Percutaneous transluminal angioplasty for renovascular hypertension in a neonate

AIM: To report on the first case of successful percutaneous transluminal renal artery angioplasty in a neonate. METHODS: Case report: a 5-d-old neonate was admitted with cardiorespiratory failure. Monitoring of blood pressure revealed severe arterial hypertension. Doppler sonography detected stenotic flow in the right renal artery. A (99m)Tc-MAG3 scan revealed highly diminished elimination by the right kidney. Selective renin levels were 23,968 ng/l in the right and 3770 ng/l in the left renal vein and the aorta. Percutaneous transluminal angioplasty using a 2 x 10 mm balloon catheter was performed on the 8th day of life. RESULTS: The patient was discharged from hospital normotensive without anti-hypertensive medication. During 8 mo follow-up the blood pressure remained normal, Doppler sonography revealed no recurrent artery stenosis, and renal function improved. CONCLUSION: Neonatal percutaneous transluminal angioplasty for renal artery stenosis may be feasible in selected patients.     

Successful percutaneous transluminal angioplasty for hepatic artery stenosis in an infant undergoing living-related liver transplantation

A 1-yr-old girl underwent a living-related liver transplant, with reconstruction of hepatic artery of 2 mm in diameter under microscopy. She developed intestinal perforation requiring closure on day 4 post-transplant and suffered from hepatic artery stenosis (HAS) on post-transplant day 9. Conservative therapies, such as intravenous or transluminal administration of anti-coagulants, vasodilators or fluids, were unsuccessful and caused remarkable general edema and multiple arrhythmias as a result of increased preload. On day 15 post-transplant, because flow velocity was remarkably reduced (as shown by Doppler ultrasound) the patient underwent percutaneous transluminal angioplasty (PTA) using a kit for coronary angioplasty. The balloon catheter was inflated [first: 1.5 mm diameter, 4 atmospheric pressure (a.p.) for 30 seconds (s); second: 2.0 mm diameter, 4 a.p. for 30 s; third: 2.5 mm diameter, 10 a.p. for 30 s]. The stenosis was successfully dilated without any complication. The patient has been doing well with normal liver functions for 4 months after PTA. From this experience, PTA can be performed for HAS after liver transplantation, even in an infantile case, with a careful technique and a special device.     

Moyamoya disease associated with bilateral renal artery stenosis

Recent research has suggested that an association exists between moyamoya disease and fibromuscular dysplasia which involves systemic vessels, including renal arteries. We report a 3 year old girl with moyamoya disease associated with bilateral renal artery stenosis. This case may support the common etiology of these two clinical conditions. To our knowledge this is the youngest case of moyamoya disease associated with bilateral renal artery stenosis.     

Diagnosis of renovascular hypertension by echo-Doppler velocimetry

A 13 year old boy suffering hypertension was examined for peripheral plasma renin, angiotensin-I, angiotensin-II and aldosterone. All data were within the normal range. The Captopril test and renal scintigraphy (both with and without Captopril) also showed normal patterns. Echo-Doppler velocimetry of the renal artery revealed that left renal arterial peak flow velocity was fast (3.4 m/s). The patient was therefore diagnosed with left renal arterial stenosis. Angiography demonstrated the duplex of the left renal artery and stenosis of the left lower renal artery. Percutaneous transluminal angioplasty was successfully performed.     

