Superior mesenteric artery stenting to augment splenorenal arterial bypass for intractable complex renovascular hypertension

An alternative source of visceral arterial inflow is sometimes necessary for renal revascularization when aortorenal endarterectomy or bypass is inappropriate due to severely diseased aorta. We report the case of a 46-year-old male with recurrent intractable renovascular hypertension in renal failure secondary to occlusion of the celiac axis due to progression of aortoarteritis following splenorenal arterial bypass performed 5 years before. Aortogram visualized intestinal arterial arcade supporting patent bypass with critically stenosed superior mesenteric artery. Successful angioplasty with stenting of superior mesenteric artery restored adequate renal flow through the bypass leading to recovery and easy control of hypertension.     

ACE inhibition scintigraphy in the management of hypertension in children

Angiotensin converting enzyme (ACE) inhibition scintirenography was performed to help establish the diagnosis and plan treatment of renovascular hypertension (RVH) in 57 hypertensive pediatric patients, 33 infants and 24 children older than 1 year. In 16 of 33 hypertensive infants, ACE inhibition scintirenography established the diagnosis of RVH from renal ischemia (due to aortic or renal arterial thrombi). Two scintigraphic criteria were used for the diagnosis of RVH: criterion I, ischemic and damaged kidney (a non-functioning kidney on or off ACE inhibition) and criterion II, ischemic but not damaged kidney (ACE inhibition induced deterioration of function of the kidney). When criterion I was present and the contralateral kidney was normal, ACE inhibitors could be used for treatment of hypertension without deterioration of renal function; kidneys satisfying criterion I eventually involuted or manifested growth arrest and frequently caused persistent RVH, even after resolution of the thrombus, requiring nephrectomy. When criterion II was present bilaterally, or it was associated with criterion I contralaterally, the use of antihypertensive drugs other than ACE inhibitors was necessary in order to prevent renal insufficiency or failure from ACE inhibitors. However, kidneys with criterion II showed normal growth and, following retraction or dissolution of the aortic thrombus, hypertension resolved. In 2 of 24 hypertensive children older than 1 year, the test was diagnostic of branch renal artery stenosis; RVH was cured by selective angioplasty. ACE inhibition scintirenography is useful in the evaluation and planning of treatment in children with hypertension and may predict the outcome of therapy and ultimate renal function. Received: 7 May 1997 / Revised: 3 September 1998 / Accepted: 3 September 1998     

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.

Inadequacy of captopril challenge test for diagnosing renovascular hypertension in children and adolescents

A captopril challenge test (CCT) for renovascular disease in adults was described recently. We used it in 20 consecutive, untreated hypertensive children and adolescents. All had a normal urinalysis and glomerular filtration rate and non-diagnostic renal sonograms or intravenous urograms. Plasma renin activity (PRA) was measured before and 1 h after administration of captopril (0.76±0.17 mg/kg). The CCT was positive in 10 patients. Renal arteriograms were performed in 7 patients with a positive CCT and in 2 with a negative CCT. Renovascular disease was found in 4 patients, 1 of whom had a negative CCT. The PRA response to captopril was the same in patients with true- and the false-positive tests. The predictive value of the positive test was 43%. In conclusion, we did not find the CCT, as described for adults, to be of value in children and adolescents.     

Pulmonary arterial hypertension in four patients treated by leflunomide

Pulmonary arterial hypertension (PAH) is a rare disorder that can be drug-induced, mostly following treatment by appetite-suppressant drugs. We report four cases of patients who developed PAH following a treatment by leflunomide for rheumatoid arthritis, psoriatic arthritis or undetermined connective tissue disease. All patients described a progressive dyspnea from grade II to IV of NYHA classification; clinical examination found signs of heart failure. PAH was finally diagnosed and confirmed by right heart catheterisation. Haemodynamic explorations found pre-capillary pulmonary hypertension with mean pulmonary arterial pressure above 25 mmHg, and pulmonary capillary wedge pressure under 15 mmHg. Explorations of this pre-capillary pulmonary hypertension were conducted according to international guidelines: pulmonary or chronic thromboembolic aetiologies were excluded after ventilation/perfusion lung scan and high-resolution computed tomography. All other etiologic explorations were negative. Imputability of leflunomide was finally retained. Leflunomide was stopped for all patients; three of them received specific PAH treatments. A favourable clinical and/or haemodynamic evolution was observed for all patients. The conclusions of the investigations conducted by our pharmacovigilance centre were communicated to the European Medicines Agency, leading to the addition of “pulmonary hypertension” in the paragraph “special warning and precautions of use” of the package leaflet of leflunomide.     

