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Abstract
Renovascular hypertension (RVH) is a secondary form of high blood pressure resulting from impaired blood flow to the kidneys with subsequent activation of the renin-angiotensin-aldosterone system. Often, this occurs due to abnormally small, narrowed, or blocked blood vessels supplying one or both kidneys (ie: renal artery occlusive disease) and is correctable. Juxtaglomerular cells release renin in response to decreased pressure, which in turn catalyzes the cleavage of circulating angiotensinogen synthesized by the liver to the decapeptide angiotensin I. Angiotensin-converting enzyme then cleaves angiotensin I to form the octapeptide angiotensin II, a potent vasopressor and the primary effector of renin-induced hypertension. The effects of angiotensin II are mediated by signaling downstream of its receptors. Angiotensin receptor type 1 is a G-protein-coupled receptor that activates vasoconstrictor and mitogenic signaling pathways resulting in peripheral arteriolar vasoconstriction and increased renal tubular reabsorption of sodium and water which promotes intravascular volume expansion. Angiotensin II stimulates the adrenal cortical release of aldosterone, which promotes renal tubular sodium reabsorption, resulting in volume expansion. Angiotensin II acts on glial cells and regions of the brain responsible for blood pressure regulation increasing renal sympathetic activation. Angiotensin II simulates the release of vasopressin from the pituitary which stimulates thirst and water reabsorption from the kidney to expand the intravascular volume and cause peripheral vasoconstriction (increased sympathetic tone). All of these mechanisms coalesce to increase arterial pressure by way of arteriolar constriction, enhanced cardiac output, and the retention of sodium and water.
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Affiliation(s)
- Jessie Dalman
- University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, USA
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Cortenbach KRG, Yosofi B, Rodwell L, Meek J, Patel R, Prakash SK, Riksen NP, Jenniskens SFM, Dirven M, DeRuiter MC, van Kimmenade RRJ. Editor's Choice - Therapeutic Options and Outcomes in Midaortic Syndrome: A Systematic Review and Meta-analysis. Eur J Vasc Endovasc Surg 2023; 65:120-130. [PMID: 36220622 DOI: 10.1016/j.ejvs.2022.10.017] [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] [Received: 04/01/2022] [Revised: 09/05/2022] [Accepted: 10/05/2022] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Midaortic syndrome (MAS) is narrowing of the distal thoracic and or abdominal aorta with congenital, inflammatory, or idiopathic aetiology. If left untreated, the prognosis is poor due to hypertensive complications. Follow up data after treatment are sparse, contrary to aortic coarctation. This study aimed to investigate hypertension during follow up after medical, endovascular, and surgical therapy in juveniles and adults. DATA SOURCES A meta-analysis of case series and reports was performed, focusing on the incidence of hypertension during the follow up of juvenile (i.e., age 0-17 years) and adult MAS patients after medical, endovascular, or surgical therapy. REVIEW METHODS Search queries were performed in PubMed, Embase, and Web of Science, and eligible articles underwent quality control. Descriptive statistics were reported based on available data, and individual patient data meta-analyses were performed using a one stage approach, accounting for clustering by case series or decades of reporting for case reports. For the meta-analysis, missing outcome and aetiology data were multiply imputed. RESULTS The number of juveniles and adults who underwent endovascular therapy (33.7% vs. 27.3%; p = .42) and surgery (52.2% vs. 58.0%; p = .46) was similar. At baseline, 92.4% of juveniles and 87.5% of adults were hypertensive, decreasing to 23.2% and 24.1% during a follow up of 23 months (juveniles) and 18 months (adults), respectively. More hypertension was found compared with surgery in juveniles after endovascular therapy (38.1% vs. 10.8%; p = .020). Meta-analysis also demonstrated a trend for hypertension after endovascular therapy in juveniles, whereas hypertension was more prevalent following surgery in adults compared with endovascular therapy or medication. CONCLUSION This review and meta-analysis investigated therapeutic options for MAS in juveniles and adults. It found that complications and hypertension during follow up were more common in juveniles after endovascular treatment, whereas surgery in adults was associated with more hypertension.
