Percutaneous transluminal angioplasty for renovascular hypertension in children: initial and long-term results

Percutaneous Transluminal Renal Angioplasty for Pediatric Hypertension Secondary to Total Renal Artery Occlusion

PURPOSE

To assess the feasibility and effectiveness of percutaneous transluminal renal angioplasty (PTRA) for pediatric renovascular hypertension (RVH) secondary to total renal artery occlusion (RAO).

MATERIALS AND METHODS

From 2011 to 2021, 13 pediatric patients with RVH confirmed with 14 renal artery occlusions were reviewed. The mean age was 11.2 years (range, 4-16 years). Nine occlusions involved main artery occlusion, and 5 involved branch occlusion. Blood pressure ratio (BPR) was defined as the ratio of the actual measured blood pressure (BP) value to the 95th percentile value adjusted for age, sex, and height.

RESULTS

PTRA was performed in 9 patients (9/13, 69%). Technical success was achieved in 5 patients (5/9, 56%), with stent placement in 2 children (2/9, 22%). During the 12-month follow-up, restenosis was identified in both of the stent-receiving patients at the 12-month follow-up visit (2/9, 22%). Mean systolic BPR decreased from 1.20 (SD ± 0.07) to 0.96 (SD ± 0.06; P = .003), mean diastolic BPR decreased from 1.19 (SD ± 0.07) to 0.95 (SD ± 0.08; P = .005), and the number of medications required decreased from 3.8 (SD ± 0.8) to 2.4 (SD ± 0.9; P = .052) after PTRA. Subsequent to PTRA, the mean glomerular filtration rate of the occluded kidney improved from 19.5 mL/min (SD ± 12.3) to 36.3 mL/min (SD ± 10.8; P = .007), and the mean longitudinal dimension of the affected kidneys significantly increased from 8.2 cm (SD ± 1.5) to 9.2 cm (SD ± 1.7; P = .006).

CONCLUSIONS

Endovascular treatment is often feasible for pediatric patients with RAO, results in acceptable BP control, and preserves renal function.

Long-term outcomes of angioplasty for pediatric renovascular hypertension: A single-center experience

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.

Percutaneous cutting balloon angioplasty for the treatment of renovascular hypertension in children and adolescents

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.

Left ventricular function assessment after aortic and renal intervention in Takayasu arteritis by speckle tracking echocardiography: a pilot study

Background

Overt left ventricular (LV) dysfunction and congestive heart failure are known entities in Takayasu arteritis (TA). Subclinical LV dysfunction may develop in these patients despite normal LV ejection fraction (LVEF). Moreover, effect of treatment of aortic or renal artery narrowing in such patients is unknown.

Methods

This study included 15 angiographically confirmed TA patients undergoing aortic and/or renal intervention. A comprehensive clinical, biochemical and echocardiographic (2-dimensional, speckle tracking and tissue doppler imaging) evaluation were done at baseline, 72 h, and six months post intervention.

Results

Six patients (40%) had reduced LVEF (<50%) at baseline while rest 9 (60%) patients had reduced global longitudinal strain (GLS) but normal EF. Diastolic filling pattern was abnormal in all the patients. In patients with baseline reduced EF, mean EF improved from 24.62 ± 12.14% to 45.6 ± 9.45% (p = 0.001), E/e’ ratio decreased from 15.15 ± 3.19 to 10.8 ± 2.56 (p = 0.005) and median NT pro BNP decreased from 1673 pg/ml (970–2401 pg/ml) to 80 pg/ml (40–354 pg/ml) (p = 0.001) at 6 months after interventional procedure. In patients with baseline normal EF, median NT pro BNP decreased from 512 pg/ml (80–898.5 pg/ml) to 34 pg/ml (29–70.8 pg/ml) (p < 0.01), mean GLS improved from −8.80 ± 0.77% to −16.3 ± 0.78% (p < 0.001) and mean E/e’ decreased from 12.93 ± 2.63 to 7.8 ± 2.73 (p = 0.005) at 6 months follow up.

Conclusion

LV dysfunction is common in patients with TA and obstructive lesions in aorta or renal arteries. GLS can be used to assess subclinical systolic dysfunction in these patients. Timely intervention can improve LV dysfunction and can even reverse the subclinical changes.

