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 Harrisons)
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 dont 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,

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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. - Sir
William Osler

DIAGNOSTIC TESTS-PLAIN ABDOMINAL X-RAY

Most of the time you cannot see aneurysm in CXR.

AP and lateral views are taken to see the outline of

the aorta.

Not routinely done because sensitivity is low

May produce several differentials - e.g. intestinal

obstruction

May be helpful if the aneurysm is calcified - more

visible

DIAGNOSTIC TESTS-ULTRASOUND (DUPLEX UTZ)

Advantages: Highly accurate, cost-effective,

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), organs and lesions can
be visualized - 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 (RCTs) done a few years ago

Two predominant studies (RCTs)

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

AAAs which are 4.0- 5.4 cm in diameter

Bea, Anna, <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 4.0 - 5.4 cm wide: it can be
safely observed without significant risk of
rupture
When AAA is more than 5.5 cm wide,
surgery/repair is usually indicated
Problems encountered:
90% of the patients are male: women should
have a lower size threshold
Rapidly growing aneurysms? (>0.5 cm a year)
5cm aneurysm has a risk of <1 % of rupture.
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, 5 cm is the threshold for
surgical intervention

o
o

o
o
o

o
o

Figure 2. Algorithm for evaluation and

management of abdominal aortic aneurysm.

TREATMENT OPTIONS
OPEN SURGERY

Midline laparotomy

Retroperitoneal

Laparoscopy assisted

Mini laparotomy

Most common forms of surgical intervention (2014)

Procedure
1. Starts with a midline laparotomy (most common;
incision from xiphoid process to symphysis pubis)
2. Aorta is exposed
3. Aneurysm is located
4. Aorta is clamped on either end of the aneurysm
5. Aorta is opened to expose the aneurysm
6. Lesion is taken out and the vessel is repaired
with a graft

A major operation done by a vascular surgeon

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OS 213: Human Disease and Treatment 3

(Circulation and Respiration)
LEC 15: SURGERY FOR PERIPHERAL VASCULAR
DISEASES I
Figure 5. Endovascular Surgery II
The catheter has now reached the AAA and the graft
is deployed.

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, however, that most patients who
undergo the surgery are elderly; hence, the
mortality & morbidity are high
Co-morbidities if present, will complicate the
surgery

Provide proximal control of the AAA

Blood loss in surgery 2 Liters

Hospital stay- 1 week

Two options: GRAFT or CLAMP replacement

Figure 3. Open Surgery

Figure 6. Common Grafts in Current Use

Different mechanisms entail variations in
characteristics and specifications
In Phil., Talent graft most commonly used

ENDOVASCULAR SURGERY

Relatively novel way of treating AAAs

No midline incision; only 2 small incisions

Has been increasingly used in the past 10 years

Talent graft most commonly used in the Phils.

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.
4. Guided by an angiogram, the catheter enters the
site of the aneurysm.
5. The graft is deployed and the catheter is taken
out.
1.
2.
3.

Figure 4. Endovascular Surgery

Note the site of catheter insertion. Exclude the
aneurysm sac.

Bea, Anna, <JC> says

<2014> says:
Anatomic and device constraints
o Diameter (Depending on the neck of
aneurysm, graft is oversized by 10-15% = can be a floating
graft)
o Radial force

Mechanism
o Since aneurysm is due to systolic flow,
if you block the flow above the aneurysm, it will eventually
shrink
o Instances when the aneurysm doesnt
shrink:

Blood flow from lumbar vessels is not excluded (usually

this is somehow blocked in open surgeries) - type II
endoleak

Poor seal - type I endoleak

Advantages
(Short
Outcome)

RelativeTerm
Contraindications

Less blood losso

Young
patients
(because
after
Faster recovery, 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: 1.8 yrs (OVER)
6.0 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 4.0-5.0 cm in diameter?

