Long-term follow-up for percutaneous transluminal angioplasty in renal artery fibromuscular dysplasia.

AIM: Percutaneous transluminal angioplasty (PTA) is an effective treatment for renal artery stenosis secondary to fibromuscular dysplasia (FMD). This study aimed to evaluate the short-and long-term outcomes of percutaneous transluminal angioplasty in patients with hypertension and renal artery fibromuscular dysplasia (FMD). Additionally, we sought to identify specific patient factors that may affect outcomes. METHODS: This study prospectively enrolled 29 patients with uncontrolled hypertension and renal artery FMD diagnosed by duplex ultrasound and angiography. All patients underwent PTA with the goal of cure or improvement of hypertension. Follow-up was at one-month, 6 months, 12 months and then yearly with minimum follow-up of 2 years and maximum of 5 years. RESULTS: Technical success from the intervention was 100%. 21 patients were included in the final analysis. Short-term outcomes: One month after PTA mean systolic blood pressure (138.1 mmHg), diastolic blood pressure (78.6 mmHg), and number of anti-hypertensive medications (1.4) were significantly reduced. Blood pressure improvement was driven by 14/21 (67%) patients who had significant improvement in blood pressure, while 7/21 (33%) did not. These two groups (improved vs. not improved) differed significantly in mean age at intervention (40.6 vs. 58.3 years), duration of hypertension (3.1 vs. 15.4 years), systolic blood pressure (150.4 mmHg vs. 162.1 mmHg), diastolic blood pressure (86.4 mmHg vs. 95.7 mmHg), number of anti-hypertensive medications (2.2 vs. 3.0), serum creatinine (0.82 vs. 1.45), and renal resistive index (0.59 vs. 0.74) prior to intervention. Long-term outcomes: Mean follow-up was 3.86 years. Improvements in blood pressure and anti-hypertensive medications remained significant at five-year follow-up. CONCLUSION: PTA is effective at reducing blood pressure in patients with renal artery FMD. Age at intervention, duration of hypertension, and renal function may be used to predict outcomes prior to intervention.

Prospective analysis of incidence, extent and chronicity of lower extremity venous thrombosis.

OBJECTIVE: This study was designed to determine all variables related to lower extremity deep venous thrombosis (DVT) to be used as reference in patients examined in a hospital setting. METHODS: Consecutive patients presented with signs and symptoms of venous thromboembolism over a one-year period, examined in our university hospital. Patients' demographics and clinical characteristics in a data base organized to answer all the pertinent questions. RESULTS: There were 2594 patients. Thrombosis was found in 348 (13.4%) of which 249 were acute and 72 had chronic luminal changes. Unilateral thrombosis was found in 268 and bilateral in 80. Acute DVT and/or chronic changes were more common on the left limb. Chronic thrombosis was more prevalent in the proximal veins. Acute thrombosis was more often found in the inpatients. Both acute DVT and chronic changes were found in 27 patients (7.8%) of whom 15 were bilateral. CONCLUSIONS: Various patterns of thrombosis are found in both inpatients and outpatients with the former having a higher incidence of acute events. Acute, chronic and recurrent thrombosis are very frequent and very important to report as they could change the management of the patients.

Pharmaco-mechanical thrombectomy for early thrombus removal.

OBJECTIVES: To review the current literature on the outcomes of pharmaco-mechanical thrombectomy (PMT) for early thrombus removal in patients with venous thromboembolism (VTE). METHODS: We searched the MEDLINE database and performed a manual search of the references of selected articles to select reports reporting the outcomes of PMT alone and PMT compared to catheter-direct thrombolysis (CDT). Outcomes of interest included clot lysis rate, incidence of pulmonary embolism, major bleeding, recurrent deep vein thrombosis, number of venograms needed and amount of lytic utilized. RESULTS: We found nine articles that reported outcomes of PMT. Three devices were utilized for PMT, the Angiojet, Trellis and Helix. Different thrombolytics were used to facilitate thrombus removal including urokinase, reteplase, tecneteplase, and tissue plasminogen activator (t-PA). Complete and partial thrombus removal were achieved in up to 84% and 64% and 81% and 59% of the limbs treated with PMT and CDT alone, respectively. Data on PE and bleeding risk after PMT compared to CDT are scarce. The duration of the thrombolysis process, amount of lytics and number of venograms were substantially reduced in the patients who had PMT compared to those who underwent CDT alone. Two articles evaluated the obstacles that limit the indication of PMT in patients with VTE. CONCLUSION: VTE is a prevalent burden in Western societies. The rationale of early thrombus is to reduce valvular damage and improve venous patency in order to reduce the risk of PTS. PMT is a feasible, safe and faster alternative to expedite the thrombolysis process in patients with VTE.

How to diagnose giant cell arteritis.

AIM: Current debate on how to diagnose giant cell arteritis (GCA) has strayed from the traditional approach of temporal artery biopsy and has instead explored the effectiveness of alternative imaging modalities. METHODS: We have reviewed the literature and pooled published results for temporal artery imaging including magnetic resonance imaging (MRI), Duplex ultrasound, positron emission tomography-computed tomography (PET-CT) scan. RESULTS: The results of this review show that ultrasound and MRI both represent viable options for evaluation of GCA; however utilizing ultrasound first may be the best first option in diagnostic tools. In 1990 the American College of Rheumatology offered criteria for positive pathology in GCA. CONCLUSION: In this study, we propose a risk stratification criteria as well as an algorithm for the best diagnostic approach when GCA is suspected.

Impact and clinical significance of recurrent venous thromboembolism.

BACKGROUND: The purpose of this review was to analyse current knowledge and controversies associated with the diagnosis, treatment and prevention of recurrent venous thromboembolism (VTE). METHODS: MEDLINE and manual searches were performed to select prospective papers on the diagnosis, treatment and prevention of recurrent VTE for their relevance and quality. RESULTS: The cumulative incidence of recurrent VTE increases from 11 per cent at 1 year to 40 per cent at 10 years. The incidence of recurrence is higher in unprovoked thrombosis compared with provoked VTE. Patients with unprovoked deep vein thrombosis also have a greater number of multiple recurrences. Ultrasonography or D-dimer monitoring may have an impact on the duration of anticoagulation but further refinements are needed. The incidence of skin damage is higher in ipsilateral recurrence compared with contralateral or no recurrence. Legs with ipsilateral recurrence more often have both reflux and obstruction. CONCLUSION: The role and weight of the predictive factors for recurrent VTE and its sequelae, and the type and optimal duration of anticoagulation have not been studied adequately. Fatality associated with pulmonary embolism and rates of recurrent VTE remain unacceptably high.

Nutritional support in the patient with HIV infection.

Weight loss and malnutrition are the most common symptoms associated with active infection with human immunodeficiency virus. The origin of the malnutrition is considered multifactorial and broadly includes decreased nutrient intake, nutrient malabsorption, and metabolic alterations. Steady advances have been made in understanding the mechanisms underlying weight loss in these patients. The utility and optimal modes of nutrition support have not yet been fully established.

Visceral patch rupture after repair of thoracoabdominal aortic aneurysm--a case report.

This is a unique case of a visceral patch rupture in a Marfan patient after a repair of a thoracoabdominal aneurysm. The patient presented with abdominal pain and in shock 6 years after repair. The retained aortic wall containing the origins of the celiac, mesenteric, and renal arteries was aneurysmal and had ruptured. Clinical presentation, diagnosis, and operative modalities are discussed.