Percutaneous transluminal angioplasty in fibromuscular dysplasia of the internal carotid artery: case report

We report a case of symptomatic cervical carotid artery stenosis associated with fibromuscular dysplasia (FMD) successfully treated by percutaneous transluminal angioplasty (PTA). A 49-year-old female presented with repeated ischemic attacks of right hemiparesis and aphasia. Digital subtraction angiography revealed a string of beads appearance of the left internal carotid artery typical of the medial type of FMD, at the level of the C2 vertebra. Similar findings were also evident in the right internal carotid artery at the level of the C1 vertebra, but without significant narrowing. MR angiogram of the left carotid artery revealed a marked flow gap, suggestive of severe stenosis. Forty days after onset PTA was indicated for symptomatic FMD of the left internal carotid artery because of the relative difficulty in approaching and repairing this highly located lesion surgically. The stenotic lesion was very easily dilated without any procedural complications. Although angiography just after PTA showed slight residual irregularity of the wall, this smoothed up with time. Follow-up MR angiography 7 years after PTA demonstrated long-term patency without clinical evidence of deterioration. Patients with the medial type of FMD in the carotid artery seem to be excellent candidates for PTA.     

Aneurysm of the extracranial internal carotid artery caused by fibromuscular dysplasia

A case of aneurysm of the extracranial internal carotid artery (ICA) caused by fibromuscular dysplasia (FMD) is reported. The patient also had an aneurysm of the contralateral intracranial ICA, but the renal arteries were normal. A review of the literature shows extracranial ICA aneurysms to be uncommon, with only 3% caused by FMD. The surgical management of such difficult lesions at the base of the skull is discussed.     

Cutting balloon angioplasty of resistant renal artery stenosis caused by fibromuscular dysplasia

Balloon angioplasty is an established intervention to treat renovascular hypertension. Conventional balloon angioplasty is usually effective in cases of renovascular hypertension caused by fibromuscular dysplasia. In the present report, we describe two cases of renovascular hypertension caused by fibromuscular dysplasia in which stenotic lesions were resistant to conventional balloon angioplasty but were successfully managed by a cutting balloon. After cutting balloon angioplasty, systemic blood pressure was normalized in both patients, without the use of antihypertensive agents. Angioplasty by using a cutting balloon is a new therapeutic choice against renal artery stenosis that is resistant to dilation by a conventional balloon.     

Two unusual variants of internal carotid artery aneurysms due to fibromuscular dysplasia

Aneurysms of the internal carotid artery (ICA) secondary to fibromuscular dysplasia (FMD) are extremely rare. We report two unique variants of extracranial ICA aneurysms due to FMD. The first patient was a hypertensive 51-year-old woman who was found to have a nontraumatic, nonmycotic saccular pseudoaneurysm of the right ICA. The second patient was a 46-year-old woman who presented with 90% stenosis and a focal dissecting aneurysm of the right ICA. Both underwent successful aneurysm resection with interposition saphenous vein grafting after anterior subluxation of the mandible. A review of the literature revealed only 21 other reported cases of aneurysms of the extracranial ICA due to FMD; all were managed successfully with surgical repair. Surgery can be performed with minimal or no morbidity, even in the distal ICA, if the exposure is adequate. Presented at the Fourth Annual Winter Meeting of the Peripheral Vascular Surgery Society, Breckenridge, Colo., January 21–23, 1994.     

Transluminal dilatation of internal carotid artery in fibromuscular dysplasia: A preliminary report

A patient with transient ischemic attacks and fibromuscular dysplasia of the internal carotid artery was treated by Grüntzig balloon-catheter dilatation of the involved area of the internal carotid artery. The clinical and angiographic results were excellent.     

Traumatic occlusion in fibromuscular dysplasia of the carotid artery

A patient with fibromuscular dysplasia involving the cervical carotid artery developed subtotal occlusion after a trivial head injury. An association between occlusion in fibromuscular dysplasia-diseased carotid arteries and trivial blunt head injuries is suggested and appropriate treatment options are discussed.     

