Fibromuscular Dysplasia

Fibromuscular dysplasia (FMD) is a nonatherosclerotic, noninflammatory, medium-sized angiopathy due to fibroplasia of the vessel wall. The condition leads to complications related to arterial stenosis, aneurysm Aneurysm An aneurysm is a bulging, weakened area of a blood vessel that causes an abnormal widening of its diameter > 1.5 times the size of the native vessel. Aneurysms occur more often in arteries than in veins and are at risk of dissection and rupture, which can be life-threatening. Extremity and Visceral Aneurysms, or dissection. The clinical presentation can differ depending on which arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries are affected, but may include secondary hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension from renal artery stenosis Renal artery stenosis Renal artery stenosis (RAS) is the narrowing of one or both renal arteries, usually caused by atherosclerotic disease or by fibromuscular dysplasia. If the stenosis is severe enough, the stenosis causes decreased renal blood flow, which activates the renin-angiotensin-aldosterone system (RAAS) and leads to renovascular hypertension (RVH). Renal Artery Stenosis ( RAS RAS Renal artery stenosis (RAS) is the narrowing of one or both renal arteries, usually caused by atherosclerotic disease or by fibromuscular dysplasia. If the stenosis is severe enough, the stenosis causes decreased renal blood flow, which activates the renin-angiotensin-aldosterone system (RAAS) and leads to renovascular hypertension (RVH). Renal Artery Stenosis), neurologic deficits from cerebrovascular involvement, claudication due to limb involvement, and intestinal angina from mesenteric artery disease. The diagnosis is confirmed with imaging, such as computed tomography with angiography. Treatment includes lifestyle modifications, antihypertensive therapy for RAS RAS Renal artery stenosis (RAS) is the narrowing of one or both renal arteries, usually caused by atherosclerotic disease or by fibromuscular dysplasia. If the stenosis is severe enough, the stenosis causes decreased renal blood flow, which activates the renin-angiotensin-aldosterone system (RAAS) and leads to renovascular hypertension (RVH). Renal Artery Stenosis patients, and potential revascularization.

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Overview

Definition

Fibromuscular dysplasia (FMD) is a noninflammatory, nonatherosclerotic angiopathy characterized by stenosis, aneurysm Aneurysm An aneurysm is a bulging, weakened area of a blood vessel that causes an abnormal widening of its diameter > 1.5 times the size of the native vessel. Aneurysms occur more often in arteries than in veins and are at risk of dissection and rupture, which can be life-threatening. Extremity and Visceral Aneurysms, dissection, and tortuosity of medium-sized arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries.

Fibromuscular dysplasia primarily affects the renal (most common), carotid, visceral, external iliac, and vertebral arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries.

Epidemiology

  • Common, and often found incidentally
  • Women > men
  • Affects all ages, but primarily young to middle-aged adults
  • Caucasians are more commonly affected.
  • Frequent cause of renal artery stenosis Renal artery stenosis Renal artery stenosis (RAS) is the narrowing of one or both renal arteries, usually caused by atherosclerotic disease or by fibromuscular dysplasia. If the stenosis is severe enough, the stenosis causes decreased renal blood flow, which activates the renin-angiotensin-aldosterone system (RAAS) and leads to renovascular hypertension (RVH). Renal Artery Stenosis ( RAS RAS Renal artery stenosis (RAS) is the narrowing of one or both renal arteries, usually caused by atherosclerotic disease or by fibromuscular dysplasia. If the stenosis is severe enough, the stenosis causes decreased renal blood flow, which activates the renin-angiotensin-aldosterone system (RAAS) and leads to renovascular hypertension (RVH). Renal Artery Stenosis) in young patients

Pathophysiology

The cause of this disease is unknown.

