An experience of single dose captopril renal scintigraphy in the diagnosis and management of bilateral renovascular hypertension

A 41-year-old woman visited our hospital with chief complaint of hypertension which was refractory to multiple antihypertensive drugs. Her blood pressure was 200/140 mmHg and her plasma renin activity was as high as 3.1 ng/ml/hr. Angiography revealed bilateral renal artery stenosis. To determine the laterality of the kidney which were responsible for her hypertension, the 99mTc-DTPA renal scintigraphy with captopril was performed. The estimated GFR of the right kidney was lowered than that of the control, while there was no change in the left kidney. Subsequently Percutaneous Transluminal Angioplasty (PTA) was performed to the right kidney. Postoperatively blood pressure remained elevated as well as serum renin level. 99mTc-DTPA scintigraphy with captopril was repeated and revealed no decrease in the GFR of the right kidney this time, but significant reduction in the GFR of the left kidney. After the second PTA to the left kidney, her blood pressure was finally normalized. Postoperatively GFR of both kidneys was not affected by captopril on renal scintigraphy, and currently she has remained normotensive without medication. 99mTc-DTPA scintigraphy with captopril appears to be a useful method to diagnose the laterality and to evaluate in clinical response to therapeutic intervention.     

A case report of atypical coarctation of the aorta with coarctation and left subclavian arterial aplasia

A 18 year-old female was admitted to our hospital with hypertension of 190/100 mmHg in her right arm and 140/110 mmHg in the left arm. Femoral arterial pulsation was not palpable. Her physical status and growth of the lower limbs were normal. Aortography demonstrated slight coarctation with a pressure gradient of 10 mmHg and descending aortic stenosis with a pressure gradient of 80 mmHg. Main three branches from aortic arch were anatomically normal. However, the left subclavian artery distal to the origin of the left vertebral artery was not visualized and the axillary artery was perfused by collaterals. Atypical coarctation was replaced using a woven Dacron graft of 14 x 40 mm. Postoperatively proximal pressure decreased from 180/113 to 156/98 mmHg and there was no pressure gradient between proximal and distal of the graft. After six months blood pressure in the right arm gradually decreased to 120/78 mmHg.     

Cerebral infarction during operation on the neck of the femur under epidural anesthesia: a report of two cases]

Cerebral infarction occurred during operation in two cases. An 83-year-old senile demented female underwent osteosynthesis with Ender pins under epidural anesthesia. Soon after Ender pins were inserted, her systolic blood pressure fell from 180 mmHg to 140 mmHg. The patient complained of chest pain and developed disturbed consciousness and right hemiparesis. On the second postoperative day, CT scanning showed the infarction of a left middle cerebral artery region. A 93-year-old female was another patient. She underwent a cup arthroplasty of the right hip bone fracture. Soon after bone cement was applied, she developed a mental confusion and her blood pressure increased from 120/60 mmHg to 160/80 mmHg. CT scanning on the first postoperative day showed the infarction of a left middle cerebral artery region. Sudden changes in systolic blood pressure and changes of mental status are possible signs of cerebral infarction not to be neglected. If elderly patients with any episodes of cerebral function troubles would undergo operation of the hip fracture, it is necessary to pay a particular attention to possible cerebral infarction.     

Nonsurgical treatment of renovascular hypertension by percutaneous transluminal angioplasty

A case of renovascular hypertension treated with percutaneous transluminal angioplasty is reported. Our patient was a 22-year-old housewife with 90 per cent stenosis of the right renal artery due to fibromuscular dysplasia. The renal artery was dilatated by percutaneous transluminal angioplasty with a Grützig balloon catheter to 25 per cent stenosis. Five hours after the procedure, blood pressure decreased from 180/114 mmHg to 130/95 mmHg; one day after, plasma renin activity fell from 4.7 ng/ml/hr to 1.7 ng/ml/hr. The patient was rehospitalized six months after percutaneous transluminal angioplasty to examine restenosis of the dilatated renal artery. Although her blood pressure remained normotensive and plasma renin activity was normal, replasty was performed since selective renal arteriography revealed 50 per cent stenosis.     

