Presentation, clinical features and outcome in different patterns of atherosclerotic renovascular disease

Atherosclerotic renovascular disease (ARD) is an increasinglyimportant cause of renal failure. However, important featuresof the clinical presentation are not fully described, and theoutcome after intervention by angioplasty remains controversial.Ninety-four patients with ARD diagnosed at angiography werereviewed. Twenty-four patients were diabetic. Thirty-nine patientshad unilateral renal artery stenosis or occlusion (group A),28 had bilateral stenosis (group B), and 27 had unilateral occlusionplus contralateral occlusion or stenosis (group C), Two yearsafter presentation, actuarial patient survival was 96%, 74.3%and 47.1% in groups A, B and C, respectively (p<0.001 forall differences); actuarial renal survival in surviving patientswas 97.3%, 82.4% and 44.7%, respectively (p<0.001 for alldifferences). Percutaneous transluminal balloon angioplasty(PCTA) was performed in 74 patients. Renal function improvedin only a minority of cases, but was stable in 73% of nondiabeticpatients 12 months after PCTA. Angioplasty was less effectivein diabetic subjects, with only 53.3% having stable renal functionat 12 months follow-up. Renal and patient survival were stronglyrelated to the initial angiographic findings. In nondiabeticsubjects, PCTA resulted in stabilization of renal function forat least one year in nearly threequarters of cases, which suggestsa benefit from intervention in this disease whose natural historyis otherwise of progression.     

Guidelines for the management of hypertensive disorders of pregnancy 2008

This is the Executive Summary of updated guidelines developed by the Society of Obstetric Medicine of Australia and New Zealand for the management of hypertensive diseases of pregnancy. They address a number of challenging areas including the definition of severe hypertension, the use of automated blood pressure monitors, the definition of non-proteinuric pre-eclampsia and measuring proteinuria. Controversial management issues are addressed such as the treatment of severe hypertension and other significant manifestations of pre-eclampsia, the role of expectant management in pre-eclampsia remote from term, thromboprophylaxis, appropriate fluid therapy, the role of prophylactic magnesium sulfate and anaesthetic issues for women with pre-eclampsia. The guidelines stress the need for experienced team management for women with pre-eclampsia and mandatory hospital protocols for treatment of hypertension and eclampsia. New areas addressed in the guidelines include recommended protocols for maternal and fetal investigation of women with hypertension, preconception management for women at risk of pre-eclampsia, auditing outcomes in women with hypertensive diseases of pregnancy and long-term screening for women with previous pre-eclampsia.     

Hemiplegia as a Complication of Therapeutic Embolisation of the Internal Maxillary Artery

A hemiplegia complicating a successfully treated angioma arising from the internal maxillary artery is described. The probable pathogenesis of the complication is discussed. A right common carotid arteriogram and a selective right external carotid arteriogram were carried out. The common carotid arteriogram showed that the intra-cerebral arteries were normal. The external carotid arteriogram showed an enlarged main stem and a greatly enlarged internal maxillary artery (Figure 1). A rapid series of films in the antero-posterior and lateral projections were taken and subtraction films prepared, to identify the feeding vessels to the arterio-venous malformation and to exclude any connections between the external and internal carotid arterial systems. The internal maxillary artery and its branches were the only feeding vessels demonstrated as supplying a large arterio-venous malformation situated in the pterygo-palatine fossa (Figure 2). Because of the anatomical site of the angioma and its wide ramification, it was decided that the most suitable method of treatment would be embolisation of the main feeding arteries rather than an attempt at surgical removal. Following embolisation the patient developed a hemiplegia. A C.T. Scan confirmed the presence of an area of infarction in the right hemisphere of the brain. The hemiplegia slowly improved over a period of four months but left a residual partial paralysis of the left arm. The embolisation therapy was successful in abolishing the bruit and the vascular hum complained of by the patient.     

The Angiographic Findings in a Haemophilic Pseudotumour of Bone

The angiographic findings in a patient with haemophilic pseudotumour of the femur are presented. The examination showed the position of the displaced femoro-poplited vessels, enabling these structures to be avoided at operation. Under anti-haemophilic globulin cover no complications occurred. It is suggested that angiography may be safely employed provided the coagulation defect is controlled. The examination may be useful in differentiating other bone lesions and in defining more clearly the extent of a haemophilic pseudotumour.