Predictor factors for the development of arterial hypertension following heart transplantation

Abstract: Introduction: Up to 95% of the patients with heart transplantation (HT) suffer from arterial hypertension (AHT). The development of de novo AHT after HT has not been greatly studied. Aim: To identify the predictor variables for the development of de novo AHT after HT. Materials and methods: We retrospectively studied 253 patients with HT and who did not previously have AHT. We excluded cases of early mortality, re‐transplants and combined transplants. We considered AHT as the constant need to take anti‐hypertensive drugs to maintain blood pressure < 140/90 mmHg. We studied all the variables relating to recipient, donor, surgical procedure, immunosuppression and follow‐up. The statistics used were the Student's t‐test, chi‐square statistic and a logistic regression analysis. Results: Of the 253 patients, 109 (43%) developed AHT. The variables associated with more prevalent AHT were male recipient/donor, idiopathic dilated cardiomyopathy (IDCM) as cause of HT, having been a smoker as well as renal deterioration (RD) and hypercholesterolemia after HT. The multivariate analysis found smoking prior to the HT and hypercholesterolemia during follow‐up as independent risk factors and urgent HT as a protective variable. Conclusions: AHT after HT is frequent. The variables associated in our population were smoking before HT, male recipient/donor, IDCM prior to HT and hypercholesterolemia and RD after HT.     

Severe renovascular hypertension in an infant with congenital solitary pelvic kidney

Renal artery stenosis (RAS) is one of the most common causes of severe arterial hypertension in infants. Its management is very difficult, especially when present in a single kidney. We report a case of severe hypertension caused by RAS of congenital single pelvic kidney in a 4-month-old boy. The patient presented with cardiorespiratory insufficiency that was first treated as acute fulminate myocarditis. Medical treatment of arterial hypertension was disappointing, as it had to be balanced between congestive cardiac failure and acute renal failure. Percutaneous transluminal angioplasty (PTA) done by coronary balloon dilatation catheters through the left axillary access was successful. Following dilatation of the renal artery, blood pressure decreased and its good control was possible by only one drug. With improved medical blood pressure control and normal growth development, the reassessment of clinical therapy options adjusted to a larger vessel size would be possible. Renovascular hypertension due to RAS in infants with a solitary kidney is difficult to control by medical treatment alone. PTA should be considered as a viable option in infants with refractory hypertension due to renal artery stenosis in a solitary kidney, since it has the potential of improving hypertension while preserving renal function.     

Severe hyperreninemic hypertension associated with spontaneous renal cholesterol crystal embolization

A 70-year-old man was admitted because of severe hypertension and renal insufficiency. Marked elevation in plasma renin activity (PRA; 34.2ng/ml per h) was noted. Five days later, the patient developed hemorrhagic duodenal ulcers and panperitonitis, went into shock, and died. An autopsy revealed severe atherosclerosis with marked ulceration in the abdominal aorta. Renal histology showed multiple cholesterol crystal embolization (CCE) associated with infarction. Cholesterol crystals were also detected in the vessels of the gastrointestinal system, including the liver, stomach, colon, and pancreas. Although not common, spontaneous CCE should be considered in elderly patients who present with abrupt onset of severe hypertension associated with renal insufficiency. The most important finding in this patient was severe hyperreninemia. Although potentiation of the renin-angiotensin-aldosterone system is the suggested mechanism for the hypertension in renal CCE, we could not find any reported case of renal CCE with hyperreninemia. It is reasonable to consider that severe hyperreninemia might be overlooked in renal CCE. PRA should be measured in patients with renal CCE, because it may give important information for selecting antihypertensive agents and improving the prognosis. To clarify this possibility, an accumulation of similar cases is necessary.     

Percutaneous transluminal angioplasty for renovascular hypertension in children

Percutaneous transluminal angioplasty (PTA) has been developed over the past 8 years as an alternative to reconstructive surgery for renovascular hypertension. We report three cases and review the use of PTA in children with renal artery stenosis. At least 37 cases of PTA have been reported in patients whose ages ranged from 1.3 to 17 years (mean 10 years). Of these, 10 had fibromuscular dysplasia; 13 unspecified unilateral renal artery stenosis; 4 bilateral stenosis; 4 neurofibromatosis; 4 renal transplant; 1 atherosclerosis; and 1 postsurgical stenosis. Nine of 10 patients with fibromuscular dysplasia were cured and 3 of 4 with renal transplant arterial stenosis were cured or improved. There were 11 failures of PTA, including all 4 patients with neurofibromatosis and 1 with transplant arterial stenosis. We conclude that PTA is the treatment of choice for children with hypertension due to fibromuscular dysplasia and should be attempted for stenosis of the transplanted renal artery. Other lesions resulting in renal artery stenosis may not be as amenable to dilation and should be considered on an individual basis.R. L. Chevalier is an Established Investigator of the American Heart Association     

