Duplex ultrasonography in the diagnosis of celiac and mesenteric artery occlusive disease

Duplex ultrasound criteria for the diagnosis of celiac and superior mesenteric artery (SMA) occlusive disease have not been well defined. We performed a blinded retrospective comparison of mesenteric duplex data with arteriography in 24 consecutive patients who underwent both studies. Arteriography revealed that eight superior mesenteric arteries were normal; five were minimally stenotic; eight had stenoses greater than or equal to 50%, and three were occluded. Nine celiac arteries were normal or minimally stenotic; 12 had stenoses greater than or equal to 50%, and three were occluded. Duplex scans were obtained after an overnight fast. In normal superior mesenteric arteries, peak systolic velocity (PSV) was 134 +/- 18 cm/sec and end-diastolic velocity (EDV) was 24 +/- 4 cm/sec. Superior mesenteric artery PSV in patients with minimal or no stenosis (171 +/- 22 cm/sec) was less than PSV in patients with severe (greater than 50%) stenosis (299 +/- 40 cm/sec, p = 0.006), and less than PSV in patients with patent superior mesenteric arteries who underwent revascularization (366 +/- 86 cm/sec, p = 0.017). Similarly, EDV was elevated in superior mesenteric arteries with severe stenosis (78 +/- 11 cm/sec, p = 0.001) and in patients who underwent revascularization (111 +/- 19 cm/sec, p less than 0.001) compared to those with less than 50% stenosis (30 +/- 6 cm/sec, p = 0.001). An EDV greater than 45 cm/sec was the best indicator of severe stenosis (sensitivity, 1.0; specificity, 0.92). Peak systolic velocity greater than 300 cm/sec was less sensitive (0.63), but highly specific (1.0) for severe superior mesenteric artery stenosis.(ABSTRACT TRUNCATED AT 250 WORDS)     

Duplex ultrasound criteria for diagnosis of splanchnic artery stenosis or occlusion

Mesenteric artery duplex scanning appears promising for detection of splanchnic artery stenosis or occlusion or both in patients with symptoms suggestive of chronic intestinal ischemia. However, no specific duplex criteria have been developed for detection of mesenteric artery stenosis. We obtained mesenteric artery duplex scans and infradiaphragmatic lateral aortograms in 34 patients to determine duplex criteria for mesenteric stenosis. Seventy percent or greater angiographic stenosis was present in 10 superior mesenteric arteries and 16 celiac arteries. Duplex scans were reviewed to determine if celiac artery and superior mesenteric artery ratios of peak systolic velocities and end-diastolic velocities to peak aortic systolic velocity, as well as celiac artery and superior mesenteric artery peak systolic velocities and end-diastolic velocities alone, could predict a greater than or equal to 70% angiographic stenosis or occlusion or both. The results obtained by use of receiver operator curves indicated peak systolic velocity alone was an accurate predictor of splanchnic artery stenosis. Specifically, a peak systolic velocity greater than or equal to 275 cm/sec in the superior mesenteric artery and greater than or equal to 200 cm/sec in the celiac artery or no flow signal (superior mesenteric artery and celiac artery) predicted a 70% to 100% stenosis with sensitivity, specificity, and positive predictive values of 89%, 92%, and 80% for the superior mesenteric artery. Similar values for the celiac artery were 75%, 89%, and 85%, respectively. End-diastolic velocities or calculated velocity ratios conveyed no additional accuracy in predicting splanchnic artery stenosis.     