  • Possibly due to a combination of genetics Genetics Genetics is the study of genes and their functions and behaviors. Basic Terms of Genetics, hormones Hormones Hormones are messenger molecules that are synthesized in one part of the body and move through the bloodstream to exert specific regulatory effects on another part of the body. Hormones play critical roles in coordinating cellular activities throughout the body in response to the constant changes in both the internal and external environments. Hormones: Overview, and an underlying connective tissue Connective tissue Connective tissues originate from embryonic mesenchyme and are present throughout the body except inside the brain and spinal cord. The main function of connective tissues is to provide structural support to organs. Connective tissues consist of cells and an extracellular matrix. Connective Tissue defect → arterial wall weakness → arterial dilation and injury → compensatory fibroplasia (development of fibrous tissue) in the vessel wall
  • This can result in:
    • Stenosis
    • Artery dissection
    • Aneurysm formation
  • Disease manifestations result from:
    • Disruption in blood flow through affected vessels
    • Aneurysm rupture
    • Intravascular thrombi and embolization
  • In RAS RAS Renal artery stenosis (RAS) is the narrowing of one or both renal arteries, usually caused by atherosclerotic disease or by fibromuscular dysplasia. If the stenosis is severe enough, the stenosis causes decreased renal blood flow, which activates the renin-angiotensin-aldosterone system (RAAS) and leads to renovascular hypertension (RVH). Renal Artery Stenosis: FMD results in arterial stenosis → ↓ renal perfusion → ↑ renin production through activation of the renin-angiotensin-aldosterone system (RAAS) → secondary hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension
Fibromuscular dysplasia

Diagram showing fibroplasia of the tunic media, which can result in narrowing of the arterial lumen: Aneurysms may form as well, with thinning of the vessel wall.

Image by Lecturio.

Classification

  • Multifocal FMD 
    • Most common type
    • “String of beads” appearance on angiography
    • Primarily corresponds to medial fibroplasia
      • Due to alternating collagen-containing fibromuscular webs and aneurysmal dilation
      • Internal elastic lamina may be absent in the dilated areas. 
    • May also be due to perimedial fibroplasia
      • Outer zone of the media is replaced with collagen, resulting in irregular thickening.
      • Aneurysm formation is less common.
  • Focal FMD 
    • Tubular or circumferential stenosis on angiography
    • Primarily corresponds to intimal fibroplasia (caused by circumferential collagen deposition in the intima)
    • Rare manifestations:
      • Medial hyperplasia (smooth muscle hyperplasia)
      • Periarterial hyperplasia (fibrous adventitia expansion)
Multifocal and focal fibromuscular dysplasia

Representations of multifocal FMD and focal FMD

Image by Lecturio.

Clinical Presentation

The clinical presentation depends on the affected vessels and the degree of blood flow disruption. Most patients are asymptomatic. 

  • Cerebrovascular arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries (most common presentation in women):
    • Headache
    • Pulsatile tinnitus
    • Neck pain Neck Pain Neck pain is one of the most common complaints in the general population. Depending on symptom duration, it can be acute, subacute, or chronic. There are many causes of neck pain, including degenerative disease, trauma, rheumatologic disease, and infections. Neck Pain
    • Cervical bruit
    • Transient ischemic attack Transient ischemic attack Transient ischemic attack (TIA) is a temporary episode of neurologic dysfunction caused by ischemia without infarction that resolves completely when blood supply is restored. Transient ischemic attack is a neurologic emergency that warrants urgent medical attention. Transient Ischemic Attack (TIA) ( TIA TIA Transient ischemic attack (TIA) is a temporary episode of neurologic dysfunction caused by ischemia without infarction that resolves completely when blood supply is restored. Transient ischemic attack is a neurologic emergency that warrants urgent medical attention. Transient Ischemic Attack (TIA)) or stroke
    • Amaurosis fugax (vision loss due to a lack of blood flow to the eye)
    • Horner’s syndrome (ptosis, miosis, and anhidrosis)
  • Renal arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries (most common presentation in men):
    • Hypertension
    • Abdominal bruit
    • Flank pain
  • Mesenteric arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries:
    • Intestinal angina
    • Weight loss
    • Epigastric bruit
  • Limb arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries:
    • Claudication 
    • Cyanotic toes 
    • Asymmetric pulses
    • Weakness
    • Paresthesias
    • Femoral bruit

