Percutaneous transluminal angioplasty improves blood pressure and renal function in renovascular hypertension

Thirty-three patients with renal angiographic evidence of significant renal artery stenosis were referred for percutaneous transluminal angioplasty. The indications were poorly controlled hypertension (n = 13) or hypertension associated with deteriorating renal function (n = 20). Their mean age was 56 (23-73) years (12 males, 21 females). Causes of the renal artery stenosis were fibromuscular dysplasia (n = 8) and atheromatous changes (n = 25). Four patients were excluded, three due to technical failure. Forty-five angioplasties were performed in 29 patients with a mean observation period after angioplasty of 18 (one to 60) months. During this period eight patients (28 per cent) had a diastolic blood pressure of less than 90 mmHg without antihypertensive drugs, a further 15 patients (52 per cent) had improved blood pressure control with a significant reduction in the number and amount of antihypertensive drugs, but six patients (20 per cent) showed no improvement in blood pressure. Hypertension associated with the stenosis of fibromuscular dysplasia responded better to angioplasty than hypertension associated with atheromatous renal artery stenosis. Improvement in renal function was noted in eight patients with no change in 16 patients. Two patients with end-stage renal failure and atheromatous intrarenal vascular disease became dialysis dependent within four weeks of the procedure. One major and four minor complications occurred but there were no deaths related to angioplasty. Together with results from other centres this study indicates that percutaneous transluminal angioplasty should be considered the initial treatment choice for all patients with renovascular hypertension due to fibromuscular dysplasia and atheromatous renal artery stenosis.     

Percutaneous transluminal angioplasty for atheromatous renal artery stenosis--blood pressure response and discriminant analysis of outcome predictors

Percutaneous transluminal angioplasty was performed in 39 consecutive patients with atheromatous renal artery stenosis associated with hypertension. The mean blood pressure before angioplasty was 191/107 mmHg and this had dropped to a mean of 167/90 mmHg at the patient's most recent visit, representing a significant fall in both systolic (p less than 0.01) and diastolic pressures (p less than 0.001). The mean serum creatinine was 166.7 mumol/l before percutaneous transluminal angioplasty and 155.3 mumol/l at the most recent visit (not statistically significant). The mean number of anti-hypertensive drugs fell from 2.4 to 1.9 after percutaneous transluminal angioplasty (p less than 0.05). Three patients (eight per cent) were 'cured' (diastolic blood pressure less than 90 mmHg without medication), 25 (64 per cent) had 'improved' (diastolic blood pressure less than 109 mmHg, with a fall of more than 15 per cent) and 11 (28 per cent) had not improved. Logistic discriminant analysis showed that pre-percutaneous transluminal angioplasty diastolic blood pressure, age, serum creatinine and smoking habit together correctly predicted the outcome of percutaneous transluminal angioplasty in 90 per cent of patients, with four 'false positives' and no 'false negatives'. Ten patients suffered a total of 12 serious complications related to the procedure: one death in acute renal failure, one myocardial infarction, one severe hypotension just after the procedure, one deep vein thrombosis, one episode of transient ischaemia of the toes and seven groin haematomas. Thus percutaneous transluminal angioplasty for atheromatous renal artery stenosis rarely 'cures' hypertension, but improved blood pressure control is often achieved, albeit at the expense of troublesome complications. A prospective, randomized trial is needed to establish whether or not the improvement is due directly to percutaneous transluminal angioplasty.     

Percutaneous Transluminal Angioplasty for Atheromatous Renal Artery Stenosis - Blood Pressure Response and Discriminant Analysis of Outcome Predictors

