A challenging case of renovascular hypertension

Abstract

vmj.sagepub.com Moderate arterial hypertension was incidentally diagnosed in an asymptomatic 14-year-old girl with an otherwise unremarkable medical history and physical examination. Serum creatinine, acute phase reactants and echocardiography were normal, whilst ocular fundus examination revealed mild retinal vascular tortuosity. High plasma renin and aldosterone levels suggested renovascular hypertension. Three-dimensional volume-rendering computed tomographic (CT) angiography (Panel A) and catheter-based digital subtraction angiography (DSA) (Panel B) showed an absence of flow in both ostial and proximal segments of the left renal artery with a normal appearance of the aortic wall (arrow). A complex collateral arterial network, originating from a hypertrophic left lumbar artery (chevron), bypassed these segments and merged with a normal-sized middle tract of the left renal artery, causing a delayed parenchimography of the ipsilateral kidney in comparison with the contralateral (Panel B). All other aortic branches including right renal artery, as well as aorta and supra-aortic arteries, appeared normal on DSA. Left and right kidney size were comparable on CT. Surgical exploration could not find any vascular structure or remnant connecting the aortic wall to the residual segment of the left renal artery. Histological examination of a sample of aortic wall and periaortic tissue was unremarkable: the former showed a normal arterial wall, the latter revealed the presence of adipose tissue. Normalization of blood pressure was achieved after surgical reconstruction with aortorenal bypass.