Fibromuscular dysplasia of the renal artery: Management and outcome

SUMMARY: Renovascular hypertension may be caused by atherosclerotic disease or less commonly by fibromuscular dysplasia (FMD) of the renal arteries. Fibromuscular dysplasia is the commonest cause of renal artery stenosis in the younger age group and affects women predominantly. A review of our clinical database identified all patients with renovascular hypertension. All relevant clinical, biochemical and radiological findings on those with FMD were noted. the outcome of percutaneous transluminal renal angioplasty (PTRA) or reconstructive surgery was evaluated. Eight out of 62 (13%) patients with hypertension secondary to renovascular disease had FMD (all female; bilateral in four; mean age at diagnosis 37.6 years; age range 12–70 years). the mean duration of hypertension before the diagnosis of FMD was 3.3 years (range 3 months-10 years). A renal artery bruit was detected in five, hypertensive retinopathy in three and one had mild renal insufficiency. Twelve PTRAs were attempted on 10 stenotic lesions in six women. This cured the hypertension in three, while the other three have required less antihypertensive therapy. Percutaneous transluminal renal angioplasty was complicated by a trivial renal artery dissection in one, and a small upper pole infarction in another. One patient required a repeat PTRA. the other two women presented before the availability of PTRA and had successful reconstructive surgery. Fibromuscular dysplasia was the cause of hypertension in eight out of 62 (13%) patients with renovascular hypertension. Percutaneous transluminal renal angioplasty has shown encouraging results with a low complication rate. If technically feasible, PTRA should be attempted on all patients with FMD of the renal artery.     

Fibromuscular dysplasia of the renal artery: Management and outcome

Renovascular hypertension may be caused by atherosclerotic disease or less commonly by fibromuscular dysplasia (FMD) of the renal arteries. Fibromuscular dysplasia is the commonest cause of renal artery stenosis in the younger age group and affects women predominantly. A review of our clinical database identified all patients with renovascular hypertension. All relevant clinical, biochemical and radiological findings on those with FMD were noted. The outcome of percutaneous transluminal renal angioplasty (PTRA) or reconstructive surgery was evaluated. Eight out of 62 (13%) patients with hypertension secondary to renovascular disease had FMD (all female; bilateral in four; mean age at diagnosis 37.6 years; age range 12–70 years). The mean duration of hypertension before the diagnosis of FMD was 3.3 years (range 3 months–10 years). A renal artery bruit was detected in five, hypertensive retinopathy in three and one had mild renal insufficiency. Twelve PTRAs were attempted on 10 stenotic lesions in six women. This cured the hypertension in three, while the other three have required less antihypertensive therapy. Percutaneous transluminal renal angioplasty was complicated by a trivial renal artery dissection in one, and a small upper pole infarction in another. One patient required a repeat PTRA. The other two women presented before the availability of PTRA and had successful reconstructive surgery. Fibromuscular dysplasia was the cause of hypertension in eight out of 62 (13%) patients with renovascular hypertension. Percutaneous transluminal renal angioplasty has shown encouraging results with a low complication rate. If technically feasible, PTRA should be attempted on all patients with FMD of the renal artery.     

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.     

Should percutaneous transluminal renal artery angioplasty be applied to ostial renal artery atherosclerosis?

Purpose: The purpose of this study was to review the results of percutaneous transluminal renal artery angioplasty (PTRA) in patients with atherosclerosis to assess safety, anatomic and functional outcome, and differences in outcome between ostial and nonostial lesions.Methods: We used retrospective review of 52 consecutive patients who had undergone attempted PTRA for renal artery atherosclerosis during the calendar years 1987 to 1992.Results: Fifty-two patients had 60 renal arteries on whom PTRA was attempted. The mean age was 68 years. Atherosclerosis was generalized in 81% of the patients. The indication for angioplasty was salvage of functioning renal parenchyma in 81% of patients. Eight patients were undergoing dialysis at the time of attempted PTRA. Five arteries (8%) could not be dilated. There were one cardiac death and two arterial complications requiring surgery within 30 days. Thirty-five percent of patients with available angiograms had an anatomic improvement above a threshold of one stenotic group (30% to 40% diameter improvement), with residual stenosis of less than 50%. Half of patients treated for hypertension had improvement in their hypertension. Overall, there was no change in creatinine levels before and after the procedure. Four of eight patients undergoing dialysis at the time of PTRA were able to discontinue dialysis during follow-up. Four patients (11%) required surgical bypass and five patients (14%) required chronic dialysis during follow-up.Conclusions: Modest success at low risk can be expected from PTRA in a group of patients with severe atherosclerosis. No significant difference in results between ostial and nonostial lesions was noted. (J VASC SURG 1995;21:909-15.)     

