In Reply to: Re: Case 0298_01 -- Hypertension in a 40-year-old woman posted by Daniel B. Brown, MD on February 03, 1998 at 22:07:09:
Here are two abstracts that I found that are related:
Morimoto A; Nakatani A; Matsui K; Hashimoto T; Maeda M; Uchida H; Dohi K.
A unique case of renovascular hypertension caused by combined renal artery disease.
Hypertension Research, 1995 Sep, 18(3):255-7.
Abstract: We present a unique case of renovascular hypertension due to combined renal artery disease in a 22-year-old woman. Renal angiography revealed renal artery stenosis with poststenotic dilatation and an aneurysm due to fibromuscular dysplasia in the left kidney, and a congenital arteriovenous fistula in the right kidney. The results of a captopril test and plasma renin sampling demonstrated that the renin-angiotensin-aldosterone system
was stimulated in both kidneys, accounting for the hypertension in this patient. Almost all cases of renovascular hypertension are due to only one underlying renal artery disease. This is the first case of renovascular hypertension associated not only with renal artery stenosis and an aneurysm due to fibromuscular dysplasia, but also with a congenital arteriovenous fistula.
Vinchon M; Laurian C; George B; D'arrigo G; Reizine D; Aymard A; Riche MC; Merland JJ; Cormier JM.
Vertebral arteriovenous fistulas: a study of 49 cases and review of the literature.
Cardiovascular Surgery, 1994 Jun, 2(3):359-69.
Abstract: The experience is reported with 50 vertebral fistulas treated by the authors in a joint radiological and surgical team. Of the 28 fistulas that were traumatic, 18 occurred after incidental iatrogenic puncture, and 22
were spontaneous, of which four presented in patients displaying angiographic features of fibromuscular dysplasia. Eleven patients were operated on and 33 had endovascular treatment. In nine patients who were either symptom-free or in poor health, no treatment was advised. The fistula was occluded in 38 (93%) of the treated patients, and the vertebral artery patency was preserved in 32 (78%). A total of 224 published cases were reviewed: 152 were traumatic, most after a penetrating injury; 72 were spontaneous, with three age peaks (at 7, 26 and 52 years). Treatment has evolved considerably and endovascular occlusion is now the treatment of choice, surgery being reserved for specific indications.
I guess hypertension can be caused by either one of the three conditions or all simultaneously. FMD is clearly associated with aneurysms which occasionally rupture. They can rupture into a vein thus creating an AV fistula. That is well documented in the head and neck area. Did the patient have renal biopsy at any time? I would first work up the mass (it could be malignant?) and then worry about the kidney. Both lesions in the kidney can be treated pecutaneously.