John Reidy

Transcatheter embolization in the treatment of coronary artery fistulas

Seven patients with a coronary artery fistula underwent percutaneous transcatheter embolization (five were male and two female; the age range was 2 to 67 years [median 17]). Three patients were symptomatic. The left to right shunt ranged from 1.6 to 2.6:1. In six patients, the fistula was an isolated congenital anomaly; in one, it was acquired. The fistula arose from branches of the left (n = 5) and right (n = 2) coronary arteries and drained to the right ventricle (n = 2), right atrium (n = 2), coronary sinus (n = 1), pulmonary artery (n = 1) and a bronchial artery (n = 1). Different embolization techniques were used to occlude eight feeding arteries. The embolization materials included a detachable balloon (n = 3), coaxial embolization with platinum microcoils (n = 3), a combination of detachable balloon and microcoil (n = 1) and standard steel coils (n = 1). Satisfactory occlusion was achieved in six patients. In one case, the valve of the detachable balloon was damaged, resulting in early balloon deflation and a residual fistula. There were no associated complications in any patient. Follow-up investigation by Doppler ultrasound or coronary angiography 4 months to 4 years later showed that permanent occlusion was achieved in all six patients in whom embolization was initially successful. Transcatheter embolization should be considered the treatment of choice for coronary artery fistulas.

Central Aortic Blood Pressure From Ultrasound Wall-Tracking of the Carotid Artery in Children Comparison With Invasive Measurements and Radial Tonometry

Differences between central aortic root (c) and peripheral (p) systolic blood pressure (SBP) may be particularly marked in children, but noninvasive methods for assessing cSBP in children have not been validated. We compared estimates of cSBP obtained from radiofrequency ultrasound wall tracking of the carotid artery (ART.LAB system) with that measured directly by a catheter in the aortic root at the time of arterial cannulation. Carotid waveforms were calibrated from invasive measurements of mean and diastolic pressures. In 9 children aged 10.5±5.0 years (mean±SD), cSBP obtained from carotid wall tracking was highly correlated with invasive measures of cSBP (r=0.99) with mean (±SD) difference 3.9±2.5 mmu2009Hg. Second, we compared values of cSBP obtained from the carotid with those obtained using noninvasive applanation tonometry at the radial artery and a radial-to-aortic transfer function (SphygmoCor). Both carotid and radial tonometric measurements were calibrated from the same peripheral mean and diastolic measurements of blood pressure obtained by sphygmomanometry. In 84 children aged 13.2±3.2 years, there was excellent agreement between the 2 methods (r=0.95; P<0.001) with mean difference 0.71±3.7 mmu2009Hg (95% confidence interval =−1.53 to 1.01). This invasive validation study confirms that cSBP as estimated by carotid wall tracking provides an acceptable measurement of true cSBP when calibration is from true mean and diastolic pressures. Close agreement of cSBP obtained by carotid wall tracking and radial tonometry suggests that these provide similar results when calibrated from the same peripheral blood pressure measurements.Differences between central aortic root (c) and peripheral (p) systolic blood pressure (SBP) may be particularly marked in children, but noninvasive methods for assessing cSBP in children have not been validated. We compared estimates of cSBP obtained from radiofrequency ultrasound wall tracking of the carotid artery (ART.LAB system) with that measured directly by a catheter in the aortic root at the time of arterial cannulation. Carotid waveforms were calibrated from invasive measurements of mean and diastolic pressures. In 9 children aged 10.5±5.0 years (mean±SD), cSBP obtained from carotid wall tracking was highly correlated with invasive measures of cSBP ( r =0.99) with mean (±SD) difference 3.9±2.5 mmu2009Hg. Second, we compared values of cSBP obtained from the carotid with those obtained using noninvasive applanation tonometry at the radial artery and a radial-to-aortic transfer function (SphygmoCor). Both carotid and radial tonometric measurements were calibrated from the same peripheral mean and diastolic measurements of blood pressure obtained by sphygmomanometry. In 84 children aged 13.2±3.2 years, there was excellent agreement between the 2 methods ( r =0.95; P <0.001) with mean difference 0.71±3.7 mmu2009Hg (95% confidence interval =−1.53 to 1.01). This invasive validation study confirms that cSBP as estimated by carotid wall tracking provides an acceptable measurement of true cSBP when calibration is from true mean and diastolic pressures. Close agreement of cSBP obtained by carotid wall tracking and radial tonometry suggests that these provide similar results when calibrated from the same peripheral blood pressure measurements.nn# Novelty and Significance {#article-title-25}