Mesenteric artery disease in the elderly

PURPOSE: The purpose of this study was to estimate the population-based prevalence of mesenteric artery stenosis (MAS) and occlusion among independent elderly Americans. METHOD: As part of an ancillary investigation to the Cardiovascular Health Study (CHS), participants in the Forsyth County, NC cohort had visceral duplex sonography of the celiac arteries and superior mesenteric arteries (SMAs). Critical MAS was defined by celiac peak systolic velocity >or=2.0 m/s and/or SMA peak systolic velocity >or=2.7 m/s. Occlusion of either vessel was defined by lack of a Doppler-shifted signal within the imaged artery. Demographic data, blood pressures, and blood lipid levels were collected as part of the baseline CHS examination. Participants' weights were measured at baseline and before the duplex exam. Univariate tests of association were performed with two-way contingency tables, Student t tests, and Fisher exact tests. Multivariate associations were examined with logistic regression analysis. RESULTS: A total of 553 CHS participants had visceral duplex sonography technically adequate to define the presence or absence of MAS. The study group had a mean age of 77.2 +/- 4.9 years and comprised 63% women and 37% men. Participant race was 76% white and 23% African-American. Ninety-seven participants (17.5%) had MAS. There was no significant difference in age, race, gender, body mass index, blood pressure, cholesterol, or low-density lipoproteins for participants with or without MAS. Forward stepwise variable selection found renal artery stenosis (P =.008; odds ratio [OR], 2.85; 95% confidence interval [CI], 1.31, 6.21) and high-density lipoprotein >40 (P =.02; OR, 3.03; 95% CI, 1.17, 7.81) significantly associated with MAS in a multivariate logistic regression model. Eighty-three of the 97 participants with MAS (15.0% of the cohort) had isolated celiac stenosis. Seven participants (1.3% of the cohort) had combined celiac and SMA stenosis. Five participants (0.9% of the cohort) had isolated SMA stenosis. Two participants (0.4% of the cohort) had celiac occlusion. Considering all participants with MAS, there was no association with weight change. However, SMA stenosis and celiac occlusion demonstrated an independent association with annualized weight loss (P =.028; OR, 1.54; 95% CI, 1.05, 2.26) and with renal artery stenosis (P =.001; OR, 9.48; 95% CI, 2.62, 34.47). CONCLUSION: This investigation provides the first population-based estimate of the prevalence of MAS among independent elderly Americans. MAS existed in 17.5% of the study cohort. The majority had isolated celiac disease. SMA stenosis and celiac artery occlusion demonstrated a significant and independent association with weight loss and concurrent renal artery disease.     

Should aortography be used routinely in the elective management of abdominal aortic aneurysm?

Until recently aortography was performed routinely for elective abdominal aortic aneurysm at our institution. A death resulting from this procedure prompted us to evaluate this policy by a retrospective study of 105 elective aneurysm patients. These studies identified 21 renal artery stenoses, 2 renal artery aneurysms, 2 cases of multiple renal arteries, 8 celiac stenoses, 6 superior mesenteric artery stenoses or occlusions, and a number of peripheral occlusive processes and associated iliac aneurysms. However, the impact of these findings on surgical management was limited to six renal artery reconstructions: one for reimplantation of a renal artery arising from the aneurysm, one for serious hypertension, and four in normotensive patients with severe arterial stenosis. No celiac or mesenteric reconstructions were undertaken, and no visceral complications ensued. In only one patient, the one with renal artery reimplantation, was the angiographic information unsuspected and significant for operative management. This did not appear to justify the risk and expense involved in routine preoperative aortography.     

Use of hemodynamic parameters in the diagnosis of mesenteric insufficiency

To evaluate the hemodynamic characteristics of the normal mesenteric circulation, five parameters of the velocity waveforms were measured in 15 normal subjects in the celiac and superior mesenteric arteries (SMA) in the pre- and postprandial periods. It was noted that changes in celiac artery flow after eating was minimal, indicating that this vessel's major supply function is not to the gut. SMA parameters showing the most significant and consistent changes after a meal were the diastolic reverse flow and diastolic forward flow (DFF). Four patients referred with symptoms of intestinal angina underwent scanning and subsequent angiography of their mesenteric circulation. All four exhibited loss of reverse flow in the SMA. The change in DFF in the SMA was statistically significant (p = 0.01). Change in peak systolic velocity in the celiac artery was marginally significant (p = 0.05). Angiography revealed that three patients had greater than 90% stenosis of both vessels. The fourth patient had a 90% celiac artery and 65% SMA stenosis. The technique described offers the first noninvasive means of identifying mesenteric insufficiency. It is an effective screening method for a disease entity difficult to verify without selective arteriography. The use of velocity waveform parameters giving good discrimination between normal subjects and those with stenoses of the visceral arteries should reduce both the incidence of missed diagnosis and unnecessary angiography.     