PIVOTAL trial (Ouriel et al., 2010

(Positive Impact of EndoVascular Options for
Treating Aneurysm earLy)

CAESAR trial (Cao et al., 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

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OS 213: Human Disease and Treatment 3

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LEC 15: SURGERY FOR PERIPHERAL VASCULAR
DISEASES I
Not all patients with AAA are candidates for
EVAR (10,000 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.

Access
Smallest graft has French 18, whose outer
diameter is 6 mm
Hence, 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, 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 90, 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, you will also exclude blood
flow to these arteries and cause infarcts colonic ischemia - to areas supplied by them,
2013)

Neck angulated
Difficult to maneuver the
device if less than <60, also another
relative contraindication.
60 angle is necessary to
create a good proximal seal
Length should be at least
1.5 cm
Diameter should be at
least 28 mm
Having a reversed cone
shape neck is also a RC
No thrombus, atheroma,
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.
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.)
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.
5 mm just for abdominal aorta
Popliteal: 2.5 mm
Iliac: 2.5 mm
Thoracic: 6 mm

CAROTID ARTERY DISEASES

INTRODUCTION
Bea, Anna, <JC> says

Stroke, or a cerebrovascular accident, is

defined by this abrupt onset of a neurologic
deficit that is attributable to a focal vascular
cause. The definition of stroke is clinical, and
laboratory studies including brain imaging
are used to support the diagnosis. (Harrisons)
Stroke is the leading cause of serious long-term
disability; it is a very costly disease.
The risk of getting stroke increases with a history of
stroke incidents
Mortality from initial stroke is 15-35%.
Carotid artery atherosclerosis is a major factor in
carotid artery disease
Risk for recurrence is 4.8 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, patients are asymptomatic
Transient Ischemic Attacks (TIAs) 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. Less common causes are in situ
arterial thrombosis, arterial dissection and venous
sinus thrombosis. The symptoms reflect the area of
ischemia. (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 TIAs 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; 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, the
higher risk of stroke)
Plaque density
o For asymptomatic patients, 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. Soft plaques
may be dislodged and embolize.

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OS 213: Human Disease and Treatment 3

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LEC 15: SURGERY FOR PERIPHERAL VASCULAR
DISEASES I
Risk of neurologic event and
characteristics
Duplex
Stenosi
n
charc.
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,
calcification, lipid core, soft and ulcerated plaques
have higher risk.
<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 pts symptoms
To assess the potential for operability
Remember!
Stroke in Filipinos stems from intracranial carotids,
while in Caucasians it is from the extracranial
carotids
History and Physical Examination
There are three main foci in doing the PE: bruits,
absence of carotid pulse, 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;
when there is high grade stenosis, there is almost
no flow, and therefore, no bruit
o
PE must be thorough: examine all arteries,
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, then the bruit is
just an extension of the precordial murmur.
o
Degree of bruit degree of stenosis
o
No correlation between bruit volume or intensity
and severity of the disease - Some presentations
with very tight stenosis have almost no flow, so the
bruit cant be heard anymore; severe stenosis but
no bruits

Bea, Anna, <JC> says

Absence of Carotid Pulse

o Rare - 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 - cholesterol embolus
Diagnostics
Carotid Duplex
o Measures the degree of blood flow (velocity) going
through the artery (e.g. carotid)
o Combines the ultrasound with the Doppler to
produce a 3D image with sound
o Has two components:

B Mode- provides anatomic information; shows

flow irregularities and evidences of blockage

Doppler- derived Data- provides functional

information
o Data obtained:

degree of stenosis, plaque density, other

morphological characteristics (like ulcerations)

To determine the plaque density (i.e. degree of

stenosis), 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, University of Washington Criteria)

Determined by the Doppler component

If there is increased velocity in the area

proximal to the carotid bulb, 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, 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 RCTs
Form the basis for the treatment guidelines being
implemented
Symptomatic
NASCET data is used as gold standard.
o Patients all had more than 70% stenosis

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OS 213: Human Disease and Treatment 3

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LEC 15: SURGERY FOR PERIPHERAL VASCULAR
DISEASES I
The patients were divided into two groups: Medical
management vs surgery
o The incidence of stroke, TIAs 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, 71% risk reduction
o Ipsilateral stroke was also noted
Therefore, in practice, if the patient is symptomatic
and the stenosis is greater than 70%, surgery is
recommended
o

Figure 8. 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 5.1% 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 6.4 % stroke risk in medical arm vs 11.8% 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, in clinical practice, when the patient is

asymptomatic, medical management is indicated
for stenoses which are 80% or less; for those which
are greater than 80%, surgery is indicated.