Transplant renal artery stenosis in a child with BK nephropathy

TRAS and BK nephropathy are known complications of RT, but the association between both has not been reported. A 2‐year‐old girl underwent a deceased donor renal transplant from a 20‐year‐old donor, along with bilateral native nephrectomies. She had a DGF due to a renal artery thrombus and required thrombectomy with re‐anastomosis. Heparin and aspirin were used. Immunosuppressive agents included thymoglobulin, steroid, tacrolimus, and MMF. CMV and EBV DNA PCRs were negative, but she developed BK viremia at 2 months with stable allograft function. Immunosuppression was reduced, and leflunomide was initiated. Blood pressures were well controlled on low‐dose amlodipine. Five months after RT, she presented with hypertensive emergency, following a respiratory infection, and required dialysis for oliguric acute kidney injury. Allograft biopsy showed evidence of BK nephropathy. Immunosuppression was further minimized. Doppler renal US and renal artery duplex studies were both suggestive of TRAS. Angiogram showed severe proximal anastomotic TRAS (>95% occlusion). PTA with stenting was done with immediate improvement in the blood flow and reduction in the pressure gradient. BPs and renal function normalized. Ten months post‐RT, she remains normotensive with stable renal function and resolution of BK viremia. Although ureteral stenosis and nephropathy are known to occur with BK infection, TRAS is an interesting association and possibly suggest the tropism of BK virus to the vascular endothelial cells. Timely recognition and management of both is important to prevent uncontrolled hypertension and allograft dysfunction.     

Non‐invasive renal artery embolization for renal dysplasia accompanied by hypertension

Renovascular hypertension caused by renal dysplasia often is resistant to drug therapy. For a 14‐year‐old girl with such refractory hypertension, a non‐invasive right renal ablation by embolization with anhydrous ethanol using a shepherd ‘s‐crook’ balloon catheter, was done. Blood pressure then rapidly normalized. Apart from mild fever after the procedure, no adverse effects occurred. In patients with mild renal artery stenosis and hypertension resistant to anti‐hypertensive drug therapy, renal artery embolization may be a useful option.     

彩色多普勒超声诊断儿童肾动脉狭窄的临床研究

目的　通过彩色多普勒超声观察高血压患儿肾动脉血流频谱形态及参数 ,对肾动脉狭窄进行初步筛查。方法　对 1999～ 2 0 0 3年首都儿科研究所附属儿童医院 75例高血压患儿、5 2名正常儿童应用远端法探测肾动脉血流频谱 ,记录肾动脉血流频谱形态、血流性质、收缩期最大流速、加速时间 ,对结果分组进行比较 ;11例高血压患儿做肾动脉造影 ,与超声结果进行对比。结果　 14例 (2 0个肾脏 )超声诊断肾动脉狭窄 ,其中 9例 (14个肾脏 )做肾动脉造影 ,结果均与超声诊断相符。肾动脉狭窄组收缩期最大流速、加速时间与肾实质性高血压组、原发性高血压组及正常对照组进行t检验 ,差异具有显著性 (P <0 0 1)。结论　彩色多普勒超声探测高血压患儿肾动脉血流频谱 ,对初步筛查肾动脉狭窄具有重要临床价值     

Percutaneous Transluminal Coronary Angioplasty for Coronary Arterial Stenosis in a 10-Year-Old Boy with Kawasaki Disease and a Brief Review

A 10-year-old boy developed coronary artery stenosis 9 years after suffering Kawasaki disease with coronary artery aneurysms at the age of 7 months old. Percutaneous transluminal coronary angioplasty was performed successfully to dilate the coronary arteries in order to prevent obstruction of the coronary arteries.     

Successful percutaneous transluminal angioplasty for treatment of renovascular hypertension in a 15-month-old child

In young children with renal artery stenosis the applicability of percutaneous transluminal angioplasty is limited by the small vessel size. We report our experience in a 15-month-old girl with severe hypertension, who underwent successful balloon dilatation of a tight renal artery stenosis caused by fibromuscular dysplasia. The procedure was performed using the guided co-axial balloon catheter technique with a 6 F right coronary Judkins catheter, a 0.014′′ guidewire and a 2 mm coronary artery balloon dilatation catheter. Antihypertensive medication was discontinued 6 weeks after the procedure. During a follow up period of 11 months, Doppler sonography revealed no evidence of recurrent renal artery stenosis. Conclusion Percutaneous transluminal angioplasty of renal artery stenosis can be performed safely in young children using equipment originally designed for treatment of coronary artery stenosis in adults. Received: 4 July 1997 / Accepted in revised form: 3 November 1997     

Three‐dimensional visualization of renal artery stenosis by 64‐channel multiple detector‐row computed tomographical angiography: review of two paediatric cases

Three‐dimensional visualization of renal arteries has recently been established by helical contrast‐enhanced multiple detector‐row computed tomographical angiography (MDCTA) in adults. So far, no information is available on its use in children. We reported two children with renal artery stenosis detected by 64‐channel MDCTA. The first patient probably had fibromuscular dysplasia and the other neurofibromatosis type1. The technique showed a left renal artery stenosis with a small left kidney in the first patient and a right renal artery stenosis in the second. Conclusion: MDCTA is an accurate and noninvasive imaging technique, easily performed in children, and can be used as an alternative diagnostic modality in children with suspected renovascular hypertension.     

