Operative Management Of Pediatric Renovascular Hypertension
Frank M. Davis, MD1, Jonathan Eliason, MD1, Zubin Modi, MD1, Sahira Kazanjian, MD1, Dawn Coleman, MD2.
1University of Michigan, Ann Arbor, MI, USA, 2University of Michigan Pediatric Renovascular Hypertension Center, Ann Arbor, MI, USA.
DEMOGRAPHICS: An 8 year-old male was transferred from an international medical center to a United States tertiary referral center with a longstanding history of renovascular hypertension and new onset acute kidney injury (AKI) requiring emergent dialysis.
HISTORY: To review, the patient suffered presumed hemolytic uremic syndrome managed by eculizumab therapy at 2 months of age which resulted in chronic kidney disease. He was initially managed during his childhood on a multi-drug regimen for his renovascular hypertension. Outside hospital work-up demonstrated a dysfunctional right kidney, for which right nephrectomy was performed. Hypertension failed to improve, and he was left with a single kidney and a GFR of 90 ml/min/m2. Approximately two years following nephrectomy, and one month prior to his transfer, he presented with a viral respiratory illness and malignant hypertension with anuric AKI requiring emergent dialysis. Angiogram demonstrated abdominal aortic coarctation with occlusion of the proximal left renal artery and reconstitution of the mid-artery (Figure 1). Given his medical complexity and need for specialized surgical correction he was transferred for further operative management.
PLAN: Following medical optimization of his five-drug antihypertensive regimen and dialysis needs, the patient underwent single stage aortic and left renal artery revascularization through a transverse supraumbilical incision via patch aortoplasty and left renal artery reimplantation. This required a 36 minute supra-SMA aortic cross clamp. There were no post-operative complications. The child was maintained on anti-platelet therapy following reconstruction, and completion angiogram demonstrated patent reconstruction with normal flow patterns and indexes on renal duplex. At the time of discharge from the hospital, his blood pressure was controlled on a three-drug oral regimen, and he was off dialysis with a stable creatine (0.71 mg/dL).
DISCUSSION: Renovascular hypertension associated with renal artery and abdominal aortic narrowing is the third most common cause of pediatric hypertension. Left untreated, children may experience major cardiopulmonary complications, stroke, renal failure, and death. While correction of abdominal coarctation may successfully optimize candidacy for future transplantation for end-stage renal disease, salvage renal revascularization can successfully accomplish restoration of renal function and should be considered for appropriately selected patients at high volume multidisciplinary centers of excellence.
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