Management of severe hypertension in childhood Takayasu's arteritis

Milner, Lawrence S.; Jacobs, David W.; Thomson, Peter D.; Kala, Udai; Franklin, John L.; Beale, P. G.; Levin, Solomon E.

doi:10.1007/bf00852840

Cited by 29 publications

(12 citation statements)

References 16 publications

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“…In addition to our six cases, Table 2 summarizes the data from 36 children reported over the last decade in which it is possible to determine treatment and outcome of bilateral RAS [4][5][6][7][8][9]. Not included in Table 2 are data from three large series which included another 64 children with bilateral RAS in whom such information is not available [10][11][12].…”

Section: Discussionmentioning

confidence: 99%

“…Moreover, hypertension was cured or improved in 18 of 20 (89%) patients. The ultimate prognosis in Takayasu's arteritis and bilateral RAS may be the worst with any form of revascularization due to late thrombosis of Goretex arterial grafts (2 of 2 patients) or failure of autotransplantation (1 of 2 patients) occurring in a series of 4 children with this disorder (Table 2 [4]). Long-term followup with repeat renal angiography after renal autotransplantation in adults has shown this to be superior to bypass surgery for the treatment of renovascular hypertension [69].…”

Section: Percutaneous Transluminal Angioplasty Compared Withmentioning

confidence: 99%

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

et al. 1995

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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.

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Section: Discussionmentioning

confidence: 99%

Section: Percutaneous Transluminal Angioplasty Compared Withmentioning

confidence: 99%

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

et al. 1995

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“…Steroids were commenced at a daily dose of 2 mg/kg and gradually tapered according to clinical response. Ten patients included in this review have been described elsewhere [23,26].…”

Section: Methodsmentioning

confidence: 99%

A review of Takayasu's arteritis in children in Gauteng, South Africa

Hahn

Thomson

Kala

et al. 1998

Pediatric Nephrology

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101

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We have reviewed 31 patients with Takayasu's arteritis followed at two pediatric nephrology units in Gauteng, South Africa over a 15-year period. There were 25 black patients, 4 white, and 2 of mixed race. The mean age at diagnosis was 8.42+/-3.59 (range 2.4-14.5, median 8) years. The most common presenting sign was hypertension, followed by cardiac failure, bruits, and absent pulses. The Mantoux test was strongly positive in 27 patients (90%, control population 5%). Markers of activity included a raised erythrocyte sedimentation rate (23 patients) or Gallium single photon emission tomography (positive in 12 of 16 patients). Angiography revealed type II (abdominal aorta) and III (arch plus abdominal aorta) lesions to be most common (11 in each group). All patients received antituberculous therapy and most low-dose aspirin for its antithromboxane effect. Corticosteroids and further immunosuppression were used to control disease activity. We added total lymphoid irradiation (TLI) or cyclophosphamide. Twenty-six patients in all received further immunosuppression, with 13 patients in each group. Results were similar in the two groups, with similar pre- and posttherapy systolic blood pressures and creatinine clearances. Two patients in each group relapsed, 3 died in the TLI group and 2 in the cyclophosphamide group. Surgical intervention, usually in the quiescent phase, consisted mainly of renal autotransplantation. Because of the problems with TLI and 2 patients with papillary carcinoma of the thyroid with long-term follow-up, we no longer use TLI. We have shown that with active medical and surgical intervention the aggressive course of this disease in children can be modified.

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“…The role of surgery is limited by significant morbidity, mortality, 407 Tyagi et al: Percutaneous Transluminal Angioplasty for Stenosis of the Aorta cost, and postoperative complications viz. graft occlusion and aneurysm at the anastomotic site [9,19,26]. In addition, surgery for AA in children is limited by a relative lack of experience of complex vascular surgery in very young children, and bypass graft done in a small child may over a period of time become inadequate because of growth of child.…”

Section: Discussionmentioning

confidence: 99%

Percutaneous Transluminal Angioplasty for Stenosis of the Aorta Due to Aortic Arteritis in Children

et al. 1999

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Percutaneous transluminal balloon angioplasty for stenosis of the aorta due to aortic arteritis was attempted on 45 lesions in 41 children (age range, 4-14 years; mean, 9.9+/-4.2 years) presenting with symptoms of hypertension, severe congestive heart failure, and lower limb claudication. Balloon dilatation was technically successful in 38 (92.7%) patients for 41 stenotic lesions (91.1%). The mean peak systolic pressure gradient (PSG) decreased from 71.7 +/- 23.9 mmHg to 23.2 +/- 17.5 mmHg (p < 0.001) and the diameter of the stenosed segment increased from 3.3 +/- 1.1 mm to 7.5 +/- 2.2 mm (p < 0.001) immediately after angioplasty. Patients with short-segment (<3 cm) stenosis had a lower residual gradient (17.9 +/- 11.1 mmHg vs 30.5 +/- 22.6 mmHg; p < 0.05) and a wider diameter of the aorta (8.8 +/- 1.1 mm vs 7.5 +/- 2.2 mm; p < 0.02) compared to patients with long-segment (>/=3 cm) stenosis. Four patients required stent implantation; 2 for flow-limiting dissection, 1 for failure to reduce PSG by >50%, and 1 for recurrent restenosis. There was marked hemodynamic and angiographic improvement in these 4 patients. Hemodynamic and angiographic restudy in 21 of the 41 patients at mean follow-up period of 6.2 +/- 4.2 months (range, 3-24 months) showed restenosis in 4 (19%) patients. Restenosis was more common in patients with long-segment stenosis than those with short-segment stenosis (30% vs 9.1%). Late restudy in 8 patients, done at 3-7 years after first restudy, showed no recurrence of aortic narrowing. On clinical follow-up of 38 patients for a mean of 58.8 +/- 36.0 months (range, 8-146 months) there was marked improvement in symptoms. Hypertension was cured in 11 (29%), improved in 24 (63%), and persisted in 3 (8%). Six patients with associated severe renal artery stenosis showed further improvement in hypertension after successful renal angioplasty. Severe congestive heart failure improved in 21 (95.4%) of 22 patients. Mean left ventricular ejection fraction improved from 0.32 +/- 0.08 to 0. 48 +/- 0.10 (p < 0.001) at a mean follow-up of 28.7 +/- 8.4 months in these patients. Hemodynamic restudy in 10 of these patients showed improvements in left ventricular end-diastolic pressure from a mean 37 +/- 9 mmHg (range, 25-55 mmHg) to 16.4 +/- 6.2 mmHg (range, 6-25 mmHg) (p < 0.001). Lower limb claudication improved in all 4 patients. Our results suggest that percutaneous transluminal balloon angioplasty in children is safe and highly effective in relieving stenosis of the aorta due to aortic arteritis, with marked clinical improvement, and should be the treatment of choice particularly for discrete stenosis.

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Management of severe hypertension in childhood Takayasu's arteritis

Cited by 29 publications

References 16 publications

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

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

A review of Takayasu's arteritis in children in Gauteng, South Africa

Percutaneous Transluminal Angioplasty for Stenosis of the Aorta Due to Aortic Arteritis in Children

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