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Matthew S Edwards

Publications and source records attributed to Matthew S Edwards.

At least 19 recordsLinked to original sources
PubMed2006

Clinical course of mesenteric artery stenosis in elderly americans.

BACKGROUND: To examine prospectively the relationship between stenosis or occlusion of the celiac and superior mesenteric arteries and symptoms of chronic intestinal ischemia in free-living elderly patients in the United States. METHODS: As part of an ancillary study to the Cardiovascular Health Study, participants in the Forsyth County (North Carolina) cohort underwent visceral duplex ultrasonography of the celiac and superior mesenteric arteries. Critical mesenteric artery stenosis (MAS) or occlusion was defined by Doppler flow ultrasound-derived criteria. Clinical outcomes were assessed at annual follow-up examinations and review of death certificates. Multivariate associations between the presence of MAS and all-cause mortality and adverse cardiovascular events were analyzed. Participants with MAS were contacted to determine the presence of symptoms consistent with chronic intestinal ischemia. RESULTS: Of 553 participants who underwent visceral duplex ultrasonography, 97 (17.5%) had disease of the celiac or superior mesenteric artery. At a mean follow-up of 6(1/2) years, 20 participants with MAS (20.6%) and 93 without MAS (20.4%) had died (relative risk, 1.01; 95% confidence interval, 0.66-1.55). No deaths were attributed to intestinal infarction. No association existed between the presence of MAS and prevalent cardiovascular disease, all-cause mortality, or adverse cardiovascular events. A questionnaire was completed by 71% of the surviving participants with MAS. No participant reported symptoms or weight loss consistent with chronic intestinal ischemia. CONCLUSIONS: Mesenteric artery stenosis was a common finding in free-living elderly patients. At long-term follow-up, the presence of asymptomatic MAS was not associated with death or adverse cardiovascular events. Participants with asymptomatic MAS by duplex ultrasonographic criteria did not experience intestinal infarction or develop chronic intestinal ischemia.

Aged↗
PubMed2006

Progression of atherosclerotic renovascular disease: A prospective population-based study.

OBJECTIVE: Previous reports from select hypertensive patients suggest that atherosclerotic renovascular disease (RVD) is rapidly progressive and associated with a decline in kidney size and kidney function. This prospective, population-based study estimates the incidence of new RVD and progression of established RVD among elderly, free-living participants in the Cardiovascular Health Study (CHS). METHOD: The CHS is a multicenter, longitudinal cohort study of cardiovascular risk factors, morbidity, and mortality among men and women aged >65 years old. From 1995 through 1996, 834 participants underwent renal duplex sonography (RDS) to define the presence or absence of significant RVD. Between 2002 and 2005, a second RDS study was performed in 119 participants (mean study interval, 8.0 +/- 0.8 years). Significant RVD was defined as hemodynamically significant stenosis (renal artery peak systolic velocity [RA-PSV] exceeding 1.8 m/s) or renal artery occlusion. Prevalent RVD was significant RVD at the first RDS, and incident disease was defined as new significant RVD at the second RDS. Significant change of RVD was defined as a change in RA-PSV of greater than two times the standard deviation of expected change over time, regardless of hemodynamic significance or progression to renal artery occlusion. RESULTS: The second RDS study cohort included 119 CHS participants with 235 kidneys (35% men; mean age, 82.8 +/- 3.4). On follow-up, no prevalent RVD (n = 13 kidneys; 6.0%) progressed to occlusion. Twenty-nine kidneys without RVD at the first RDS demonstrated significant change in PSV at the second RDS; including nine kidneys with new significant RVD (8 new stenoses; 1 new occlusion). Controlling for within-subject correlation, the overall estimated change in RVD among all 235 kidneys was 14.0% (95% confidence interval [CI], 9.2% to 21.4%), with progression to significant RVD in 4.0% (95% CI, 1.9% to 8.2%). Longitudinal increase in diastolic blood pressure and decrease in renal length were significantly associated with progression to new (ie, incident) significant RVD but not prevalent RVD. CONCLUSIONS: This is the first prospective, population-based estimate of incident RVD and progression of prevalent RVD among free-living elderly Americans. In contrast to previous reports among select hypertensive patients, CHS participants with a low rate of clinical hypertension demonstrated a significant change of RVD in only 14.0% of kidneys on follow-up of 8 years (annualized rate, 1.3% per year). Progression to significant RVD was observed in only 4.0% (annualized rate, 0.5% per year), and no prevalent RVD progressed to occlusion.