Diagnosis

When to suspect FMD

  • Young, hypertensive patients (especially women < 60 years of age) with:
    • Severe, resistant, or sudden worsening of hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension
    • Onset of hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension < 35 years of age
    • Significant rise in creatinine with the initiation of:
      • Angiotensin-converting enzyme (ACE) inhibitors
      • Angiotensin receptor blockers (ARBs) 
    • Abdominal bruit
  • Patients < 60 years of age without risk factors for atherosclerosis Atherosclerosis Atherosclerosis is a common form of arterial disease in which lipid deposition forms a plaque in the blood vessel walls. Atherosclerosis is an incurable disease, for which there are clearly defined risk factors that often can be reduced through a change in lifestyle and behavior of the patient. Atherosclerosis and:  
    • Carotid bruit
    • TIA TIA Transient ischemic attack (TIA) is a temporary episode of neurologic dysfunction caused by ischemia without infarction that resolves completely when blood supply is restored. Transient ischemic attack is a neurologic emergency that warrants urgent medical attention. Transient Ischemic Attack (TIA) or stroke
    • Aortic aneurysm Aneurysm An aneurysm is a bulging, weakened area of a blood vessel that causes an abnormal widening of its diameter > 1.5 times the size of the native vessel. Aneurysms occur more often in arteries than in veins and are at risk of dissection and rupture, which can be life-threatening. Extremity and Visceral Aneurysms
  • Significant headache or tinnitus with no explanation
  • Peripheral or coronary arterial dissection or aneurysms
  • Subarachnoid hemorrhage Subarachnoid Hemorrhage Subarachnoid hemorrhage (SAH) is a type of cerebrovascular accident (stroke) resulting from intracranial hemorrhage into the subarachnoid space between the arachnoid and the pia mater layers of the meninges surrounding the brain. Most SAHs originate from a saccular aneurysm in the circle of Willis but may also occur as a result of trauma, uncontrolled hypertension, vasculitis, anticoagulant use, or stimulant use. Subarachnoid Hemorrhage (SAH)
  • Renal infarction

Diagnosis

Imaging is used to confirm the diagnosis.

  • Noninvasive testing (preferred):
    • Computed tomography with angiography (CTA) 
      • Method of choice
      • Less sensitive for small branch involvement
      • Will show the characteristic “string of beads” or smooth, concentric, focal stenosis
    • Magnetic resonance imaging with angiography (MRA)
      • Used when CTA is contraindicated
      • More useful in detecting aneurysms and dissections
      • Vessel resolution tends to be inconsistent.
    • Duplex ultrasonography
      • Generally not used for diagnosis
      • May report changes in velocity, turbulent flow, and tortuosity that could signal FMD
  • Invasive testing:
    • Digital subtraction angiography (DSA)
      • Reference standard
      • Catheter-based procedure
      • Dye is injected and imaged with serial radiographs.
      • Used when there is a high suspicion of FMD and revascularization is planned

