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Faccinetto ACB, Santos GRF, Taguchi JC, Orellana HC, Galhardo A, Kanhouche G, Barteczko MLM, Tedesco Júnior H, Bravo-Valenzuela NJM, Moises VA, Pestana JOM, Silva CMC, Barbosa AHP. Retrospective analysis of percutaneous intervention of the renal artery in transplanted kidneys in children and adolescents at a tertiary public hospital. PLoS One 2024; 19:e0297975. [PMID: 38551934 PMCID: PMC10980230 DOI: 10.1371/journal.pone.0297975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 01/15/2024] [Indexed: 04/01/2024] Open
Abstract
BACKGROUND This study evaluated the long-term effects of percutaneous intervention in children and adolescents with transplant renal artery stenosis (TRAS). METHODS Twenty patients had significant stenosis (>50%) and underwent percutaneous transluminal angioplasty (PTA/stenting) (TRAS group-intervention); 14 TNS (non-significant group -control) patients did not have significant stenosis (≤50%) and were treated clinically. The combined primary endpoints were death from all causes and late graft failure. The secondary endpoints were serum creatinine (SCr), systolic blood pressure (SBP), and diastolic blood pressure (DBP). RESULTS No statistically significant difference was found between TRAS-Intervention(N = 20) and TNS groups-Control (N = 14) for these clinical parameters: deaths, 1 (5.0%) vs. 0 (0.0%) (p = 1.000) and graft loss, 4 (20.0%) vs. 2 (14.3%) (p = 1.000). For the secondary endpoints, after 1 month and 1 year the values of SCr, SBP, and DBP were similar between the two groups but not statistically significant. DISCUSSION In the TRAS group (intervention), the stent implantation was beneficial for treating refractory hypertension and reducing blood pressure (BP) in children and adolescents. Despite the outcomes being similar in the two groups, it can be inferred that the patients in the TRAS group (intervention) would have had a worse outcome without the percutaneous intervention. CONCLUSION TRAS treatment with stenting can be considered for children and adolescents. Because the sample in the present study comprised of only a specific population, further studies are needed for generalization. TRIAL REGISTRATION The trial was registered at clinictrials.gov with trial registration number NCT04225338.
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Affiliation(s)
| | | | - Juliana Cristina Taguchi
- Department of Medicine, Cardiology Division, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Henry Campos Orellana
- Department of Medicine, Cardiology Division, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Attílio Galhardo
- Department of Medicine, Cardiology Division, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Gabriel Kanhouche
- Department of Medicine, Cardiology Division, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | | | - Hélio Tedesco Júnior
- Division of Nephrology, Hospital do Rim e Hipertensão, A Part of the Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Nathalie Jeanne Magioli Bravo-Valenzuela
- Department of Medicine, Cardiology Division, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
- Faculty of Medicine/ Federal University of Rio de Janeiro (UFRJ), Department of Pediatrics, Pediatric Cardiology Discipline, IPPMG, Rio de Janeiro, RJ, Brazil
| | - Valdir Ambrósio Moises
- Department of Medicine, Cardiology Division, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - José Osmar Medina Pestana
- Division of Nephrology, Hospital do Rim e Hipertensão, A Part of the Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Célia Maria Camelo Silva
- Department of Medicine, Cardiology Division, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
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Sharma P, Shah R, Zavaletta V, Bertino F, Sankhla T, Kim JM, Leshen M, Shah J. Pediatric Transplant Interventions. Tech Vasc Interv Radiol 2023; 26:100930. [PMID: 38123288 DOI: 10.1016/j.tvir.2023.100930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
The field of pediatric organ transplantation has grown significantly in recent decades, with interventional radiology (IR) playing an essential role in managing pre and post-transplant complications. Pediatric transplant patients face unique challenges compared to adults, including donor-recipient size mismatch, and complications of a growing child with changing physiology. Interventional radiologists play a major role in pediatric renal and liver transplant. IR interventions begin early in the child's pretransplant journey, with diagnostic procedures such as biopsies, angiograms, and cholangiograms. These procedures are essential for understanding the etiology of organ failure and identifying potential transplant candidates. Minimally invasive therapeutic procedures may serve as bridges to transplant and may include vascular access optimization for hemodialysis, transjugular intrahepatic portosystemic shunts (TIPS) creation, and tumor embolization or ablation. After transplant, image-guided biopsies for the surveillance of graft rejection and treatment of vascular or luminal stenoses, pseudoaneurysms, and anastomotic leaks can maintain the function and longevity of the transplant organ. Careful consideration must be given to patient size and evolving anatomy, radiation exposure, and the need for deeper sedation for pediatric patients. Despite these challenges, the integration of IR in pediatric transplant care has proven beneficial, offering minimally invasive alternatives to surgery, faster recovery times, and improved outcomes.
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Affiliation(s)
- Pareena Sharma
- Medical College of Georgia, Augusta University, Augusta, GA
| | - Ritu Shah
- Seth G.S Medical College and K.E.M Hospital, Mumbai, Maharashtra, India
| | - Vaz Zavaletta
- Department of Radiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Frederic Bertino
- Department of Radiology, Interventional Radiology Section, NYU Langone Health/NYU Grossman School of Medicine, New York, NY
| | - Tina Sankhla
- Department of Radiology and Imaging Sciences, Division of Interventional Radiology and Image Guided Medicine, Emory University School of Medicine, Atlanta, GA
| | - Jun Man Kim
- Department of Radiology and Imaging Sciences, Division of Interventional Radiology and Image Guided Medicine, Emory University School of Medicine, Atlanta, GA
| | - Michael Leshen
- Department of Radiology, Division of Interventional Radiology, Children's Healthcare of Atlanta, Atlanta, GA
| | - Jay Shah
- Department of Radiology, Division of Interventional Radiology, Children's Healthcare of Atlanta, Atlanta, GA; Department of Radiology and Imaging Sciences, Division of Interventional Radiology and Image Guided Medicine, Emory University School of Medicine, Atlanta, GA.
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3
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Goyal K, Yadav T, Garg PK, Khera P, Tiwari S, Rajagopal R. Pediatric Renovascular Hypertension: A Pediatric Interventional Radiologist's Perspective. Indian J Radiol Imaging 2023; 33:508-513. [PMID: 37811187 PMCID: PMC10556328 DOI: 10.1055/s-0043-1772496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023] Open
Abstract
Renovascular hypertension (RVH) contributes close to one-fourth of the secondary etiologies of hypertension in children and a delay in diagnosis can result in adverse clinical outcomes. RVH in children is clinically silent with elevations in blood pressure measurements sometimes as its sole manifestation. Only a high index of suspicion by the clinician can prompt its detection. Despite the availability of other imaging modalities like ultrasound, computed tomography, and magnetic resonance imaging, digital subtraction angiography is still considered the gold standard to make a diagnosis of RVH. Angioplasty is considered the treatment of choice in appropriately selected patients. In this article, we shall focus on the various imaging findings, and management of RVH in children, which requires a multidisciplinary approach with a special focus on the role of interventional radiology.
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Affiliation(s)
- Kanav Goyal
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Taruna Yadav
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Pawan Kumar Garg
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Pushpinder Khera
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Sarbesh Tiwari
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Rengarajan Rajagopal
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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4
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Guo J, Wu S, Zhang F, Zhang C, Gu Y, Guo L. Long-term outcomes of angioplasty for pediatric renovascular hypertension: A single-center experience. Vascular 2023; 31:122-130. [PMID: 34846234 DOI: 10.1177/17085381211059664] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES We used single-center data to evaluate the long-term outcome of percutaneous transluminal angioplasty (PTA) for pediatric renovascular hypertension (RVH) and to analyze the factors that influence effectiveness. METHODS We retrospectively evaluated 33 pediatric RVH patients (18 boys; mean age: 9.1 ± 4 years, range: 2-16) who underwent PTA from January 2007 to December 2019. 15 patients had Takayasu arteritis (TA) and 18 were non-TA. The median follow-up from the initial PTA was 69 months (range: 12-157; IQR: 25.5-89). RESULTS The technical success rate of 52 PTA procedures was 90.4% in 33 children. Renal artery stents were implanted in two patients, external guidewires were used in two patients, and a drug-coated balloon was used in only one patient. The overall effective rate of PTA was 63.6%, including cured 39.4% and improved 24.2%, at the end of follow-up. Overall clinical outcomes were not statistically different between the TA and non-TA groups (p = 0.316), nor were cure rates (p = 0.072). 15 patients received reintervention due to restenosis after the first successful PTA; the interval was 2-56 months (median: 12 months). Four patients received reintervention due to a failed PTA. A total of four patients received open surgery. Binary logistics regression analysis showed that stenosis length and residual stenosis rate were strongly correlated with effective PTA (p = 0.045, p = 0.044). CONCLUSIONS As a primary treatment for pediatric RVH, PTA can achieve satisfactory results, which are influenced by lesion length and residual stenosis rate.
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Affiliation(s)
- Julong Guo
- Department of Vascular Surgery, 71044Xuanwu Hospital Capital Medical University, Beijing, China
| | - Sensen Wu
- Department of Vascular Surgery, 71044Xuanwu Hospital Capital Medical University, Beijing, China
| | - Fan Zhang
- Department of Vascular Surgery, 71044Xuanwu Hospital Capital Medical University, Beijing, China
| | - Chengchao Zhang
- Department of Vascular Surgery, 71044Xuanwu Hospital Capital Medical University, Beijing, China
| | - Yongquan Gu
- Department of Vascular Surgery, 71044Xuanwu Hospital Capital Medical University, Beijing, China
| | - Lianrui Guo
- Department of Vascular Surgery, 71044Xuanwu Hospital Capital Medical University, Beijing, China
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Treatment of 12-year-old girl with midaortic syndrome by using Cook Formula stent. Cardiol Young 2022; 32:1695-1697. [PMID: 35301967 DOI: 10.1017/s1047951122000336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Middle aortic syndrome is a severe form of aortic coarctation and mostly involves the thoracic and abdominal part of the aorta. Traditional surgical approach has some potential risks and repetitive operations. Percutaneous stent implantation is a feasible and safe method for the palliation of middle aortic syndrome in childhood. Herein, a child with middle aortic syndrome was presented who has been treated by transcatheter stent implantation.
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Percutaneous cutting balloon angioplasty for the treatment of renovascular hypertension in children and adolescents. J Hypertens 2022; 40:1902-1908. [PMID: 35983863 DOI: 10.1097/hjh.0000000000003162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Percutaneous transluminal renal angioplasty (PTRA), the recommended treatment in children with renovascular hypertension (RVH), often has unsatisfactory outcomes. Cutting balloons may improve the results of angioplasty in different vascular beds with complex and resistant lesions. We retrospectively analysed the effects of percutaneous cutting balloon angioplasty (PCBA) on blood pressure, cardiac mass and renal artery acceleration time in children/adolescents referred to our centre for RVH. PATIENTS AND METHODS Thirteen patients (aged 9-19 years) with renal artery stenosis (RAS) and severe hypertension were identified. RASs were focal fibromuscular (FMD) or FMD-like dysplasia (in six cases bilateral, in five associated with mid aortic syndrome). Ten patients had uncontrolled hypertension, in nine cases associated with left ventricular hypertrophy (LVH). Acceleration time was abnormal in all stenotic arteries. Eighteen PCBA were performed, in three arteries associated with stent implantation. RESULTS PCBA was technically successful in all individuals without major complications. In one patient, an intra-stent restenosis occurred, successfully redilated with conventional angioplasty without recurrence at 4 years distance. One year after PCBA, mean SBP and DBPs were markedly reduced from 146 ± 25 to 121 ± 10 mmHg and from 87 ± 11 to 65 ± 12 mmHg, respectively (P < 0.001 for both). At that time, hypertension was cured in seven children and controlled in five individuals. This favourable outcome was confirmed with ambulatory blood pressure measurement in four patients. At the latest follow-up, left ventricular mass and acceleration time were normal in all patients. CONCLUSION PCBA proved to be a well tolerated and effective procedure that can be considered as an alternative to PTRA to treat hypertensive children/adolescents with recurrent or resistant RAS.