Aged↗
PubMed2006

Distal embolic protection during renal artery angioplasty and stenting.

BACKGROUND: Percutaneous renal artery angioplasty and/or stenting (RA-PTAS) is increasingly being used as an alternative to surgery for renal artery revascularization. Unfortunately, renal function responses after RA-PTAS appear to be inferior to those observed after surgical revascularization both in terms of improving and preventing deterioration of renal function postintervention. Atheroembolism during RA-PTAS has been postulated as a potential cause for the disparate results. Strategies to limit the occurrence of atheroembolism, such as the use of distal embolic protection (DEP) systems, may result in improved outcomes after RA-PTAS. METHODS: All RA-PTAS procedures performed with DEP (using a commercially available temporary balloon occlusion and aspiration catheter) between October 2003 and July 2005 were reviewed. Glomerular filtration rate (eGFR) was estimated preintervention and 4 to 6 weeks postintervention using the abbreviated Modification of Diet in Renal Disease formula. Renal function and hypertension response rates as well as procedural data were classified and reported according to American Heart Association guidelines. Renal function improvement and deterioration were defined as a 20% increase and decrease in eGFR, respectively, compared with preoperative values. Continuous and categoric data were analyzed using paired t tests and repeated measures linear models. RESULTS: DEP was used in 32 RA-PTAS procedures in 15 women and 11 men with a mean age of 71 years. All patients were hypertensive, 24 (92%) had renal insufficiency, and the mean preintervention degree of renal artery stenosis was 79%. Immediate technical success was achieved in 100% of RA-PTAS cases. Mean pre- and postintervention serum creatinine and eGFR values were 1.9 vs 1.6 mg/dL (P < .001) and 37 vs 43 mL/min/1.73 m(2) (P < .001), respectively. Renal function was defined as improved after 17 (53%) of 32 procedures and worsened in none (0%). CONCLUSIONS: RA-PTAS using DEP resulted in 4- to 6-week postintervention renal function results approximating those of surgical revascularization. These data suggest that DEP use may prevent renal function harm during RA-PTAS as a result of atheroembolism and warrant further investigation.

Aged↗
PubMed2006

Acute pancreatitis: A complication associated with rheolytic mechanical thrombectomy of deep venous thrombosis.

Percutaneous mechanical rheolytic thrombectomy is increasingly being used for the treatment of arterial, venous, and graft thromboses. We describe three cases of pancreatitis as a complication of mechanical rheolytic thrombectomy used in the treatment of caval and ileofemoral deep venous thrombosis and discuss the possible etiologic factors involved. To our knowledge, this complication has been previously reported in only two cases.

Adult↗
PubMed2005

Renovascular disease and the risk of adverse coronary events in the elderly: a prospective, population-based study.

BACKGROUND: Renovascular disease is a cause of secondary hypertension and renal insufficiency and is suspected to contribute to morbidity and mortality of coronary heart disease. This investigation prospectively examined associations between renovascular disease and adverse coronary events among a population-based sample of elderly Americans. METHODS: The Cardiovascular Health Study is a prospective, multicenter cohort study of cardiovascular disease risk factors, morbidity, and mortality among Americans older than 65 years. Renal duplex sonography was performed on 870 individuals between January 1995 and February 1997. Renovascular disease was defined as any focal peak systolic velocity of 1.8 m/s or greater (renal artery stenosis) or the absence of a Doppler-shifted signal from an imaged artery (renal artery occlusion). Adverse coronary events were defined as hospitalized angina, fatal or nonfatal myocardial infarction, and coronary revascularization. RESULTS: During a mean follow-up of 14 months, 68 participants experienced incident or recurrent adverse coronary events. The presence of renovascular disease demonstrated a significant relationship with adverse coronary events (hazard ratio, 1.96; 95% confidence interval, 1.00-3.83; P = .05) that remained after controlling for the effects of coexisting atherosclerotic risk factors and prevalent cardiovascular disease. The relationship between renovascular disease and adverse coronary events was not dependent on the effects of increased blood pressure. CONCLUSIONS: The presence of renovascular disease was associated with an increase in the risk of adverse coronary events in this sample. The increment in risk was not dependent on the effects of associated atherosclerotic risk factors, other prevalent cardiovascular disease, or increased blood pressure.