Presentation, treatment, and outcome of renovascular hypertension below 2 years of age

Renovascular hypertension in most cases requires endovascular treatment and/or surgery. This is technically much more difficult in small children and there is very limited published knowledge in this age group. We here present treatment and outcome of young children with renovascular hypertension at our institution. Children below 2 years of age, with renovascular hypertension between January 1998 and March 2020 were retrospectively reviewed. Demographics and treatment modalities were noted. Primary outcome was blood pressure within a week after the procedures and at last available visit. Sixty-six angiographies were performed in 34 patients. Median age at time of first angiography was 1.03 (interquartile range (IQR) 0.4-1.4) years and systolic blood pressure at presentation 130 (IQR 130-150) mm Hg. Thirty-eight percent (13/34) of children were incidentally diagnosed and 18% (6/34) presented with heart failure. Twenty-six (76%) children had main renal artery stenosis and 17 (50%) mid-aortic syndrome. Seventeen (50%) children showed intrarenal, six (18%) mesenteric, and three (9%) cerebrovascular involvement. Twenty patients underwent 45 percutaneous transluminal angioplasty procedures and seven children surgeries. In 44% of the 16 patients who underwent only percutaneous transluminal angioplasty blood pressure was normalized, 38% had improvement on same or decreased treatment and 19% showed no improvement. Complications were seen in 7.5% (5/66) of angiographies. In four of the seven (57%) children who underwent surgery blood pressure was normalized, two had improved (29%) and one unchanged (14%) blood pressure.

CONCLUSION

In small children with renovascular hypertension below the age of 2 years, percutaneous transluminal angioplasty caused significant improvement in blood pressure with low complication profile. Surgery can be recommended where percutaneous transluminal angioplasty and medical treatments failed.

WHAT IS KNOWN

• Renovascular hypertension is diagnosed in all age groups from a few weeks of life until adulthood. • Both angioplasty and surgery are significantly more difficult to perform in small children and the published information on short and long-term outcome in these children is very scarce.

WHAT IS NEW

• Children below the age of two years can safely and successfully undergo selective renal angiography and also safely be treated with angioplasty. • We here present a large group of babies and infants where angioplasty and in some cases surgery effectively and safely improved their blood pressure.

Mid-term outcome of angioplasty for pediatric renovascular hypertension

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.

Diagnostic sensitivity and specificity of CT angiography for renal artery stenosis in children

BACKGROUND

Children with suspected renal artery stenosis (RAS) are screened with renal Doppler ultrasonography or computed tomography (CT) angiography/magnetic resonance (MR) angiography depending on institutional preference. CT angiography produces images with superior resolution, allowing higher quality multiplanar two-dimensional reformats and three-dimensional reconstructions. However, there is a paucity of data in the literature regarding the utility and diagnostic performance of renal CT angiography in pediatric RAS.

OBJECTIVE

The objective of this study is to retrospectively review our experience with renal CT angiography in the diagnosis of pediatric RAS relative to digital subtraction angiography (DSA) as the reference standard.

MATERIALS AND METHODS

All patients 0-18 years of age who underwent CT angiography for evaluation of RAS as a cause of hypertension between January 2012 and May 2019 were identified for the study. A total of 131 patients were identified, 23 of whom had DSA correlation.

RESULTS

Twenty-three patients (17 boys, 6 girls) with a mean age of 6 years 3 months (range: 3 months to 14 years 7 months) were included in this study. Of the 59 renal arteries studied by DSA, 22 were abnormal on CT angiography and 20 were abnormal on DSA. Of the 59 renal arteries, CT angiography was true positive in 18 and true negative in 35. The sensitivity and specificity of CT angiography for RAS diagnosis were 90.0% and 89.7%, respectively. CT angiography identified all cases of main RAS.

CONCLUSION

Renal CT angiography has a high sensitivity and specificity for pediatric RAS diagnosis in patients referred for DSA.

Renovascular hypertension in children

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

Surgical management of pediatric renin-mediated hypertension secondary to renal artery occlusive disease and abdominal aortic coarctation

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.

Optical coherence tomography in varying aetiologies of renal artery stenosis: a case series

Background

Renal artery stenosis (RAS) is a common cause of secondary hypertension. The most common aetiology is atherosclerosis; however, other causes like fibromuscular dysplasia (FMD) and Takayasu arteritis (TA) are also frequently encountered. The lesion characteristics and its response to percutaneous intervention depend upon the aetiology of RAS. Optical coherence tomography (OCT) is an excellent imaging modality to analyse coronary lesions during percutaneous coronary interventions. The data regarding the utility of OCT in renal artery imaging is limited, consisting of a few case reports.

Case summary

We hereby report four cases of RAS, each of different aetiology (atherosclerotic, FMD, post-transplant, and TA), who underwent OCT imaging of the renal artery along with percutaneous renal angioplasty.

