Renal Artery Stenosis Complicating Essential Hypertension

A 73-year-old man who had a history of long-standing essential hypertension, congestive heart failure, mild renal insufficiency, atrial fibrillation, and a mitral valve replacement presented with refractory hypertension. His medications included labetalol, irbesartan, and furosemide.

Drs Jonathan Greenblatt, Jeffrey Guller, and Robert A. Phillips of New York City report that an irregular heart rhythm and prosthetic mitral valve sounds were heard. Ambulatory 24-hour blood pressure monitoring revealed an average awake blood pressure of 183/78 mm Hg.

Renal artery stenosis was suspected, and an abdominal ultrasound scan was performed. No detectable left renal arterial waveform was seen. Magnetic resonance angiography of the abdomen demonstrated a 0.7-cm flow defect in the proximal left renal artery suggestive of severe stenosis or occlusion. The right kidney measured 9 cm; the left, 8.2 cm.

Renal angiography was performed. A 99% stenosis noted in the left renal artery (A) was corrected by balloon angioplasty (B) and stent deployment (C). A second renal angiogram after stent implantation revealed excellent flow to the distal vessels (D).

After the patient was discharged, labetalol, 150 mg twice daily, was prescribed because his average systolic pressures ranged between 150 and 170 mm Hg. Four weeks after the procedure, the patient's blood pressure had decreased to 138/72 mm Hg and he was doing well.

A pacemaker was placed for symptomatic bradycardia 2 months after angiography. The patient continues to take labetalol, 150 mg twice daily, for blood pressure control.