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Successful cutting balloon angioplasty in a child with resistant renal artery stenosis.

Son JS - BMC Res Notes (2015)

Bottom Line: After unsuccessful attempts to perform balloon angioplasty, 3.5-mm cutting balloon angioplasty (CBA) was performed and yielded satisfactory results.The author describes a case of resistant RAS that was detected on MDCT and successfully treated using percutaneous (CBA).Although cutting balloon angioplasty is useful in many clinical conditions, including the current case, clinicians should carefully consider the associated risk of arterial disruption and pseudoaneurysm formation.

View Article: PubMed Central - PubMed

Affiliation: Department of Pediatrics, Konkuk University Medical Center, Konkuk University School of Medicine, 120-1 Neungdong-ro, Gwangjin-gu, Seoul, 05030, Korea. drsonped@kuh.ac.kr.

ABSTRACT

Background: Although renovascular hypertension is a rare disease, it is associated with 5-10 % of cases of childhood hypertension. It is a potentially treatable cause of hypertension, and is often caused by renal artery stenosis (RAS). The most common cause of RAS in children is fibromuscular dysplasia (FMD). The options for treating RAS depend on the location, severity and abnormality underlying the condition.

Case presentation: A previously healthy 7-year-old Korean boy presented to our clinic with hypertension and headache. Renal ultrasonography and multi-detector computed tomography (MDCT) showed severe focal stenosis at the middle portion of the left renal artery (LRA) and multiple collateral vessels. Percutaneous balloon angioplasty was performed as an initial treatment, but yielded unsatisfactory results. The presence of intimal-type FMD was suspected based on his clinical features, angiographic appearance, and resistance to percutaneous transluminal renal angioplasty. Thereafter, his blood pressure was normalized using antihypertensive medication. Follow-up multi-detector computed tomography at 11 years of age showed persistent severe stenosis of the LRA. After unsuccessful attempts to perform balloon angioplasty, 3.5-mm cutting balloon angioplasty (CBA) was performed and yielded satisfactory results. He was discharged without any medication. At 1 year and 6 months after the intervention, he has been normotensive and had not required any antihypertensive medication.

Conclusion: The author describes a case of resistant RAS that was detected on MDCT and successfully treated using percutaneous (CBA). Although cutting balloon angioplasty is useful in many clinical conditions, including the current case, clinicians should carefully consider the associated risk of arterial disruption and pseudoaneurysm formation.

No MeSH data available.


Related in: MedlinePlus

Three-dimensional multi-detector computed tomographic angiogram. a Severe focal stenosis is observed in the proximal area of the left renal artery on pre-mapping with 64-channel multi-detector computed tomographic angiography, before the interventional procedure. b Dilated and patent renal artery stenosis is observed at 7 months after cutting balloon angioplasty
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Fig1: Three-dimensional multi-detector computed tomographic angiogram. a Severe focal stenosis is observed in the proximal area of the left renal artery on pre-mapping with 64-channel multi-detector computed tomographic angiography, before the interventional procedure. b Dilated and patent renal artery stenosis is observed at 7 months after cutting balloon angioplasty

