[OS 213] LEC 15 Surgery for Peripheral Vascular Diseases I (B)

OS 213: Human Disease and Treatment 3(Circulation and Respiration) LEC 15: SURGERY FOR PERIPHERAL VASCULAR DISEASES I OUTLINE Aneurysmal Diseases A. Aneurysm B. Risk Factors C. Natural History D. Diagnosis E. Indications of Repair F. Treatment Options II. Carotid Artery Diseases A. Introduction B. Clinical Syndromes C. Natural History D. Diagnosis E. Indications of Repair F. Treatment G. Complications H. Intervention I. Summary 6. III.Renovascular Hypertension A. Introduction B. Pathophysiology C. Clinical Clues D. Diagnostics E. Treatment F. Surgery vs. Stenting G. Summary Objectives: To discuss the clinical presentation, diagnosis and treatment of common diseases involving the aorta and its branches, as seen in clinical practice  To review clinical data supporting use of these diagnostic strategies This trans is copied entirely from Class 2015 trans and edited to our class trans format. Suspension of classes ang salarin!!!  ANEURYSMAL DISEASES ANEURYSM High Blood Pressure (BP): Can accelerate known aneurysms and contribute to formation of new ones NATURAL HISTORY INTRODUCTION  The average growth rate of an AAA is 3.3 to 4 mm every year.  UK AAA screening (1984-2007) ○ Median AAA diameter= 35 mm ○ Median growth (3.2 yrs)= 9 mm  Aneurysms are like balloons; as the diameter increases, the wall becomes thinner and weaker.  The increase in diameter will increase the risk of rupture.  In practice, when the aneurysm is <5 cm in diameter, surgery can be indicated. This value is true for Filipinos (2014). MORTALITY   Defined as a pathologic dilatation of a segment of a blood vessel (from Harrison’s)  Most commonly located in the abdominal aorta (71%) specifically aorto-iliac area  75% of atherosclerotic aneurysms occur in the distal abdominal aorta below the renal arteries.  The focus of this discussion will be on abdominal aortic aneurysms (AAA), also called aorto-iliac aneurysms      62% of patients with ruptured AAA never reach the hospital alive; 48% of those who reach the hospital don’t get out of the hospital alive (Operative Mortality); Without surgery, the overall mortality rate is roughly 80%; Mortality for elective repair is 2-5%; Thus, Early Diagnosis and expeditious elective repair of intact AAA provides the best chance for good outcome. DIAGNOSIS Figure 1. Abdominal aortic aneurysm (AAA). True aneurysm: involves all three layers of the vessel wall Pseudoaneurysm: intimal and medial layers are disrupted and the dilatation is lined by adventitia only and sometimes by perivascular clot RISK FACTORS  Atherosclerosis is the leading cause of aneurysms. 1. Age: increased incidence in elderly population usually due to atherosclerosis; in young patients – think of other etiology such as Marfan syndrome and syphilis 2. Smoking: Incidence increases much higher with age in smokers 3. Family history: 15-20% of patients have a family history of aortic aneurysm 4. COPD: Associated elastin degradation and smoking 5. High Cholesterol Bea, Anna, <JC> says HISTORY  frequently asymptomatic • Symptoms which may be signs of beginning rupture include: o abdominal mass or fullness o Pain/ tenderness radiating to the groin, back legs o Low back pain o Abdominal rigidity o Fainting/ light-headedness o Excessive thirst and vomiting PHYSICAL EXAMINATION  Usually presents as a pulsatile mass on abdominal examination (Difficult to diagnose in obese patients. May be confused with a transmitted pulse.)  Pulsatile mass: usually cephalad to the umbilicus and when fingers are placed on its lateral walls, it will demonstrate lateral and anteroposterior movement to differentiate it from a solid tumor transmitting the pulsation. (De Gowin) o Pulsatile mass exhibits horizontal movement. (Fingers will move up and down and away from each other) o Transmitted pulses exhibit vertical movement. (Both fingers will move up and down)  Width of the pulsatile mass and not the degree of pulsatility should be measured IMPORTANT: No pulsation, however forcible; no thrill, however intense; no bruit, however loud, UPCM 2016: XVI, Walang Kapantay! 1 of 8 5 cm is the threshold for surgical intervention  • o o • o o o o o Figure 2.5.Sir William Osler DIAGNOSTIC TESTS-PLAIN ABDOMINAL X-RAY  Most of the time you cannot see aneurysm in CXR.  