Angioplasty for Renal Artery Stenosis in Pediatric

Patients: An 11-year Retrospective Experience

RFS Journal Primer

Quick Summary
BOTTOM LINE

Despite good technical success, percutaneous transluminal angioplasty (PTA) provided a clinical
benefit in a smaller majority of children compared to adults.

MAJOR POINTS

Retrospective evaluation of 19 children with hypertension who underwent PTA from 1997-2009.
Technical success achieved in 29 of 32 lesions (91%)

Cure achieved in 7 of 18 patients (39%)

Improvement in 3 patients (17%)

Failed response in 8 patients (44%)

Long term evaluation of PTA is less extensive in children than in adults.

The study describes the efficacy of PTA and suggests criteria that may be predictive of patient
response.

CRITICISM

Small number of patients.

Retrospective design.

Variable follow-up criteria and inconsistent technique .

Study design
TYPE OF STUDY

Single-center, retrospective, longitudinal follow-up study.

19 hypertensive children (9 girls and 10 boys; ages 2-18; median 9.6 years) who
underwent renal PTA by a board certified pediatric interventional radiologist
over the course of 11 years.

INCLUSION CRITERIA

Review of interventional radiology case log and cross reference with nephrology
clinic notes.

Hypertension (blood pressure >95th age-sex-specific percentile).

Referral based upon high suspicion of renal artery stenosis (refractory

hypertension, malignant hypertension, family history or clinical features of NF1).

EXCLUSION CRITERIA

Postsurgical and transplant patients.

Purpose

While atherosclerosis is the most common etiology of renal artery stenosis (RAS) in adults,
fibromuscular dysplasia (FMD) and neurofibromatosis type 1 (NF1) are the most prevalent
causes of pediatric RAS in western countries.
Both FMD and NF1 can also result in mesenteric and abdominal aortic stenosis
(middle aortic syndrome).

Whereas multiple studies have shown PTA to be effective for RAS in adults, there is less data
with respect to children.

This study provides insight into technique, immediate and long-term angiographic results,
clinical follow-up and post-procedure morbidity in children with FMD and NF1 over an 11
year period.

Intervention

All procedures performed by a board certified pediatric interventional radiologist with 10

years experience, under general anesthesia with femoral artery access.

After initial aortogram, the renal artery was selected, and selective renal arteriograms were
performed.

Balloon diameters ranged from 2.5 mm to 6 mm, and were chosen by measuring the adjacent
nonstenotic, nonaneurysmal portion of the renal artery distal to post-stenotic dilation.

After 2006, 0.014-inch Sterling balloons were used preferentially to facilitate exchange for
cutting balloons, which were used beginning in 2004.

Technical success was defined as residual stenosis 30%.

No renal artery was stented.

Intra-arterial nitroglycerin was administered as needed for arterial spasm.

Vascular surgery consultation was available in the event of a major adverse event.

Patients who underwent cutting balloon angioplasty or who sustained a visible dissection
were admitted to the ICU for overnight monitoring, while the remaining patients were
discharged home after 6 hours of observation.

Outcome

Technical success was achieved in 16 of 19 (84%) of patients and 29 of 32 (91%) lesions, but is spite of this,
a cure or benefit was only achieved in 10 (56%).

Angiographic features associated with a cure or clinical improvement:

Single, short-segment stenosis (<10mm)

Descriptor

Cure or Improvement (%)

Residual stenosis 10% after PTA

Follow-up angiography

2/8 (25)

Repeat PTA

0/5 (0)

NF1

5/7 (71)

always associated with improvement in

FMD

5/11 (45)

hypertension.

Single RA stenosis

9/10 (90)

Lesion length >10 mm

1/4 (25)

The need for repeat PTA portended failed

Parenchymal disease

0/2 (0)

clinical response, as did the presence of long lesions,

Bilateral disease

2/5 (40)

multiple lesions, bilateral or intraparenchymal

Residual stenosis <10%

8/10 (80)

disease; all features indicative of progressive disease.

Total

10/18 (55)

Patency on follow-up angiography was not

However, even in the presence of the above features,

PTA may have a role in temporizing hypertension

before surgical intervention is pursued in adolescence.

Table: Rates of Renal PTA Benefit (Hypertension Cure or

Improvement According to Various Descriptors)

Credits

SUMMARY BY:

Emily Ochmanek, DO, PGY2

Alexander Covington, MD PGY2
Department of Radiology
University of New Mexico Health Sciences Center

FULL CITATION:
Srinivasan A, Krishnamurthy G, Fontalvo-Herazo L, et al. Angioplasty for renal artery stenosis in pediatric patients: an 11-year retrospective
experience. J Vasc Interv Radiol 2010; 21:1672-80.

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