Assessment of renal artery fibromuscular dysplasia: angiography, intravascular ultrasound (with virtual histology), and pressure wire measurements.

Fibromuscular dysplasia (FMD) of the renal arteries is classically associated with secondary hypertension in younger individuals, which may be treatable and even curable by percutaneous transluminal renal angioplasty. Angiography of these renal arteries often displays "beaded" luminal abnormalities. The angiographic findings, however, may not accurately reflect the severity or precise location of the intraluminal obstruction. We present a case of an older individual with longstanding hypertension and FMD, in whom the use of a coronary pressure wire and intravascular ultrasound enabled precise localization and treatment of the hemodynamically significant stenosis. Virtual histology of FMD in the renal vasculature is also reported.

A systematic review of work accommodations for people with mental disorders.

BACKGROUND: Work accommodations are adjustments made in the work place or to policies surrounding employment to accommodate an individual with a mental disorder to be successful in completing work related tasks. OBJECTIVE: The purpose of this systematic review is to identify work accommodations that are available and that are provided to individuals with mental disorders. In addition, associated cost-effectiveness and cost-benefits of these accommodations are examined. METHODS: Studies published between 1990-2016 from four databases were reviewed. From these databases, studies that specified accommodations that were available/provided and/or addressed cost-effectiveness or cost-benefit analysis of work accommodations were included. RESULTS: Of the 1362 eligible studies, only 15 were included. Work accommodations that were provided to individuals assisted in mitigating limitations in the work place and improved length of job tenure, as well as reduced the severity of certain mental disorders. The costs associated with these accommodations were found to be minimal and had positive economic benefits for employers. CONCLUSION: Work accommodations help individuals with mental disorders meet employment expectations with minimal cost.

Utilization of an aspiration thrombectomy catheter (Pronto) to treat acute atherothrombotic embolization during percutaneous revascularization of the lower extremity.

Acute limb ischemia is typically a surgical emergency and can occur secondary to distal embolization during catheter-based percutaneous revascularization. We present a case of acute atherothrombotic embolization to the left lower extremity after stenting of the left proximal popliteal and anterior tibial arteries. This was successfully treated with the use of the coronary aspiration thrombectomy device Pronto (Vascular Solutions, Minneapolis, MN) resulting in flow restoration.

Renal artery plaque composition is associated with changes in renal frame count following renal artery stenting.

BACKGROUND: Benefit of percutaneous revascularization for atherosclerotic renal artery stenosis (RAS) may be attenuated by distal embolization of atheroemboli. The purpose of this study was to characterize RAS plaque composition with intravascular ultrasound virtual histology (IVUS-VH) and to explore the relationship between plaque components and renal frame count (RFC) after renal revascularization. METHODS: Seventeen patients (75 ± 7.5 years; 18 lesions) undergoing RAS revascularization were included. Before stenting, automated IVUS-VH pullback (0.5 mm/sec) with analysis of the minimal luminal diameter (MLD) frame and entire atherosclerotic segment was performed. RFC was also determined before and after stenting. RESULTS: The VH component analysis of the segment demonstrated predominantly fibrous tissue (56.3 ± 11.4%), followed by necrotic core (21.8 ± 8.6%), dense calcification (13.2 ± 6.6%) and fibrofatty tissue (8.7 ± 4.0%). Analysis of the MLD frame also demonstrated mostly fibrous tissue (62.1 ± 11.1%), with smaller amounts of necrotic core (15.6 ± 7.3%), fibrofatty (13.9 ± 9.6%), and dense calcification (8.4 ± 6.0%). A trend toward more fibrous tissue (p = 0.074), less necrotic core (p = 0.095) and less dense calcification (p = 0.075) at the MLD compared to the segment was observed. Analysis of the entire atherosclerotic segment revealed a positive correlation between % necrotic core and change in RFC (r = 0.582; p = 0.029), with increasing necrotic core associated with an increase in RFC after revascularization. CONCLUSION: Both the MLD frame and segmental analysis of atherosclerotic RAS lesions demonstrate predominantly fibrous tissue with smaller amounts of necrotic core, fibrofatty tissue, and dense calcification. Increased necrotic core correlates with a lack of improvement in RFC after stenting.