Strategy for Localized Stenosis Caused by Kawasaki Disease: Midterm Results of Percutaneous Transluminal Coronary Balloon Angioplasty in Two Infants

We report the midterm results of percutaneous transluminal coronary balloon angioplasty (PCBA) for localized stenosis (LS) caused by Kawasaki disease (KD). Two 2-year-olds, a girl and a boy, underwent PCBA for severe LS of the left anterior descending artery caused by KD. After 4 years, there was no ischemia and no significant restenosis in the target vessels. PCBA provided a good result for early appearing LS caused by KD in two small infants. The 5-years-old boy was the youngest patient to undergo percutaneous transluminal coronary rotablator. Although the postprocedure result was very effective, 1 year later asymptomatic occlusion occurred.     

经皮介入治疗儿童肺动脉分支狭窄疗效观察

目的评估经皮介入治疗儿童肺动脉分支狭窄的安全性和有效性。方法回顾分析2012年1月至2017年12月确诊并接受经皮介入治疗的40例18岁以下肺动脉分支狭窄患儿的临床资料,并比较治疗前后的情况。结果 40例患儿中,男28例、女12例,中位年龄3.5岁(2.0～6.8岁)。6例行经皮球囊成形术,32例行经皮支架置入。无论支架置入还是球囊成形术后,患儿收缩压压差均明显下降,狭窄段的最小直径均明显增加,右心室收缩压均明显下降,差异有统计学意义(P0.05)。34例支架置入患儿中位随访时间22个月(范围1～60个月),没有动脉夹层、动脉瘤形成、支架断裂或移位的迹象;超声心动图测术后即刻跨支架压差为16.50(9.75～25.50)mmHg,随访时为23.5(16.8～34.0)mmHg,差异有统计学意义(Z=4.02,P0.001)。6例球囊成形患儿中位随访时间13个月(范围1～36个月);超声心动图测术后即刻狭窄处压差为33.0(15.5～45.5)mmHg,随访时为36.0(16.0～58.5)mmHg,差异无统计学意义(Z=1.83,P=0.068)。所有患儿均无严重不良事件。结论经皮支架置入术和球囊成形术治疗儿童肺动脉分支狭窄的疗效可靠,安全性高。     

Two cases of hyponatremic-hypertensive syndrome in childhood with renovascular hypertension

We report two children with renovascular hypertension and fibromuscular dysplasia. They initially presented with severe hyponatremia, hypokalemia, polyuria, and transient proteinuria. This combination of symptoms is known to occur in patients with renovascular and malignant hypertension, and is known as hyponatremic-hypertensive syndrome (HHS), although it is considered rare in children. Since in both of our patients, the renal arterial stenosis was very severely or almost totally occlusive, we could not perform percutaneous transluminal renal artery angioplasty, and therefore nephrectomy was the only option. A histological study showed partial or complete occlusion with intimal hyperplasia and medial fibroplasia of intrarenal arteries such as the interlobular arteries. Conclusion: Both patients showed rapidly progressive renovascular hypertension and loss of function of the affected kidney. In order to preserve renal function in such cases, early invasive intervention appears to be necessary.     

Guidelines for catheter intervention in coronary artery lesion in Kawasaki disease

The Research Committee of Ministry of Health, Labour and Welfare 'Study of treatment and long-term management in Kawasaki disease' reported the guidelines for catheter intervention in coronary artery lesion in Kawasaki disease in this paper. The contents include: (i) background and natural history of coronary artery lesion in Kawasaki disease; (ii) indication of catheter intervention; (iii) types of procedure, and their indication and care; (iv) institute and backup system; (v) the management after procedure, evaluation and follow up; and (vi) prospects, especially in relation to bypass surgery.     

