Percutaneous transluminal revascularization for renal artery stenosis: Veterans Affairs Puget Sound Health Care System experience.

PURPOSE: The safety and efficacy of percutaneous transluminal intervention for renal artery stenosis is improving. This study evaluates the immediate and long-term anatomic and functional outcomes of percutaneous transluminal angioplasty and stenting for atherosclerotic renal artery stenosis in a Veterans Affairs population. METHODS: We performed a retrospective analysis of records from patients who underwent renal artery angioplasty with or without stenting at the Veterans Affairs Puget Sound Health Care System between January 1990 and June 1999. Indications for intervention included hypertension (78%) and rising serum creatinine (78%). Seventy-six patients (74 men, average age of 67 years, range 42-83 years) underwent 88 attempted interventions. Seventy-two percent of contralateral kidneys had significant disease (47% had a >60% stenosis; 16% were nonfunctioning or absent). RESULTS: Of the 88 planned interventions, 86 were successfully performed with placement of 46 stents (52%). Technical success (defined by <30% residual stenosis) was achieved in 78 vessels (89%). The procedure-related complication rate was 5%. Patient mortality by life table analysis was 49% at 5 years. Assisted primary patency rate at 5 years was 100%. Primary and secondary restenosis rates were 37% +/- 8% and 31% +/- 8% at 5 years, respectively. Sixty-eight percent of patients treated for hypertension demonstrated clinical benefit (improved or cured hypertension). This clinical benefit was maintained in 52% of the patients at 5 years, as measured by life table analysis. Serum creatinine was lowered or maintained in 88% of the patients, but this clinical benefit was only maintained in 25% of patients at 5 years. CONCLUSIONS: Transluminal intervention for clinically symptomatic atherosclerotic renal artery stenosis is technically successful and safe. There are excellent assisted-patency and low restenosis rates. There is immediate clinical benefit for most patients, as evidenced by improved control of hypertension and preservation of renal function. However, within 5 years the benefit is not maintained for either hypertension (50%) or renal function (20%). Therefore, although technically successful, functional outcomes after endoluminal intervention are not maintained in the long term.

Transluminal treatment of a celiac artery pseudoaneurysm with a stent graft occlusion device.

This report describes the transluminal placement of a stent graft occlusion device to treat a celiac bypass graft pseudoaneurysm which was causing biliary and duodenal obstruction.

The gallbladder also secretes.

The gallbladder is traditionally regarded as an absorptive organ. There is increasing evidence that the gallbladder mucosa can have a secretory function. We studied a patient with primary sclerosing cholangitis whose gallbladder was excluded from his extrahepatic bile ducts by stricture formation. He was admitted into hospital because of cholecystitis and cholangitis and required separate drainage tubes into his gallbladder and common hepatic duct. This unique combination of drains afforded the opportunity to examine hepatic bile and gallbladder secretion. We analyzed samples for fluid volume, protein, electrolyte concentrations and biliary lipids. The simultaneous, yet separate, drainage from the gallbladder and the liver had a striking difference. The former was colorless to opalescent; the latter always golden brown. Hepatic bile flow was continuous but gallbladder drainage was variable in volume, intermittent, and occurred only after a meal. The gallbladder fluid had no bilirubin, bile salts, cholesterol, or phospholipids and had the ionic profile of an extracellular fluid. It was alkaline and contained abundant bicarbonate. We have shown that the gallbladder can secrete. In addition, these observations may also have important implications in the pathogenesis and prevention of gallbladder sludge and stones.

Results of percutaneous transluminal angioplasty for atherosclerotic renal artery stenosis: a follow-up study with duplex ultrasonography.