Can duplex ultrasound replace arteriography in screening for mesenteric ischemia?

Duplex examination of the mesenteric vasculature is not a widely performed examination, but the published literature documents the ability of this test to accurately identify chronic atherosclerotic occlusive disease. The test is a recent addition to the armamentarium of noninvasive duplex technology, with studies of adequate size for statistical analysis appearing only since 1991. Two primary sets of diagnostic threshold values for significant stenoses of the superior mesenteric artery (SMA) and the celiac artery have been published and subsequently tested for accuracy. One of these recommends use of peak systolic velocity (PSV), whereas end diastolic velocity (EDV) was found to be most accurate in the other. Both sets of criteria identify overall accuracy of greater than 90% for identification of SMA stenosis, and greater than 80% for diagnosis of celiac stenosis. Identification of celiac disease may be aided by analysis of blood flow direction in the common hepatic artery. The finding of retrograde hepatic flow is virtually diagnostic of severe celiac stenosis or complete occlusion. Duplex also has been shown capable of identifying anatomic anomalies of the mesenteric vessel origins, a situation that occurs in approximately 20% of the population. Finally, mesenteric duplex has utility in a variety of less common abdominal visceral disorders, but statistical analysis of accuracy and adequate identification of quantitative velocity thresholds have not been performed. Skilled technologists who have access to appropriate training and equipment can master this test. There is little doubt that it can replace angiography as a screening tool in the setting of suspected chronic mesenteric ischemia.     

Pediatric renovascular hypertension: 132 primary and 30 secondary operations in 97 children

PURPOSE: This study was undertaken to characterize the contemporary surgical treatment of pediatric renovascular hypertension. METHODS: A retrospective analysis was conducted of the clinical data of 97 consecutive pediatric patients (39 girls, 58 boys), aged from 3 months to 17 years, who underwent operation at the University of Michigan from 1963 to 2006. All but one patient had refractory hypertension not responsive to contemporary medical therapy. Developmental renal artery stenoses accounted for 80% of the renal artery disease, with inflammatory and other ill-defined stenoses encountered less frequently. Splanchnic arterial occlusive lesions affected 24% and abdominal aortic coarctations, 33%. RESULTS: Primary renal artery operations were undertaken 132 times. Procedures included resection beyond the stenosis and implantation into the aorta in 49, renal artery in 7, or superior mesenteric artery in 3; aortorenal and iliorenal bypasses with vein or iliac artery grafts in 40; focal arterioplasty in 10; resection with reanastomosis in 4; operative dilation in 4; splenorenal bypass in 2; and primary nephrectomy in 13 when arterial reconstructions proved impossible. Bilateral renal operations were done in 34 children, and 17 underwent celiac or superior mesenteric arterial reconstructions, including 15 at the time of the renal operation. Thirty patients underwent abdominal aortic reconstructions with patch aortoplasty (n = 19) or thoracoabdominal bypass (n = 11). Twenty-five of the aortic procedures were performed coincidently with the renal operations. Thirty secondary renal artery procedures were done in 19 patients, including nine nephrectomies. Hypertension was cured in 68 children (70%), improved in 26 (27%), and was unchanged in three (3%). Follow-up averaged 4.2 years. No patients required dialysis, and there were no operative deaths. CONCLUSION: Contemporary surgical treatment of pediatric renovascular hypertension emphasizes direct aortic implantation of the normal renal artery beyond its stenosis and single-staged concomitant splanchnic and aortic reconstructions when necessary. Benefits accompany carefully executed operative procedures in 97% of these children.     

