Uncontrollable Hypertension Research Articles

Renal sympathetic denervation in resistant arterial hypertension: long term and updated results.

The present paper is an extension to our earlier publication (Šochman et al. 2016) documenting a beneficial effect of renal sympathetic denervation on pharmacologically uncontrollable hypertension in a group of seven patients followed up for 1-2 years post-procedure. The same patients remained on ambulatory follow-up for another 5-6 years, with the beneficial effect persisting throughout the follow-up period while on the same medication.

Ventriculoperitoneal shunts in non-HIV cryptococcal meningitis

BackgroundPersistent and uncontrollable intracranial hypertension (ICH) and difficulty in reducing Cryptococcus count are severe problems in cryptococcal meningitis (CM) patients. The therapeutic effects of ventriculoperitoneal shunts (VPS) in non-HIV CM patients are not fully known, and the procedure is somewhat unusual. Here, our study offers a review to investigate the role of VPS in non-HIV CM.MethodsWe retrospectively collected data on 23 non-HIV CM patients with and without ventriculomegaly from 2010 to 2016. Their demographic data, clinical manifestations, cerebrospinal fluid (CSF) features and outcomes were analysed.ResultsWe found that non-HIV CM patients without ventriculomegaly were older, had earlier treatment times and had shorter symptom durations than CM patients with ventriculomegaly. In both groups, headache, vomiting, fever and loss of vision were the most common clinical features. CSF pressure and Cryptococcus count were significantly decreased after operation. VPS could provide sustained relief from ICH symptoms such as headache. 13% of patients had poor outcomes because of serious underlying disease, while 87% of patients had good outcomes.ConclusionsThe use of a VPS is helpful in decreasing ICH and fungal overload in non-HIV CM patients, and VPS should be performed before CM patients present with symptoms of severe neurological deficit.

The incidence of delayed complications in acute type B aortic dissections is underestimated

ObjectiveAcute type B aortic dissections (TBADs) can have immediate or delayed complications within the first 2 weeks. Because the majority of clinical series retrospectively categorized TBAD, the incidence and outcome of delayed complications in initially uncomplicated TBAD within the first 14 days are not well described. MethodsWe retrospectively analyzed 86 patients (78% male; age, 62.5 ± 13 years) with acute TBAD treated consecutively between January 2004 and May 2016 at a tertiary referral center. All TBADs were confirmed by computed tomography angiography (CTA) on admission, after 2 to 5 days, and after 10 to 14 days. Study end points were the incidence of immediate and delayed complications (aortic rupture, malperfusion, rapid aortic expansion >4 mm, pain or hypertension resistant to medical therapy) and in-hospital mortality. In addition, we looked at CTA-detected morphometric variables (maximum diameters of descending aorta, false lumen [FL], and primary entry tear; number of intimal tears; FL configuration; true lumen collapse; course of the dissection) and their association with delayed complications. Finally, we assessed treatment modalities and clinical outcomes. ResultsOf all TBADs, 22 (26%) presented with immediate complications (rupture, n = 11); 64 patients (74%) were initially assessed as having uncomplicated TBAD. Of these 64 patients, 24 (28% of all 86) suffered from delayed complications (malperfusion, n = 10; aortic rupture, n = 3; early expansion >4 mm, n = 8; refractory pain, n = 2; uncontrollable hypertension, n = 1) at a median interval of 7.1 (2-14) days after symptom onset. During the first 14 days, 40 patients (46%) remained uncomplicated. The CTA analysis revealed a significant association of initial thoracic aortic diameter (P = .009), size of the primary entry tear (P = .018), true lumen collapse (P = .019), and partially thrombosed FL (P = .019) with the occurrence of delayed complications within the first 14 days. Of the patients with delayed complications, 87.5% underwent surgery (90% thoracic endovascular aortic repair, 10% peripheral revascularization); 12.5% in this group died following aortic rupture before they received surgical repair. The mortality of patients with delayed complicated TBAD was significantly higher compared with those who remained uncomplicated within the 14-day period (12.5% vs 0%; P = .0221). ConclusionsDelayed complications in initially uncomplicated acute TBAD are not infrequent. Morphologic variables like maximum diameter of the descending aorta, primary entry tear, true lumen collapse, and partially thrombosed FL were associated with an increased risk of delayed complications in initially uncomplicated TBAD. Future clinical research must verify the predictive role of clinical and morphologic variables in the acute phase, particularly with regard to a possible early surgical treatment to prevent a fatal outcome.

