Abstract
Resistant hypertension in the setting of renal artery occlusion should prompt further investigation for secondary causes in a young patient. We present renal artery occlusion in the setting of antiphospholipid syndrome as the initial presentation successfully treated with percutaneous intervention. This case is followed by review of the literature.
Highlights
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Resistant hypertension in the setting of renal artery occlusion should prompt further investigation for secondary causes in a young patient.
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Renal artery occlusion in the setting of antiphospholipid syndrome as the initial presentation of resistant hypertension should be considered.
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Successful percutaneous intervention of renal artery stenosis in the setting of antiphospholipid syndrome is feasible.
1
Case presentation
A 32-year-old previously healthy woman was referred for evaluation of resistant hypertension. Physical examination revealed resistant hypertension with blood pressure (BP) of 160/100 in the right and 165/110 in the left arm. She had a regular pulse rate of 88/min. The rest of her physical examination was unremarkable. Her blood pressure was uncontrolled despite the use of 5 mg of amlodipine twice a day, 50 mg of metoprolol twice a day, 25 mg of hydrochlorothiazide daily and 50 mg of captopril three times a day.
Her ECG showed normal sinus rhythm with strain pattern in leads I and AVL consistent with LVH. Transthoracic echocardiography revealed normal ejection fraction of 65%, moderate LVH and grade 1 diastolic dysfunction. Laboratory findings including serum electrolytes, complete blood count, thyroid, renal and hepatic function tests were all within normal ranges. Her urine analysis did not reveal any blood or protein. Doppler study of renal arteries showed significant stenosis of the right renal artery (right renal artery resistive index (RI) = 0.3). The patient underwent renal artery angiography which confirmed total occlusion of the right renal artery ( Fig. 1 A). Due to resistant hypertension on four anti hypertensive drugs, the decision was made to proceed with percutaneous intervention per guidelines recommendation. A conquest-pro wire was advanced through the total occlusion. The lesion was predilated using mini Trek 1.2 × 12 and 2.5 × 12 mm balloons. An express 5 × 19 mm stent was deployed at the lesion with stent post dilation using a 5.0 × 20 sterling balloon with excellent result ( Fig. 1 B).The patient was treated with dual antiplatelet therapy (aspirin 81 mg and clopidogrel 75 mg daily) for one month. She did well post stenting with improvement of her resistant hypertension. Four weeks later, she presented with arthralgia and myalgia. A full panel of autoimmune antibodies were checked which revealed positive high anti-cardiolipin IgG titer of 80 GPL units (normal: 0–14 GPL units) and positive lupus anti-coagulant (LAC). All other autoimmune antibody panels were within normal ranges. The patient was referred and treated by the rheumatology department with stable blood pressure. In follow up visits, her blood pressure remained in normal range of 120/70 to 130/80 mmHg, and she had no significant complaint.
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