Treatment of renal artery fibromuscular dysplasia with balloon angioplasty: a prospective follow-up study.

OBJECTIVES: to assess restenosis rates and blood pressure response after percutaneous transluminal renal angioplasty (PTRA) in patients treated for fibromuscular dysplastic renal artery stenosis. METHODS: a prospective 12-month follow-up study of 27 patients with 31 treated renal artery stenosis. Follow-up assessment included colour-coded duplex sonography (CCD) of renal arteries, monitoring of blood pressure, antihypertensive medication, and creatinine measurements before discharge and at 3, 6, and 12 months. Primary end point was defined as a haemodynamically significant restenosis >60% assessed by CCD. RESULTS: there was a cumulative 23% restenosis rate at 12 months. Arterial hypertension was cured or improved in 93% of patients immediately after the intervention and remained cured/improved in 74% of patients at 12 months of follow-up. Renal failure present in five patients before PTRA stabilised or improved in all patients. CONCLUSION: although restenosis rate after PTRA in fibromuscular dysplasia is as high as in non-ostial atherosclerotic lesions, there remains a considerable higher therapeutic effect. Profound pressure response and recurrent arterial hypertension with restenosis support the high probability of a renovascular origin of arterial hypertension in this young and otherwise healthy population compared to patients with atherosclerotic renal artery lesions.     

Percutaneous transluminal carotid angioplasty in fibromuscular dysplasia. Case report

A patient with fibromuscular dysplasia (FMD) of the internal carotid artery was treated by balloon percutaneous transluminal angioplasty (PTA). This is the sixth reported case of FMD stenotic disease which was dilated by PTA. All previous cases including the current example were treated successfully with resolution of symptoms. This procedure is associated with a relatively low morbidity and is an alternative method of treatment to operative endarterectomy for this disorder.     

Spontaneous obliteration of a carotid-cavernous fistula associated with fibromuscular dysplasia of the internal carotid artery

The authors present a case of spontaneous recovery of a carotid-cavernous fistula associated with fibromuscular dysplasia of the aortocranial vessels in a 31-year-old woman. The pathogenesis of the carotid-cavernous fistula and the possible mechanism responsible for its spontaneous obliteration are both discussed.     

Traumatic bilateral internal carotid artery dissection following airbag deployment in a patient with fibromuscular dysplasia

This case describes a 39-yr-old male, presenting with left hemiplegiaafter a road traffic accident involving frontal decelerationand airbag deployment. Brain computerized tomography (CT) scanrevealed a right parietal lobe infarct. Contrast angiographydemonstrated bilateral internal carotid artery dissection andfibromuscular dysplasia. The patient was treated with systemicheparinization. Neurological improvement, evidenced by fullreturn of touch sensation, proprioception and nociception began10 days after the injury. To our knowledge, this is thefirst case report of carotid artery dissection associated withairbag deployment. Forced neck extension in such settings mayresult in carotid artery dissection because of shear force injuryat the junction of the extracranial and intrapetrous segmentsof the vessel. Clinicians should consider carotid artery injurywhen deterioration in neurological status occurs after airbagdeployment. We propose that the risk of carotid artery dissectionwas increased by the presence of fibromuscular dysplasia. Br J Anaesth 2000; 85: 476–8 ^* Corresponding author     

Open operative balloon angioplasty of the internal carotid artery: A technique in evolution