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Affiliation(s)
- Kimberley R G Cortenbach
- Department of Tumour Immunology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Bahram Yosofi
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Laura Rodwell
- Department of Health Evidence, Radboud University Medical Centre, Radboud University, Nijmegen, the Netherlands
| | - Jelena Meek
- Department of Tumour Immunology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Ritesh Patel
- Department of Internal Medicine, Division of Cardiology, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Siddharth K Prakash
- Department of Internal Medicine, Division of Cardiology, The John Ritter Research Program in Aortic and Vascular Diseases, Houston, TX, USA
| | - Niels P Riksen
- Department of Internal Medicine and Radboud Centre for Infectious Diseases, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Sjoerd F M Jenniskens
- Department of Medical Imaging, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Mark Dirven
- Division of Vascular and Transplant Surgery, Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Marco C DeRuiter
- Department of Anatomy and Embryology, Leiden University Medical Centre, Leiden, the Netherlands
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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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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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Midaortic syndrome and renovascular hypertension. Semin Pediatr Surg 2021; 30:151124. [PMID: 34930586 DOI: 10.1016/j.sempedsurg.2021.151124] [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: 11/24/2022]
Abstract
Midaortic syndrome (MAS) is a rare condition characterized by stenosis of the abdominal aorta with or without the involvement of branch vessels. The majority of cases are thought to be idiopathic though MAS has been associated with a number of conditions including granulomatous vasculitis, neurofibromatosis-1 (NF-1), Alagille Syndrome, fibromuscular dysplasia (FMD), and Williams syndrome. Patients typically present with hypertension due to decreased renal perfusion. Less common presentations include renal insufficiency, heart failure, claudication, stroke, and abdominal pain. Imaging modalities help establish the diagnosis of MAS including duplex ultrasound, computed tomography angiography (CTA), magnetic resonance angiography (MRA), and angiography. Initial therapy focuses on medical management with antihypertensives prior to intervention. Invasive interventions are indicated when there is evidence of end organ damage or dysfunction such as decreased renal function, poorly growing kidneys, cerebrovascular accident, left ventricular hypertrophy or frank cardiac failure. Endovascular interventions may assist in diagnosis and may treat some lesions although reintervention rates are high. Most patients require some type of surgical intervention, and a variety of surgical options are available based on anatomic findings. Renal revascularization may be accomplished by renal artery bypass, autotransplantation, or renal artery reconstruction. Aortic lesions may be repaired using patch angioplasty or aortoaortic bypass. Mesenteric arteries do not typically require reconstruction as they are rarely symptomatic. More novel options include the use of tissue expanders to lengthen the aorta to allow for primary aortic reconstruction (TESLA) or the use of the meandering mesenteric artery as an autologous aortic bypass graft (MAGIC).
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Kim SS, Stein DR, Ferguson MA, Porras D, Chaudry G, Singh MN, Smoot L, Kim HB, Vakili K. Surgical management of pediatric renovascular hypertension and midaortic syndrome at a single-center multidisciplinary program. J Vasc Surg 2020; 74:79-89.e2. [PMID: 33340698 DOI: 10.1016/j.jvs.2020.12.053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 12/03/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To evaluate the outcomes of various surgical approaches in the treatment of renovascular hypertension and midaortic syndrome (MAS) in children. METHODS We performed a retrospective medical record review of patients who had undergone surgery for renovascular hypertension from 2010 to 2018 at our center under the care of a multidisciplinary team. The operative interventions included mesenteric artery growth improves circulation (MAGIC), tissue expander-stimulated lengthening of arteries (TESLA), aortic bypass using polytetrafluorethylene, renal artery reimplantation, and autotransplantation. The MAGIC procedure uses the meandering mesenteric artery as a free conduit for aortic bypass. The TESLA procedure is based on lengthening the normal distal aorta and iliac arteries by gradual filling of a retroaortic tissue expander for several weeks, followed by resection of the stenotic aorta and subsequent primary reconstruction. RESULTS A total of 39 patients were identified, 10 with isolated renal artery stenosis, 26 with MAS, and 3 with systemic inflammatory vasculitis. The median age at presentation and surgery was 6.4 years (range, 0-16.3 years) and 9.3 years (range, 0-9.2 years), respectively. The MAS-associated syndromes included neurofibromatosis type 1 (15.4%) and Williams syndrome (5.1%), although most cases were idiopathic. At surgery, 33.3% had had stage 1 hypertension (HTN), 53.8% stage 2 HTN, and 12.8% normal blood pressure with a median of three antihypertensive medications. Follow-up of 37 patients at a median of 2.5 years demonstrated normal blood pressure in 86.1%, stage 1 HTN in 8.3%, and stage 2 HTN in 5.6%, with a median of one antihypertensive medication for the entire cohort. CONCLUSIONS The patterns of vascular involvement leading to renovascular hypertension in children are variable and complex, requiring thoughtful multidisciplinary planning and surgical decision-making. The MAGIC and TESLA procedures provide feasible approaches for aortic bypass and reconstruction using autologous tissues and will result in normalization of blood pressure in 85% of children 2.5 years after surgery.
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Affiliation(s)
- Stephanie S Kim
- Department of Surgery, Boston Children's Hospital, Boston, Mass
| | - Deborah R Stein
- Division of Nephrology, Boston Children's Hospital, Boston, Mass
| | | | - Diego Porras
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - Gulraiz Chaudry
- Division of Interventional Radiology, Boston Children's Hospital, Boston, Mass
| | - Michael N Singh
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - Leslie Smoot
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - Heung Bae Kim
- Department of Surgery, Boston Children's Hospital, Boston, Mass
| | - Khashayar Vakili
- Department of Surgery, Boston Children's Hospital, Boston, Mass.
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Patel RS, Nguyen S, Lee MT, Price MD, Krause H, Truong VTT, Sandhu HK, Charlton-Ouw KM, LeMaire SA, Coselli JS, Prakash SK. Clinical Characteristics and Long-Term Outcomes of Midaortic Syndrome. Ann Vasc Surg 2020; 66:318-325. [DOI: 10.1016/j.avsg.2019.12.039] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 12/08/2019] [Accepted: 12/17/2019] [Indexed: 12/20/2022]
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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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Forman N, Sinskey J, Shalabi A. A Review of Middle Aortic Syndromes in Pediatric Patients. J Cardiothorac Vasc Anesth 2020; 34:1042-1050. [DOI: 10.1053/j.jvca.2019.07.130] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 07/09/2019] [Accepted: 07/12/2019] [Indexed: 01/04/2023]
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Lawrence PF. Journal of Vascular Surgery – June 2018 Audiovisual Summary. J Vasc Surg 2018. [DOI: 10.1016/j.jvs.2018.04.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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