Percutaneous Therapy for Renal Artery Fibromuscular Dysplasia

Fibromuscular dysplasia (FMD) accounts for 10% of cases of renal artery stenosis. This study evaluates the anatomic and functional outcomes of endovascular therapy for symptomatic renal artery FMD at an academic medical center. A retrospective analysis of records from patients who underwent percutaneous transluminal renal artery angioplasty (PTRA) found 14 patients (all female) who underwent 19 interventions on 18 renal artery segments. Significant cardiovascular comorbidities were few in this patient population. The PTRA technical success rate was 95%. There were no periprocedural mortalities. Primary patency rates were 81%, 69%, 69%, and 69% at 2, 4, 6, and 8 years. Assisted primary patency rates were 87%, 87%, 87%, and 87% at 2, 4, 6, and 8 years. The restenosis rate was 25% at 8 years. Clinical benefit (improved or cured hypertension) was seen in 79% of patients overall; 65% of patients maintained this benefit at 8 years by life-table analysis. Percutaneous endovascular intervention for clinically symptomatic FMD of the renal arteries is technically successful, safe, and durable. Most patients demonstrate immediate clinical benefit and retain durable functional outcomes. Presented at the Thirteenth Annual Winter Meeting of the Peripheral Vascular Surgery Society, Snowmass, CO, January 31-February 2, 2003.     

Surgical and radiological management of renovascular hypertension in a developing country

PURPOSE: We determined the long-term outcome of radiological and surgical intervention in young patients with renovascular hypertension. MATERIALS AND METHODS: Between 1989 and 2001, 85 patients with a mean age +/- SD of 21 +/- 10.3 years, including 59 with Takayasu's arteritis (TA) and 26 with fibromuscular dysplasia (FMD), underwent radiological (percutaneous transluminal angioplasty) or surgical treatment for renovascular hypertension due to renal artery stenosis. The technical success, complications and clinical response of each treatment were compared. RESULTS: Of the patients 29 with TA and 20 with FMD underwent a total of 56 balloon angioplasties. Technical success was achieved in 94.58 renal units with a clinical response in 41 patients (83.9%). However, the re-stenosis rate was 24.13% in TA and 10% in FMD cases. A total of 41 surgical procedures were performed in the 28 and 7 patients with TA and FMD, respectively, including aortorenal bypass with vein in 12, and with a polytetrafluoroethylene graft in 4, lienorenal bypass in 4, iliorenal bypass in 2, gastroduodenal bypass in 1, autotransplantation in 1, nephrectomy in 14 and partial nephrectomy in 2. The clinical response rate to renal revascularization procedures was 94.4%, whereas it was only 50.0% for nephrectomy/partial nephrectomy during a median followup of 42 months (range 9 to 96). CONCLUSIONS: Percutaneous transluminal angioplasty and renal revascularization provide comparable long-term results in the management of renal artery stenosis due to TA and FMD. Although it is technically complex, surgery for TA is safe and effective. However, the rate of re-stenosis following angioplasty for TA is higher compared with FMD.     

Surgery after failed percutaneous renal artery angioplasty.