Comparison of spiral CT scan and arteriography for evaluation of renal and visceral arteries

Renal and visceral artery images obtained concurrently with spiral CT and conventional arteriography were compared for 32 patients. Indications for imaging were occlusive disease (n=12), aneurysmal disease (n=9), and renal or visceral artery disease (n=11). Conventional arteriography enabled visualization of 64 renal arteries and 15 accessory renal arteries. Lateral aortograms obtained in 15 patients enabled visualization of 14 superior mesenteric (SMA) and 14 celiac arteries. Spiral CT enabled visualization of 60 renal arteries, 12 accessory renal arteries, 27 SMAs, and 22 celiac arteries. Calcification or a disparity in timing of contrast material injection and scanning prevented visualization of the celiac artery in 10 patients and the SMA in four patients. With conventional arteriography as the standard for comparison, spiral CT had a sensitivity of 67% and a specificity of 95% for depiction of at least 75% stenosis in the main renal artery. By means of the Pearson correlation coefficient, significant correlation (p < 0.001) was confirmed between spiral CT and arteriography for evaluation of stenosis of the main renal artery, SMA, and celiac artery. This early experience suggests that spiral CT may be useful in evaluation of renal and visceral arteries and their relationship to aortic disease.Presented at the Twentieth Annual Meeting of the Peripheral Vascular Surgery Society, New Orleans, La., June 10, 1995.     

腹腔动脉和肠系膜上动脉狭窄的介入治疗

目的评价介入技术治疗腹腔动脉（CA）和肠系膜上动脉（SMA）狭窄的安全性和临床疗效。方法对8例CA／SMA局限性狭窄患者进行了经皮穿刺经腔球囊血管成型术（PTA）和支架置入术,单纯CA狭窄2例、单纯SMA狭窄4例、CA和SMA均有狭窄2例。4例患者有典型进餐后腹痛,5例有上腹部血管杂音,8例于发病后均有不同程度的体重下降（平均8kg）。7例患者病因为动脉硬化,1例为膈肌中脚压迫综合征（MALS）所致。结果PTA和支架置人均成功,其中治疗CA狭窄3例、SMA狭窄5例,7例用1个支架,1例用2个支架。治疗结束时复查造影显示置人支架的血管血流通畅,管径接近正常。术后于穿刺侧腹股沟区出现小血肿2例,无须外科处理、自行吸收。术后腹痛完全消失5例、有所减轻2例、无改善1例;术后3个月时,体重恢复至发病前水平者6例。8例患者随访6-72个月（平均42个月,中位值28个月）,复查Doppler超声波无明确再狭窄证据。5例无症状、1例仍然有间歇性腹痛,2例分别于术后14个月、24个月死于其他原因。结论PTA和支架置入术是治疗CA、SMA局限性狭窄的安全有效方法,尤适宜于存在外科治疗高风险的患者。     

Asymptomatic carotid artery stenosis associated with peripheral vascular disease: a prospective study

This study aimed to determine the prevalence of symptomless internal carotid artery stenosis in consecutive patients presenting with peripheral vascular disease. Duplex ultrasound screening of the carotid arteries was used to determine the degree of stenosis. Co-morbidities were recorded together with age, sex and tobacco use. Internal carotid artery stenosis of > 50% was found in 35% of patients. Among these there was > or = 70% stenosis in 18% of patients and of this group 5% had an occluded carotid vessel at first presentation. Males presented with peripheral vascular disease and associated carotid stenoses at a younger age than females. Male smokers had a higher prevalence of stenosis (P = 0.036) but all smokers had developed stenoses 3-5 years before non-smokers. Females with abdominal aortic aneurysms had a greater prevalence of carotid stenosis (P = 0.037), and male aneurysmal disease diminished stenosis prevalence (P = 0.023). Men with an elevated serum creatinine were more likely to have a stenosis (P = 0.019), but not women. The other co-morbidities were not specifically associated with carotid artery stenosis.     