Management

Management of renal FMD

  • Lifestyle modifications
    • Diet
    • Exercise
    • Smoking cessation
    • Has not shown much benefit as an isolated therapy
  • Antihypertensive therapy
    • Multifocal FMD can be controlled with medication therapy.
    • 1st line: 
      • ACE inhibitors
      • ARBs
      • Goal is to block the RAAS.
      • Use may be limited by a decrease in glomerular filtration Glomerular filtration The kidneys are primarily in charge of the maintenance of water and solute homeostasis through the processes of filtration, reabsorption, secretion, and excretion. Glomerular filtration is the process of converting the systemic blood supply into a filtrate, which will ultimately become the urine. Glomerular Filtration rate (GFR) or hyperkalemia Hyperkalemia Hyperkalemia is defined as a serum potassium (K+) concentration >5.2 mEq/L. Homeostatic mechanisms maintain the serum K+ concentration between 3.5 and 5.2 mEq/L, despite marked variation in dietary intake. Hyperkalemia can be due to a variety of causes, which include transcellular shifts, tissue breakdown, inadequate renal excretion, and drugs. Hyperkalemia.
    • 2nd line: 
      • Thiazide diuretics Thiazide diuretics Thiazide and thiazide-like diuretics make up a group of highly important antihypertensive agents, with some drugs being 1st-line agents. The class includes hydrochlorothiazide, chlorothiazide, chlorthalidone, indapamide, and metolazone. Thiazide Diuretics
      • Dihydropyridine calcium channel blockers Calcium Channel Blockers Calcium channel blockers (CCBs) are a class of medications that inhibit voltage-dependent L-type calcium channels of cardiac and vascular smooth muscle cells. The inhibition of these channels produces vasodilation and myocardial depression. There are 2 major classes of CCBs: dihydropyridines and non-dihydropyridines. Class 4 Antiarrhythmic Drugs (Calcium Channel Blockers)
      • Beta-blockers 
  • Revascularization
    • Indications:
      • Recent-onset hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension in younger patients with low risk of atherosclerotic disease (particularly with focal FMD)
      • Resistant hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension despite appropriate 3-drug therapy
      • Progressive renal insufficiency thought to be from RAS RAS Renal artery stenosis (RAS) is the narrowing of one or both renal arteries, usually caused by atherosclerotic disease or by fibromuscular dysplasia. If the stenosis is severe enough, the stenosis causes decreased renal blood flow, which activates the renin-angiotensin-aldosterone system (RAAS) and leads to renovascular hypertension (RVH). Renal Artery Stenosis
      • Children with hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension
    • Hypertension can be cured in focal FMD, but not in multifocal FMD.
      • May be due to the younger age of patients and shorter duration of hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension at onset
    • Goal is to prevent renal atrophy and chronic kidney disease Chronic Kidney Disease Chronic kidney disease (CKD) is kidney impairment that lasts for ≥ 3 months, implying that it is irreversible. Hypertension and diabetes are the most common causes; however, there are a multitude of other etiologies. In the early to moderate stages, CKD is usually asymptomatic and is primarily diagnosed by laboratory abnormalities. Chronic Kidney Disease (of particular concern in focal FMD).
    • Options:
      • Percutaneous transluminal angioplasty (preferred)
      • Aortorenal bypass surgery (usually reserved for complex cases)
  • Followup and serial monitoring
    • Blood pressure
    • Serum creatinine 
    • Renal ultrasound

Management of non-renal FMD

  • Most patients are asymptomatic and do not require intervention.
  • Lifestyle and risk factor modifications 
    • Goal is to reduce the risk of atherosclerosis Atherosclerosis Atherosclerosis is a common form of arterial disease in which lipid deposition forms a plaque in the blood vessel walls. Atherosclerosis is an incurable disease, for which there are clearly defined risk factors that often can be reduced through a change in lifestyle and behavior of the patient. Atherosclerosis, which could accelerate arterial stenosis.
    • Diet, exercise, and smoking cessation
    • Diabetes, hyperlipidemia, and hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension management
  • Aspirin for stroke prophylaxis in patients with cerebrovascular FMD
  • Revascularization:
    • TIA TIA Transient ischemic attack (TIA) is a temporary episode of neurologic dysfunction caused by ischemia without infarction that resolves completely when blood supply is restored. Transient ischemic attack is a neurologic emergency that warrants urgent medical attention. Transient Ischemic Attack (TIA) or stroke
    • Claudication
    • Mesenteric ischemia Mesenteric Ischemia Mesenteric ischemia is a rare, life-threatening condition caused by inadequate blood flow through the mesenteric vessels, which results in ischemia and necrosis of the intestinal wall. Mesenteric ischemia can be either acute or chronic. Mesenteric Ischemia