Improvement of ischemic symptoms and cerebral blood flow after percutaneous transluminal angioplasty for renovascular hypertension. Report of a case with multiple cerebrovascular occlusive disease]

A 53-year-old male complained of frequent left motor-sensory transient ischemic attack for 4 months. On admission, he demonstrated mild right hemiparesis, dysarthria, and right hemisensory disturbance of all modalities. Cerebral angiography demonstrated complete occlusion of the left internal carotid artery just above the origin of the ophthalmic artery and a stenotic lesion at the horizontal segment of the right middle cerebral artery. Renal angiography showed severe stenosis of the right renal artery. Systolic blood pressure was over 200 mmHg and marked circadian variation of blood pressure was noted. Serum renin was 4.0 ng/ml/hr. Four months after superficial temporal artery-middle cerebral artery anastomosis, left carotid angiography showed good patency of the bypass and the ischemic symptoms completely disappeared. Single photon emission computed tomography (SPECT) showed increased cerebral blood flow (CBF), especially in the left hemisphere after surgery. Six months after the bypass surgery, he complained of mild right hemiparesis again. Shortly after percutaneous transluminal angioplasty (PTA) for renal arterial stenosis, his hemiparesis was improved and the systolic blood pressure stabilized to 150-170 mmHg. SPECT showed the CBF had also recovered in both hemispheres. The improvement in ischemic symptoms and increased CBF after PTA were probably related to stabilization of the systemic blood pressure or inhibition of serum renin-angiotensin.     

Renovascular hypertension associated with neurofibromatosis: two cases and review of the literature

The authors report two cases of renovascular hypertension associated with neurofibromatosis. A 19-year-old woman was admitted to our hospital with a complaint of abdominal pain and blood pressure of 180/120 mmHg. Examination revealed café-au-lait spots over her chest and extremities. Peripheral plasma renin activity (PRA) under basal conditions was 2.8 ng/ml/h and increased to 12.6 ng/ml/h after administration of 50 mg captopril. Plasma and urinary catecholamines were normal. Selective renal angiography showed left aneurysmal dilatation of the segmentary branch and right renal artery stenosis with multiple aneurysmal affecting different branches. Blood pressure was controlled by multiple drugs, including beta-blockers and angiotensin-converting enzyme inhibitor. Another patient, a 20-year-old woman, was admitted because of severe arterial hypertension, numerous café-au-lait spots, scoliosis, and mass over the right arm. PRA from the right renal vein was extremely elevated, and selective angiography demonstrated bilateral renal artery stenosis. Aortorenal bypass was performed successfully.     

Percutaneous transluminal angioplasty and stent placement for subclavian steal syndrome with concomitant anterograde flow in the left internal mammary artery graft for coronary artery bypass--case report

A 63-year-old man presented with subclavian steal syndrome associated with left internal mammary artery (IMA) bypass graft to a coronary artery. He was admitted with a history of oppressive sensation in the chest, dizziness, and light headedness on exertion for 2 weeks in March 2002. He had undergone myocardial revascularization consisting of a left IMA-to-left anterior descending coronary artery graft in April 1988. His blood pressure was 140/70 mmHg in the right arm and 80/64 mmHg in the left arm. Aortic arch arteriography revealed complete occlusion of the left subclavian artery proximal to the left IMA takeoff and subclavian steal with anterograde flow of the left IMA. Percutaneous angioplasty and stent placement with protection of the left IMA bypass graft using a balloon catheter was successfully performed without complication by cerebral or myocardial ischemia. Complete recanalization of the occluded left subclavian artery and anterograde flow of the left vertebral artery were achieved. His symptoms disappeared and blood pressure in the left arm recovered. This variant of coronary subclavian steal might require protection of the left IMA during angioplasty and stent placement.     

Effect of vacuum-assisted closure on blood flow in the peristernal thoracic wall after internal mammary artery harvesting.

