Identification and differentiation of surgically correctable hypertension due to primary aldosteronism.

During a protocol study for the evaluation of patients with primary aldosteronism, a variety of diagnostic studies were employed in an attempt to identify patients with primary aldosteronism and to differentiate patients with adrenal adenoma from patients with idiopathic adrenal hyperplasia. In this study, we are able to demonstrate the utility of (1) absent postural increase in plasma aldosterone concentration, (2) adrenal scanning and (3) normalization of blood pressure with spironolactone therapy in identifying patients with primary aldosterone excess who have an adrenal adenoma, surgical removal of which results in eliminating their hypertension.

Effects of percutaneous transluminal angioplasty on renal plasma flow.

Percutaneous transluminal angioplasty is being used with increasing frequency for the treatment of renal artery stenosis. Several noninvasive techniques that utilize radioactive tracers have been used for monitoring the effects of angioplasty and progression of disease. Forty-one patients were studied before and after renal angioplasty by using renograms and fractionated measurements of effect renal plasma flow. Although there were striking examples of improvement in effective renal plasma flow following angioplasty, this was not a consistent finding. There was a tendency for effective renal plasma flow to revert to the baseline level on follow-up studies. Cure of hypertension was more likely in patients without renal insufficiency and in patients with shorter periods of sustained hypertension. Fractionated effective renal plasma flow studies did not reliably differentiate patients who were cured from those who were improved nor were we able to delineate clearly those requiring repeat dilatation. Nevertheless, this technique is useful for noninvasively measuring fractionated renal function in the immediate postoperative or postdilatation recovery period and for detecting the difference between occlusion of the renal artery and transient renal insufficiency due to contrast material. Also, long-term measurement of fractionated function has value in following potential progression of the basic disease process.

Chronic traumatic thoracic aneurysm. Influence of operative treatment on natural history: an analysis of reported cases, 1950-1980.

A total of 401 cases of chronic traumatic aneurysm reported during the past 30 years plus 12 cases from the University of Virginia Medical Center were analyzed. Forty-two percent of the patients developed signs or symptoms of aneurysm expansion within 5 years of injury: 85% within 20 years. Pain was the most frequently occurring sign or symptom, followed by serial enlargement on chest roentgenogram. Of the 60 patients who were followed without operative intervention, 20 died of their aortic lesions. For these patients, the combined risk of dying or developing signs or symptoms was 41% at 5 years. Over 300 patients underwent operative repair of the aneurysm. Operative mortality was 4.6%. Bleeding was the major cause of death as well as the most common major complication. When the survival probability of patients treated operatively was compared with that of patients treated nonoperatively, the operative group demonstrated a significantly higher survival probability.

Clinical experience with saralasin infusion in hypertensive patients.

Renal arteriography gives a reliable anatomic delineation of the renal vasculature. However, the presence of renal arterial disease does not determine the physiologic significance of the lesion. The intravenous infusion of saralasin, a specific angiotensin II antagonist, has been investigated as a method for identifying patients with hypertension dependent upon excessive angiotensin II activity. Correlations between the blood pressure response to saralasin infusion, peripheral and differential renal vein plasma renin levels and renal angiography have been obtained in 35 hypertensive patients. The results suggest that a hypotensive response to saralasin infusion provides an adjunct to renin determinations for recognizing angiotensinogenic renovascular hypertension. However, false negative responses to saralasin occur. The reasons for these negative responses need to be determined before saralasin infusion can be employed as the sole screening test for renovascular hypertension.

Axillary, subclavian, and brachiocephalic vein obstruction.

