Post-stenotic renal artery dilatation – the smoking gun of a case of renal fibromuscular dysplasia induced secondary hypertension
DOI:
https://doi.org/10.48750/acv.712Palavras-chave:
Renal artery obstruction, Fibromuscular dysplasia, Renovascular hypertension, Renal angioplastyResumo
Introdução: A estenose da artéria renal é uma das principais causas de hipertensão arterial secundária, sendo a aterosclerose e a displasia fibromuscular as suas principais etiologias.
Caso clínico: Um homem de 41 anos de idade desenvolveu hipertensão arterial com agravamento progressive ao longo dos últimos 5 anos, acompanhado de eritrocitose apesar da utilização de terapêutica anti-hipertensiva dupla. Em ecodoppler das artérias renais, foi registada a suspeita de uma estenose ao nível da artéria renal direita, que determinou a realização de uma tomografia computorizada abdomino-pélvica contrastada. Porém apesar de evidente uma dilatação segmentar ao nível do terço médio da artéria renal, não foi valorizada nem referida a presença de qualquer estenose. No entanto, após re-apreciação da imagiologia, foi decidida a realização de uma arteriografia renal que confirmou a presença da estenose e da dilatação segmentar focal da artéria renal, morfologicamente sugestivas de dysplasia fibromuscular. Um gradiente translesional de 107mmHg foi registado. Procedeu-se a angioplastia com stent coberto 7x27mm exapansível por balão, com resultado angiográfico satisfatório. Nove meses após a intervenção, o utente suspendeu a medicação antihipertensora em curso.
Conclusão: Um elevado índice de suspeição foi a chave para o diagnóstico deste caso de hipertensão renovascular.
Downloads
Referências
Rimoldi SF, Scherrer U, Messerli FH. Secondary arterial hypertension: when, who, and how to screen? Eur Heart J. 2014;35:1245-54.
Textor SC, Lerman L. Renovascular hypertension and ischemic nephropathy. Am J Hypertens. 2010;23:1159-69.
Gaspar MA. Renovascular hypertension: The current approach. Rev Port Cardiol. 2019;38:869-71.
Writing Committee Members; Jones DW, Ferdinand KC, Taler SJ, Johnson HM, Shimbo D, et al. 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Hypertension. 2025;82:e212-e316.
Koelemay MJ, Geelkerken RH, Karkkainen J, Leone N, Antoniou GA, de Bruin JL, et al. European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the Management of Diseases of the Mesenteric and Renal Arteries and Veins. Eur J Vasc Endovasc Surg. 2025;70:153-218.
Aoun M, Jadoul M, Anders HJ. Erythrocytosis and CKD: A Review. Am J Kidney Dis. 2024;84:495-506.
Bacon BR, Rothman SA, Ricanati ES, Rashad FA. Renal artery stenosis with erythrocytosis after renal transplantation. Arch Intern Med. 1980;140:1206-11.
Bhaduria D, Sharma RK, Kaul A, Prasad N, Gupta A, Gurjar D, et al. A rare clinical syndrome of refractory secondary hypertension, renal artery stenosis and erythrocytosis. NDT Plus. 2011;4:175-7.
Gavriilaki E, Sampanis N, Kavlakoudis C, Papaioannou G, Vasileiou S. An exceptional case of renal artery restenosis in a patient with polycythaemia vera. Blood Coagul Fibrinolysis. 2014;25:904-6.
Weinberg I, Keyes MJ, Giri J, Rogers KR, Olin JW, White CJ, et al. Blood pressure response to renal artery stenting in 901 patients from five prospective multicenter FDA-approved trials. Catheter Cardiovasc Interv. 2014;83:603-9.
Moutinho M, Pedro LM, Fernandes RFE, Silva D, Fernandes JFE. Is stenting for atherosclerotic renal stenosis an effective technique? Rev Port Cardiol. 2019;38:859-67.
Plouin PF, Chatellier G, Darné B, Raynaud A. Blood pressure outcome of angioplasty in atherosclerotic renal artery stenosis: a randomized trial. Essai Multicentrique Medicaments vs Angioplastie (EMMA) Study Group. Hypertension. 1998;31:823-9.
van Jaarsveld B, Krijnen P, Bartelink A, Dees A, Derkx F, Man int Veld A, et al. The Dutch Renal Artery Stenosis Intervention Cooperative (DRASTIC) Study: rationale, design and inclusion data. J Hypertens Suppl. 1998,16:S21-7.
Bax L, Woittiez AJ, Kouwenberg HJ, Mali WP, Buskens E, Beek FJ, et al. Stent placement in patients with atherosclerotic renal artery stenosis and impaired renal function: a randomized trial. Ann Intern Med. 2009;150:840-8.
ASTRAL Investigators; Wheatley K, Ives N, Gray R, Kalra PA, Moss JG, et al. Revascularization versus medical therapy for renal-artery stenosis. N Engl J Med. 2009;361:1953-62.