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7
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Percutaneous balloon and stent angioplasty in children with renal artery stenosis. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2022. [DOI: 10.1016/j.epsc.2022.102282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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8
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Cahill AM. Pediatric Renovascular Hypertension: Not Just a “String of Beads”. J Vasc Interv Radiol 2022; 33:408-409. [DOI: 10.1016/j.jvir.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 12/02/2021] [Indexed: 11/25/2022] Open
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Eun Y, Kim JH, Lim SH, Ahn YH, Kang HG, Ha IS. Two cases of children presenting with polydipsia, polyuria, and malignant hypertension: Answers. Pediatr Nephrol 2022; 37:559-561. [PMID: 34727244 DOI: 10.1007/s00467-021-05236-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 07/12/2021] [Indexed: 11/24/2022]
Affiliation(s)
- Yong Eun
- Department of Pediatrics, Seoul National University Children's Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Ji Hyun Kim
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Republic of Korea.,Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Seon Hee Lim
- Department of Pediatrics, Uijeongbu Eulji Medical Center, Uijeongbu-si, Republic of Korea
| | - Yo Han Ahn
- Department of Pediatrics, Seoul National University Children's Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea. .,Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea. .,Kidney Research Institute, Medical Research Center, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Hee Gyung Kang
- Department of Pediatrics, Seoul National University Children's Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.,Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea.,Kidney Research Institute, Medical Research Center, Seoul National University College of Medicine, Seoul, Republic of Korea.,Wide River Institute of Immunology, Seoul National University, Hongcheon, Republic of Korea
| | - Il-Soo Ha
- Department of Pediatrics, Seoul National University Children's Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.,Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea.,Kidney Research Institute, Medical Research Center, Seoul National University College of Medicine, Seoul, Republic of Korea
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10
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Lazea C, Al-Khzouz C, Sufana C, Miclea D, Asavoaie C, Filimon I, Fufezan O. Diagnosis and Management of Genetic Causes of Middle Aortic Syndrome in Children: A Comprehensive Literature Review. Ther Clin Risk Manag 2022; 18:233-248. [PMID: 35330917 PMCID: PMC8938167 DOI: 10.2147/tcrm.s348366] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 02/21/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Cecilia Lazea
- Department Mother and Child, University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania
- Department of Pediatrics I, Emergency Pediatric Hospital, Cluj-Napoca, Romania
- Correspondence: Cecilia Lazea, Department Mother and Child, University of Medicine and Pharmacy “Iuliu Hatieganu”, 68, Motilor Street, Cluj-Napoca, 400370, Romania, Tel +40 744353764, Email ;
| | - Camelia Al-Khzouz
- Department Mother and Child, University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania
- Department of Medical Genetics, Emergency Pediatric Hospital, Cluj-Napoca, Romania
| | - Crina Sufana
- Department of Pediatrics I, Emergency Pediatric Hospital, Cluj-Napoca, Romania
| | - Diana Miclea
- Department of Medical Genetics, Emergency Pediatric Hospital, Cluj-Napoca, Romania
- Department of Molecular Sciences, University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania
| | - Carmen Asavoaie
- Department of Radiology and Medical Imaging, Emergency Pediatric Hospital, Cluj-Napoca, Romania
| | - Ioana Filimon
- Department of Radiology and Medical Imaging, Emergency Pediatric Hospital, Cluj-Napoca, Romania
| | - Otilia Fufezan
- Department of Radiology and Medical Imaging, Emergency Pediatric Hospital, Cluj-Napoca, Romania
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Zhao L, Zhao X, Hu X, Yang H, Wu L. Mid-term outcome of angioplasty for pediatric renovascular hypertension. J Vasc Interv Radiol 2021; 33:399-407. [PMID: 34896573 DOI: 10.1016/j.jvir.2021.10.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 10/04/2021] [Accepted: 10/12/2021] [Indexed: 10/19/2022] Open
Abstract
PURPOSE To evaluate the mid-term outcome of percutaneous transluminal renal angioplasty (PTRA) for pediatric renovascular hypertension (RVH). MATERIALS AND METHODS The clinical data of patients who underwent PTRA for RVH in our hospital from 2012 to 2019 were analyzed retrospectively. Post-procedural blood pressure, glomerular filtration rate (GFR) of the affected kidney, restenosis and complications were closely followed up. RESULTS The procedure of PTRA was performed in total of 30 children (20 males and 10 females), with a mean age of 7.32±0.74 years (40 days ∼13.92 years) and a mean weight of 24.99±2.26 kg (3.4 ∼ 53kg). The median follow-up period was 26.5 months (1 month ∼7.5 years). Technical success was achieved in 26 of 30 patients (86.7%). Three patients (10.0%) developed restenosis. Only 1 patient underwent stent implantation, and the stent fractured 8 months later, requiring further intervention. No other complication was found. In terms of clinical benefit of blood pressure control after the initial PTRA procedure, 15 patients (50%) were cured and 7 (23.3%) improved. There was no significant difference in etiology, lesion location and length between patients with clinical benefit and failure (p=0.06, 0.202 and 0.06). The GFR of the affected kidney was significantly improved from 19.85±11.24 (ml/min) to 38.09±11.88 (ml/min) at 6 months follow-up after PTRA (p<0.001). CONCLUSION The overall results of PTRA for pediatric RVH caused by different etiologies are promising. Not only does it provide clinical benefit of blood pressure control in 73.3% of patients, it also significantly improves the function of the affected kidney.
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Affiliation(s)
- Lu Zhao
- Cardiovascular center, Children's Hospital of Fudan University, Shanghai, P.R China, 201102
| | - Xin Zhao
- Cardiovascular center, Children's Hospital of Fudan University, Shanghai, P.R China, 201102
| | - Xihong Hu
- Department of Radiology, Children's Hospital of Fudan University, Shanghai, P.R China, 201102
| | - Haosheng Yang
- The Graduate School of Biomedical Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA, 10029
| | - Lin Wu
- Cardiovascular center, Children's Hospital of Fudan University, Shanghai, P.R China, 201102.
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12
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Fleury AS, Durand RE, Cahill AM, Zhu X, Meyers KE, Otero HJ. Validation of computed tomography angiography as a complementary test in the assessment of renal artery stenosis: a comparison with digital subtraction angiography. Pediatr Radiol 2021; 51:2507-2520. [PMID: 34374838 DOI: 10.1007/s00247-021-05145-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 05/27/2021] [Accepted: 06/28/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Renal artery stenosis is an important cause of hypertension in children, accounting for 5-10% of cases. When suspected, noninvasive imaging options include ultrasound (US), computed tomography (CT) angiography and magnetic resonance (MR) angiography. However, digital subtraction angiography (DSA) remains the gold standard. OBJECTIVE To investigate the accuracy and inter-reader reliability of CT angiography in children with suspected renal artery stenosis. MATERIALS AND METHODS This is a retrospective study of patients suspected of having renal artery stenosis evaluated by both CT angiography and DSA between 2008 and 2019 at a tertiary pediatric hospital. Only children who underwent CT angiography within 6 months before DSA were included. CT angiography studies were individually reviewed by two pediatric radiologists, blinded to clinical data, other studies and each other's evaluation, to determine the presence of stenosis at the main renal artery and 2nd- and 3rd-order branches. The sensitivity, specificity and accuracy were calculated using DSA as the reference. The effective radiation dose for CT angiography and DSA was also calculated. Kappa statistics were used to assess inter-reader agreement. RESULTS Seventy-four renal units were evaluated (18 girls, 19 boys). The patients' median age was 8 years (range: 1-21 years). Overall, CT angiography was effective in detecting renal artery stenosis with a sensitivity of 85.7%, specificity of 91.5% and accuracy of 88.9%. There was moderate inter-reader agreement at the main renal artery level (k=0.73) and almost perfect inter-reader agreement at the 2nd/3rd order (k=0.98). However, the sensitivity at the 2nd- and 3rd-order level was lower (14.3%). CT angiography provided excellent negative predictive value for evaluating renal artery stenosis at the main renal artery level (90.1%) and at the 2nd- or 3rd-order branches (82.7%). The median effective dose of CT angiography studies was 2.2 mSv (range: 0.6-6.3) while the effective dose of DSA was 13.7 mSv. CONCLUSION CT angiography has high sensitivity and specificity at the main renal artery level with a lower radiation dose than previously assumed. Therefore, it can be used as a diagnostic tool in patients with low to medium risk of renal artery stenosis, and as a screening and treatment planning tool in patients at high risk.
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Affiliation(s)
- Anilawan S Fleury
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Rachelle E Durand
- Department of Radiology and Biomedical Imaging, University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA
| | - Anne Marie Cahill
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Xiaowei Zhu
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Kevin E Meyers
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Hansel J Otero
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.
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Renovascular hypertension in pediatric patients: update on diagnosis and management. Pediatr Nephrol 2021; 36:3853-3868. [PMID: 33851262 DOI: 10.1007/s00467-021-05063-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 03/11/2021] [Accepted: 03/19/2021] [Indexed: 01/03/2023]
Abstract
Renovascular hypertension (RVH) is defined as an elevated blood pressure caused by kidney hypoperfusion, generally as a result of anatomic stenosis of the renal artery with consequent activation of the Renin Angiotensin-Aldosterone System. The main causes include genetic and inflammatory disorders, extrinsic compression, and idiopathic alterations. RVH is often asymptomatic and should be suspected in any child with refractory hypertension, especially if other suggestive findings are present, including those with severe hypertension, abdominal bruit, and abrupt fall of glomerular filtration rate after administration of angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers. There is a consensus that digital subtraction angiography is the gold standard method for the diagnosis of RVH. Nevertheless, the role of non-invasive imaging studies such as Doppler ultrasound, magnetic resonance angiography, or computed tomographic angiography remains controversial, especially due to limited pediatric evidence. The therapeutic approach should be individualized, and management options include non-surgical pharmacological therapy and revascularization with percutaneous transluminal renal angioplasty (PTRA) or surgery. The prognosis is related to the procedure performed, and PTRA has a higher restenosis rate compared to surgery, although a decreased risk of complications. This review summarizes the causes, physiopathology, diagnosis, treatment, and prognosis of RVH in pediatric patients. Further studies are required to define the best approach for RVH in children.
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Persu A, Canning C, Prejbisz A, Dobrowolski P, Amar L, Chrysochou C, Kądziela J, Litwin M, van Twist D, Van der Niepen P, Wuerzner G, de Leeuw P, Azizi M, Januszewicz M, Januszewicz A. Beyond Atherosclerosis and Fibromuscular Dysplasia: Rare Causes of Renovascular Hypertension. Hypertension 2021. [DOI: 10.1161/hypertensionaha.121.17004
bcc:009247.186-127034.186.dbf92.19420.2@bxss.me] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
Renovascular hypertension is one of the most common forms of secondary hypertension. Over 95% of cases of renovascular hypertension are due either to atherosclerosis of the main renal artery trunks or to fibromuscular dysplasia. These two causes of renal artery stenosis have been extensively discussed in recent reviews and consensus. The aim of the current article is to provide comprehensive and up-to-date information on the remaining causes. While these causes are rare or extremely rare, etiologic and differential diagnosis matters both for prognosis and management. Therefore, the clinician cannot ignore them. For didactic reasons, we have grouped these different entities into stenotic lesions (neurofibromatosis type 1 and other rare syndromes, dissection, arteritis, and segmental arterial mediolysis) often associated with aortic coarctation and other arterial abnormalities, and nonstenotic lesions, where hypertension is secondary to compression of adjacent arteries and changes in arterial pulsatility (aneurysm) or to the formation of a shunt, leading to kidney ischemia (arteriovenous fistula). Finally, thrombotic disorders of the renal artery may also be responsible for renovascular hypertension. Although thrombotic/embolic lesions do not represent primary vessel wall disease, they are characterized by frequent macrovascular involvement. In this review, we illustrate the most characteristic aspects of these different entities responsible for renovascular hypertension and discuss their prevalence, pathophysiology, clinical presentation, management, and prognosis.