Percutaneous transluminal angioplasty was performed in 39 consectivepatients with atheromatous renal artery stenosis associatedwith hypertension. The mean blood pressure before angioplastywas 191/107 mm Hg and this had dropped to a mean of 167/90 mmHG at the patient's most recent visit, representing a significantfall in both systolic (p<0.01) and diastolic pressures (p<0.001).The mean serum creatinine was 166.7 µmol/l before percutaneoustransluminal angioplasty and 155.3 µmol/1 at the mostrecent visit (not statistically significant. The mean numberof anti-hypertensive drugs fell from 2.4 to1.9 after percutaneoustransluminal angioplasty (p<0.05). Three patients (eightper cent) were ‘cured’ (diastolic blood pressure<90 mm Hg without medication), 25 (64 per cent) had ‘improved’(diastolic blood pressure <109 mmHg, with a fall of morethan 15 per cent) and 11 (28 per cent) had not improved. Logisticdiscriminant analysis showed that pre-percutaneous transluminalangioplasty diastolic blood pressure, age, serum creatinineand smoking habit together correctly predicted the outcome ofpercutaneous transluminal angioplasty in 90 per cent of patients,with four ‘false positives’ and no ‘falsenegatives’. Ten patients suffered, a total of 12 seriouscomplications related to the procedure: one death in acute renalfailure, one myocardial infarction, one severe hypotension,just after the procedure, one deep vein thrombosis, one episodeof transient ischaemia of the toes and seven groin haematomas.Thus percutaneous transluminal angioplasty for atheromatousrenal artery stenosis rarely ‘cures’ hypertension,but improved blood pressure control is often achieved, albeitat the expense of troublesome complications. A prospective,randomized trial is needed to establish whether or not the improvementis due directly to percutaneous transluminal angioplasty.     

Renovascular hypertension

Renal artery disease is the most common cause of potentially curable secondary hypertension, with atherosclerosis as the major cause of renal artery stenosis. Fibromuscular dysplasia is a less common cause of renal artery stenosis and is most frequently observed in premenopausal women. Renal artery stenosis is likely to be underappreciated and is more common in patients with other vascular disease (e.g., coronary or peripheral arterial disease). The diagnosis of renal artery stenosis requires a high clinical index of suspicion as well as an appropriate imaging strategy, with currently effective diagnostic modalities including magnetic resonance imaging, computed tomography and renal artery duplex ultrasonography. The current treatment of choice for atherosclerotic renal artery stenosis is balloon angioplasty and secondary stenting, whereas angioplasty alone is the treatment for renal artery stenosis secondary to fibromuscular dysplasia. Expected outcomes following revascularization include improved blood pressure control and possibly renal preservation. Ongoing studies will hopefully identify patient characteristics that will achieve the most benefit from percutaneous revascularization as well as the impact of percutaneous revascularization with drug-eluting stents and embolic protection devices.     

Renovascular hypertension

Renal artery disease is the most common cause of potentially curable secondary hypertension, with atherosclerosis as the major cause of renal artery stenosis. Fibromuscular dysplasia is a less common cause of renal artery stenosis and is most frequently observed in premenopausal women. Renal artery stenosis is likely to be underappreciated and is more common in patients with other vascular disease (e.g., coronary or peripheral arterial disease). The diagnosis of renal artery stenosis requires a high clinical index of suspicion as well as an appropriate imaging strategy, with currently effective diagnostic modalities including magnetic resonance imaging, computed tomography and renal artery duplex ultrasonography. The current treatment of choice for atherosclerotic renal artery stenosis is balloon angioplasty and secondary stenting, whereas angioplasty alone is the treatment for renal artery stenosis secondary to fibromuscular dysplasia. Expected outcomes following revascularization include improved blood pressure control and possibly renal preservation. Ongoing studies will hopefully identify patient characteristics that will achieve the most benefit from percutaneous revascularization as well as the impact of percutaneous revascularization with drug-eluting stents and embolic protection devices.     

Percutaneous transluminal renal artery angioplasty: who benefits most?

We set out to assess the long-term benefits of renal percutaneous transluminal angioplasty (PTA) in 107 consecutive hypertensive patients with atheromatous renal artery stenosis. During 12-month follow-up, blood pressure fell to normal levels in 10 (8.8%) patients and improved in 76 (67.3%); renal function improved or remained stable in 74% of patients. In patients with atheromatous disease, renal angioplasty was most successful in those with stenosis in a single functioning kidney, and in nine patients who presented with symptoms and signs of heart failure, in the absence of overt ischaemic or valvular heart disease. In the latter group, renal PTA resulted in a large loss of sodium and water, resolution of the 'apparent' heart failure, and a marked improvement in blood pressure and renal function. It is suggested that all hypertensive patients with haemodynamically significant renal artery stenosis (and/or mild to moderate impairment in renal function), should be considered for renal PTA. Patients with atheromatous stenosis in a single functioning kidney, and those who present with signs of sodium and water retention, are likely to benefit most.     

