Gian Pietro Feltrin

Dynamic testing with high-dose adrenocorticotrophic hormone does not improve lateralization of aldosterone oversecretion in primary aldosteronism patients.

Objective Diagnosing aldosterone-producing adenoma (APA) involves a demonstration of the lateralization of aldosterone oversecretion because adrenal incidentalomas are common in hypertensive individuals and many small-sized APA escape identification with available imaging techniques. However, because of the pulsatile pattern of aldosterone secretion this can be a difficult undertaking. Stimulation of aldosterone secretion before adrenal vein sampling (AVS) can overcome this difficulty, but anecdotal data exist. We, therefore, prospectively investigated the usefulness of AVS with dynamic testing in primary aldosteronism (PA) patients. Methods We enrolled 24 consecutive consenting patients with a biochemical diagnosis of PA from a tertiary referral centre to measure the effects of adrenocorticotrophic hormone (ACTH) on selectivity, the lateralization of aldosterone secretion to the APA side, and adverse effects. After correcting the hypokalemia we performed bilateral AVS. After 3 h supine resting, blood was simultaneously obtained from both sides. A high-dose ACTH (250 μg intravenous) bolus was then administered and AVS was repeated after 30 min. Results AVS was bilaterally selective in 88% of patients; no adverse effects occurred. Of the 21 patients with bilaterally selective AVS, three had idiopathic hyperaldosteronism and 18 an APA that was surgically removed in 12 with an ensuing fall in blood pressure at follow-up. After ACTH patients showed a significant increase (P = 0.007) of aldosterone from contralateral adrenal vein blood, but not from the APA gland. Therefore, lateralization of aldosterone secretion on the APA side did not improve. Conclusion AVS is safe and accurate for identifying APA. However, at a statistical power of 99%, these results do not support the usefulness of high-dose ACTH testing to improve the diagnostic accuracy of AVS.

Transcatheter arterial chemoembolization for hepatocellular carcinoma in patients with Child's grade A or B cirrhosis : A multivariate analysis of prognostic factors

We evaluated factors affecting long-term survival after transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) complicating cirrhosis. One hundred eighty-two patients with Childs class A or B cirrhosis and an HCC, not amenable to surgery or percutaneous ethanol injection, underwent 346 TACEs (mean 1.9) with epirubicin, iodized oil, and gelatin sponge. Many prognostic factors were subjected to univariate analysis and thereafter, when significant, to the Coxs hazard proportional model. Finally, the significant indices in the Coxs model were used to estimate the accuracy of the probability of death with computation of the area under the receiving operative characteristic (ROC) curve. The cumulative survival rates at 1, 2, 3, and 5 years were 0.83, 0.52, 0.40, and 0.16, respectively. According to Coxs model, the factors associated with significantly worse survival were the presence of ascites (p = 0.0027), elevated bilirubin levels (p = 0.0163), elevated alpha-fetoprotein (alphaFP) values (p = 0.0067), a tumor greater than 5 cm in diameter (p = 0.0001), and the absence of a tumor capsule-like rim (p = 0.0278). According to these parameters, the accuracy of the probability of death estimated with ROC analysis was 0.63. Minor and major complications occurred in 82 patients (45%) and caused death in 2 patients. Long-term prognosis after TACE for HCCs in patients with Childs class A or B cirrhosis depends on the presence of ascites, the bilirubin level, the alphaFP value, the diameter of the tumor, and the presence of a tumor capsule-like rim. However, when considered altogether, these variables are poor predictors to evaluate survival, and other factors should be investigated to identify subjects more responsive to TACE. Complications occur in a high percentage of patients, but they do not affect long-term prognosis.

Esophageal motor function in patients with myotonic dystrophy

To investigate pharyngeal and esophageal motor function in myotonic dystrophy (MD), and its relationship to esophageal symptoms, we used low-compliance, high-fidelity esophageal manometry and videofluorography to evaluate 14 consecutive MD patients. Patients exhibited a consistent, typical motor pattern, involving a marked reduction in resting tone of both the upper and lower esophageal sphincters, and a reduction in contraction pressure in the pharynx and throughout the esophagus. Radiology showed hypotonic pharynx with stasis and a hypo- or amotile, often dilated, esophagus. These findings were nonspecific, however, being present in patients both with and without dysphagia, which suggests that MD patients have valid compensatory mechanisms. Dysphagia only correlated to the pharyngeal impairment at manometry. Furthermore, the results of our study suggest that not only the proximal, striated part of the gullet, but also the distal part (in which smooth muscle dominates) is involved in the disease. The latter leads to the impairment of the LES resting tone and competence, highlighting the risk of gastroesophageal reflux disease in these patients.

