Advertisement

Pediatric Renal Artery Stenosis: A 19-Year Experience in Management and Outcomes at a Tertiary Pediatric Hospital

Published:March 11, 2022DOI:https://doi.org/10.1016/j.avsg.2022.02.010

      Background

      Renal artery stenosis (RAS) is an uncommon cause of pediatric hypertension. Guidelines for workup and management have not been established. The most widely reported etiology of the pediatric renovascular disease has been fibromuscular dysplasia; however, other etiologies including middle aortic syndrome (MAS) and vasculitides have been described. We reviewed cases of radiologically identified pediatric RAS and describe etiologies, management, and long-term clinical outcomes in our patients.

      Methods

      Reports for duplex ultrasound, computed tomography angiography, magnetic resonance imaging, and conventional angiography from an academic children's hospital between 2000 and 2019 were evaluated. Positive reports for RAS were confirmed by a vascular surgeon and a radiologist. Demographics, indications for evaluation, management, and long-term clinical outcomes were documented. Data are summarized as count (n), geometric mean, median, or standard deviation as appropriate. Univariate differences between treatment cohorts were analyzed using Chi-squared tests for categorical variables. Nonparametric paired Wilcoxon signed-rank test and Mann–Whitney U-test were used for the analysis of paired ordinal or continuous data. A statistical analysis was performed with SPSS software (SPSS Inc., Chicago, IL) with significance defined at a P < 0.05 level.

      Results

      Imaging for suspected RAS was performed on 984 children. Of the 38 patients with positive imaging for RAS, 60.5% were idiopathic, 31.5% (n = 12) had concomitant congenital/systemic comorbidity, and 21.0% (n = 8) had RAS and concomitant aortic pathology. Fibromuscular dysplasia only accounted for 13.2% (n = 5) of patients. Regarding management, 34.2% (n = 13) underwent invasive intervention, 23.7% (n = 9) underwent endovascular intervention alone, and 10.5% (n = 4) underwent endovascular plus surgical intervention. Conservative management was performed for 65.8% (n = 25) of patients at a long-term follow-up (33.8 months), 34.2% (n = 13) requiring only lifestyle changes, and 31.6% (n = 12) requiring only medical management.

      Conclusions

      Pediatric RAS is a low-frequency disease and long-term outcomes have been under-reported. The incidence of associated aortic pathology in our intervention cohort appears higher than that was previously reported. A long-term follow-up demonstrated that up to 65.8% of patients could be managed successfully with conservative therapy.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Annals of Vascular Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

