Abstract Introduction Renal artery stenosis (RAS) is a potentially reversible cause of secondary hypertension and progressive renal failure. Bilateral RAS may present acutely with flash pulmonary edema due to volume overload and loss of autoregulatory control. Despite its recognized association with atherosclerosis, clinical suspicion often remains low until patients develop refractory hypertension or unexplained heart failure. Case Presentation A 68-year-old male with a history of hypertension, hyperlipidemia, and chronic kidney disease presented with acute-onset dyspnea and severe hypertension (BP 220/120 mmHg). Physical examination revealed bibasilar crackles and elevated jugular venous distension. Chest X-ray showed pulmonary edema. Laboratory studies revealed elevated serum creatinine from baseline 1.1 mg/dL to 3.2 mg/dL. Initial management with intravenous nitroglycerin and loop diuretics produced limited improvement.Echocardiography demonstrated preserved left ventricular systolic function, excluding systolic heart failure as the etiology. Given the abrupt renal dysfunction and refractory hypertension, renal duplex ultrasonography was obtained, showing elevated peak systolic velocities bilaterally. Subsequent computed tomography angiography (CTA) confirmed 90% stenosis of both renal arteries. The patient underwent percutaneous transluminal renal angioplasty with stent placement in the right renal artery, followed by staged intervention of the left side.Following revascularization, the patient’s blood pressure gradually normalized, creatinine improved to 1.6 mg/dL, and pulmonary edema resolved. The patient was discharged on dual antiplatelet therapy and optimized antihypertensive regimen. Discussion This case highlights the diagnostic challenge of bilateral RAS presenting as hypertensive emergency with flash pulmonary edema. The pathophysiology involves volume retention and abrupt afterload increase secondary to activation of the renin–angiotensin–aldosterone system. Early recognition is critical since renal revascularization can reverse both cardiorenal dysfunction and hypertensive crises. CTA and duplex ultrasonography remain essential diagnostic modalities, while intervention should be reserved for patients with recurrent pulmonary edema or rapidly deteriorating renal function. Conclusion Bilateral renal artery stenosis should be considered in patients with refractory hypertension, unexplained renal dysfunction, or recurrent pulmonary edema. Timely diagnosis and revascularization may lead to dramatic clinical improvement. This abstract is funded by: N/A
Abdullah et al. (Fri,) studied this question.