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Renovascular disease, the third most common cause of pediatric hypertension (ranking just behind coarctation of the thoracic aorta and parenchymal renal disease), may account for five to 10 percent of children with marked blood pressure elevation.

According to University of Michigan researchers, untreated pediatric renovascular hypertension can be associated with hemorrhagic stroke or hypertensive encephalopathy with impaired mental development. It also can result in left ventricular hypertrophy and severe diastolic dysfunction, including flash pulmonary edema associated with renal insufficiency if the entire renal mass is involved.  

Conventional surgical revascularization, which emphasizes direct renal artery implantations and single staged concomitant aortic and splanchnic arterial reconstructions, offers excellent results for renovascular disease, according to a retrospective clinical report by a multi-specialty group of researchers. The study appears in the December issue of the Journal for Vascular Surgery.

Data gathered from 97 consecutive University of Michigan Medical Center patients (age three months to 17 years) who underwent surgery for renovascular hypertension from 1963 to 2006, was reviewed. According to study lead-author James C. Stanley, MD, a director of the University of Michigan’s Cardiovascular Center, this is the largest cohort study ever published on this childhood disease.  
        
Dr. Stanley said that all but one of the study’s 97 children had refractory hypertension unresponsive to contemporary medical therapy. One hundred and thirty-two primary operations and 30 had secondary operations were performed on the study’s 97 patients. Hypertension was cured in 70 percent of the children, improved in 27 percent and unchanged in three percent. Follow-up averaged 4.2 years. No patients required dialysis and there were no operative deaths.

He added that renal revascularization is most likely to be successful for patients after the age of three years and drug treatment in very young children requires frequent and fastidious monitoring.

The researchers reported that developmental renal artery stenoses accounted for 80 percent of the renal artery disease in the study, and that inflammatory and other ill-defined stenoses were less frequent. “Contemporary surgical treatment for 40 patients in the later cases emphasized direct aortic implantation of the normal renal artery beyond its stenosis as well as single-staged concomitant splanchnic and aortic reconstructions when necessary,” said Dr. Stanley. Splanchnic arterial occlusive lesions and abdominal aortic coarctations affected 24 and 32 of the series’ 97 children, respectively.     

“Now and in the future pediatric renovascular hypertension is more likely to be considered because children are screened for blood pressure and cardiac abnormalities more often.” said Dr. Stanley, “Less invasive diagnostic testing also will be able to confirm renal artery disease. Physicians must remember these patients are often critically ill and because procedures are frequently complex, optimal care requires long-term follow-up. 

Resection beyond the stenosis and implantation in the abdominal aorta was the most common primary renal artery operation in this study (49 cases). Thirty-four children underwent bilateral renal operations, which counted for only one of 20 procedures in the first decade of this experience compared with 19 of the 40 most recently performed procedures. Irreparable renal disease (12 patients) was the usual reason for performance of a nephrectomy which can include multiple intrarenal aneurysms that can not be corrected with open reconstruction. 

Fifteen percent of the children were made worse by previous failures of percutaneous transluminal angioplasty which is now rarely pursued as a primary therapeutic modality. Dr Stanley and his coauthors, including vascular surgeons, pediatric nephrologists and interventional radiologists, concluded that benefits accompanied carefully executed operative procedures in 97 percent of these severely hypertensive children.