Age Distribution↗
PubMed2005

Atheroemboli during renal artery angioplasty: an ex vivo study.

OBJECTIVE: We hypothesized that atheroemboli released during renal angioplasty could be responsible for the modest functional result of renal angioplasty even after anatomic reduction of renal artery stenosis. To test this hypothesis, we enumerated and sized fragments released during ex vivo angioplasty and stenting of human renal artery atherosclerotic specimens removed during aortorenal endarterectomy. METHODS: Thirty-three intact aortorenal atheroma specimens (16 pairs with adjacent aortic atheroma and one specimen with a single renal artery orifice) were removed from 17 patients with renal artery occlusive disease who underwent renal artery endarterectomy. specimens. Endarterectomy specimens were removed with a ring of aortic plaque and "fitted" with a polytetrafluoroethylene "adventitia". Ex vivo angioplasty was technically successful in 31 of the 33 specimens and was performed by using a 0.018-inch guidewire and 3.0-mm and 5.0-mm angioplasty balloons inflated for 30 seconds at 15 atmospheres pressure. Stenting was performed with either a 5-mm or 6-mm self-expanding Wallstent. Each artery was flushed with 20 mL of saline after guidewire placement, each angioplasty, and stent placement. The effluent was collected for analysis for counting with either a microscope (size >100 microm) or a Coulter counter (size <100 microm). The number and size of embolic fragments in the effluent collected after each manipulation was recorded. RESULTS: Each manipulation of the specimens, including simply advancing the guidewire through the atherosclerotic lesion, released thousands of fragments. The numbers of fragments in each size category increased with decreasing particle size. Positioning and deploying the Wallstent released an additional bolus of fragments similar to that released after balloon angioplasty. CONCLUSIONS: Ex vivo renal angioplasty releases thousands of atherosclerotic fragments of sufficient size to create vascular occlusions and initiate significant renal parenchymal damage. The results of renal angioplasty procedures could be improved by placing distal protection devices to prevent atheroembolization. CLINICAL RELEVANCE: Athero-emboli produce a local arteritis in the kidney and could cause substantial damage to the renal parenchyma. This report explores the quantity of athero-emboli released during ex vivo angioplasty and stenting of renal atheroma specimens. The number of emboli found in this ex vivo study suggest that the use of protection devices may be advisable to protect the end organ, as done with angioplasty of the carotid artery. Of necessity, this was an ex vivo study and direct application to the clinical setting will need further study. Fortunately, multi-center trials examining the value of protection devices are currently in progress.

Aged↗
PubMed2005

Renal duplex parameters, blood pressure, and renal function in elderly people.

BACKGROUND: Changes in renal artery and renal parenchyma perfusion are believed to correlate with severity of hypertension and worsened renal function, but population-based studies of these associations are not available. This study examines relationships between parameters derived from renal duplex sonography (RDS), blood pressure (BP), and excretory renal function in a population-based cohort of elderly Americans. METHODS: Through an ancillary study to the Cardiovascular Health Study, 758 participants (37% men; mean age, 77 years) underwent RDS in which flow velocities and frequency shifts were determined from spectral analysis of Doppler-shifted signals obtained from the renal artery and parenchyma. Associations of these duplex parameters with BP and inverse serum creatinine were examined by using multivariate regression techniques. RESULTS: Main renal artery peak systolic flow velocity (PSV) showed independent associations with BP, with an SD increase in PSV (0.53 m/s) associated with a 3.3-mm Hg increase in systolic BP (SBP) and a 2.4-mm Hg decrease in diastolic BP (DBP). An SD decrease in end-diastolic frequency shift (EDF; 131 kHz) was associated with a 6.0-mm Hg increase in SBP, a 4.2-mm Hg decrease in DBP, and a significant 3.7% decrease in inverse serum creatinine. CONCLUSION: Increases in renal artery PSV and decreases in parenchymal EDF are associated with increased SBP and decreased DBP. Moreover, decreased parenchymal EDF showed significant associations with impaired excretory renal function. These results suggest that renal duplex parameters are associated with renal parenchymal changes caused by hypertension and progressive renal dysfunction in elderly people.