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Affiliation(s)
- Alexandre Persu
- Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique and Division of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium (A.P.)
| | - Caitriona Canning
- Department of Vascular Medicine and Surgery, St. James’s Hospital, Dublin, Ireland (C.C.)
| | - Aleksander Prejbisz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., P.D., M.J., A.J.)
| | - Piotr Dobrowolski
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., P.D., M.J., A.J.)
| | - Laurence Amar
- Université de Paris, INSERM CIC1418, France (L.A., M.A.)
- AP-HP, Hôpital Européen Georges-Pompidou, Hypertension Department and DMU CARTE, Reference Centre for Rare Vascular Disease, Paris, France (L.A., M.A.)
| | | | - Jacek Kądziela
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, Warsaw, Poland (J.K.)
| | - Mieczysław Litwin
- Department of Nephrology and Arterial Hypertension, The Children’s Memorial Health Institute, Warsaw, Poland (M.L.)
| | - Daan van Twist
- Zuyderland Medical Centre, Sittard/Heerlen, the Netherlands (D.v.T.)
| | - Patricia Van der Niepen
- Department of Nephrology and Hypertension, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Belgium (P.V.d.N.)
| | - Gregoire Wuerzner
- Service of Nephrology and Hypertension, Lausanne University Hospital and University of Lausanne, Switzerland (G.W.)
| | - Peter de Leeuw
- Department of Internal Medicine and Gastroenterology, Zuyderland Medical Center, Heerlen, the Netherlands (P.d.L.)
- Department of Internal Medicine, Division of General Internal Medicine (P.d.L.), Maastricht University Medical Center, Maastricht University, the Netherlands
- CARIM School for Cardiovascular Diseases (P.d.L.), Maastricht University Medical Center, Maastricht University, the Netherlands
| | - Michel Azizi
- Université de Paris, INSERM CIC1418, France (L.A., M.A.)
- AP-HP, Hôpital Européen Georges-Pompidou, Hypertension Department and DMU CARTE, Reference Centre for Rare Vascular Disease, Paris, France (L.A., M.A.)
| | - Magda Januszewicz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., P.D., M.J., A.J.)
- II Department of Clinical Radiology, Medical University of Warsaw, Poland (M.J.)
| | - Andrzej Januszewicz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., P.D., M.J., A.J.)
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15
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Timing of procedural interventions in childhood renovascular hypertension. Pediatr Nephrol 2021; 36:3089-3096. [PMID: 34143295 DOI: 10.1007/s00467-021-05152-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 05/04/2021] [Accepted: 05/19/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Renovascular hypertension (RVHTN) is a rare, often complex condition due to multiple etiologies including congenital stenoses, vasculitides, and fibromuscular dysplasia. Among children with RVHTN who require multiple and escalating medications to control blood pressure, the optimal timing of a procedural intervention involves a balance of numerous factors. CASE-DIAGNOSIS/TREATMENT In this presentation of a 1-month-old girl with RVHTN, the treating medical team had to consider multiple factors in the initial management and timing of interventions to treat her underlying cause of RVHTN, including concerns for kidney health, degree of hypertension, age and size of the patient, and potential methods of procedural intervention. Initially, she was treated conservatively until concern for poor renal growth arose and a durable surgical intervention was thought feasible and safe. CONCLUSION The evidence regarding the timing of non-medical interventions in pediatric RVHTN is limited. Considerations should include patient age, size, disease severity, comorbid conditions, and degree of medical management required to maintain safe blood pressures that allow for growth and reverse cardiac damage. The optimal interventions have not been evaluated by controlled trials and should be decided on a case-by-case basis with consideration of center expertise and family preferences.
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16
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Persu A, Canning C, Prejbisz A, Dobrowolski P, Amar L, Chrysochou C, Kądziela J, Litwin M, van Twist D, Van der Niepen P, Wuerzner G, de Leeuw P, Azizi M, Januszewicz M, Januszewicz A. Beyond Atherosclerosis and Fibromuscular Dysplasia: Rare Causes of Renovascular Hypertension. Hypertension 2021. [PMID: 34455817 DOI: ./10.1161/hypertensionaha.121.17004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
Renovascular hypertension is one of the most common forms of secondary hypertension. Over 95% of cases of renovascular hypertension are due either to atherosclerosis of the main renal artery trunks or to fibromuscular dysplasia. These two causes of renal artery stenosis have been extensively discussed in recent reviews and consensus. The aim of the current article is to provide comprehensive and up-to-date information on the remaining causes. While these causes are rare or extremely rare, etiologic and differential diagnosis matters both for prognosis and management. Therefore, the clinician cannot ignore them. For didactic reasons, we have grouped these different entities into stenotic lesions (neurofibromatosis type 1 and other rare syndromes, dissection, arteritis, and segmental arterial mediolysis) often associated with aortic coarctation and other arterial abnormalities, and nonstenotic lesions, where hypertension is secondary to compression of adjacent arteries and changes in arterial pulsatility (aneurysm) or to the formation of a shunt, leading to kidney ischemia (arteriovenous fistula). Finally, thrombotic disorders of the renal artery may also be responsible for renovascular hypertension. Although thrombotic/embolic lesions do not represent primary vessel wall disease, they are characterized by frequent macrovascular involvement. In this review, we illustrate the most characteristic aspects of these different entities responsible for renovascular hypertension and discuss their prevalence, pathophysiology, clinical presentation, management, and prognosis.
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Affiliation(s)
- Alexandre Persu
- Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique and Division of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium (A.P.)
| | - Caitriona Canning
- Department of Vascular Medicine and Surgery, St. James’s Hospital, Dublin, Ireland (C.C.)
| | - Aleksander Prejbisz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., P.D., M.J., A.J.)
| | - Piotr Dobrowolski
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., P.D., M.J., A.J.)
| | - Laurence Amar
- Université de Paris, INSERM CIC1418, France (L.A., M.A.)
- AP-HP, Hôpital Européen Georges-Pompidou, Hypertension Department and DMU CARTE, Reference Centre for Rare Vascular Disease, Paris, France (L.A., M.A.)
| | | | - Jacek Kądziela
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, Warsaw, Poland (J.K.)
| | - Mieczysław Litwin
- Department of Nephrology and Arterial Hypertension, The Children’s Memorial Health Institute, Warsaw, Poland (M.L.)
| | - Daan van Twist
- Zuyderland Medical Centre, Sittard/Heerlen, the Netherlands (D.v.T.)
| | - Patricia Van der Niepen
- Department of Nephrology and Hypertension, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Belgium (P.V.d.N.)
| | - Gregoire Wuerzner
- Service of Nephrology and Hypertension, Lausanne University Hospital and University of Lausanne, Switzerland (G.W.)
| | - Peter de Leeuw
- Department of Internal Medicine and Gastroenterology, Zuyderland Medical Center, Heerlen, the Netherlands (P.d.L.)
- Department of Internal Medicine, Division of General Internal Medicine (P.d.L.), Maastricht University Medical Center, Maastricht University, the Netherlands
- CARIM School for Cardiovascular Diseases (P.d.L.), Maastricht University Medical Center, Maastricht University, the Netherlands
| | - Michel Azizi
- Université de Paris, INSERM CIC1418, France (L.A., M.A.)
- AP-HP, Hôpital Européen Georges-Pompidou, Hypertension Department and DMU CARTE, Reference Centre for Rare Vascular Disease, Paris, France (L.A., M.A.)
| | - Magda Januszewicz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., P.D., M.J., A.J.)
- II Department of Clinical Radiology, Medical University of Warsaw, Poland (M.J.)
| | - Andrzej Januszewicz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., P.D., M.J., A.J.)
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17
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Tian Y, Yuan B, Zhang N, Huang Z. Outcomes Following the Endovascular Treatment of Renal Artery Stenosis Caused by Fibromuscular Dysplasia: A Systematic Review and Meta-Analysis. Ann Vasc Surg 2021; 78:362-372. [PMID: 34543714 DOI: 10.1016/j.avsg.2021.06.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 05/31/2021] [Accepted: 06/24/2021] [Indexed: 11/01/2022]
Abstract
OBJECTIVE Renal artery revascularization has been performed to improve blood pressure control and to cure hypertension in patients with renal artery fibromuscular dysplasia (RAFMD). We herein conducted a systematic review and meta-analysis of studies assessing outcomes associated with the treatment of hypertensive RAFMD patients via endovascular angioplasty in order to offer an up-to-date overview of the relative costs and benefits of this approach to revascularization in RAFMD patients. METHODS We systematically searched the PubMed and Embase databases and the Cochrane Central Register for Controlled Trials to identify relevant studies published as of January 15, 2020. Key outcomes of interest in these studies included technical success, the incidence of perioperative complications, cure rates, and overall improvement rates. RESULTS In total, we identified 36 relevant studies of 1916 total repairs conducted in 1191 patients. Of these included studies, 33 were retrospective, while 3 were prospective. The overall technical success rate across these studies was 94.3%. Rates of total, major, and minor complications in these pooled studies were 12.9%, 4.6%, and 7.4%, respectively. Pooled rates of cured hypertension and improved hypertension following angioplasty, defined according to study-specific criteria, were 37.0% [95% CI: 27.0%-47.0%] and 80.0% [95% CI: 75.0% to 84.0%], respectively, although these rates varied highly among studies. Cure rates for studies used current clinical definitions for substantial variations across studies. Cure rates in studies using current definitions of cured hypertension (blood pressure <140/90 mm Hg without treatment) were just 18.1% following angioplasty. Cure rates fell markedly with increasing mean patient age (OR associated with an increase in mean age of 10 years: -0.24 [95% CI: -0.44 to -0.04, P = 0.019] and with mean known duration of hypertension (OR associated with an increase in mean hypertension duration of 5 years: -0.09 [95% CI: -0.12 to -0.05, P = 0.001]). CONCLUSIONS These findings suggest that endovascular treatment yielded moderate benefits to RAFMD patients, with substantial variation across studies. The blood pressure outcome was strongly influenced by patient age.
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Affiliation(s)
- Yu Tian
- Department of Vascular Surgery, The 3rd Affiliated Hospital of Shenzhen University, Shenzhen, Guangdong Province, China
| | - Biao Yuan
- Department of Vascular Surgery, Beijing Chao Yang Hospital, Affiliate of Capital Medical University, Beijing, People's Republic of China.
| | - Ning Zhang
- Department of Vascular Surgery, The 3rd Affiliated Hospital of Shenzhen University, Shenzhen, Guangdong Province, China
| | - Zhiyong Huang
- Department of Vascular Surgery, The 3rd Affiliated Hospital of Shenzhen University, Shenzhen, Guangdong Province, China
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18
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Persu A, Canning C, Prejbisz A, Dobrowolski P, Amar L, Chrysochou C, Kądziela J, Litwin M, van Twist D, Van der Niepen P, Wuerzner G, de Leeuw P, Azizi M, Januszewicz M, Januszewicz A. Beyond Atherosclerosis and Fibromuscular Dysplasia: Rare Causes of Renovascular Hypertension. Hypertension 2021; 78:898-911. [PMID: 34455817 PMCID: PMC8415524 DOI: 10.1161/hypertensionaha.121.17004] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Renovascular hypertension is one of the most common forms of secondary hypertension. Over 95% of cases of renovascular hypertension are due either to atherosclerosis of the main renal artery trunks or to fibromuscular dysplasia. These two causes of renal artery stenosis have been extensively discussed in recent reviews and consensus. The aim of the current article is to provide comprehensive and up-to-date information on the remaining causes. While these causes are rare or extremely rare, etiologic and differential diagnosis matters both for prognosis and management. Therefore, the clinician cannot ignore them. For didactic reasons, we have grouped these different entities into stenotic lesions (neurofibromatosis type 1 and other rare syndromes, dissection, arteritis, and segmental arterial mediolysis) often associated with aortic coarctation and other arterial abnormalities, and nonstenotic lesions, where hypertension is secondary to compression of adjacent arteries and changes in arterial pulsatility (aneurysm) or to the formation of a shunt, leading to kidney ischemia (arteriovenous fistula). Finally, thrombotic disorders of the renal artery may also be responsible for renovascular hypertension. Although thrombotic/embolic lesions do not represent primary vessel wall disease, they are characterized by frequent macrovascular involvement. In this review, we illustrate the most characteristic aspects of these different entities responsible for renovascular hypertension and discuss their prevalence, pathophysiology, clinical presentation, management, and prognosis.
