[An unusual case of severe arterial hypertension and acute renal failure in an obese young adult]. / Un inusuale caso di ipertensione arteriosa severa e insufficienza renale acuta in un soggetto obeso di età giovane-adulta.

We report a case of type-B aortic dissection occurring in a 38-year-old obese man, whose past medical history was positive for arterial hypertension and apparently negative for chronic kidney disease. The patient had severe refractory hypertension and acute renal insufficiency due to renal vascular impairment. The correct diagnosis was delayed because the clinical presentation was atypical, initially mimicking an acute abdominal inflammatory process (such as acute pyelonephritis) with secondary sepsis, and there was no major hemodynamic impairment. Percutaneous management (endografting of the thoracic aorta to seal the thoracic intima tear and renal revascularization by PTA+stenting) led to remission, albeit partial, of the acute renal insufficiency and to target blood pressure achievement with use of multiple antihypertensive agents. Follow-up at 12 months showed stable renal function, normal endograft placement and normal aortic diameter at CT examination. The percutaneous endovascular management of aortic dissection is a valid alternative to traditional surgery, with less morbidity and mortality; when the renal circulation is impaired by the aortic dissection, aortic endografting and renal revascularization by PTA+stenting, where appropriate, may allow at least partial reversal of renal insufficiency and target blood pressure achievement.

Quantification of coronary flow velocity reserve by means of semiautomated analysis of coronary flow Doppler images.

Coronary flow reserve (CFVR) is conventionally obtained by manual tracings of Doppler profiles, as ratio of control vs stress diastolic peak velocity. This parameter could help in discriminating between normal (N) and microcirculatory pathologic (P) subjects, even the clinical meaning of 1.93) and 15 P (CFVR<1.8) subjects, to assess whose of the new parameters could be able to discriminate between these groups. Results indicated that many of the new parameters were able to evidence significant differences between N and P, thus representing new clinical indices useful for the diagnosis.

Percutaneous transmyocardial revascularization with holmium laser in patients with refractory angina: a pilot feasibility study.

BACKGROUND: Percutaneous transluminal myocardial revascularization (PTMR) is a new procedure to improve perfusion of the ventricular wall for patients with intractable angina that is untreatable by surgery or conventional catheter-based intervention. PTMR allows the creation of myocardial channels through the controlled delivery of holmium laser energy from the ventricular chamber. Preliminary studies in animals and human subject have yielded promising results. We now report the feasibility study of PTMR using a laser delivered through a novel Eclipse system, and we present the results of this sole therapy in patients with severe coronary disease and angina refractory to maximal medical treatment angina (III-IV CCS). METHODS: Percutaneous vascular access for PTMR treatment was obtained via the femoral artery. A 9F directional catheter carrying flexible fiber optics was used with a holmium laser (Eclipse system) and was placed across the aortic valve into the left ventricle cavity to create channels with a depth of 5 mm from the endocardial surface into the myocardial tissue. From April to November 1998, 15 patients underwent PTMR with Eclipse system. Two patients were female; the mean age was 66 +/- 8 (range 59-74). Five patients had a severe LV dysfunction (FE < 30%). Preoperative angina class was III in 10 patients and IV in 5 and previous myocardial procedures had been performed in all patients. RESULTS: The procedure was well tolerated and procedural success was obtained in 14 of 15 patients. There was one myocardial perforation because of guiding-catheter manipulation (pericardial drainage in fourth day). We performed a mean of 13 +/- 4 channels in a mean fluoro time of 23 +/- 11 min. Upon release and during follow-up (5.3 months +/- 4.2, range 2-10), angina class had significantly improved in 14 of 14 patients with complete PTMR treatment, with 4 asymptomatic patients, 6 patients in CCS I, 3 in CCS II, 2 in CCS III and only one patient hospitalized due to angina. CONCLUSION: This pilot study confirmed the safety and technical feasibility of PTMR. Immediate and short-term results confirm that a clinical improvement is obtained in most patients. Although these are early clinical benefits, the true efficacy of this approach will necessarily be defined by a randomized trials with prospectively-defined endpoints and with PTMR compared with medical therapy.