Black or African American↗
PubMed2005

Associations between retinal microvascular abnormalities and declining renal function in the elderly population: the Cardiovascular Health Study.

BACKGROUND: Microvascular abnormalities in the kidney are common histopathologic findings in individuals with chronic kidney disease or renal failure. These abnormalities may represent one manifestation of ongoing systemic microvascular damage. We hypothesized that retinal microvascular abnormalities, when present, would be associated with progressive renal dysfunction in elderly individuals. METHODS: The Cardiovascular Health Study (CHS) is a prospective, multicenter, cohort study initiated in 1989 designed to examine cardiovascular risk factors, morbidity, and mortality in elderly Americans. As part of an ancillary study, CHS participants underwent retinal photography in 1997 and 1998. Retinal microvascular abnormalities were assessed and graded by using standardized measures. Retinal microvascular abnormalities were defined as retinopathy (hard and soft exudates, hemorrhages, or microaneurysms) and/or retinal arteriolar abnormalities (arteriovenous nicking, focal arteriolar narrowing, or lowest quartile arteriole-venule ratio). Associations between these abnormalities and observed 4-year changes in serum creatinine levels and estimated glomerular filtration rates (eGFRs) from study years 5 to 9 (encompassing years 1994 to 2001) were examined by using regression modeling. RESULTS: A total of 1,394 CHS participants had retinal and serum creatinine data. After adjustments for age, race, sex, weight, diabetes, hypertension, angiotensin-converting enzyme inhibitor use, and proteinuria, participants with retinopathy showed a significant increase in serum creatinine level and decline in eGFR compared with those without retinopathy during the 4-year study period (+0.24 mg/dL [+21 micromol/L] versus -0.21 mg/dL [-19 micromol/L] and -0.48 mL/min/1.73 m2 [-0.01 mL/s/1.73 m2] versus +1.74 mL/min/1.73 m2 [+0.03 mL/s/1.73 m2], respectively). Participants with retinopathy also were significantly more likely to have an observed significant deterioration in renal function, defined as a 0.3-mg/dL (27-micromol/L) increase in serum creatinine level or 20% or greater decline in eGFR (odds ratio, 3.20; 95% confidence interval, 1.58 to 6.50; and odds ratio, 2.84; 95% confidence interval, 1.56 to 5.16, respectively). These associations remained in separate stratified analyses of patients with and without diabetes. The presence of retinal arteriolar abnormalities was not associated with deteriorating renal function. CONCLUSION: Retinal microvascular abnormalities defined as retinopathy were significantly associated with renal function deterioration. The observed findings were independent of effects of any associated diabetes or hypertension. These findings suggest that systemic microvascular disease may be associated with progressive renal dysfunction in the elderly population.

Black or African American↗
PubMed2004

Multiple aneurysms in childhood.

Arterial aneurysms in children are rare. When present, they are often associated with connective tissue disorders or arteritidies. Idiopathic aneurysms occurring at multiple sites throughout the arterial tree are rare, with only ten cases reported. This report describes a case of multiple arterial aneurysms of uncertain origin involving upper-extremity, extracranial cerebrovascular, aortoiliac, and renal arteries in a 14-year-old boy. The clinical presentation, vascular reconstruction, pathologic findings, and a brief review of the literature are described.

Adolescent↗
PubMed2004

Mesenteric artery disease in the elderly.