Discussion

The advantages of OCT imaging include demonstration of the arterial wall, pathological features of the disease, and to guide percutaneous interventions. The major limitation of OCT is its lower imaging depth, which may render imaging of large vessels difficult.

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

Aims:

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

Materials and Methods:

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

Results:

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

Conclusion:

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

Renal autotransplantation for the management of renal artery in-stent restenosis in an adult patient with Takayasu arteritis

Renovascular hypertension is a common clinical presentation in Takayasu arteritis (TA), when the renal arteries are involved. Although most of the patients respond to optimal antihypertensive drug therapy, certain patients with TA require percutaneous or surgical renal artery revascularisation to manage renovascular hypertension. We, hereby, present a 45-year-old woman, who had resistant hypertension secondary to in-stent restenosis (ISR) of renal artery stent in a single functioning kidney. She had successful renal autotransplantation following a failed endovascular attempt to treat ISR. Endovascular and surgical interventions related to renal artery stenosis in TA are discussed in the article.

The management of pediatric renovascular hypertension: a single center experience and review of the literature

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.

Orthotopic renal autotransplantation for young-onset and medical treatment-requiring complex renovascular hypertension

OBJECTIVE

In this article, we aim to prove the safety and effectiveness of orthotopic renal autotransplantation using ex vivo repair for the treatment of complex renovascular hypertension (RVH).

METHODS

We retrospectively reviewed five consecutive patients (three women, two men) with young-onset RVH from January 2009 to August 2014. Orthotopic renal autotransplantation using ex vivo repair was performed and perioperative data were collected for statistical analysis.

RESULTS

The median age at diagnosis was 20 years (range, 11 to 27 years). Technique success was achieved in all the patients with no in-hospital or late deaths. During a median follow-up of 3.4 years (range, 1.5 to 6 years), the postoperative blood pressure was decreased compared with preoperative level (204 ± 8/133 ± 8 mm Hg vs 129 ± 3/78 ± 5 mm Hg; p < 0.0001). The postoperative anti-hypertensive medications number was reduced (3.4 ± 0.4 vs 0.2 ± 0.2; p < 0.0001). Early and late renal functions were both well preserved as measured by no changes in serum creatinine level ( p > 0.05). The primary patent rate was 100% (5/5) at one-year follow-up.

CONCLUSION

In our small series, orthotopic renal autotransplantation using ex vivo repair was safe and effective for the resolution of complex young-onset RVH.

Revascularization of Concurrent Renal and Cerebral Artery Stenosis in a 14-Year-Old Girl with Takayasu Arteritis and Moyamoya Syndrome

Concurrent involvement of bilateral renal and cerebral arteries, usually incurred as stenosis, is rare in childhood-onset Takayasu arteritis (c-TA). We report the case of a 14-year-old girl, with c-TA, presenting with transient ischemic attack after endovascular revascularization for renal artery stenosis and cerebrovascular stroke after surgical revascularization for cerebral artery stenosis associated with childhood-onset moyamoya syndrome. We deem that decrease of blood pressure by endovascular revascularization and improvement of cerebral perfusion by surgical revascularization may have jeopardized the cerebral deep watershed zone to cerebral ischemia followed by cerebral hyperperfusion syndrome and caused transient ischemic attack and cerebrovascular stroke in our patient. Revascularization could be a double-edge sword for c-TA patients presenting with concomitant renal artery stenosis and cerebral artery stenosis, and should be performed with caution. Quantitative analysis of cerebral blood flow by brain magnetic resonance imaging and angiography should be performed within 48 hours after surgical revascularization in c-TA.

Pediatric renovascular hypertension: Treatment outcome according to underlying disease

BACKGROUND

Renovascular hypertension (RVH) accounts for 5-10% of pediatric hypertension, and can be associated with underlying disease involving other organs. The purpose of this study was to evaluate the clinical characteristics and assess the treatment outcomes of Korean pediatric patients with RVH.

METHODS

The medical records of 25 Korean pediatric patients with RVH were retrospectively reviewed.

RESULTS

Twenty-four patients had underlying disease, and the most common cause was moyamoya disease (MMD; n = 10; 40%). Of 10 patients with MMD, seven had RVH prior to MMD. All patients required antihypertensive medication as the initial treatment and 22 patients subsequently underwent percutaneous transluminal angioplasty (PTA). The majority of patients with MMD had ostial lesions on angiography. Eight patients had favorable outcomes after the first PTA. One patient received nephrectomy, and two patients received bypass surgery because of restenosis after PTA and technical failure of PTA, respectively. During follow up, blood pressure was well-controlled in nine patients, but only four patients were able to discontinue medication. Eight patients had target-organ damage of the brain, heart, and retina at the time of initial diagnosis, and five patients developed chronic kidney disease during follow up.

