Technical consideration in management of renovascular hypertension in an infant with double renal arteries

Abstract

Renovascular hypertension is a curable disease that has recently been recognized with increasing frequency. A renal scan in a 1-month-old hypertensive white male showed diminished function of the right kidney, and his peripheral vein renin was elevated. Multiple antihypertensive medications failed to control his hypertension, and right kidney function deteriorated. An arteriogram showed two stenotic renal arteries supplying the right kidney. The smaller inferior artery supplied 35% of the kidney. Selective vein renin levels were greater than 15,000 ng/dL on the right side. Technical considerations in the repair of this lesion included (1) midline transabdominal incision to expose the abdominal aorta and the inferior vena cava; (2) dissection of inferior vena cava (IVC) with division of selected lumbar veins; (3) full mobilization of right kidney and transsection of both renal arteries and the renal vein; (4) perfusion of kidney via each renal artery with cold Sach's solution after resection of arterial stenoses; (5) end-to-side microvascular anastomosis of the smaller (2 mm) renal artery to the main renal artery at the hilum with 10-0 nylon over in situ perfusion cannula; (6) renal artery passed under the IVC to the aorta; and (7) right kidney autotransplanted to a new site on the abdominal aorta with an end-to-side (5.0 mm) renal artery to the aorta and an end-to-side renal vein to IVC anastomosis. Following revascularization, perfusion was excellent and the blood pressure returned to normal. At 6 months follow-up, selective renal vein renins were normal and an arteriogram showed no stenosis. Meticulous dissection, cold perfusion, microvascular anastomosis, and autotransplantation salvaged this kidney and resolved the hypertension.