PURPOSE: The short and long-term anatomic results of percutaneous transluminal renal angioplasty (PTRA) in the treatment of atherosclerotic renovascular disease have been poorly documented because of a lack of follow-up arteriography. The purpose of this study was to evaluate the anatomic results of PTRA with serial duplex examinations. METHODS: The records of 41 patients who underwent 52 primary PTRA procedures and had subsequent duplex follow-up of at least 6 months were reviewed. After PTRA, renal arteries were classified as normal, < 60% stenosis, > or = 60% stenosis, or occluded on the basis of previously validated duplex criteria. RESULTS: The study group included 26 men and 15 women with a mean age of 65 years, who were observed for a mean interval of 34 months. Endovascular stents were placed in 12 of the 52 arteries. The initial post-PTRA renal artery stenosis classification (based on arteriography or duplex scan) was normal in 23, < 60% in 19, and > or = 60% in 10. The cumulative incidence of restenosis from normal to > or = 60% was 13% at 1 year and 19% at 2 years. The cumulative incidence of restenosis from < 60% to > or = 60% was 44% at 1 year and 55% at 2 years. The cumulative incidence of progression from > or = 60% to occlusion was 10% at 2 years. Although 83% of the 12 stented arteries and only 33% of the 40 nonstented arteries were normal immediately after PTRA, after 1 year the stented renal arteries showed a 44% restenosis rate, whereas the nonstented renal arteries showed a 18% restenosis rate (p = 0.087). CONCLUSIONS: Restenosis after PTRA for atherosclerotic disease is relatively common and correlates with the initial anatomic result. Although PTRA with stent placement yields superior immediate technical results, the high early restenosis rate is disturbing.

Successful treatment of early postoperative aortic graft infection by percutaneous catheter drainage.

Successful treatment by percutaneous catheter drainage of an acute aortic graft infection with an associated pancreatic fistula is reported. Percutaneous catheter drainage can be considered in selected patients when the risk of reoperation is deemed unacceptable or when other reasonable treatment options do not exist.

Cardiac-gated MR angiography of the entire lower extremity: a prospective comparison with conventional angiography.

OBJECTIVE: The purpose of this study was to prospectively evaluate cardiac-gated two-dimensional (2D) time-of-flight MR angiography in patients with peripheral arterial occlusive disease (PAOD). SUBJECTS AND METHODS: Twenty-three patients with PAOD were studied using cardiac-gated 2D time-of-flight MR angiography in the body coil from each patients' aortic bifurcation to the pedal arches. Blinded comparison with conventional angiograms was used to determine sensitivity, specificity, and positive and negative predictive values of this MR angiography technique. Kappa statistics were used to compare treatment plans of these patients studied with MR angiography and with conventional angiography. RESULTS: In the aortoiliac region, MR angiography had a correlation coefficient of .89 for all degrees of narrowing. For hemodynamically significant lesions, MR angiography had an 89% sensitivity, 98% specificity, 84% positive predictive value, and 99% negative predictive value. In the femoral region, MR angiography had a correlation coefficient of .91 for all degrees of narrowing. For hemodynamically significant lesions, MR angiography had an 89% sensitivity, 98% specificity, 93% positive predictive value, and 97% negative predictive value. In the popliteal region, MR angiography had a correlation coefficient of .93 for all degrees of narrowing. For hemodynamically significant lesions, MR angiography had an 89% sensitivity, 98% specificity, 94% positive predictive value, and 95% negative predictive value. In the tibioperoneal and foot regions, MR angiography had a correlation coefficient of 88% for all degrees of narrowing. For hemodynamically significant lesions, MR angiography had an 86% sensitivity, 93% specificity, 89% positive predictive value, and 91% negative predictive value. When the treatment planning data were classified into one of four outcomes (no intervention, surgery, percutaneous angioplasty, or further diagnostic study), MR angiography and conventional angiography had excellent agreement, with a Cohen's kappa value of .78. CONCLUSION: Cardiac-gated 2D time-of-flight MR angiography that uses the body coil provides a useful examination for PAOD with reasonable resolution. This imaging technique is potentially more time-efficient than techniques using extremity coils.

Urokinase in gastrointestinal tract bleeding.

Selective urokinase infusion into the superior mesenteric artery allowed the accurate determination of the site of small bowel bleeding in a patient with recurrent lower gastrointestinal bleeding who bled despite resective surgery and who had negative findings on four angiograms. Fibrinolytic agents are useful in rare cases in which the need for successful and accurate diagnosis outweighs the risks of reactivating the bleeding.