Cooper CJ, Murphy TP, Cutlip DE, Jamerson K, Henrich W, Reid DM, et al. Stenting and medical therapy for atherosclerotic renal-artery stenosis. N Engl J Med. 2014;370:13-22.
Li Y, Cui WH, Wang J, Chen X, Zhang C, Zhu LZ, et al. Percutaneous revascularization for atherosclerotic renal artery stenosis: a meta-analysis. Eur Rev Med Pharmacol Sci. 2022;26:7007-14.
Chen Y, Pan H, Luo G, Li P, Dai X. Use of percutaneous transluminal renal angioplasty in atherosclerotic renal artery stenosis: a systematic review and meta-analysis. J Int Med Res. 2021;49:300060520983585.
Holman E. The obscure physiology of poststenotic dilatation; its relation to the development of aneurysms. J Thorac Surg. 1954;28:109-33.
Crotty TP. Poststenotic dilatation in arteries and the role of turbulence. Med Hypotheses. 1994;42:367-70.
Calvo WJ, Hajduczok G, Russell JA, Diamond SL. Inhibition of nitric oxide but not prostacyclin prevents poststenotic dilatation in rabbit femoral artery. Circulation. 1999;99:1069-76.
Gong X, Liu J, Yao D, Huang R. Successful treatment of focal renal artery fibromuscular dysplasia by balloon dilatation demonstrated via fractional flow reserve. Clin Med (Lond). 2023;23:625-29.
Savard S, Steichen O, Azarine A, Azizi M, Jeunemaitre X, Plouin PF. Association between 2 angiographic subtypes of renal artery fibromuscular dysplasia and clinical characteristics. Circulation. 2012;126:3062-9.
Plouin PF, Perdu J, La Batide-Alanore A, Boutouyrie P, Gimenez-Roquepol AP, Jeunemaitre X. Fibromuscular dysplasia. Orphanet J Rare Dis. 2007 Jun 7;2:28.
McKenzie GA, Oderich GS, Kawashima A, Misra S. Renal artery fibromuscular dysplasia in 2,640 renal donor subjects: a CT angiography analysis. J Vasc Interv Radiol. 2013;24:1477-80.
Hendricks NJ, Matsumoto AH, Angle JF, Baheti A, Sabri SS, Park AW, et al. Is fibromuscular dysplasia underdiagnosed? A comparison of the prevalence of FMD seen in CORAL trial participants versus a single institution population of renal donor candidates. Vasc Med. 2014;19:363-67.
Dorros G, Prince C, Mathiak L. Stenting of a renal artery stenosis achieves better relief of the obstructive lesion than balloon angioplasty. Cathet Cardiovasc Diagn. 1993;29:191-8.
van de Ven PJ, Kaatee R, Beutler JJ, et al. Arterial stenting and balloon angioplasty in ostial atherosclerotic renovascular disease: a randomized trial. Lancet. 1999;353:282-6.
Leertouwer TC, Gussenhoven EJ, Bosch JL, et al. Stent placement for renal artery stenosis: where do we stand? A meta-analysis. Radiology. 2000;216:78-85.
Drachman DE, Metzger DC, Jain A, Sachar R, El-Sayed Abbas A, Rosenfield K, Ansel GM. De Novo Atherosclerotic Renal Artery Stenosis Covered Stent Treatment for Resistant Hypertension (ARTISAN) Results. J Soc Cardiovasc Angiogr Interv. 2024;3:102400.
Oderich GS, Erdoes LS, Lesar C, Mendes BC, Gloviczki P, Cha S, et al. Comparison of covered stents versus bare metal stents for treatment of chronic atherosclerotic mesenteric arterial disease. J Vasc Surg. 2013;58:1316-23.
Iannone LA, Underwood PL, Nath A, Tannenbaum MA, Ghali MG, Clevenger LD. Effect of primary balloon expandable renal artery stents on long-term patency, renal function, and blood pressure in hypertensive and renal insufficient patients with renal artery stenosis. Cathet Cardiovasc Diagn. 1996;37:243-50.
Edwards MS, Corriere MA, Craven TE, Pan XM, Rapp JH, Pearce JD, et al. Atheroembolism during percutaneous renal artery revascularization. J Vasc Surg. 2007;46:55-61.
Edwards MS, Craven BL, Stafford J, Craven TE, Sauve KJ, Ayerdi J, et al. Distal embolic protection during renal artery angioplasty and stenting. J Vasc Surg. 2006;44:128-35.
Henry M, Klonaris C, Henry I, Tzetanov K, Le Borgne E, Foliguet B, et al. Protected renal stenting with the PercuSurge GuardWire device: a pilot study. J Endovasc Ther. 2001;8:227-37.
Holden A, Hill A, Jaff MR, Pilmore H. Renal artery stent revascularization with embolic protection in patients with ischemic nephropathy. Kidney Int. 2006;70:948-55.
Cooper CJ, Haller ST, Colyer W, Steffes M, Burkert MW, et al. Embolic protection and platelet inhibition during renal artery stenting. Circulation. 2008;117:2752-60.
