J. Edgren

Long-Term Results of Percutaneous Transluminal Angioplasty in Renovascular Hypertension

PURPOSE The long-term effect of percutaneous transluminal renal angioplasty (PTRA) was assessed in 50 patients with renovascular hypertension. MATERIAL AND METHODS Thirty-eight of the patients had atherosclerotic disease and 12 patients fibromuscular dysplasia (FMD). Dilatation with a balloon catheter were performed at 6 to 8 atm for 15 to 30 s. RESULTS PTRA was technically successful in 46 (92%) patients. Three of the failures underwent surgical revascularization. There was no mortality connected with PTRA. Minor complications occurred in 6 (12%) patients, and surgical intervention was required in 1. In 4 patients with restenosis, repeated PTRA was performed in 2, and surgery in the other 2 patients. Bilateral disease occurred in 12 patients, and 3 had sequential bilateral PTRA. In 9 patients with atherosclerotic ostial stenosis, PTRA was technically successful in 8 (89%). Thirty-eight patients were re-examined with a mean follow-up of 4 years. At follow-up, 5 (45%) of the patients with FMD were classified as cured, 6 (55%) as improved, and none as failed. In the 27 patients with atherosclerotic disease, 23 (85%) had long-term benefit, 3 (11%) were cured, 20 (74%) were improved, and 4 (15%) were failures. In the 8 patients with ostial atherosclerotic lesions and successful PTRA, there was a 75% long-term benefit. Two patients died during follow-up, both from myocardial infarction. CONCLUSION The result suggest that PTRA is effective in long-term management of renovascular hypertension, not only in patients with fibromuscular stenosis, but also in patients with atherosclerotic disease, even when ostial lesions are present.

Doppler Ultrasound in the Diagnosis of Renal Transplant Artery Stenosis - Value of Resistive Index

Doppler ultrasound (DU) with angiographic correlation was performed in 19 hypertensive renal transplant recipients suspected for transplant artery stenosis. DU included calculation of the intrarenal resistive index (RI) and measurement of the maximum systolic velocity in the transplant artery. All 10 cases having a pathologically low RI (≤0.6) had a ≥ 50% stenosis; specificity and positive predictive values were thus 100%. There were 5 false-negative diagnoses, sensitivity 67%. The measurement of maximum systolic velocity was feasible in only 15 cases (79%). Using a cut-off point of 2 m/s the sensitivity was 91% and there were 4 false-positive cases and one false-negative case. Balloon percutaneous transluminal angioplasty (PTA) was performed in 13 cases, of which 9 were successful. In all successful cases RI was <0.6 after PTA. We conclude that low RI (<0.6) is highly suggestive for transplant artery stenosis. RI may serve as an indicator of the hemodynamic success of PTA.

Aortofemoral surgery and sexual function.

OBJECTIVES To determine the incidence and pathophysiology of erectile dysfunction (ED) in patients with aortoiliac occlusive disease (AIOD) and the effects of aortofemoral surgery, including endarterectomy (E) and reconstruction (R), on erectile function (EF). DESIGN Evaluation of EF before and 3 months after surgery. METHODS 31 out of 40 male patients scheduled for aortofemoral surgery were given multiple choice questionnaires and penile dynamic Colour Doppler Ultrasonography. RESULTS Of the 31 who agreed to enter the study five (16%) were found to be potent and 26 (84%) to suffer from ED. This was purely arteriogenic in 8% of the cases, purely venogenic in 23%, combined arteriogenic and venogenic in 53%, and neurogenic in 16%. Twenty patients returned for postoperative evaluation of EF, nine who had undergone E and 11 who had undergone R. Improvement of EF, in terms of increased penile arterial inflow, occurred in seven patients, six who had undergone E and one who had undergone R. EF remained unchanged in nine patients, three who had undergone E and six who had undergone R. Deterioration of EF occurred in four patients, all who had undergone R, and was attributable to decreased arterial inflow in two cases and to neurogenic surgical injury in the other two. CONCLUSIONS The majority of patients with AIOD suffers from ED. Reduced penile arterial inflow and cavernovenous leakage are equally important in the pathophysiology of ED in patients with AIOD, suggesting that atherosclerosis may also compromise the penile veno-occlusive mechanism. Endarterectomy seems more likely than reconstruction to improve or maintain EF.

Haemodynamic results of femoropopliteal percutaneous transluminal angioplasty

OBJECTIVES To determine the utility of percutaneous transluminal angioplasty (PTA) of the femoropopliteal segment in patients with claudication and critical leg ischaemia (CLI). DESIGN Longitudinal observational study. SETTING A university based vascular surgical centre. MATERIAL Ninety-five patients with stenosing or occlusive arterial lesions of the femoropopliteal segment underwent 52 primary PTA for claudication and 50 primary PTA for CLI. METHODS The procedure was considered haemodynamically successful when the increase of immediate postprocedural ABI was 0.15 or more. The criterion for haemodynamic success during follow-up was an ABI having not decreased by more than 0.15 from the immediate postprocedural level. The run-off arteries were graded according to the scoring system proposed by the SVS/ISCVS. RESULTS Among the technically successful procedures (83%), the haemodynamic success rate was 77% at 1 month, 55% after 1 year, and 51% after 2 years. The cumulative haemodynamic success rates were 83%, 66% and 61% in claudicants, and 70%, 42%, and 38% in CLI (p = 0.03). In patients with a run-off score < or = 7.5, the success rates were 84%, 67%, and 60%, respectively, whereas in those with a crural score > 7.5 these were 61%, 39%, and 39%, respectively (p = 0.04). CONCLUSIONS The haemodynamic results suggest that PTA to the femoropopliteal segment is seldom a procedure of choice for critically ischaemic legs with poor run-off. The run-off score is useful in identifying patients who may benefit from PTA.