Prognosis of Critically-ill Patients with Acute Renal Failure: APACHE II Score and Other Predictive Factors

The survival from acute renal failure requiring renal replacementtherapy was studied in 90 critically-ill patients admitted toan intensive care unit. Mean age (± SD) was 51 ±14.6 (range 17 to 81) years. Mechanical ventilation was requiredin 88 patients and 71 patients received total parenteral nutrition.Thirty-three per cent of patients left the intensive care unitalive and 24 per cent survived to leave hospital. Final survivalwas 20 per cent in medical patients (n= 49), 29 per cent insurgical patients (n= 38) and 100 per cent in obstetric patients(n= 3). Hypotension, requirement for inotropic support, oliguriaand sepsis were all associated with a poorer prognosis. Themode of renal replacement therapy did not affect survival, butadditional haemodialysis was required in 33 of 65 patients treatedby continuous arteriovenous haemofiltration but none of 22 treatedwith continuous arteriovenous haemodialysis (p < 0.001).APACHE II score was calculated for 87 patients. Mean APACHED score was 26.1 ± 6.9 (range 14 to 44). APACHE II scoreon admission predicted the likelihood of survival well. No patientswith a score of more than 40 survived, compared to 40 per centof those with scores of 10 to 19. Pre-existing organ insufficiencyor immunosuppression meriting a CHE score of 5 was associatedwith a very poor survival (1 of 30 patients). APACHE II scoreis a reliable indicator of severity of illness and likelihoodof survival in critically-ill patients with acute renal failure.The widespread adoption of APACHE II scoring for patients withacute renal failure requiring intensive care would facilitatemedical audit and comparison of studies from various centres.     

The Association of Autoimmune Disorders with Inflammatory Bowel Disease

Medical records of patients with ulcerative colitis (n= 858),Crohn's disease (n= 378) and coeliac disease (n = 148) wereexamined to determine the prevalence of associated autoimmunedisorders. Of outpatient controls (n= 300), 2 per cent had atleast one autoimmune disorder, compared to 7 per cent with ulcerativecolitis, 2 per cent with Crohn's disease and 6 per cent withcoeliac disease. Inclusion of primary sclerosing cholangitiswith the autoimmune disorders increased the overall prevalencein ulcerative colitis to over 9 per cent The results providefurther indirect evidence of involvement of autoimmune mechanismsin the pathogenesis of ulcerative colitis.     

Recognizing and managing fibromuscular dysplasia

Fibromuscular dysplasia typically occurs in young women and most commonly presents with hypertension, transient ischemic attack, stroke, or an asymptomatic cervical bruit. The disease is nonatherosclerotic and noninflammatory and most often affects the renal and carotid arteries, although almost any artery can be involved. On angiography, affected blood vessels characteristically resemble a string of beads in the most common type of fibromuscular dysplasia, medial fibroplasia. Patients with renal artery stenosis and hypertension or renal impairment should be treated with percutaneous transluminal angioplasty without a stent. Patients with fibromuscular dysplasia of the internal carotid artery should also be treated with angioplasty if they develop focal neurologic symptoms such as a transient ischemic attack or stroke.     

A refractory hypertensive patient with fibromuscular dysplasia and multicystic dysplastic kidney

The case of a 16-year-old male patient with left renal artery stenosis due to fibromuscular dysplasia (FMD) and an atrophic kidney due to a right multicystic dysplastic kidney (MCDK) who presented with refractory hypertension is reported. On continuous Doppler imaging, the peak systolic velocity (PSV) at the stenotic site of the left renal artery was 404 cm/s. The FMD formed a “string-of-beads” appearance on computed tomographic angiography (CTA) and renal artery angiography. Percutaneous transluminal renal angioplasty (PTRA) with a balloon catheter was performed, after which the left renal artery returned to near normal, and his blood pressure decreased to within the normal range. In this case, the main cause of refractory hypertension was considered to have been renal artery stenosis due to left FMD.     

Successful Wallstent implantation for extensive iatrogenic renal artery dissection in a patient with fibromuscular dysplasia.