Renovascular hypertension complicated with VATER association

We report herein a case of a girl with renovascular hypertension associated with VATER association. Her plasma renin activity and aldosterone were high. The ultrasonic echogram and renogram revealed a right hypoplastic kidney without function and a normal-sized left kidney with normal function. Renal angiography revealed a small diameter right main renal artery and a normal left main renal artery with segmental stenosis of left branching renal arteries in the middle segment. Selective renal vein sampling indicated that renin secretion was primarily from the left kidney. This is the first report of renovascular hypertension complicated with VATER association.     

Renal cell carcinoma and arterial hypertension

Background  The association between renal cell carcinoma and arterial hypertension has been the subject of various studies. These studies have not been consistent in clarifying the relationship between the two. Some authors contend that arterial hypertension is a consequence of renal cell carcinoma, which secretes vasoactive peptides. Others claim that arterial hypertension is a risk factor for the development of renal cell carcinoma. The purpose of our study is to assess if there is a direct connection between arterial hypertension and renal cell carcinoma. Methods  Out of 16,755 patients who were examined by ultrasonography, 40 were diagnosed with renal tumors. Of the 40 patients, 29 had malignant renal tumors, and 11 had benign renal tumors. These diagnoses were confirmed by CT scan, renal biopsy, and histology. Most of the patients with renal cell carcinoma (79.3%) had arterial hypertension. The group with benign renal tumors served as a control group. Out of the 29 patients with malignant renal cell carcinoma, 24 patients were treated with total nephrectomy, one had a partial nephrectomy, and four patients were too unwell for surgical intervention. In the group of those with benign renal tumors, seven patients had partial nephrectomies for the removal of angiomyolipomas. The personal histories were taken at the initiation of the study, and vital signs were obtained before and after surgery. Statistical analyses were performed using the Statistical Package for Social Sciences, version 10.0. Results  In the malignant group, the systolic blood pressure (SBP) before surgery was 157.41 ± 27.86 mmHg, and the diastolic blood pressure (DBP) was 97.24 ± 15.33 mmHg, while in the benign group, SBP was 134.55 ± 17.53 mmHg, and DBP was 88.18 ± 14.01 mmHg. In the malignant group in those who had undergone nephrectomies, the mean systolic pressure was 136.82, and the diastolic pressure was 85.90. In the benign group, the systolic and diastolic blood pressures were normal before and after surgery. Conclusion  In the group of patients with both renal cell carcinoma and arterial hypertension, their hypertension was resolved after they underwent nephrectomies. In conclusion, our data suggest that renal cell carcinomas may cause arterial hypertension.     

Yield of renal arteriography in the evaluation of pediatric hypertension

The prevalence of renovascular disease is estimated to be 3%–5% in pediatric patients with hypertension. The utility of non-invasive imaging tests has not been evaluated in children, and renal arteriography remains the diagnostic test of choice. However, there are no established guidelines for the application of this test and information is not available about the likelihood of detecting an abnormality if an arteriogram is performed in children with hypertension. Therefore, we reviewed the yield of renal arteriography in pediatric patients if the test was performed based on the following two criteria: (1) severe hypertension exceeding the 99th percentile for age and sex or (2) failure to control high blood pressure with one antihypertensive drug. During the period 1983–1998, 28 children (mean age 11.7 years) who satisfied one of the above criteria underwent renal arteriography to investigate hypertension. None of the patients were renal transplant recipients. The average duration of hypertension was 11 months and the peak blood pressure was 168/107 mmHg. The renal arteriogram was abnormal in 12 patients (43%). Unilateral renal artery stenosis was the most-common abnormality. When the patients were divided into two groups – those with an abnormal or normal test result – they did not differ in age, sex, or racial distribution. The peak systolic blood pressure was higher in children with an abnormal renal arteriogram (P<0.05). Among those undergoing the arteriogram on the basis of the first criterion, i.e., severe hypertension, 11 of 23 (48%) studies were abnormal. Five children had an arteriogram based on the second criterion – failure to control the blood pressure with one medication – and in 1 patient (20%) the test was abnormal. We conclude that the prevalence of renovascular disease in a population of hypertensive children subjected to renal arteriography is around 40%. Two clinical criteria – namely severe hypertension or failure to control hypertension effectively with one drug – are useful to guide the application of renal arteriography in children with hypertension. Received: 12 August 1999 / Revised: 24 November 1999 / Accepted: 28 November 1999     