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Affiliation(s)
- Alexandre Persu
- Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique and Division of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium (A.P.)
| | - Caitriona Canning
- Department of Vascular Medicine and Surgery, St. James’s Hospital, Dublin, Ireland (C.C.)
| | - Aleksander Prejbisz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., P.D., M.J., A.J.)
| | - Piotr Dobrowolski
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., P.D., M.J., A.J.)
| | - Laurence Amar
- Université de Paris, INSERM CIC1418, France (L.A., M.A.)
- AP-HP, Hôpital Européen Georges-Pompidou, Hypertension Department and DMU CARTE, Reference Centre for Rare Vascular Disease, Paris, France (L.A., M.A.)
| | | | - Jacek Kądziela
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, Warsaw, Poland (J.K.)
| | - Mieczysław Litwin
- Department of Nephrology and Arterial Hypertension, The Children’s Memorial Health Institute, Warsaw, Poland (M.L.)
| | - Daan van Twist
- Zuyderland Medical Centre, Sittard/Heerlen, the Netherlands (D.v.T.)
| | - Patricia Van der Niepen
- Department of Nephrology and Hypertension, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Belgium (P.V.d.N.)
| | - Gregoire Wuerzner
- Service of Nephrology and Hypertension, Lausanne University Hospital and University of Lausanne, Switzerland (G.W.)
| | - Peter de Leeuw
- Department of Internal Medicine and Gastroenterology, Zuyderland Medical Center, Heerlen, the Netherlands (P.d.L.)
- Department of Internal Medicine, Division of General Internal Medicine (P.d.L.), Maastricht University Medical Center, Maastricht University, the Netherlands
- CARIM School for Cardiovascular Diseases (P.d.L.), Maastricht University Medical Center, Maastricht University, the Netherlands
| | - Michel Azizi
- Université de Paris, INSERM CIC1418, France (L.A., M.A.)
- AP-HP, Hôpital Européen Georges-Pompidou, Hypertension Department and DMU CARTE, Reference Centre for Rare Vascular Disease, Paris, France (L.A., M.A.)
| | - Magda Januszewicz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., P.D., M.J., A.J.)
- II Department of Clinical Radiology, Medical University of Warsaw, Poland (M.J.)
| | - Andrzej Januszewicz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., P.D., M.J., A.J.)
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19
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Persu A, Canning C, Prejbisz A, Dobrowolski P, Amar L, Chrysochou C, Kądziela J, Litwin M, van Twist D, Van der Niepen P, Wuerzner G, de Leeuw P, Azizi M, Januszewicz M, Januszewicz A. Beyond Atherosclerosis and Fibromuscular Dysplasia: Rare Causes of Renovascular Hypertension. Hypertension 2021. [PMID: 34455817 DOI: 10.1161/hypertensionaha.121.17004
bcc:009247.186-127706.186.264be.19420.2@bxss.me] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
Renovascular hypertension is one of the most common forms of secondary hypertension. Over 95% of cases of renovascular hypertension are due either to atherosclerosis of the main renal artery trunks or to fibromuscular dysplasia. These two causes of renal artery stenosis have been extensively discussed in recent reviews and consensus. The aim of the current article is to provide comprehensive and up-to-date information on the remaining causes. While these causes are rare or extremely rare, etiologic and differential diagnosis matters both for prognosis and management. Therefore, the clinician cannot ignore them. For didactic reasons, we have grouped these different entities into stenotic lesions (neurofibromatosis type 1 and other rare syndromes, dissection, arteritis, and segmental arterial mediolysis) often associated with aortic coarctation and other arterial abnormalities, and nonstenotic lesions, where hypertension is secondary to compression of adjacent arteries and changes in arterial pulsatility (aneurysm) or to the formation of a shunt, leading to kidney ischemia (arteriovenous fistula). Finally, thrombotic disorders of the renal artery may also be responsible for renovascular hypertension. Although thrombotic/embolic lesions do not represent primary vessel wall disease, they are characterized by frequent macrovascular involvement. In this review, we illustrate the most characteristic aspects of these different entities responsible for renovascular hypertension and discuss their prevalence, pathophysiology, clinical presentation, management, and prognosis.
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Affiliation(s)
- Alexandre Persu
- Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique and Division of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium (A.P.)
| | - Caitriona Canning
- Department of Vascular Medicine and Surgery, St. James's Hospital, Dublin, Ireland (C.C.)
| | - Aleksander Prejbisz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., P.D., M.J., A.J.)
| | - Piotr Dobrowolski
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., P.D., M.J., A.J.)
| | - Laurence Amar
- Université de Paris, INSERM CIC1418, France (L.A., M.A.).,AP-HP, Hôpital Européen Georges-Pompidou, Hypertension Department and DMU CARTE, Reference Centre for Rare Vascular Disease, Paris, France (L.A., M.A.)
| | | | - Jacek Kądziela
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, Warsaw, Poland (J.K.)
| | - Mieczysław Litwin
- Department of Nephrology and Arterial Hypertension, The Children's Memorial Health Institute, Warsaw, Poland (M.L.)
| | - Daan van Twist
- Zuyderland Medical Centre, Sittard/Heerlen, the Netherlands (D.v.T.)
| | - Patricia Van der Niepen
- Department of Nephrology and Hypertension, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Belgium (P.V.d.N.)
| | - Gregoire Wuerzner
- Service of Nephrology and Hypertension, Lausanne University Hospital and University of Lausanne, Switzerland (G.W.)
| | - Peter de Leeuw
- Department of Internal Medicine and Gastroenterology, Zuyderland Medical Center, Heerlen, the Netherlands (P.d.L.).,Department of Internal Medicine, Division of General Internal Medicine (P.d.L.), Maastricht University Medical Center, Maastricht University, the Netherlands.,CARIM School for Cardiovascular Diseases (P.d.L.), Maastricht University Medical Center, Maastricht University, the Netherlands
| | - Michel Azizi
- Université de Paris, INSERM CIC1418, France (L.A., M.A.).,AP-HP, Hôpital Européen Georges-Pompidou, Hypertension Department and DMU CARTE, Reference Centre for Rare Vascular Disease, Paris, France (L.A., M.A.)
| | - Magda Januszewicz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., P.D., M.J., A.J.).,II Department of Clinical Radiology, Medical University of Warsaw, Poland (M.J.)
| | - Andrzej Januszewicz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., P.D., M.J., A.J.)
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20
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Sivasubramanian R, Meyers KE. Hypertension in Children and Adolescents with Turner Syndrome (TS), Neurofibromatosis 1 (NF1), and Williams Syndrome (WS). Curr Hypertens Rep 2021; 23:18. [PMID: 33779870 DOI: 10.1007/s11906-021-01136-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2021] [Indexed: 01/15/2023]
Abstract
PURPOSE OF REVIEW Turner syndrome (TS), neurofibromatosis type 1(NF1), and William Syndrome (WS) are 3 genetic conditions that are all associated with a substantial increase in risk of hypertension. In this review, we focus on factors leading to hypertension and on clinical manifestations and management of hypertension in children and adolescents with these genetic conditions RECENT FINDINGS: In most instances, hypertension is secondary. There is a high prevalence of masked hypertension in TS; however, the extent to which control of the BP helps reduce the risk of aortic dissection/aneurysm in TS is not yet fully elucidated. Vasculopathies are the least emphasized but most important manifestation of NF1. Of note, routine screening for pheochromocytoma in NFI is not recommended as it is not cost-effective. Cardiovascular complications are the major cause of death in patients with WBS. ABPM identifies patients without overt aortic or renovascular narrowing. Antihypertensive agents such as ARBs that have direct vascular wall effects and agents that inhibit oxidative stress (minoxidil) should be considered, even in those who do not exhibit overt hypertension. Elevated blood pressure in children and adolescence manifests early with end-organ changes and when left untreated, increases risk for premature onset of cardiovascular disease. Vigilant monitoring of the blood pressure is recommended. Accurate early diagnosis and management of hypertension will delay or prevent target organ damage and ensure a healthier transition to adulthood among children afflicted with these conditions.
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Affiliation(s)
- Ramya Sivasubramanian
- Division of Pediatric Nephrology, Department of Pediatrics, Children's Hospital of Philadelphia, 9th Floor Beurger Building, 3405 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Kevin E Meyers
- Division of Pediatric Nephrology, Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania, 9th Floor Beurger Building, 3405 Civic Center Boulevard, Philadelphia, PA, 19104, USA.
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21
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Abstract
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.
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Affiliation(s)
- Premal Amrishkumar Patel
- Interventional Radiology, Radiology Department, Great Ormond Street Hospital for Children, Great Ormond Street, London, WC1N 3JH, UK.
| | - Anne Marie Cahill
- Interventional Radiology, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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22
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Coleman DM, Eliason JL, Beaulieu R, Jackson T, Karmakar M, Kershaw DB, Modi ZJ, Ganesh SK, Khaja MS, Williams D, Stanley JC. Surgical management of pediatric renin-mediated hypertension secondary to renal artery occlusive disease and abdominal aortic coarctation. J Vasc Surg 2020; 72:2035-2046.e1. [PMID: 32276020 DOI: 10.1016/j.jvs.2020.02.045] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 02/15/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Renovascular hypertension (RVH) associated with renal artery and abdominal aortic narrowings is the third most common cause of pediatric hypertension. Untreated children may experience major cardiopulmonary complications, stroke, renal failure, and death. The impetus of this study was to describe the increasingly complex surgical practice for such patients with an emphasis on anatomic phenotype and contemporary outcomes after surgical management as a means of identifying those factors responsible for persistent or recurrent hypertension necessitating reoperation. METHODS A retrospective analysis was performed of consecutive pediatric patients with RVH undergoing open surgical procedures at the University of Michigan from 1991 to 2017. Anatomic phenotype and patient risk factors were analyzed to predict outcomes of blood pressure control and the need for secondary operations using ordered and binomial logistic multinomial regression models, respectively. RESULTS There were 169 children (76 girls, 93 boys) who underwent primary index operations at a median age of 8.3 years; 31 children (18%) had neurofibromatosis type 1, 76 (45%) had abdominal aortic coarctations, and 28 (17%) had a single functioning kidney. Before treatment at the University of Michigan, 51 children experienced failed previous open operations (15) or endovascular interventions (36) for RVH at other institutions. Primary surgical interventions (342) included main renal artery (136) and segmental renal artery (10) aortic reimplantation, renal artery bypass (55), segmental renal artery embolization (10), renal artery patch angioplasty (8), resection with reanastomosis (4), and partial or total nephrectomy (25). Non-renal artery procedures included patch aortoplasty (32), aortoaortic bypass (32), and splanchnic arterial revascularization (30). Nine patients required reoperation in the early postoperative period. During a mean follow-up of 49 months, secondary interventions were required in 35 children (21%), including both open surgical (37) and endovascular (14) interventions. Remedial intervention to preserve primary renal artery patency or a nephrectomy if such was impossible was required in 22 children (13%). The remaining secondary procedures were performed to treat previously untreated disease that became clinically evident during follow-up. Age at operation and abdominal aortic coarctation were independent predictors for reoperation. The overall experience revealed hypertension to be cured in 74 children (44%), improved in 78 (46%), and unchanged in 17 (10%). Children undergoing remedial operations were less likely (33%) to be cured of hypertension. There was no perioperative death or renal insufficiency requiring dialysis after either primary or secondary interventions. CONCLUSIONS Contemporary surgical treatment of pediatric RVH provides a sustainable overall benefit to 90% of children. Interventions in the very young (<3 years) and concurrent abdominal aortic coarctation increase the likelihood of reoperation. Patients undergoing remedial surgery after earlier operative failures are less likely to be cured of hypertension. Judicious postoperative surveillance is imperative in children surgically treated for RVH.
