Renovascular Hypertension, Surgical Treatment Follow-up

  • Author: Andre Hebra, MD; Chief Editor: Mary C Mancini, MD, PhD   more...
 
Updated: Aug 8, 2008
 

Further Inpatient Care

  • Preoperative care
    • Provide pharmacologic treatment for patients with renovascular hypertension before the operations in an attempt to control blood pressure.
    • Routine chest radiography, ECG, and, perhaps, echocardiography are important in evaluating the patient's cardiovascular stability under the stress of hypertension.
    • Abdominal aortography and arteriography are necessary, not only for diagnosis but also to determine the extent of disease and the approach to surgical intervention.
  • Postoperative care
    • Carefully monitor patients' blood pressures because postoperative medical therapy may be necessary.
    • Renal scanning or arteriography is also important after surgery to identify possible thrombosis, stricture, or any failures in the graft or anastomosis.
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Further Outpatient Care

  • Because the long-term outcome has not yet been determined, monitor sequential blood pressure measurements indefinitely.
    • In unilateral disease, development of contralateral stenosis has been reported to occur years (as many as 14 y) later in some cases.
    • In addition, stenosis of the graft or thrombosis may occur as many as 2 years postoperatively.
  • Approximately 25% of patients treated surgically still require some drug therapy to maintain blood pressure measurements within the reference range.
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Complications

  • The rate of PTA complications varies among physicians, but potential complications include thrombosis, vascular or renal perforation, and tearing or dissection of the vessel wall. Restenosis appears to occur approximately 25% of the time.
  • Most authors have reported a 0% mortality rate because of surgery. Failure or complications in revascularization procedures lead to another operation approximately 27% of the time. Usually, the second operation is curative.
    • Reports in larger series indicate that graft stenosis may occur about 5% of the time, and thromboses have occurred in approximately 10% of revascularization operations. Specific complications of each graft material were delineated above under Surgical Care.
    • Take care to provide secure anastomoses. Likewise, implement a sufficient length of graft material to allow for growth in the child without kinking secondary to too much graft length.
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Prognosis

  • The prognosis in untreated renovascular hypertension is poor. The severity of the hypertension produces a lot of strain on target organs and can lead to death. Fortunately, most renovascular disease is correctable with surgical intervention.
  • For 35% of patients, PTA produces normotensive blood pressures. Another one third of patients have decreased blood pressures. Unfortunately, a high rate of recurrence of hypertension and vascular stenosis appears to be observed in patients treated with PTA.
  • Surgical revascularization provides a very good prognosis for patients with renovascular hypertension.
    • Approximately 70% of patients become normotensive without requiring additional pharmacologic treatment. Another 25% have reduced hypertension that can usually be resolved with the addition of medical therapy. Thus, fewer than 5% of patients appear refractory to revascularization. Some of the patients can experience resolution of their hypertension following nephrectomy.
    • Successful surgical intervention is expected to provide patients with a normal life span without complication. Children who undergo surgical revascularization appear to do well for at least 16 years postoperatively. They are able to participate in active sports and similar vigorous activities without problems. Further long-term follow-up is needed to determine the durability of these reconstructions and the actual life potential of these children.
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Contributor Information and Disclosures
Author

Andre Hebra, MD  Chief, Division of Pediatric Surgery, Professor of Surgery and Pediatrics, Medical University of South Carolina College of Medicine

Andre Hebra, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Association for Academic Surgery, Society of Laparoendoscopic Surgeons, South Carolina Medical Association, Southeastern Surgical Congress, and Southern Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Patrick B Thomas, MD  Fellow, Department of Pediatric Surgery, Texas Children's Hospital

Patrick B Thomas, MD is a member of the following medical societies: American Medical Association and South Carolina Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Jonah Odim, MD, PhD, MBA  Senior Medical Officer, Transplantation Immunology Branch, Division of Allergy, Immunology, and Transplantation, National Institute of Allergy and Infectious Diseases, National Institutes of Health

Jonah Odim, MD, PhD, MBA is a member of the following medical societies: American College of Cardiology, American College of Chest Physicians, American College of Physician Executives, American College of Surgeons, American Heart Association, American Society for Artificial Internal Organs, American Society of Transplant Surgeons, Association for Academic Surgery, Association for Surgical Education, Canadian Cardiovascular Society, International Society for Heart and Lung Transplantation, National Medical Association, New York Academy of Sciences, Royal College of Physicians and Surgeons of Canada, Society of Critical Care Medicine, and Society of Thoracic Surgeons

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Pharmacy Editor, eMedicine

Disclosure: Nothing to disclose.

