Nicholas P. Tsapatsaris

Renal Revascularization to Preserve and Restore Renal Function

A total of 97 patients underwent 107 renal revascularization procedures for restoration and preservation of renal function. Of the 4 groups of high risk surgical patients that emerged an overall successful outcome was achieved in 83%, with a 6% mortality rate and an 11% morbidity rate. Renal revascularization for restoration and preservation of renal function can be performed safely with good results. The preoperative serum creatinine level was not predictive of the surgical outcome. Alternative bypass procedures are preferred.

Increased Prevalence of Migraine and Chest Pain in Patients with Primary Raynaud Disease

OBJECTIVE To investigate the prevalence of headaches and recurrent chest pain in patients with primary Raynaud disease. DESIGN Postal survey. SETTING Raynaud disease clinic at the Lahey Clinic Medical Center, a tertiary care hospital. PARTICIPANTS A consecutive series of 120 patients with primary Raynaud disease who had been observed for at least 2 years, 97 of whom received and 93 of whom completed the questionnaire, and a control group of 93 age- and sex-matched hospital employees without Raynaud phenomenon. RESULTS Migraine was diagnosed in 57 (61%) patients with primary Raynaud disease and in 21 (23%) of the control group (odds ratio, 5.4; 95% CI, 2.8 to 10.3). Migraine with aura and migraine without aura were more common in patients with Raynaud disease than in the control subjects (27% compared with 5%; P less than 0.001 and 34% compared with 17%; P = 0.008, respectively). Nonmigrainous headaches were more common in the control group (51% compared with 25%; P = 0.003). Chest pains were reported by 44 (47%) of the patients with Raynaud disease and by 15 (16%) of the control group (odds ratio, 4.4; CI, 2.4 to 9.3). Chest pains were more frequently reported by patients with Raynaud disease who had migraine (34 of 57, 60%) than by patients without migraine (10 of 36, 28%; P = 0.003). CONCLUSIONS An increased prevalence of migraine was found in patients with primary Raynaud disease. Chest pain, often diagnosed as musculoskeletal or nonspecific, was common in patients with primary Raynaud phenomenon, especially in patients who had coexisting migraine.

Role of digital artery adrenoceptors in Raynaud's disease.

Raynauds disease is characterized by excessive cutaneous vasoconstriction in response to ambient cold. A functional disturbance in the local regulation of digital vasomotion has been proposed. The purpose of this study was to determine whether there is an alteration in the postjunctional adrenergic receptors in the digital circulation of patients with Raynauds disease. Furthermore, we sought to determine whether this abnormality was responsible for the excessive cold-induced vasoconstriction in these patients. Finger blood flow was measured by strain-gauge venous occlusion plethysmography in 10 patients with Raynauds disease and in 10 normal volunteers in a 22 °C room. Measurements of finger blood flow and mean systemic arterial pressure were made during intra-arterial infusions of the alpha1-adrenergic antagonist, prazosjn, or the alpha2-adrenergic antagonist, yohimbine, at room temperature and during local cooling of the hand. Basal finger blood flow in normal subjects was significantly greater than that of patients (8.6 ± 2.7 vs 1.7 ± 0.5 ml/100 ml per min; normal vs Raynauds subjects; p < 0.05). In normal subjects, either prazosin or yohimbine induced dose-dependent increases in finger blood flow. The maximal increase in finger blood flow induced by prazosin was significantly greater than that in response to yohimbine (29.2 ± 10.1 vs 2.8 ± 2.1 ml/100 ml per min; prazosin vs yohimbine; p < 0.05). By contrast, in the Raynauds patients, prazosin or yohimbine induced maximal increases in finger blood flow that were not significant (7.1 ± 1.8 vs 5.0 ± 2.2 ml/100 ml per min; prazosin vs yohimbine; p = NS). The response to prazosin in Raynauds patients was significantly less than that of the normal volunteers (p < 0.05). In normal subjects, during intra-arterial infusion of vehicle alone, cooling induced a 52.6 ± 5.8% reduction in finger blood flow. This cold-induced vasoconstriction was blunted, but not qualitatively altered, by either adrenergic antagonist. In the Raynauds patients, during the intra-arterial infusion of the vehicle, cooling induced a 68.2 ± 7.8% reduction in finger blood flow. Infusion of either adrenergic antagonist blunted, but did not qualitatively alter, the response to cold. Finger blood flow is less in patients with Raynauds disease than in normal subjects when studied in a 22 °C room. In normal subjects, postjunctional alpha1-adrenergic receptors appear to predominate in the control of digital vasoconstriction. Postjunctional alpha1- and alpha2- adrenoceptors play an equal role in adrenergic regulation of finger blood flow in patients with Raynauds disease. In both normal and Raynauds subjects, selective antagonism of alpha1- or alpha2-adrenergic receptors does not abolish local cold-induced vasoconstriction. Therefore, it is likely that a nonadrenergic mechanism contributes to local cold-induced vasoconstriction.

