Print this page2006 Abstracts: Endovascular Therapy for Renovascular Hypertension Secondary to Takayasu’s Arteritis: A bridge to definitive treatment
Back to Annual Meeting
Back to Program
Trent L. Prault, M.D., Michael Freeman, MD, David Langley, MD, Amy Lipscomb, MD, Oscar Grandas, MD, David Cassada, MD, Scott Stevens, MD, Mitchell Goldman, MD.
University of Tennessee Medical Center, Knoxville, Knoxville, TN, USA.
Background: Takayasu’s arteritis (TA) is a disease with a constellation of clinical symptoms which result primarily from the inflammatory effects on the aorta and its branches. It is classified pathologically as a giant cell vasculitis, but has no pathognomonic histologic finding. The most common variant of the disease, Ueno Classification type III, affects both the aortic arch and the abdominal aorta, as well as their branches. Renovascular hypertension (RVH) is a major contributor to the mortality associated with TA. Surgical bypass remains the modality of choice in this setting. However, endovascular interventions in the treatment of RVH due to TA have been reported. Recent series of endovascular therapy have reported moderate success, but long-term follow-up is lacking.
Case: A 17 year old female with Type III (Ueno) TA was referred for evaluation of RVH. At the time of presentation to the vascular surgery service, her ESR was elevated despite aggressive corticosteroid therapy. Angiography revealed mesenteric and bilateral renal artery stenosis, left subclavian occlusion, as well as thoracic and abdominal aortic narrowing. Cardiac catheterization performed to evaluate a heart murmur and associated angina, demonstrated severe aortic and mitral valvular insufficiency, but no coronary artery involvement. Cardiac valve replacement was recommended prior to renal and mesenteric revascularization. In order to control the patient’s medically refractory hypertension prior to cardiac surgery, bilateral renal artery angioplasty and stenting was performed as a bridge to future treatment of her renovascular disease. This resulted in normalization of her blood pressure, allowing her to undergo valve replacement surgery. Two months later, despite normalization of the patient’s ESR, she developed mesenteric ischemic symptoms, mid-abdominal aortic coarctation, as well as recurrent RVH. Therefore, aortic, renal, and mesenteric bypass was performed. Currently, her blood pressure is well controlled with a single agent, and there are no symptoms of mesenteric ischemia, or lower extremity claudication. She is receiving maintenance immunosuppressive therapy for treatment of her TA.
Discussion: This patient demonstrates the usefulness of endovascular therapy for RVH in the setting of TA, but also the potentially limited durability of the technique. While most studies report high technical success rates, recurrence rates range from 15-20% within short and mid-term follow-up periods. In this case renal angioplasty and stenting provided adequate control of her blood pressure, which allowed valvular repair and normalization of her ESR with immunosuppressive therapy prior to undergoing definitive surgical bypass.