TREATMENT
Iron Man (irony of treatment): the means by which
stroke is prevented can also trigger stroke.
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. Carotid endarterectomy.

Note the process mentioned above. Heparin is used in
order to prevent immediate coagulation and risk of
post-surgical embolism

Bea, Anna, <JC> says

Fluoroscopic guide is used, embolic

protection device
Distal filter most common
For symptomatic, 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, only a puncture wound
Main Problem: there is no long-term data
(e.g. risk of restenosis) since the modality is young
Risk if soft plaque stroke
o Higher risk because of continuous poking with the
wire, 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, instead of a forward flow,
blood will flow backward and towards the external carotid
artery, 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, then, be aware of his stroke
risk. So that, if his stroke risk is greater than the
mortality from the procedure, he should not
perform the procedure.
Surgical
o Bleeding, infections
o Cranial nerve injury (esp. CN IX and XII)
Endovascular
o Dissections
o Common vessel occlusion
o Bleeding
CEA vs
CAS studied EVA3s, SPACE and CREST
Being
CREST, 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.g. 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

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OS 213: Human Disease and Treatment 3

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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.

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, esp. in symptomatic, high risk
patients

HYPERTENSION
A lot of hypertension <HPN> idiopathic, small % HPN is
because of renovascular disease

DIAGNOSTICS

o
o
o

o
o

TREATMENT

o
o

o
o

RENOVASCULAR HYPERTENSION
INTRODUCTION (2014)

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)

The hypoperfused kidney responds as though

under conditions of low blood pressure, 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. HTN after age 55
Presence of an abdominal bruit
Accelerated HTN over prev. 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,
Anna,
<JC>
says
Blockers (ARBs)

If there is compromised blood flow to the kidneys,

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

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- or balloon

catheter (if balloon: Fogarty catheter)

Stenting is safer, has lower

mortality and is prescribed by most doctors

Guided
by
either
duplex
ultrasound or angiogram

Results:
rare
cure
of
hypertension,
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, daily drug doses, and
renal function
o Revascularization vs Medical treatment for RAS
o

UPCM 2016: XVI, Walang

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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. Splenorenal bypass (venous in this

case)
<jc> says:
Hi everyone! No greetings from my transmates, so ako na lang!
Una sa lahat, I wanna invite you all to Agapes
Series on Its Not About Me (Max Lucado),
every Tuesdays starting this August 7 until
September 25, 2012, 5-7pm at MSU 2nd flr. This
is open to ALL UPCM students, and its FREE!
We hope to see you.
Gusto ko rin i-greet ang aking mga research
groupmates (Ho-Sia group), Tricia Isada to Alex
Martinez. 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, if given the option, one should really
consider doing an endovascular intervention instead.

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. Each
player contributes his own gifts and efforts so that
the greater goal winning can be reached. But
players who seek their own glory at the sacrifice of
the teams glory drive the team away from success.
So it is with life. The goal is not our own glory. In fact,
trying to make life all about us pushes happiness
further out of reach.
The Bible is full of men and women who struggled
with me-centric thinking, so our generation is not
alone. If we would learn from them, we could live in
freedom. We would be able to enjoy successes
without taking the credit. We could bear up under
troubles with confidence in God. By letting go of our
own agendas and time-tables, we would discover
that Gods plans are mind-blowing. In the end, a
God-centric lifestyle would free us to live life to the
fullest!
[David Robinson, former NBA
player]

Bea, Anna, <JC> says

UPCM 2016: XVI, Walang

Kapantay!

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