Not routinely done because sensitivity is low  May produce several differentials . <JC> says Patients were randomized into two groups: those who would have an early surgery and those who would have the surgery later  Found that there was no significant difference in the mortality rates of the two groups after 5 years of follow-up In practice: When AAA is 4.5.5 cm wide.g.  AP and lateral views are taken to see the outline of the aorta.useful for preoperative planning  Disadvantages: o Operator dependent o Some aneurysms may be extremely difficult to detect o Contraindicated in obese individuals and patients with a full stomach o Difficult to get measurements for tortuous vessels DIAGNOSTIC TESTS-COMPUTER TOMOGRAPHY SCAN (CT SCAN)  Gold standard for detecting AAAs  Also provides all the information provided by an ultrasound  The difference: it can use this information to reconstruct the aneurysm and its relations in 3D  Can also show neighboring structures that can help tell what the patient is feeling  Versus the ultrasound: o Delivers a more anatomically accurate image o Less prone to reader error o More expensive INDICATIONS FOR REPAIR   Not all AAA patients need surgical repair Decision to intervene is based on randomized controlled trials (RCT’s) done a few years ago  Two predominant studies (RCT’s) o Aneurysm Detection And Management (ADAM) of the US o UK Small Aneurysm Trial (UKSAT) of the UK o RCT Results and Findings  Designs are basically the same  Patients employed were diagnosed cases of AAA’s which are 4.more visible DIAGNOSTIC TESTS-ULTRASOUND (DUPLEX UTZ)  Advantages: Highly accurate.0.0 . Other risk factors include:  strong family history  irregular shape (saccular/eccentric)  hypertension  COPD  Filipino Are these criteria applicable to Filipinos? Tests were done on Caucasians In the Philippines. surgery/repair is usually indicated Problems encountered: 90% of the patients are male: women should have a lower size threshold Rapidly growing aneurysms? (>0. organs and lesions can be visualized . Aorta is clamped on either end of the aneurysm 5. Walang Kapantay! 2 of 8 . Aneurysm is located 4. cost-effective. Starts with a midline laparotomy (most common. Anna. incision from xiphoid process to symphysis pubis) 2.4 cm wide: it can be safely observed without significant risk of rupture When AAA is more than 5. Aorta is exposed 3.e. Algorithm for evaluation and management of abdominal aortic aneurysm. Aorta is opened to expose the aneurysm 6. intestinal obstruction  May be helpful if the aneurysm is calcified . TREATMENT OPTIONS OPEN SURGERY  Midline laparotomy  Retroperitoneal  Laparoscopy assisted  Mini laparotomy  Most common forms of surgical intervention (2014)  Procedure 1.4 cm in diameter Bea.OS 213: Human Disease and Treatment 3 (Circulation and Respiration) LEC 15: SURGERY FOR PERIPHERAL VASCULAR DISEASES I  singly or together can justify the diagnosis of an aneurysm of the abdominal aorta The presence of a palpable expansile tumor is the only sure indication of an AAA.5 cm a year) 5cm aneurysm has a risk of <1 % of rupture. Lesion is taken out and the vessel is repaired with a graft  A major operation done by a vascular surgeon UPCM 2016: XVI. no radiation and is readily available  Gives the following information (2014): o Involvement of iliac artery o Absolute diameter of the aneurysm can be determined o Effective lumen can be measured o Thrombi may be visualized o Relationship of aneurysm with nearby vessels (iliac and renal arteries). . Bea. 5. it will eventually shrink o Instances when the aneurysm doesn’t shrink:  Blood flow from lumbar vessels is not excluded (usually this is somehow blocked in open surgeries) . Anna. <JC> says  <2014> says:  Anatomic and device constraints o Diameter (Depending on the neck of aneurysm.0 cm in diameter?  PIVOTAL trial (Ouriel et al. the mortality & morbidity are high  Co-morbidities if present. 4. Walang Kapantay! 3 of 8 .. Endovascular Surgery II The catheter has now reached the AAA and the graft is deployed. if you block the flow above the aneurysm. 1. graft is oversized by 10-15% = can be a floating graft) o Radial force  Mechanism o Since aneurysm is due to systolic flow. Common Grafts in Current Use Different mechanisms entail variations in characteristics and specifications  In Phil. Open Surgery Figure 6. 