Malignant hypertension secondary to renovascular disease during infancy—an unusual cause of failure to thrive

An 11-month-old girl presented with a history of failure to thrive, vomiting, polydipsia, polyuria and visual inattention. She was found to have malignant hypertension due to unilateral renal artery stenosis. This was successfully treated with percutaneous transluminal balloon angioplasty. Nearly 10 years following this initial presentation, she remains normotensive on no anti-hypertensive medications.

Middle aortic syndrome—an 8-year story of pills, pretty balloons and struts

BackgroundMiddle aortic syndrome (MAS) is an uncommon cause of hypertension in children. The management of hypertension secondary to MAS frequently requires several anti-hypertensive medications along with endovascular and often surgical intervention.Case–Diagnosis/Treatment A 9-year-old boy presented with headaches and vomiting and was diagnosed with severe hypertension secondary to idiopathic MAS affecting a long segment of the abdominal aorta and left renal artery stenosis. Over the following 8 years his hypertension was successfully managed initially with percutaneous transluminal balloon angioplasty (PTA) of his left renal artery, followed by balloon dilatation of his abdominal aortic narrowing. He subsequently underwent abdominal aortic stent placement following failed repeat aortic balloon dilatation. Aged 17xa0years and 6xa0months he is now on a single anti-hypertensive agent with normal renal function and no evidence of target organ damage.ConclusionIn selected cases, MAS may be managed with PTA and stent placement with good long-term outcomes. Limited data on the use of PTA and stent insertion in children means that a structured approach to the management of refractory hypertension secondary to MAS remains elusive.

Response to Validation of Devices and Methods for Noninvasive Estimation of Central Aortic Blood Pressure in Children

We thank Papaioannou and colleagues for their interest in our study.1nnThey raise several related concerns regarding the influence of errors in the determination of peripheral blood pressure (BP; which our study did not address) on estimates of central blood pressure.2 We agree that this is a most important point.nnAll of the current noninvasive methods for measuring central blood pressure require calibration from peripheral BP measurements. However, errors in peripheral BP are transferred to central blood pressure, so that the difference between central and peripheral systolic blood pressure is affected little by peripheral calibration3 and the ratio of central to peripheral pulse pressure is not affected by calibration. Thus, if relative differences (eg, effects of treatment on central versus peripheral BP) are of interest, the issue of calibration is less critical. For absolute measurements …

Central Aortic Blood Pressure From Ultrasound Wall-Tracking of the Carotid Artery in Children

