Title : Exploring a therapeutic dilemma: A case study of bilateral renal artery stenosis induced by aortoarteritis manifesting as a hypertensive emergency
Abstract:
Introduction: Hypertensive emergencies present diagnostic and therapeutic challenges, particularly in young patients. We present a compelling case of a 23-year-old female presenting with refractory hypertensive emergency, ultimately diagnosed with bilateral renal artery stenosis secondary to aortoarteritis.
Case Presentation: The patient presented with severe hypertension (250/140 mmHg) and altered sensorium in the emergency department. The hypertension was found to be refractory on four antihypertensives including IV infusions. Extensive workup revealed bilateral renal artery stenosis due to aortoarteritis, compounded by severe abdominal aortic narrowing near the renal artery origins, as seen on CT aortogram. Initial approach was to perform balloon angioplasty bilaterally, following which clinical and angiographical response was reviewed which were inadequate, likely due to early recoil. Hence it was decided to use stents and successful angioplasty was performed, deploying stents in both renal arteries (7 X 19mm stent in LRA, 6 X 18mm stent in RRA), resulting in significant improvement of blood pressure to 150/100 mmHg post-procedure. The patient was discharged after 5 days of hospitalisation in total with near normal blood pressure on single antihypertensive and immunomodulators for aortoarteritis.
Discussion: This case highlights the diagnostic challenges in young patients presenting with hypertensive emergencies and underscores the importance of considering rare etiologies such as aortoarteritis-induced renal artery stenosis. The successful management of this case demonstrates the efficacy of endovascular interventions in restoring renal perfusion and normalizing blood pressure.
Conclusion: Aortoarteritis-induced bilateral renal artery stenosis can present as a hypertensive emergency, necessitating prompt diagnosis and intervention. This case elaborates the importance of a thorough diagnostic workup and timely endovascular intervention in achieving favorable outcomes in patients with refractory hypertension due to renovascular etiologies.
Audience Take Away:
- Understanding the diagnostic challenges and clinical implications of such rare presentations will enhance their ability to recognize and appropriately manage similar cases in their own clinical practice. By learning about the successful utilization of endovascular interventions in restoring renal perfusion and normalizing blood pressure, attendees will be equipped with valuable knowledge and techniques
- First and foremost, it will enhance their diagnostic acumen by broadening their awareness of rare etiologies that can underlie hypertensive emergencies, particularly in young patients
- Additionally, the case demonstrates the successful management of refractory hypertension through endovascular interventions, highlighting the efficacy of such approaches in restoring renal perfusion and controlling blood pressure. It also underscores the importance of individualizing patient care to obtain optimal outcome, while keeping past research knowledge in mind
- Absolutely, the presented case of aortoarteritis-related bilateral renal artery stenosis presenting as a hypertensive emergency offers valuable insights that other faculty members could leverage to expand their research or teaching endeavours. For research purposes, this case provides a unique and compelling clinical scenario that could serve as a foundation for further investigation into the epidemiology, pathophysiology, and optimal management strategies of hypertensive emergencies with renovascular etiologies, especially to revisit the role of stenting which is traditionally reserved in such cases. In terms of teaching, this case offers a rich educational resource for medical students, residents, and fellows to deepen their understanding of hypertensive emergencies and rare etiologies