PCV13 - Cost Effective Analysis Of Pharmaceutical Care In Management Of Patients With Stage Iii Hypertension: An Indian Pharmacists Experience

To calculate and compare cost effectiveness in hypertensive patients between intervention and usual care group in Stage III uncontrollable hypertension. The present study was a prospective, randomized, comparative study in 1525 patients of stage III hypertension for 24 months. Patients were randomly divided into two groups. Intervention group patients were provided self-care education through a structured training session over 6 month period. Usual care group received usual care provided by the hospital and pharmacists. The economic evaluation on pharmaceutical care was based on patients perspective. The impact of the interventions on QoL was estimated by using the MINICHAL questionnaire. The primary outcomes were incremental cost-utility ratio and net monetary benefit. The data of the present study sowed an incremental cost due to periodic monitoring cost INR 2245 ($33.59) with 0.17 quality adjusted life year (QALY) gained. The present study also showed an incremental utility ratio INR 17,960 ($268.78) per QALY gained. In the cost-effectiveness acceptability curve, the probability that PC was more cost-effective than UCG was 90% at the INR 56,125 ($840) per QALY gained threshold and 66% at the INR 17,960 ($268.78) per QALY gained threshold. The PC was not very cost-effective among patients with stage III uncontrollable hypertension at the INR 17,960 ($268.78) per QALY gained threshold. However, there are considerable limitations in this study.

Computed Tomography Imaging Features in Acute Uncomplicated Stanford Type-B Aortic Dissection Predict Late Adverse Events.

Medical treatment of initially uncomplicated acute Stanford type-B aortic dissection is associated with a high rate of late adverse events. Identification of individuals who potentially benefit from preventive endografting is highly desirable. The association of computed tomography imaging features with late adverse events was retrospectively assessed in 83 patients with acute uncomplicated Stanford type-B aortic dissection, followed over a median of 850 (interquartile range 247-1824) days. Adverse events were defined as fatal or nonfatal aortic rupture, rapid aortic growth (>10 mm/y), aneurysm formation (≥6 cm), organ or limb ischemia, or new uncontrollable hypertension or pain. Five significant predictors were identified using multivariable Cox regression analysis: connective tissue disease (hazard ratio [HR] 2.94, 95% confidence interval [CI]: 1.29-6.72; P=0.01), circumferential extent of false lumen in angular degrees (HR 1.03 per degree, 95% CI: 1.01-1.04, P=0.003), maximum aortic diameter (HR 1.10 per mm, 95% CI: 1.02-1.18, P=0.015), false lumen outflow (HR 0.999 per mL/min, 95% CI: 0.998-1.000; P=0.055), and number of intercostal arteries (HR 0.89 per n, 95% CI: 0.80-0.98; P=0.024). A prediction model was constructed to calculate patient specific risk at 1, 2, and 5 years and to stratify patients into high-, intermediate-, and low-risk groups. The model was internally validated by bootstrapping and showed good discriminatory ability with an optimism-corrected C statistic of 70.1%. Computed tomography imaging-based morphological features combined into a prediction model may be able to identify patients at high risk for late adverse events after an initially uncomplicated type-B aortic dissection.

Management of unilateral retinoblastoma with buphthalmia

PurposeLocally advanced unilateral retinoblastoma (RB) not amenable to conservative treatments is treated with enucleation. Surgery is challenging in presence of buphthalmia, exophthalmia or severe periocular inflammation, carrying a risk for globe rupture with tumour dissemination. The aim of this study was to report the long‐term results of neoadjuvant chemotherapy (CT) in this setting.MethodsRetrospective case series of unilateral group E RB patients without extraocular disease receiving pre‐enucleation CT (etoposide‐carboplatin) in a single centre between 1999 and 2011. Clinical, radiological and histopathological data were collected. Outcome measures were: surgical complications, pathological risk factors (PRF) for metastatic dissemination, systemic side effects, metastatic dissemination, survival.Results21 patients, median age 9 months (range 1.5–48) were included: 16 with clinical buphthalmia, 2 with orbital inflammation and 3 with uncontrollable ocular hypertension. MRI confirmed the clinical findings and ruled out extraocular disease in all cases. Enucleation was performed after 1 course of neoadjuvant CT in 16/21 (77%), the remaining 5 patients needing two. No surgical complications occurred. Pathological examination showed complete resection in all cases. PRF for were present in 7/21 (33%) eyes. Irrespectively, all children completed a 4‐cycle CT regimen, as CT could mask PRF. Two children required hospitalisation for complicated aplasia, no other systemic side effects were reported. With a median follow‐up time of 8 years (range 4–12), no metastatic dissemination occurred. Survival is 100%.ConclusionsLocally advanced unilateral RB with buphthalmia can be successfully treated with neoadjuvant CT prior to enucleation to make the surgery safer.

