Heart failure associated with renal artery stenosis and Pickering syndrome: the critical role of endovascular revascularization: a case series and meta-analysis

Background: Heart failure associated with renal artery stenosis (RAS) and Pickering syndrome, characterized by recurrent flash pulmonary oedema (FPE) in the setting of bilateral RAS or unilateral stenosis in a solitary kidney, represent 2 severe forms of renovascular disease. Despite their clinical significance, the role of endovascular treatment is still debated due to inconsistent findings from randomized trials. Methods: This study combines a case series of patients with Pickering syndrome undergoing percutaneous transluminal renal angioplasty (PTRA) with a meta-analysis evaluating the efficacy of endovascular treatment in patients with atherosclerotic RAS and heart failure. The meta-analysis included studies comparing endovascular intervention plus medical therapy against medical therapy alone. Results: In the case series, all patients experienced significant improvement in blood pressure (BP) control, reduction in pulmonary congestion, and stabilization of renal function following PTRA. The meta-analysis demonstrated a significant reduction in systolic BP (−11.73 mmHg, 95% confidence interval, −22.97, −0.48) in patients with heart failure undergoing PTRA, while no significant benefit was observed in those without heart failure. Conclusions: Our findings suggest that endovascular therapy is beneficial in selected patients with RAS, particularly in those with recurrent FPE or heart failure. Future research should refine patient selection criteria to improve outcomes and reconsider the role of revascularization in high-risk subgroups.