Unstable hypertension due to renal artery compression by the developed diaphragm in a 17-year-old athlete: a case report

A 17-year-old high school boy was admitted to our hospital because of hypertension. Doppler ultrasound of the renal arteries and 3D-CT angiography showed a stenosis of the right renal artery, which was pushed against the aorta by the right crus of the diaphragm. He underwent aortography and selective renal arteriography. His right renal artery originated from the aorta at a higher level than the left renal artery, between the celiac artery and the superior mesenteric artery. Renal arteriography confirmed a 50% reduction in diameter (stenosis) of the proximal right renal artery entrapped by the right diaphragmatic crus. This pathology, unlike common renal artery stenosis, sometimes requires surgical decompression or an aortorenal bypass graft, because renal angioplasty with stenting is reported to be at risk of complication by a fracture of the stent. However, the patient rejected surgical decompression for fear of deterioration of his athletic ability. Therefore we decided to follow up his blood pressure and renal size by ultrasound every six months. Renovascular hypertension caused by diaphragmatic entrapment is a very rare disease. The diagnosis may be overlooked easily at angiography if optimal views are not obtained. It is important to display images of the renal arteries, the celiac artery and the superior mesenteric artery in both inspiration and expiration.     

Deployment of balloon expandable stents during open repair of thoracoabdominal aortic aneurysms: a new strategy for managing renal and mesenteric artery lesions.

OBJECTIVE: Patients undergoing graft repair of thoracoabdominal aortic aneurysms (TAAAs) often require concomitant correction of ostial stenoses or dissection involving visceral branches. The purpose of this report is to describe our initial experience with a new strategy for addressing these lesions during open TAAA repair-direct deployment of balloon expandable stents into the renal and mesenteric arteries. METHODS: Over a two-year period, 367 patients have undergone TAAA surgery. Balloon expandable stents were used to manage visceral branch lesions during open TAAA repair in 93 (25.3%) of these patients. Fifteen patients (16%) had preoperative renal insufficiency. After opening the aneurysm and exposing the branch artery ostia, premounted balloon expandable stents were deployed in the affected vessels under direct vision. Stents were deployed after an endarterectomy in 40 patients (43%). Eighty patients (86%) had stents placed in one or both renal arteries and 36 (39%) had stents placed in the celiac axis and/or superior mesenteric artery. Postoperative renal function was monitored with daily serum creatinine levels. RESULTS: There were nine early operative deaths (10%). Two patients (2%) had bleeding complications related to stenting, one of which died after developing multiple organ failure. Twelve patients (13%) developed renal failure, eight of which required dialysis. CONCLUSIONS: This study demonstrates the feasibility of treating ostial lesions of the visceral branches with balloon expandable stents during open TAAA repair. Despite a high prevalence of preoperative renal insufficiency, the incidence of postoperative renal failure was acceptable. This new strategy may be a valuable adjunct to TAAA repair and warrants further investigation.     

The natural history of superficial femoral artery stenoses

Since the natural history of specific superficial femoral artery stenoses is not known, we examined progression rates of superficial femoral artery stenoses in 45 lower extremities found when arteriograms were obtained of 38 patients for symptomatic atherosclerotic disease in the opposite leg or abdomen. These initial superficial femoral artery arteriograms were compared with later arteriograms in 25 limbs, duplex scans in 27 limbs, and both modalities in 7 limbs. After a mean interval of 37 months, most superficial femoral artery stenoses (72%) did not progress. However, 12 superficial femoral artery stenoses progressed (28%; mean follow-up, 37 months, including 7 that occluded (17%). Superficial femoral artery stenoses progressed among patients who complained of symptom progression at a rate faster than that among asymptomatic patients (15.6%/year vs 3%/year; p = 0.006). Superficial femoral artery lesions also progressed more rapidly among patients whose contralateral superficial femoral artery was occluded (10%/year vs 1.6%/year; p = 0.04). By multivariate regression analysis, symptom progression and smoking history were predictive of superficial femoral artery stenosis progression. In the seven patients whose superficial femoral artery stenoses progressed to occlusion, the average rate of stenosis progression was 12%/year (maximum predicted rate, 30% per year by 95% confidence limit). These results indicate that superficial femoral artery stenoses usually progress with synchronous symptomatic deterioration. Other than symptom progression, only cumulative smoking history and contralateral superficial femoral artery occlusion could be associated with superficial femoral artery stenosis progression in this small series.(ABSTRACT TRUNCATED AT 250 WORDS)     