Differences between central aortic root (c) and peripheral (p) systolic blood pressure (SBP) may be particularly marked in children, but noninvasive methods for assessing cSBP in children have not been validated. We compared estimates of cSBP obtained from radiofrequency ultrasound wall tracking of the carotid artery (ART.LAB system) with that measured directly by a catheter in the aortic root at the time of arterial cannulation. Carotid waveforms were calibrated from invasive measurements of mean and diastolic pressures. In 9 children aged 10.5±5.0 years (mean±SD), cSBP obtained from carotid wall tracking was highly correlated with invasive measures of cSBP (r=0.99) with mean (±SD) difference 3.9±2.5 mmu2009Hg. Second, we compared values of cSBP obtained from the carotid with those obtained using noninvasive applanation tonometry at the radial artery and a radial-to-aortic transfer function (SphygmoCor). Both carotid and radial tonometric measurements were calibrated from the same peripheral mean and diastolic measurements of blood pressure obtained by sphygmomanometry. In 84 children aged 13.2±3.2 years, there was excellent agreement between the 2 methods (r=0.95; P<0.001) with mean difference 0.71±3.7 mmu2009Hg (95% confidence interval =−1.53 to 1.01). This invasive validation study confirms that cSBP as estimated by carotid wall tracking provides an acceptable measurement of true cSBP when calibration is from true mean and diastolic pressures. Close agreement of cSBP obtained by carotid wall tracking and radial tonometry suggests that these provide similar results when calibrated from the same peripheral blood pressure measurements.Differences between central aortic root (c) and peripheral (p) systolic blood pressure (SBP) may be particularly marked in children, but noninvasive methods for assessing cSBP in children have not been validated. We compared estimates of cSBP obtained from radiofrequency ultrasound wall tracking of the carotid artery (ART.LAB system) with that measured directly by a catheter in the aortic root at the time of arterial cannulation. Carotid waveforms were calibrated from invasive measurements of mean and diastolic pressures. In 9 children aged 10.5±5.0 years (mean±SD), cSBP obtained from carotid wall tracking was highly correlated with invasive measures of cSBP ( r =0.99) with mean (±SD) difference 3.9±2.5 mmu2009Hg. Second, we compared values of cSBP obtained from the carotid with those obtained using noninvasive applanation tonometry at the radial artery and a radial-to-aortic transfer function (SphygmoCor). Both carotid and radial tonometric measurements were calibrated from the same peripheral mean and diastolic measurements of blood pressure obtained by sphygmomanometry. In 84 children aged 13.2±3.2 years, there was excellent agreement between the 2 methods ( r =0.95; P <0.001) with mean difference 0.71±3.7 mmu2009Hg (95% confidence interval =−1.53 to 1.01). This invasive validation study confirms that cSBP as estimated by carotid wall tracking provides an acceptable measurement of true cSBP when calibration is from true mean and diastolic pressures. Close agreement of cSBP obtained by carotid wall tracking and radial tonometry suggests that these provide similar results when calibrated from the same peripheral blood pressure measurements.nn# Novelty and Significance {#article-title-25}

Central Aortic Blood Pressure From Ultrasound Wall-Tracking of the Carotid Artery in ChildrenNovelty and Significance

Differences between central aortic root (c) and peripheral (p) systolic blood pressure (SBP) may be particularly marked in children, but noninvasive methods for assessing cSBP in children have not been validated. We compared estimates of cSBP obtained from radiofrequency ultrasound wall tracking of the carotid artery (ART.LAB system) with that measured directly by a catheter in the aortic root at the time of arterial cannulation. Carotid waveforms were calibrated from invasive measurements of mean and diastolic pressures. In 9 children aged 10.5±5.0 years (mean±SD), cSBP obtained from carotid wall tracking was highly correlated with invasive measures of cSBP (r=0.99) with mean (±SD) difference 3.9±2.5 mmu2009Hg. Second, we compared values of cSBP obtained from the carotid with those obtained using noninvasive applanation tonometry at the radial artery and a radial-to-aortic transfer function (SphygmoCor). Both carotid and radial tonometric measurements were calibrated from the same peripheral mean and diastolic measurements of blood pressure obtained by sphygmomanometry. In 84 children aged 13.2±3.2 years, there was excellent agreement between the 2 methods (r=0.95; P<0.001) with mean difference 0.71±3.7 mmu2009Hg (95% confidence interval =−1.53 to 1.01). This invasive validation study confirms that cSBP as estimated by carotid wall tracking provides an acceptable measurement of true cSBP when calibration is from true mean and diastolic pressures. Close agreement of cSBP obtained by carotid wall tracking and radial tonometry suggests that these provide similar results when calibrated from the same peripheral blood pressure measurements.Differences between central aortic root (c) and peripheral (p) systolic blood pressure (SBP) may be particularly marked in children, but noninvasive methods for assessing cSBP in children have not been validated. We compared estimates of cSBP obtained from radiofrequency ultrasound wall tracking of the carotid artery (ART.LAB system) with that measured directly by a catheter in the aortic root at the time of arterial cannulation. Carotid waveforms were calibrated from invasive measurements of mean and diastolic pressures. In 9 children aged 10.5±5.0 years (mean±SD), cSBP obtained from carotid wall tracking was highly correlated with invasive measures of cSBP ( r =0.99) with mean (±SD) difference 3.9±2.5 mmu2009Hg. Second, we compared values of cSBP obtained from the carotid with those obtained using noninvasive applanation tonometry at the radial artery and a radial-to-aortic transfer function (SphygmoCor). Both carotid and radial tonometric measurements were calibrated from the same peripheral mean and diastolic measurements of blood pressure obtained by sphygmomanometry. In 84 children aged 13.2±3.2 years, there was excellent agreement between the 2 methods ( r =0.95; P <0.001) with mean difference 0.71±3.7 mmu2009Hg (95% confidence interval =−1.53 to 1.01). This invasive validation study confirms that cSBP as estimated by carotid wall tracking provides an acceptable measurement of true cSBP when calibration is from true mean and diastolic pressures. Close agreement of cSBP obtained by carotid wall tracking and radial tonometry suggests that these provide similar results when calibrated from the same peripheral blood pressure measurements.nn# Novelty and Significance {#article-title-25}