Long-term follow-up of neonatal renovascular hypertension

Twelve neonates with hypertension have been followed for a mean of 5.75 years. At onset of hypertension, mean peak blood pressure was 159/99 mmHg. Ten infants had umbilical artery catheters, 9 placed above the origin of the renal arteries. Radionuclide renal scan, and/or angiography demonstrated renovascular disease, primarily renal artery thrombosis, in 11 infants. Onethird of infants were asymptomatic, one-third had normal urinalyses and two-thirds had elevated peripheral plasma renin activities. Blood pressure normalized with medical therapy in all infants and remained normal when therapy was discontinued. Ten infants have normal creatinine clearances on follow-up but 5/11 have unilateral renal atrophy. Radionuclide scans have remained abnormal, even in infants without renal atrophy. In summary, neonatal renovascular hypertension is frequently secondary to renal artery thrombosis, associated with umbilical artery catheterization. Blood pressure usually normalizes with conservative medical management and remains normal off medications. Persistent abnormalities in renal size and function are common.     

法舒地尔对肺血管重构的肺动脉高压大鼠的影响

目的 观察法舒地尔对发生肺血管重构的肺动脉高压(PAH)大鼠的影响.方法 将32只雄性Wistar大鼠随机均分为4组:对照3周组,模型3、6周组及治疗组;予野百合碱建模;治疗组于3周后予法舒地尔腹腔内注射.于3、6周末测定各组大鼠右心室收缩压(RVSP)、内皮素-1(ET-1)、N端脑钠素前体(NT-proBNP)、肺小动脉病理等.结果 (1)造模后RVSP随时间升高(31.2±7.6)、(43.3±8.3)、(56.9±6.9)mm Hg(1 mm Hg=0.133 kPa),治疗组(47.3±6.3)mmHg较模型6周组明显降低.(2)ET-1、NT-proBNP与RVSP呈正相关(r=0.721、0.454).(3)病理:造模后肺动脉平滑肌增生,管壁狭窄,至6周时近于闭塞,治疗组则明显好转.结论 对于已发生肺血管重构的PAH大鼠,法舒地尔能阻止肺动脉高压进展,ET-1、NT-proBNP可成为较理想的评估指标.

Abstract：

Objective To investigate the effects of Rho kinase inhibitor fasudil on monocrotaline (MCT)-induced pulmonary arterial hypertension (PAH) with vascular remodeling in rats. Methods Thirty-two male Wistar rats were randomly and equally divided into control group ( C3 ), MCT-PAH 3- and 6-week model groups (H3, H6 ) and fasudil-treated group (F6). The right ventricle systolic pressure( RVSP), right ventricle/left ventricle and septum[RV/( LV + S)], plasma endothelin-1 and NT-proBNP were measured; small pulmonary arterial morphometry, ratio of vascular wall thickness to vascular external diameter (WT) and ratio of vascular wall area to the total area (WA) were also observed. Results ( 1 )The RVSP was highest in H6 group, followed by F6 group, H3 group, and C3 group[(56. 9 ±6. 9), (47. 3±6.3), (43.3±8.3) and (31.2±7.6) mm Hg (1 mm Hg=0. 133 kPa)]. But no significant difference was found between H3 and F6 groups; (2) The levels of plasma ET-1 and NT-proBNP were positively associated with RVSP, RV/(LV +S), WT and WA (r for ET-1 was 0.721, 0.607, 0.652, 0.707,P＜0.01; r for NT-proBNP was 0. 454, 0. 330, 0. 365, 0. 398,P ＜0. 05); (3) Pathematological assessment showed that the thickness and muscularization of small pulmonary artery were increased in H3 group as compared with C3 group, most significantly in H6 group, and those were significantly decreased in F6 group as compared with H6 group. Conclusion Fasudil can improve the MCT-induced PAH with vascular remodeling in rats. The plasma ET-1 and NT-proBNP could be used as good makers to evaluate the severity of PAH.     

