Evaluation and management of bilateral renal artery stenosis in children: A case series and review

Abstract

This report describes the clinical course, diagnostic evaluation and management of six children with bilateral renal artery stenosis (RAS) and concurrent narrowing of the abdominal aorta. Except for one child with active arteritis, the others were asymptomatic. There were no clinical or laboratory features suggesting the etiology of hypertension in four of six patients, and diagnostic procedures, including Doppler duplex ultrasound and captopril scintigraphy, were unreliable in screening for such hypertension. Abdominal aortography and selective renal angiography confirmed the diagnosis of bilateral RAS and associated anatomical alterations of the aorta and its branches. The hypertension was severe and minimally responsive to antihypertensive agents. It was cured or improved after percutaneous transluminal angioplasty (PTA) of three vessels in two children with mid-vessel stenoses, while hypertension persisted after PTA of two mid-vessel stenoses in a third child and one vessel with ostium stenosis in a fourth child. Autotransplantation of seven kidneys in four children resulted in cure of significant improvement of the hypertension. Renal function was preserved in all children during a mean follow-up time of 41 months. Based on illustrative data from these six children, as well as information from a review of the literature, this report discusses the key diagnostic issues and stresses the potential advantages of renal autotransplantation in selected children with this disorder.

A review of vascular surgery in the pediatric population

“…Up to 10% of patients seen in pediatric referral centers for hypertension have renovascular lesions [84,85]. MedPediatr Surg Int (2007) 23: 1-10 5 ical control of hypertension secondary to aorto-arteriopathy has been essentially ineffective [86,87] and these lesions are surgically correctable in about 75% of young children, and about 20% of teenagers [88].…”

“…Bilateral renal autotransplantation has shown efficacy in some series with high cure rates in patients with bilateral renovascular hypertension [88]. Therefore, bilateral renal autotransplantation or bypass offers superior management to unilateral treatment in the face of aortic or bilateral disease [87].…”

Successful management of a resistant renal artery stenosis in a child using a 4 mm cutting balloon catheter

“…The majority of children with RAS suffer from neurofibromatosis, Williams syndrome, mid-aortic syndrome, Takayasu arteriitis, and idiopathic or unspecified RAS together with fibromuscular dysplasia and RAS post renal transplant [11,30]. However, the primary success rate of PTRA is not as good as that for revascularization surgery [5,12,31].…”

“…The inability to cross the lesion with a guidewire/balloon may be one reason for the primary failure rate [2,11,24,31]. Lesions resistant to dilatation with balloon inflation to 6 atm pressure can be treated using high-pressure balloons [6,14].…”

Long-Term Outcomes of Pediatric Renovascular Hypertension

“…The degree of BP control was determined using the criteria proposed by Ellis et al [25] as follows: 1) cured, defined as normal BP with no antihypertensive treatment; 2) improved BP with the same or reduced treatment; 3) no change in BP despite angiographic success; or 4) technical failure (i.e., unable to pass a balloon catheter or unable to dilate the vessel with a balloon). We sub-categorized patients with "improved BP" into group (A), including patients with normal BP, and group (B), including patients with stage I hypertension.…”