Renovascular Hypertension, Surgical Treatment Workup

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

Laboratory Studies

  • Basic diagnostic tests for pediatric renovascular hypertension should accomplish 2 things.
    • Because the most common medical cause of hypertension in children is renal disease, the aim in initial testing should be the detection of unsuspected renal parenchymal disease.
    • Secondly, tests should identify the presence of end-organ damage due to the hypertension.
  • The 1987 Report of the Second Task Force on blood pressure control in childhood recommends a fasting lipid profile in patients with findings suggestive of essential hypertension to evaluate atherosclerotic cardiovascular disease.[3] The report also recommends the following initial tests in children with hypertension:
    • CBC count
    • Urinalysis
    • Urine culture (all girls, selected boys)
    • Serum electrolyte levels (sodium, potassium, chloride, and total carbon dioxide)
    • BUN levels
    • Serum creatinine levels
  • Remember that the renal function test results are frequently normal in children with renovascular disease, even when the lesions are bilateral.
  • Findings on a 24-hour urine study should also be within the reference range in renovascular hypertension.
  • CBC count, serum electrolyte levels, BUN levels, and serum creatinine levels should indicate whether a pattern of renal function impairment or a pattern of aldosteronoma is present.
  • Measure a 24-hour urine sample for electrolytes, creatinine, vanillylmandelic acid, catecholamines, 17-hydroxy steroids, and 17-keto steroids. Results should rule out the possibility of a medullary or cortical tumor.
  • The erythrocyte sedimentation rate is a good indicator of active arteritis.
  • Elevation of peripheral or renal vein plasma renin activity has been used to diagnose unilateral renal disease and predict surgical curability. However, an elevated level does not establish the cause of hypertension, and plasma renin levels that are within the reference range do not rule out renovascular disease.
    • Renal vein renin ratios compare the effluent activity of each kidney. Ratios greater than 1.5 are suggestive of functionally important renovascular disease. Volume depletion exaggerates reduced renal perfusion and may increase the ratio of renal vein renins in asymmetric disease.
    • One study found that nearly 90% of renal artery disease was detected when pretreated with furosemide. However, these findings can also be misleading, especially in bilateral disease.
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Imaging Studies

  • When renovascular hypertension is suspected, the criterion standard for diagnosis is renal arteriography. Because this is a very invasive procedure, performing less specific tests to modify the physician's suspicion of renovascular disease is frequently necessary before submitting the patient to this test. The following studies are useful in the assessment of patients with suspected renovascular hypertension.
    • Ultrasonography: Most authors think that radiographic studies should begin with Doppler ultrasonography of the kidneys and abdomen. This is useful in identifying renal disease and abdominal masses. In renal artery stenosis, ultrasonography often reveals a slowing and dampening of systole distal to the stenosis. Renal ultrasonographic findings are insufficient to rule out the need for angiography.
    • Renal scanning: Intravenous pyelography may be useful in detecting unilateral lesions, but is often unhelpful when bilateral disease is present. Many think that intravenous pyelography is an unnecessary part of the evaluation because results are often inaccurate in children. Likewise, technetium-99m (99m Tc) scanning, diethylenetriamine pentaacetic acid (DTPA) renal scanning, and other radionuclide studies may be misleading in bilateral renovascular hypertension. However, some think that DTPA or99m Tc dimercaptosuccinic acid (DMSA) scanning is helpful in identifying patients at increased risk for renovascular hypertension when performed before and after the administration of the ACE inhibitor, captopril. Decreased function after treatment with captopril indicates a high likelihood of renovascular stenosis. If the scan findings remain normal, renovascular disease is not ruled out.
    • Intravenous digital subtraction angiography (DSA): Intravenous DSA has also been suggested as a means of identifying renovascular disease. Unfortunately, this test is dependent on the skill of the individual interpreting the radiograph, and image quality is diminished by patient or intestinal motion, gas, overlying vessels, and poor cardiac output. The use of abdominal pressure and glucagon can reduce interference from gas and intestinal motion.
    • Renal arteriography: Selective renal arteriography is the only reliable means to document renal artery stenosis. This test is still considered the criterion standard for diagnosis of renovascular hypertension. Renal arteriography is necessary whenever surgery or percutaneous transluminal angioplasty is anticipated. Adding digital subtraction technology to renal arteriography requires one half the volume of dilute contrast medium of standard arteriography, with comparable results. Use abdominal pressure and glucagon to prevent bowel motion and gas from affecting the image quality.
    • Magnetic resonance angiography (MRA), CT angiography, and spiral angiography: MRA, CT angiography, and spiral angiography are newer studies that hold a lot of promise for diagnosis and evaluation of renovascular hypertension. Unfortunately, they have not yet been sufficiently investigated for use in children with renovascular disease. At present, interpretation of the images is technically difficult, and their usefulness appears limited to imaging of main vessels.
  • Chest radiography and echocardiography may be helpful in differentiating left ventricular failure from chronic hypertension.
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Other Tests

  • ECG may be helpful in differentiating left ventricular failure from chronic hypertension.
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Histologic Findings

  • Because many of the lesions in FMD occur at the renal artery orifice, obtaining a good histologic sample is frequently difficult.
  • Evaluation of stenotic lesions invariably reveals the characteristic FMD in the medial or perimedial muscular layers associated with varying degrees of intimal hyperplasia.
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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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