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Affiliation(s)
- Dawn M Coleman
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich.
| | - Jonathan L Eliason
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Robert Beaulieu
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Tatum Jackson
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Monita Karmakar
- Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - David B Kershaw
- Division of Pediatric Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor, Mich
| | - Zubin J Modi
- Division of Pediatric Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor, Mich; Susan B. Meister Child Evaluation and Research Center, University of Michigan, Ann Arbor, Mich
| | - Santhi K Ganesh
- Division of Cardiovascular Medicine, Department of Medicine, University of Michigan, Ann Arbor, Mich; Department of Human Genetics, University of Michigan, Ann Arbor, Mich
| | - Minhaj S Khaja
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Michigan, Ann Arbor, Mich
| | - David Williams
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Michigan, Ann Arbor, Mich
| | - James C Stanley
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
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Villegas L, Cahill AM, Meyers K. Pediatric Renovascular Hypertension: Manifestations and Management. Indian Pediatr 2020. [DOI: 10.1007/s13312-020-1820-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Patel PA, Stojanovic J. Diagnosis and Treatment of Renovascular Disease in Children. Semin Roentgenol 2019; 54:367-383. [PMID: 31706370 DOI: 10.1053/j.ro.2019.06.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Premal A Patel
- Interventional Radiology, Radiology Department, Great Ormond Street Hospital for Children, London, United Kingdom.
| | - Jelena Stojanovic
- Renal Unit, Great Ormond Street Hospital for Children, London, United Kingdom
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Raborn J, McCafferty BJ, Gunn AJ, Moawad S, Mahmoud K, Aal AKA, Saddekni S. Endovascular Management of Neurofibromatosis Type I-Associated Vasculopathy: A Case Series and Brief Review of the Literature. Vasc Endovascular Surg 2019; 54:182-190. [DOI: 10.1177/1538574419885257] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: Neurofibromatosis type 1 (NF1) is an autosomal-dominant disorder found in approximately 1 of every 3000 individuals. Neurofibromatosis type 1 can have vascular manifestations including aneurysms, stenoses, and arteriovenous malformations. The purpose of this article is to describe the clinical manifestations of NF1 vasculopathy, discuss therapeutic options, and highlight endovascular therapies from our institutional experience. Materials and Methods: The radiology information system was searched for cases of NF1. Cases with vasculopathy managed with endovascular therapies were included. Demographics, clinical histories, procedural details, and outcomes were recorded. A review of the literature for the management strategies of NF1 vasculopathy was performed. Results: Two pediatric patients with NF1 were identified, both of whom presented with hypertension found to be secondary to renal artery stenosis. One of the patients also had infrarenal aortic narrowing. Both patients were successfully treated with balloon angioplasty, resulting in improved blood pressures. The review of the literature identified case series of pharmacologic, surgical, and endovascular therapies, although, endovascular therapies appear to be preferred due to lower morbidity and mortality. Conclusions: NF1 vasculopathy is a rare condition that most often presents with hypertension due to renal artery stenosis. In these situations, endovascular management is the preferred approach.
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Affiliation(s)
- Joel Raborn
- Department of Radiology, University of Alabama at Birmingham School of Medicine, AL, USA
| | | | - Andrew J. Gunn
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Alabama at Birmingham School of Medicine, AL, USA
| | - Sherif Moawad
- Department of Radiology, University of Alabama at Birmingham School of Medicine, AL, USA
| | - Khalid Mahmoud
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Alabama at Birmingham School of Medicine, AL, USA
| | - Ahmed K. Abdel Aal
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Alabama at Birmingham School of Medicine, AL, USA
| | - Souheil Saddekni
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Alabama at Birmingham School of Medicine, AL, USA
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Lobeck IN, Alhajjat AM, Dupree P, Racadio JM, Mitsnefes MM, Karns R, Tiao GM, Nathan JD. The management of pediatric renovascular hypertension: a single center experience and review of the literature. J Pediatr Surg 2018; 53:1825-1831. [PMID: 29397961 DOI: 10.1016/j.jpedsurg.2017.12.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 11/06/2017] [Accepted: 12/10/2017] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Renal artery occlusive disease is poorly characterized in children; treatments include medications, endovascular techniques, and surgery. We aimed to describe the course of renovascular hypertension (RVH), its treatments and outcomes. METHODS We performed literature review and retrospective review (1993-2014) of children with renovascular hypertension at our institution. Response to treatment was defined by National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents at most-recent follow-up. RESULTS We identified 39 patients with RVH. 54% (n=21) were male, with mean age of 6.93 ± 5.27 years. Most underwent endovascular treatment (n=17), with medication alone (n=12) and surgery (n=10) less commonly utilized. Endovascular treatment resulted in 18% cure, 65% improvement and 18% failure; surgery resulted in 30% cure, 50% improvement and 20% failure. Medication alone resulted in 0% cure, 75% improvement and 25% failure. 24% with endovascular treatment required secondary endovascular intervention; 18% required secondary surgery. 20% of patients who underwent initial surgery required reoperation for re-stenosis. Mean follow-up was 52.2 ± 58.4 months. CONCLUSIONS RVH treatment in children includes medications, surgical or endovascular approaches, with all resulting in combined 79% improvement in or cure rates. A multidisciplinary approach and individualized patient management are critical to optimize outcomes. TYPE OF STUDY Retrospective comparative study LEVEL OF EVIDENCE: Level III.
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Affiliation(s)
- Inna N Lobeck
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Amir M Alhajjat
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Phylicia Dupree
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - John M Racadio
- Department of Radiology and Medical Imaging, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Mark M Mitsnefes
- Division of Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Rebekah Karns
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Greg M Tiao
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jaimie D Nathan
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
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Rumman RK, Matsuda-Abedini M, Langlois V, Radhakrishnan S, Lorenzo AJ, Amaral J, Mertens L, Parekh RS. Management and Outcomes of Childhood Renal Artery Stenosis and Middle Aortic Syndrome. Am J Hypertens 2018; 31:687-695. [PMID: 29373648 DOI: 10.1093/ajh/hpy014] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Accepted: 01/20/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Renal artery stenosis (RAS) in isolation or in conjunction with middle aortic syndrome (MAS) are important vascular causes of childhood hypertension. Few longitudinal studies have assessed the risk of surgical or endovascular intervention, and outcomes by etiology or extent of vascular disease. METHODS In a retrospective study of 93 children seen over 30 years with RAS and/or MAS, data on vascular involvement (isolated RAS vs. RAS with MAS), etiology (unknown, inflammatory, or genetic), and management were collected. Time to first intervention (endovascular or surgical) was assessed by Cox regression. Mixed-effects analysis examined the longitudinal change in blood pressure after intervention compared to antihypertensive medications alone. RESULTS Children were 7.0 ± 5.4 years old. Etiology was unknown in 50%, genetic in 26% and inflammatory in 24% of children. Children had isolated RAS (49%) or MAS with or without RAS (51%). Overall, 70% were managed with surgical or endovascular intervention. After adjusting for age, sex, and systolic blood pressure, children with unknown etiology had a higher risk of intervention compared to those with genetic and inflammatory diseases (hazard ratio 3.1, 95% confidence interval [CI] 1.7, 5.6). Children with RAS and MAS were less likely to receive intervention (hazard ratio 0.4, 95% CI 0.2, 0.8) than isolated RAS. Over a median follow-up of 2 years, 65% remained hypertensive. The longitudinal changes in systolic blood pressure did not differ by etiology, or between interventional and medical management. CONCLUSIONS Hypertension persists despite endovascular or surgical management of childhood RAS and MAS highlighting the importance of close monitoring and ongoing medical management.
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Affiliation(s)
- Rawan K Rumman
- Institute of Medical Science, and the Cardiovascular Sciences Collaborative Program, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mina Matsuda-Abedini
- Division of Nephrology, Department of Pediatrics, Hospital for Sick Children, and University of Toronto, Ontario, Canada
| | - Valerie Langlois
- Division of Nephrology, Department of Pediatrics, Hospital for Sick Children, and University of Toronto, Ontario, Canada
| | - Seetha Radhakrishnan
- Division of Nephrology, Department of Pediatrics, Hospital for Sick Children, and University of Toronto, Ontario, Canada
| | - Armando J Lorenzo
- Division of Urology, Hospital for Sick Children and Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Joao Amaral
- Division of Image Guided Therapy, Hospital for Sick Children and Department of Diagnostic Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Luc Mertens
- Division of Cardiology, Labatt Family Heart Center, Department of Pediatrics, Hospital for Sick Children, and University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Rulan S Parekh
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Nephrology, Department of Pediatrics, Hospital for Sick Children, and University of Toronto, Ontario, Canada
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
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Agrawal H, Moodie D, Qureshi AM, Acosta AA, Hernandez JA, Braun MC, Justino H. Interventions in children with renovascular hypertension: A 27-year retrospective single-center experience. CONGENIT HEART DIS 2018; 13:349-356. [DOI: 10.1111/chd.12608] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 03/16/2018] [Indexed: 12/01/2022]
Affiliation(s)
- Hitesh Agrawal
- Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine; Lillie Frank Abercrombie Section of Cardiology; Houston Texas
- Texas Children's Hospital and Baylor College of Medicine; C. E. Mullins Cardiac Catheterization Laboratories; Houston Texas
| | - Douglas Moodie
- Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine; Lillie Frank Abercrombie Section of Cardiology; Houston Texas
| | - Athar M. Qureshi
- Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine; Lillie Frank Abercrombie Section of Cardiology; Houston Texas
- Texas Children's Hospital and Baylor College of Medicine; C. E. Mullins Cardiac Catheterization Laboratories; Houston Texas
| | - Alisa A. Acosta
- Renal Section, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine; Houston Texas
| | - Jose A. Hernandez
- Interventional Radiology Section, Pediatric Radiology, Texas Children's Hospital and Baylor College of Medicine; Houston Texas
| | - Michael C. Braun
- Renal Section, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine; Houston Texas
| | - Henri Justino
- Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine; Lillie Frank Abercrombie Section of Cardiology; Houston Texas
- Texas Children's Hospital and Baylor College of Medicine; C. E. Mullins Cardiac Catheterization Laboratories; Houston Texas
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Renovascular hypertension: results in adulthood of renal autotransplantation performed in children. Pediatr Nephrol 2017; 32:1935-1940. [PMID: 28429121 DOI: 10.1007/s00467-017-3664-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 03/23/2017] [Accepted: 03/23/2017] [Indexed: 01/02/2023]
Abstract
BACKGROUND This study describes the long-term results of renal autotransplantation for renovascular hypertension performed in children who are now 21 years of age or older. METHODS Sixteen children (4 boys, 12 girls) with a mean age of 11.2 years at the time of the procedure underwent ex-vivo surgery at the university hospital of Saint-Etienne between 1992 and 2008. Acetylsalicylic acid was used for antiplatelet therapy in the postoperative period, without routine anticoagulation. The mean follow-up period was 15 years. The clinical course of these patients was retrospectively reviewed in adulthood and the results analyzed. RESULTS The children were treated with a mean of 2.37 drugs per patient, and the mean preoperative blood pressure of the entire patient population was 151/89 mmHg. Mean preoperative creatinine clearance was 80 ml/min/1.73 m2. There was no postoperative death. One patient experienced a thrombosis immediately after the surgery, leading to a redo surgery. In this patient diuresis was restarted, but without efficient concentration and filtration, ultimately leading the patient to have a renal transplant after 1 year. At the end of the follow-up period, eight of the 16 patients (50%) were cured and the others were improved. At the last follow-up the mean blood pressure was 127/70 mmHg, and the mean number of drugs per patient was 0.68. The mean creatinine clearance at last follow-up was 104.3 ml/min/1.73 m2. Three patients had secondary procedures, with two undergoing percutaneous angioplasty (at postoperative months 9 and 12, respectively) and one having an hepatorenal bypass at postoperative year 4. Primary patency was 12/16 (75%); primary assisted patency was 15/16 (94%); secondary patency was 16/16 (100%). CONCLUSION This study shows that renal autotransplantation has good and stable long-term results and is an effective conservative strategy for treating renovascular hypertension in children, thus avoiding nephrectomy.