Open operative balloon angioplasty is a treatment alternative for certain nonatherosclerotic lesions of the internal carotid artery (ICA) including fibromuscular dysplasia (FMD). Standard operative exposure of the carotid bifurcation is performed with atraumatic passage of a guidewire and balloon through a carotid bulb arteriotomy. Under direct fluoroscopic guidance, precise dilatation of the involved area is possible with minimal risk of intimal tear/flap or distal embolization as compared with graduated intraluminal dilatation or percutaneous balloon angioplasty. Vascular control of the common and external carotid arteries lessens the risk of embolization resulting from the constant backflow of blood through the ICA before, during, and after balloon angioplasty, adding to the overall safety and efficacy of the procedure. We report a case of asymptomatic critical carotid artery stenosis associated with FMD successfully treated with open operative balloon angioplasty and review the current literature regarding treatment options for FMD of the ICA.Presented at the Annual Meeting of the Southern California Chapter of the American College of Surgeons, Newport Beach, Calif, January 23, 1994.     

Aneurysms of the extracranial internal carotid artery due to fibromuscular dysplasia: Results of surgical management

Between January 1977 and December 1990, eight patients underwent surgical correction of aneurysms of the extracranial internal carotid artery due to fibromuscular dysplasia. Mean age of patients was 50 years (range 31 to 70 years). Five patients presented with neurologic hemispheric symptoms. Most aneurysms were saccular and occurred preferentially at the level of C2 or C3. All of these patients underwent operation through conventional cervicotomy. Resection-anastomosis was performed in three cases whereas resection-graft was performed in five. Histopathological examination of the eight specimens was consistent with fibromuscular dysplasia of the media. There was no central nervous system-related mortality and morbidity. Seven patients were alive and free of new neurological manifestations at mean follow-up of 156 months (18 to 180 months). One patient died of myocardial infarction at 96 months. All patients had postoperative duplex scanning or arteriograms. These revealed that carotid restorations were patent in seven whereas one patient had asymptomatic occlusion at 18 months.Presented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, June 21–22, 1991, Marseille, France.     

Fibromuscular dysplasia of the internal carotid artery

Sixty-eight patients underwent 104 operations for symptomatic fibromuscular dysplasia between 1965 and 1977. In 8 of the early operations, the artery was resected and primarily anastomosed or replaced with saphenous vein. The remainder of the patients had graduated dilatation of the carotid artery combined, if necessary, with a bifurcation endarterectomy. Four patients had a contralateral endarterectomy for atherosclerosis. There were no operative deaths. Two patients had neurologic deficits after operation, while 7 had 1 transient ischemic attack or amaurosis in the early postoperative period. The follow-up period extends from 6 months to 12 years. One patient developed a deficit that could be attributed to the carotid artery at the site of the prior dilatation, and 2 patients developed neurologic difficulties secondary to subarachnoid hemorrhage. The exact nature of the disease, its incidence in the community, and the mechanism of symptom production remain unknown. Symptomatic fibromuscular dysplasia is not a benign disorder, and there are no data available to confirm or deny the benefit of medical treatment. Intraluminal dilatation, however, is a safe, durable operation that relieves symptoms and offers prophylaxis against further neurologic sequelae.

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Résumé Entre 1965 et 1977, nous avons réalisé chez 68 patients 104 opérations pour dysplasie fibromusculaire symptomatique. Dans 8 cas, au début de la série, l'artère a été réséquée et réanastomosée ou remplacée par un segment de veine saphène. Les autres patients ont subi une dilatation graduée de la carotide, combinée, si nécessaire, à une endartériectomie de la bifurcation. Une endartériectomie controlatérale pour athéromatose a été faite dans 4 cas. Il n'y a pas eu de décès postopératoire. Deux malades ont des séquelles neurologiques et 7 ont présenté, dans la période post-opératoire précoce, un épisode d'ischémie transitoire ou une amaurose. Le follow-up est de 6 mois à 12 ans. Un malade a présenté un accident vasculaire cérébral qui peut être attribué à une lésion carotidienne à l'endroit oú la dilatation avait été faite; 2 autres ont eu des troubles neurologiques par hémorragie sousarachnoïdienne. La nature exacte de la maladie, sa fréquence, les mécanismes d'apparition des symtomes restent inconnus. La dysplasie fibromusculaire symptomatique n'est pas une maladie bénigne et aucune donnée ne permet de préciser la valeur du traitement médical. Mais la dilatation vasculaire intra-luminale est une opération sans risque, aux résultats durables, qui soulage les symptomes et prévient les séquelles neurologiques.

