Progression of atherosclerotic renovascular disease: A prospective population-based study.

OBJECTIVE: Previous reports from select hypertensive patients suggest that atherosclerotic renovascular disease (RVD) is rapidly progressive and associated with a decline in kidney size and kidney function. This prospective, population-based study estimates the incidence of new RVD and progression of established RVD among elderly, free-living participants in the Cardiovascular Health Study (CHS). METHOD: The CHS is a multicenter, longitudinal cohort study of cardiovascular risk factors, morbidity, and mortality among men and women aged >65 years old. From 1995 through 1996, 834 participants underwent renal duplex sonography (RDS) to define the presence or absence of significant RVD. Between 2002 and 2005, a second RDS study was performed in 119 participants (mean study interval, 8.0 +/- 0.8 years). Significant RVD was defined as hemodynamically significant stenosis (renal artery peak systolic velocity [RA-PSV] exceeding 1.8 m/s) or renal artery occlusion. Prevalent RVD was significant RVD at the first RDS, and incident disease was defined as new significant RVD at the second RDS. Significant change of RVD was defined as a change in RA-PSV of greater than two times the standard deviation of expected change over time, regardless of hemodynamic significance or progression to renal artery occlusion. RESULTS: The second RDS study cohort included 119 CHS participants with 235 kidneys (35% men; mean age, 82.8 +/- 3.4). On follow-up, no prevalent RVD (n = 13 kidneys; 6.0%) progressed to occlusion. Twenty-nine kidneys without RVD at the first RDS demonstrated significant change in PSV at the second RDS; including nine kidneys with new significant RVD (8 new stenoses; 1 new occlusion). Controlling for within-subject correlation, the overall estimated change in RVD among all 235 kidneys was 14.0% (95% confidence interval [CI], 9.2% to 21.4%), with progression to significant RVD in 4.0% (95% CI, 1.9% to 8.2%). Longitudinal increase in diastolic blood pressure and decrease in renal length were significantly associated with progression to new (ie, incident) significant RVD but not prevalent RVD. CONCLUSIONS: This is the first prospective, population-based estimate of incident RVD and progression of prevalent RVD among free-living elderly Americans. In contrast to previous reports among select hypertensive patients, CHS participants with a low rate of clinical hypertension demonstrated a significant change of RVD in only 14.0% of kidneys on follow-up of 8 years (annualized rate, 1.3% per year). Progression to significant RVD was observed in only 4.0% (annualized rate, 0.5% per year), and no prevalent RVD progressed to occlusion.

Vena cava filters: an update.

Venous thromboembolism is a major health problem that results in significant long-term complications and mortality. The management of venous thromboembolism is complex and can be particularly challenging when pharmacological therapy alone cannot be effectively utilized. Vena cava filters provide protection from pulmonary embolism for patients in whom therapeutic anticoagulation is contraindicated or inadequate. Recent innovations in caval interruption have included the use of alternative imaging modalities for filter insertion and the emergence of devices designed to allow temporary caval filtration. These developments have been accompanied by a controversial increase in the use of vena cava filters for prophylactic indications in the absence of venous thromboembolism. In addition to a brief historical perspective on caval filtration, this update reviews the indications for vena cava filter insertion, associated complications, methods of caval imaging and filter insertion and current FDA-approved devices.

Renovascular disease in children and adolescents.