The consequences of occlusion of a major upper extremity vein were evaluated in eight patients with effort thrombosis, ten with thrombosis secondary to intimal injury, six with extrinsic compression, and one hypercoagulable patient, all of whom were followed for an average of 4 years. Twenty-two patients had venography, which confirmed the diagnosis but often failed to define the proximal extent of obstruction. Thirteen patients had noninvasive hemodynamic studies which did not corroborate chronic morbidity, but which were valuable in assessing the effect os specific therapy. Twelve patients were treated with anticoagulants, and six had operative removal or bypass of the obstruction. Three patients had pulmonary emboli; two embolized while on anticoagulants and both died. Swelling, pain, prominent veins, and easy fatigability of the affected extremity were the late sequelae of occlusion. Chronic morbidity was more dependent on etiology than on initial treatment. Thrombosis secondary to intimal injury caused no persistent symptoms, whether treated with anticoagulants or not. Effort thrombosis was intermediate: three fourths complained that their affected arm tired easily and half had prominent veins or persistent swelling. All of those with obstruction secondary to extrinsic compression had easy fatigability. The majority also had concomitant swelling, pain, and prominent collaterals. Operative treatment produced objective improvement in venous outflow but often was unsuccessful in relieving symptoms, particularly in patients with obstruction from extrinsic compression.

Symptomatic double aortic arch causing tracheal and esophageal compression in the adult.

A 50-year-old woman with a symptomatic double aortic arch that was successfully treated surgically is presented. Review of this abnormality notes that this anomaly rarely causes symptoms in adults. Greater awareness of the possibility of this condition as a cause of tracheal compression and dysphagia may lead to symptomatic relief for these patients.

Contemporary diagnostic approaches to acute pulmonary emboli.

Because of its availability and familiarity, the V/Q scan remains the most frequently used noninvasive screening study for the diagnosis of acute PE. Fast CT and MR imaging techniques probably will have more significant roles in the future in the diagnosis and management of PE, but limited availability and familiarity with these imaging modalities make it impractical to currently recommend them as primary screening tools for acute PE. Although the cost and time benefits appear to place fast CT ahead of MR imaging, more clinical experience and a greater understanding of the imaging nuances and pitfalls of interpretation for both fast CT and MR imaging are needed. Medicare reimbursements (both technical and professional fees) for a CT or MR scan are already competitive with a V/Q scan (Table 2), so that they may ultimately prove to be more cost-effective screening modalities for PE than a V/Q scan. Until the role for intraarterial DSA becomes further defined with clinical trials and outcome analyses, it cannot be recommended as a reference standard for the diagnosis of PE. Although conventional pulmonary angiography is associated with a 1% to 2% major nonfatal complication rate and a 0.1% to 0.5% mortality rate, chronic anticoagulation has reported major bleeding complication rates of 1.5% to 20% at 1 year, and inferior vena cava filters are associated with inferior vena cava thrombosis rates of 3% to 25%. Therefore, initiating or withholding therapy for the "presumed" presence or absence of PE based on a V/Q scan alone has the potential for generating excessive costs and morbidity in a large population of patients. Until the validity of fast CT and MR imaging have been proven, a pulmonary angiogram is required when there is any doubt about the diagnosis of PE. A negative pulmonary angiogram is often more useful in the management of a patient than an angiogram that demonstrates PE. By ruling out the presence of PE, an alternative and possibly more significant diagnosis will be pursued. Lastly, it is necessary for us to define more clearly the term clinically significant PE. This is important because fast CT, MR imaging and intraarterial DSA techniques can now reliably visualize third order pulmonary artery branches. Whether this degree of resolution allows for adequate detection of clinically significant PE will only be determined by extensive patient tracking and outcome analyses.

Malignant rectal carcinoid: a sequential multidisciplinary approach for successful treatment of hepatic metastases.

