right renal artery while an ostial occlusion of the left renal artery was noted (Figures 1 and 2). Based on the emergent nature of patient's presentation we decided to proceed with percutaneous intervention (PCI) of the culprit lesion. The left renal artery was reengaged with a JR4 guide catheter and 5000 units of Heparin were administered. The lesion was probed with a Prowater wire whose passage proved difficult; therefore, a 1.25 mm support balloon was used to cross the lesion. Intrarenal position was confirmed by advancing wire into upper and lower pole arteries. This was followed by sequential balloon dilatation with 1.5 mm, 2.5 mm, and 3.0 mm balloons. Intravascular ultrasound (IVUS) was used to assess the lumen of the renal artery. It was found to be a 5.0 mm vessel with severe thrombus load. Thromboaspiration was performed with an export catheter. A Liberte bare metal stent (5.0/12) was inserted and expanded to 16 atm. It was postdilated with a noncompliant balloon to 20 atm and proximal stent edge was flared in the aorta. Multiple injections of isosorbide dinitrate were given (total of 15 mg). IVUS was performed after stenting which revealed appropriate stent size and expansion with good angiographic result (Figure 3). A fractional flow reserve (FFR) wire was used to measure the gradient across the ostial right renal artery which showed a maximum gradient of 10 mmHg. This was consistent with the angiographic data and hence no intervention was performed on the right side.


Emergent unilateral renal artery stenting for treatment of flash pulmonary edema: fact or fiction?

Khan AA, McFadden EP - Case Rep Cardiol (2015)

Left renal artery after intervention.
© Copyright Policy - open-access
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4352438&req=5

fig3: Left renal artery after intervention.
Mentions: Coronary angiogram revealed nonobstructive coronary artery disease with severely raised end diastolic pressure. In view of the nature of her presentation, renal angiography was performed which showed a normal right renal artery while an ostial occlusion of the left renal artery was noted (Figures 1 and 2). Based on the emergent nature of patient's presentation we decided to proceed with percutaneous intervention (PCI) of the culprit lesion. The left renal artery was reengaged with a JR4 guide catheter and 5000 units of Heparin were administered. The lesion was probed with a Prowater wire whose passage proved difficult; therefore, a 1.25 mm support balloon was used to cross the lesion. Intrarenal position was confirmed by advancing wire into upper and lower pole arteries. This was followed by sequential balloon dilatation with 1.5 mm, 2.5 mm, and 3.0 mm balloons. Intravascular ultrasound (IVUS) was used to assess the lumen of the renal artery. It was found to be a 5.0 mm vessel with severe thrombus load. Thromboaspiration was performed with an export catheter. A Liberte bare metal stent (5.0/12) was inserted and expanded to 16 atm. It was postdilated with a noncompliant balloon to 20 atm and proximal stent edge was flared in the aorta. Multiple injections of isosorbide dinitrate were given (total of 15 mg). IVUS was performed after stenting which revealed appropriate stent size and expansion with good angiographic result (Figure 3). A fractional flow reserve (FFR) wire was used to measure the gradient across the ostial right renal artery which showed a maximum gradient of 10 mmHg. This was consistent with the angiographic data and hence no intervention was performed on the right side.

Bottom Line: Acute increase of left ventricular (LV) end diastolic pressure is the usual cause of sudden decompensated cardiac failure in this patient population.Presence of bilateral renal artery stenosis or unilateral stenosis in combination with a single functional kidney in the susceptible cohort is usually blamed for this condition.Percutaneous stent implantation in the affected renal artery resulted in rapid resolution of pulmonary edema.

View Article: PubMed Central - PubMed

Affiliation: Cardiology Department, Massachusetts General Hospital, Boston, MA 02114, USA ; Interventional Cardiology Department, Cork University Hospital, Cork, Ireland.

ABSTRACT
Flash pulmonary edema is characteristically sudden in onset with rapid resolution once appropriate therapy has been instituted (Messerli et al., 2011). Acute increase of left ventricular (LV) end diastolic pressure is the usual cause of sudden decompensated cardiac failure in this patient population. Presence of bilateral renal artery stenosis or unilateral stenosis in combination with a single functional kidney in the susceptible cohort is usually blamed for this condition. We describe a patient who presented with flash pulmonary edema in the setting of normal coronary arteries. Our case is distinct as our patient developed flash pulmonary edema secondary to unilateral renal artery stenosis in the presence of bilateral functioning kidneys. Percutaneous stent implantation in the affected renal artery resulted in rapid resolution of pulmonary edema.

No MeSH data available.


Related in: MedlinePlus