PURPOSE: The purpose of this study was to estimate the population-based prevalence of mesenteric artery stenosis (MAS) and occlusion among independent elderly Americans. METHOD: As part of an ancillary investigation to the Cardiovascular Health Study (CHS), participants in the Forsyth County, NC cohort had visceral duplex sonography of the celiac arteries and superior mesenteric arteries (SMAs). Critical MAS was defined by celiac peak systolic velocity >or=2.0 m/s and/or SMA peak systolic velocity >or=2.7 m/s. Occlusion of either vessel was defined by lack of a Doppler-shifted signal within the imaged artery. Demographic data, blood pressures, and blood lipid levels were collected as part of the baseline CHS examination. Participants' weights were measured at baseline and before the duplex exam. Univariate tests of association were performed with two-way contingency tables, Student t tests, and Fisher exact tests. Multivariate associations were examined with logistic regression analysis. RESULTS: A total of 553 CHS participants had visceral duplex sonography technically adequate to define the presence or absence of MAS. The study group had a mean age of 77.2 +/- 4.9 years and comprised 63% women and 37% men. Participant race was 76% white and 23% African-American. Ninety-seven participants (17.5%) had MAS. There was no significant difference in age, race, gender, body mass index, blood pressure, cholesterol, or low-density lipoproteins for participants with or without MAS. Forward stepwise variable selection found renal artery stenosis (P =.008; odds ratio [OR], 2.85; 95% confidence interval [CI], 1.31, 6.21) and high-density lipoprotein >40 (P =.02; OR, 3.03; 95% CI, 1.17, 7.81) significantly associated with MAS in a multivariate logistic regression model. Eighty-three of the 97 participants with MAS (15.0% of the cohort) had isolated celiac stenosis. Seven participants (1.3% of the cohort) had combined celiac and SMA stenosis. Five participants (0.9% of the cohort) had isolated SMA stenosis. Two participants (0.4% of the cohort) had celiac occlusion. Considering all participants with MAS, there was no association with weight change. However, SMA stenosis and celiac occlusion demonstrated an independent association with annualized weight loss (P =.028; OR, 1.54; 95% CI, 1.05, 2.26) and with renal artery stenosis (P =.001; OR, 9.48; 95% CI, 2.62, 34.47). CONCLUSION: This investigation provides the first population-based estimate of the prevalence of MAS among independent elderly Americans. MAS existed in 17.5% of the study cohort. The majority had isolated celiac disease. SMA stenosis and celiac artery occlusion demonstrated a significant and independent association with weight loss and concurrent renal artery disease.

Age Factors↗
PubMed2004

Surgical management of renal artery aneurysms.

PURPOSE: This retrospective review describes the surgical management and clinical outcome for renal artery aneurysms (RAAs) in 62 consecutive patients. METHODS: From January 1987 through July 2003, 804 patients had operative renal artery (RA) repair involving 1206 kidneys at our center. A subgroup of 62 patients (42 women, 20 men; mean age 46 +/- 18 years) received repair of 72 RAAs. Demographic data, comorbidity, and surgical technique were examined. Blood pressure and renal function response were determined. Patency of repair was evaluated by renal duplex sonography. Primary patency and patient survival were estimated by life-table methods. Tests of association were performed using chi(2) and the Student t tests. RESULTS: Seventy-two RAs were repaired for RAA with a mean diameter of 2.6 cm (range, 1.3 to 5.5 cm). Bilateral RAAs were present in 21 patients. Associated conditions included fibromuscular dysplasia, atherosclerosis, and arteritis in 54%, 35%, and 7%, respectively. Hypertension was present in 89% (mean blood pressure, 171 +/- 35/95 +/- 19 mm Hg; mean medications, 2.2 +/- 1.2 drugs) and renal insufficiency was present in 8% (mean serum creatinine, 1.9 +/- 0.6 mg/dL). RAA repair included bypass (67%), aneurysmorrhaphy (15%), or a combination (17%). One planned nephrectomy (1%) was performed for un-reconstructable disease. Branch RA reconstruction in 78% used ex vivo cold perfusion in 50%, in situ cold perfusion in 29%, and warm in situ repair in 21%. Of 9 bilateral RAA repairs, 7 (78%) were staged and 2 (22%) were simultaneous. Combined aortic reconstruction was required in 6 (10%) patients. Perioperative death occurred in 1 patient (1.6%), and significant morbidity was observed in 8 patients (12%). Hypertension was considered improved in 54%, cured in 21%, and unchanged in 25% at mean follow-up of 48 months (range, 1-156 months). Among patients with renal insufficiency, renal function was improved in 3 (60%), unchanged in 1 (20%), and declined in 1 (20%). Follow-up patency (mean, 33 months; range, 1-118 months) was determined for 64 (91%) RA reconstructions. Product-limit estimate of primary patency at 48 months was 96%. Product-limit estimate of survival was 91% at 120 months. CONCLUSION: RAAs were repaired with low morbidity and mortality. Complex branch RAA repair using cold perfusion preservation and ex vivo techniques resulted in no unplanned nephrectomy, with an estimated primary patency of 96% at 48 months. Beneficial blood pressure response was observed in the majority of hypertensive patients. These results support selective surgical management of RAA.

