Managing a Patient With Hypertensive Crisis

Abstract

Renal artery stenosis (RAS) is a common yet under-recognized cause of secondary hypertension and acute kidney injury, especially in elderly patients with multiple comorbidities. We report the case of a 74-year-old woman with longstanding hypertension, chronic kidney disease stage 3, and tobacco use who presented with flash pulmonary edema and hypertensive emergency. Despite a negative renal duplex ultrasound, persistent clinical suspicion prompted further evaluation with renal angiography, which revealed significant right RAS. Following successful stenting, the patient showed marked improvement in renal function and was discharged with stable kidney parameters. This case highlights the importance of integrating clinical judgment, physical exam findings, and laboratory data when noninvasive imaging is inconclusive. It also emphasizes the value of timely intervention in improving patient outcomes and the need to rely on a comprehensive diagnostic approach in high-risk patients.

Keywords: acute kidney injury; clinical decision-making; diagnostic imaging; flash pulmonary edema; hypertensive emergency; renal artery stenosis.

Figure 1. Chest X-ray demonstrating flash pulmonary edema with bilateral pleural effusions; arrows highlight key areas of pulmonary congestion and fluid accumulation

Figure 2. Renal ultrasound revealed a left kidney measuring 9.1 × 3.6 × 4.3 cm (A) and a right kidney measuring 10.7 × 1.0 × 1.9 cm (B). Although sonographic findings were unremarkable for RAS, the left kidney appeared mildly atrophic. Arrows indicate the dimensions and surrounding anatomical context of each kidney

RAS: renal artery stenosis

Figure 3. (A) Renal angiogram of the right renal artery demonstrating two significant stenoses. The rightmost arrow marks the most severe and tortuous narrowing proximal to the ostium, with an estimated diameter of <2.5 mm (unmeasurable). A second measurable stenotic lesion, located distal to the ostium at X1, measures 2.99 mm in diameter. X2 denotes the diameter of a normal, non-stenotic reference vessel segment, while X3 indicates the estimated stent length considered for the procedure. (B) Post-stent deployment angiogram demonstrating successful revascularization of the right renal artery, with restoration of vessel caliber and no evidence of residual stenosis