Heun Y. Yune

Primary Aldosteronism: Diagnosis, Localization, and Treatment

New diagnostic techniques have enhanced the detection of primary aldosteronism. However, the response of blood pressure after operation in unilateral and bilateral adrenal disease is different. We have compared four localizing techniques--adrenal venography, adrenal isotopic scanning, a modified adrenal venous sampling for steroid measurements, and the anomalous postural decrease in plasma aldosterone concentration--in 51 patients with primary aldosteronism, all of whom had undergone operative confirmation. Adrenalectomy resulted in normal blood pressure in 59%, improvement in 25%, and no change in 16%. Correct localization of the lesion was obtained in 47% by the adrenal isotopic scan, in 66% by adrenal venography, and in 91% by the modified adrenal venous hormone technique despite four false-positives. Of the 26 patients with an anomalous postural decrease in plasma aldosterone, 88% had a unilateral lesion.

Percutaneous Transluminal Dilatation in the Treatment of Renal Vascular Hypertension

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.

Diagnosis and Treatment of Pericardial Cysts

The authors present 2 cases of pericardial cyst accurately diagnosed by cyst puncture and radiographic studies following the injection of contrast material. Both cysts were completely aspirated at the completion of the examination and have not recurred during a three-year period. It is concluded that pericardial cyst injection is a simple technique for the unequivocal diagnosis of pericardial cysts.

Intrathoracic Cystic Hygroma A Report of Three Cases

Three cases of cystic hygroma in adults are presented. Cystic hygroma is a type of lymphangioma with large dilated cystic lymph spaces which usually occur in the neck or axillae in infants. The mediastinal type of cystic hygroma is rare (less than 1%) and is usually not discovered until adulthood because of its asymptomatic nature and deep location. Roentgen findings are not specific, but features which help differentiate cystic hygroma from other malignant processes include a sharp border and uniform density to the mass, macroscopic cystic lymph spaces, and little lobulation of the surface of the mass. Treatment is early surgical excision.

Diagnosis and localization of pheochromocytoma: Detection by measurement of urinary norepinephrine excretion during sleep, plasma norepinephrine concentration and computerized axial tomography (CT-scan)

The feasibility of differentiating patients with pheochromocytoma from other hypertensive patients by measuring urinary excretion rates of norepinephrine during sleep, a period of physiologic suppression of norepinephrine release, was investigated. The mean excretion rates of norepinephrine in 248 normal subjects and in 109 patients with essential hypertension were 1.03 +/- 0.03 and 1.12 +/- 0.06 (SEM) micrograms/hour, respectively, whereas the lowest excretion rate among the six patients with pheochromocytoma was about seven times higher. Plasma norepinephrine concentration in patients with pheochromocytoma was also consistently above the range observed in both normotensive and hypertensive subjects. CT scan correctly identified the same tumors visualized by selective arteriography. It is suggested that the usefulness of these approaches will provide simpler means of screening and detecting pheochromocytoma.

Percutaneous Transluminal Angioplasty for Renal Artery Stenosis in a Solitary Functioning Kidney: An Alternative to Surgery in the High-Risk Patient

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.

Collateral circulation to an ischemic kidney.

A review of 301 consecutive abdominal arteriograms given to patients suspected of having occlusive arterial diseases was conducted. In 99 patients, 35% or more stenosis of the renal artery was demonstrated; of these, 40 showed demonstrable collaterals to the ischemic kidney. The adrenal and lumbar arteries contributed four times more frequently than the periureteric arteries to the collateral circulation. Characteristic ureteral notching from the periureteric artery collateral was noted in only 50% of the cases. Intrarenal collaterals were observed and appeared to contribute to the preservation of the size and function of the affected kidney.

Balloon Dilatation for Renal Artery Stenosis Causing Hypertension: Criteria, Concerns, and Cautions

Excerpt Percutaneous transluminal dilatation of the renal artery using a balloon-tipped catheter may be the most important advance in the management of renal vascular hypertension since the advent ...

Page kidney: an unusual cause of hypertension.

A case of classical Page kidney with emphasis on radiographic findings is presented. Onset of hypertension following trauma associated with angiographic findings of attenuation, splaying and stretching of the intrarenal vessels on the arterial phase with a definite delay in transit time through the parenchyma and a non-homogeneous nephrogram should make the diagnosis of Page kidney or constricting subcapsular mass the most logical consideration.

Percutaneous transluminal angioplasty in complicated renal vascular hypertension.

Fourteen patients with renovascular hypertension complicated by renal impairment and/or a nonfunctioning kidney underwent percutaneous transluminal angioplasty of the remaining kidney(s) for the purpose of improving blood pressure control and/or renal function. The outcome of percutaneous transluminal angioplasty in these individuals was evaluated over periods ranging from 1 to 72 months. All patients had atherosclerotic renovascular hypertension as judged by the X-ray appearance of the stenotic lesions of the renal artery as well as evidence of aortic atherosclerosis. Four of the 14 subjects demonstrated a decrease in serum creatinine greater than or equal to 20% following the procedure, and an equal number showed a similar increase in serum creatinine. In the 1st month following the procedure, 5 patients required dialysis because of deterioration of renal function, 4 of whom subsequently died. Over the entire population, only 4 subjects showed improvement in blood pressure and renal function which persisted for 18 to 72 months. One of these subjects had a recurrence of renovascular hypertension and underwent successful repeat dilatation for bilateral disease after 2 years following the initial angioplasty. This patient remains improved. These observations confirm that when renovascular hypertension occurs in an older population with cardiac and renal disease or occurs in a solitary functioning kidney, the remote prognosis is not good. The improvement rate of 29% with dilatation alone in this population appears to be less than that observed following surgical intervention in a similar population. Thus, transluminal angioplasty should be reserved for those subjects who are not surgical candidates or who refuse surgical intervention.