Adult↗
PubMed2004

Differential effects of Rho-kinase inhibition on artery wall mass and remodeling.

PURPOSE: Constrictive remodeling and new artery wall mass contribute to lumen narrowing in atherosclerosis and following injury. Rho-kinase, an important regulator of myosin phosphorylation and cytoskeletal reorganization, is critical to smooth muscle cell (SMC) growth and vasoconstriction, but its role in artery wall remodeling is poorly defined. We hypothesized that constrictive artery wall remodeling is dependent on Rho signaling so that blocking Rho-kinase would promote outward artery wall remodeling in response to intimal hyperplasia and thus limit lumen narrowing. METHODS: To test this hypothesis, we first studied the effects of the Rho-kinase inhibitor fasudil on SMC remodeling of collagen matrix in vitro. Mouse aortic SMCs were seeded into three-dimensional collagen gels with and without fasudil, and extent of contraction was measured at 24 hours. We then used the mouse carotid ligation model to study the effects of Rho-kinase inhibition on remodeling and intimal hyperplasia in vivo. C57B6/J mice were randomly assigned to fasudil (100 mg/kg per day) or vehicle and underwent unilateral carotid artery ligation or sham ligation. Remodeling and wall mass were measured after 28 days. RESULTS: Fasudil blocked SMC contraction of collagen gels in a dose-dependent manner. Complete inhibition of collagen gel remodeling was achieved between 10 and 30 micromol/L fasudil. In control mice, carotid ligation caused significant thickening of the adventitia, media, and intima (P <.01) and outward remodeling of the carotid wall. The external elastic lamina (EEL) area increased by 14% versus sham (P <.05), but this increase was insufficient to prevent lumen narrowing (-42% vs sham, P <.05). Fasudil treatment had favorable effects on wall mass, inhibiting neointimal (P =.04), medial (P =.03), and adventitial thickening (P =.07) versus controls. Opposite our hypothesis, however, fasudil did not enhance outward artery wall remodeling or improve lumen caliber. Rather, inhibiting Rho-kinase blocked outward remodeling in response to ligation. EEL area was significantly smaller in treated versus control animals (P =.04) and slightly smaller versus shams (P = NS). These data suggest that Rho activation contributes significantly to both hyperplasia and outward remodeling of the injured artery wall. Rho-kinase may prove an important target to limit intimal hyperplasia and prevent restenosis when remodeling is improved by other means (eg, stents).

1-(5-Isoquinolinesulfonyl)-2-Methylpiperazine↗
PubMed2003

Estimating scale-dependency in disturbance impacts: El Niños and giant kelp forests in the northeast Pacific.

Recent discussions on scaling issues in ecology have emphasized that processes acting at a wide range of spatial and temporal scales influence ecosystems and thus there is no appropriate single scale at which ecological processes should be studied. This may be particularly true for environmental disturbances (e.g. El Niño) that occur over large geographic areas and encompass a wide range of scales relevant to ecosystem function. However, it may be possible to identify the scale(s) at which ecosystems are most strongly impacted by disturbances, and thus provide a measure by which their impacts can be most clearly described, by assessing scale-dependent changes in the patterns of variability in species abundance and distribution. This, in turn, may yield significant insight into the relative importance of the various forcing factors responsible for generating these impacts. The 1997-98 El Niño was one of the strongest El Niños ever recorded. I examined how this event impacted giant kelp populations in the northeast Pacific Ocean at 90 sites ranging from central Baja California, Mexico to central California, USA. These sites spanned the geographic range of giant kelp in the Northeast Pacific and were surveyed just before, immediately following, several months after, more than 1 year after, and nearly 2 years after the El Niño. I used a hierarchical sample design to compare these impacts at five spatial scales spanning six orders of magnitude, from a few meters to more than 1,000 km. Variance Components Analyses revealed that the El Niño shifted control over giant kelp abundance from factors acting at the scale of a few meters (local control) to factors operating over hundreds to thousands of kilometers (regional control). Moreover, El Niño resulted in the near-complete loss of all giant kelp throughout one-half of the species' range in the northeast Pacific Ocean. Giant kelp recovery following El Niño was far more complex and variable at multiple spatial scales, presumably driven by numerous factors acting at those scales. Recovery returned local control of giant kelp populations within 6 months in southern California, and within 2 years in Baja California.