Use of the internal jugular vein approach in balloon dilatation angioplasty of pulmonary artery stenosis in children

Generally, the approach used for balloon dilatation angioplasty for pulmonary artery stenosis in children is from the femoral vein. However, sometimes an alternative approach must be used because of femoral vein occlusion or some other reason. As reports have been limited about the results achieved using the internal jugular vein approach in pediatric interventional catheterization, we report on the internal jugular vein approach in balloon dilatation angioplasty of the pulmonary artery for pediatric patients and discuss the advantages of this approach. From 1991 through 1993 15 balloon dilatation angioplasties of the pulmonary artery using the internal jugular vein approach were performed in 14 pediatric patients, ranging in age from 4 months to 13 years. Based on this experience, we have evaluated this method from several viewpoints including the technique and possible complications. All procedures were performed without complications in all patients; and by inserting a 7 sheath it was even possible to perform balloon dilatation in a 4-month-old infant. A sheath as large as 9 F could be inserted in other patients, and the double-balloon method was used in seven patients. The Seldinger method was also available when the balloon catheter was too large to use with a sheath. For pediatric interventional cardiac catheterization, it was found that the internal jugular vein approach is relatively safe and reliable. Furthermore, catheterization of the pulmonary artery was easier with the internal jugular vein approach than with the femoral vein approach.     

Extracorporeal cardiopulmonary resuscitation for breath‐holding spells followed by cardiac arrest due to left main coronary artery stenosis

Non‐syndromic congenital supravalvular aortic stenosis (SVAS) leads to ventricular hypertrophy and increased oxygen consumption, and when combined with other factors reduces coronary blood flow, potentially resulting in myocardial ischemia and sudden cardiac death. While the anatomic obstruction of coronary circulation is as common in non‐syndromic SVAS as in Williams syndrome, it often remains unacknowledged. Extracorporeal membrane oxygenation (ECMO) is an elective procedure that can be used to support patients with cardiac arrest during diagnosis as a way to reduce cardiopulmonary load in preparation for surgery or further treatment. In this report, we describe the rare case of an infant with severe SVAS and mild valvular pulmonary and left main coronary artery stenosis, as well as breath‐holding spells. After multiple cardiac arrests, the infant underwent diagnostic catheter angiography on ECMO and had the pathology surgically corrected.     

Practice recommendations for the monitoring of renal function in pediatric non‐renal organ transplant recipients

The management of non‐renal pediatric solid organ transplant recipients has become complex over the last decade with innovations in immunosuppression and surgical techniques. Post‐transplantation follow‐up is essential to ensure that children have functioning allografts for as long as possible. CKD is highly prevalent in these patients, often under recognized, and has a profound impact on patient survival. These practice recommendations focus on the early detection and management of hypertension, proteinuria, and renal dysfunction in non‐renal pediatric solid organ transplant recipients. We present seven practice recommendations. Renal function should be monitored regularly in organ transplant recipients, utilizing assessment of serum creatinine and cystatin C. GFR should be calculated using the new Schwartz formula. Transplant physicians should also monitor blood pressure using automated oscillometric devices and confirm repeated abnormal measures with manual blood pressure readings and ambulatory 24‐h blood pressure monitoring. Proteinuria and microalbuminuria should also be assessed regularly. Referrals to a pediatric nephrologist should be made for non‐renal organ transplant recipients with repeated blood pressures >95th percentile using the Fourth Task Force reference intervals, microalbumin/creatinine ratio >32.5 mg/g (3.7 mg/mmol) creatinine on repeated testing and/or GFR <90 mL/min/1.73 m².     

