5 Years Experience With Drug Eluting and Bare Metal Stents as Primary Intervention in Transplant Renal Artery Stenosis.

BACKGROUND: Transplant renal artery stenosis (TRAS) is a common vascular complication after kidney transplantation and is associated with refractory hypertension, volume overload, and graft injury or loss. This article describes 5-year outcomes of endovascular intervention for TRAS with bare metal and drug eluting stents (DES). METHODS: We investigated, as a prospective cohort study, patient and graft outcomes after the targeted use of DES for vessel diameter less than 5 mm and bare metal stents (BMS) for vessel diameter greater than 5 mm as the primary management for TRAS. RESULTS: From March 2008 to November 2014, 57 patients were stented for hemodynamically significant TRAS; 29 received DES, 26 received BMS, and 2 patients received both stent types. They were followed up for a mean of 35.1 ± 22.8 months; a subset of these patients who all received DES were followed up for 61.7 ± 17.5 months. Mean serum creatinine declined from 2.87 ± 1.5 mg/dL at the time of intervention to 1.98 ± 0.76 mg/dL (P < 0.001) at one month follow-up and was 1.96 ±0.92 mg/dL (P < 0.001) at 35.1 ± 22.8 months. Mean systolic blood pressure declined from 159.05 ± 19.68 mm Hg at time of intervention to 135.65 ± 15.10 mm Hg (P < 0.001) at most recent visit. Clinically driven restenosis requiring repeat revascularization occurred in 15.7% of patients. CONCLUSIONS: Primary stenting with DES and BMS is both successful in the initial treatment of TRAS and also produced an immediate and long-term reduction in serum creatinine and systolic blood pressure.

Assessment of Left Ventricular Mass and Hypertrophy by Cardiovascular Magnetic Resonance Imaging in Pediatric Hypertension.

Cardiovascular magnetic resonance (CMR) imaging in adults is considered the gold standard for assessment of left ventricular mass (LVM) and left ventricular hypertrophy (LVH). The authors aimed to evaluate agreement of LVM measurements and LVH determination between echocardiography (ECHO) and CMR imaging in children with hypertension (HTN) confirmed by 24-hour ambulatory blood pressure monitoring (ABPM). The children (n=22) underwent contemporaneous ECHO, CMR imaging, and ABPM. Patients had a mean body mass index of 30.9±7.5 (kg/m2 ), and 81.8% had severe HTN. LVM measured by ECHO was 189.6±62.1 g and by CMR imaging was 164.6±44.7 g (P<.0001). Bland-Altman analysis revealed significant variability between ECHO and CMR imaging in the measurement of LVM. Interobserver error was higher with ECHO than with CMR imaging. ECHO had high sensitivity and low specificity in LVH determination. In conclusion, ECHO overestimates LVM and is less accurate in measuring LVM as compared with CMR imaging in children with HTN. Further prospective study using CMR imaging to assess LVM in children is warranted.

Use of a 1.0 Tesla open scanner for evaluation of pediatric and congenital heart disease: a retrospective cohort study.

BACKGROUND: Open cardiovascular magnetic resonance (CMR) scanners offer the potential for imaging patients with claustrophobia or large body size, but at a lower 1.0 Tesla magnetic field. This study aimed to evaluate the efficacy of open CMR for evaluation of pediatric and congenital heart disease. METHODS: This retrospective, cross-sectional study included all patients ≤18 years old or with congenital heart disease who underwent CMR on an open 1.0 Tesla scanner at two centers from 2012-2014. Indications for CMR and clinical questions were extracted from the medical record. Studies were qualitatively graded for image quality and diagnostic utility. In a subset of 25 patients, signal-to-noise (SNR) and contrast-to-noise (CNR) ratios were compared to size- and diagnosis-matched patients with CMR on a 1.5 Tesla scanner. RESULTS: A total of 65 patients (median 17.3 years old, 60% male) were included. Congenital heart disease was present in 32 (50%), with tetralogy of Fallot and bicuspid aortic valve the most common diagnoses. Open CMR was used due to scheduling/equipment issues in 51 (80%), claustrophobia in 7 (11%), and patient size in 3 (5%); 4 patients with claustrophobia had failed CMR on a different scanner, but completed the study on open CMR without sedation. All patients had good or excellent image quality on black blood, phase contrast, magnetic resonance angiography, and late gadolinium enhancement imaging. There was below average image quality in 3/63 (5%) patients with cine images, and 4/15 (27%) patients with coronary artery imaging. SNR and CNR were decreased in cine and magnetic resonance angiography images compared to 1.5 Tesla. The clinical question was answered adequately in all but 2 patients; 1 patient with a Fontan had artifact from an embolization coil limiting RV volume analysis, and in 1 patient the right coronary artery origin was not well seen. CONCLUSIONS: Open 1.0 Tesla scanners can effectively evaluate pediatric and congenital heart disease, including patients with claustrophobia and larger body size. Despite minor artifacts and differences in SNR and CNR, the majority of clinical questions can be answered adequately, with some limitations with coronary artery imaging. Further evaluation is necessary to optimize protocols and image quality.

Venous gangrene a rare but dreadful complication of deep venous thrombosis.

