PICKERING SYNDROME: THE CRITICAL ROLE OF ENDOVASCULAR REVASCULARIZATION. A CASE SERIES AND META-ANALYSIS

Objective: Pickering Syndrome is a severe and underrecognized form of renovascular hypertension, characterized by recurrent flash pulmonary oedema due to bilateral renal artery stenosis (RAS) or unilateral stenosis in a solitary kidney. Despite its clinical relevance, the role of endovascular treatment remains debated due to inconsistent results from randomized trials. This study assesses the impact of percutaneous transluminal renal angioplasty (PTRA) in this setting, integrating a case series with a meta-analysis evaluating its efficacy in patients with atherosclerotic RAS and heart failure. Design and method: We analysed a case series of patients diagnosed with Pickering Syndrome undergoing PTRA, assessing changes in blood pressure (BP), renal function, and pulmonary congestion. Additionally, a systematic review and meta-analysis were performed, including studies comparing endovascular revascularization plus medical therapy against medical therapy alone in patients with atherosclerotic RAS. Primary endpoints included variations in systolic and diastolic BP and recurrency of heart failure-related hospitalizations. Subgroup analyses were conducted based on HR presence. Results: In the case series, all patients experienced significant clinical improvements following PTRA, with a marked reduction in BP, resolution of pulmonary congestion, and stabilization or improvement of renal function. The meta-analysis showed that in heart failure (HR) patients, PTRA led to a significant reduction in systolic BP (-11.73 mmHg, 95% CI: -22.97; -0.48), while no significant benefit was observed in those without HR. No statistically significant difference was observed in terms of reduction in diastolic BP (-3.23 mmHg, 95% CI: -8.01 to 1.55) and of reduction in HR-related hospitalizations (OR 0.87, 95% CI: 0.64 to 1.18).Conclusions: As suggested by our clinical experience, PTRA may play a crucial role in patients with Pickering Syndrome. This seems to be supported by our meta-analysis in terms of improvement in BP control. Despite no available data on benefit in renal function, the absence of benefit in terms of HR-related hospitalizations may relate to significant patient morbidity and frequent diagnostic delays. Nevertheless, such results may lead to a more tailored approach to optimize outcomes and reconsider the role of PTRA in this high-risk population.