CONCLUSION

The most common cause of RVH in Korean children is MMD, and RVH caused by MMD with an ostial lesion is associated with poor PTA outcomes. Angioplasty alone does not appear to control blood pressure effectively in MMD patients, and combined treatment is necessary to prevent target organ damage.

Outcomes of percutaneous transluminal angioplasty for pediatric renovascular hypertension

BACKGROUND

Up to 10% of hypertensive children will have renovascular disease. Where medical therapy fails to control the hypertension, endovascular techniques can improve renal perfusion. The purpose of this study was to assess the efficacy of angioplasty in controlling renovascular hypertension (RVH) in children.

METHODS

This is a single-center, retrospective review of patients who underwent angioplasty for RVH between 1992 and 2009. All patients were selected from the Interventional Radiology database. The primary outcome measure was clinical success as reflected by a favorable, sustained response in blood pressure for at least 1year following the angioplasty.

RESULTS

Two hundred sixteen patients underwent diagnostic angiography for suspected RVH, of these 28 required 42 angioplasties. Ten (36%) were cured, 9 (32%) were improved and 9 (32%) failed to respond to treatment. Major complications occurred in three patients and minor complications occurred in 18 angioplasties. Fibromuscular dysplasia (FMD) was the most common diagnosis in this series and was associated with a 79% success rate.

CONCLUSION

In our exclusively pediatric population angioplasty safely improved blood pressure control in 68% of patients, more than half of which are cured. FMD appeared to have the best clinical outcomes in our series.

Clinical, angiographic profile and percutaneous endovascular management of Takayasu's arteritis - A single centre experience

OBJECTIVE

Aim of the study was to evaluate clinical, angiographic profile and percutaneous endovascular management of Takayasu's arteritis.

BACKGROUND

Takayasu's arteritis is a chronic inflammatory vasculitis affecting the aorta and its major branches. Although it is more prevalent in Asia, the distribution of the disease is worldwide with different vascular involvement patterns and clinical manifestations.

METHODS

In this prospective study a total of 50 consecutive patients who were reported as having Takayasu's arteritis between January 2010 and April 2016 were evaluated. Detailed clinical presentation and angiograms of all patients were analysed.

RESULTS

50 patients were analysed during study period. Among 50 patients, 43(86%) were female and 7 (14%) were male. Average age of presentation was 26.92years. Most common clinical presentation was claudication (74%) followed by, musculoskeletal symptoms (48%), fatigue (46%), weight loss (22%), headache (22%), visual disturbances (16%), syncope (10%), dyspnoea (20%). Most common features were absent/diminished pulses (80%), difference in blood pressure (80%), followed by bruit (70%)hypertension (64%), cerebrovascular accident (8%),heart failure (8%) and aortic regurgitation (4%). According to the new angiographic classification, angiographic type I (40%) was encountered most frequently, followed by type III (30%), type V (16%), type IIb (8%), type IIa (2%), and type IV is (4%). Angioplasty was the main stay of treatment in 66% of the patients, remaining 34% of them were treated medically either with corticosteroids or methotrexate.

CONCLUSION

Takayasu's arteritis is a rare disease, affects mainly women, manifestations range from asymptomatic disease, found as a result of impalpable pulses or bruits, to catastrophic neurological impairment. Takayasu's arteritis is the common cause of renovascular hypertension. Angiography remains the gold standard for diagnosis. Angiographic evaluation and percutaneous transluminal angioplasty with stenting is useful in selected cases.

Takayasu's Arteritis: Current Status of Angioplasty and Stenting

Takayasu's arteritis is a chronic inflammatory disease characterized by stenotic occlusive lesions of the aorta and its major branches. The medical management of such lesions is far from satisfactory and surgical treatment is associated with high morbidity and mortality. Angioplasty with or without stenting has emerged as the treatment of choice for such lesions. Angioplasty and stenting of various vessels in Takayasu's arteritis are reviewed, highlighting the advantage of stents in reducing the rate of restenosis in chronically occluded or diffusely diseased vessels.

