Victor G. Millan

Percutaneous transluminal renal angioplasty in management of atherosclerotic renovascular hypertension: results in 100 patients.

The long-term effect of percutaneous transluminal renal angioplasty (PTRA) on blood pressure and renal function was assessed in 100 consecutive patients with atherosclerotic renovascular hypertension. Technical success rates (complete plus partial) of a first PTRA averaged 76.2%, 74.1%, and 67.7% for the unilateral (n=42), bilateral (n=27), and solitary (n=31) groups, respectively. Of the technical successes, 59% (43/73) experienced sustained blood pressure benefit (mostly amelioration) during a mean follow-up period of 29 months. Rates of blood pressure benefit were similar in the three groups. Ostial lesions comprised the majority of blood pressure benefit failures. Repeat angioplasty in 14 patients resulted in a 71% technical success rate and a 50% blood pressure benefit rate during a mean follow-up period of 22 months. Long-term stability of mean serum creatinine level was observed after technically successful angioplasty in all three groups. Acute renal insufficiency, which was reversible in all but one patient, complicated 26% of the procedures. Mechanical complications occurred in 14% (20/145) of the arteries acted on; surgical intervention was required in five patients. The mortality rate was 2%. These results suggest that angioplasty is effective in both the long-term management of renovascular hypertension and the preservation of renal function hi a large fraction of patients with atherosclerotic renovascular hypertension.

Therapeutic Bilateral Renal Infarction in End-Stage Renal Disease

Bilateral nephrectomy, which has been performed in patients with end-stage renal disease for a variety of reasons, has a substantial morbidity and an appreciable mortality.1 2 3 We recently used th...

Percutaneous transluminal renal angioplasty in nonatherosclerotic renovascular hypertension. Long-term results.

Nineteen stenotic arteries in 16 patients with severe renovascular hypertension of nonatherosclerotic nature (fibromuscular dysplasia in 13, neurofibromatosis in 3) were treated with percutaneous transluminal renal angioplasty. The procedure was technically successful in 12 of 14 (86%) stenoses in the fibromuscular dysplasia subgroup but in only one of five (20%) lesions in the neurofibromatosis subgroup. Hypertension was abated (3 patients) or disappeared (8 patients) in 11 of the 12 (92%) patients with fibromuscular dysplasia who had a technically successful angioplasty, an effect that was sustained at latest follow-up (avg, 37 mo; range, 10-73 mo). The only complication encountered was a retroperitoneal hematoma that resolved uneventfully. Coupled with those from other centers, the results of the present study indicate that angioplasty offers a strong potential for curability in patients with renovascular hypertension caused by fibromuscular dysplasia and that percutaneous transluminal renal angioplasty should be considered the treatment of choice for the initial management of all patients with fibromuscular renovascular hypertension.

Infrarenal aortic occlusion: A reassessment of surgical indications☆

Citing a high incidence of proximal propagation of aortic thrombosis, several authors have advocated aortic reconstruction for all patients with infrarenal aortic occlusion irrespective of their preoperative symptoms and potential operative risks. To test this thesis, the records and follow-up data of 38 patients seen at our institution between 1965 and 1982 with infrarenal aortic occlusion were analyzed. Twenty-four of the 38 patients were treated surgically (Group I); 16 (42 percent) had an aortobifemoral graft and 8 (21 percent) had an axillofemoral bypass graft. When the 14 patients who did not have surgery (Group II) and the 8 patients who had an axillofemoral graft were combined, 22 patients (58 percent) did not have aortic reconstruction (Group III), thus the aortic thrombus was left in situ. There was no significant difference in cumulative survival between the three groups at 4 year follow-up. Of 13 patients in Group III who were followed for more than 6 months (mean 48 months), none died from proximal propagation of aortic thrombosis. The decision for surgical intervention in patients with distal aortic occlusion should be arrived at, as in other patients with aortoiliac occlusive disease, by weighing preoperative symptoms and operative risks and not primarily by the level of risk of proximal propagation of thrombosis.

Percutaneous transluminal renal angioplasty in the treatment of unilateral atherosclerotic renovascular hypertension

Thirteen patients with severe, unilateral, atherosclerotic renovascular hypertension were treated with percutaneous transluminal renal angioplasty. The procedure produced wide patency of the stenosed vessel in 10 patients and partial dilatation in the remaining three. All patients exhibited a beneficial response in their hypertension; at latest follow-up, ranging from two to eighteen months, all patients were normotensive, four in the complete absence of any antihypertensive medication and the remaining nine while taking substantially less medication than before. Suppression of the differential renal-vein renin ratio was also documented. In one patient follow-up angiography, performed after seven months because of deterioration in renal function, revealed an occluded renal artery. Complications that were encountered included two small, segmental renal infarcts, three episodes of nonoliguric, presumably radiocontrast-induced, acute renal insufficiency and a soft-tissue hematoma that occurred one month after the procedure and was due to excessive anticoagulation. Percutaneous transluminal renal angioplasty may be an effective modality in the management of unilateral, atherosclerotic renovascular hypertension.