OBJECTIVE: Vacuum-assisted closure (VAC) is a recently introduced method for the treatment of poststernotomy mediastinitis. The aim was to examine the effects of VAC negative pressure on peristernal soft tissue blood flow after internal mammary artery harvesting. METHODS: Microvascular blood flow was measured using laser Doppler velocimetry in a porcine sternotomy wound model. The effect of VAC negative pressure on blood flow to the wound edge was investigated on the right side, where the internal mammary artery was intact, and on the left side, where the internal mammary artery had been removed. RESULTS: Before removal of the left internal mammary artery, the blood flow was similar in the right and left peristernal wound edges, 2.5 cm from the edge (27+/-4 perfusion units (PU) on the right side and 32+/-3 PU on the left side, in muscle tissue). When the left internal mammary artery was surgically removed, the blood flow on the left side decreased (19+/-3 PU, in muscle tissue), while the skin blood flow was not affected. VAC negative pressure induced an immediate increase in wound edge blood flow both on the right side (43+/-9 PU, in muscle tissue at -75 mmHg), where the internal mammary artery was intact, and on the left side, where the internal mammary artery had been removed (49+/-11 PU, in muscle tissue at -75 mmHg). The increase in blood flow was similar on both sides at -75 mmHg and at -125 mmHg. CONCLUSIONS: The peristernal wound edge microvascular blood flow is decreased when the left internal mammary artery is removed. VAC therapy stimulates blood flow in the peristernal thoracic wall after internal mammary artery harvesting.     

Middle cerebral artery occlusion associated with acute myocardial infarction in the perioperative period--case report

A 68-year-old woman with no history of cardiac events suffered acute myocardial infarction after surgery for middle cerebral artery (MCA) occlusion manifesting as transient left motor weakness. Diffusion-weighted magnetic resonance imaging revealed multiple infarctions in the right cerebral hemisphere. Magnetic resonance angiography and cerebral angiography demonstrated an occlusion at the horizontal segment of the right MCA and no collateral circulation. Cerebral blood flow study 6 weeks after the initial presentation indicated decreased blood flow in the right cerebral hemisphere. Superficial temporal artery-MCA anastomosis was conducted to prevent recurrent cerebral infarction. Two hours after surgery, her systolic blood pressure fell to 60 mmHg and her consciousness worsened. Emergency coronary angiography indicated occlusion of the right coronary artery. Percutaneous coronary intervention was successfully performed and the subsequent course was uneventful. Preoperative evaluation of the coronary artery may be necessary before surgery for cerebral ischemic disease in both the intracranial and extracranial arteries.     

A case of traumatic aneurysm of innominate artery with occlusion of right subclavian artery

A 42-year-old woman with history of chest blunt trauma from an automobile accident 250 days earlier had suffered easy fatigability of the right upper extremity. She had difference of blood pressure between upper extremities, 94/60 mmHg in the right and 126/70 mmHg in the left. Chest CT showed dilation of the innominate artery which compressed the trachea. Aortography showed an aneurysm of the innominate artery and occlusion of the right subclavian artery at its origin. The aneurysm of the innominate artery was resected and replaced with a 6 mm Dacron graft with aid of the external shunt. The right subclavian artery was also reconstructed with same graft. The aneurysm of the innominate artery should be suspected as a rare complication in blunt trauma of the chest.     

Two cases of percutaneous transluminal angioplasty (PTA) for the treatment of subclavian steal syndrome