Cost-effectiveness of percutaneous transluminal angioplasty (PTA) versus vascular surgery in limb-threatening ischaemia

The purpose of this study was to analyze the cost and cost-effectiveness of femoropopliteal PTA compared to femoropoliteal bypass surgery in chronic critical ischaemia of the lower limb. A total of 772 patients were treated either by femoropopliteal PTA or vascular reconstruction in two of the three largest vascular centers in Finland 1991–1992. A subset of 124 cases with chronic critical leg ischaemia, which according to a retrospective independent analysis by a vascular surgeon and a radiologist could have been treated with either modality, were included in the study. Eighty-six of those were treated with PTA and 38 with surgery. The patients were followed up for to three years after treatment. Clinical outcomes were measured as change in the ABI (ankle-brachial pressure index) and avoidance of reoperation and amputation. The hospital costs covering all events from preoperative examinations to the three-year follow-up visit were identified by using hospital discharge register and accounting data. Cost-effectiveness was calculated as cost per reoperation-free year and year of leg saved. Surgery cases were found to have a more severe disease as indicated by lower distal pressures and longer occlusions and they also showed a slightly better clinical outcome, although the differences were not statistically significant. PTA costs were half of those of vascular surgery. The cost-effectiveness rates were significantly better for the PTA patients. PTA is a feasible and cost-effective procedure in chronic critical ischaemia of the lower limb and should be the treatment of choice in the subset of patients where both procedures are possible.

Increased Urinary Excretion of Iohexol after Enteral Administration in Patients with Ileal Crohn's Disease A New Test for Disease Activity

Iohexol is a water-soluble contrast medium that is partly absorbed/permeated through mucosa of the small bowel and excreted unchanged in the urine. Iohexol was administered orally to 12 patients with Crohns disease of the ileum and to 10 healthy controls to measure its excretion in the urine. The location and activity of Crohns disease were determined by barium double-contrast radiography in all patients and by ileoscopy and biopsy in 9 patients. Iohexol concentrations in serum and 24-hour urine were measured using reversed phase high-performance liquid chromatography. Urinary excretion of iohexol was significantly greater in patients with active Crohns disease than in controls. We suggest this method as a new way of measuring Crohns disease activity and mucosal damage in the small bowel. Bowel inflammation and mucosal cell damage are strongly indicated if the iohexol excreted in the urine is over 1% of the oral intake.

Renal Papillary Necrosis in Patients With IDDM

Although diabetes mellitus is reported in 29% of patients with renal papillary necrosis (RPN), the frequency of RPN among patients with insulin-dependent diabetes mellitus (IDDM) has from autopsy studies been estimated to be only 4.4%. In vivo data on the prevalence of RPN in patients with IDDM have been lacking. We therefore studied the prevalence of RPN in 76 patients with long-standing IDDM and in 34 age-matched control subjects by intravenous urography. None of the control subjects showed radiographic signs of papillary necrosis. RPN was observed in 18 patients (23.7%); 15 were women (83.3%). Age and duration of diabetes was not different between patients with and without papillary necrosis, and there was no significant difference between the two groups regarding the prevalence of microangiopathic complications, i.e., proliferative retinopathy and diabetic nephropathy. Microscopic hematuria was three times more frequent in patients with than without RPN (44 vs. 16% P < .02). In addition, pyuria was reported in 40% of patients with papillary necrosis, and 61% of them gave a positive history of urinary tract infection compared to 16% (P < 05) and 32% (P < .02), respectively, in patients without papillary necrosis. It is concluded that RPN is a more frequent complication of long-standing IDDM than appreciated from autopsy studies, and being female and having a history of urinary tract infection are associated with an increased risk of RPN.

Reversed Diastolic Blood Flow at Duplex Doppler A Sign of Poor Prognosis in Renal Transplants

In 25 renal allografts out of 253 with graft dysfunction a reversed diastolic blood flow was observed at duplex ultrasonography during the first post-transplant month. Eleven grafts were lost and 14 survived. The cause of graft loss was arterial thrombosis (n = 1), venous thrombosis or obstruction (n = 4), steroid resistant acute rejection (n = 4) and acute tubular necrosis (ATN) (n = 2). The cause of graft dysfunction in the surviving grafts was ATN (n = 7) and acute allograft rejection (n = 7). Grafts with only peak-like or low velocity continuous diastolic flow reversal had a better prognosis (3 out of 15 were lost) than grafts with any other type of reversed flow pattern (8 out of 10 were lost). This difference was statistically significant (p < 0.01).

Reversed Diastolic Blood Flow at Duplex Doppler

In 25 renal allografts out of 253 with graft dysfunction a reversed diastolic blood flow was observed at duplex ultrasonography during the first post-transplant month. Eleven grafts were lost and 14 survived. The cause of graft loss was arterial thrombosis (n=1), venous thrombosis or obstruction (n=4), steroid resistant acute rejection (n=4) and acute tubular necrosis (ATN) (n=2). The cause of graft dysfunction in the surviving grafts was ATN (n=7) and acute allograft rejection (n=7). Grafts with only peak-like or low velocity continuous diastolic flow reversal had a better prognosis (3 out of 15 were lost) than grafts with any other type of reversed flow pattern (8 out of 10 were lost). This difference was statistically significant (p<0.01).

Iohexol and metrizoate in urography of insulin dependent patients.

A double blind urographic study with the ionic contrast medium metrizoate or the non-ionic medium iohexol was perfomed on 69 insulin dependent diabetic patients. Metrizoate caused 24 per cent and iohexol 11 per cent mild adverse reactions and metrizoate a significant decrease in creatinine clearance values. Thus iohexol turned out to be better tolerated by these diabetic patients than metrizoate. References