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.

Endoscopic management of upper urinary tract stones.

In a two year period from March 1983, 157 patients with upper urinary tract stones were managed primarily by endoscopy. Of 90 patients with renal stones, extraction was achieved in 91% of patients with complete extraction in 76%. Of the remaining patients with ureteric stones, successful extraction was achieved in 75%. Ten patients required open surgery which was for failed extraction in 9. Morbidity is low with a mean hospital stay of 4.7 days for patients with kidney stones, and of 3.7 days for patients undergoing extraction of ureteric stones.

The incidence of microaneurysms in polyarteritis nodosa.

Following reports of hemorrhage from renal microaneurysms caused by renal biopsy, renal arteriography has been used increasingly as a screening procedure prior to renal biopsy as well as for diagnostic investigation. The incidence of renal microaneurysms has been documented in a group of 40 cases of suspected polyarteritis nodosa, of whom 15 were confirmed, and only 2 had microaneurysms. Both subjects with microaneurysms had more florid clinical disease. In view of the low incidence of microaneurysms it is suggested that renal angiography should be used as a diagnostic investigation only in cases with florid clinical disease and not as a screening procedure prior to renal biopsy.

Doppler waveform analysis and percutaneous dilatation of arteries in ischaemia of the lower limb.

Percutaneous transluminal dilatation of narrowed atheromatous arteries using the inflatable Gruntzig catheter is becoming an accepted non-surgical treatment for patients with disabling intermittent claudication of the lower limb. The use of doppler ultrasound to study limb blood flow in a group of patients having aortic or iliac dilatation is described.

Percutaneous transhepatic occlusion for bleeding oesophageal varices in polycystic disease.

A 7-year-old boy with congenital polycystic disease of the kidneys and liver developed portal hypertension and gastro-oesophageal varices. After two episodes of upper gastrointestinal bleeding, percutaneous transhepatic occlusion of varices and of the left gastric vein was carried out. During the next year there was no evidence of further haemorrhage.

Medium-term follow-up of forty autogenous vein and forty polytetrafluoroethylene (Gore-Tex) grafts for vascular access.

Patency of 40 polytetrafluoroethylene (PTFE) and 40 autogenous vein arteriovenous grafts for vascular access among 56 patients is compared. Most patients required access for hemodialysis, but six grafts were for other reasons including hyperalimentation and drug administration. Cumulative patency at 3 years for both PTFE grafts and vein grafts was 64%. The complication rate necessitating secondary operation was more than three times greater in the PTFE group in which 35 secondary procedures were needed. No grafts became infected as a result of the initial operation, but eight serious complications were associated with subsequent infection of PTFE grafts and three with vein grafts, including postcannulation bleeding, abscess, and aneurysm. Twenty-six PTFE grafts developed associated stenosis in the runoff vein. This was demonstrated with angiography in 10 and the stenoses were excised and grafted, one being dilated by intravascular balloon. In 16 thrombosis was the first indication of stenosis. Histologically narrowed runoff veins showed intimal hyperplasia. Runoff stenosis did not occur among vein grafts, but in eight vein grafts themselves became stenotic. These results indicate that owing to a higher complication rate with PTFE grafts, vein grafts should be used when possible.

Renal fibromuscular hyperplasia associated with subarachnoid hemorrhage from a berry aneurysm: a case report.

An 11-year-old girl with renal artery fibromuscular hyperplasia and a berry aneurysm of the anterior communicating artery with subarachnoid haemorrhage is reported. She presented with subarachnoid hemorrhage and was shown to have hypertension attributable to unilateral renal artery fibromuscular hyperplasia. Cerebral angiography showed an aneurysm of the anterior communicating artery. The aneurysm was not treated surgically, but control of the hypertension was obtained by renal revascularisation with an aortorenal graft of saphenous vein. The patient remained well subsequently, and follow-up angiography demonstrated virtual disappearance of the aneurysm and also a functioning aortorenal graft.

Gastric emptying in diabetic autonomic neuropathy.

Gastric emptying was studied in 12 diabetic patients, six with and six without objective evidence of autonomic neuropathy and in 20 nondiabetic controls, using a double isotope scintiscanning technique which differentiated between solid and liquid emptying. Three patients with autonomic neuropathy exhibited gastric stasis, although this was detected by conventional radiology in only one. Neither the patients with stasis nor those without exhibited abnormally rapid early gastric emptying. In patients without stasis, the normal differentiation between solid and liquid emptying was impaired, suggesting an abnormality of antral peristalsis not attributable to vagal denervation. Both intravenous and oral metoclopramide produced symptomatic improvement in two patients with gastric stasis and restored their gastric emptying to normal.

Arteriovenous malformations of the intestine.

Arteriovenous malforamtions of the intestine are recognized as an uncommon cause of chronic gastrointestinal bleeding. In previous reports, the role of selective mesenteric angiography in the localization of the lesion has been emphasized; with confirmation by in vitro injection of radioopaque dye into the resected specimen. The histologic appearances of arteriovenous malformations are well recognized, although terminology is still confused. In this report, two distinct entities of small vessel malformation are described and the terms submucosal endothelial angiodysplasia and submucosal fibromuscular angiodysplasia are offered.

Percutaneous transhepatic occlusion for bleeding oesophageal varices.

Using the technique described by Lunderquist et al. (1977), transhepatic injection of oesophageal varices has been performed under local anaesthesia in 9 patients with portal hypertension (11 procedures). On 2 occasions it was not possible to enter the left gastric vein. Bleeding resumed within 2 days of radiologically satisfactory occlusion in 2 patients and at 1, 3, 4 and 10 months after 4 procedures in 3 patients. Other complications included portal vein thrombosis, gross ascites and right pleural effusion. There were 2 hospital deaths, both in alcoholic patients with poor hepatic function. In spite of the apparently high morbidity we consider that there is a place for this technique in tiding over patients who are bleeding from oesophageal varices and are medically unsuitable for any surgical procedure.

High flow oxygen therapy for pneumatosis coli.

Symptomatic and radiological resolution of pneumatosis coli was achieved by intermittent high flow oxygen therapy in five patients. In each case the extent of the disease was defined by colonoscopy and contrast radiography before treatment. Despite the confirmation of pneumocyst resolution, recurrence of colonic gas cysts was noted in two patients at six months and one year after treatment. Bacteriological studies indicated that resolution of the disease, induced by oxygen therapy, was not associated with eradication of anerobic bacteria from stool and colonic mucosa. The clinical features and response to treatment of this group of patients are discussed, with particular reference to previously reported methods of oxygen administration.

Hazards of hepatic artery infusion of streptozocin.

Three patients with metastatic malignancy received streptozocin by hepatic artery infusion through a percutaneous transfemoral catheter. Two patients developed major arterial thrombosis, from which one died. The other suffered renal damage following displacement of the catheter tip. Possible avoidable risk factors are identified.