Fibromuscular Hyperplasia in Extrarenal Arteries

Abstract

Hypertension secondary to fibromuscular hyperplasia of one or both renal arteries is now a well recognized clinical syndrome. In many instances the occlusive process is amenable to vascular reconstructive procedures. The severity of the lesion varies. Well developed ones show prominent irregular thickenings in the arterial wall encroaching on the vessel lumen; septa-like invaginations alternate with small aneurysmal dilatations producing a honeycomb appearance of the longitudinally sectioned specimen. The lesion is characterized microscopically by hyperplasia of both smooth muscle and fibrous elements of the renal artery wall. Its etiology is unknown. The process is characteristically situated in the middle and distal third of the main renal artery, frequently is bilateral, and commonly extends into the proximal portions of the main renal artery branches. Its typical roentgen appearance has been described in recent publications (1, 2). Fibromuscular hyperplasia has a decided sexual affinity. Approximately 90 per cent of the cases seen at the University of California Medical Center, San Francisco, have been in females. To date the lesion has been regarded as unique to the renal arteries (3), and, to the authors' knowledge, reports of its occurrence in other vessels have not yet been published. The purpose of this communication is to suggest that fibromuscular hyperplasia may represent a general arterial dysplasia rather than a lesion limited to the renal arteries. A case of proved fibromuscular hyperplasia of the celiac artery is presented to support this possibility. In addition, examples of microscopically unconfirmed but roentgenolog-ically suspected fibromuscular hyper-plasia in nonrenal arteries are demonstrated. Case Report A 36-year-old white woman had been hospitalized on two previous occasions because of daily, in-capacitating right upper quadrant pain of three months duration. She had been in good health before the onset of symptoms. The pain was described as an ache, but sometimes of a stabbing or colicky nature and occasionally accompanied by nausea and vomiting. Jaundice or clay-colored stools were denied. The findings of a barium enema examination and upper gastrointestinal series were normal. An oral cholecystogram revealed a pendulous gallbladder with delayed emptying. Just prior to the patient's admittance to the Doctors Hospital, San Leandro, Calif., Dr. G. P. Wiedman noted an epigastric bruit and referred her to Dr. H. R. Ripley for further studies. The patient's past history was not contributory. On physical examination, localized pain and tenderness were noted in the gallbladder region. The liver was palpated three fingerbreadths below the right costal margin. A Grade II systolic bruit was observed, sharply localized to the epigastrium, approximately 3 cm. below the xiphoid process. Blood pressure was normal. Aortography was performed to rule out the possibility of disease of the hepatic or celiac artery.