Acute Aortic Dissection and Intramural Hematoma: A Systematic Review.

Acute aortic syndrome (AAS), a potentially fatal pathologic process within the aortic wall, should be suspected in patients presenting with severe thoracic pain and hypertension. AAS, including aortic dissection (approximately 90% of cases) and intramural hematoma, may be complicated by poor perfusion, aneurysm, or uncontrollable pain and hypertension. AAS is uncommon (approximately 3.5-6.0 per 100,000 patient-years) but rapid diagnosis is imperative as an emergency surgical procedure is frequently necessary. To systematically review the current evidence on diagnosis and treatment of AAS. Searches of MEDLINE, EMBASE, and the Cochrane Register of Controlled Trials for articles on diagnosis and treatment of AAS from June 1994 to January 29, 2016, were performed. Only clinical trials and prospective observational studies of 10 or more patients were included. Eighty-two studies (2 randomized clinical trials and 80 observational) describing 57,311 patients were reviewed. Chest or back pain was the most commonly reported presenting symptom of AAS (61.6%-84.8%). Patients were typically aged 60 to 70 years, male (50%-81%), and had hypertension (45%-100%). Sensitivities of computerized tomography and magnetic resonance imaging for diagnosis of AAS were 100% and 95% to 100%, respectively. Transesophageal echocardiography was 86% to 100% sensitive, whereas D-dimer was 51.7% to 100% sensitive and 32.8% to 89.2% specific among 6 studies (n = 876). An immediate open surgical procedure is needed for dissection of the ascending aorta, given the high mortality (26%-58%) and proximity to the aortic valve and great vessels (with potential for dissection complications such as tamponade). An RCT comparing endovascular surgical procedure to medical management for uncomplicated AAS in the descending aorta (n = 61) revealed no dissection-related deaths in either group. Endovascular surgical procedure was better than medical treatment (97% vs 43%, P < .001) for the primary end point of "favorable aortic remodeling" (false lumen thrombosis and no aortic dilation or rupture). The remaining evidence on therapies was observational, introducing significant selection bias. Because of the high mortality rate, AAS should be considered and diagnosed promptly in patients presenting with acute chest or back pain and high blood pressure. Computerized tomography, magnetic resonance imaging, and transesophageal echocardiography are reliable tools for diagnosing AAS. Available data suggest that open surgical repair is optimal for treating type A (ascending aorta) AAS, whereas thoracic endovascular aortic repair may be optimal for treating type B (descending aorta) AAS. However, evidence is limited by the paucity of randomized trials.

Clinical case report: a rare cause of acute kidney failure – tissue is the issue

A patient was admitted to the medical emergency department by his family physician. His complaints were weakness and fatigue for more than one week. Four days before admission, he went to his general practitioner for these complaints and also for painful elbows. His physician prescribed diclofenac and esomeprazole. Upon presentation, he had high systolic/diastolic blood pressure (>180/>90 mm Hg, measured repeatedly), and otherwise normal parameters. He had gained 6.5 kg in body weight. Clinical examination was normal, except for very mild bilateral malleolar edema. Routine blood tests showed a strongly elevated serum creatinine, hyperkalemia, and elevated lactate dehydrogenase. Haptoglobin levels were normal. Urinalysis showed a normal sediment, urine and blood cultures remained sterile. Ophthalmoscopy was completely normal, as was a routine chest X-ray. Renal ultrasound demonstrated kidneys with a diameter of 13 cm. Due to uncontrollable hypertension, our patient was hospitalized at the intensive care department where intravenous nifedipine was started, with good instantaneous control of blood pressure. Because of increasing potassium levels acute hemodialysis was started within 24 h after admission. Differential diagnosis consisted of diclofenac- or esomeprazole-induced interstitial nephritis or rapidly progressive glomerulonephritis. A renal biopsy was performed within 72 h after admission. The kidney biopsy showed an overwhelming inflammatory cell infiltrate consisting of a monoclonal lymphocytic cell population. However, the numerous mitotic figures, polyploidy, and prominent nucleoli present, were indicative of a lymphoma. Additional stainings confirmed a non-Hodgkin diffuse large-cell B-cell lymphoma. Treatment with R-CHOP (rituximab, cyclophosphamide, doxorubicine, vincristine, and prednisolone) was initiated with very good clinical and biochemical response, yet only mild recovery of kidney function. Occasionally the kidney is involved as an extranodal non-Hodgkin lymphoma (NHL) localization. However, a primary presentation of acute kidney failure due to lymphoma localization is extremely rare. Our case demonstrates that early renal biopsy is indispensable for fast and adequate diagnosis and treatment.

