Endovascular Therapy of Renovascular Hypertension in Children: Single Center Analysis

Abstract

Introduction: We present our results after percutaneous transluminal renal angioplasty (PTRA) and stent implantation in the treatment of eight children with renal artery stenosis (RAS) with consequential development of malignant renovascular hypertension (RVH) despite the administration of antihypertensive drugs.

Patients and methods: In the period between January 2000 and November 2007, endovascular interventional procedures in the renal arteries were performed in 8 children (six boys and two girls) to treat malignant RVH caused by RAS. The mean patient age±standard deviation was 10.8 years±3.7 years (median age 9 years; range 8–17 years). Interdisciplinary discussion and evaluation of the indications for endovascular treatment was carried out for all of the eight patients. Our indications for the PTRA procedure were severe RVH with arterial blood pressure (BP) values above the 99th percentile, which did not respond to the administration of antihypertensive drugs. Renal artery stenting was performed due to re-stenosis after PTRA.

Results: Diagnostic digital subtraction angiography demonstrated unilateral RAS of the main renal artery in seven children and bilateral stenosis of the renal arteries in one child. We performed 11 endovascular interventions on 9 main renal arteries in 8 children (10 PTRA and one stent placement). In 7 of 8 children, complete correction of RAS was achieved. Follow-up assessment over a mean period of 39 months (range 6–84 months) showed normotension with no antihypertensive treatment in 6 children. One child had a technically successful PTRA and improved BP with reduced requirement for antihypertensive treatment. Technical failure of the endovascular intervention occurred in a boy with severe FMD who underwent successful surgical autotransplantation of the kidney.

Conclusions: Endovascular therapy of RAS in children with consequential development of malignant RVH despite antihypertensive drugs represents the treatment of choice. PTRA and/or stent implantation are technically and clinically feasible and safe in this group of children. Optimal treatment results in children can be expected in a clinical environment with successful interdisciplinary cooperation between the pediatrician, interventional radiologist and pediatric surgeon.

Key words

renovascular hypertension - renal artery stenosis - percutaneous transluminal renal angioplasty (PTRA), stent - child