Recently percutaneous transluminal angioplasty (PTA) has been used to treat atherosclerotic lesion of the brachiocephalic arteries. We treated two patients with subclavian steal syndrome successfully by PTA. The first patient was a 52-year-old man complaining of vertigo and ischemic symptoms of the left arm. Blood pressure was 110/90 mmHg in the left arm and 140/92 mmHg in the right. On the angiogram, about 80% stenosis was found in the proximal portion of the left subclavian artery, and retrograde filling of the left vertebral artery was observed. At first, a carotid-subclavian bypass surgery was performed, but unfortunately failed because of obstruction of the artificial arterial graft. Then we performed PTA using Grüntzig balloon dilatation catheter. The dilatation was carried out successfully. Immediately after PTA, to-and-fro and antegrade flow of the vertebral artery was observed, and one month later it became normal flow. Neurological symptoms gradually disappeared within two months. The second patient was a 57-year-old man suffering from vertigo on effort and TIA. Blood pressure was 130/78 mmHg in the left arm, and 152/82 mmHg in the right. Angiogram showed more than 95% stenosis of the left subclavian artery, and retrograde filling of the left vertebral artery. We also observed bilateral severe stenosis of the MCA. Carotid-subclavian bypass was dangerous because of the low perfusion of the ipsilateral MCA area. PTA was performed as the first choice, and the dilatation of the stenosis was sufficient. In two months natural antegrade filling of the left vertebral artery was obtained. We followed these patients for 12 months and no restenosis was observed neurologically and radiologically. We performed PTA with the Grüntzig balloon catheter using the Seldinger's method through the right femoral artery. Diameter of the balloon was 6 mm and its length was 4 cm. After setting the balloon to the stenotic lesion, we inflated the balloon with 5atm (75 psi) pressure for 30 minutes. Monitoring the blood pressure and arterial pressure wave at the tip of the catheter, we repeated inflation of the balloon 4 times. We used continuous venous infusion of low molecular dextran and heparin during PTA procedures. No complication occurred and neurological symptoms disappeared gradually. PTA is a safe and effective method, so it should be the first choice in the treatment of subclavian steal syndrome caused by severe stenosis of the subclavian artery.     

A case of renovascular hypertension with nephrotic syndrome, accompanied by focal segmental glomerulosclerosis-like lesion in the contralateral kidney]

A 66-year-old male patient of renovascular hypertension with nephrotic syndrome was described. Besides, focal segmental glomerulosclerosis like lesion was accompanied in the contralateral kidney. On admission, his blood-pressure amounted to 220/140 mmHg. Laboratory investigation included; urinary protein 10.5 g/day, serum creatinine 1.8 mg/dl, creatinine clearance 71.4/day, plasma renin activity 10.0 ng/ml/hr, angiotensin I 890 pg/ml and angiotensin II 40.0 pg/ml. Renogram and renal scintigram showed non-functioning pattern of left kidney. Arteriography disclosed approximately more than 95% stenosis of left main artery. Administration was discontinued because of poor control both in blood pressure and in proteinuria. After the left nephrectomy, the former normalized and the latter decreased. Microscopic examination of the right kidney revealed focal segmental glomerulosclerosis like lesion. So far as we know, this report is the first designed to elucidate renovascular hypertension with nephrotic syndrome accompanied by focal segmental glomerulosclerosis like lesion. The relationship between renovascular hypertension and nephrotic syndrome, and microscopic findings has been briefly discussed. It is suggested that the etiology of focal segmental glomerulosclerosis like lesion may be based on compensatory glomerular hyperfiltration caused by renovascular hypertension.     

Contralateral response in renal pelvic pressure and diuresis during increasing ipsilateral pelvic pressure and flow: a study of the normal and denervated upper urinary tract in pigs

OBJECTIVE: To examine, in young pigs, changes in baseline pelvic pressure and diuresis in the contralateral kidney during conditions of increasing pelvic pressure and perfusion with isotonic saline in the ipsilateral renal pelvis; the role of a reno-renal nervous mechanism was examined by denervating the kidneys, and the effect of bladder filling on these variables assessed. MATERIALS AND METHODS: Female pigs (37-40 kg) were assessed under general anaesthesia. Transparenchymally, one 6 F and two 6 F catheters were introduced into the right and left renal pelvis, respectively. Through a bladder incision an 8 F catheter was introduced 10 cm into the right ureter to collect urine and the orifice closed around the catheter. For bladder drainage and to measure bladder pressure a 10 F catheter was placed in the bladder and both the 8 F and 10 F catheters lead out through the urethra. In group A, five animals served as controls, with group B comprising eight with intact nerves and group C eight with denervated kidneys. In group B and C the left renal pelvis was perfused with isotonic saline at 2, 4, 6, 8, 10, 12 and 16 mL/min while the bilateral pelvic pressure and right renal diuresis were recorded; the bladder was kept empty and 0.5 h later the left pelvis was perfused with 10 mL/min while the bladder catheter was closed. Perfusion continued until micturition occurred. The bilateral pelvic pressure, bladder pressure and right renal diuresis were recorded. In group C the kidneys were surgically denervated, dividing all adhesions and all connective tissue around the pelvis and the vascular pedicle. The renal artery was freed to the aortic level. RESULTS: During the pressure-perfusion study the mean (sd) right pelvic pressure was 7.4 (0.2) mmHg in group B and 8.6 (0.2) mmHg in group C. The diuresis from the right kidney in both groups was similar and the same as that in group A. The perfusion rate and pressure on the left side had no influence on pelvic pressure and diuresis on the right side. During perfusion with a full bladder the right pelvic pressure was 8.6 mmHg in group B and 9.5 mmHg in group C. Diuresis in group B was approximately 0.6 mL/min and a little higher in group C, at approximately 1 mL/min, but identical to that in group A. CONCLUSION: These results indicate that a reno-renal reflex mechanism has no apparent role in young pigs during pressure-perfusion measurements with an empty or full bladder.     