Mentions: A previously healthy 7-year-old Korean boy presented to our clinic with hypertension and intermittent headaches. His blood pressure (BP) was 137/93 mmHg and 24 h ambulatory mean BP was 181/117 mmHg (daytime, 197/125 mmHg; nighttime, 160/91 mmHg). He was admitted for further evaluation of the hypertension. He had no episodes of persistent fever of unknown origin, and no symptoms such as stomatitis, arthritis, and skin rash that were indicative of autoimmune disease. There was no family history for autoimmune, cardiovascular, or renal disease. Except for the high BP values, the physical examination yielded unremarkable results. He also didn’t exhibit any facial anomalies or skin lesions. Laboratory examination indicated that blood cell count, serum creatinine levels, serum electrolyte levels, thyroid function, and urinalysis results were normal. In addition, serum C-reactive protein (CRP) levels and erythrocyte sedimentation rate (ESR) were normal. Vasculitis screening, including tests for antinuclear antibodies, antibodies to double-stranded DNA, and anti-neutrophil cytoplasmic antibodies, indicated normal results. Fundoscopic examination showed minimally increased vascular tortuosity. Echocardiography showed no specific abnormalities. Renal ultrasonography demonstrated abnormal Doppler waveforms in the left kidney, characterized by a tardus–parvus pattern [6]. A 64-channel MDCT showed severe focal stenosis at the middle portion of the left renal artery (LRA) and multiple collateral vessels. PTRA was performed with multiple inflations; during the final attempt, the balloon was inflated at a pressure beyond the burst pressure. However, unsatisfactory results were obtained. The author suspected a diagnosis of intimal-type FMD based on his clinical features, angiographic appearance, and resistance to PTRA. As his BP could be well controlled with antihypertensive medication after the initial intervention, the author decided to attempt PTRA once more or another surgery after he reached puberty. A repeat MDCT (Fig. 1a) at 11 years of age showed persistent severe stenosis at the middle portion of the LRA with post-stenotic dilatation. Abdominal angiography (Fig. 2a) showed similar results, and hence, PTRA was attempted 3 times by using high pressure balloons with different sizes. However, as the dilatation was not successful and the levels of inflammatory markers (ESR and CRP) were within normal range, we decided to attempt percutaneous revascularization via CBA. After CBA was performed with a 3.5-mm cutting balloon (Fig. 2b), repeat abdominal angiography (Fig. 2c) showed no clinically significant residual stenosis. He was discharged without any antihypertensive medication. At 7 months after CBA, on follow-up MDCT, no signs of re-stenosis of the LRA were noted (Fig. 1b). Subsequently, at 1 year and 6 months after CBA, he appears normotensive and has not required any antihypertensive medication.Fig. 1


Successful cutting balloon angioplasty in a child with resistant renal artery stenosis.

Son JS - BMC Res Notes (2015)

Three-dimensional multi-detector computed tomographic angiogram. a Severe focal stenosis is observed in the proximal area of the left renal artery on pre-mapping with 64-channel multi-detector computed tomographic angiography, before the interventional procedure. b Dilated and patent renal artery stenosis is observed at 7 months after cutting balloon angioplasty
© Copyright Policy - OpenAccess
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4643536&req=5

