Hypertension due to combination of pheochromocytoma and unilateral renal ischemia by tumor compression

Coexistence of pheochromocytoma with uncommon vascular lesions

BACKGROUND

Pheochromocytoma/paragangliomas have been described to be associated with rare vascular abnormalities like renal artery stenosis. Coexistence of physiologically significant renal artery lesions is a compounding factor that alters management and prognosis of pheochromocytoma patients. Apart from individual case reports, data on such association in Indian population is not available. The aim of this study is to find the nature and prevalence of associated vascular abnormalities.

MATERIALS AND METHODS

From 1990 to 2010, a total of 50 patients were diagnosed with pheochromocytoma/paragangliomas. Hospital charts of these patients were reviewed retrospectively to identify those with unusual vascular abnormalities. Available literature was also reviewed.

RESULTS

Of the 50 patients with pheochromocytoma, 7 (14%) had coexisting vascular lesions including renal artery stenosis in 4, aortoarteritis in 1, aortic aneurysm in 1 and inferior vena cava thrombosis in 1. Pheochromocytoma was adrenal in 42 and extra adrenal in 8. Laparoscopic adrenalectomy was done in the patients. One patient with renal artery stenosis due to intimal fibrosis was subjected to percutaneous balloon angioplasty; the other three improved after adrenalectomy and lysis of fibrous adhesive bands. The patient with aortoarteritos was treated with oral steroids. Inferior vena cava thrombosis was reversed with anticoagulants. The patient with abdominal aortic aneurysm was advised for annual follow-up on account of its size of 4.5 cm and asymptomatic presentation.

CONCLUSION

There are multiple mechanisms that can lead to renal artery stenosis and other vascular abnormalities in a case of pheochromocytoma. A high index of suspicion is necessary to enable both entities to be diagnosed preoperatively and allow proper planning of surgical therapy. Incomplete diagnosis may lead to persistent hypertension postoperatively in a case of associated renal artery stenosis.

Bilateral adrenal phaeochromocytomas associated with unilateral renal artery stenosis

A 21 year old male was discovered to be severely hypertensive. He was found to have bilateral adrenal phaeochromocytomas and a single renal artery stenosis. More than 40 cases of coexisting renal artery stenosis and phaeochromocytomas have been reported. The aetiology of renal artery stenosis in association with phaeochromocytoma maybe multifactorial and the radiographic appearances are not always clear-cut. Renin levels in this patient were elevated prior to the removal of the phaeochromocytomas but the renal vein renin ratio did not suggest that the renal artery stenosis contributed significantly to his hypertension. The patient's hypertension resolved following successful removal of the phaeochromocytomas despite persistence of the renal artery stenosis. Thus, though renin levels may be misleading in these cases, renal vein renin ratios may still be helpful in deciding on patient management.

The coexistence of renal artery stenosis and pheochromocytoma

The coexistence of renal artery stenosis and pheochromocytoma has been recognized since 1958 and a total of 36 patients reported. This article provides an additional patient with an extra adrenal pheochromocytoma and fibrous bands constricting the left renal artery. Hypertension was confirmed to occur from both excess catecholamine production and hyperreninemia from the left kidney. Surgical removal of the functioning paraganglioma and correction of the renal artery stenosis restored the postoperative plasma catecholamine, renin, and blood pressure to normal. A literature review confirmed the coexistence of these two lesions but failed to provide a common etiology to explain the pathophysiology encountered. However, when the two diseases occur simultaneously, both must be diagnosed accurately and treated in a definitive manner.

Extra-adrenal pheochromocytoma producing renal artery stenosis

A case of extra-adrenal pheochromocytoma on the left side in relation to the left renal pedicle, producing renal artery stenosis, is described because of its rarity, and diagnostic and therapeutic problems. The pheochromocytoma was excised and the kidney was preserved.

Renal vein renin studies in a patient with renal hilar pheochromocytoma and renal artery stenosis

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