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

Renal artery obstruction is uncommon in the pediatric population and therefore represents a challenging diagnosis to ascertain and treat. While angioplasty and surgery have been used to treat it, stent implantation has been left mainly for adult use. In the following paper, we expose the case of an 8-year-old female who presented with severe arterial hypertension. Initially, the patient was evaluated and up to 5 antihypertensive medications were started. After complete evaluation, she was found to have severe right renal artery distal and proximal stenosis. She underwent recurrent angioplasties and then a bare metal stent (BMS) implantation, due to recurrence of stenosis. The original BMS developed a circumferential fracture, leading to a second stent implant, this time using a drug eluting stent (DES). She has been stable for 8 years since the last intervention, although using 2 antihypertensive medications. The use of BMS and DES may add another tool in the armamentarium of the pediatric interventionist to treat these children with recurrent stenosis that fail angioplasty.

Remedial operations for failed endovascular therapy of 32 renal artery stenoses in 24 children

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.

Differences between the pediatric and adult presentation of fibromuscular dysplasia: results from the US Registry

BACKGROUND

Fibromuscular dysplasia (FMD) is a non-inflammatory arteriopathy that causes significant morbidity in children.

METHODS

The clinical features, presenting symptoms, and vascular beds involved are reviewed in the first 33 patients aged <18 years who are enrolled in the United States Registry for FMD from five registry sites and compared with 999 adult patients from 12 registry sites.

RESULTS

Mean age at diagnosis was 8.4 ± 4.8 years (16 days to 17 years). Compared with adults, pediatric FMD occurs in more males (42.4 vs 6 %, p < 0.001). Children with FMD have a stronger previous history of hypertension (93.9 vs 69.9 %, p = 0.002). Hypertension (100 %), headache (55 %), and abdominal bruits (10.7 %) were the most common presenting signs and symptoms. FMD affects renal vasculature in almost all children (97 vs 69.7 %, p = 0.003). The extra-cranial carotid vessels are less commonly involved in children (23.1 vs 73.3 %, p < 0.001). The mesenteric arteries (38.9 vs 16.2 %, p = 0.02) and aorta (26.3 vs 2.4 %, p < 0.001) are more commonly involved in children.

CONCLUSIONS

In the United States Registry for FMD, pediatric FMD affects children from infancy throughout childhood. All children presented with hypertension and many presented with headache and abdominal bruits. In children, FMD most commonly affects the renal vasculature, but also frequently involves the mesenteric arteries and abdominal aorta; the carotid vessels are less frequently involved.

Management of the renovascular disease in children with Takayasu arteritis

Takaysu arteritis (TA), together with fibromuscular dysplasia, is the most common cause for renovascular hypertension. The diagnosis of vasculitis is important to make as these children benefit from immunosuppressive treatment. In many cases, however, it is more difficult than commonly realised to differentiate between these two diagnoses. Imaging which allows the inflamed arterial wall to be outlined, such as magnetic resonance or positron emission tomography scans, can be very helpful in this context. Revascularisation, either with angioplasty or surgery, seems to be effective and safe, also in children with TA. Patients with inactive disease have a more successful outcome and experience fewer complications from the intervention than those with active on-going inflammation.

Impact of revascularization on hypertension in children with Takayasu's arteritis-induced renal artery stenosis: a 21-year review

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.

Angioplasty for pediatric renovascular hypertension: a 13-year experience

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.

Angioplasty for renovascular hypertension in 78 children

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.

Optimal management of renal artery fibromuscular dysplasia

Fibromuscular dysplasia (FMD) is a nonatherosclerotic, noninflammatory angiopathy of unknown cause affecting medium-sized (most commonly renal) arteries and causing renovascular hypertension. The most common medial multifocal type of FMD (with the “string of beads” appearance) is more than four times more prevalent in females than in males. FMD accounts for up to 10% of cases of renovascular hypertension. Compared with patients with atherosclerotic renal artery stenosis, patients with FMD are younger, have fewer risk factors for atherosclerosis, and a lower occurrence of atherosclerosis in other vessels. The etiology is multifactorial, including vessel wall ischemia and smoking, as well as hormonal and genetic factors. Intra-arterial digital subtraction angiography is still the gold standard for exclusion or confirmation of renal artery stenosis caused by FMD, at least in young patients, who more often have lesions in branches of the renal artery. For FMD patients with atherosclerosis and those who are older (>50–55 years), significant renal artery stenosis may be confirmed or excluded with ultrasonography. The FMD lesion is typically truncal or distal, whereas atherosclerotic lesions are more often proximal or ostial. Treatment options are medical, endovascular (percutaneous transluminal renal angioplasty [PTRA]), and surgical. Invasive treatment should be considered when hypertension cannot be controlled with antihypertensive drugs and in patients with impaired renal function or ischemic nephropathy. PTRA has become the treatment of choice and normally yields good results, especially in unifocal disease and young patients. Pressure gradients are normally completely abolished, and there is no indication for stent placement. Surgical revascularization is indicated after PTRA complications; thrombosis, perforation, progressive dissection, repeated PTRA failure or restenosis. Centralization of handling is recommended.