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Chung H, Lee JH, Park E, Hyun H, Ahn YH, Jae HJ, Kim GB, Ha IS, Cheong HI, Kang HG. Long-Term Outcomes of Pediatric Renovascular Hypertension. Kidney Blood Press Res 2017; 42:617-627. [PMID: 28950261 DOI: 10.1159/000481549] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 07/22/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Renovascular hypertension (RVHT) is an important cause of childhood hypertension. This study evaluated the clinical characteristics and outcomes of Korean children with RVHT. METHODS Children treated for RVHT between 2000 and 2015 at our center were retrospectively reviewed. RESULTS Forty-six children were followed for a median of 6.5 (0.66-27.23) years. Forty-five percutaneous transluminal angioplasties (PTAs) were performed in 32 children. At the last visit, clinical benefit was observed in 53.3% of children. Patients with comorbid cerebrovascular disease (CVD) showed less favorable long-term outcomes after PTA (clinical benefit in 41.7% vs. 61.1% in others) and higher restenosis rates (50% vs. 31.6% in others). Surgical procedures (bypass or nephrectomy) were performed in 8 patients. After surgery, blood pressure was normalized in 2 patients, improved in 3 patients, and unchanged in the remaining patients. Between PTA group (n=21) and medication group (n=14), percentage of atrophic kidneys became higher after follow-up period in medication group than in PTA group (60.0% vs. 26.1%, P=0.037). CONCLUSION Aggressive treatment of pediatric RVHT yielded fair outcomes in our cohort. CVD comorbidity was associated with relatively poor PTA outcomes. To confirm our findings, larger cohort studies with a longer follow-up period are warranted.
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Affiliation(s)
- Hyun Chung
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Jae Hwan Lee
- Division of Intervention, Department of Radiology, National Cancer Center Hospital, Goyang, Republic of Korea
| | - Eujin Park
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Hyesun Hyun
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Yo Han Ahn
- Department of Pediatrics, Hallym University Kangnam Sacred Heart Hospital, Seoul, Republic of Korea
| | - Hwan Jun Jae
- Department of Radiology, Seoul National University Hospital, Seoul, Republic of Korea.,Seoul National University, College of Medicine, Seoul, Republic of Korea
| | - Gi Beom Kim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea.,Seoul National University, College of Medicine, Seoul, Republic of Korea
| | - Il Soo Ha
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea.,Seoul National University, College of Medicine, Seoul, Republic of Korea
| | - Hae Il Cheong
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea.,Seoul National University, College of Medicine, Seoul, Republic of Korea
| | - Hee Gyung Kang
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea.,Seoul National University, College of Medicine, Seoul, Republic of Korea
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Thorsteinsdottir H, Dorenberg E, Line PD, Bjerre A. [Renovascular disease in children - a rare diagnosis with few symptoms]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2017; 137:279-282. [PMID: 28225234 DOI: 10.4045/tidsskr.16.0156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND To estimate the prevalence, symptoms, causes and treatment of renovascular disease in children, and also to assess the degree of secondary organ damage to the heart, kidneys and eyes (end organ damage).MATERIAL AND METHOD Retrospective review of data for all children (0 - 16 years) who were examined for resistant hypertension in the period 1998 - 2013 at Oslo University Hospital Rikshospitalet.RESULTS A total of 21 children/adolescents (median age 8.5 years, 11 girls) were assessed and treated for resistant hypertension in the study period. Altogether had 38 % no symptoms at the time of diagnosis and 19 % had classical symptoms of hypertension. Fifteen patients received invasive treatment in the form of percutaneous transluminal renal angioplasty (PTRA) (n = 5), nephrectomy (n = 6), coiling (n = 1), autotransplantation (n = 1) or a combination of these (n = 2). Blood pressure improved following treatment in 10 of 14 patients for whom outcomes were recorded in the medical records. End organ damage to the heart and retina was observed in 60 % and 50 % of patients, respectively.INTERPRETATION Children with severely elevated blood pressure as a result of renovascular disease often have unspecific or no symptoms. Blood pressure improved following invasive treatment in 10 of 14 children and few complications were recorded. Invasive treatment may be considered in children and adolescents when standard treatment for hypertension is insufficient.
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Affiliation(s)
| | | | - Pål-Dag Line
- Avdeling for transplantasjonsmedisin og Institutt for klinisk medisin Universitetet i Oslo
| | - Anna Bjerre
- Barne- og ungdomsklinikken Oslo universitetssykehus
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Cutting Balloon Angioplasty (CBA) for the Treatment of Renal Artery Fibromuscular Dysplasia (FMD) in Six Patients: 5-Year Long-Term Results. Cardiovasc Intervent Radiol 2016; 40:546-552. [PMID: 28035431 DOI: 10.1007/s00270-016-1536-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 12/08/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE To evaluate long-term outcomes in terms of hypertension control, recurrent stenosis, and reinterventions from patients who underwent cutting balloon angioplasty (CBA) for symptomatic renal artery fibromuscular dysplasia (FMD). MATERIALS AND METHODS From 2011, six consecutive renal artery FMD women underwent CBA for poorly controlled hypertension, despite antihypertensive therapy. Follow-up consisted of blood pressure monitoring and duplex ultrasonography at 1, 6, and 12 months and thereafter annually for 5 years. RESULTS All treatments were technically successful. Recurrence of hypertension was found in two patients within 12 months, and reinterventions were performed using CBA. CONCLUSION Results show the efficacy of CBA for renal artery FMD.
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Remedial operations for failed endovascular therapy of 32 renal artery stenoses in 24 children. Pediatr Nephrol 2016; 31:809-17. [PMID: 26628283 DOI: 10.1007/s00467-015-3275-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 11/09/2015] [Accepted: 11/10/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Percutaneous transluminal angioplasty (PTA) for the treatment of pediatric renovascular hypertension (RVH) in contemporary practice is accompanied with ill-defined complications. This study examines the mode of pediatric renal PTA failures and the results of their surgical management. METHODS Twenty-four children underwent remedial operations at the University of Michigan from 1996 to 2014 for failures of renal PTA. Their clinical courses were retrospectively reviewed and results analyzed. RESULTS Renal PTA of 32 arteries, including 13 with stenting, was performed for severe RVH in 12 boys and 12 girls, having a mean age of 9.3 years. Developmental ostial stenoses affected 22 children. PTA failures included: 27 restenoses and five thromboses. Remedial operations included: 13 renal artery-aortic reimplantations, one segmental renal artery-main renal artery reimplantation, ten aortorenal bypasses, one arterioplasty, one iliorenal bypass, and six nephrectomies for unreconstructable arteries; the latter all in children younger than 10 years. Follow-up averaged 2.1 years. Postoperatively, hypertension was cured, improved, or unchanged in 25, 54, and 21 %, respectively. There was no perioperative renal failure or mortality. CONCLUSIONS Renal PTA for the treatment of pediatric RVH due to ostial disease may be complicated by failures requiring complex remedial operations or nephrectomy, the latter usually affecting younger children.
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Peco-Antić A, Stajić N, Krstić Z, Bogdanović R, Miloševski-Lomić G, Đukić M, Paripović D. Associated extrarenal vascular diseases may complicate the treatment and outcome of renovascular hypertension. Acta Paediatr 2016; 105:e35-41. [PMID: 26437121 DOI: 10.1111/apa.13229] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 04/01/2015] [Accepted: 09/24/2015] [Indexed: 11/29/2022]
Abstract
AIM This studied reviewed renovascular hypertension (RVH) due to renal artery stenosis (RAS) in two Serbian paediatric centres from 2001 to 2013. METHODS The patients' demographic data, underlying syndromes, blood pressure (BP), antihypertensive treatments and outcomes were reviewed. RESULTS The incidence of RVH was 1.9 per million children per year during the study period, and there were 25 patients with RAS, aged 10.4 ± 5.2 years. At presentation, their mean blood pressure (BP) standard deviation scores were 6.9 ± 3.4 systolic and 5.2 ± 2.6 diastolic. BP loads on 24-hour ambulatory BP were 88 ± 14% systolic and 80 ± 29% diastolic. We found that 72% had fibromuscular dysplasia and 28% had underlying syndromes. RAS was unilateral in 64% and bilateral in 28%, and 8% had RAS of a single kidney. Antihypertensive treatment included antihypertensive drugs (100%), percutaneous transluminal angioplasty (92%), renal auto-transplantation (16%), surgical revascularisation (12%) and nephrectomy (12%). After 4.4 ± 3.6 years of follow-up, high BP was cured in 40% of the patients and 39.4% of the kidneys and improved in 48% (75.7%), with BP decreases of 20.3 ± 3.7% systolic and 16.3 ± 6.2% diastolic. CONCLUSION Fibromuscular dysplasia was the most common cause of RVH in this study, and hypertension was cured or improved in 88% of the patients.
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Affiliation(s)
- Amira Peco-Antić
- Medical School of University of Belgrade; Belgrade Serbia
- Nephrology Department; University Children's Hospital; Belgrade Serbia
| | - Nataša Stajić
- Department of Nephrology; Institute of Mother and Child Health Care of Serbia ‘Dr Vukan Ćupić’; Belgrade Serbia
| | - Zoran Krstić
- Medical School of University of Belgrade; Belgrade Serbia
- Urology Department; University Children's Hospital; Belgrade Serbia
| | - Radovan Bogdanović
- Medical School of University of Belgrade; Belgrade Serbia
- Department of Nephrology; Institute of Mother and Child Health Care of Serbia ‘Dr Vukan Ćupić’; Belgrade Serbia
| | | | - Milan Đukić
- Medical School of University of Belgrade; Belgrade Serbia
- Cardiology Department; University Children's Hospital; Belgrade Serbia
| | - Dušan Paripović
- Nephrology Department; University Children's Hospital; Belgrade Serbia
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Jerónimo M, Dionísio T, Gomes C, Neves JF. Renovascular hypertension: a case with atypical neurological signs. BMJ Case Rep 2015; 2015:bcr-2014-208336. [PMID: 26351310 DOI: 10.1136/bcr-2014-208336] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Secondary hypertension is the most frequent form of hypertension in children. Renovascular disease accounts for 5-10% of all childhood hypertension and should be suspected in the presence of severe hypertension found difficult to manage with medical therapy. Uncontrolled hypertension can lead to severe target organ damage. We describe the case of a 13-month-old baby boy with failure to thrive, recent muscular weakness of the lower extremities and irritability. Hypertension was detected and he was admitted to the paediatric intensive care unit with a refractory hypertensive emergency, despite multiple antihypertensive therapies. Bilateral renal artery stenosis was diagnosed through renal angiography and balloon dilation was performed, leading to lower blood pressure. He is currently withdrawing from antihypertensive medication, and slowly gaining weight and recovering from target organ damage. However, weakness of the lower extremities persists and he has been diagnosed with a neurogenic bladder.
