Diagnostic Considerations
Clues to the presence of renovascular hypertension (RVHT) that might lead to serious complications (eg, stroke, renal failure, and cardiac decompensation) include the following:
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Recurrent and otherwise unexplained flash pulmonary edema or heart failure
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Recalcitrant hypertension that previously was controlled easily
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Hypertension that abruptly becomes more difficult to control and requires increased antihypertensive agents
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Slowly increasing serum creatinine levels, signifying the evolution of ischemic nephropathy
In addition to the conditions listed in the differential diagnosis, other problems to be considered include the following:
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Adrenal tumor
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Aldosteronoma
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Aortic insufficiency
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Arterial hypoplasia
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Cushing disease
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Cushing syndrome
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Essential hypertension
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Fibromuscular dysplasia
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Increased intracranial pressure
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Intracranial mass
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Irradiation
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Moyamoya disease
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Other nonessential forms of hypertension
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Renal cyst
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Renal failure
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Renal hypoplasia
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Renal parenchymal disease
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Retinopathy
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Stroke
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Thrombosis
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Umbilical catheter embolism
Differential Diagnoses
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Pediatric Congestive Heart Failure
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Magnetic resonance angiography (MRA) showing renal artery stenosis. Courtesy of Patricia Stoltzfus, MD, Chief of Interventional Radiology, West Virginia University.
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Proposed pathogenesis of renovascular hypertension.
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Angiogram showing bilateral renal artery stenosis. Courtesy of Department of Radiology, Henry Ford Hospital.
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After percutaneous transluminal angioplasty (right renal artery). Courtesy of Department of Radiology, Henry Ford Hospital.
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After percutaneous transluminal angioplasty and stent placement (left renal artery). Courtesy of Department of Radiology, Henry Ford Hospital.
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Close-up of the Palmaz stent. Courtesy of Department of Radiology, Henry Ford Hospital.
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Aortogram of 4-year-old child with renovascular hypertension caused by stenosis of left renal artery. Note that left kidney has 2 renal arteries and that artery to superior pole has stenosis.
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Close-up view of aortogram of 4-year-old child. Stenotic lesion begins at ostium of left superior renal artery. This lesion was caused by fibromuscular dysplasia and did not respond well to balloon angioplasty.
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Operative photograph of 4-year-old child. Patient underwent aortorenal bypass with reinforced saphenous vein graft. Inferior pole renal artery was preserved.
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Aortogram of 8-year-old child with neurofibromatosis and renovascular hypertension caused by right renal artery stenosis.
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Operative photograph of 8-year-old child. Aortorenal bypass was performed with Dacron-reinforced saphenous vein graft. Aorta is completely exposed, and graft is visible inferior to native renal artery.
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Although nephrectomy is rarely indicated in treatment of renovascular hypertension in children, it can be safely performed with modern pediatric surgical laparoscopy technique. This 3-month-old child with renal dysplasia and refractory hypertension underwent laparoscopic nephrectomy. Photograph illustrates patient positioning and placement of small trocars at time of nephrectomy. Dysplastic kidney was easily removed through slightly enlarged umbilical incision.
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3-month-old child immediately after laparoscopic nephrectomy. This patient was discharged from hospital 2 days after surgery. This approach eliminates need for large incisions and facilitates recovery from surgery, minimizing pain and length of hospital stay.
