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Pediatric renovascular hypertension: a thirty-year experience of operative treatment
J C Stanley1, G B Zelenock, L M Messina
1Department of Surgery, University of Michigan Medical School, Ann Arbor.
Insights
Surgical management of pediatric renovascular hypertension has evolved, with contemporary approaches favoring direct renal artery reimplantation. This operative therapy significantly benefits children, achieving high rates of hypertension cure or improvement.
Area of Science:
- Pediatric Surgery
- Vascular Surgery
- Hypertension Management
Background:
- Pediatric renovascular hypertension is a complex condition requiring surgical intervention.
- Treatment strategies have evolved over three decades.
Purpose of the Study:
- To characterize changes in operative treatment for pediatric renovascular hypertension.
- To evaluate outcomes over a 30-year period at a single institution.
Main Methods:
- Analysis of clinical data from 57 pediatric patients (1963-1993).
- Categorization of data into three chronologic eras to identify therapeutic trends.
- Evaluation of renal artery disease, including medial-perimedial dysplasia and inflammatory mural fibrosis.
Main Results:
- Surgical procedures shifted from aortorenal bypasses to direct renal artery reimplantations.
- 98% of patients benefited from operative therapy, with 79% cured and 19% improved.
- No operative deaths occurred; 14 patients required secondary operations.
Conclusions:
- Contemporary pediatric renovascular hypertension surgery emphasizes direct reimplantation and single-stage procedures.
- Associated abdominal aortic coarctations were managed with patch aortoplasty.
- Pediatric renovascular hypertension patients benefit significantly from well-executed surgical treatment.
Purpose:
This study was undertaken to characterize the changing operative treatment of pediatric renovascular hypertension and subsequent outcomes in a 30-year experience at a single institution.
Methods:
Clinical data were analyzed on 57 pediatric patients, 24 girls and 33 boys, ranging in age from 10 months to 17 years, who underwent operations for renovascular hypertension from 1963 to 1993 at the University of Michigan. Renal artery disease included atypical medial-perimedial dysplasia, often with secondary intimal fibroplasia (88%), and inflammatory mural fibrosis (12%). Abdominal aortic narrowings affected 15 patients. Data were categorized into three chronologic eras (I:1963-1972, II:1973-1980, and III:1981-1993) to allow identification of therapeutic trends.
Results:
Primary surgical procedures were undertaken 74 times. Ex vivo reconstruction was necessary once. Primary operations included aortorenal bypass with autogenous vein grafts (n = 26) or internal iliac artery grafts (n = 7); iliorenal bypass with vein grafts (n = 2); renal artery resection beyond the stenosis and reimplantation into the aorta (n = 10), the main renal artery (n = 2), an adjacent segmental renal artery (n = 3), or the superior mesenteric artery (n = 3); renal artery resection and reanastomosis (n = 3); focal renal arterioplasty (n = 2); operative dilation (n = 7); splenorenal bypass (n = 2); and primary nephrectomy (n = 7). Among 23 primary operations performed in era I, 56.5% were aortorenal bypasses with vein grafts, but in era III this form of revascularization represented only 3% of 33 primary operations. No reimplantations were performed in era I, whereas reimplantations accounted for 51.5% of era III procedures. Thirteen patients underwent staged or concomitant aortic reconstructions with thoracoabdominal aortoaortic bypass grafts (n = 5) or patch aortoplasty (n = 8). Fourteen patients underwent a total of 20 secondary operations, including seven secondary nephrectomies. Operative therapy benefited 98% of these children: hypertension was cured in 45 (79%), improved in 11 (19%), and unchanged in one (2%). There were no operative deaths.
Conclusions:
Contemporary surgical management emphasizes direct reimplantation of main renal arteries into the aorta, reimplantation of segmental arteries into adjacent renal arteries, patch aortoplasty for associated abdominal aortic coarctations, and single-stage revascularizations. Pediatric patients with renovascular hypertension clearly benefit from carefully executed operative therapy.