PURPOSE: To describe a case of renal artery stenosis with fibromuscular dysplasia (FMD) and extensive iatrogenic dissection treated with Wallstent implantation. METHODS AND RESULTS: An 83-year-old woman with a history of coronary artery disease and hypertension presented at another facility with exertional angina and poorly controlled hypertension. Renal arteriography uncovered a critical right renal artery stenosis with severe FMD. However, angioplasty resulted in extensive dissection of the renal artery, for which the patient was referred to our institution. The renal artery was recanalized via the left brachial approach with restoration of flow using a Wallstent and a Palmaz stent. The patient's blood pressure was controllable after this procedure, and follow-up duplex imaging with flow velocities at 6 months showed patent right renal artery stents. CONCLUSIONS: Owing to its length and flexibility, the Wallstent endoprosthesis was a useful treatment modality in this case of extensive renal artery dissection.     

Progression of Diabetic Autonomic Neuropathy over a Decade in Insulin-Dependent Diabetics

The prognosis for diabetics with autonomic neuropathy is littleknown. We therefore studied the progress of young insulin-dependentdiabetics, first identified as having abnormal autonomic function10–15 years ago. We have shown that the mortality of diabeticswith symptomatic authonomic neuropathy is increased, but isless than previously reported. Mortality in asymptomatic diabeticswith an isolated abnormality in autonomic function tests isnot increased. The heart rate variability declines at 1.02±0.47(SD) per annum in diabetics with an initially normal heart ratevariability. While symptoms of autonomic neuropathy do not usuallyremit even over a decade, they do not commonly progress. Three groups of young insulin-dependent diabetics had heartrate variability tested between 1972 and 1977 and have beenreviewed 10–15 years later. Group A (n=49) had symptomaticautonomic neuropathy and an abnormal heart rate variability(<12), Group B (n=24) were asymptomatic yet had an abnormalheart rate variability and Group C (n=38) were asymptomaticand had a normal heart rate variability (16–26). The 10-yearsurvival in Group A (73.4 per cent) was less (P<0.05) thanin Groups B (91.7 per cent) or C (89.5 per cent) which did notdiffer from each other. The 18 Group A deaths were due predominantlyto renal failure (n=4), myocardial infarction in patients withnephropathy (n=3) and sudden unexpected death (n=3). The chiefsymptoms of autonomic neuropathy-diarrhoea, postural hypotensionand gustatory sweating, were very persistent but did not necessarilydeteriorate or become disabling in the majority of patients.The development of autonomic symptoms in asymptomatic patientswith abnormal heart rate variability was uncommon over a decade.     

Renovascular hypertension: the small kidney updated

We report the results of treatment in 57 patients with renovascular hypertension associated with one poorly perfused, small kidney with less than 25 per cent of total 131I-hippurate uptake shown by renography. Arteriography in 29 patients demonstrated occlusion of the artery of the small kidney, and in 28 there was stenosis. In addition, 25 patients had stenosis of the artery supplying the larger contralateral kidney. Stenosis of the arteries of the contralateral kidneys was dilated by percutaneous transluminal arterioplasty in all but one of the 25 patients with bilateral disease of the artery, stenosis of the small kidney could be dilated successfully by percutaneous transluminal arterioplasty in 22 of the 28 patients, and cure or improvement of blood pressure was achieved in 12 of them. Percutaneous transluminal arterioplasty of occluded arteries was generally unsuccessful. In 17 patients with unilateral disease not manageable by percutaneous transluminal arterioplasty, nephrectomy of the small kidney improved blood pressure control without significant deterioration of renal function. Renal function improved in 10 patients with bilateral lesions treated by nephrectomy of the small kidney in combination with contralateral percutaneous transluminal arterioplasty. Histological examination of excised kidneys showed large infarcts or several cholesterol emboli whether percutaneous transluminal arterioplasty had been attempted or not. After observation periods ranging from two to 79 months, 48 patients were normotensive (21 without and 27 with medication) and nine patients were still hypertensive even with medication. This study showed that by using percutaneous transluminal arterioplasty initially if possible, supplemented with nephrectomy and/or medication, normotension without loss of renal function or immediate serious complications could be obtained in the majority of these severely hypertensive patients.     