Central Aortic Blood Pressure From Ultrasound Wall-Tracking of the Carotid Artery in ChildrenNovelty and Significance: Comparison With Invasive Measurements and Radial Tonometry

Differences between central aortic root (c) and peripheral (p) systolic blood pressure (SBP) may be particularly marked in children, but noninvasive methods for assessing cSBP in children have not been validated. We compared estimates of cSBP obtained from radiofrequency ultrasound wall tracking of the carotid artery (ART.LAB system) with that measured directly by a catheter in the aortic root at the time of arterial cannulation. Carotid waveforms were calibrated from invasive measurements of mean and diastolic pressures. In 9 children aged 10.5±5.0 years (mean±SD), cSBP obtained from carotid wall tracking was highly correlated with invasive measures of cSBP (r=0.99) with mean (±SD) difference 3.9±2.5 mmu2009Hg. Second, we compared values of cSBP obtained from the carotid with those obtained using noninvasive applanation tonometry at the radial artery and a radial-to-aortic transfer function (SphygmoCor). Both carotid and radial tonometric measurements were calibrated from the same peripheral mean and diastolic measurements of blood pressure obtained by sphygmomanometry. In 84 children aged 13.2±3.2 years, there was excellent agreement between the 2 methods (r=0.95; P<0.001) with mean difference 0.71±3.7 mmu2009Hg (95% confidence interval =−1.53 to 1.01). This invasive validation study confirms that cSBP as estimated by carotid wall tracking provides an acceptable measurement of true cSBP when calibration is from true mean and diastolic pressures. Close agreement of cSBP obtained by carotid wall tracking and radial tonometry suggests that these provide similar results when calibrated from the same peripheral blood pressure measurements.Differences between central aortic root (c) and peripheral (p) systolic blood pressure (SBP) may be particularly marked in children, but noninvasive methods for assessing cSBP in children have not been validated. We compared estimates of cSBP obtained from radiofrequency ultrasound wall tracking of the carotid artery (ART.LAB system) with that measured directly by a catheter in the aortic root at the time of arterial cannulation. Carotid waveforms were calibrated from invasive measurements of mean and diastolic pressures. In 9 children aged 10.5±5.0 years (mean±SD), cSBP obtained from carotid wall tracking was highly correlated with invasive measures of cSBP ( r =0.99) with mean (±SD) difference 3.9±2.5 mmu2009Hg. Second, we compared values of cSBP obtained from the carotid with those obtained using noninvasive applanation tonometry at the radial artery and a radial-to-aortic transfer function (SphygmoCor). Both carotid and radial tonometric measurements were calibrated from the same peripheral mean and diastolic measurements of blood pressure obtained by sphygmomanometry. In 84 children aged 13.2±3.2 years, there was excellent agreement between the 2 methods ( r =0.95; P <0.001) with mean difference 0.71±3.7 mmu2009Hg (95% confidence interval =−1.53 to 1.01). This invasive validation study confirms that cSBP as estimated by carotid wall tracking provides an acceptable measurement of true cSBP when calibration is from true mean and diastolic pressures. Close agreement of cSBP obtained by carotid wall tracking and radial tonometry suggests that these provide similar results when calibrated from the same peripheral blood pressure measurements.nn# Novelty and Significance {#article-title-25}