2011) (Comparison of Surveillance vs Aortic Endografting for Small Aneurysm Repair) No significant difference in mortality 1/6 patients lose feasibility for EVAR (Endovascular repair) o o o o UPCM 2016: XVI. only 2 small incisions  Has been increasingly used in the past 10 years  Talent graft – most commonly used in the Phils.OS 213: Human Disease and Treatment 3 (Circulation and Respiration) LEC 15: SURGERY FOR PERIPHERAL VASCULAR DISEASES I Figure 5. The graft is deployed and the catheter is taken out. will complicate the surgery  Provide proximal control of the AAA  Blood loss in surgery – 2 Liters  Hospital stay. however.. 2. hence..8 yrs (OVER) 6. 3. Exclude the aneurysm sac. 2010 (Positive Impact of EndoVascular Options for Treating Aneurysm earLy)  CAESAR trial (Cao et al.  Major operation which entails at least one week in the hospital and may even involve a stay in the ICU  Statistics o 10% morbidity rate o 2-5% mortality rate Note. Figure 4.0-5.type I endoleak Advantages (Short Outcome)  RelativeTerm Contraindications Less blood losso Young patients (because after Faster recovery. that most patients who undergo the surgery are elderly. the catheter enters the site of the aneurysm.1 week  Two options: GRAFT or CLAMP replacement Figure 3.  Procedure A small incision is made in the groin area The femoral artery is located and punctured A catheter which contains the graft in an enclosed vessel is inserted through the femoral artery. Guided by an angiogram. Endovascular Surgery Note the site of catheter insertion.type II endoleak  Poor seal . Talent graft most commonly used ENDOVASCULAR SURGERY  Relatively novel way of treating AAA’s  No midline incision.0 yrs (EVAR 2) o No significant difference in major morbidity and mortality o Higher graft related complications and reinterventions with endovascular repair OVER Trial JAMA 2009 EVAR 2 Trial N Eng J Med 2010  Early Repair for Small AAA? o AAA 4. shorter ICU stay Reduction in early major adverse events Significantly reduced 30 day mortality (usually due to cardiac problems) EVAR 1 Trial Lancet 2004 DREAM Trial N Eng J Med 2004 OVER Trial JAMA 2009  Long Term Outcome o Median follow-up: 1. if less than it is a relative contraindication  Presence of aberrant vessels Large Inferior Mesenteric Artery (IMA) Accessory Renal Artery (if there are accessory renal arteries and you block the aortic aneurysm. <JC> says          Stroke. atheroma. also another relative contraindication. whose outer diameter is 6 mm Hence. risk increases with the plaque density o According to increased risk of TIA & stroke: Calcified < Dense < Soft Plaque Therefore: soft plaque is WORSE than calcified plaque o There is always forward blood flow. UPCM 2016: XVI. and laboratory studies including brain imaging are used to support the diagnosis. The risk of getting stroke increases with a history of stroke incidents Mortality from initial stroke is 15-35%.to areas supplied by them. patients are asymptomatic  Transient Ischemic Attacks (TIA’s) are common o Definition: focal neurologic deficit which disappears within 24 hours o Pathophysiology: TIA results from a failure of perfusion due to hemodynamic causes or microembolism.8 – 20% 30% of patients die 30% survive without sequelae 30% survive and are left with a disability that amounts to a high cost CLINICAL SYMPTOMS  Generally. Soft plaques may be dislodged and embolize. The definition of stroke is clinical. is defined by this abrupt onset of a neurologic deficit that is attributable to a focal vascular cause. (Harrison’s) Stroke is the leading cause of serious long-term disability. you will also exclude blood flow to these arteries and cause infarcts colonic ischemia . Less common causes are in situ arterial thrombosis.5 mm Iliac: 2. Walang Kapantay! 4 of 8 .)  Anatomic selection criteria absolutely important for EVAR  Not all patients with AAA are candidates for EVAR ADDITIONAL INFO  o o o o Is the 5 mm threshold applicable for all aneurysms? NO.  Access Smallest graft has French 18. The symptoms reflect the area of ischemia. 6 mm vessel to accommodate delivery vessel) Not for kids and women No calcified or stenotic arteries  Iliac Vessels The angle between aorta and common iliac arteries should be at least 90º. or a cerebrovascular accident. arterial dissection and venous sinus thrombosis. 