John Myers, MD  Director, Pediatric and Congenital Cardiovascular Surgery, Departments of Surgery and Pediatrics, Professor, Penn State Children's Hospital, Milton S Hershey Medical Center

John Myers, MD is a member of the following medical societies: American Association for Thoracic Surgery, American College of Cardiology, American College of Surgeons, American Heart Association, American Medical Association, Congenital Heart Surgeons Society, Pennsylvania Medical Society, and Society of Thoracic Surgeons

Disclosure: Nothing to disclose.

Daniel Rauch, MD, FAAP  Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine

Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine

Disclosure: Baxter Honoraria Consulting

Chief Editor

Mary C Mancini, MD, PhD  Professor and Chief, Cardiothoracic Surgery, Department of Surgery, Louisiana State University Health Sciences Center-Shreveport

Mary C Mancini, MD, PhD is a member of the following medical societies: American Association for Thoracic Surgery, American College of Surgeons, American Surgical Association, Phi Beta Kappa, Society of Thoracic Surgeons, and Southern Surgical Association

Disclosure: Nothing to disclose.

References

  1. Stanley JC, Zelenock GB, Messina LM, Wakefield TW. Pediatric renovascular hypertension: a thirty-year experience of operative treatment. J Vasc Surg. Feb 1995;21(2):212-26; discussion 226-7. [Medline].

  2. Tyagi S, Kaul UA, Satsangi DK, Arora R. Percutaneous transluminal angioplasty for renovascular hypertension in children: initial and long-term results. Pediatrics. Jan 1997;99(1):44-9. [Medline]. [Full Text].

  3. Task Force on Blood Pressure Control in Children. Report of the Second Task Force on Blood Pressure Control in Children--1987. Task Force on Blood Pressure Control in Children. National Heart, Lung, and Blood Institute, Bethesda, Maryland. Pediatrics. Jan 1987;79(1):1-25. [Medline].

  4. Guzzetta PC. Arterial disease. In: Surgery of Infants and Children: Scientific Principles and Practice. Philadelphia, PA: Lippincott Williams & Wilkins; 1997:1722-4.

  5. Casalini E, Sfondrini MS, Fossali E. Two-year clinical follow-up of children and adolescents after percutaneous transluminal angioplasty for renovascular hypertension. Invest Radiol. Jan 1995;30(1):40-3. [Medline].

  6. Guzzetta PC, Potter BM, Ruley EJ, et al. Renovascular hypertension in children: current concepts in evaluation and treatment. J Pediatr Surg. Dec 1989;24(12):1236-40. [Medline].

  7. O'Neill JA Jr. Renovascular hypertension. Semin Pediatr Surg. May 1994;3(2):114-23. [Medline].

  8. Berkowitz HD, O'Neill JA Jr. Renovascular hypertension in children. Surgical repair with special reference to the use of reinforced vein grafts. J Vasc Surg. Jan 1989;9(1):46-55. [Medline].

  9. Bartosh SM, Aronson AJ. Childhood hypertension. An update on etiology, diagnosis, and treatment. Pediatr Clin North Am. Apr 1999;46(2):235-52. [Medline].

  10. Behrman RE, Kliegman RM, Jenson HB. Systemic hypertension. In: Nelson Textbook of Pediatrics. Philadelphia, PA: WB Saunders Co; 2000:1450-5.

  11. Bleacher J, Turner ME, Quivers E, Schwartz MZ. Renal autotransplantation for renovascular hypertension caused by midaortic syndrome. J Pediatr Surg. Feb 1997;32(2):248-50; discussion 250-1. [Medline].

  12. Bloch MJ, Basile J. The diagnosis and management of renovascular disease: a primary care perspective. Part II. Issues in management. J Clin Hypertens (Greenwich). Jul-Aug 2003;5(4):261-8. [Medline].

