Abrupt, severe hypertension associated with dissection of a renal artery during selective catheterization

A 23-year-old woman with longstanding renovascular disease associated with intimal dysplasia presented with stage I-II hypertension 6 years following bilateral percutaneous renal artery angioplasties (associated with normotension after antihypertensive agents). Following the diagnostic selective left renal arteriogram, blood pressure (BP) rose from 140/90 mm Hg to 200/130 mm Hg over 30-40min. Reassessment angiography revealed a proximal intimal dissection with the development of a lengthy false lumen. Attempts to cross the dissected area for stent placement were unsuccessful. To avoid the consequences of severe and accelerated hypertension, intravenous enalaprilat was administered (which lowered BP to 160-170/100 mm Hg) and the patient underwent emergency aortorenal bypass surgery. Fortunately, the BP normalised post-operatively and renal function remained normal. This case illustrates the possibility that catheterisation of a renal artery may lead to acute, severe hypertension by creating an acutely ischaemic kidney through intimal or medial arterial dissection. In such cases, pharmacologic blockade with angiotensin-converting enzyme inhibitors may provide stabilisation of BP to allow surgical revascularisation to proceed safely.