5 mm – just for abdominal aorta Popliteal: 2.5 cm Diameter should be at least 28 mm Having a reversed cone shape neck is also a RC No thrombus. or calcifications (to allow the graft to attach and to avoid leakage into the aneurysm)  SUMMARY      Early diagnosis is beneficial Risk for rupture when the AAA (<5 mm) is low. 2013)  Neck angulated Difficult to maneuver the device if less than <60°.5 mm Thoracic: 6 mm CAROTID ARTERY DISEASES INTRODUCTION Bea. vessel must be at least 7 mm for the device to enter (because a very thick delivery sheath is going to be used into the aorta. Mortality of elective repair is low (3-5% in Phils) Decision for repair must be individualized EVAR is a viable alternative treatment of AAA (Always take note of the anatomical criteria. Anna. it is a very costly disease. described as “curtain fall” over eyes o Due to emboli (usually cholesterol emboli) which go into ophthalmic artery and may cause calcification  Stroke NATURAL HISTORY Risk of Stroke  Presence of symptoms  Degree of stenosis (higher degree of stenosis. 60° angle is necessary to create a good proximal seal Length should be at least 1.000 dollars – cost of endovascular repair graft) Anatomic Criteria o Not all patients are candidates for EVAR o A criterion is used to ascertain whether a person is a possible candidate for EVAR. Carotid artery atherosclerosis is a major factor in carotid artery disease Risk for recurrence is 4. (De Gowin) o The patient returns to pre-TIA neurological state within the day  Reversible Ischemic Neurologic Deficit (RIND) o Lasts more than 24 hours o Takes at least a week for the patient to return to his or her pre-ischemic neurological state  Crescendo TIA o Multiple TIA’s occurring in a short period of time o Connotative of high grade stenoses  Amaurosis fugax o Pathophysiology: Cholesterol emboli from ruptured atherosclerotic plaques in the common or internal carotid artery transiently occlude flow to the retinal artery (De Gowin) o Evidence of ischemia seen in the ophthalmic arteries o Presents as fleeting blindness or monocular loss of vision.OS 213: Human Disease and Treatment 3 (Circulation and Respiration) LEC 15: SURGERY FOR PERIPHERAL VASCULAR DISEASES I Not all patients with AAA are candidates for EVAR (10. the higher risk of stroke)  Plaque density o For asymptomatic patients. and embolic material  Bruit o An obstruction causes turbulent blood flow that is heard as a bruit upon auscultation o Extends into diastole in high-grade lesions. Walang Kapantay! 5 of 8 . and therefore. then the bruit is just an extension of the precordial murmur. Anna. plaque density. carotid) o Combines the ultrasound with the Doppler to produce a 3D image with sound o Has two components:  B Mode.e. request for an MRI or CT Angiography  Largely operator-dependent  Limited access area  Magnetic Resonance Imaging (MRI) and CT Angiography o Able to display anatomical information about the lesion o Also able to let the examiner visualize the relationship of the disease with other organs or vessels o Compensate for shortcomings of Duplex  CT angiography  Contrast Angiography o Gold Standard o Examiner is able to visualize the degree of the stenosis o Also provides comparisons and percentages INDICATIONS FOR REPAIR  Based on RCT’s  Form the basis for the treatment guidelines being implemented Symptomatic  NASCET data is used as gold standard.OS 213: Human Disease and Treatment 3 (Circulation and Respiration) LEC 15: SURGERY FOR PERIPHERAL VASCULAR DISEASES I Risk of neurologic event and characteristics Duplex Stenosi n charc.provides anatomic information.g. severe stenosis but no bruits Bea. there is a significant lesion in the area of the carotid artery  Able to help the examiner visualize other morphologic characteristics of the lesion o Limitations:  Operator dependent  Cannot provide an image of the carotid arch and the intracranial circulation (recall how important this is for the unique pathophysiology of stroke in Filipinos)  Different labs have different parameters  Hence. we look at the velocity of blood flow through the vessel not at how broad the lesion appears on the ultrasound (not at anatomic criteria. soft and ulcerated plaques have higher risk. o Patients all had more than 