California↗
PubMed2003

Acute occlusive mesenteric ischemia: surgical management and outcomes.

Acute mesenteric ischemia secondary to arterial occlusion (AMI) remains a highly lethal condition. To examine recent trends in management and associated outcomes, we examined our institutional experience over a recent 10-year period. All patients treated for AMI between January 1990 and January 2000 were identified (76 patients, 77 cases) and their medical records examined. At presentation, 64% demonstrated peritonitis and 30% exhibited hypotension. The interval from symptom onset to treatment exceeded 24 h in 63% of cases. Etiology was mesenteric thrombosis in 44 patients (58%) and embolism in 32 patients (42%). Thirty-five patients (46%) had prior conditions placing them at high risk for the development of AMI including chronic mesenteric ischemia (n = 26) and inadequately anticoagulated chronic atrial fibrillation (n = 9). Surgical management consisted of exploration alone in 16 patients, bowel resection alone in 18 patients, and revascularization in 43 patients, including 28 who required concomitant bowel resection. Overall, intestinal necrosis was present in 81% of cases. Perioperative mortality was 62% and long-term parenteral nutrition (TPN) was required in 31% of survivors. Peritonitis (odds ratio [OR] 9.4, 95% confidence interval [CI] 1.6, 54.0; p = 0.012 and bowel necrosis (OR 10.4, CI 1.9, 56.3; p = 0.007) at presentation were independent predictors of death or survival dependent upon TPN. We conclude that AMI remains a highly lethal condition due in large part to advanced presentation and inadequate recognition and treatment of patients at high risk.

Adult↗
PubMed2003

Relationships between renovascular disease, blood pressure, and renal function in the elderly: a population-based study.

BACKGROUND: The purpose of this study is to examine the associations between renovascular disease (RVD) and cross-sectional measures of blood pressure and renal function among participants in the Cardiovascular Health Study (CHS). METHODS: The CHS is a prospective cohort study of cardiovascular disease among elderly Americans. As part of an ancillary study, participants in the Forsyth County, NC, cohort of the CHS were invited to undergo renal duplex sonography (RDS) to define the presence or absence of RVD (defined as any focal peak systolic velocity > or = 1.8 milliseconds or the absence of a Doppler shifted signal from an imaged artery). Demographic, risk factor, blood pressure, and serum creatinine data were obtained at the time of RDS and from the annual CHS examination. RESULTS: Eight hundred thirty-four CHS participants (including 525 women [63%], 309 men [37%], 194 African Americans [23%], and 635 Caucasians [76%]) with a mean age of 77.2 +/- 4.9 years underwent successful RDS. RVD was present in 57 participants (6.8%). When examined according to the presence or absence of RVD, significant univariate differences were observed in the prevalence of clinical hypertension (72% versus 50%; P = 0.001), systolic blood pressure (145 versus 136 mm Hg; P = 0.001), and renal insufficiency (16% versus 8%; P = 0.041). Multivariate analyses showed significant and independent associations for the presence of RVD with increasing systolic blood pressure (P = 0.034), clinical hypertension (odds ratio, 2.68; 95% confidence interval, 1.44 to 4.99; P = 0.002), increasing serum creatinine level, and renal insufficiency (odds ratio, 2.21; 95% confidence interval, 1.02 to 4.79; P = 0.043). A significant interaction was observed between the presence of RVD and increasing systolic blood pressure in association with increasing serum creatinine levels (P = 0.041). CONCLUSION: These results suggest important population-based associations between RVD and cross-sectional measures of blood pressure and renal function. Furthermore, the observed relationship between RVD and increasing serum creatinine level was influenced strongly by increasing blood pressure.

Aged↗
PubMed2002

Results of valve replacement with Omniscience mechanical prostheses.