Localization of Occult Insulinoma by Super-Selective Pancreatic Venous Sampling for Insulin Assay through Percutaneous Transhepatic Catheterization

Preoperative localization of insulinomas by arteriography is successful only 66% of the time. With small tumors, intraoperative localization is usually unsuccessful also. Because surgical morbidity and mortality are increased greatly when major, blind, pancreatic resections or reoperations are performed, additional preoperative localization procedures are needed. We now report the successful localization of an occult insulinoma by means of blood sampling for insulin radioimmunoassay, obtained by selective pancreatic vein sampling through percutaneous transhepatic catheterization. Our patient had symptoms of fasting hypoglycemia for 11 months. Routine studies were normal and two fasting plasma glucose concentrations were 34 and 16 mg/dl to correspond with insulin values of 33 and 75 μU/ml. Celiac arteriography was normal. Percutaneous transhepatic portal and pancreatic venous catheterization revealed insulin concentrations (μU/ml) of between 23 and 36 in portal and splenic veins, 17 in the short, gastric vein, 17 in the dorsal pancreatic vein, 19 in the superior, mesenteric vein, and 61 and 288 in two pancreatic magna veins draining the tail. An insulinoma of 2 × 3 cm was resected from the tail. On the basis of our experience with this patient, it is clear that selective venous sampling may facilitate the localization of occult insulinomas at surgery and thereby avoid extensive, blind, pancreatic resections and the need for reoperation.

Superiority of Balloon Occlusion Arteriography to Reactive Hyperemic Arteriography in Visualization of Distal Lower Limb Vessels

Balloon occlusion arteriography was performed in 38 lower limbs; reactive hyperemic arteriography was also performed in 16 of these limbs. To assess the safety and utility of this technique the balloon occlusion arteriograms of all 38 patients were reviewed retrospectively by a vascular surgeon and vascular radiologist who were unaware of the patients identity and ultimate treatment. After the arteriograms were reviewed and the outflow vessels identified, a decision was made regarding operability and optimal recipient vessel for distal bypass. Twenty-two of the 38 patients underwent balloon occlusion arteriography only, and 21/22 (95.5%) of these patients only had studies deemed adequate for surgical planning. Twelve of the 16 (75%) patients underwent both reactive hyperemic arteriography and balloon occlusion arteriography; potential distal outflow vessels not seen on reactive hyperemic arteriograms were observed on balloon occlusion arteriograms. In only 4/16 (25%) patients the balloon occlusion arteriograms did not yield additional information. No complications were associated with this technique. Approximately 8.5 g of iodine per run is used for balloon occlusion arteriography compared with approximately 37 g of iodine per run for reactive hyperemic arteriography. Balloon occlusion arteriography is a safe and accurate adjunctive technique that can be used when identification of lower limb vessels is critical.

Diagnostic Evaluation of Hirsutism in Women by Selective Bilateral Adrenal and Ovarian Venous Catheterization*†*Supported in part by General Clinical Research Centers Branch Grant RR-0054.†Presented at the Thirty-Fourth Annual Meeting of The American Fertility Society, March 29 to April 1, 1978, New Orleans, La.

To determine the most significant secretory source of their androgens, 13 hirsute nonvirilized women underwent selective bilateral adrenal and ovarian venous catheterization to obtain effluent blood for the assay of testosterone and delta4-androstenedione. In three patients the testosterone and delta4-androstenedione gradients were significantly greater in the adrenal venous effluents. Testosterone and delta4-androstenedione gradients were significantly greater in the ovarian venous effluents in four patients. In six patients there were no significant differences in the testosterone gradients between the adrenal and ovarian venous effluents. The delta4-androstenedione gradients were greater in the adrenal venous effluents in three of these patients, greater in the ovarian venous effluents in one, and not significantly different in two of these patients. The fact that the measurement of urinary 17-ketosteroid excretion, the suppressibility of peripheral plasma androgens with dexamethasone, and the stimulation of peripheral plasma androgens with human chorionic gonadotropin correlated poorly with the selective catheterization data suggests that the former modalities are imprecise in the diagnostic evaluation of hirsutism in women.