Klin Padiatr 2016; 228(02): 94-95
DOI: 10.1055/s-0041-111178
Pictorial Essay
© Georg Thieme Verlag KG Stuttgart · New York

Transcatheter Intervention of Bilateral Renal Artery Stenosis in an Infant after arterial Switch to Control Arterial Hypertension

Katheterinterventionelle Behandlung einer beidseitigen Nierenarterienstenose eines Säuglings mit Hypertonie nach arterieller Switch-Operation
B. Wiewrodt
1   University Children’s Hospital, University Hospital Würzburg, Würzburg, Germany
,
S. Dittrich
2   Pediatric Cardiology, University Hospital, Erlangen, Germany
,
M. Uder
3   Department of Radiology, Pediatric Radiology, Erlangen, Germany
,
J. Wirbelauer
1   University Children’s Hospital, University Hospital Würzburg, Würzburg, Germany
› Author Affiliations
Further Information

Publication History

Publication Date:
07 March 2016 (online)

Images in Cardiovascular Medicine

Postnatal diagnosis of simple transposition of the great arteries (D-TGA) was made to an otherwise healthy term male newborn (birth weight 3 050 g, 10th centile). Because of a restrictive ovale foramen, Rashkind’s procedure was performed at the first day of life. At day 8 of life arterial switch operation lead to excellent anatomic and functional results: only simple regurgitation of the neo-aortic valve and mild supravalvular pulmonary stenosis (gradient 12–15 mmHg). Regular examination in infancy included non-invasive measurement of blood pressure. At the age of 10 weeks blood pressure at the right arm measured 112/66 mmHg, above the 95th centile correlated with age, gender and height [National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents, Pediatrics 2004; 114: 555–576]. No blood pressure gradient could be found between the upper and lower extremity. Ultrasound of the kidneys showed physiological morphology and size. Catecholamine metabolites in urine, creatinine, cortisone and renin concentration in serum were unremarkable. Repeated doppler examination did not detect any abnormal blood flow in the intrarenal arteries. Renal vein thrombosis was excluded. Repeated ambulant blood pressure measurements were accomplished. At the age of 9 months, blood pressure increased up to 158/89 mmHg at the right arm. Doppler examination was repeated without any conspicuous findings. The parents refused MR-angiography due to necessity of sedation. Instead sedation was performed for the invasive diagnostic coronar angiography after arterial switch operation. Though renal arteries’ filiform stenosis was shown by arteriography in the same session ([Fig. 1]), repeated doppler examination was unable to detect it [Krumme B et al., Kidney Int 1996; 50: 1288–1292]. Due to the apparent risks of the procedure, both stenosis were treated separately in 2 consecutive sessions. Dilatation was performed successfully at the age of 14 (left) and 17 months (right), respectively ([Fig. 2]) using 2.5 mm cutting balloons to expand the stenosis. The complication of a retroperitoneal bleeding after cutting the right renal artery could be managed conservatively. Co-medication with bisoprolol and captopril was established. At the age of 3 years no additional vascular anomalies are substantiated, no unifying diagnosis is made. Blood pressure is about 115/60 mmHg and renal function is uncompromised. Comment: Bilateral renal artery stenosis is an uncommon disease [Vo NJ et al., Pediatr Radiol 2006; 36: 1032–1036]. About 25% of patients with arterial hypertension suffer from renal artery stenosis like our patient. Since up to 85 percent of young children with hypertension have an identifiable cause, evaluation for an underlying etiology is requested and based on renal ultrasonography [Viera AJ et al., Am Fam Physician 2010; 82: 1471–1478]. Our case report substantiates the need for further diagnostic measures, since angioplasty and the application of cutting balloons in certain circumstances can even be offered to infants with renal artery stenosis and successfully resolves the secondary hypertension [Shroff R et al., Pediatrics 2006; 118: 268–275]. The relation between D-TGA and renal artery stenosis – esp. for bilateral involvement – remains uncommon.

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Fig. 1 Angiography shows the native stenosis of the main renal artery of the right a and left side b at the age of 11 months (arrows).
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Fig. 2 Dilatation of a stenosis of the left main renal artery in the 14 months old boy is demonstrated. The ballon-catheter is inflated a and the early post-interventional result documented with angiography b.