70% stenosis UPCM 2016: XVI. so the bruit can’t be heard anymore.provides functional information o Data obtained:  degree of stenosis. while in Caucasians it is from the extracranial carotids History and Physical Examination There are three main foci in doing the PE: bruits. s Calcified >75% 37 < 75% 53 Dense >75% 42 Soft <75% >75% <75% 76 42 46 carotid plaque TIA Stroke 4(11%) 0 23 (55%) 7 (9%) 32 (76%) 10 (21%) 1(3%) 0 4 (10%) 1 (1%) 9 (21%) 4 (9%)  For symptomatic patients (risk increases with increasing severity of stenosis) has: o Intraplaque hemorrhage o Large superficial lipid core o Low intraplaque calcification Those who have intraplaque hemmorhage. degree of stenosis). pulses and pressures o Make sure that the bruit is not an extension of a cardiac murmur into the carotids  If the bruit is loudest in the precordial area and diminishes as you approach the carotids of the neck area.Some presentations with very tight stenosis have almost no flow.the external carotid artery is almost always patent o Occurs only when there is common carotid artery occlusion  Embolic Material o Often found in the retinal artery and its branches o Hollenhorst plaque . o Degree of bruit ≠ degree of stenosis o No correlation between bruit volume or intensity and severity of the disease . <JC> says  Absence of Carotid Pulse o Rare . there is almost no flow. calcification.cholesterol embolus Diagnostics  Carotid Duplex o Measures the degree of blood flow (velocity) going through the artery (e. <2014> says: OUTCOMES  Progression of the Disease o Increase in the degree of stenosis which may lead to full occlusion of the artery  Rupture o Embolization of thrombosis may ensue causing transient ischemic attack and stroke o Neurologic deficits may also present as a consequence of emboli reaching the brain  Healing & Repair DIAGNOSIS Goals  To ascertain whether or not carotid disease is present  To asses the severity of the disease  To determine whether or not the carotid lesion is responsible for the pt’s symptoms  To assess the potential for operability Remember! Stroke in Filipinos stems from intracranial carotids. absence of carotid pulse.derived Data. no bruit o PE must be thorough: examine all arteries. shows flow irregularities and evidences of blockage  Doppler. lipid core. when there is high grade stenosis. other morphological characteristics (like ulcerations)  To determine the plaque density (i. University of Washington Criteria)  Determined by the Doppler component  If there is increased velocity in the area proximal to the carotid bulb. higher risk of stroke  CAS is usually indicated for high-risk patients only  High Risk Patients are those who had: o severe co-morbidities (e. in clinical practice. the plaque might become dislodged Modifications o Balloon – serves as blockade to possible emboli o Basket – used to catch particles that might dislodge Reversal of flow is possible. COPD) o Previous CEA with restenosis o previous neck surgeries o prior neck irradiation with skin changes o presence of tracheostomy o contralateral vocal cord paralysis UPCM 2016: XVI.g. 71% risk reduction o Ipsilateral stroke was also noted  Therefore.8% in combined CEA + best medical treatment Carotid Artery Stenting (CAS)       <2014> says:  Problem: only the 5-year risk was assessed o Risk of stroke with regard to the procedure is estimated to be 5% o This large risk invalidates the advantage presented by the study  Therefore. risk of restenosis) since the modality is young Risk if soft plaque  stroke o Higher risk – because of continuous poking with the wire. instead of a forward flow. infections o Cranial nerve injury (esp. high risk patients Procedure o The vessel is accessed via the femoral artery o A catheter is inserted towards the common carotid artery o A balloon or stent is used to open the stenosis No incision needed.OS 213: Human Disease and Treatment 3 (Circulation and Respiration) LEC 15: SURGERY FOR PERIPHERAL VASCULAR DISEASES I The patients were divided into two groups: Medical management vs surgery o The incidence of stroke. Carotid endarterectomy. for those which are greater than 80%. surgery is recommended o Figure 8. Anna. embolic protection device Distal filter – most common For symptomatic. Carotid Endarterectomy  Gold Standard  Patients under general anesthesia  