Barry M. Potter

Renovascular hypertension in children: Current concepts in Evaluation and treatment

Since 1981, we have evaluated and treated 22 children with renovascular hypertension (RVH). Seventeen patients had stenosis of their native renal arteries, and five had stenosis of the artery in a transplanted kidney. RVH was caused by fibromuscular dysplasia in 13 patients, by trauma in 2 patients, and by arteritis in 2 patients. Among the patients who had transplanted kidneys, three had technical causes for stenosis and two had stenosis due to rejection. The disease was unilateral in 10 patients, bilateral in 5, and present in a solitary kidney in 7, including the five renal transplants. Diagnostic studies that strongly suggested the presence of renovascular disease were an initial diastolic blood pressure greater than 100 mm Hg, an elevated peripheral vein renin activity level, and an abnormal renal scan if the patients hypertension was being controlled with an angiotensin-converting enzyme inhibitor (ACEI). Only the renal arteriogram was 100% accurate in confirming the presence of RVH. Percutaneous angiographic correction was attempted in 13 patients and resulted in lasting improvement of the hypertension in five (38%). Surgical revascularization was attempted in 17 children, including the 8 with failed angioplasty, with improvement or cure of the hypertension in 15 patients (88%). Combining percutaneous transluminal angioplasty (PTA) and surgical results gave 20 of 22 patients (91%) with cure or improvement of their hypertension. Four of 27 affected kidneys (15%) could not be revascularized and were removed. We conclude from this series of patients that despite improvements in noninvasive studies, renal arteriogram remains the only study that is 100% accurate in evaluating children for RVH.(ABSTRACT TRUNCATED AT 250 WORDS)

Reconstruction of the renal artery after unsuccessful percutaneous transluminal angioplasty in children.

The use of percutaneous transluminal angioplasty as the primary treatment of renovascular stenosis in adults has recently been described. Previously, only three children have been reported to have undergone transluminal angioplasty for stenosis of the renal artery and hypertension. At our hospital, transluminal angioplasty was attempted in four children with renal artery stenosis; one attempt was successful and three were unsuccessful. The three patients who required surgical repair of the renal artery after unsuccessful transluminal angioplasty have been described in detail. The histopathology of the stenotic vessels is also discussed. Based on the analysis of the three children, certain criteria have been derived to select pediatric patients with renovascular hypertension either for attempted transluminal angioplasty or for primary surgical revascularization.

Persistent left fifth aortic arch with complex coarctation.

Abstract Persistent fifth aortic arch is a rare anomaly, with only 22 cases reported. 1,2 Its recognition and successful management when associated with coarctation is even rarer. We present a child with persistent left fifth aortic arch and complex coarctation successfully diagnosed and repaired.

Portal decompression in infants and children with the interposition mesocaval shunt

The mesocaval graft for portal decompression is applicable in infants and children with portal hypertension secondary to extrahepatic or intrahepatic causes. It is recommended in patients in whom extensive previous surgery in the portahepatis (Kasai procedure) would make dissection of the portal vein difficult and endanger the integrity of the functioning biliary conduit. It can be performed in patients who have had previous splenectomy or in whom portacaval or splenorenal shunts have failed. Autogenous jugular vein is favored for creation of the shunt.

NON-INVASIVE INDICATORS OF RENAL ARTERY STENOSIS |[lpar]|RAS|[rpar]| IN CHILDREN

Unilateral and bilateral RAS are significant and potentially correctable causes of secondary hypertension in children. The technical difficulties and risks of angiography led us to do a retrospective analysis of non-invasive predictors of RAS in 10 consecutive hypertensive children who had renal arteriograms. Five had RAS and all had similar preliminary diagnostic evaluations. Patient ages ranged from 2 to 17 years and there were no differences in sex or age distribution between the RAS and non-RAS groups. An abnormal physical examination (abdominal bruit, cafe-au-lait spots) was highly related to RAS. Further, small sample predictive analysis indicated that a high accuracy of RAS classification may be possible utilizing only the variables of absolute elevations of plasma renin activity and BP [s/d 95%] (BP [s/d 95%] is the sum of the age-adjusted difference for systolic and diastolic BP exceeding the 95%). By contrast, poor correlation with the diagnosis of RAS was found with the following: renal scintillation scanning, depression in blood pressure (BP) using saralasin, and plasma aldosterone. We conclude that physical examination, plasma renin activity and BP [s/d 95%] are important predictors of RAS and help in the pre-selection of children needing renal angiography. In addition, the value of performing the other diagnostic tests studied is questioned.