Color duplex ultrasonography of the superior mesenteric artery after placement of endografts with suprarenal stents

After endovascular repair of abdominal aortic aneurysm with endografts with suprarenal stents, the proximal uncovered stent may cross the origin of the superior mesenteric artery. Effects on splanchnic circulation are unknown and may include development of stenosis at the vicinity of the stent. The criteria of high-grade superior mesenteric artery stenosis using color duplex ultrasonography have been previously reported. The purpose of this study is to examine the incidence of high-grade superior mesenteric artery stenosis in patients with endografts with suprarenal stents using color duplex ultrasonography. Candidates for the study were patients who had placement of an aortic endograft with a suprarenal stent and were able to undergo ultrasonography of the superior mesenteric artery. After reviewing computed tomography scans, patients who had the origin of the superior mesenteric artery crossed by the suprarenal stent underwent color duplex ultrasonography of this vessel. Presence of turbulence or narrowing of the superior mesenteric artery, or a peak systolic velocity greater than 2.75 m/sec, or an end-diastolic velocity greater than 0.45 m/sec were considered significant for the presence of high-grade superior mesenteric artery stenosis. There were 24 patients (21 males, three females), median age 71 years (range, 59-83). The suprarenal stent was crossing the superior mesenteric artery in 17 of 24 patients (71%). Color duplex ultrasound was technically successful in 13 of 17 (76%). The test was performed after a median follow-up of 9 months (range, 3 days to 34 months). No patient had evidence of turbulence or narrowing of the superior mesenteric artery during ultrasonography. The median peak systolic velocity was 0.92 m/sec (range, 0.53-1.21 m/sec). No patient had peak systolic velocity greater than 2.75 m/sec. The median end-diastolic velocity was 0.10 m/sec (range, 0.09-0.14 m/sec). No patient had end-diastolic velocity greater than 0.45 m/sec. Color duplex ultrasonography did not demonstrate the presence of high-grade superior mesenteric artery stenosis during early follow-up of patients with endografts with suprarenal stents. Longer follow-up of larger series of patients is needed to determine the long-term effects of suprarenal stents on splanchnic circulation.     

Atherosclerotic occlusive disease of the superior mesenteric artery: Late results of reconstructive surgery

Between 1975 and 1988, 103 patients underwent reconstruction of the superior mesenteric artery for atherosclerotic occlusive disease. Patients undergoing revascularization with associated mesenteric infarction were excluded. There were 89 men and 14 women whose mean age was 57.2 years. Six patients were operated on emergently for impending mesenteric infarction; six patients underwent revascularization after intestinal resection for ischemic lesions; 20 patients had typical abdominal angina; 39 patients had nonspecific abdominal symptoms, and 32 patients underwent revascularization of their superior mesenteric artery for asymptomatic lesions. Revascularization of the celiac axis and inferior mesenteric artery was associated in 36 and four cases, respectively. Four patients (4%) died postoperatively. Four early occlusions (4%) were observed. During the follow-up period (mean=69 months), 18 patients died; five patients had recurrent intestinal ischemic symptoms, four of whom died. All surviving patients underwent follow-up duplex scanning, examination, and arterial or venous digitalized angiograms in selected cases. Nine patients (9%) had anatomical abnormalities: two stenoses and seven occlusions. Failure of revascularization of the superior mesenteric artery was observed in patients with severe initial intestinal ischemia. Late complications were not statistically significantly related to the different techniques of revascularization used. Presented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, June 23–24, 1989, Strasbourg, France.     

