Diffuse atherosclerotic disease: a challenge in the management of renovascular hypertension.

A case report.

Abstract

Introduction: Chronic non-communicable diseases are the leading cause of morbidity in Ecuador; 20% of adults suffer from arterial hypertension. In older adults, atherosclerotic renovascular disease accounts for up to 35% of cases of secondary hypertension, thereby increasing cardiovascular risk.

Case Report: An 82-year-old male with a history of arterial hypertension since age 77 (treated with valsartan/amlodipine) presented with weakness in the right lower limb that had persisted for 45 days. Upon admission, his blood pressure was 160/98 mmHg. Brain MRI revealed subacute ischemic lesions and evidence of prior hemorrhages. CT angiography showed a "shaggy aorta" and severe stenosis (involving the right internal carotid and renal arteries) (Figure 1, Table 1); laboratory findings included creatinine 1.85 mg/dL, eGFR 35 mL/min/1.73 m², and ACR 445.4 mg/g, consistent with chronic kidney disease secondary to hypertensive nephroangiosclerosis. Due to deteriorating renal function (creatinine 2.3 mg/dL; eGFR 27 mL/min/1.73 m²), the ARB was discontinued and treatment with calcium channel blockers and beta-blockers was initiated, resulting in partial recovery of renal function (creatinine 1.6; eGFR 42). Revascularization was ruled out due to high embolic risk, and medical management was prescribed. Two months later, the patient was readmitted with a thrombogenic spinal cord infarction (C7-T1), arterial hypertension, and a need for antithrombotic treatment adjustment.

Results: Renal artery stenosis >50% causes hemodynamic impact, while stenosis >70% leads to renovascular hypertension. A "shaggy aorta" is associated with a high risk of systemic embolization, and medical management offers greater benefit than interventional procedures. The use of ACE inhibitors or ARBs in the presence of bilateral renal artery stenosis promotes the deterioration of renal function.

Conclusion: Diffuse aortic atheromatosis increases morbidity and mortality 4.1-fold and predisposes patients to thromboembolic events. Endarterectomy is not recommended due to the high risk of stroke; individualized medical management is the best alternative, especially when renovascular hypertension coexists.