BACKGROUND: The Omniscience mechanical valve has been the subject of multiple clinical investigations with variable results, including reports of high complication and reoperation rates. METHODS: Records of all patients who received Omniscience valves were reviewed, and follow-up interviews were conducted to determine the incidence of valve-related morbidity, mortality, and functional results. Incidence of complications was expressed as events per 100 patient-years follow-up. Survival and freedom from valve-related complications and mortality were calculated using a product limit method. RESULTS: Between 1984 and 1988, 192 patients received 213 Omniscience valves [93 mitral (M), 79 aortic (A), and 20 multiple (D) valve replacements]. Perioperative mortality was 9%. The incidence of major valve-related morbidity was as follows: thrombosis, 1.30 M, 0.17 A, 0.72 D; endocarditis, 0.48 M, 0.18 A, 0 D; hemorrhagic, 4.67 M, 2.84 A, 5.00 D; embolic, 2.90 M, 2.27 A, 1.57 D; nonstructural dysfunction, 1.66 M, 1.08 A, 2.27 D; reoperation, 4.02 M, 1.99 A, 6.48 D. All explanted valves (n = 43) were examined, and 40% (n = 17) were found to have limited disc excursion in the absence of thrombus. Freedom from valve-related morbidity, mortality, or reoperation at 10 years was 22% for mitral, 39% for aortic, and 17% for multivalve replacements. At follow-up, only 73% of patients were New York Heart Association class I or II. Five- and 10-year estimated survivals were 72% and 55% for M, 80% and 51% for A, and 65% and 50% for D replacements. CONCLUSIONS: Use of the Omniscience valve provided poor functional improvement and a significant incidence of valve-related complications, including the need for reoperation.

Adolescent↗
PubMed2002

Surgical management of atherosclerotic renovascular disease.

OBJECTIVE: This review describes the clinical outcome of surgical intervention for atherosclerotic renovascular disease in 500 consecutive patients with hypertension. METHODS: From January 1987 to December 1999, 626 patients underwent operative renal artery (RA) repair at our center. A subgroup of 500 patients (254 women and 246 men; mean age, 65 plus minus 9 years) with hypertension (mean blood pressure, 200 plus minus 35/104 plus minus 21 mm Hg) and atherosclerotic RA disease forms the basis of this report. Hypertension response was determined from preoperative and postoperative blood pressure measurements and medication requirements. Change in renal function was determined with estimated glomerular filtration rates (EGFRs) calculated from serum creatinine levels. Proportional hazards regression models were used for the examination of associations between selected preoperative parameters, blood pressure and renal function response, and eventual dialysis-dependence or death. RESULTS: Two hundred three patients underwent unilateral RA procedures, 297 underwent bilateral RA procedures, and 205 patients underwent combined renal and aortic reconstruction. After surgery, there were 23 deaths (4.6%) in the hospital or within 30 days of surgery. Significant and independent predictors of perioperative death included advanced age (P <.0001; hazard ratio [HR], 3.23; 95% confidence interval [CI], 1.85 to 5.70) and clinical congestive heart failure (P =.013; HR, 3.05; 95% CI, 1.26 to 7.34). Among the patients who survived surgery, hypertension was considered cured in 12%, improved in 73%, and unchanged in 15%. For the entire group, renal function increased significantly after operation (preoperative versus postoperative mean EGFR, 41.1 plus minus 23.9 versus 48.2 plus minus 25.5 mL/min/m(2); P <.0001). For individual patients, with a 20% or more change in EGFR considered significant, 43% had improved renal function (including 28 patients who were removed from dialysis-dependence), 47% had unchanged function, and 10% had worsened function. Preoperative renal insufficiency (P <.001; HR, 2.35; 95% CI, 1.86 to 2.98), diabetes mellitus (P =.007; HR, 2.14; 95% CI, 1.15 to 3.97), prior stroke (P =.042; HR, 1.50; 95% CI, 1.02 to 2.22), and severe aortic occlusive disease (P =.003; HR, 1.69; 95% CI, 1.19 to 2.31) showed significant and independent associations with death or dialysis during the follow-up examination period. After operation, blood pressure cured (P =.014; HR, 0.52; 95% CI, 0.30 to 0.88) and improved renal function (P =.011; HR, 0.40; 95% CI, 0.19 to 0.81) showed significant and independent associations with improved dialysis-free survival rate. All categories of function response and time to death or dialysis showed significant interactions with preoperative EGFR. CONCLUSION: The surgical correction of atherosclerotic renovascular disease resulted in blood pressure benefit and retrieval of renal function in selected patients with hypertension. The patients with cured hypertension or improved EGFR after operation showed increased dialysis-free survival as compared with other patients who underwent surgery.

Aged↗