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A 61 year old woman with a background history of systemic hypertension, hyperlipidaemia, recurrent episodes of flash pulmonary oedema (four episodes in two years), normal left ventricular systolic function on echocardiography, normal stress testing, and angiographically normal coronary arteries underwent renal angiographic studies. The right renal artery was normal. There was a high grade ostial lesion affecting the left renal artery with intraluminal thrombus (top panel). The thrombus resolved following direct intra-arterial administration of 10 mg of recombinant tissue plasminogen activator (middle panel). The ostial lesion was successfully stented with a 6 × 14 mm stent following predilatation with a 5 × 20 mm balloon. An excellent angiographic result was obtained (bottom panel). An angiotensin converting enzyme inhibitor was successfully introduced following the intervention leading to better blood pressure control and resolution of the episodes of pulmonary oedema.
Significant renovascular disease must be suspected in all patients presenting with “flash” pulmonary oedema and normal left ventricular systolic function. Successful intervention often leads to complete resolution of these episodes.