PURPOSE: This retrospective review describes the surgical management of 51 patients after failed percutaneous renal artery angioplasty (F-PTRA). METHODS: From January 1987 through June 1998, 51 consecutive patients underwent surgical repair of either atherosclerotic (32 patients) or fibromuscular dysplastic (FMD; 19 patients) renovascular vascular disease after F-PTRA. These patients form the basis of this report. Surgical repair was performed for hypertension (29 patients with atherosclerosis: mean blood pressure, 205 +/- 34/110 +/- 23 mm Hg; 18 patients with FMD: mean blood pressure, 194 +/- 24/118 +/- 18 mm Hg) or ischemic nephropathy (20 patients with atherosclerosis: mean serum creatinine level, 2.0 +/- 0.8 mg/dL; three patients with FMD: mean serum creatinine level, 2.0 +/- 1.1 mg/dL). Emergency operation was required in four patients for acute renal artery thrombosis (one patient with atherosclerosis, one patient with FMD), renal artery rupture (one patient with atherosclerosis), or infected pseudoaneurysm (one patient with atherosclerosis). Operative management, blood pressure and renal function response to operation, and dialysis-free survival rate were examined and compared with 487 patients (441 patients with atherosclerosis, 46 patients with FMD) treated by operation alone. RESULTS: Among the patients with atherosclerotic renovascular disease, there were three postoperative deaths (9.4%) after repair for F-PTRA. Secondary operative repair was associated with emergent repair or nephrectomy in 16% of cases, while more extensive renal artery exposure and more complex operative management was required in 50% of patients with atherosclerosis and 65% of patients with FMD repaired electively. Among the 28 operative survivors with hypertension and atherosclerotic renovascular disease, blood pressure benefit after F-PTRA was significantly lower when compared with patients with atherosclerosis who underwent treatment with operation only (57% vs 89%; P <.001). However, blood pressure benefit in the 19 patients with FMD did not differ (89% vs 96%). Among the 28 patients with atherosclerosis, preoperative estimated glomerular filtration rate (EGFR) as compared with postoperative EGFR was significantly increased (47.4 +/- 4.2 mL/min/1.73m(2) vs 56. 6 +/- 5.1 mL/min/1.73m(2); P =.002). However, EGFR prior to PTRA was not significantly different from postoperative EGFR (51.6 +/- 3.4 mL/min/1.73m(2) vs 56.6 +/- 4.9 mL/min/1.73m(2); P =.121). As compared with patients with atherosclerosis who underwent treatment with operation alone, there was no difference in the dialysis-free survival rate. CONCLUSION: Operative repair after F-PTRA was altered in 59% of the patients with atherosclerosis and in 68% of patients with FMD. Blood pressure benefit for patients with FMD was unchanged after F-PTRA. However, the blood pressure benefit was significantly decreased among patients with atherosclerosis. Decreased EGFR after F-PTRA was recovered with operative renal artery repair. However, postoperative EGFR as compared with EGFR prior to PTRA was unchanged. Blood pressure and renal function response after F-PTRA for atherosclerotic renovascular disease warrants further study.     

Interventional radiology in the treatment of renal artery stenosis.

Percutaneous transluminal renal angioplasty (PTRA) alone or in combination with stent implantation, is increasingly used as an alternative technique to surgical revascularization for treatment of renal artery stenosis (RAS) wich may cause hypertension or jeopardize renal function. Herein we report the results obtained with 305 PTRAs performed in 242 hypertensive patients, 144 of whom had atherosclerotic RAS, 69 fibromuscolar dysplasia, 15 Ras in transplanted kidneys, 6 restenosis in surgically revascularized kidneys, 4 Takayasu arteritis and 4 neurofibromatosis. Stents were implanted in 68 cases, mostly in atherosclerotic stenoses. The technical success was achieved in 261 arteries (85.6%), with 33 failures (10.8%) and 11 (3.6%) procedures not completed for anatomical reasons. PTRA related complications were observed in 23 cases (7.5%), but no fatalities occurred. An overall benefit on blood pressure control was observed in 41% of patients with atherosclerotic RAS and in 68% of those with fibromuscolar dysplasia. It appears that independently from the ethiology PTRA is technically effective in correcting RAS; yet the position of PTRA with respect to that of medical or surgical treatment needs to be better delineated through randomized, controlled studies aimed at comparing the clinical efficacies of these different approaches.     