  13. Deal JE, Snell MF, Barratt TM. Renovascular disease in childhood. J Pediatr. Sep 1992;121(3):378-84. [Medline].

  14. Dillon MJ. The diagnosis of renovascular disease. Pediatr Nephrol. Jun 1997;11(3):366-72. [Medline].

  15. Hiner LB, Falkner B. Renovascular hypertension in children. Pediatr Clin North Am. Feb 1993;40(1):123-40. [Medline].

  16. Inatomi J, Miyazaki O, Fujimaru R, Iijima K. Renovascular hypertension complicated with VATER association. Pediatr Nephrol. Aug 2005;20(8):1174-6. [Medline].

  17. McLaren CA, Roebuck DJ. Interventional radiology for renovascular hypertension in children. Tech Vasc Interv Radiol. Dec 2003;6(4):150-7. [Medline].

  18. O'Neill JA. Arterial disorders. In: Pediatric Surgery. St. Louis, MO: Mosby-Year Book; 1998:1958-61.

  19. O'Neill JA Jr. Long-term outcome with surgical treatment of renovascular hypertension. J Pediatr Surg. Jan 1998;33(1):106-11. [Medline].

  20. Pasaoglu I, Boke E, Dogan R, Bozer AY. Surgical treatment of renovascular hypertension in children. Turk J Pediatr. Jan-Mar 1991;33(1):27-34. [Medline].

  21. Piercy KT, Hundley JC, Stafford JM, et al. Renovascular disease in children and adolescents. J Vasc Surg. Jun 2005;41(6):973-82. [Medline].

  22. Pollard SG, Hornick P, Macfarlane R, Calne RY. Renovascular hypertension in neurofibromatosis. Postgrad Med J. Jan 1989;65(759):31-3. [Medline].

  23. Rowe MI, Fonkalsrud EW, O'Neill JA. Arterial disorders. In: Essentials of Pediatric Surgery. St. Louis, MO: Mosby-Year Book; 1995:817-8.

  24. Simoes E Silva AC, Diniz JS, Regueira Filho A, Santos RA. The renin angiotensin system in childhood hypertension: selective increaseof angiotensin-(1-7) in essential hypertension. J Pediatr. Jul 2004;145(1):93-8. [Medline].

  25. Simunic S, Winter-Fuduric I, Radanovic B, et al. Percutaneous transluminal renal angioplasty (PTRA) as a method of therapy for renovascular hypertension in children. Eur J Radiol. Mar-Apr 1990;10(2):143-6. [Medline].

  26. Textor SC. Managing renal arterial disease and hypertension. Curr Opin Cardiol. Jul 2003;18(4):260-7. [Medline].

  27. Wilson DI, Appleton RE, Coulthard MG, et al. Fetal and infantile hypertension caused by unilateral renal arterial disease. Arch Dis Child. Aug 1990;65(8):881-4. [Medline].

  28. Wyszynska T, Cichocka E, Wieteska-Klimczak A, et al. A single pediatric center experience with 1025 children with hypertension. Acta Paediatr. Mar 1992;81(3):244-6. [Medline].

 
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Aortogram of a 4-year-old child with renovascular hypertension caused by stenosis of the left renal artery. Note that the left kidney has 2 renal arteries, and the artery to the superior pole has stenosis.
Close-up view of the same arteriogram described above. The stenotic lesion begins at the ostium of the left superior renal artery. This lesion was caused by fibromuscular dysplasia and did not respond well to balloon angioplasty.
Operative photograph of the patient described above. The patient underwent aortorenal bypass using a reinforced saphenous vein graft. The inferior pole renal artery was preserved.
Aortogram of an 8-year-old child with neurofibromatosis and renovascular hypertension caused by right renal artery stenosis.
Operative photograph of the patient shown above. An aortorenal bypass was performed using saphenous vein graft reinforced with Dacron. The aorta is completely exposed as observed in this picture, and the graft is visible inferior to the native renal artery.
Although nephrectomy is rarely indicated in the treatment of renovascular hypertension in children, it can be safely performed using modern pediatric surgical laparoscopy technique. This 3-month-old child with renal dysplasia and refractory hypertension underwent laparoscopic nephrectomy. The photograph illustrates the patient positioning and the placement of small trocars at the time of the nephrectomy. The dysplastic kidney was easily removed through a slightly enlarged umbilical incision.
Same patient shown above. The photograph was taken immediately after laparoscopic nephrectomy. This patient was discharged from the hospital 2 days after surgery. This approach eliminates the need for large incisions and facilitates recovery from surgery, minimizing pain and length of hospital stay.
 
 
 
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