Images in vascular medicine

Abstract

Panel B Panel AProgressive ischemic nephropathy with intractable hypertension from experimental occlusion of one or both of the renal arteries has been well documented in animal models, following Goldblatt's pioneering work in this eld more than 60 years ago.1 A direct human template for the Goldblatt kidney model, however, is a rather rare occurrence. 2A 71-year-old man with progressive chronic renal insufciency was referred to our institution for severe hypertension unresponsive to a ve drug anti-hypertensive regimen. He had a prior history of chronic hypertension, which had been well controlled on a single anti-hypertensive medication, until he underwent aorto-bifemoral bypass surgery at another institution for distal aortic occlusion and severe bilateral lower extremity claudication. Moderate atherosclerotic bilateral renal artery stenosis had been noted on angiography at the time of aortic surgery two years previously. Distal aortic reconstruction was performed with a 16 mm 3 8 mm bifurcated Dacron graft, and was complicated by signi cant bleeding from several 'sheared branches' of the abdominal aorta; the bleeding was eventually controlled with extensive stapling of these branch vessels. A rather rapid escalation in blood pressures occurred less than two weeks after the operation, resulting in systolic blood pressures consistently in the 200-240 mmHg range and diastolic values in the 120-140 mmHg range. The severe hypertension had contributed to two strokes over the ensuing two years, resulting in a residual right hemiparesis, and in four episodes of hypertensive crisis requiring hospitalization. Physical examination revealed a resting blood pressure of 230/120 mmHg in both arms, with a resting heart rate of 64 beats/min. Midline and bilateral systolic ank bruits were auscultated on abdominal exam. Vascular exam was also signicant for palpable bilateral femoral pulses with bruits, and bilateral carotid bruits with preserved carotid pulses. Serum creatinine was 2.2 mg/dl, and blood urea-nitrogen was 24 mg/dl. Renal ultrasound revealed a right kidney long axis dimension of 10 cm and a left kidney long axis dimension of 9.2 cm. Echocardiography revealed severe concentric left ventricular hypertrophy with preserved left ventricular systolic function. Selective right and left renal arteriography from the