经皮腔内血管成形术及支架治疗儿童和青少年肾动脉狭窄短期及长期疗效

目的 评估经皮经腔内血管成形术(PTA)及支架治疗儿童和青少年肾动脉狭窄的短期及长期疗效.方法 分析34例接受PTA及支架治疗的儿童和青少年肾动脉狭窄患者,并分为肌纤维发育不良(FMD,n=17)和大动脉炎(TA,n=17)两组,术后短期(围手术期< 30天)、3、6、12个月进行随访,之后每隔1年随访.记录介入治疗前及随访期血压,采用限定每日剂量(DDD)比较介入治疗前后药物剂量变化,比较介入治疗前后血肌酐水平,并比较两组的疗效.结果 34例患者(40支病变肾动脉)接受PTA,手术成功率为90.00%(36/40).随访中位时间30.0个月.随访期间血压较术前明显下降(P <0.001).患者术后短期DDD较术前无明显变化(P >0.05);但术后3个月、1年、3年、5年较术前差异有统计学意义(P <0.05).随访期间平均血肌酐较术前无明显变化(P >0.05).患者术后1年、3年、5年总体获益率(治愈+改善)分别为89.54%、66.89%、61.53%.随访期间FMD组的总体治愈率高于TA组.结论 采用PTA及支架治疗儿童和青少年RAS安全可靠,且短期及长期临床获益良好.PTA治疗对于FMD患者获益程度大于TA患者.     

Treatment of renal artery fibromuscular dysplasia with balloon angioplasty: a prospective follow-up study.

OBJECTIVES: to assess restenosis rates and blood pressure response after percutaneous transluminal renal angioplasty (PTRA) in patients treated for fibromuscular dysplastic renal artery stenosis. METHODS: a prospective 12-month follow-up study of 27 patients with 31 treated renal artery stenosis. Follow-up assessment included colour-coded duplex sonography (CCD) of renal arteries, monitoring of blood pressure, antihypertensive medication, and creatinine measurements before discharge and at 3, 6, and 12 months. Primary end point was defined as a haemodynamically significant restenosis >60% assessed by CCD. RESULTS: there was a cumulative 23% restenosis rate at 12 months. Arterial hypertension was cured or improved in 93% of patients immediately after the intervention and remained cured/improved in 74% of patients at 12 months of follow-up. Renal failure present in five patients before PTRA stabilised or improved in all patients. CONCLUSION: although restenosis rate after PTRA in fibromuscular dysplasia is as high as in non-ostial atherosclerotic lesions, there remains a considerable higher therapeutic effect. Profound pressure response and recurrent arterial hypertension with restenosis support the high probability of a renovascular origin of arterial hypertension in this young and otherwise healthy population compared to patients with atherosclerotic renal artery lesions.     

Surgical Management of Renal Fibromuscular Dysplasia: Challenges in the Endovascular Era

Percutaneous transluminal renal angioplasty (PTRA) is the primary treatment for renal fibromuscular dysplasia (RFMD). Surgical revascularization is limited to patients who fail or are unsuitable for PTRA. All patients who were operated on with RFMD since the indications for renal PTRA were expanded in our institution were retrospectively reviewed. Outcome included patency, hypertension, and renal function. Twenty-six patients had reconstruction of 32 renal arteries between 1998 and 2004. The mean age was 47.1±14 years; the majority (81%) were female. Six patients had bilateral disease and three had a solitary kidney. Operations were done for hypertension in 25 patients, renal artery aneurysm in 8, and chronic dissection in 1, alone or in combination. Six patients had a failed PTRA and 20 were unsuitable for it. Aortorenal bypass was done most often (n=28) and saphenous vein was the preferred conduit (n=25). The distal anastomosis was to the main renal artery in 13 patients and to the branch arteries in 19. Ex vivo repair was needed in five patients. Five intraoperative revisions were done because of abnormalities on duplex scan. One patient died unexpectedly 42 days after operation from myocardial infarction. Extrarenal complications occurred in five patients. Median follow-up was 2.4 (range, 42 days to 6.3) years and was available in all but one patient (96%). Two bypasses occluded at 3 and 376 days, which resulted in loss of the kidneys. One graft stenosis was treated successfully with PTRA at 239 days. All failures occurred in men. One-year cumulative primary patency was 89±8% and was not adversely affected by prior PTRA or complex repair. Hypertension at 1 year was cured in 27% of the patients and improved in 60%. No patient developed acute or chronic renal failure. Surgical reconstruction for RFMD has excellent short-term patency. Failed PTRA or complex reconstructions did not adversely affect outcome.Presented at the Twenty-ninth Annual Meeting of the Peripheral Vascular Surgery Society, Anaheim, CA, June 4-5, 2004.     

