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Surgical Treatment of Renovascular Hypertension in Children
Renal artery occlusive disease affecting pediatric patients is an important but very uncommon cause of hypertension in children. Renal artery stenoses in this age group represent a wide spectrum of heterogeneous diseases, although developmental anomalies with concomitant narrowings of the splanchnic arteries and the abdominal aorta itself are most common. Inflammatory aortoarteritis is the second most common cause of renal artery stenoses in children, and in South America and Asia it is a more commonly encountered form of renovascular disease.
Pediatric renovascular hypertension when unrecognized and untreated has been associated with serious complications including hemorrhagic stroke, hypertensive encephalopathy with impaired mental development, and failure to thrive. Poorly controlled hypertension in these children often results in left ventricular hypertrophy and severe diastolic dysfunction. Additionally, when the entire renal mass is involved, flash pulmonary edema associated with renal insufficiency can occur.
Operative Therapy
Arterial reconstructive surgery for pediatric renovascular hypertension must be individualized, taking into account the patient’s anatomic renal artery disease, as well as concomitant aortic and splanchnic arterial disease.
Types of Surgery
Renal Artery Implantation
Implantation of the normal renal artery beyond an ostial stenosis has become an important means of pediatric renal revascularization. In these circumstances, the transected renal artery should be spatulated anteriorly and posteriorly to create a generous anastomotic orifice. An oval aortotomy can be best made with an aortic punch, being a little more than twice the diameter of the renal artery being implanted. This provides a sufficiently large anastomosis, so as the child grows an anastomotic narrowing will not evolve.
The aortorenal anastomoses should usually be performed using interrupted monofilament sutures. However, a continuous suture may be used in older adolescents with large renal arteries. Most implantations of the renal artery will be into a normal infrarenal segment of the aorta ( Figure 1 ). Medial mobilization of the kidney may be necessary to ensure that there is no tension on the implanted renal artery.
A renal artery branch or accessory renal artery beyond its stenotic segment may also be implanted into a nondiseased adjacent main or segmental renal artery. This also involves spatulation of the segmental vessel and completion of the anastomosis using monofilament sutures ( Figure 2 ). A renal artery may be implanted into the superior mesenteric artery when implantation elsewhere is deemed hazardous.
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