Simultaneous Bilateral Renal Revascularization in an Elderly Patient With Recurrent Flash Pulmonary Edema: A Case Report

Renal artery stenosis (RAS) is a well-established cause of secondary hypertension and progressive chronic kidney disease (CKD), and severe bilateral disease may precipitate recurrent episodes of acute heart failure, including flash pulmonary edema, particularly in elderly patients with multiple cardiovascular comorbidities. This report highlights the diagnostic approach, therapeutic strategy, and outcomes in a complex patient with multiple comorbidities. A 78-year-old woman with multiple comorbidities, including hypertension, insulin-dependent diabetes mellitus, dyslipidemia, asthma, peripheral arterial disease, spherocytosis, and chronic kidney disease, presented with recurrent episodes of acute pulmonary edema (APE) initially attributed to heart failure with preserved ejection fraction (HFpEF). Transthoracic echocardiography showed grade II diastolic dysfunction, pulmonary hypertension, and mild valvular disease. Coronary catheterization excluded significant obstructive coronary artery disease, whereas renal angiography revealed severe bilateral renal artery stenosis (right: 65%, left: 80%-90%), associated with worsening renal function and refractory hypertension. Given the high-risk clinical phenotype, the patient underwent bilateral renal artery angioplasty with stent placement, following nephroprotective measures due to the elevated risk of contrast-induced nephropathy. The procedure was uneventful with good angiographic results. At one-year follow-up, no further episodes of pulmonary edema occurred, renal function improved, blood pressure was well controlled, and renal arteries remained patent on ultrasound. This case highlights the importance of evaluating renal artery stenosis in patients with sudden or recurrent acute pulmonary edema, refractory hypertension, or progressive renal dysfunction, particularly in the presence of multiple comorbidities. Bilateral renal revascularization was effective in stabilizing renal function and improving blood pressure control; however, long-term follow-up remains essential.