A 36-year-old obese female presented with acute onset headache, vomiting, and weakness of right side of the body. Her blood pressure was noted to be 220/140 mmHg. On physical examination, she had right-sided hemiparesis. Fundoscopy showed Grade 1 hypertensive retinopathy. No renal bruit was audible. Electrocardiogram revealed left ventricular hypertrophy (LVH). On echocardiography, she had concentric LVH, with normal left ventricular systolic function and Grade 1 diastolic dysfunction. Computed tomography (CT) scan head revealed intracranial haemorrhage (left basal ganglia bleed) (Supplementary material online, Figure S1) She was managed with intravenous labetolol, furosemide, and oral amlodipine. Gradually, the intravenous drugs were discontinued and oral medications including amlodipine, telmisartan, moxonidine, eplerenone, and furosemide optimized. Serum biochemistry including renal functions was unremarkable. Ultrasound abdomen revealed normal kidney size. Renal Doppler was suggestive of pulsus parvus et tardus (Supplementary material online, Figure S2) in the intra-renal branch of the left renal artery. A CT aortogram revealed a discrete narrowing of the left renal artery due to entrapment by the left crux of diaphragm. There was no evidence of atherosclerosis or calcification of the renal artery (Figures 1 and 2; Supplementary material online, Figure S3).
Figure 1.
Computed tomography angiography (coronal section). Asterisk indicates discrete luminal stenosis caused by the left renal artery coursing through the crux of diaphragm. Ao, thoracic aorta.
Figure 2.
Computed tomography curved reformat showing compression of the left renal artery by the left diaphragmatic crux as compared to the normal course and calibre of the right renal artery. Ao, aorta; LRA, left renal artery; RRA, right renal artery.
The renal artery entrapment causing malignant hypertension is very rare.1 A renal artery with high origin, coursing parallel to the aorta in its proximal part, discrete stenosis and adjacent prominent crux should raise a strong suspicion of this diagnosis. Occasionally, respirophasic compression of renal artery may be demonstrable on CT imaging.2 The treatment options include medical therapy, stents or surgical (laparoscopic) decompression of the artery or reconstruction. The laparoscopic decompression is considered to be the gold standard of treatment because of the high risk of stent deformation or fracture in the entrapped renal artery.2,3 In our case, the patient is well controlled on oral medications. She has refused for any interventional procedure.
Supplementary material
Supplementary material is available at European Heart Journal - Case Reports online.
Consent: The author/s confirm that written consent for submission and publication of this case report including image(s) and associated text has been obtained from the patient in line with COPE guidance.
Conflict of interest: none declared.
Supplementary Material
References
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