Renal artery stenosis in children: therapeutic percutaneous balloon and stent angioplasty

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.

Emergency renal artery stenting in acute anuric renal failure in children with Takayasu's arteritis

We report on emergency percutaneous renal artery stenting in two children who developed acute anuria due to bilateral renal artery stenosis and near-total occlusion. In both children, urine output could be reestablished following the procedure. One patient died from persistent severe cardiac failure. Emergency stenting is feasible, and may buy time for future procedures.

Renovascular hypertension--is it fibromuscular dysplasia or Takayasu arteritis

Renovascular hypertension (RVH) can be caused by many different diseases, with the most common being fibromuscular dysplasia (FMD) and Takayasu arteritis (TA). A strikingly different diagnostic pattern is seen in children with RVH from different parts of the world. In Europe and North America, these children are mainly diagnosed as having FMD while in Asia and South Africa they will most often get a diagnosis of TA. When comparing the clinical diagnosis for FMD and TA, it becomes obvious that there is a great deal of overlap between the definitions of these two conditions. Different ways to come to the most accurate diagnosis using imaging of the blood vessel wall and positron emission tomography (PET) will be discussed. How an accurate diagnosis should influence the treatment of the children with these conditions will also be addressed.

Endovascular treatment of stenoses in a pediatric patient with incomplete aortic duplication, mesenteric ischemia, and renovascular hypertension

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.

Renal artery stenosis due to neurofibromatosis

A 4-year-old boy with hypertension due to renal artery stenosis and neurofibromatosis type 1 is presented for its rarity. Renal artery stenosis due to neurofibromatosis is underrecognized and may masquerade Takayasu’s arteritis in Asian children.

Renal artery stenosis: is angiography still the gold standard in 2011?

Renovascular hypertension (RVH) is an unusual cause of hypertension in children that is important to diagnose as it is potentially curable with angioplasty or surgery. Digital subtraction angiography is the gold standard for diagnosing RVH; for other methods like ultrasound, isotope studies, magnetic resonance angiography and computed tomography angiography sensitivity is still too low to reliably exclude RVH. Clinical and laboratory criteria that suggest RVH will be proposed and recommendations when digital subtraction angiography should be performed will be made. A treatment algorithm that suggests when to use medical treatment, interventional radiology and surgery in children with RVH will be given.

Renal autotransplantation for the treatment of renovascular hypertension in the pediatric population

PURPOSE

To evaluate the effectiveness of renal autotransplantation (RA) for the treatment of renovascular hypertension (RVH) in a selected group of children in whom medical care, a percutaneous transluminal angioplasty or vascular reconstruction failed or was technically impossible, in addition to the short-term and long-term morbidity.

MATERIALS AND METHODS

A retrospective case review of 13 pediatric patients with severe or complicated RVH who underwent RA between May 1993 and August 2008 was conducted. We defined blood pressure (BP) response as follows: Cured: normal BP values with no need of antihypertensive medication (AM); Improved: normal BP values with AM requirements; Failed: abnormal BP values despite treatment with AM.

RESULTS

16 RA were performed in 7 female and 6 male patients. Bilateral RA were performed in 2 females and in 1 male. The average age at consultation for hypertension was 8.5 years (range 4-12 years) and the time of transplantation was 9.12 years (range 6-13 years). Etiological diagnoses were: Takayasu disease (n = 5); renal artery fibrodysplasia (n = 3); mid-aortic syndrome (n = 3) and neurofibromatosis type I (n = 2). Results after RA were: Cured: 61.5%; Improved: 38.5%. No patient presented therapeutic failure during follow up time (median = 53.4 months). Only 1 case presented a postoperative complication.

CONCLUSIONS

RA is a procedure with no mortality and low morbidity rates that renders very satisfactory therapeutic results in the pediatric population.

Spectrum of renal findings in pediatric fibromuscular dysplasia and neurofibromatosis type 1

BACKGROUND

Fibromuscular dysplasia (FMD) and neurofibromatosis type 1 (NF1) are the most common causes of pediatric renal artery stenosis (RAS) in western countries, and characterization of their angiographic features could aid in an accurate diagnosis and in treatment.

OBJECTIVE

This study characterizes renal angiographic findings in pediatric fibromuscular dysplasia (FMD) and neurofibromatosis type 1(NF1).