Digestive arterial bypass. Long-term clinical results

In the period between September 1966 and December 1988, 69 patients were operated, including 92 cases of restorative surgery on celiac, hepatic or superior mesenteric arteries. This is a presentation, of the detailed retrospective analysis of 12 years' experience with more homogeneously matched indications and technics. Only indirect, venous or prosthetic bypasses and reimplants are discussed; excluded are all other digestive revascularization procedures, as well as acute ischemic surgery cases. 31 patients (28 men, 3 women) of mean age 59.8 years (47-80) have undergone consecutive surgery: 11 presented with symptoms of predominantly digestive origin; 18 had a combined aortoiliac bypass operation; radiological signs of disease occurred in 46 cases. (celiac artery): 22 including 14 stenoses, 5 thrombotic cases and 3 aneurysms; superior mesenteric artery: 21 including 13 stenoses and 8 thrombotic cases; inferior mesenteric: 3 thrombotic cases). A restorative operation was carried out on 45 patients, 6 of whom had had previous surgery. 21 patients had a single artery restored: celiac (3), hepatic (9), superior mesenteric (9). Double artery surgery was performed in 12 cases. The procedures most commonly used on the hepatic and superior mesenteric arteries were indirect reimplantation and bypass surgery, respectively. Evolution showed increased numbers of anterograde constructions. No deaths were recorded in the perioperative period. Two patients had early recurrences of thrombosis at D10, which required new bypassing. During the mean retrospective period of 6.1 years, we recorded 6 cases of blindness, 8 secondary deaths, 1 single case of mesenteric infarction 18 months after a repeated restorative operation on the superior mesenteric artery; 17 patients remained symptom-free.     

Natural history of atherosclerotic renal artery stenosis associated with aortic disease

The natural history of atherosclerotic renal artery stenosis has not been well defined, particularly when discovered in conjunction with aortic disease requiring correction. To better define the natural history of such lesions, 194 sequential aortograms in 48 patients were studied to define predictive criteria for stenoses at risk for progression. Sixty-six unsuspected atherosclerotic renal arterial stenoses were identified on the initial aortograms. Disease progressed in 42 arteries (53%), 14 bilateral and 28 unilateral. Seven arteries developed occlusion. All had stenoses averaging 80% (range 61% to 94%) noted on the most recent aortogram preceding occlusion. Risk factors including smoking, diabetes mellitus, elevated serum lipids, coronary artery disease, peripheral arterial disease, or change in blood pressure or creatinine, did not correlate with degree or rate of progression of the renal artery stenosis. A difference in kidney size, although varying inversely with degree of stenosis, was not a statistically significant marker of disease progression. This analysis suggests that identification of renal arterial stenoses that will progress is best determined by sequential aortography. Highly stenotic vessels are more prone to occlude than those less stenotic. Consequently, individuals with preocclusive lesions should benefit from prophylactic renal revascularization during aortic reconstruction.     

Endovascular treatment of celiac and mesenteric arteries stenoses: applications and results

PURPOSE: To evaluate the safety and assess the role of endovascular therapy in a variety of conditions related to celiac and mesenteric vascular occlusive disease.Patients and methods Our retrospective study population included 25 consecutive patients (mean age, 66 years), in whom 28 procedures were performed on 26 stenosed or occluded mesenteric vessels (superior mesenteric artery [SMA] or celiac artery [CA]). Indications included chronic mesenteric ischemia (21 patients), including 2 patients who underwent stenting prior to a planned operative repair of a juxtamesenteric AAA. Three liver transplantation patients underwent stenting of an associated CA stenosis. One patient with a splenorenal bypass underwent stenting on an associated CA stenosis. The technical and clinical success rates and the incidence of complications were determined. Follow-up parameters included maintained patency on duplex sonography and sustained clinical benefit. The need for additional interventions was noted. RESULTS: All procedures but one were technically successful (96%). Major complications occurred in three patients (one transient contrast-induced nephrotoxicity and two pseudoaneurysms). Immediate clinical success was achieved in 22 patients (88%). The three clinical failures included two patients with an excellent angiographic outcome, but with single-vessel moderate severity disease. Survival table analysis of delayed clinical outcome showed primary and primary-assisted clinical benefits at 11 months of 85% and 91%, respectively. Primary and primary-assisted stent patencies, as assessed by duplex sonography and/or angiography, at 6 months were both 92%. Angiographically documented restenosis occurred in three patients. Restenosis in two patients with CA stents was due to extrinsic compression, and it was without symptoms in one patient and was treated satisfactorily by restenting in the other patient. Restenosis in one patient with an SMA stent was successfully treated by restenting. CONCLUSIONS: Our experience suggests a potential role for endovascular therapy of celiac and mesenteric arterial occlusive disease in a variety of clinical scenarios, with a low incidence of complications and a high technical success rate.     