Renovascular Hypertension: The Small Kidney Updated

SUMMARY We report the results of treatment in 57 patients with renovascularhypertension associated with one poorly perfused, small kidneywith less than 25 per cent of total ¹³¹I-hippurate uptake shownby renography. Arteriography in 29 patients demonstrated occlusionof the artery of the small kidney, and in 28 there was stenosis.In addition, 25 patients had stenosis of the artery supplyingthe larger contralateral kidney. Stenosis of the arteries ofthe contralateral kidneys was dilated by percutaneous transluminalarterioplasty in all but one of the 25 patients with bilateraldisease of the artery, stenosis of the small kidney could bedilated successfully by percutaneous transluminal arterioplastyin 22 of the 28 patients, and cure or improvement of blood pressurewas achieved in 12 of them. Percutaneous transluminal arterioplastyof occluded arteries was generally unsuccessful. In 17 patients with unilateral disease not manageable by percutaneoustransluminal arterioplasty, nephrectomy of the small kidneyimproved blood pressure control without significant deteriorationof renal function. Renal function improved in 10 patients withbilateral lesions treated by nephrectomy of the small kidneyin combination with contralateral percutaneous transluminalarterioplasty. Histological examination of excised kidneys showedlarge infarcts or several cholesterol emboli whether percutaneoustransluminal arterioplasty had been attempted or not. After observation periods ranging from two to 79 months, 48patients were normotensive (21 without and 27 with medication)and nine patients were still hypertensive even with medication. This study showed that by using percutaneous transluminal arterioplastyinitially if possible, supplemented with nephrectomy and/ormedication,normotension without loss of renal function or immediateserious complications could be obtained in the majority of theseseverely hypertensive patients.     

Renovascular hypertension: ten years' experience in a regional centre

In a unit serving a population of three million, 60 hypertensive patients with renovascular disease were identified over a 10-year period. The presence of renovascular disease was usually suggested by intravenous urography (IVU), although this was falsely negative in 21 per cent of cases; isotope renography (IR) was normal in a similar proportion of patients (25 per cent). Eight patients were treated medically and 52 underwent surgical procedures; nephrectomy in 32, autotransplantation in 10, by pass graft in six and percutaneous transluminal angioplasty in four. Twenty-three per cent of patients were cured, 37 per cent improved and 40 per cent unchanged one year after surgery, but the response could not be accurately predicted. Clinical features were of some value in that those patients most likely to benefit from surgery were younger, had less severe hypertension of shorter duration, smoked less, had less severe retinopathy and less cardiomegaly. There was also a trend for those with better renal function and less electrocardiographic evidence of left ventricular hypertrophy to benefit from surgery. The IVU and IR did not predict response to surgery but arteriographic appearances of fibromuscular dysplasia indicated there should be a favourable response. The renal vein renin ratio, basal or stimulated, was of no prognostic value since approximately two-thirds of patients with ratios above or below the threshold value had some benefit from surgery. We conclude that the surgical treatment of renovascular hypertension is worthwhile but the number of patients suitable for surgery is small. Clinical features and the results of simple investigations provided the best guide to surgical outcome in our patients.     

Renovascular hypertension. Difficulties in diagnosis and treatment

Renovascular hypertension is not easily identified clinically, and most tests are not totally reliable in detecting its presence. The condition may be due to fibromuscular dysplasia or congenital anomalies in patients younger than age 30 or to atherosclerosis in patients older than 50. The goal of treatment is to lower blood pressure and improve or maintain renal function. Cure or improvement of hypertension is more likely in patients with fibromuscular dysplasia than in those with atherosclerosis. Interventional procedures include percutaneous transluminal angioplasty, surgical revascularization, and nephrectomy.     