Process: create a long cervical incision expose carotid arteries extract plaque close with a patch  Risk of stroke  Difference in risk reduction not significant Figure 7. SPACE and CREST  Being  CREST.g. blood will flow backward and towards the external carotid artery. Carotid endarterectomy: plaque excision Asymptomatic  Carotid Artery Stenosis with Asymptomatic Narrowing: Operation vs Aspirin (CASANOVA)  ACAS (Asymptomatic Carotid Artery Study) data is used as gold standard. o 5. be aware of his stroke risk. surgery is indicated. if his stroke risk is greater than the mortality from the procedure. when the patient is asymptomatic. CN IX and XII)  Endovascular o Dissections o Common vessel occlusion o Bleeding CEA vs CAS studied EVA3s. <JC> says   Fluoroscopic guide is used.4 % stroke risk in medical arm vs 11. he should not perform the procedure. Heparin is used in order to prevent immediate coagulation and risk of post-surgical embolism Bea. Walang Kapantay! 6 of 8 . hence emboli may block ECA – this is alright because ECA is dispensable according to sir since it only supplies the face (vs. brain supplied by ICA) COMPLICATIONS  Stroke o The means to prevent stroke can cause a stroke o The surgeon should. only a puncture wound Main Problem: there is no long-term data (e. TREATMENT Iron Man (irony of treatment): the means by which stroke is prevented can also trigger stroke. medical management is indicated for stenoses which are 80% or less. TIA’s and death (mortality) was noted  NASCET Findings o Surgery: mortality rate was 7% o Medical management: mortality rate was 24% o Mortality rate: Surgery < medical mgt o Hence. in practice. So that. if the patient is symptomatic and the stenosis is greater than 70%. then.  Surgical o Bleeding.1% vs 11% incidence of ipsilateral stroke at 5 yrs in pts w/ 60-99% stenosis (53% risk reduction) o Mortality rate: Surgery < medical mgt  ACST (Asymptomatic Carotid Surgery Trial) data: o 6. Note the process mentioned above. HTN after age 55 Presence of an abdominal bruit Accelerated HTN over prev. Walang Kapantay! 7 of 8 . and renal function o Revascularization vs Medical treatment for RAS o UPCM 2016: XVI. suspect renal stenosis if after administering ACE History and Physical Examination Anatomic studies Renal duplex US MRI/MRA (magnetic resonance angiography) Angiography Functional studies Captopril renography Renal vein rennin assay o  Goals Control HPN (hypertension) Preserve renal function Options Medical treatment to control hypertension Percutaneous Transluminal renal Angioplasty without stenting Surgical to draw renal inflow from aorta/splenic artery  Aortorenal bypass  Splenorenal bypass Laparotomy expose renal vessels  aortorenal/ splenorenal bypass  take out plaque  close up with patch Very good response to surgery Endovascular (Endarterectomy) Treatment  Used to repair obstructed/stenosed renal arterial supply  Uses a stent.OS 213: Human Disease and Treatment 3 (Circulation and Respiration) LEC 15: SURGERY FOR PERIPHERAL VASCULAR DISEASES I  CEA is usually indicated for patients who have unstable plaques which might embolize if a catheter is used  More benefit: CEA > CAS INTERVENTIONS Symptomatic Extent of Stenosis Intervention <70% stenosis Optimal medical tx ≥ 70% Stenosis CEA + medical tx ≥ 70% stenosis and CAS + medical tx high operative risk Asymptomatic Extent of Stenosis Intervention ≤ 60% Stenosis Optimal medical tx ≥ 60% stenosis and CEA + medical tx low operative risk The table shows the type of intervention relative to the degree of stenosis among asymptomatic and symptomatic patients. reduction in number of medications to be taken Transaortic Endarterectomy (recommended for extensive aortic lesions) Endovascular and Med Treatment Hypertension  Slight reduction in BP or drug medication is the best that can be hoped for  Hypertension is rarely cured o Renal Function  Evidence less clear cut o Angioplasty vs Medical treatment for Hypertension (Dutch Renal Artery Stenosis Cooperative Study)  no significant difference in systolic and diastolic blood pressures.or balloon catheter (if balloon: Fogarty catheter)  Stenting is safer. daily drug doses. Anna. releasing renin and activating the Renin-AngiotensinAldosterone System (RAAS) o o The RAAS will induce sodium and water retention This retention