Treatment of a recurrent renal artery stenosis and stent fracture using a drug eluting stent in a pediatric patient

Role of drug-eluting stent on Takayasu arteritis with renal artery stenosis

Takayasu arteritis (TA) is defined as granulomatous inflammation of large arteries involving the aorta and its primary branches. Takayasu arteritis with renal artery stenosis (TARAS) is a common cause of pediatric renovascular hypertension. The main purposes of TARAS management are to improve high blood pressure and recover renal function. When general medication fails to improve symptoms, renal revascularization may be attempted.  Implantation of a drug-eluting stent (DES) has been used as an alternative strategy for pediatric renal revascularization. Here, we report on a 10-year-old, female, Javanese patient with bilateral TARAS who underwent DES implantation. Her clinical presentation was hypertensive crisis and worsened renal function. Bilateral renal artery DES implantation was performed successfully without complications. The child’s blood pressure was controlled using two anti-hypertensive medications after DES implantation and her renal function recovered. Dual anti-platelet therapy was given to minimize the risk of stent thrombosis.

Retrograde Recanalization for Proximal Occlusion of the Right Renal Artery through a Compensated Collateral Artery in a 10-year-old Patient

BACKGROUND

To describe a retrograde recanalization for the proximal occluded lesion in right renal artery (RRA) in young patient with fibromuscular dysplasia (FMD).

METHODS

A 10-year-old girl presented to our hospital with proximal RRA occlusion and refractory hypertension though she took anti-hypertension medicines. Her renin and aldosterone were beyond the normal level in both base state and excited state. Her glomerular filtration rate at right kidney was only 18.4 ml/min. Angiography revealed proximal RRA occlusion and a compensated collateral artery (CCA) from the infrarenal aorta to the RRA. She was thus diagnosed with focal FMD. A retrograde recanalization was performed through this CCA.

RESULTS

Angioplasty and stenting were successfully performed to treat the proximal RRA occlusion. Postoperatively, the glomerular filtration rate in the right kidney improved. One-year follow-up revealed that, the blood pressure maintained at normal range without any antihypertensive agents. No other discomfort was complained.

CONCLUSIONS

It is feasible to establish a working pathway with patient's compensated collateral artery to treat the renal artery occlusion.

Renovascular hypertension in children

Paediatric hypertension, defined as systolic blood pressure > 95th percentile for age, sex and height is often incidentally diagnosed. Renovascular hypertension (RVH) is responsible for 5-25% of hypertension in children. Renal artery stenosis and middle aortic syndrome can both can be associated with various conditions such as fibromuscular dysplasia, Williams syndrome & Neurofibromatosis type 1. This paper discusses the approaches to diagnosis and interventional management and outcomes of renovascular hypertension in children. Angiography is considered the gold standard in establishing the diagnosis of renovascular disease in children. Angioplasty is beneficial in the majority of patients and generally repeated angioplasty is considered more appropriate than stenting. Surgical options should first be considered before placing a stent unless there is an emergent requirement. Given the established safety and success of endovascular intervention, at most institutions it remains the preferred treatment option.

Diagnostically Challenging Case of Renal Artery Stenosis in a Pediatric Patient

In this study we report a diagnostically challenging case of bilateral renal artery stenosis (RAS) in a nine-year-old boy presenting as uncontrolled hypertension (HTN). The objective of this clinical case report is to draw attention to the unlikely combination of a classical clinical presentation with several normal investigations.

This is a nine-year-old boy, known to have uncontrolled HTN, later diagnosed as a case of bilateral RAS. This patient underwent several imaging studies including: renal Doppler ultrasonography (US), diethylenetriamine pentaacetic acid (DTPA) scan, and mercaptuacetyltriglycine (MAG3) renal scintigraphy with captopril challenge, with the aim of determining the cause of his uncontrolled HTN. The previously mentioned imaging procedures were carried out at two different medical centers over an extended period of time; however, the images failed to show any anatomical abnormalities to explain his clinical presentation. Due to this unexpected result the primary team in charge of this case opted for a percutaneous transluminal angioplasty, as a diagnostic and therapeutic approach, by which the final diagnosis of bilateral RAS was concluded. During follow-up the patient was asymptomatic in all outpatient clinic appointments.

Even though several initial investigations failed to indicate RAS, clinicians may pursue further investigations in cases of classical clinical presentation of uncontrolled HTN in pediatric population so as to not miss any diagnostically challenging cases.

Treatment of Renal Artery Stenosis in a Solitary Kidney Using Cutting Balloon Angioplasty in a Paediatric Patient

Aims:

Renovascular hypertension is a rare cause of paediatric hypertension. It is however, a potentially treatable cause particularly when caused by renal artery stenosis (RAS).

Materials and Methods:

We present the case of an 11-month-old girl presenting with cardiac dysfunction. She was found to be hypertensive with a systolic blood pressure >180mmHg. DMSA demonstrated a small right kidney and a divided renal function of 6% on the right and 94% on the left. Spectral analysis demonstrated abnormal waveforms suggestive of RAS of the left kidney.

Results:

Angioplasty with a cutting balloon was successful. Blood pressure measurements, renal function and left ventricular function improved.

Conclusion:

RAS can be successfully treated with cutting balloon angioplasty after failure of convention balloon angioplasty to relieve the narrowing. In our case, there was an immediate successful angiographic result that on mid-term follow-up demonstrated significant improvement in clinical and biochemical outcomes and cessation of all anti-hypertensive medication.