Outcomes of two‐drug maintenance immunosuppression for pediatric renal transplantation: 10‐yr follow‐up in a single center

Minimizing IS to reduce side effects without compromising long‐term renal transplant survival is the goal of all IS protocols. We conducted a retrospective study of pediatric renal transplants performed August 1988 to July 2008 and treated with two‐drug maintenance therapy by one of three protocols: prednisone/cyclosporine without induction (SB) or with daclizumab induction (SBI), or tacrolimus/mycophenolate with daclizumab induction (SF). Kaplan–Meier survival curves were used to determine graft and patient survival at one, three, five, and 10 yr. Associations between graft survival and patient/transplant characteristics were determined using log‐rank test and CPH model adjusting for treatment group. About 208 patients were included in the analysis (96 SB, 97 SBI, 15 SF; 148 DD, 60 LD, 37 pre‐emptive). Overall graft and patient survival at one, three, five, and 10 yr were similar to the previously published results of pediatric renal transplants in similar years treated predominantly with three‐drug maintenance therapy ( https://web.emmes.com/study/ped/annlrept/2010 ). Only biopsy‐proven TG was significantly associated with worse graft survival (HR 11.5, 95% CI: 3.4, 38.7). Malignancy rate was low (2.4%) with little PTLD (0.5%). Few opportunistic or other infections occurred (<5% patients). Minimizing IS to a two‐drug maintenance regimen had no adverse effect on long‐term transplant outcome and had low malignancy and infection rates.     

Percutaneous Transluminal Angioplasty for Stenosis of the Aorta Due to Aortic Arteritis in Children

Percutaneous transluminal balloon angioplasty for stenosis of the aorta due to aortic arteritis was attempted on 45 lesions in 41 children (age range, 4–14 years; mean, 9.9±4.2 years) presenting with symptoms of hypertension, severe congestive heart failure, and lower limb claudication. Balloon dilatation was technically successful in 38 (92.7%) patients for 41 stenotic lesions (91.1%). The mean peak systolic pressure gradient (PSG) decreased from 71.7 ± 23.9 mmHg to 23.2 ± 17.5 mmHg (p < 0.001) and the diameter of the stenosed segment increased from 3.3 ± 1.1 mm to 7.5 ± 2.2 mm (p < 0.001) immediately after angioplasty. Patients with short-segment (<3 cm) stenosis had a lower residual gradient (17.9 ± 11.1 mmHg vs 30.5 ± 22.6 mmHg; p < 0.05) and a wider diameter of the aorta (8.8 ± 1.1 mm vs 7.5 ± 2.2 mm; p < 0.02) compared to patients with long-segment (≥3 cm) stenosis. Four patients required stent implantation; 2 for flow-limiting dissection, 1 for failure to reduce PSG by >50%, and 1 for recurrent restenosis. There was marked hemodynamic and angiographic improvement in these 4 patients. Hemodynamic and angiographic restudy in 21 of the 41 patients at mean follow-up period of 6.2 ± 4.2 months (range, 3–24 months) showed restenosis in 4 (19%) patients. Restenosis was more common in patients with long-segment stenosis than those with short-segment stenosis (30% vs 9.1%). Late restudy in 8 patients, done at 3–7 years after first restudy, showed no recurrence of aortic narrowing. On clinical follow-up of 38 patients for a mean of 58.8 ± 36.0 months (range, 8–146 months) there was marked improvement in symptoms. Hypertension was cured in 11 (29%), improved in 24 (63%), and persisted in 3 (8%). Six patients with associated severe renal artery stenosis showed further improvement in hypertension after successful renal angioplasty. Severe congestive heart failure improved in 21 (95.4%) of 22 patients. Mean left ventricular ejection fraction improved from 0.32 ± 0.08 to 0.48 ± 0.10 (p < 0.001) at a mean follow-up of 28.7 ± 8.4 months in these patients. Hemodynamic restudy in 10 of these patients showed improvements in left ventricular end-diastolic pressure from a mean 37 ± 9 mmHg (range, 25–55 mmHg) to 16.4 ± 6.2 mmHg (range, 6–25 mmHg) (p < 0.001). Lower limb claudication improved in all 4 patients. Our results suggest that percutaneous transluminal balloon angioplasty in children is safe and highly effective in relieving stenosis of the aorta due to aortic arteritis, with marked clinical improvement, and should be the treatment of choice particularly for discrete stenosis.