Prognostic value of nephrography in atherosclerotic occlusion of the renal artery.

artery Prognostic value of nephrography in atherosclerotic occlusion of the renal ISSN: 1524-4563 Copyright

Excess Prevalence of Supraaortic Artery Lesions in Renovascular Hypertension: An Arteriographic Study

PurposeHigh renin or renovascular hypertension (RVH) has been associated with a higher risk of stroke than low-to-normal renin hypertension. Our present purpose was to investigate the angiographic prevalence and distribution of lesions of the supraaortic arteries in a series of consecutive patients with RVH compared with control patients with low-to-normal renin primary hypertension (PH).MethodsThirty-two consecutive hypertensives (21 females, 11 males, aged 23–72 years) were investigated by renal and aortic arch digital subtraction arteriography (DSA). None of them had any history or symptoms of cerebrovascular disease. In each, the presence and severity of lesions at 17 different segments of the supraaortic arteries were evaluated and a score for supraaortic lesions was then calculated based on the number and severity of lesions. RVH was diagnosed in 16 patients with renal artery stenoses and normalization of blood pressure after percutaneous transluminal renal angioplasty (PTRA) (n=12) or surgery (n=4). The cause of renal artery obstruction was fibrodysplasia in 5 patients (31%) and atherosclerosis in 11 (69%). PH was diagnosed in 16 patients based on a normal renal DSA and exclusion of all other possible causes of hypertension.ResultsThe RVH and PH groups were similar with respect to age, sex, body mass index, diabetes, smoking habits, serum triglycerides, cholesterol, and blood pressure values, and differed only in plasma renin activity (6.0±1.7 ng AngI/ml/h in RVH vs. 1.4±0.3 in PH, mean±SEM, p=0.008). The score for supraaortic arterial lesions was significantly higher in RVH than in PH (181±32 vs. 17±9, p=0.001). This difference was also evident when the five patients with fibrodysplasia were compared with five age- and sex-matched PH patients. The sites most frequently involved were the carotid artery bulb and the internal carotid artery sinus. At each affected site the score was higher for RVH than for PH.ConclusionFor the same demographic features and risk profile, RVH was associated with a higher prevalence and severity of supraaortic artery lesions than PH.

Intravascular Ultrasound Evaluation for Assessment and Therapeutic Decisions in Aortic Diseases

Intravascular sonography (IVS) was employed in several aortic pathologies. Acute dissecting aneurysm, chronic or recurrent dissection in previously re paired aneurysm, iatrogenic (postcatheterism) dissection, noncommunicating dissection (mural hematoma), chronic and acute partial thrombosis, and mural fibrosis following aspecific aortitis were studied. The stationary and dynamic observations combined with angiographic findings provided useful information for characterization of the lesions and for therapeutic decisions. In all 14 pa tients studied, supplemental data achieved from IVS suggest that a combination of angiography and IVS is the most nearly complete examination for concomi tant and fast diagnostic workup.

Re: Embolization of pancreaticoduodenal aneurysms associated with occlusive disease of the celiac artery

We read with interest the paper by Uher et al. concerning aneurysms of the pancreaticoduodenal artery associated with occlusion of the celiac artery [1], and we would like to add the following considerations. Aneurysms of the pancreaticoduodenal artery associated with stenosis or occlusion of the celiac artery can also rupture when the aneurysm is very small [2]. Therefore, superior mesenteric angiograms should be evaluated very carefully to detect these lesions whenever the gastroduodenal artery serves as a collateral pathway to the celiac artery. We agree with Uher et al. [1] when they state that embolization should be the primary therapeutic choice in the case of a ruptured aneurysm: the successful longterm results support this approach [2]. However, we feel that embolization should be primarily attempted in patients with a nonruptured aneurysm when the vascular anatomy is suitable for selective catheterization because an arterial ligation or an aneurysm resection are not always feasible, and a major operation (i.e., a partial pancreatectomy) might be necessary [3, 4]. As concerns their case 4, we disagree with Uher et al. who rejected the hypothesis that the gastrointestinal bleeding was caused by the aneurysms of the pancreaticoduodenal artery. This case resembles cases of gastrointestinal hemorrhage from pancreatic pseudoaneurysms. In these circumstances, endoscopy of the upper digestive tract often fails to detect the bleeding through the ampulla of Vater because the bleeding is often selflimiting and no mucosal abnormalities are associated [5]. Therefore, a negative endoscopy cannot rule out a parenchymal source of gastrointestinal bleeding. Did the level of serum amylases increase after every episode of gastrointestinal bleeding suffered by the patient of case 4? Did the gastrointestinal bleeding recur after the discharge from the hospital? In any case, although the previous multiorgan transplantation could make the operation difficult to perform, why was surgery not planned? These aneurysms, in fact, can rupture, as was reported by Uher et al. in their case 2. Aneurysms of the pancreaticoduodenal artery associated with occlusive disease of the celiac artery may be life-threatening lesions. Transcatheter embolization, because it is noninvasive and highly reliable, should be the primary therapeutic choice to treat both ruptured and nonruptured aneurysms. Nevertheless, when adverse vascular anatomy prevents or jeopardizes the arterial liver supply and contraindicates the embolization, surgery should be always considered as a second therapeutic option because conservative management of these aneurysms may be hazardous for the patient.