Venous gangrene is a rare complication of deep venous thrombosis. It is certain from review of literature that there is a significant causative relationship between malignant disease and venous gangrene. Data from the National hospital discharge survey from 1979 to 2006 showed that 0.43% of patients with deep venous thrombosis had gangrene, while 1.39% patients with gangrene had deep venous thrombosis. Toes and fingers are frequent site of venous gangrene in patients with massive deep venous thrombosis, as evident by review of literature. A possible explanation for this occurrence can be the fact that because of the scarcity of subcutaneous fat and the small spaces of fingers and toes, massive edema can generate large compressive forces; these forces may have a compressive effect on the arterioles, which may contribute to the development of venous gangrene. Lower extremities develop venous gangrene more commonly than upper extremities. The condition has an extremely high rate of mortality either from pulmonary embolism or from the serious underlying disease, such as neoplasms.

Asymptomatic saddle pulmonary embolism: case report and literature review.

Saddle pulmonary embolism is defined as a visible thromboembolus straddling the bifurcation of the main pulmonary artery trunk. Patient with saddle pulmonary embolism have a 2-week mortality of 5.8%. 46 years old, hypertensive male, presented with right leg swelling and pain, with no evidence of cardiopulmonary distress. CTA showed a large saddle pulmonary embolus. Doppler ultrasound of right lower extremity, revealed a large filling defect extending from the common femoral vein distally involving the deep femoral vein, femoral vein and popliteal vein on the right. Diagnosis of saddle embolus on its own is not associated with an unfavorable outcome, therefore should not influence management of PE. Echocardiography done within 48 hours in-patient with symptomatic saddle pulmonary embolism reveals mild to moderate right ventricular enlargement in 90% and mild to severe right ventricular dysfunction in 80%. Emerging evidence suggest that primary therapy with thrombolytics and embolectomy, should be used in PE patients who presents with hypotension plus moderate to severe right ventricular dysfunction on echo cardiogram. Patients with saddle pulmonary embolism can have normal cardiopulmonary reserve; these patients can be managed with conventional treatment for pulmonary embolism in hospital settings, in order to deal with any complications developed during management. Aggressive management should be reserved for patients who are hemodynamically unstable as well as those with echocardiographic evidence of severe right ventricular strain. Physicians should decrease their threshold for suspicion of pulmonary embolism in patients with deep venous thrombosis in the hope of revealing more and more hidden cases of pulmonary embolism.

Venous compression for prevention of postthrombotic syndrome: a meta-analysis.

PURPOSE: To determine the effectiveness of venous compression stockings or compression bandages on the reduction of postthrombotic syndrome in patients with deep venous thrombosis. METHODS: We attempted to identify all published trials in all languages identified by PubMed through June 2009. Meta-analysis was performed. RESULTS: Based on 5 randomized trials of patients with deep venous thrombosis comparing treatment with venous compression to controls, mild-to-moderate postthrombotic syndrome occurred in 64 of 296 (22%) treated with venous compression, compared with 106 of 284 (37%) in controls (relative risk=0.52). Severe postthrombotic syndrome occurred in 14 of 296 (5%) treated, compared with 33 of 284 (12%) controls (relative risk=0.38). Any postthrombotic syndrome occurred in 89 of 338 (26%) treated, compared with 150 of 324 (46%) controls (relative risk=0.54). CONCLUSION: Venous compression reduced the incidence of postthrombotic syndrome, particularly severe postthrombotic syndrome. Venous compression in patients with deep venous thrombosis would seem to be indicated for this purpose. There was, however, wide variation in the type of stockings used, time interval from diagnosis to application of stockings, and duration of treatment. Further investigation, therefore, is needed.

Silent pulmonary embolism in patients with deep venous thrombosis: a systematic review.

PURPOSE: To determine, by systematic review of the literature, the prevalence of silent pulmonary embolism in patients with deep venous thrombosis. METHODS: Twenty-eight included published investigations were identified through PubMed. Studies were selected if methods of diagnosis of pulmonary embolism were described; if pulmonary embolism was stated to be asymptomatic; and if raw data were presented. Studies were stratified according to whether silent pulmonary embolism was diagnosed by a high-probability ventilation-perfusion lung scan using criteria from the Prospective Investigation of Pulmonary Embolism Diagnosis, computed tomography pulmonary angiography, or conventional pulmonary angiography (Tier 1), or by lung scans based on non-Prospective Investigation of Pulmonary Embolism Diagnosis criteria (Tier 2). RESULTS: Silent pulmonary embolism was diagnosed in 1665 of 5233 patients (32%) with deep venous thrombosis. This is a conservative estimate because many of the investigations used stringent criteria for the diagnosis of pulmonary embolism. The incidence of silent pulmonary embolism was higher with proximal deep venous thrombosis than with distal deep venous thrombosis. Silent pulmonary embolism seemed to increase the risk of recurrent pulmonary embolism: 25 of 488 (5.1%) with silent pulmonary embolism versus 7 of 1093 (0.6%) without silent pulmonary embolism. CONCLUSION: Silent pulmonary embolism sometimes involved central pulmonary arteries. Because approximately one third of patients with deep venous thrombosis have silent pulmonary embolism, routine screening for pulmonary embolism may be advantageous.