Unilateral renal vascular hypertension: surgery vs. dilation.
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Publications and source records attributed to E C Klatte.
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Since there are few data regarding complications and long-term efficacy of balloon catheter dilatation for advanced lower extremity atherosclerosis, we are reporting our experience with 132 attempted dilatations in 88 patients. Dilatation was attempted on 51 aortoiliac-common femoral lesions, 80 superficial femoral-popliteal lesions and 1 peroneal lesion. Twenty procedures were technically unsuccessful and led to urgent surgery in three patients. Thirty-one complications in the 109 technically successful dilatations led to emergency surgery in only one, but another required closure of an arteriovenous fistula at the site of catheterization. There were three episodes of embolism, but none required operation. In 109 dilatations monitored for 1 month, there was significant hemodynamic improvement in 52 and mild to moderate improvement in 37; 10 had no change; 10 occluded at the site of dilatation. Of the 42 patients observed 6 months or longer, 11 maintained a significant increase, and 15 had mild to moderate improvement; 11 reverted to predilatation levels; 1 had progressive worsening; 4 occluded. Sixteen patients who had significant increases in flow after dilatation and were followed longer than 6 months showed a trend to restenosis as the length of follow-up increased. We conclude that dilatation is a useful adjunctive procedure in treating lower extremity atherosclerosis, that the early results are good, and that the incidence of recurrent stenosis is high. Indications for dilatation and its complications are similar to those for operations. It should not be done without hemodynamic monitoring.
In a blind prospective study of 158 limbs, Doppler ultrasound, pneumoplethysmography, and radionuclide venography (RNV) using 99mTc-MAA were compared to phlebography as methods of detecting thrombophlebitis. All three noninvasive modalities were very insensitive to isolated thrombus below the knee. In patients with extension of thrombus above the knee and isolated thrombus in the deep veins of the upper limb, Doppler ultrasound had a sensitivity of 81% and RNV had a sensitivity of 77%. All of the noninvasive modalities were found to be dependent on venous occlusion. Overall, pneumoplethysmography had a sensitivity of 28% and specificity of 96%, compared with 56% and 91%, respectively, for Doppler ultrasound and 51% and 84% for RNV. Based on these findings, phlebography would still seem to be the modality of choice in the diagnosis of thrombophlebitis.
Twenty-six patients with renal vascular hypertension were treated with percutaneous transluminal dilatation. Twenty-one were followed for more than 1 year; 18 underwent repeat angiography. Recurrence of stenosis was shown angiographically in one of six patients with fibromuscular disease and in 12 of 12 patients with atherosclerotic disease. The procedure was more likely to result in cure of hypertension (six of 10) in patients with fibromuscular disease than in patients with atherosclerotic disease (one of 16). Although percutaneous transluminal angioplasty provides the advantages of simplicity, reduced cost, and probably reduced risk, long-term utility of the procedure remains to be established. A prospective randomized trial, establishment of a registry, or both would serve this purpose.
1. We have treated 25 patients with renovascular hypertension with balloon catheter dilatation. 2. In 17 patients, surgical treatment was thought to be either risky or difficult due to the presence of a serious medical condition or because of the peripheral location of the lesion. 3. Seventeen patients had atherosclerotic lesions, six patients had fibromuscular dysplasia and one patient had neurofibromatosis and one had stricture of an aorto-renal bypass graft. 4. Of the total group, six in the atherosclerotic group, three patients with fibromuscular dysplasia and the one with neurofibromatosis are normotensive without medications. 5. Five patients with atherosclerosis, two patients with fibromuscular dysplasia and the patient with aorto-renal bypass graft are either normotensive or have reasonable control of blood pressure with medication. 6. Four technical and treatment failures and three major medical complications were encountered. Recurrence of stenosis occurred in eight patients but none of these was in the fibromuscular dysplasia group.
During an 18-month period, percutaneous transluminal angioplasty (PTA) was performed in 66 patients who had renal artery stenosis. All of the patients were hypertensive, and 12 were in renal failure. Of 52 patients with renovascular hypertension in whom dilatation was achieved, 23 (44%) are cured and 25 (48%) are improved. Four (8%) did not respond to attempted dilatation. Of the 12 patients in renal failure, two (17%) are now out of failure, seven (58%) are stable, and one (8%) is slowly deteriorating after an initial favorable response. Significant complications were noted in two patients (17%) in this group. While the initial results are promising, a long-term study of this technique is indicated.
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Ultrasound and computed tomography (CT) are ideal for imaging enlarged retroperitoneal lymph nodes. The authors evaluated 290 ultrasound and 188 CT examinations in 136 patients with testicular cancer. Although interpretation of CT was more reproducible than that of ultrasound, there was no significant difference in accuracy of enlarged retroperitoneal lymph node detection between the two modalities. Accuracy improved when both examinations were used and interpreted in combination by a single radiologist. Accuracy rates for ultrasound and CT were equal to those reported for lymphangiography. Lymphangiography and excretory urography are no longer routinely indicated in testicular cancer patients.
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In five patients with hypertension and marked impairment of renal function due to renal artery stenosis in a solitary functioning kidney, a nonsurgical technique, percutaneous transluminal angioplasty, was used to dilate the stenotic renal artery. Blood pressure improved in all five patients, and renal function improved in three. One patient subsequently died of multiple cardiovascular complications, and in one patient the procedure resulted in acute renal failure requiring hemodialysis. Although preliminary, this experience suggests that percutaneous transluminal angioplasty may provide an attractive alternative to surgery in severely ill patients at high surgical risk.
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Patent ductus arteriosus in an infant with hyaline membrane disease is usually a serious complication. To evaluate the diagnostic role of chest radiography in these infants, a double-blind study comparing patients with both hyaline membrane disease and patent ductus arteriosus and matched controls was undertaken. Three pediatric radiologists acted as observers. In no instance were they more reliable than chance in predicting the presence of a patent ductus arteriosus. Analysis according to various clinical criteria (e.g., severity of illness, PAO2) also failed to show any subgroup in which the observers were accurate. From these data it is concluded that chest radiography does not play a significant role in the diagnosis of patent ductus arteriosus in infants with hyaline membrane disease.
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