Mid-term outcome of angioplasty for pediatric renovascular hypertension

Mid-to-long term outcomes following renal artery angioplasty in children and young adults with renal artery stenosis: a retrospective review

BACKGROUND

This study investigates the efficacy of renal artery angioplasty for pediatric renovascular hypertension (RVH) and describes the role of pre-procedural diagnostic imaging.

METHODS

Clinical data of patients who underwent angioplasty for RVH from July 2014-May 2023 at a single, tertiary-care children's hospital were retrospectively analyzed. Renal angiography was performed in 74 children, mean age: 10.6 years (range, 3mos-20y). Mean follow-up: 2.5 years (range, 4d-10.4y). 45 angioplasty procedures were performed on 28 patients.

RESULTS

11(39.3%) were cured (normotensive, no anti-hypertensive medications), 10(35.7%) were improved (improved BP, decreased anti-hypertensive dose or number of meds), and 7(25%) failed (no improvement) following 1st angioplasty. Of the 17 patients who improved/failed, 12 had a 2nd angioplasty procedure. Of those, 3(25%) were treated with cutting-balloons. 2(16.7%) were cured, 8(66.7%) improved, and 2(16.7%) failed. 5 patients underwent a 3rd angioplasty procedure. 4(80%) were treated with cutting-balloons. 3 (60%) of the 5 patients were cured, 2 (40%) improved. In all, 16/28(57.1%) of patients were cured, and 12/28(42.9%) improved. 19 patients with abnormal angiography had normal CTA(10), MRA(3), and US(17). 14 patients with normal angiography had abnormal CTA(4), MRA(2), and US(13). Major complication rate was 8.9%(4/45) and included renal artery stent with residual in-stent stenosis, arterial extravasation following cutting-balloon angioplasty, arterial dissection, and vasospasm, partially resolved with nitroglycerin/TPA.

CONCLUSIONS

Angioplasty is an efficacious treatment for pediatric RVH, but may require more than one procedure to achieve successful clinical results. Angiography should be pursued when RVH is suspected, as other imaging modalities are commonly discordant with angiography.

Percutaneous Transluminal Renal Angioplasty for Pediatric Hypertension Secondary to Total Renal Artery Occlusion

PURPOSE

To assess the feasibility and effectiveness of percutaneous transluminal renal angioplasty (PTRA) for pediatric renovascular hypertension (RVH) secondary to total renal artery occlusion (RAO).

MATERIALS AND METHODS

From 2011 to 2021, 13 pediatric patients with RVH confirmed with 14 renal artery occlusions were reviewed. The mean age was 11.2 years (range, 4-16 years). Nine occlusions involved main artery occlusion, and 5 involved branch occlusion. Blood pressure ratio (BPR) was defined as the ratio of the actual measured blood pressure (BP) value to the 95th percentile value adjusted for age, sex, and height.

RESULTS

PTRA was performed in 9 patients (9/13, 69%). Technical success was achieved in 5 patients (5/9, 56%), with stent placement in 2 children (2/9, 22%). During the 12-month follow-up, restenosis was identified in both of the stent-receiving patients at the 12-month follow-up visit (2/9, 22%). Mean systolic BPR decreased from 1.20 (SD ± 0.07) to 0.96 (SD ± 0.06; P = .003), mean diastolic BPR decreased from 1.19 (SD ± 0.07) to 0.95 (SD ± 0.08; P = .005), and the number of medications required decreased from 3.8 (SD ± 0.8) to 2.4 (SD ± 0.9; P = .052) after PTRA. Subsequent to PTRA, the mean glomerular filtration rate of the occluded kidney improved from 19.5 mL/min (SD ± 12.3) to 36.3 mL/min (SD ± 10.8; P = .007), and the mean longitudinal dimension of the affected kidneys significantly increased from 8.2 cm (SD ± 1.5) to 9.2 cm (SD ± 1.7; P = .006).

CONCLUSIONS

Endovascular treatment is often feasible for pediatric patients with RAO, results in acceptable BP control, and preserves renal function.

Evidence for routine brain-to-pelvis imaging and antiplatelet therapy in patients diagnosed with fibromuscular dysplasia

Fibromuscular dysplasia (FMD) is a disease of the musculature of arterial walls leading to stenoses, aneurysms, and dissections. The purpose of this report was to summarize the evidence for (1) one-time routine imaging from brain-to-pelvis and (2) lifelong antiplatelet therapy, for example, aspirin, for patients diagnosed with FMD as suggested by an international consensus report from 2019. PubMed was systematically searched, and the evidence providing a basis for the current consensus points, as well as articles published since, were reviewed. In four registries evaluating patients with FMD, the prevalence of multivessel involvement, aneurysms, and dissections was reported to be 43.5%-66.3%, 21.6%-30.6%, and 5.6%-28.1%, respectively. Any antiplatelet drug was used in 72.9% of patients, and aspirin was prescribed in up to 70.2% of patients. Based on the high prevalence of vascular manifestations, their associated morbidity, and the potential for endovascular or surgical intervention, the suggestion of one-time brain-to-pelvis screening with computed tomography angiography or magnetic resonance angiography is well supported. Contrarily, the evidence to support the consensus statement of lifelong antiplatelet therapy to all patients in the absence of contraindications is more uncertain since a beneficial effect has not been demonstrated specifically in patients with fibromuscular dysplasia. Therefore, until the efficacy and safety of primary thromboprophylaxis have been demonstrated in this patient group specifically, it may be equally appropriate to only use antiplatelet agents in patients with a clear indication after individual evaluation according to risk factors for thrombotic and thromboembolic complications.

Cardiovascular outcomes improve in children with renovascular hypertension following endovascular and surgical interventions

BACKGROUND

Renovascular hypertension (RenoVH) is a cause of hypertension in children. A common cause of RenoVH is renal artery stenosis which acts by reducing blood supply to renal parenchyma and activating the renin-angiotensin-aldosterone axis, often leading to cardiac remodelling. This longitudinal observational study aims to describe occurrence of cardiovascular changes secondary to RenoVH and also any improvement in cardiac remodelling after successful endovascular and/or surgical intervention.

METHODS

All patients with RenoVH referred to our centre, who received ≥ 1 endovascular intervention (some had also undergone surgical interventions) were included. Data were collected by retrospective database review over a 22-year period. We assessed oscillometric blood pressure and eight echocardiographic parameters pre- and post-intervention.

RESULTS

One hundred fifty-two patients met inclusion criteria and had on average two endovascular interventions; of these children, six presented in heart failure. Blood pressure (BP) control was achieved by 54.4% of patients post-intervention. Average z-scores improved in interventricular septal thickness in diastole (IVSD), posterior Wall thickness in diastole (PWD) and fractional shortening (FS); left ventricular mass index (LVMI) and relative wall thickness (RWT) also improved. PWD saw the greatest reduction in mean difference in children with abnormal (z-score reduction 0.25, p < 0.001) and severely abnormal (z-score reduction 0.23, p < 0.001) z-scores between pre- and post-intervention echocardiograms. Almost half (45.9%) had reduction in prescribed antihypertensive medications, and 21.3% could discontinue all antihypertensive therapy.

CONCLUSIONS

Our study reports improvement in cardiac outcomes after endovascular + / - surgical interventions. This is evidenced by BP control, and echocardiogram changes in which almost half achieved normalisation in systolic BP readings and reduction in the number of children with abnormal echocardiographic parameters. A higher resolution version of the Graphical abstract is available as Supplementary information.

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