Percutaneous transluminal renal angioplasty

Summary Percutaneous transluminal renal angioplasty (PTRA) is a simple, efficient procedure with a low risk/benefit ratio when carried out by experienced interventional radiologists. The role of radiology in the diagnosis and treatment of renovascular hypertension (RVH) is discussed, with special attention to technique. PTRA and surgical results are dependent on the etiology and location of renal artery stenosis (RAS). At New York Hospital-Cornell Medical Center, PTRA is the procedure of choice in fibromuscular dysplasia (FMD), unilateral non-ostial atheroma, arteritis, renal transplantation, and pediatrics. The choice between surgery and PTRA in patients with bilateral and ostial atherosclerotic disease and/or azotemia depends on the surgical risk category of the patient. At our institution, coronary and cerebrovascular disease do not preclude PTRA.     

Long-term results after percutaneous transluminal angioplasty of atherosclerotic renal artery stenosis--the importance of intensive follow-up.

The aim of this study was to investigate the long-term results of percutaneous transluminal angioplasty of atherosclerotic renal artery stenosis (PTRA) in patients with renovascular hypertension with or without impending renal insufficiency who were followed up intensively with aggressive reintervention. Diagnostic work-up was based on angiography, pressure gradient and renal venous renin measurement. Patients were scheduled for regular follow-up after the PTRA and a deterioration in blood pressure or renal function was an indication for re-evaluation, and reintervention if necessary. Sixty-five patients had 71 renal artery stenoses where PTRA was attempted. It was technically successful in 59 stenoses and two occlusions and failed in ten (14%). At the end of follow-up (median 56 months [2-99]), the primary patency rate was 55%, 27 had restenosed and four were occluded, all but two within 12 months. Seventeen were treated by a further PTRA and eight by surgical reconstruction. At the end of follow-up the secondary patency after all interventions was 90%. One patient died 1 month after PTRA, and at the end of follow-up 21 patients (32%) had died, most of them (80%) from cardiovascular disease. Multivariate analyses showed a significantly reduced survival rate in patients with multiocular atherosclerosis, renal insufficiency, contralateral renal artery stenosis and ischaemic heart disease. At the end of follow-up 90% of the patients were cured or improved with regard to blood pressure. In patients with impending renal insufficiency renal function was improved in 50% and unchanged in 39%. With this strategy 55% of the patients needed only one treatment with PTRA, 25% needed a re-PTRA and 20% had to be operated on. PTRA can be recommended as initial treatment of atherosclerotic renal artery stenosis provided intensive follow-up and aggressive reintervention are performed when indicated.     

Preservation of renal function by percutaneous transluminal angioplasty in ischaemic renal disease.