A malignant rectal carcinoid metastatic to the liver presents a formidable challenge. The uniformly fatal course in patients with liver metastases (average survival of 2 years) justifies an aggressive approach. Although in an occasional patient the tumor is resectable, most are managed by chemotherapy, which generally is of limited effectiveness. Although certain drug combinations such as 5-fluorouracil and streptozotocin have achieved higher response rates, these responses are often brief (3 to 4 months) and poorly documented. Surgical hepatic dearterialization and, more recently, hepatic intraarterial embolization are quite effective in inducing regression in a variety of hepatic neoplasms, including metastatic carcinoids, but these are usually temporary. We have been timely instructed on the value of combined therapy by a patient who is a long-term survivor of a metastatic carcinoid to the liver. She is the only survivor among a group of 14 patients who had an average survival of 17 months. This patient emphasizes the benefit of combined hepatic dearterialization and chemotherapy in patients with metastatic carcinoid to the liver. She initially had intrahepatic infusion of 5-fluorouracil and streptozotocin through the surgically placed hepatic artery and portal vein catheters, but this was curtailed after 2 months because of catheter sepsis. She then had four sequential selective hepatic intraarterial embolizations with Gelfoam over a 16 month period. She also received systemic therapy with 5-fluorouracil and streptozotocin during a major portion of this period (10 months). Significant tumor regression was documented radiologically. Although she had another trial with intrahepatic chemotherapy infusion using surgically placed catheters, this was again discontinued because of catheter sepsis, and systemic chemotherapy was resumed. Currently, the patient is asymptomatic, has excellent performance status, and continues to show objective tumor regression on a program of systemic therapy with fluorodeoxyuridine and doxorubicin. She has survived more than 7 years with liver metastases from a rectal carcinoid.

The importance of accurate angiography in determining the approach to chronic traumatic thoracic aneurysm of the aortic arch.

The successful treatment of a chronic traumatic thoracic aneurysm of the aortic arch is described. The use of median sternotomy, cardiopulmonary bypass, and circulatory arrest was essential in the successful treatment of this particular patient. Accurate angiography was critical in defining the detailed pathologic anatomy, which allowed planning of the appropriate operative approach.

Vascular injury following foreign body perforation of the esophagus. Review of the literature and report of a case.

Esophageal perforation resulting from foreign body ingestion is a rare occurrence. Most of the complications associated with this event, such as retroesophageal abscess, mediastinitis, pericarditis, pneumothorax, and pneumomediastinum, are widely recognized. However, little attention has been directed to the possibility of vascular injury caused by the perforating object. Isolated case reports have described significant morbidity and mortality subsequent to major vascular trauma resulting from an esophageal foreign body, usually emphasizing the presence of a "signal" hemorrhage from the gastrointestinal tract as a key to diagnosis. This report describes a case of esophageal perforation caused by an ingested fishbone that resulted in significant aerodigestive hemorrhage, possibly as the result of an unusual isolated vascular injury. The literature on vascular trauma following foreign body perforation of the esophagus is reviewed, and suggestions for the diagnosis and treatment of these dreaded complications are made.

Therapeutic embolization for delayed rectal hemorrhage following episiotomy: a case report.

A case of severe, delayed rectal bleeding following an episiotomy was treated with selective pelvic arteriography and embolization after surgery failed to control the hemorrhage.

The "mucous plug syndrome". A pulmonary embolism mimic.

Reported are ten instances of major bronchial obstruction by mucous plugs in eight patients during which the clinical features resembled pulmonary embolism. Perfusion lung studies showed significantly diminished perfusion of the involved portions of the lungs. The chest radiographs generally did not, however, reflect the severity of the airway obstruction and in some instances were completely normal. The ventilation studies indicated the extent and severity of the obstruction and matched with the perfusion scans. Pulmonary arteriograms were performed in three patients and gave direct evidence of focally diminished lung perfusion without embolism. The physiologic mechanisms underlying the condition are discussed.

Guide wire angioplasty balloon catheter: preliminary report.

A new balloon catheter has been developed for angioplasty. The balloon is more flexible and its walls are thinner than those of conventional catheters. It folds down better yet withstands 8-10 atm of pressure. This advance has been married to new guide wire technology, producing a low-profile angioplasty balloon on a 0.038-inch guide wire. It compared favorably with a standard 7-F angioplasty catheter when tested at 4 atm in a rabbit and has been successfully used to dilate ten peripheral stenoses in four patients.