PURPOSE: This retrospective review describes the surgical management of renovascular disease in 25 consecutive children and adolescents with severe hypertension. METHODS: Patients 95 th percentile systolic or diastolic pressure adjusted for gender, age, and height). RA repair comprised 25 bypasses (73%) consisting of 28% saphenous vein, 60% hypogastric artery, and 12% polytetrafluoroethylene; 2 patch angioplasties (6%), and 7 reimplantations (21%). Branch RA exposure was required in 28 kidneys (88%), and branch reconstruction was required in 61%. Warm in situ repair was used in 53%, in situ cold perfusion in 24%, and ex vivo cold perfusion in 23%. Of six bilateral RA repairs, one was staged and two patients are awaiting a staged repair. Combined aortic reconstruction was required in three patients. No unplanned nephrectomy was performed. There were no perioperative deaths. Hypertension was cured in 36%, improved in 56%, and failed in 8% at mean follow-up of 46.4 +/- 7.8 months. The mean calculated glomerular filtration rate increased from 82.0 mL/min/1.73 m 2 preoperatively to 98.2 mL/min/1.73 m 2 postoperatively. The postoperative patency of 30 RA reconstructions was evaluated by angiography, RDS scanning, or both. At mean follow-up of 32.8 months (median, 21.2 months), primary RA patency was 91%. No failures were observed after 2 months follow-up. Estimated survival was 100% at 60 months, with one death 9 years after surgery. CONCLUSIONS: Renovascular hypertension in children and adolescents was caused by a heterogeneous group of lesions. All patients had RA repair, with arterial autografts in most of the RA bypasses. Cold perfusion preservation was used in half of the complex branch RA repairs. These strategies provided 91% primary patency at mean follow-up of 32.8 months, with beneficial blood pressure response in 92%. Surgical repair of clinically significant renovascular disease in children and adolescents is supported by these results.

Endotension in an experimental aneurysm model.

PURPOSE: The purpose of this study was to design an experimental model of endotension and to investigate whether attachment site failure without endoleak results in higher aneurysm sac pressure (ASP). METHODS: Infrarenal aortic aneurysms were created in canines with an elliptical knitted polyester patch. Pressure transducers were inserted into the aneurysm. Group I (n = 4) underwent endovascular stent graft exclusion of the aneurysm. An attachment site failure was formed in group II (n = 5) before aneurysm exclusion. ASP measurements were obtained for 3 weeks, and the ratio of mean ASP to mean systemic blood pressure (ASP/BP) was calculated. Before explant, norepinephrine was administered and ASPs were recorded at varying systemic pressures. Stent graft cuff exclusion of the attachment site failure was performed in group II. RESULTS: Intraoperative arteriography and duplex ultrasonagraphy did not reveal an endoleak in either group. ASP/BP in group I was 0.39 +/- 0.02 compared with 1.01 +/- 0.02 in group II (P <.001). Mean systemic pressure varied from 55 to 177 mm Hg after norepinephrine administration. Within this interval, ASP/BP was 0.51 +/- 0.10 in group I compared with 0.91 +/- 0.10 in group II (P <.001). ASP/BP before cuff deployment in group II was 0.98 +/- 0.08 compared with 0.46 +/- 0.04 after cuff deployment (P <.001). CONCLUSION: Systemic pressure is transmitted to the aneurysm sac through an attachment site failure, despite no endoleak, resulting in endotension. Cuff exclusion of the attachment site failure decreases ASP. ASP may help determine the need for future intervention after endovascular aneurysm repair.

Effects of estrogen, progesterone, and combination exposure on interleukin-1 beta-induced expression of VCAM-1, ICAM-1, PECAM, and E-selectin by human female iliac artery endothelial cells.

The cardioprotective effect of hormone replacement therapy (HRT) in healthy, postmenopausal women is well documented. Little work has been performed on the effect of HRT in peripheral arteries. Recent work suggests that HRT may adversely affect the patency of peripheral grafts. This study investigates the in vitro effects of estrogen and/or progesterone exposure on adhesion molecule expression by normal human female iliac artery endothelial cells (HIAEC). Control and interleukin-1 beta (IL-1 beta)-stimulated HIAEC monolayers were labeled with fluorescent-tagged antibodies against the adhesion molecules VCAM-1, ICAM-1, PECAM, and E-selectin. FACS analysis was used to measure antibody-labeled adhesion molecule expression. ICAM-1 and PECAM were found to be constitutively expressed. VCAM-1 and ICAM-1 expression were significantly upregulated by IL-1 beta, while E-selectin was neither constitutively expressed nor upregulated by IL-1 beta. Pretreatment with estrogen or progesterone alone decreased IL-1 beta-stimulated VCAM-1 and ICAM-1 expression, but not to statistically significant levels. Combined hormone exposure significantly decreased, in an additive fashion, the expression of VCAM-1 and ICAM-1 in stimulated cells. This study supports extension of the beneficial effects ascribed to HRT to include the peripheral arterial endothelium of healthy women.