BACKGROUND: The purpose of this study was to evaluate the effects of percutaneous transluminal renal angioplasty (PTRA) on preservation of renal function in patients with bilateral renal artery stenoses or stenosis of the artery of one functioning kidney. METHODS: A total of 227 PTRAs of 223 stenoses in 135 patients were performed from 1982 to 1993 in a single centre and retrospectively reviewed. The number of PTRAs per patient was 1.7, range 1-6. Angiographical follow-up was performed in 77%, 120+/-82 days after the first PTRA and 273+/-345 days after the last PTRA. Follow-up of serum creatinine and blood pressure was performed in 85% after 414+/-558 days. Long-term follow-up was performed for dialysis, surgical revascularization, renal transplantation and death, mean follow-up 8.8 years, range 5.5-14.8. RESULTS: The immediate technical success was 90%, and another 5% were improved. The primary patency rate per patient was 43% and the secondary patency rate 64%. Improved renal function was achieved in 23% of the patients, stabilized in 56% and failed in 21%. Stabilized or improved function was higher when baseline serum creatinine was < or =250 micromol/l (85%) than >250 micromol/l (60%). Three of 99 (3%) patients with creatinine < or =250 micromol/l started dialysis during follow-up (41 days, 7.4 and 8 years), as did 13 of 36 (36%) patients with creatinine >250 micromol/l. Blood pressure and the number of antihypertensive drugs decreased in patients with creatinine < or =250 micromol/l, but was unchanged in those with creatinine >250 micromol/l. The 5-year survival rates were 84, 66 and 17% for patients with creatinine <125 micromol/l, 125-250 micromol/l and >250 micromol/l, respectively. Twelve patients (9%) experienced complications, including two deaths. CONCLUSIONS: Our study shows that PTRA improved or preserved the renal function in most patients with normal to moderately impaired renal function. Close follow-up and possibly re-intervention are necessary to obtain satisfactory clinical and angiographical result.     

Captopril renography and duplex Doppler sonography in the diagnosis of renovascular hypertension

Background. The purpose of this prospective study was to determine the clinical usefulness of captopril renal scintigraphy and duplex Doppler sonography in detecting haemodynamically significant renal artery stenosis (⩾60%) and predicting cure or improvement of hypertension following revascularisation. Methods. Twenty-eight patients with moderate or high index of clinical suspicion of renovascular hypertension underwent both captopril renal scintigraphy and duplex Doppler sonography before undergoing renal angiography. Patients with angiographically proved (⩾60%) RAS were treated by percutaneous transluminal renal angioplasty unless it was contraindicated. Results. The results of captopril renal scintigraphy and duplex Doppler sonography were compared by renal angiography of 45 renal arteries in 28 patients. Eleven renal arteries were excluded from further comparison, because no accurate Doppler signal could be obtained. The sensitivity and specificity of captopril renal scintigraphy in the identification of RAS (⩾60%) was 78% and 81% respectively. The sensitivity of duplex Doppler sonography was 83% and the specificity was 81%. Positive predictive values of both tests for blood pressure cure or improvement after PTRA were 86% for CRS and 85% for DDS. Conclusions. Captopril renal scintigraphy and duplex Doppler sonography are comparable tests for detection of patients with haemodynamically significant renal artery stenosis (⩾60%). Positive predictive values of both tests for cure or improvement of hypertension after percutaneous transluminal renal angioplasty are good and comparable.     

Treatment of severe renal artery stenosis by percutaneous transluminal renal angioplasty and stent implantation

The clinical course of two children with mid-aortic syndrome and renal artery stenosis (RAS) who suffered from severe arterial hypertension is described. Hypertension was uncontrollable by antihypertensive medication and was managed by percutaneous transluminal renal angioplasty (PTRA) with stent implantation. The pediatric experience with PTRA is limited, and there are only few cases reported with additional stent implantation. Complications of these procedures are well known from experience with adult patients. However, since surgical revascularization may be technically difficult especially in small children, PTRA with or without stenting should be considered as a valuable treatment option in pediatric RAS.     