A case of ruptured cerebral aneurysm associated with coarctation of the aorta

A 15-year-old boy with subarachnoid hemorrhage was planned for emergency cerebral aneurysm clipping under general anesthesia. He had different blood pressure between the upper limbs and we found coarctation of the aorta at left subclavian artery bifurcation in the preoperative angiography. To prevent re-rupture of cerebral aneurysm and ischemia of abdominal organs, we monitored arterial blood pressure in bilateral radial arteries and non-invasive blood pressure in the left thigh, and his blood pressure was maintained within 120-150 mmHg of systolic pressure in the right radial artery and 50-70 mmHg of mean arterial pressure in the left radial artery and the left thigh during general anesthesia. The preoperative period elapsed uneventfully and the patient was planned for repair of coarctation of the aorta after discharge.     

Traumatic subclavian steal syndrome. Report of a case

Traumatic obstruction of the subclavian artery without major hemorrhage is rare. Only eleven cases have been disclosed retrograde flows from the ipsilateral vertebral artery into the distal segment of subclavian artery in the world. One case of the traumatic subclavian occlusion is presented in this paper. A 63-year-old man was struck on his chest by heavy machinery. On admission he was alert and had no neurological deficits. His blood pressure was 140/80 mmHg in his right arm but was not palpable in his left radial artery. Aortogram showed incomplete obstruction of the left subclavian artery 2 cm beyond its origin. On the second admission day it was occluded and the distal flow was supplied from the left vertebral artery in a retrograde fashion. Without operative vascular reconstruction he has never experienced ischemic symptoms for a year.     

Paradoxical response of blood pressure to salt loading in renovascular hypertension

We studied the effect of high salt intake on blood pressure in two cases with renovascular hypertension. They had hypertension with hyperreninemia and marked difference in plasma renin activity between both renal veins. Blood pressure significantly decreased after single oral administration of captopril. Renal arteriogram revealed significant stenosis in the main artery to the left (case 1) and right (case 2) kidney. Blood pressure response was evaluated after seven (case 1) and five (case 2) days of low salt and seven days (both cases) of high salt intake. Mean blood pressure in two patients was significantly decreased (case 1; 118 +/- 5.5 to 108 +/- 6.1 mmHg and case 2; 150 +/- 3.8 to 138 +/- 3.1 mmHg). Plasma renin activity was also decreased (case 1; 6.25 to 0.77 ng/ml/hr and case 2; 22.8 to 6.3 ng/ml/hr). In case 2, blood pressure elevated markedly during low salt intake, compared with blood pressure level during normal salt intake. The results suggest that excessive salt intake in patients with unilateral renovascular hypertension produces blood pressure reduction because of suppression of renin-angiotensin system. We concluded that in patients with unilateral renovascular hypertension dietary sodium depletion may be harmful, whereas salt supplement may have a beneficial effect.     

