When medical management fails to adequately control high blood pressure (hypertension), interventions are required to improve blood flow to the kidneys.
Surgical repair is a frequent option for many children with pediatric renovascular hypertension. Often, surgical repair opens up a new world of opportunity for children with renal (kidney) artery disease, reducing limitations on physical activity and allowing them to live a normal, healthy lifestyle along with their peers.
Some patients may also have aneurysms (swelling of the blood vessel) of the thoracic and/or abdominal aorta (the main artery that carries blood away from your heart to the rest of your body) or other aortic branch vessels. These may require treatment. We are committed to comprehensive assessments and patient-centered precision treatments.
In the last 15 years, our work has become increasingly complicated. A third of children with pediatric renovascular hypertension referred to Michigan Medicine have experienced failures of previous open surgical and endovascular procedures performed elsewhere. In addition, the complexity of the disease has increased with coinciding midaortic syndrome now affecting 45% of the children referred to the Michigan Medicine Pediatric Renovascular Hypertension Program.
Surgery for pediatric renovascular hypertension
The goal of surgical treatment is to restore blood flow to the kidneys. Surgical interventions include either removal of the obstructing material and reconstructing the normal artery beyond the obstruction, or a bypass usually using a small nonessential artery from within the abdomen.
The surgical approach to renal revascularization at Michigan Medicine has varied little in recent decades. When possible, reimplantation onto the aorta of the normal renal (kidney) artery, beyond its stenosis, remains preferred to renal revascularization to aortorenal bypass using hypogastric artery (the main artery of the pelvis) (Figure 1).
Our surgical approach to midaortic syndrome considers the length and severity of the narrowing. When feasible, patch aortoplasty (reconstruction of a damaged aorta) is the preferred technique for aortic restoration (Figure 2).
In children with very narrow abdominal aortic coarctations (midaortic syndrome), aorto-aortic bypass is favored (Figure 3).
Open revascularization of both renal (kidney) artery stenosis and midaortic syndrome provides sustainable hypertension benefits in 90% of children treated in our high-volume referral program. Nevertheless, interventions in children less than three years old and the presence of coinciding aortic disease increase the likelihood of a later reoperation. Those undergoing secondary procedures are less likely to be cured of high blood pressure.
Established criteria for the diagnosis and management of pediatric renovascular hypertension must consider specific patient’s physical characteristics to define the most appropriate interventions and best practices, especially when balancing the risks of open operative and endovascular interventions. Further multi-center investigation of this rare, but debilitating, condition is urgently required to improve the outcomes and quality of life for affected children. We are committed to advancing the care of these special children.