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Affiliation(s)
| | - Teresa Dionísio
- Pediatric Intensive Care Unit, Hospital Pediátrico de Coimbra, Coimbra, Portugal
| | - Clara Gomes
- Department of Paediatric Nephrology, Hospital Pediátrico de Coimbra, Coimbra, Portugal
| | - José Farela Neves
- Pediatric Intensive Care Unit, Hospital Pediátrico de Coimbra, Coimbra, Portugal
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Ladapo TA, Gajjar P, McCulloch M, Scott C, Numanoglu A, Nourse P. Impact of revascularization on hypertension in children with Takayasu's arteritis-induced renal artery stenosis: a 21-year review. Pediatr Nephrol 2015; 30:1289-95. [PMID: 25648879 DOI: 10.1007/s00467-015-3049-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2014] [Revised: 12/31/2014] [Accepted: 01/06/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Surgery for reno-vascular hypertension (RVH) is complex, and the techniques utilized vary with anatomical presentations of the disease. The long-term outcome of revascularization on RVH in children with Takayasu's arteritis (TA)-induced renal artery stenosis (RAS) at our centre was reviewed. METHODS This study was a 21-year retrospective review of pre- and post-intervention RVH in children with angiographically confirmed RAS. The outcome of hypertension was defined as follows: (1) cured (normotensive off anti-hypertensives), (2) improved (normotensive on same or reduced number of medications), or (3) failure (no cure or improvement in number of medications). RESULTS The medical histories of 59 children (median age 9.98 years) were reviewed, of whom 20 (44 %) had revascularization procedures. All were hypertensive, with a mean systolic and diastolic blood pressure of 161.5 ± 36 and 106.5 ± 31 mmHg, respectively. RAS was present in 45 (76.3 %) children. Twenty-four revascularization procedures were performed in 20 children (44 %), of whom five had contralateral nephrectomies. Outcome was available for 17 patients at the 3- and 6-months follow-up, with cure, improvement and failure rates at 3 months of 2/17 (11.8 %), 7/17 (41.2 %) and 8/19 (47 %), respectively, and similar rates at 6 months. Associations between outcome and age (p = 0.51), sex (p = 0.32), number of pre-surgery anti-hypertensives (p = 0.18) and stenosis sites (p = 0.22) were not statistically significant. CONCLUSIONS Revascularization was beneficial to the management of blood pressure control in about half of our RVH patients.
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Affiliation(s)
- Taiwo Augustina Ladapo
- Pediatric Nephrology, Department of Pediatrics, College of Medicine, University of Lagos and Lagos University Teaching Hospital, PMB 12003, Idi-Araba, Lagos, Nigeria,
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Zhu G, He F, Gu Y, Yu H, Chen B, Hu Z, Liang W, Wang Z. Angioplasty for pediatric renovascular hypertension: a 13-year experience. Diagn Interv Radiol 2015; 20:285-92. [PMID: 24675165 DOI: 10.5152/dir.2014.13208] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE We aimed to evaluate the long-term outcome and efficacy of percutaneous transluminal renal angioplasty (PTRA) for pediatric renal artery stenosis (RAS), which is an important cause of medication-refractory pediatric hypertension. MATERIALS AND METHODS We retrospectively evaluated 22 hypertensive children (age range, 3-17 years) who underwent PTRA from February 2000 to July 2012. Sixteen patients had Takayasu arteritis and six fibromuscular dysplasia. Five were not included in the statistical analysis due to loss to follow-up. RESULTS Technical success was achieved in 32 of 34 procedures (94.1%). The stenosis rate decreased from 84.5% before PTRA to 20.1% after PTRA. Treatment was effective in 72.7% (16/22) of patients, including complete cure in 27.3% (6/22) and improvement in 45.5% (10/22). Systolic and diastolic blood pressures decreased from 153 ± 19.1 to 131.7 ± 21.4 mmHg and from 97.9 ± 14.2 to 83.6 ± 19.3 mmHg, respectively (P <0.01). Number of antihypertensive agents decreased from 2.7 to 0.5 per patient. Restenosis was detected in 40.9% (9/22) of patients, with a restenotic interval of 11.8 months (range, 3-47 months). Lesion length was strongly correlated with clinical success (cure and improvement) (independent-sample t test, P <0.001; binary logistic regression, P = 0.040). CONCLUSION Lesion length is an important determination of clinical success with PTRA for pediatric RAS. PTRA is an appropriate treatment option for pediatric renovascular hypertension due to Takayasu arteritis and fibromuscular dysplasia.
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Affiliation(s)
- Guangchang Zhu
- From the Department of Vascular Surgery Second Artillery General Hospital, Beijing Normal University, Beijing, China.
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Rumman RK, Nickel C, Matsuda-Abedini M, Lorenzo AJ, Langlois V, Radhakrishnan S, Amaral J, Mertens L, Parekh RS. Disease Beyond the Arch: A Systematic Review of Middle Aortic Syndrome in Childhood. Am J Hypertens 2015; 28:833-46. [PMID: 25631383 DOI: 10.1093/ajh/hpu296] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 12/13/2014] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Middle aortic syndrome (MAS) is a rare clinical entity in childhood, characterized by a severe narrowing of the distal thoracic and/or abdominal aorta, and associated with significant morbidity and mortality. MAS remains a relatively poorly defined disease. This paper systematically reviews the current knowledge on MAS with respect to etiology, clinical impact, and therapeutic options. METHODS A systematic search of 3 databases (Embase, MEDLINE, and Cochrane Central Register of Controlled Trials) yielded 1,252 abstracts that were screened based on eligibility criteria resulting in 184 full-text articles with 630 reported cases of childhood MAS. Data extracted included patient characteristics, clinical presentation, vascular phenotype, management, and outcomes. RESULTS Most cases of MAS are idiopathic (64%), 15% are associated with Mendelian disorders, and 17% are related to inflammatory diseases. Extra-aortic involvement including renal (70%), superior mesenteric (30%), and celiac (22%) arteries is common, especially among those with associated Mendelian disorders. Inferior mesenteric artery involvement is almost never reported. The majority of cases (72%) undergo endovascular or surgical management with residual hypertension reported in 34% of cases, requiring medication or reintervention. Clinical manifestations and extent of extra-aortic involvement are lacking. CONCLUSIONS MAS presents with significant involvement of visceral arteries with over two thirds of cases having renal artery stenosis, and one third with superior mesenteric artery stenosis. The extent of disease is worse among those with genetic and inflammatory conditions. Further studies are needed to better understand etiology, long-term effectiveness of treatment, and to determine the optimal management of this potentially devastating condition.
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Affiliation(s)
- Rawan K Rumman
- Institute of Medical Science and The Cardiovascular Sciences Collaborative Program, University of Toronto, Toronto, Ontario, Canada; Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Cheri Nickel
- Hospital Library and Archives, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mina Matsuda-Abedini
- Department of Pediatrics, Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada; Faculty of Medicine, University of Toronto, Ontario, Canada
| | - Armando J Lorenzo
- Faculty of Medicine, University of Toronto, Ontario, Canada; Department of Surgery, Division of Urology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Valerie Langlois
- Department of Pediatrics, Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada; Faculty of Medicine, University of Toronto, Ontario, Canada
| | - Seetha Radhakrishnan
- Department of Pediatrics, Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada; Faculty of Medicine, University of Toronto, Ontario, Canada
| | - Joao Amaral
- Faculty of Medicine, University of Toronto, Ontario, Canada; Division of Image Guided Therapy, Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Luc Mertens
- Faculty of Medicine, University of Toronto, Ontario, Canada; Division of Cardiology, Labatt Family Heart Center, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Rulan S Parekh
- Department of Pediatrics, Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada; Faculty of Medicine, University of Toronto, Ontario, Canada; Department of Medicine, University Health Network, Toronto, Ontario, Canada.
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Kari JA, Roebuck DJ, McLaren CA, Davis M, Dillon MJ, Hamilton G, Shroff R, Marks SD, Tullus K. Angioplasty for renovascular hypertension in 78 children. Arch Dis Child 2015; 100:474-8. [PMID: 25527520 DOI: 10.1136/archdischild-2013-305886] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Accepted: 11/23/2014] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To evaluate the outcome of percutaneous transluminal angioplasty (PTA) in children with renovascular hypertension (RVH) treated at a single centre over 29 years. METHODS A retrospective study of the medical charts of all children with RVH who underwent PTA between 1984 and 2012. The primary outcome measurement was blood pressure (BP) achieved after the procedure. The BP before the procedure was compared with that at last available follow-up, 6 (range 0.6-16) years after the initial procedure. RESULTS Seventy-eight children with median (range) age of 6.5 (0.5-17) years were studied. Twenty-three (29.5%) had an underlying syndrome, 35 (44.9%) children had bilateral renal artery stenosis (RAS), 18 (23%) intrarenal disease and 11(14%) showed bilateral RAS and intrarenal disease. Twenty (25.6%) children had mid-aortic syndrome and 14 (17.9%) cerebrovascular disease. One hundred and fourteen PTA procedures were carried out including 31 stent insertions. Following PTA, BP was improved in 49 (62.8%) children and of those 18 (23.1%) were cured. Children with involvement of only the main renal arteries showed improved BP control in 79.9% of the children with cure in 39.5%. BP was intentionally maintained above the 95th centile for age and height in four children with coexistent cerebrovascular disease. No change in BP was seen in 18 children despite observed technical success of the PTA, and in seven children due to technical failure of the procedure. CONCLUSIONS PTA provided a clinical benefit in 62.8% of children with RVH.
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Affiliation(s)
- Jameela A Kari
- Department of Paediatrics, Faculty of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Derek J Roebuck
- Department of Radiology, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Clare A McLaren
- Department of Radiology, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Meryl Davis
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Michael J Dillon
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - George Hamilton
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Rukshana Shroff
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Stephen D Marks
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Kjell Tullus
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Trust, London, UK
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Lee ML, Wang YM. Angioplasty for recurrent renal artery stenosis in flare-up of Hashimoto's thyroiditis. Pediatr Int 2015; 57:e23-6. [PMID: 25868954 DOI: 10.1111/ped.12507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2014] [Revised: 07/27/2014] [Accepted: 09/01/2014] [Indexed: 11/29/2022]
Abstract
Takayasu arteritis is the most common disease seen in children presenting with renovascular hypertension (RVH) in Asia, and can manifest anatomically as renal artery stenosis (RAS). We report the case of a 16-year-old girl presenting with RVH due to recurrent and novel RAS in Hashimoto's thyroiditis (HT) flare-up. After treatment with thyroxin and percutaneous transluminal renal angioplasty (PTRA), she was free of hypothyroidism and systemic hypertension. RVH due to recurrent and novel RAS in HT flare-up has not previously been reported in the English-language literature. PTRA is the procedure of choice, providing there is no renal artery dissection or aneurysm.
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Affiliation(s)
- Meng-Luen Lee
- Division of Pediatric Cardiology, Department of Pediatrics, Changhua Christian Children's Hospital, Changhua, Taiwan
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Humbert J, Roussey-Kesler G, Guerin P, LeFrançois T, Connault J, Chenouard A, Warin-Fresse K, Salomon R, Bruel A, Allain-Launay E. Diagnostic and medical strategy for renovascular hypertension: report from a monocentric pediatric cohort. Eur J Pediatr 2015; 174:23-32. [PMID: 24953377 DOI: 10.1007/s00431-014-2355-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 05/20/2014] [Accepted: 05/29/2014] [Indexed: 11/26/2022]
Abstract
UNLABELLED Renovascular hypertension accounts for 5-10 % of hypertension cases in children; there is currently no consensus on treatment. Here, we report on our clinical experience with this disease and outline the different pathways in which to investigate it. We report retrospectively on ten children diagnosed with renovascular hypertension at the University Hospital of Nantes from 2001 to 2012. The main findings were obtained by fortuitous screening of children aged 2 months to 14 years old with neurofibromatosis (n = 2) and fibromuscular dysplasia (n = 8). The hypertension was always severe yet asymptomatic. Lesions were complicated in nine out of ten cases and included bilateral, multiple, mid-aortic syndrome and aneurysm. Doppler ultrasound associated with computed tomography allowed for a precise diagnosis in seven out of ten cases. Where ambiguities persisted, they were highlighted by arteriography, the gold standard investigation. Medical treatment was insufficient, leading to invasive procedures in nine out of ten children: 2 nephrectomies, 2 autotransplantations, and 21 repetitive percutaneous transluminal angioplasties. After invasive procedures, blood pressure control improved in four cases and was resolved in three. CONCLUSION Arteriography remains to be the gold standard technique for renovascular hypertension in children and can be combined with angioplasty when medical treatment is rendered obsolete. The role of computed tomography is controversial. Despite the heterogeneity of the children studied, we present a general medical and therapeutic management pathway for the treatment of this disease.