Idiopathic midaortic syndrome: normalization of blood pressure on medication

Midaortic syndrome (MAS) is a rare, idiopathic condition in children usually presenting with severe hypertension. We report a case of a 13-year-old girl who presented with severe hypertension (200/110 mmHg) associated with renal artery stenosis and normal renal function (creatinine clearance 110 ml/min/1.73m²). Percutaneous angioplasty (PTA) was first performed, but early recurrence of hypertension occurred. Subsequent imaging evaluation demonstrated association of aortic narrowing, proximal stenosis of the left renal artery, and wall thickening of superior mesenteric artery and right common carotid artery. Although previous large-vessel arteritis cannot be absolutely excluded, a diagnosis of idiopathic MAS was made, given the absence of any other clinical signs of inflammation (C-reactive protein <0.5 mg/dl; erythrocyte sedimentation rate 5 mm/h). Medical treatment was undertaken without repeat PTA or surgery. Blood pressure control was good, and antihypertensive therapy was stopped 4 years later. At age 22, the patient was still normotensive and receiving no antihypertensive therapy; normalization of Doppler velocities in the proximal left renal artery was confirmed. In the absence of renal dysfunction or target-organ damage, medical management of hypertension in MAS is feasible without intervention if blood pressure is well controlled on two antihypertensive agents.     

Long-term immunosuppressive treatment of a child with Takayasu's arteritis and high IgE immunoglobulins

A 7-year-old child presented with a severe form of Takayasu's arteritis, with two consecutive episodes involving the right testis and then the left kidney 6 months later. The renal artery obstruction was accompanied by severe hypertension. An aortography showed a complete obstruction of the left renal artery and a narrowing of the right subclavian artery. Plasma renin activity was high. Serum immunoglobulins were within the normal range, except for an increase in IgE (880 /l). Despite 4 months', treatment with antihypertensive drugs, prednisone, cyclophosphamide, and anticoagulant, the blood pressure never returned to normal and the left renal function remained completely absent. A nephrectomy was performed which immediately normalized plasma renin activity and blood pressure. The child was subsequently treated with alternateday prednisone for 3 months, alternating with 3 months of cyclophosphamide or, later, azathioprine. Persantine (dipyridamole) and acetylsalicylic acid were administered continuously. The right radial pulse returned to normal within 2 years. An 8-year follow-up failed to detect any new episode of arteritis. The right kidney showed signs of compensatory hypertrophy. Finally, a recent arteriography demonstrated not only a normal right renal artery blood flow but almost total disappearance of the right subclavian artery obstruction. However, the IgE remained abnormally high (2,023 g/l).     

A hemodynamic study of the biventricular bypass total artificial heart with special reference to intrarenal flow distribution.

The present study was undertaken to determine whether a biventricular bypass total artificial heart driven in an independent variable rate mode can maintain circulation in vital organs such as the brain and kidney. Special emphasis was placed on investigating flow distribution. Two pusher-plate pumps were used to bypass the right and left ventricles in 11 goats and 12 sheep with fibrillating hearts. The carotid artery and renal artery flows were then measured using an ultrasonic blood flow meter and the regional renal blood flow calculated using the hydrogen gas clearance method. Thirteen animals were kept alive for 24 hours in physiological hemodynamics but 10 animals died of shock within 24 hours. In the latter group, a decrease in the fractional distribution of flow to the kidney and renal cortex were observed. At a peak aortic pressure of less than 100 mmHg, the renal flow ratio was significantly correlated with the peak aortic pressure. It was thus concluded that the biventricular bypass total artificial heart operated in an independent variable rate mode maintains physiological circulation and is therefore able to substitute for native heart function in any situation.     

A hemodynamic study of the biventricular bypass total artificial heart with special reference to intrarenal flow distribution

The present study was undertaken to determine whether a biventricular bypass total artificial heart driven in an independent variable rate mode can maintain circulation in vital organs such as the brain and kidney. Special emphasis was placed on investigating flow distribution. Two pusher-plate pumps were used to bypass the right and left ventricles in 11 goats and 12 sheep with fibrillating hearts. The carotid artery and renal artery flows were then measured using an ultrasonic blood flow meter and the regional renal blood flow calculated using the hydrogen gas clearance method. Thirteen animals were kept alive for 24 hours in physiological hemodynamics but 10 animals died of shock within 24 hours. In the latter group, a decrease in the fractional distribution of flow to the kidney and renal cortex were observed. At a peak aortic pressure of less than 100 mmHg, the renal flow ratio was significantly correlated with the peak aortic pressure. It was thus concluded that the biventricular bypass total artificial heart operated in an independent variable rate mode maintains physiological circulation and is therefore able to substitute for native heart function in any situation.