Images in vascular medicine Hypothenar hammer syndrome

A 31-year-old carpenter was evaluated for the recent onset of coolness and pallor of the right fourth finger. He has used the palm of his right hand to drive tacks for many years. His family and past medical history was unremarkable. He took no medication. On physical examination, he had normal brachial, radial, and ulnar pulses in both arms. Allen’s test with right radial artery compression revealed mild slowness of capillary refill in the fourth and fifth fingers. Angiography of the right hand revealed a tortuous, redundant, and ectatic ulnar artery forming a small aneurysm (open arrows on Panels A and B), with abrupt occlusion of its distal distribution over the fourth and fifth digits and intraluminal filling defects (solid arrows in Panel A) consistent with an embolic process. This condition, hypothenar hammer syndrome, is caused by repetitive blunt trauma to the hypothenar eminence and consequently to a vulnerable portion of the ulnar artery over the

Management of Hypertension in the Perioperative Period

This chapter focuses on common clinical challenges in hypertension management faced by intensive care providers. They include the treatment of patients with preexisting hypertension who cannot take oral medications, the treatment of hypertensive urgencies and emergencies, and the use of specific antihypertensive medications. The challenge for the clinician is not the lowering of blood pressure with parenteral drugs, but rather the more difficult questions about in whom to use them and what goals to achieve. We have learned a great deal about the treatment of chronic hypertension and the attendant long-term reduction in cardiovascular morbidity and mortality associated with effective blood pressure lowering. Currently, the definition of hypertension, goals for treatment, and benefits of therapy have been established in numerous clinical trials, and widely disseminated in evidence-based consensus documents to practicing physicians. Unfortunately, these goals do not necessarily apply to acutely ill surgical intensive care unit patients, some of whom benefit and some of whom are harmed from blood pressure lowering. Thus, the management of hypertension in the intensive care unit is highly individualized. There are few, if any, prospective trials regarding choice of antihypertensive medications in this setting. Recommendations are generally on the basis of consensus opinion, customary use, extrapolation from animal models, and common sense application of physiologic principles.

Diseases of the Aorta and Arterial Tree

Diseases of the aorta and arterial tree in the elderly are common and most often are complications of atherosclerosis. These conditions frequently are potent markers of severe coronary artery disease and should prompt careful cardiac evaluation. Although a single pathologic disease is present, clinical manifestations are diverse and depend on the particular expression of atherosclerosis (aneurysm formation, stenosis, and occlusion or embolism) and on its specific anatomic location (thoracic aorta and its cervical and intracranial branches, or abdominal aorta and its visceral and extremity branches).

Diseases of the Aorta and Arterial Tree in the Elderly

Diseases of the aorta and arterial tree in the elderly are common and most often are complications of atherosclerosis. These conditions frequently are potent markers of severe coronary artery disease and should prompt careful cardiac evaluation. When a single pathologic disease is present, clinical manifestations are diverse and depend on the particular expression of atherosclerosis—aneurysm formation, stenosis, and occlusion or embolism—and on its specific anatomic location thoracic aorta and its cervical and intracranial branches or abdominal aorta and its visceral and extremity branches.