Elevated plasma fibrinogen and diabetes mellitus are associated with lower inhibition of platelet reactivity with clopidogrel.

OBJECTIVES: The goal of this study was to identify factors associated with lower platelet inhibition (PI) with clopidogrel in subjects with cardiovascular disease (CVD). BACKGROUND: A heterogeneous platelet reactivity response to clopidogrel exists, and the clinical or biochemical predictors of suboptimal PI with clopidogrel remain unclear. METHODS: This study prospectively enrolled subjects with CVD requiring treatment with clopidogrel (75 mg daily for > or =7 days or 600-mg bolus > or =24 h before recruitment). A bedside rapid platelet function assay (VerifyNow, Acccumetrics, San Diego, California) to measure maximal and clopidogrel-mediated platelet reactivity was utilized, and factors associated with lower PI were identified. RESULTS: A heterogeneous, normally distributed PI (mean 40.8 +/- 26.2%) response to clopidogrel was observed in 157 subjects (age 67.2 +/- 12.2 years; 59.9% men). Multiple variable analysis of clinical and biochemical factors known to affect platelet reactivity revealed lower PI in patients with an elevated plasma fibrinogen level (> or =375 mg/dl), diabetes mellitus, and increased body mass index (BMI) (> or =25 kg/m(2)). On testing for interaction, elevated fibrinogen level was associated with diabetic status, resulting in lower PI in diabetic patients (23.9 +/- 3.9% vs. 45.1 +/- 4.5%, p < 0.001), but not nondiabetic patients (44.7 +/- 4.4% vs. 46.3 +/- 4.8%, p = 0.244). Increased BMI remained independently associated with lower PI after clopidogrel therapy regardless of diabetic status or fibrinogen level (36.8 +/- 9.0% vs. 49.0 +/- 7.0%, p < 0.001). CONCLUSIONS: Elevated plasma fibrinogen (> or =375 mg/dl) in the presence of diabetes mellitus and increased BMI (> or =25 kg/m(2)) are associated with lower PI with clopidogrel in patients with CVD.

Renal frame count and renal blush grade: quantitative measures that predict the success of renal stenting in hypertensive patients with renal artery stenosis.

OBJECTIVES: This study sought to identify angiographic parameters of favorable clinical response to renal artery stenting. BACKGROUND: Stenting improves blood pressure (BP) control in patients with renal artery stenosis (RAS), but markers predicting a favorable clinical response are limited. METHODS: Renal perfusion was quantified in hypertensive patients (BP >or=140/90 mm Hg) without RAS by determining renal frame count (RFC) (angiographic frames [30 frames/s] for contrast to reach distal renal parenchyma after initial renal artery opacification) and renal blush grade (RBG) (0: none, 1: minimal, 2: normal, 3: hyperemic parenchymal blush). It was hypothesized that stenting unilateral RAS in hypertensive patients would result in decreased RFC and increased RBG, which might predict BP reduction. RESULTS: The RFC in 17 consecutive hypertensive patients without RAS (control group) (64.4 +/- 14.2 years, 12 male, 22 kidneys) was 20.1 +/- 5.4, whereas RBG was 2.33 +/- 0.66. In 24 consecutive hypertensive patients with unilateral RAS (study group) (72.7 +/- 11.3 years, 8 male), reduced RFC (26.6 +/- 9.1 to 21.4 +/- 6.7, p < 0.001) and increased RBG (1.63 +/- 0.71 to 2.13 +/- 0.85, p = 0.03) were observed after renal stenting. At 6 months, reduced BP (systolic BP 150.6 +/- 15.6 mm Hg to 128.6 +/- 15.5 mm Hg, p < 0.001; diastolic BP 77.2 +/- 15.6 mm Hg to 68.3 +/- 10.4 mm Hg, p = 0.022) without change in number of hypertensive medications was observed. Clinical responders (systolic BP reduction >15 mm Hg) had a greater decrease in RFC (7.7 +/- 4.6 vs. 1.7 +/- 5.1, p = 0.009) and 78.6% of patients with >4 RFC decrease were responders (p = 0.024). CONCLUSIONS: This study shows that quantitative indices of renal perfusion (RFC and RBG) are impaired in patients with RAS and improve after stenting, and that RFC reduction is associated with BP reduction.