Fig1: Three-dimensional multi-detector computed tomographic angiogram. a Severe focal stenosis is observed in the proximal area of the left renal artery on pre-mapping with 64-channel multi-detector computed tomographic angiography, before the interventional procedure. b Dilated and patent renal artery stenosis is observed at 7 months after cutting balloon angioplasty
Mentions: A previously healthy 7-year-old Korean boy presented to our clinic with hypertension and intermittent headaches. His blood pressure (BP) was 137/93 mmHg and 24 h ambulatory mean BP was 181/117 mmHg (daytime, 197/125 mmHg; nighttime, 160/91 mmHg). He was admitted for further evaluation of the hypertension. He had no episodes of persistent fever of unknown origin, and no symptoms such as stomatitis, arthritis, and skin rash that were indicative of autoimmune disease. There was no family history for autoimmune, cardiovascular, or renal disease. Except for the high BP values, the physical examination yielded unremarkable results. He also didn’t exhibit any facial anomalies or skin lesions. Laboratory examination indicated that blood cell count, serum creatinine levels, serum electrolyte levels, thyroid function, and urinalysis results were normal. In addition, serum C-reactive protein (CRP) levels and erythrocyte sedimentation rate (ESR) were normal. Vasculitis screening, including tests for antinuclear antibodies, antibodies to double-stranded DNA, and anti-neutrophil cytoplasmic antibodies, indicated normal results. Fundoscopic examination showed minimally increased vascular tortuosity. Echocardiography showed no specific abnormalities. Renal ultrasonography demonstrated abnormal Doppler waveforms in the left kidney, characterized by a tardus–parvus pattern [6]. A 64-channel MDCT showed severe focal stenosis at the middle portion of the left renal artery (LRA) and multiple collateral vessels. PTRA was performed with multiple inflations; during the final attempt, the balloon was inflated at a pressure beyond the burst pressure. However, unsatisfactory results were obtained. The author suspected a diagnosis of intimal-type FMD based on his clinical features, angiographic appearance, and resistance to PTRA. As his BP could be well controlled with antihypertensive medication after the initial intervention, the author decided to attempt PTRA once more or another surgery after he reached puberty. A repeat MDCT (Fig. 1a) at 11 years of age showed persistent severe stenosis at the middle portion of the LRA with post-stenotic dilatation. Abdominal angiography (Fig. 2a) showed similar results, and hence, PTRA was attempted 3 times by using high pressure balloons with different sizes. However, as the dilatation was not successful and the levels of inflammatory markers (ESR and CRP) were within normal range, we decided to attempt percutaneous revascularization via CBA. After CBA was performed with a 3.5-mm cutting balloon (Fig. 2b), repeat abdominal angiography (Fig. 2c) showed no clinically significant residual stenosis. He was discharged without any antihypertensive medication. At 7 months after CBA, on follow-up MDCT, no signs of re-stenosis of the LRA were noted (Fig. 1b). Subsequently, at 1 year and 6 months after CBA, he appears normotensive and has not required any antihypertensive medication.Fig. 1

Bottom Line: After unsuccessful attempts to perform balloon angioplasty, 3.5-mm cutting balloon angioplasty (CBA) was performed and yielded satisfactory results.The author describes a case of resistant RAS that was detected on MDCT and successfully treated using percutaneous (CBA).Although cutting balloon angioplasty is useful in many clinical conditions, including the current case, clinicians should carefully consider the associated risk of arterial disruption and pseudoaneurysm formation.

View Article: PubMed Central - PubMed

Affiliation: Department of Pediatrics, Konkuk University Medical Center, Konkuk University School of Medicine, 120-1 Neungdong-ro, Gwangjin-gu, Seoul, 05030, Korea. drsonped@kuh.ac.kr.

ABSTRACT

Background: Although renovascular hypertension is a rare disease, it is associated with 5-10 % of cases of childhood hypertension. It is a potentially treatable cause of hypertension, and is often caused by renal artery stenosis (RAS). The most common cause of RAS in children is fibromuscular dysplasia (FMD). The options for treating RAS depend on the location, severity and abnormality underlying the condition.

Case presentation: A previously healthy 7-year-old Korean boy presented to our clinic with hypertension and headache. Renal ultrasonography and multi-detector computed tomography (MDCT) showed severe focal stenosis at the middle portion of the left renal artery (LRA) and multiple collateral vessels. Percutaneous balloon angioplasty was performed as an initial treatment, but yielded unsatisfactory results. The presence of intimal-type FMD was suspected based on his clinical features, angiographic appearance, and resistance to percutaneous transluminal renal angioplasty. Thereafter, his blood pressure was normalized using antihypertensive medication. Follow-up multi-detector computed tomography at 11 years of age showed persistent severe stenosis of the LRA. After unsuccessful attempts to perform balloon angioplasty, 3.5-mm cutting balloon angioplasty (CBA) was performed and yielded satisfactory results. He was discharged without any medication. At 1 year and 6 months after the intervention, he has been normotensive and had not required any antihypertensive medication.

Conclusion: The author describes a case of resistant RAS that was detected on MDCT and successfully treated using percutaneous (CBA). Although cutting balloon angioplasty is useful in many clinical conditions, including the current case, clinicians should carefully consider the associated risk of arterial disruption and pseudoaneurysm formation.

No MeSH data available.


Related in: MedlinePlus