MATERIALS AND METHODS

We reviewed 68 angiograms performed over 11 years on 43 children with renovascular hypertension (20 male, 23 females; ages 1 month to -19 years; median/average 9.8 years). Ten patients were diagnosed with NF1, and 33 had presumed FMD. The frequency, extent and distribution of lesions were determined and analyzed.

RESULTS

Stenosis was found in 91% of patients (n=39/43), with 86% showing stenosis of 1st or 2nd order arteries, and 12% distal to 2nd order. Stenoses in multiple 1st/2nd order arteries were found in 32% of patients, and 36/43 patients had 1-2 stenoses. The most common lesion was a ≤ 5 mm stenosis in a 1st/2nd order artery, in 42%. Mean percentage of stenosis in a 1st/2nd order vessel was 62%; ≥ 70% stenosis was found in 53%, and ≥ 90% stenosis in 29%. Bilateral disease was noted in 30% of patients. Intraparenchymal disease, distal to 2nd order branches, was seen in 30%. Aneurysms were seen in 28%, beading in 19% and collaterals in 51% (associated with ≥ 70% stenosis). Mid-aortic narrowing was seen in 16%, more often in patients with NF1.

CONCLUSION

We provide a descriptive characterization of renal angiographic findings in pediatric FMD and NF1.

Large vessel vasculitis

Takayasu arteritis is a chronic granulomatous disease of the aorta and its major branches that usually affects women during the second and third decades of life, but it has been reported in young children. This review details the clinical, pathological and radiological features, differential diagnoses and management of the condition, focusing chiefly on the disease in children. The recent definition of Takayasu arteritis is discussed. The condition should be considered in patients with unexplained arterial hypertension or unexplained inflammatory syndromes without signs of localization. Since the disease may be life-threatening and progressive, early recognition is necessary to initiate appropriate therapy. Patients with persistent ischaemic symptoms including hypertension might benefit from revascularization procedures.

Surgical treatment and long-term outcome of renovascular hypertension in children and adolescents

OBJECTIVES

This article describes the long-term outcome of surgical treatment in children with renovascular hypertension (RVH) over a 40-year period.

DESIGN

Retrospective study.

MATERIALS AND METHODS

Twenty-five consecutive patients, aged 5-21 years, underwent renal artery (RA) repair from 1967 to 1995. The disease consisted of fibromuscular dysplasia in 17 patients, Takayasu's arteritis in 7 and neurofibromatosis type 1 in one patient.

RESULTS

Twenty-nine RAs were repaired. Primary procedures included aortorenal bypass (ARB) with prosthesis in 10 RAs, autologous vein in five or internal iliac artery in four as conduits, direct reimplantation (DR) in four and nephrectomy in two RAs. Immediate graft failure occurred in three patients despite no peri-operative deaths. After a mean follow-up of 24.4 years, seven patients required secondary nephrectomy. Autologous ARB or DR showed better RA patency and fewer chances for secondary nephrectomy than prosthetic ARB. Hypertension was cured or improved in 21 patients. The overall cumulative survival rate at 20 years was 84%. All five deaths, observed a mean of 12.6 years after the initial operation, were attributed to cardiovascular events.

CONCLUSIONS

Surgical treatment, especially autologous ARB or DR, seems to provide durable results for paediatric RVH. Long-term observation and control of hypertension is mandatory.

Failure and success of percutaneous angioplasty in a hypertensive child with bilateral renal artery stenosis

We describe the clinical course of a 5-year-old girl with severe arterial hypertension that was uncontrollable with antihypertensive medication. Renal angiography revealed bilateral renal artery stenoses. Because percutaneous transluminal renal angioplasty (PTRA) failed to dilate the stenotic lesions, a renal artery bypass grafting in both renal arteries was performed. The patient remained normotensive for 7 months, and after that the arterial pressure increased again. Digital subtraction angiography demonstrated stenosis at the peripheral and central anastomosis of the vein graft that was used for revascularization of the left kidney. PTRA was decided on and successful patency was achieved. The patient has now been normotensive for a period of 5 years.

Renovascular hypertension in children

Renovascular disease is an uncommon but important cause of hypertension in children. It is usually diagnosed after a long delay because blood pressure is infrequently measured in children and high values are generally dismissed as inaccurate. Many children with renovascular disease have abnormalities of other blood vessels (aorta, cerebral, intestinal, or iliac). Individuals suspected of having the disorder can be investigated further with CT, MRI, or renal scintigraphy done before and after administration of an angiotensin-converting-enzyme inhibitor, but angiography is still the gold standard. Most children with renovascular disease will need interventional or surgical treatment. Endovascular treatment with or without stenting will cure or reduce high blood pressure in more than half of all affected children. Surgical intervention, if needed, should be delayed preferably until an age when the child is fully grown. Modern treatment provided by a multidisciplinary team of paediatric nephrologists, interventional radiologists, and vascular surgeons offers good long-term treatment results.