may induce other forms of hypertension CLINICAL CLUES ONSET        Onset before age 30 without risk factors or onset of sig. small % HPN is because of renovascular disease DIAGNOSTICS   o o o  o o TREATMENT  o o  o o RENOVASCULAR HYPERTENSION INTRODUCTION (2014)  o This is a syndrome of decreased kidney perfusion due to increased arterial blood pressure Also known as renal artery occlusive disease and fibrodysplastic disease of the renal arteries Most common form of secondary hypertension 80% of cases is caused by atherosclerosis    PATHOPHYSIOLOGY (2014)  o The hypoperfused kidney responds as though under conditions of low blood pressure. stable baseline or resistant HTN despite multidrug therapy Renal failure of uncertain etiology Recurrent flash edema Coexisting diffuse atherosclerotic vascular disease ARF precipitated by ACEI or ARBs <2014> says: SIGNS AND SYMPTOMS  Abdominal bruit  Signs of renal failure of uncertain etiology  No proteinuria  No sediments in urine  Recurrent flush edema ACUTE RENAL FAILURE Acute Renal Failure (ARF) precipitated by ACE (Angiotensin Converting Enzyme) Inhibitors or Angiotensin Receptor Bea. <JC> says Blockers (ARB’s)  If there is compromised blood flow to the kidneys. in symptomatic. esp. high risk patients HYPERTENSION A lot of hypertension <HPN> idiopathic. SUMMARY  Coronary artery disease is a major risk factor for stroke  Surgical intervention in symptomatic patients prove to decrease the risk Carotid artery stenting is emerging as a viable alternative to CEA. has lower mortality and is prescribed by most doctors  Guided by either duplex ultrasound or angiogram  Results: rare cure of hypertension. But players who seek their own glory at the sacrifice of the team’s glory drive the team away from success. In fact.OS 213: Human Disease and Treatment 3 (Circulation and Respiration) LEC 15: SURGERY FOR PERIPHERAL VASCULAR DISEASES I (Angioplasty and Stenting for Renal Artery Lesions)  revascularization carried substantial risks but had NO benefit in renal function and blood pressure o Stent vs Medical treatment for Renal Function  primary endpoint is 20% or greater decrease in creatinine clearance  Conclusion: stent placement had no clear effect on progression of impaired renal function but was associated with significant procedure related complications  Recommendation: focus on cardiovascular risk factor management and avoid stenting Figure 19. Tricia Isada to Alex Martinez. if given the option. a “God-centric” lifestyle would free us to live life to the fullest!” [David Robinson. SUMMARY  Renovascular diseases are a known cause of hypertension and renal insufficiency  Revascularization is an option to cure or better control the renovascular disease END “NBA championship teams have something in common: they play with one goal in mind. <JC> says UPCM 2016: XVI. The goal is not our own glory.  Salamat at hindi na ako (pati si Ruby) mag-isa sa pananaliksik >hehe< Hello rin sa Class 2017!  God bless everyone!    SURGERY VS STENTING  Surgical interventions are really superior and very effective but the mortality & morbidity very high  Surgery has more complications  Therefore. so our generation is not alone. 5-7pm at MSU 2nd flr. every Tuesdays starting this August 7 until September 25. We would be able to enjoy successes without taking the credit. one should really consider doing an endovascular intervention instead. so ako na lang! Una sa lahat. So it is with life. 2012. We could bear up under troubles with confidence in God. If we would learn from them. By letting go of our own agendas and time-tables. I wanna invite you all to Agape’s Series on It’s Not About Me (Max Lucado). Each player contributes his own gifts and efforts so that the greater goal – winning – can be reached. and it’s FREE! We hope to see you. Anna.  Gusto ko rin i-greet ang aking mga research groupmates (Ho-Sia group). we could live in freedom. trying to make life “all about us” pushes happiness further out of reach. This is open to ALL UPCM students. Splenorenal bypass (venous in this case) <jc> says: Hi everyone! No greetings from my transmates. The Bible is full of men and women who struggled with “me-centric” thinking. former NBA player] Bea. Walang Kapantay! 8 of 8 . In the end. we would discover that God’s plans are mind-blowing.