Bench repair of complex renal arterial lesions

Between 1968 and 1989, 160 patients underwent aortorenal bypass for renovascular hypertension. During the same interval, 13 patients had ex-vivo bench repair of complex renal arterial pathology. There were eight men and five women, with a mean age of 36 years. Twelve of the 13 patients had fibromuscular disease; one had atherosclerosis. Twelve patients had renovascular hypertension with complex stenotic disease beyond the main renal artery. Seven of these also had an associated renal aneurysm as did the sole normotensive patient. Saphenous vein patch or bypass were used to correct stenotic segments in four patients, while the remaining nine patients had excision of stenotic or aneurysmal segments with primary arterial anastomosis. There were no deaths in the series. One kidney was lost because of arterial thrombosis. One patient required reoperation to control postoperative bleeding. Nine of the 12 patients with renovascular hypertension were normotensive off medication, and three were improved, with reduced medication controlling their blood pressure. Ureteric obstruction occurred in two patients; this settled spontaneously in one patient and was corrected by reoperation in the other. From this experience, we conclude that bench repair is a safe and effective way to maximize salvage of kidneys affected by complex arterial pathology.Presented at the Fifteenth Annual Meeting of the Peripheral Vascular Surgery Society, June 2, 1990, Los Angeles, California.     

靶向纳米载体包封西地那非对肺高压大鼠肺血管重构的影响

目的观察包封西地那非的靶向纳米载体对野百合碱肺高压大鼠肺动脉压力、肺小血管中膜增殖以及右心室心肌肥厚的治疗作用。方法雄性SD大鼠42只,随机分为六组,每组7只。除对照组(CON组)外,其余各组皮下注射野百合碱60mg/kg,4周后分别经尾静脉注射西地那非8mg/kg(SIL组)、靶向纳米空载体(GL组)、普通纳米载体包封西地那非(L-SIL组)和靶向纳米载体包封西地那非(GL-SIL组)干预2周,CON组与模型组(MCT组)则给予等体积的生理盐水。2周后,开胸测量大鼠平均肺动脉压(mPAP)并处死动物取心肺组织,进行HE染色,测定肺小血管中膜厚度比例(WT),右心室心肌细胞的面积。采用免疫组织化学法检测肺血管中膜α-平滑肌肌动蛋白(α-SMA)含量。采用活体荧光示踪观察靶向纳米载体的组织分布。结果与CON组比较,MCT组、GL组、SIL组和L-SIL组mPAP明显升高(P0.05)。与MCT组比较,GL-SIL组mPAP明显降低(P0.05)。与CON组比较,MCT组、SIL组、GL组和L-SIL组WT明显增加(P0.05),α-SMA表达明显增高(P0.05)。与MCT组比较,GL-SIL组WT和α-SMA的表达明显降低(P0.05)。与CON组比较,MCT组、SIL组、GL组和L-SIL组心肌细胞面积明显增大(P0.05)。但GL-SIL组明显小于MCT组(P0.05)。结论靶向纳米载体包封西地那非可明显降低肺动脉高压大鼠的平均肺动脉压力,改善肺血管中膜增殖和右心室肥大,与其具有良好的肺组织靶向性相关。     

Indications for laparoscopic adrenalectomy for non-functional adrenal tumor with hypertension: Usefulness of adrenocortical scintigraphy

AIM: Laparoscopic adrenalectomy is currently indicated for biochemically and clinically functional adrenal tumors and potentially malignant tumors of the adrenal glands. Non-functional adenomas greater than 5 cm in diameter of the adrenal gland are generally considered to represent potentially malignant tumors. The present study shows indications of laparoscopic adrenalectomy for non-functional adrenal tumors with hypertension in a retrospective fashion. METHODS: Between 1994 and 2004, 110 laparoscopic adrenalectomies were performed at Tokushima University Hospital. All 110 patients underwent detailed endocrinological examination before surgery. Medical and operative records of these 110 patients (57 men, 53 women), including operative parameters, histopathological findings and pre- and postoperative hypertension, were reviewed. Forty-five patients underwent laparoscopic adrenalectomy for non-functional adrenal tumors, and [(131)I]6beta-iodomethyl-19-norcholest-5(10)-en-3beta-ol (NP-59) scintigraphy was performed for patients with preoperative hypertension. RESULTS: Mean patient age was 55.0 years (range, 22-77 years). Mean maximum tumor diameter was 42 mm (range, 20-105 mm). All adrenal tumors were removed successfully by laparoscopic surgery. Hypertension was postoperatively improved in seven of the 11 patients with preoperative hypertension, without subclinical Cushing syndrome. Importantly, all patients who improved hypertension after adrenalectomy displayed strong accumulation in adrenal tumors with visualization of the contralateral gland on NP-59 scintigraphy. Conversely, blood pressure did not improve in four patients for whom scintigraphy yielded negative results. CONCLUSIONS: The indication of laparoscopic adrenalectomy for non-functional adrenal tumors is generally considered for lesions more than 5 cm diameter. However, the present study suggests that laparoscopic surgery should be considered even in patients with tumors less than 5 cm in diameter, if both hypertension and accumulation in tumors on NP-59 scintigraphy are present.