     

Petrous carotid artery pseudoaneurysm in bilateral carotid fibromuscular dysplasia: treatment by means of self-expanding covered stent

BACKGROUND: Pseudoaneurysms of the petrous carotid artery may occur in the setting of trauma, dissection, invasive tumors, or as a complication of surgery. These aneurysms may grow and constitute a potential source of thromboembolic complications or rupture. CASE DESCRIPTION: We present a patient with bilateral carotid FMD presenting with a large petrous pseudoaneurysm. Because carotid occlusion was not appropriate, a self-expandable covered stent was implanted. This treatment allowed complete exclusion of the pseudoaneurysm and preservation of the parent artery. CONCLUSION: The accepted treatment of psuedoaneurysms located at petrous ICA is either sacrifice of the carotid artery or exclusion of the aneurysm from the preserved carotid artery. These procedures have specific limitations, and they are technically demanding and associated with a substantial morbidity rate. The endovascular treatment of these lesions is the preferred alternative. Among the various endovascular techniques that have been tested so far, we propose self-expandable covered stents as ideal for treating arterial aneurysms and pseudoaneurysms of the petrous and cavernous carotid segments.     

经皮血管成形术治疗肌纤维发育不良型肾动脉狭窄的临床疗效

目的评价经皮血管腔内血管成形术(PTA)治疗肾动脉肌纤维性发育不良的疗效及安全性。方法选择肌纤维发育不良型肾动脉狭窄患者32例(均合并2~3级高血压或难治性高血压),行经皮肾动脉成形术治疗。术后随访观察患者血压、药物治疗种类、术后再狭窄、生存率和并发症等。结果 PTA技术成功率93.94%(31/33)。术前、术后收缩压分别为(189.6±26.0)mmHg、(136.6±8.0)mmHg(t=9.117,P0.001),舒张压分别为(121.6±21.7)mmHg、(81.1±11.5)mmHg(t=7.745,P0.001)。无肾动脉破裂、夹层、分支堵塞及血栓形成等相关并发症和术后不良事件发生。术后随访时间5~100个月,平均(40.4±26.1)个月,患者生存率100%(32/32)。结论经皮血管成形术治疗肌纤维发育不良肾动脉狭窄安全、有效。     

Renal artery fibromuscular dysplasia

Fibromuscular dysplasia (FMD) encompasses a heterogeneous group of idiopathic, segmental, nonatherosclerotic diseases of the musculature of arterial walls, leading to the narrowing of small and medium-sized arteries. The most common locations of FMD are renal arteries and carotid arteries. The diagnosis of FMD is made on the "string of beads" appearance of the arteries. The French Health Authority recommends performing a CT scan or an MRA to assess the diagnosis of FMD. A recent meta-analysis showed the cure rates using current definitions of hypertension cure are only 36% and 54% after angioplasty and surgery, respectively.     

Carotid artery fibromuscular dysplasia

Extracranial carotid artery fibromuscular dysplasia (FMD) is a rare finding that is frequently incidental and asymptomatic. It usually occurs in middle-age women and is secondary to medial fibrodysplasia or, less commonly, intimal fibrodysplasia. The carotid artery may be elongated or kinked and associated aneurysms have been reported. Symptoms including transient ischemic attack or stroke are uncommon and are due to low flow or embolization of platelet aggregates. Digital subtraction angiography demonstrates high-grade stenosis with the characteristic "string of beads" pattern. Antiplatelet medication with sequential imaging is the accepted therapy for asymptomatic lesions. Graduated endoluminal dilation under direct vision should be reserved for patients with documented lateralizing symptoms.