Patient
with renovascular hypertension refractory to clinical treatment with
hypertensive crisis and acute pulmonary edema
(Portuguese
PDF version)
Coordinated
by Dr. Fausto Miranda Jr
Telmo
P. Bonamigo*
*
Head, Service of Vascular Surgery, Irmandade da Santa Casa de Porto
Alegre; Associate Professor, Fundação Faculdade Federal
de Ciências Médicas de Porto Alegre.
J
Vasc Br 2003;2(1):35-36
Part
I - CLINICAL CASE
Sixty-five-year-old
female white patient, housewife, was admitted to the Emergency Service
of a Tertiary Hospital on June 12, 1994, when she complained of intense
dyspnea preceded by dry cough and chest pain.
On clinical examination, she was extremely dyspneic (orthopnea) with
sweating and cyanosis at the extremities, tachycardia and tachypnea.
Arterial pressure was 300/170mmHg and lung auscultation revealed crackles
up to the medial third of the chest. ECG traces did not show ischemic
abnormalities. The patient's past history included smoking for 40 years
(20 cigarettes a day), dyslipidemia and systemic arterial hypertension
(SAH) detected six years ago. She reported regular use of hydrochlorothiazide,
propranolol, methyldopa and lovastatin. The clinical status was described
by the on-call doctor as acute pulmonary edema secondary to hypertensive
crisis.
The following treatment was immediately used: oxygen 4l/min., IV morphine
4 mg, SL isosorbide 10 mg, IV furosemide 40 mg, IV aminophylline 240
mg and sodium nitroprusside. The patient was transferred to the ICU.
Two hours after that, she showed some clinical improvement, but dyspnea
and sweating persisted. Vital signs were as follows: AP= 180/110 mmHg,
RF: 28 mrm; HR: 72 bpm and axillary temperature: 36.8 oC.
Lab exams yielded the following results: glycemia 148 mg/dl; creatinine
1.0 mg/dl; Na+ 137mEq/l; K+ 2.8 mEq/l; GOT 9 U/l; CPK 27 U/l and CPK-MB
3.0 U/l.
The patient spent the first two days at the ICU, and received sodium
nitroprusside, oral furosemide 40 mg 12/12 h, oral captopril 25 mg 6/6
h, oral nifedipine 10 mg 6/6 h, in addition to IV and oral potassium
chloride. Water balance was still negative during this period, and the
patient was discharged from the ICU with no symptoms and with normal
arterial pressure.
On June 16, she was submitted to abdominal echography, which showed
normal liver, pancreas, spleen and gallbladder. Right kidney with approximately
7.8 cm and left one with 9.2 cm at its largest axis. Dilation of collecting
ducts was not observed. The abdominal aorta revealed extensive parietal
calcifications and no expansive lesions were identified. On the subsequent
day, abdominal and renal aortography was performed. (Fig 1). Due to
deterioration of renal function (Cr: 3.l mg/dl on January 18), the administration
of captopril was discontinued, and replaced with hydralazine and clonidine.
On June 20, her creatinine level was 1.9 and endogenous creatinine clearance
was 29 ml/min.
A medical conference was held and the following opinions were obtained.
The angiographer regarded the case as inadequate for endovascular treatment,
due to the risk of thrombosis during the procedure and because of difficult
access. The vascular surgeon considered left renal revascularization,
as the only alternative to the recovery and treatment of the patient.
Without revascularization, the patient would certainly die soon.
Therefore, the patient was discharged from hospital on July 1st, 1994,
with the following prescription: oral hydralazine 100 mg every six hours,
oral clonidine 0.150 mg every six hours and AAS 200 mg/day.
FOLLOW-UP
AT THE OUTPATIENT CLINIC
On the
subsequent days, the patient stayed at home and rested, until July 17,
when she returned to the emergency service with a new hypertensive crisis,
in addition to dizziness, headache and dyspnea, with arterial pressure
of 200/100 mmHg. The dose of antihypertensive drugs was increased and
lab exams were requested.
On July
27, the patient was dyspneic and hypertensive again with arterial pressure
equal to 300/130 mmHg. The lab exams revealed the following: Glycemia:
107 mg/dl, U.: 60 mg/dl. Cr.: 2.0 mg/dl and endogenous creatinine clearance
of 14.9 ml/min. The increased dose of antihypertensive drugs was maintained
and the patient was kept under observation for two days.
On August 4, 1994, the patient was admitted to Hospital Santa Casa,
upon request of her family, for the surgery proposed during her first
hospital stay.
CHALLENGE
Patient
with long-lasting SAH, refractory to usual medication in the last few
months, with administration of three antihypertensive drugs. In the
last weeks, the patient was admitted to a cardiological ICU with acute
pulmonary edema, event that occurred two more times.
After the etiology of SAH was confirmed and the angiographer considered
that endovascular treatment was inappropriate for the patient, the clinician
regarded the patient as unfit for the surgical procedure proposed by
the vascular surgeon. We reached an impasse. The family was informed
about the alternatives, that is, to resume clinical treatment or accept
surgical intervention, and the decision was up to them.
This clinical case took place eight years ago.
Our proposal for therapeutic discussion includes some questions:
1. What
would you do given the two proposed alternatives?
2. Would
you recommend surgical treatment or the clinical one?
3. Should
you opt for endovascular treatment, how would you solve the following
problems?
a. What vascular access would you use in the presence of stenosing aortoiliac
disease?
b. What is the actual success rate?
c. What is the 3-5 year follow-up for similar cases according to the
literature?
d. What is the risk of immediate thrombosis of the renal artery?
4. Should
you opt for direct conventional surgery, how would you solve the following
issues?
a. How would you determine surgical risk?
b. What are the most appropriate survival alternatives?
c. Would you perform isolated endarterectomy of the left renal artery?
d. Would you perform extended endarterectomy of the aorta and left renal
artery?
e. Would you opt for aortoiliac _ aortorenal bypass?
f. Would you use an alternative shunt (splenorenal)?
g. Would you suggest another surgical alternative?
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