Differential Diagnosis

  • Atherosclerotic disease: narrowing of arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries due to patchy intimal plaques. Risk factors include diabetes, hyperlipidemia, hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension, and smoking. Patients tend to be older. The clinical presentation depends on the vessels involved, but can include heart disease, stroke, RAS RAS Renal artery stenosis (RAS) is the narrowing of one or both renal arteries, usually caused by atherosclerotic disease or by fibromuscular dysplasia. If the stenosis is severe enough, the stenosis causes decreased renal blood flow, which activates the renin-angiotensin-aldosterone system (RAAS) and leads to renovascular hypertension (RVH). Renal Artery Stenosis, and peripheral artery disease Peripheral artery disease Peripheral artery disease (PAD) is obstruction of the arterial lumen resulting in decreased blood flow to the distal limbs. The disease can be a result of atherosclerosis or thrombosis. Patients may be asymptomatic or have progressive claudication, skin discoloration, ischemic ulcers, or gangrene. Peripheral Artery Disease. Diagnosis is based on clinical history, duplex ultrasound, or angiography. The characteristic appearance of FMD on angiography will not be seen. Treatment includes risk factor modification, antiplatelet agents Antiplatelet agents Antiplatelet agents are medications that inhibit platelet aggregation, a critical step in the formation of the initial platelet plug. Abnormal, or inappropriate, platelet aggregation is a key step in the pathophysiology of arterial ischemic events. The primary categories of antiplatelet agents include aspirin, ADP inhibitors, phosphodiesterase/adenosine uptake inhibitors, and glycoprotein IIb/IIIa inhibitors. Antiplatelet Agents, and revascularization.
  • Vasculitis: a vascular inflammatory disease, often resulting in ischemia, necrosis, and organ damage. Any vessel can be involved. Etiologies include autoimmune disorders, drugs, and infections. Unlike FMD, patients present with fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever, arthralgias, arthritis, and potential end-organ damage. Diagnosis involves inflammatory markers, autoimmune serology, infectious workup, and biopsy, which will differentiate this condition from FMD. Management depends on the underlying cause.
  • Primary hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension: idiopathic elevation in blood pressure, and most commonly associated with increasing age (unlike RAS RAS Renal artery stenosis (RAS) is the narrowing of one or both renal arteries, usually caused by atherosclerotic disease or by fibromuscular dysplasia. If the stenosis is severe enough, the stenosis causes decreased renal blood flow, which activates the renin-angiotensin-aldosterone system (RAAS) and leads to renovascular hypertension (RVH). Renal Artery Stenosis, which is due to FMD). Most patients are asymptomatic, but severe elevations can cause headache and dizziness. Diagnosis is based on history and 3 separate blood pressure readings. Treatment includes lifestyle modifications and antihypertensive therapy. Patients who do not respond to treatment should be evaluated for secondary hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension, such as RAS RAS Renal artery stenosis (RAS) is the narrowing of one or both renal arteries, usually caused by atherosclerotic disease or by fibromuscular dysplasia. If the stenosis is severe enough, the stenosis causes decreased renal blood flow, which activates the renin-angiotensin-aldosterone system (RAAS) and leads to renovascular hypertension (RVH). Renal Artery Stenosis.

References

  1. Olin, J.W. (2020). Clinical manifestations and diagnosis of fibromuscular dysplasia. In Forman, J.P. (Ed.), Uptodate. Retrieved December 1, 2020, from https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-fibromuscular-dysplasia
  2. Olin, J.W. (2020). Treatment of fibromuscular dysplasia of the renal arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries. In Forman, J.P. (Ed.), Uptodate. Retrieved December 1, 2020, from https://www.uptodate.com/contents/treatment-of-fibromuscular-dysplasia-of-the-renal-arteries
  3. Wilson, J.A., and Hughes, R.L. (2018). Fibromuscular dysplasia. In Lutsep, H.L. (Ed.), Medscape. Retrieved December 1, 2020, from https://emedicine.medscape.com/article/1161248-overview
  4. Teo, K.K. (2019). Fibromuscular dysplasia. [online] MSD Manual Professional Version. Retrieved December 1, 2020, from https://www.msdmanuals.com/professional/cardiovascular-disorders/peripheral-arterial-disorders/fibromuscular-dysplasia
  5. Kasper, D.L., Fauci, A.S., Hauser, S.L., Longo, D.L., Lameson, J.L., and Loscalzo, J. Harrison’s Principles of Internal Medicine. New York, NY: McGraw-Hill Education; 2018.

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