移植肾动脉狭窄的介入治疗

目的：探讨移植肾动脉狭窄介入治疗的方法和疗效。方法：9例移植肾动脉狭窄的病人，经股动脉入路行狭窄段的导管球囊扩张和内支架植入术。结果：9例移植肾动脉的患者均成功完成球囊扩张术，其中3例行内支架植入术，治疗后一周7例血压基本恢复正常，2例靠药物维持，所有患者的肌酐术后均明显下降。结论：导管球囊扩张和内支架植入术对治疗移植肾动脉狭窄有较高的临床应用价值。     

Hyperthyroidism in the Land of Graves: Results of Treatment by Surgery, Radio-iodine and Carbimazole in 837 Cases

A review of the outcome of treatment by subtotal thyroidectomy,radio-iodine and carbimazole of 837 patients with hyperthyroidismseen consecutively over the period 1954–78 inclusive ispresented. The age and sex distribution, the male to femaleratio, the ABO blood group distribution and the prevalence ofpernicious anaemia and diabetes mellitus in these patients wasalso analysed. Life-table data showed that the five-year andten-year cumulative relapse rates following a two-year courseof carbimazole (n = 162) were 56 per cent and 62 per cent; followingsurgery (n = 266), 6 per cent and 10 per cent and followingradio-iodine (n = 43), 3 per cent and 14 per cent. Five-yearand ten-year cumulative hypothyroid rates after surgery were10 per cent and 18 per cent, and after radio-iodine 10 per centand 30 per cent. Hypothyroidism did not occur after carbimazoletherapy. Of 31 patients who took carbimazole for less than twoyears (mean 11 months, range 6–19 months), 91 per centhad relapsed at five years. Of 79 patients treated for longerthan two years (mean 3.8 years, range 2–14 years), relapserates at five and eight years were 49 per cent and 62 per cent.Nine patients (3.4 per cent) suffered permanent vocal cord paralysisand five (1.9 per cent) had permanent hypocalcaemia. The male/female ratio was 9.9 to 1, with a peak female prevalencebetween 25 and 30 years and a peak male prevalence between 40and 45 years. The ABO blood group distribution among patients did not differsignificantly from the distniution in the general population(x² = 13.4, p = 0.2). Forty-seven patients (5.6 per cent) had diabetes mellitus andthyrotoxicosis whilst two patients (0.23 per cent) had diabetes,thyrotoxicosis and pernicious anaemia.     

CT灌注成像评估单侧大脑中动脉狭窄患者脑血流动力学和血管成形术及支架置入术疗效

目的 CT灌注(CTP)成像评价单侧大脑中动脉(MCA)狭窄患者脑血流动力学变化和血管成形术及支架置入术(PTAS)效果。方法 选取单侧MCA狭窄患者40例, 根据CTA测量狭窄程度分为中度狭窄(50%-69%)组14例和重度狭窄(70%-99%)组26例, 另根据药物疗效将重度狭窄组分为有效亚组16例和无效亚组10例。利用CTP评估狭窄侧与对侧的绝对灌注值, 包括脑血流量(CBF)、脑血容量(CBV)和达峰时间(TTP), 及相对灌注值(rCBF、rCBV、rTTP), 评价支架治疗术前及术后脑血流动力学情况。结果 中度狭窄组狭窄侧与对侧比较, 仅TTP差异有统计学意义(t=20.55, P <0.01), 重度狭窄组CBV和TTP的差异均有统计学意义(CBV:t=3.83, P <0.001;TTP:t=8.89, P <0.001)。治疗无效亚组rTTP较有效亚组显著延长(t=-2.18, P=0.04)。无效亚组接受PTAS后, rTTP较术前明显缩短(t=5.94, P <0.001)。结论 CTP能有效评估MCA狭窄患者脑血流动力学的变化, 筛选介入治疗患者, TTP能敏感反映术后血流动力学改变。     

肾动脉球囊成形术或支架置入治疗肾血管性高血压

目的　评估球囊成形术或支架置入治疗肾血管性高血压的安全性和疗效。方法　对 2 1例患者共 2 7条肾动脉狭窄 ,应用单纯高压球囊扩张或置入球囊扩张支架治疗。结果　 2 7条病变动脉 ,2 0条扩张满意 ,7条狭窄肾动脉预扩张支架置入后 ,1例病变残余狭窄 11% ,其余 6条无残余狭窄。 2 1例患者血压均有明显下降 ,收缩压从 172± 11mmHg降至 12 6± 8mmHg ;舒张压从 115± 7mmHg降至 79± 6mmHg。 15例停用降压药血压仍正常。另 6例降压药从 4种减至 1种 ,血压仍能满意控制。结论　肾动脉扩张或支架置入是治疗肾血管性高血压简便、安全、有效的方法