References

• 1 Birrer M, Do DD, Mahler F, Triller J, Baumgartner I. Treatment of renal artery fibromuscular dysplasia with balloon angioplasty: a prospective follow-up study.  Eur J Vasc Endovasc Surg. 2002;  23 ((2)) 146-152
• 2 Casalini E, Sfondrini MS, Fossali E. Two-year clinical follow-up of children and adolescents after percutaneous transluminal angioplasty for renovascular hypertension.  Inves Radiol. 1995;  30 ((1)) 1235-1240
• 3 Chalmers RT, Dhadwal A, Deal JE, Sever PS, Wolfe JH. The surgical management of renovascular hypertension in children and young adults.  Eur J Vasc Endovasc Surg. 2000;  19 ((4)) 400-405
• 4 Ellis D, Shapiro R, Scantlebury VP, Simmons R, Towbin R. Evaluation and management of bilateral renal artery stenosis in children: a case series and review.  Pediatr Nephrol. 1995;  9 ((3)) 259-267
• 5 Green TJ, Mauro MA. SIR 2003 film panel case 4: neurofibromatosis.  J Vasc Interv Radiol. 2003;  14 663-666
• 6 Grüntzig A, Vetter W, Meier B, Kuhlmann U, Lütolf U, Siegenthaler W. Treatment of renovascular hypertension with percutaneous transluminal dilatation of a renal-artery stenosis.  Lancet. 1978;  1 801-802
• 7 Gruskin AB, Dabbagh S, Fleischmann LF, Apostol EL, Mattoo TK. Mechanisms of hypertension in childhood diseases. In: Barratt TM, Avner ED, Harmon W. Pediatric Nephrology. 4th ed. Lippincott, Williams & Wilkins 1998: 1009-1011
• 8 Hiner LB, Falkner B. Renovascular hypertension in children.  Pediatr Clin North Am. 1993;  40 ((1)) 123-140
• 9 König K, Gellermann J, Querfeld U, Schneider MB. Treatment of severe renal artery stenosis by percutaneous transluminal renal angioplasty and stent implantation: review of the pediatric experience: apropos of two cases.  Pediatr Nephrol. 2006;  21 ((5)) 663-671
• 10 Mali WP, Puijlaert CB, Kouwenberg HJ, Klinge J, Donckerwolcke RA, Geijskes BG, Overbosch EH, Rosenbusch GJ, Ludwig WW, Feldberg MA. Percutaneous transluminal renal angioplasty in children and adolescents.  Radiology. 1987;  165 ((2)) 391-394
• 11 McCook TA, Mills SR, Kirks DR, Heaston DK, Seigler HF, Malone RB, Osofsky SG. Percutaneous transluminal renal artery angioplasty in a 3 1/2-year-old hypertensive girl.  J Pediatr. 1980;  97 ((6)) 958-960
• 12 National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents . The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents.  Pediatrics. 2004;  114 ((2)) 555-576
• 13 Norwood VF. Hypertension.  Pediatr Rev. 2002;  23 197-208
• 14 O’Neill Jr JA. Long-term outcome with surgical treatment of renovascular hypertension.  J Pediatr Surg. 1998;  33 ((1)) 106-111
• 15 Patterson LT, Bock GH, Guzzetta PC, Ruley EJ. Restoration of kidney function after prolonged renal artery occlusion.  Pediatr Nephrol. 1990;  4 ((2)) 163-165
• 16 Radermacher J, Chavan A, Schäffer J, Stoess B, Vitzthum A, Kliem V, Rademaker J, Bleck J, Gebel MJ, Galanski M, Brunkhorst R. Detection of significant renal artery stenosis with color Doppler sonography: combining extrarenal and intrarenal approaches to minimize technical failure.  Clin Nephrol. 2000;  53 ((5)) 333-343
• 17 Repetto HA, Rodríguez-Rilo L, Mendaro E, Basso L, Galvez H, Morrone G, Vazquez LA. Percutaneous treatment of transplant renal artery stenosis in children.  Pediatr Nephrol. 2004;  19 ((12)) 1400-1403
• 18 Rosner B, Prinaes RJ, Loggie JMH, Daniels SR. Blood pressure nomograms for children and adolescents by height, sex and age in the United States.  J Pediatr. 1993;  123 871-886
• 19 Safian RD, Textor SC. Renal-artery stenosis.  N Engl J Med. 2001;  344 ((6)) 431-442
• 20 Shroff R, Roebuck DJ, Gordon I, Davies R, Stephens S, Marks S, Chan M, Barkovics M, MacLaren CA, Shah V, Dillon MJ, Tullus K. Angioplasty for renovascular hypertension in children: 20-year experience.  Pediatrics. 2006;  118 ((1)) 268-275
• 21 Stanley P, Hieshima G, Mehringer M. Percutaneous transluminal angioplasty for pediatric renovascular hypertension.  Radiology. 1984;  153 ((1)) 101-104
• 22 Textor SC. Ischemic nephropathy: where are we now?.  J Am Soc Nephrol. 2004;  15 1974-1982
• 23 Tullus K, Brennan E, Hamilton G, Lord R, MacLaren CA, Marks SD, Roebuck DJ. Renovascular hypertension in children.  Lancet. 2008;  371 ((9622)) 1453-1463
• 24 Tyagi S, Kaul UA, Satsangi DK, Arora R. Percutaneous transluminal angioplasty for renovascular hypertension in children: initial and long-term results.  Pediatrics. 1997;  99 ((1)) 44-49
• 25 Waksman R. Biodegradable stents: they do their job and disappear.  J Invasive Cardiol. 2006;  18 ((2)) 70-74
• 26 Waksman R. Update on bioabsorbable stents: from bench to clinical.  J Interv Cardiol. 2006;  19 ((5)) 414
• 27 Zakanj Z. Hypertension – literature review of diagnosis and management procedures in childhood.  Lijec Vjesn. 2007;  129 ((6–7)) 214-223

Correspondence