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Affiliation(s)
- J Humbert
- Pediatric Nephrology Department, University Hospital of Nantes, Nantes, France
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Voiculescu A, Heusch A, Düppers P, Pourhassan S, Klee D, Rump LC, Sandmann W. Duplex ultrasound findings before and after surgery in children and adolescents with renovascular hypertension. ULTRASOUND IN MEDICINE & BIOLOGY 2014; 40:2786-2793. [PMID: 25308948 DOI: 10.1016/j.ultrasmedbio.2014.07.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Revised: 07/07/2014] [Accepted: 07/16/2014] [Indexed: 06/04/2023]
Abstract
We report our experience with duplex ultrasound in young patients with renal artery stenosis (RAS) or middle aortic syndrome (MAS) before and after surgery (1995 and 2009). Of 36 patients (mean age: 13 ± 7 y), 21 had RAS and 15 had MAS. For patients with RAS, the Vmax in the affected artery was 350 ± 111 cm/s before surgery and 145 ± 55 cm/s after surgery. The resistance index was 0.46 ± 0.1 in the post-stenotic kidney and increased to 0.60 ± 0.08 after revascularization. Determination of the flow profile in the iliac artery revealed triphasic flow. In individuals with MAS, Vmax in the aorta was 323 ± 98 and the resistance index in both kidneys was low, even in the absence of RAS. The flow profile in the iliac arteries was monophasic before surgery and became triphasic after surgery. Duplex ultrasound is useful for the evaluation of children and young adults both pre- and post-surgery. Duplex ultrasound criteria for RAS in adults appear to be applicable in children and young adults also. The diagnostic evaluation of suspected renal vascular disease should include assessment of the aorta and the flow profile in the iliac arteries, as this could help differentiate between aortic and isolated renal artery stenosis.
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Affiliation(s)
- Adina Voiculescu
- Renal Division, Brigham and Women's Hospital, Boston, Massachusetts, USA; Nephrology Department, University Hospital Dusseldorf, Dusseldorf, Germany.
| | - Andreas Heusch
- Paediatric Cardiology and Pulmonary Medicine, Helios Klinikum Wuppertal, Wuppertal, Germany
| | - Philip Düppers
- Department of Vascular Surgery and Kidney Transplantation University Hospital Dusseldorf, Dusseldorf, Germany
| | - Siamak Pourhassan
- Department of Vascular Surgery and Kidney Transplantation University Hospital Dusseldorf, Dusseldorf, Germany
| | - Dirk Klee
- Diagnostic and Interventional Radiology, University Hospital Dusseldorf, Dusseldorf, Germany
| | - Lars C Rump
- Nephrology Department, University Hospital Dusseldorf, Dusseldorf, Germany
| | - Wilhelm Sandmann
- Department of Vascular Surgery and Kidney Transplantation University Hospital Dusseldorf, Dusseldorf, Germany
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Chrysant SG, Chrysant GS. Treatment of hypertension in patients with renal artery stenosis due to fibromuscular dysplasia of the renal arteries. Cardiovasc Diagn Ther 2014; 4:36-43. [PMID: 24649423 DOI: 10.3978/j.issn.2223-3652.2014.02.01] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2013] [Accepted: 01/27/2014] [Indexed: 11/14/2022]
Abstract
Renal artery stenosis (RAS) from fibromuscular dysplasia (FMD) is an uncommon cause of hypertension that affects mostly women. FMD is a noninflammatory vascular disease that predominantly affects mainly the renal arteries, but can also affect arteries in other vascular territories. The most common type of FMD is the media fibroplasia with the characteristic "string of beads" appearance (80-90%), whereas the two other types, the "intimal" and "adventitial" FMD are much less common accounting for 10% and <5% of cases, respectively. The prevalence of FMD in the general population is not well known. Estimates are derived from screening kidney donors, with a prevalence of about 2.6%. Among patients with renovascular hypertension (RVH), its incidence is about 10%, whereas 80-90% of RVH is due to atherosclerotic renal artery stenosis (ARAS). The treatment of choice of hypertension due to FMD is percutaneous renal angioplasty (PTRA). In contrast, hypertension due to ARAS is not frequently responsive to PTRA. In order to achieve successful control of hypertension in patients with FMD, a combination of PTRA with drugs that block the renin-angiotensin-aldosterone system (RAAS) is often necessary. The purpose of this review was to search the literature for newer diagnostic methods and treatment of FMD. Therefore, a Medline search of the English literature of published papers between 2008 and December 2013 was performed. Of 58 papers reviewed, 19 pertinent papers were selected including, studies, reviews, registries and case reports. The information from these studies together with collateral literature will be discussed in this concise review.
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Affiliation(s)
- Steven G Chrysant
- 1 University of Oklahoma College of Medicine, 2 INTEGRIS Baptist Medical Center, Oklahoma City, OK, USA
| | - George S Chrysant
- 1 University of Oklahoma College of Medicine, 2 INTEGRIS Baptist Medical Center, Oklahoma City, OK, USA
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Colyer JH, Ratnayaka K, Slack MC, Kanter JP. Renal artery stenosis in children: therapeutic percutaneous balloon and stent angioplasty. Pediatr Nephrol 2014; 29:1067-74. [PMID: 24445432 DOI: 10.1007/s00467-013-2730-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Revised: 12/03/2013] [Accepted: 12/12/2013] [Indexed: 11/24/2022]
Abstract
BACKGROUND Renal artery stenosis (RAS) accounts for 10 % of cases of systemic hypertension in children. Initial management involves anti-hypertensive therapy. Percutaneous interventions are documented for the treatment of RAS in the adult population. In children, case reports suggest benefit. METHODS This is a retrospective analysis of consecutive patients referred for catheterization for RAS between 2002 and 2010 at a single institution. Recorded variables included: age, weight, systemic blood pressure, minimal luminal diameter, interventional devices, antihypertensive medications, contrast volume, and complications. RESULTS Twelve patients (median age 8.2, IQR 6-12.4 years); median weight 42.8 kg, IQR: 25-47.4 kg) were referred for renal artery catheterization and underwent percutaneous intervention. Overall, minimal luminal diameter (MLD) increased by 1.2 ± 0.9 mm for all patients (p < 0.05) and by 1.3 ± 0.9 mm for post-renal transplant patients (p < 0.05). Only stent angioplasty patients demonstrated significant improved blood pressure (p < 0.05). One patient had stent thrombosis requiring re-intervention with repeat balloon angioplasty. CONCLUSIONS This retrospective analysis suggests that percutaneous intervention might play a role in the management of RAS, with an improvement in MLD in children with RAS. Transcatheter intervention is technically feasible with low morbidity. A prospective, longitudinal study is warranted to compare standard medical therapy with percutaneous interventions.
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Affiliation(s)
- Jessica H Colyer
- Children's National Heart Institute, Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC, 20010, USA
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Sandmann W, Dueppers P, Pourhassan S, Voiculescu A, Klee D, Balzer K. Early and Long-term Results after Reconstructive Surgery in 42 Children and Two Young Adults with Renovascular Hypertension due to Fibromuscular Dysplasia and Middle Aortic Syndrome. Eur J Vasc Endovasc Surg 2014; 47:509-16. [DOI: 10.1016/j.ejvs.2013.12.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Accepted: 12/02/2013] [Indexed: 10/25/2022]
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Meyers KE, Cahill AM, Sethna C. Interventions for Pediatric Renovascular Hypertension. Curr Hypertens Rep 2014; 16:422. [DOI: 10.1007/s11906-014-0422-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Renal sonography with Doppler for detecting suspected pediatric renin-mediated hypertension - is it adequate? Pediatr Radiol 2014; 44:42-9. [PMID: 24037085 DOI: 10.1007/s00247-013-2785-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2012] [Revised: 07/18/2013] [Accepted: 08/20/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Renal Doppler US is used to evaluate suspected vascular causes of hypertension in children, despite mostly unknown diagnostic performance characteristics. OBJECTIVE To evaluate renal Doppler US for detecting vascular causes of hypertension in children with high clinical suspicion of aortic or renal artery narrowing. MATERIALS AND METHODS We identified pediatric renal Doppler US examinations performed for hypertension between January 1995 and June 2010 at our institution. We excluded children without follow-up angiography (CT-, MR-, or catheter-based). Two pediatric radiologists reviewed imaging studies and documented relevant findings. Intrarenal spectral Doppler resistive index measurement <0.5 or tardus parvus waveform constituted a positive examination. RESULTS Thirty-five boys and 13 girls underwent renal Doppler US and confirmatory imaging (mean age = 9.0 years). Nineteen US examinations were truly negative, two were falsely negative, 18 were truly positive (16 involved narrowing of the aorta or main renal artery) and nine were falsely positive. Sonography had a sensitivity and specificity of 90% and 68%, respectively, for detecting a vascular cause of hypertension. CONCLUSION Renal Doppler sonography reliably detects renin-mediated hypertension caused by aortic or main renal artery narrowing in children. More studies are needed to determine its ability to detect intrarenal and accessory renal artery stenoses.
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Kurian J, Epelman M, Darge K, Meyers K, Nijs E, Hellinger JC. The role of CT angiography in the evaluation of pediatric renovascular hypertension. Pediatr Radiol 2013. [PMID: 23208533 DOI: 10.1007/s00247-012-2567-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Historically, the evaluation of renovascular hypertension has been accomplished by US, renal scintigraphy and digital subtraction angiography. Based on its high accuracy reported in adults renal CT angiography (CTA) with pediatric-appropriate low radiation dose techniques has become an important tool in the workup of renovascular hypertension in children. Renal CTA has several advantages over more conventional imaging modalities, including rapid and non-invasive acquisition, high resolution and easy reproducibility. Additionally, in our experience high-quality renal CTA can be performed using low-dose radiation exposures and can be acquired without sedation in most instances. This article illustrates by examples the usefulness of renal CTA for diagnosis of childhood renovascular hypertension and provides an overview of renal CTA findings in the most common childhood renovascular diseases.
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Affiliation(s)
- Jessica Kurian
- Department of Radiology, The Children's Hospital of Philadelphia, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Abstract
Neurofibromatosis is one of several genetic disorders characterized by hyperpigmented skin spots (café au lait spots) and multiple neurofibromas. It was first reported by Friedrich Daniel von Recklinghausen in 1882. There are 2 types of neurofibromatosis described in the literature: von Recklinghausen disease, or neurofibromatosis 1 that involves peripheral nerve sheaths, and central, or neurofibromatosis 2. Neurofibromatosis 1 very commonly involves renal arteries, and hypertension commonly is present in these patients due to stenotic ostial lesions resulting in bilateral renal artery stenosis. However, renal artery aneurysms, renal artery thrombosis, or external compression by neurofibromas also may cause hypertension. We present a unique case of a man with neurofibromatosis 1 presenting with anuric acute kidney injury, followed by a brief discussion of neurofibromatosis 1 and its association with renovascular disease.
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Affiliation(s)
- Usman Khan
- Department of Medicine, Section of Nephrology, Yale University School of Medicine, New Haven, CT 06520-8029, USA.
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Endovascular treatment of stenoses in a pediatric patient with incomplete aortic duplication, mesenteric ischemia, and renovascular hypertension. J Vasc Surg 2012; 57:214-7. [PMID: 23141677 DOI: 10.1016/j.jvs.2012.06.104] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Revised: 06/28/2012] [Accepted: 06/29/2012] [Indexed: 11/23/2022]
Abstract
Variations in abdominal aortic anatomy may have significant implications in various surgical procedures. We report here a pediatric patient with symptoms of chronic mesenteric ischemia, labile hypertension, and lower extremity claudication. Angiography revealed a partially duplicated aorta with the anterior aorta containing the splanchnic and renal arteries and the posterior segment perfusing the lower extremities. She was successfully treated with balloon angioplasty of two focal stenoses and is normotensive without abdominal symptoms at 1-year follow-up. To our knowledge, this is the first report of a successful endovascular intervention in a partially duplicated aorta.
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