Renovascular disease and hypertension in children with neurofibromatosis

Neurofibromatosis type 1 (NF1) is associated with vascular lesions, such as renal artery stenosis, and secondary hypertension. The real prevalence is largely unknown, particularly in children. We observed 27 patients with NF1, mean age 12.8 years (range 4.2–24 years), for 2–10 years to assess the association of NF1 with vascular abnormalities and secondary hypertension. Patients were studied with angiography, 24-h blood pressure monitoring, a captopril test, and Doppler ultrasonography of aorta and renal arteries. The prevalence of hypertension was 18.5%; 61.5% of patients studied with angiography had vascular lesions, half of whom were apparently normotensive. However, they had abnormal 24-h blood pressure monitoring, which was a first sign of poor blood pressure control. Those patients with severe hypertension (11.1%) were successfully treated with percutaneous transluminal angioplasty (PTA); stenosis recurred in 2 of 3 patients after a 2-year follow-up period, and was responsive to drugs. We conclude that hypertension is a frequent complication of NF1 in pediatric patients, it is usually secondary to typical vascular lesions, and requires careful follow-up. Ambulatory blood pressure monitoring (24-h) is a sensitive method for detecting initial alterations of the blood pressure pattern. PTA may be an effective treatment in this condition. Received: 2 June 1999 / Revised: 1 November 1999 / Accepted: 1 November 1999     

Combined renal artery stenosis and aortic aneurysm: Treatment options

The purpose of this study was to analyze outcomes of two different treatment strategies in patients treated for renal artery (RA) stenosis and a coincidental abdominal aortic aneurysm (AAA). A total of 50 patients were encountered who required treatment for concomitant RA stenosis and an AAA from 1980 to 1994. Simultaneous operative aortic and RA reconstruction was done in 32 patients, whereas 18 patients were treated with preoperative percutaneous transluminal renal artery angioplasty (PTRA). The two groups were well matched with respect to age, AAA size, incidence of hypertension, preoperative creatinine level, and creatinine clearance (allp values >0.07). Aortorenal bypass (18 RAs), reimplantation (18 RAs), or endarterectomy (2 RAs) was performed to correct a mean RA stenosis of 88%, whereas 23 RAs (91% mean stenosis) were treated with preoperative PTRA. PTRA failed in four patients with RA stenosis, and they were successfully treated with surgery (3 bypasses and 1 reimplantation). Statistical analysis did not demonstrate a significant difference between these four failed PTRA-patients, the 14 successful PTRA patients, and the 32 RA reconstruction patients in terms of operating time (p=0.15), operative blood loss (p=0.20), intensive care unit days (p=0.71), or total hospital days (p=0.94). Among the 40 patients available for follow-up, hypertension was cured in seven, improved in 10, unchanged in 15, and worse in eight with no difference demonstrated between the groups (p=0.73). These data suggest that preoperative PTRA has no specific advantage over surgical RA reconstruction in patients with concomitant RA stenosis and AAA. Failed PTRA did not preclude or complicate subsequent operative RA revascularization.Presented at the Fourteenth Annual Meeting of the Southern California Vascular Surgical Society, September 15–17, 1995, La Jolla, Calif.     

Evaluating patients with renal failure for renal artery stenosis with gadolinium-enhanced magnetic resonance angiography

The incidence and prevalence of end-stage renal disease (ESRD) continues to increase, especially in the elderly population. The role of renovascular disease in contributing to ESRD is still not well defined. The objective of this study was to determine the utility of gadolinium (Gd)-enhanced magnetic resonance angiography (MRA) in evaluating elderly patients with renal insufficiency for renal artery stenosis (RAS). A 7-month prospective study conducted in a tertiary referral center evaluated 40 consecutive patients with progressive renal insufficiency (18 men and 22 women; mean age, 70 +/- 5.6 [standard deviation] years) and high clinical suspicion for renovascular disease with Gd-enhanced MRA. Digital subtraction angiography (DSA) was obtained in only those patients with significant RAS detected by MRA. Twelve patients had significant RAS. Six of these patients had percutaneous transluminal renal angioplasty (PTRA), five patients had renal artery bypass surgery, and one patient had a stent placed after PTRA. Seventy-eight renal arteries were satisfactorily evaluated by MRA. Twenty-two renal arteries were evaluated by both MRA and DSA. Of the 12 significant stenoses detected by the MRA, 11 were confirmed by DSA and 1 was confirmed at the time of surgical revascularization. It is concluded that Gd-enhanced MRA is a useful test for the evaluation of RAS in patients with compromised renal function.     

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.