Department of Internal Medicine, Ascension Providence Hospital/Michigan State University College of Human Medicine, Southfield, MI, USA.
Department of Internal Medicine, Division of Cardiology, Ascension Providence Hospital/Michigan State University College of Human Medicine, Southfield, MI, USA.
Am J Case Rep. 2023 May 21;24:e939881. doi: 10.12659/AJCR.939881.
BACKGROUND Atherosclerotic renal artery stenosis (ARAS) and renovascular fibromuscular dysplasia (FMD) are 2 of the most common etiologies of renovascular hypertension. They have different pathophysiologies, risk factors, presentations, and treatment options. However, as our population ages, it can become increasingly common to see patients who previously had FMD who develop ARAS at an advanced age, indicated by recurrent renovascular hypertension. CASE REPORT We present a case of a 66-year-old female patient who, in 2007, had presented with uncontrolled hypertension. She underwent magnetic resonance angiography and was found to have bilateral FMD, for which she received balloon angioplasty to a severe lesion on the mid-right renal artery and subsequently had normalization of blood pressures and resolution of symptoms. In 2021 she returned with uncontrolled hypertension while being treated with 3 antihypertensives. Bilateral renal arteriography revealed new severe ostial stenosis of the left renal artery and a patent right renal artery in which balloon angioplasty was performed 14 years ago. Based on the angiographic pattern of this new left RAS, we concluded this lesion was caused by atherosclerosis. The left ostial lesion was treated with a bare-metal stent and the patient was continued on antihypertensive medication and statin; at follow-up 4 months later, her blood pressures had normalized. CONCLUSIONS This case features a patient who developed severe ARAS with underlying history of bilateral renal artery FMD. Clinicians need to be aware that in patients with FMD, worsening renovascular hypertension at an advanced age could indicate the development of new hemodynamically significant ARAS. These patients need repeat diagnostic testing and treatment with medial optimization with or without endovascular revascularization in the appropriate clinical setting.
动脉粥样硬化性肾动脉狭窄（ARAS）和肾血管纤维肌性发育不良（FMD）是引起肾血管性高血压的两种最常见病因。它们具有不同的病理生理学、危险因素、表现和治疗选择。然而，随着人口老龄化，越来越常见的是看到以前患有 FMD 的患者在老年时出现 ARAS，表现为复发性肾血管性高血压。
我们报告了一位 66 岁女性患者的病例，她于 2007 年因无法控制的高血压就诊。她接受了磁共振血管造影检查，发现双侧 FMD，对右肾中重度病变进行了球囊血管成形术，随后血压恢复正常，症状缓解。2021 年，她因血压控制不佳（同时使用 3 种降压药）而再次就诊。双侧肾血管造影显示左肾动脉新出现严重开口狭窄，右肾动脉 14 年前进行过球囊血管成形术。根据新的左 RAS 的血管造影模式，我们推断该病变是由动脉粥样硬化引起的。左开口病变采用裸金属支架治疗，患者继续服用降压药和他汀类药物；4 个月后随访时，她的血压已恢复正常。
本病例特点为患有双侧肾动脉 FMD 的患者出现严重的 ARAS。临床医生需要意识到，在 FMD 患者中，老年时肾血管性高血压恶化可能表明新的具有血流动力学意义的 ARAS 的发展。这些患者需要重复诊断性检查，并在适当的临床情况下进行药物治疗（包括优化药物治疗）或血管内血运重建。