Screening for mesenteric vascular insufficiency and follow-up of mesenteric artery bypass procedures

Duplex ultrasonography is the preferred noninvasive screening test for superior mesenteric artery (SMA) and celiac artery (CA) stenosis. Although postprandial increases in SMA peak systolic velocity (PSV) are known to occur, the principal duplex criteria for hemodynamically significant SMA and CA stenosis are based on fasting flow velocities. In the SMA, a PSV > or =275 cm/s predicts a > or =70% angiographic stenosis with a sensitivity of 92% and a specificity of 96%, whereas a CA PSV of > or =200 cm/sec predicts a > or =70% stenosis with a sensitivity of 87% and a specificity of 80%. Patients with appropriate symptoms of chronic visceral ischemia and a duplex scan showing high-grade stenosis of the SMA, especially when combined with CA stenosis, should have a confirmatory mesenteric angiogram. This approach will facilitate prompt intervention in these patients. If the duplex examination indicates widely patent mesenteric arteries, alternative diagnoses should be investigated. Other applications of mesenteric duplex scanning include evaluation of median arcuate ligament syndrome and postoperative surveillance of mesenteric artery revascularizations.     

Natural history of atherosclerotic renal artery stenosis: A prospective study with duplex ultrasonography

Purpose: Although the prevalence of renal artery stenosis in patients with peripheral arterial disease is in the range of 30% to 40%, the role of renal revascularization in patients without severe hypertension or kidney failure is controversial. Duplex scanning is a noninvasive technique that is ideally suited for screening and follow-up of renal artery disease. The purpose of this study was to document the natural history of renal artery stenosis in patients who were not candidates for immediate renal revascularization.Methods: Eighty-four patients with at least one abnormal renal artery detected by duplex scanning were recruited from patients being screened for renal artery stenosis. Of the 168 renal artery/kidney sides, 29 were excluded (15 prior interventions, 6 nondiagnostic duplex scans, 8 presumed nonatherosclerotic lesions), leaving 80 patients with 139 sides for the follow-up protocol. Renal arteries were classified as normal, less than 60% stenosis, 60% or greater stenosis, or occluded by use of previously validated criteria.Results: The study group included 36 men and 44 women with a mean age of 66 years who were monitored for a mean interval of 12.7 months. The initial status of the 139 renal arteries was normal in 36, less than 60% stenosis in 35, 60% or greater stenosis in 63, and occluded in 5. Although none of the initially normal renal arteries showed disease progression, the cumulative incidence of progression from less than 60% to 60% or greater renal artery stenosis was 23% ± 9% at 1 year and 42% ± 14% at 2 years. All four renal arteries that progressed to occlusion had 60% or greater stenoses at the initial visit, and for those sides with a 60% or greater stenosis, the cumulative incidence of progression to occlusion was 5% ± 3% at 1 year and 11% ± 6% at 2 years. The mean decrease in kidney length associated with progression of renal artery stenosis to occlusion was 1.8 cm.Conclusions: Progression of renal artery stenosis, as defined in this study, occurs at a rate of approximately 20% per year. Progression to occlusion is associated with a marked decrease in kidney length. Whether this natural history can be improved by earlier intervention for renal artery stenosis remains to be determined. (J VASC SURG 1994;19:250-8.)