      1. Hypertension in children and adolescents: epidemiology and natural history.
      2. Reno-vascular hypertension in childhood: a nationwide survey | SpringerLink.
      3. Tracking of blood pressure from childhood to adulthood: a systematic review and meta-regression analysis. - PubMed - NCBI.
        https://www.ncbi.nlm.nih.gov/pubmed/18559702
        Date accessed: January 23, 2020
      4. Blood pressure Trajectories from childhood to adolescence in pediatric hypertension.
      5. Clinical assessment of hypertension in children.
      6. Diagnosis of secondary hypertension: an age-based approach. - PubMed - NCBI.
        https://www.ncbi.nlm.nih.gov/pubmed/21166367
        Date accessed: January 23, 2020
        • Fry W.J.
        • Ernst C.B.
        • Stanley J.C.
        • et al.
        Renovascular hypertension in the pediatric patient.
        Arch Surg. 1973; 107: 692-698
      7. Pediatric renal artery Occlusive disease and renovascular hypertension: etiology, diagnosis, and operative treatment | JAMA surgery | JAMA Network.
      8. Renovascular disease in children and adolescents - ScienceDirect.
        • Stanley J.C.
        • Zelenock G.B.
        • Messina L.M.
        • et al.
        Pediatric renovascular hypertension: a thirty-year experience of operative treatment.
        J Vasc Surg. 1995; 21: 212-227
      9. Percutaneous balloon angioplasty of renovascular hypertension in pediatric cases: Acta Chirurgica Belgica: Vol 108.
        • Shroff R.
        • Roebuck D.J.
        • Gordon I.
        • et al.
        Angioplasty for renovascular hypertension in children: 20-year experience.
        Pediatrics. 2006; 118: 268-275
        • Zhu G.
        • He F.
        • Gu Y.
        • et al.
        Angioplasty for pediatric renovascular hypertension: a 13-year experience.
        Diagn Interv Radiol. 2014; 20: 285-292
      10. Angioplasty for renal artery stenosis in pediatric patients: an 11-year retrospective experience- ClinicalKey.
      11. Hypertension in pediatric patients - ScienceDirect.
      12. Non-invasive imaging cannot replace formal angiography in the diagnosis of renovascular hypertension | SpringerLink.
      13. Imaging in the evaluation of renovascular disease | SpringerLink.
      14. Duplex ultrasound scanning in the diagnosis of renal artery stenosis: a prospective evaluation. - PubMed - NCBI.
        https://www.ncbi.nlm.nih.gov/pubmed/3276934
        Date accessed: January 27, 2020
      15. Noninvasive diagnosis of renal artery stenosis by ultrasonic duplex scanning - Journal of Vascular Surgery.
        • Schäberle W.
        • Leyerer L.
        • Schierling W.
        • et al.
        Ultrasound diagnostics of renal artery stenosis.
        Gefasschirurgie. 2016; 21: 4-13
        • Castelli P.K.
        • Dillman J.R.
        • Smith E.A.
        • et al.
        Imaging of Renin-Mediated hypertension in children.
        Am J Roentgenol. 2013; 200: W661-W672
        • Patel P.A.
        • Cahill A.M.
        Renovascular hypertension in children.
        CVIR Endovasc. 2021; 4: 10
        • Vasbinder G.B.C.
        • Nelemans P.J.
        • Kessels A.G.H.
        • et al.
        Accuracy of computed tomographic angiography and magnetic resonance angiography for diagnosing renal artery stenosis.
        Ann Intern Med. 2004; 141 (discussion 682): 674-682
        • Tullus K.
        Renal artery stenosis: is angiography still the gold standard in 2011?.
        Pediatr Nephrol. 2011; 26: 833-837
        • Shahdadpuri J.
        • Frank R.
        • Gauthier B.G.
        • et al.
        Yield of renal arteriography in the evaluation of pediatric hypertension.
        Pediatr Nephrol. 2000; 14: 816-819
        • Robitaille P.
        • Garel L.
        • Dubois J.
        • et al.
        Transient renal artery stenosis in infants: myth or reality?.
        Acta Paediatr. 1994; 83: 998-1001
        • Passwell J.
        • Rosenthal T.
        • Boichis H.
        • et al.
        Transient renovascular hypertension in childhood.
        Eur J Pediatr. 1984; 141: 254-255
        • Thind G.S.
        • Baum S.
        • Kuroda K.
        Transient renal-artery stenosis.
        N Engl J Med. 1968; 278: 1201-1203
        • Jensen S.R.
        • Novelline R.A.
        • Brewster D.C.
        • et al.
        Transient renal artery stenosis produced by a pheochromocytoma.
        Radiology. 1982; 144: 767-768
        • Bendel-Stenzel M.
        • Najarian J.S.
        • Sinaiko A.R.
        Renal artery stenosis in infants: long-term medical treatment before surgery.
        Pediatr Nephrol. 1996; 10: 147-151
        • Chung H.
        • Lee J.H.
        • Park E.
        • et al.
        Long-term outcomes of pediatric renovascular hypertension.
        Kidney Blood Press Res. 2017; 42: 617-627
        • Lobeck I.N.
        • Alhajjat A.M.
        • Dupree P.
        • et al.
        The management of pediatric renovascular hypertension: a single center experience and review of the literature.
        J Pediatr Surg. 2018; 53: 1825-1831
        • Srinivasan A.
        • Krishnamurthy G.
        • Fontalvo-Herazo L.
        • et al.
        Spectrum of renal findings in pediatric fibromuscular dysplasia and neurofibromatosis type 1.
        Pediatr Radiol. 2011; 41: 308-316
        • Stanley J.C.
        • Criado E.
        • Upchurch G.R.
        • et al.
        Pediatric renovascular hypertension: 132 primary and 30 secondary operations in 97 children.
        J Vasc Surg. 2006; 44: 1219-1228
      16. Renovascular disease in childhood - ScienceDirect.
        • Rumman R.K.
        • Matsuda-Abedini M.
        • Langlois V.
        • et al.
        Management and outcomes of childhood renal artery stenosis and middle aortic syndrome.
        Am J Hypertens. 2018; 31: 687-695
      17. Middle aortic syndrome: from presentation to contemporary open surgical and endovascular treatment. - PubMed - NCBI.
        https://www.ncbi.nlm.nih.gov/pubmed/16273154
        Date accessed: January 23, 2020
      18. Disease Beyond the Arch: A Systematic Review of Middle Aortic Syndrome in Childhood | American Journal of Hypertension | Oxford Academic.
        • Forman N.
        • Sinskey J.
        • Shalabi A.
        A review of middle aortic syndromes in pediatric patients.
        J Cardiothorac Vasc Anesth. 2020; 34: 1042-1050