A 32-year-old woman has resistant hypertension despite three drugs. She is a non-smoker with no family history. Abdominal examination reveals a bruit to both sides of the midline. Catheter angiography shows bilateral irregular narrowing of the distal renal arteries with alternating segments of stenosis and dilatation giving a 'string of beads' appearance. Which statement is correct regarding management?

• A Lifelong anticoagulation with warfarin
• B Open aortorenal bypass as first-line therapy
• C Nephrectomy of the more affected kidney
• D Percutaneous transluminal balloon angioplasty alone, without routine stenting ✓

Explanation

The string of beads lesion in a young woman with hypertension is medial fibromuscular dysplasia, which affects the mid and distal renal artery, unlike atherosclerosis which involves the ostium and proximal third. Cure rates of hypertension after percutaneous transluminal angioplasty are high in this group, and stents are reserved for complications such as flow-limiting dissection because restenosis rates are low after plain balloon dilation. Atherosclerotic renal artery stenosis behaves differently, where angioplasty has shown no clear benefit over medical therapy.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.