Management of systemic hypertension in children and adolescents: An update

Identification and treatment of hypertension should be an important focus of physicians caring for children. Ultimately, a link between hypertension in children and the risk of cardiovascular disease will be established. Further long-term studies are likely to show that morbidity and mortality will be decreased by the institution of treatment of hypertension in children. Additional risk factors such as obesity and lipid disorders should be sought and targeted for treatment as well. Lifestyle modifications are advised for all patients and can be tried solely for those with blood pressures between the 95th and 99th percentiles. Drug therapy is indicated in children with blood pressures greater than the 99th percentile, secondary hypertension, coexisting diabetes, left ventricular hypertrophy, or those who fail a trial of nonpharmacologic treatment. Children with white coat hypertension should not be treated with drugs. Children with renal artery stenosis and drug-refractory hypertension should be considered for percutaneous angioplasty or surgery depending on the anatomy of the lesion and operator experience. Children requiring multiple drug classes for control of blood pressure and older adolescents on one drug with renal artery lesions amenable to a percutaneous procedure may elect intervention in an attempt to reduce or eliminate drug therapy. Infants and children with hypertension due to native coarctation of the aorta should undergo surgical repair. Older children and adolescents with native coarctation should have surgical repair or percutaneous angioplasty/stenting. Hypertension secondary to recurrent coarctation is usually treated with a percutaneous intervention.

Renal Artery Intervention in Pediatric and Adolescent Patients: A 20-Year Experience

Between 1986 and 2005, 22 patients (mean age, 14.7 years; range, 3-21) with renal hypertension underwent renal artery revascularization for 28 lesions, 23 with open repair (OR) and 5 with percutaneous transluminal renal angioplasty (PTRA). Thirty-day morbidity was 17% (4/23). Hypertension was cured in 13 (57%), improved in 8 (38%), and unchanged in 1 (5%). Renal function worsened in 1. At a mean follow-up of 4.9 years, 1-year patency rate was 94% and maintained for 5 years. Hypertension at 1 year was cured in 6 of 14 patients (43%; OR, 4; PTRA, 2) and improved in 8 (57%; OR, 7; PTRA, 1); hypertension at 5 years was cured in 50% and improved in 50%. Renal function remained unchanged in all patients who were followed. The authors conclude that both OR and PTRA benefit pediatric patients. PTRA for selected patients may be promising as a first line treatment or as a bridge to definitive OR in children with small arteries.

Reno-vascular hypertension in childhood: a nationwide survey

Renovascular disease accounts for 8-10% of all cases of paediatric hypertension, whereas, in adults, its incidence is approximately 1%. The Turkish Paediatric Hypertension Group aimed to create the first registry database for childhood renovascular hypertension in Turkey. Twenty of the 28 paediatric nephrology centres in Turkey responded to the survey and reported 45 patients (27 girls, 18 boys) with renovascular hypertension between 1990 and 2005. The age at presentation ranged from 20 days to 17 years. The mean blood pressure at the diagnosis was 169/110 mmHg. Chief complaints of symptomatic patients were headache (38%), seizure (18%), epistaxis (4%), growth retardation (4%), cognitive dysfunction (4%), polyuria (2%), palpitation (2%), and hemiplegia (2%). Renovascular hypertension was found incidentally in 11 children. The diagnosis of renovascular hypertension was established with conventional angiography in 39 patients, MR angiography in three, CT angiography in two, and captopril diethylene triamine penta-acetic acid (DTPA) scintigraphy in one patient. Twenty-one children had bilateral renal artery stenosis and 24 had unilateral renal artery stenosis. Of these, 14 (31%) had fibromuscular dysplasia; 12 (27%) Takayasu's arteritis; six (13%) neurofibromatosis; two (5%) Williams syndrome; one (2%) Kawasaki disease; one (2%) mid-aortic syndrome; one (2%) extrinsic compression to the renal artery, and eight (18%) unspecified bilateral renal artery stenosis. Hypertension was controlled with antihypertensive drugs in 17 patients. Percutaneous transluminal angioplasty (PTRA) or surgery had to be performed in 28 patients: PTRA in 16 patients, PTRA + surgery in one patient and surgery in 11 patients (four nephrectomies). The importance of vasculitic disease, especially Takayasu's arteritis, should not be underestimated in children with renovascular hypertension.