Retraction Note: Decompressive craniectomy without durotomy for traumatic coma and uncontrollable intracranial hypertension

The Publisher has retracted this article [1] because it appears that the authors did not obtain the necessary consent to publish their case details from the patients described. The article is no longer available online in order to protect the patients’ privacy. Darlene Lobel has agreed to retraction, Daniel Miller could not be reached by the journal for comment on the retraction.

Surgical Repair of Renal Artery Aneurysms

The pathogenesis of renal artery aneurysms (RAAs) is degenerative, which eventually leads to weakening of the vessel wall and, in extreme cases, rupture. RAAs are a rare occurrence. Patients generally are asymptomatic, with a small number presenting with uncontrollable hypertension or hematuria. Most RAAs are discovered incidentally on imaging and do not pose an immediate health threat. However, the risk of rupture is an indication for prophylactic repair in certain patients. Interest in interventional radiologic procedures in the management of RAAs has recently increased; however, open repair should still be considered in select instances. In this case series, we present three patients for whom an open approach was indicated and performed.

Abstract P227: Safety and Efficacy of Losartan/hydrochlorothiazide Combination in Elderly Patients With Morning Hypertension

Background: Cardiovascular events occur most frequently in the morning. Elevation of blood pressure (BP) in the early morning (morning hypertension) is characteristic feature of hypertension in the elderly, and is attributed to cardiovascular events. However, treatment of morning hypertension has not been established, especially in the elderly patients. A combination of an angiotensin II receptor blocker (ARB) and hydrochlorothiazide (HCTZ) is a desirable choice of treatment for uncontrollable hypertension by antihypertensive monotherapy. Purpose: The aim of this study was to compare the safety and effectiveness between an ARB/HCTZ combination therapy and high-dose ARB therapy in the elderly (75 years or more) and younger (less than 75 years) patients. Methods: This study enrolled 201 (66 elderly and 135 younger) on-treatment patients having morning hypertension evaluated by home BP self-measurement. Patients were randomly assigned to receive 50mg-losartan/12.5mg-HCTZ combination (Combination) or 100mg-losartan (High-dose) therapy. Results: During the 3-month treatment, the incidence of adverse events of Combination and High-dose therapies was similar in the elderly and younger patients. In the elderly patients, Combination therapy induced greater morning systolic BP reduction than High-dose therapy, whereas the two therapies showed the similar effects on estimated glomerular filtration rate (eGFR), serum K, and uric acid, as well as in younger patients (Table). Conclusions: ARB/HCTZ combination therapy was safe and more effective for controlling morning hypertension than high-dose ARB in the elderly patients, as seen in younger patients.

Twenty-year experience with laparoscopic and retroperitoneoscopic nephrectomy in children: considerations and details of technique.

Nephrectomy is probably the most common urological indication for minimally invasive surgery (MIS) in children. The authors reported their experience in laparoscopic and retroperitoneoscopic nephrectomy analyzing their 20years of experience in this procedure. In a 20-year period (1995-2015), the authors performed 149 nephrectomies in children using MIS (87 left, 62 right). One hundred and one nephrectomies were performed using laparoscopy (LN) and 48 using retroperitoneoscopy (RN). Patients included 90 girls and 59 boys (average age 5.7years). All the removed kidneys were nonfunctioning because of benign diseases: VUR (84), UPJO (38), MKDK (20), xanthogranulomatosis pyelonephritis (4), nephropathy causing uncontrollable hypertension (2) and nephrolithiasis (1). We had no conversion in laparoscopy. As for RN, we had 2 conversions to laparoscopy at the beginning of experience due to peritoneal opening. Operative time varied from 30 to 130min in laparoscopy (average 47min) and from 60 to 150min (average 78min) in retroperitoneoscopy. We recorded 8 complications (5.3%): 3 small bleedings (2 RN, 1 LN) during dissection, 2 peritoneal perforations during RN requiring conversion in LN, 1 abdominal abscess in case of xanthogranulomatosis pyelonephritis after LN requiring a redo surgery to drain the abscess, 1 instrumentation failure (LN) and 1 refluxing ureteral stump after RN requiring a redo surgery to remove it. LN is easier and faster to perform compared to RN. Complication rate was higher after RN compared to LN. In case of xanthogranulomatous pyelonephritis or other kidney infections or in case of previous renal surgery, retroperitoneoscopy is contraindicated. In case of VUR, LN is preferable to RN because it is fundamental to remove all the ureter. On the basis of our 20-year experience, we clearly prefer to perform nephrectomy using laparoscopy rather than retroperitoneoscopy leaving the indication to adopt RN only for the rare cases of MKDK.

Commentary on ‘Early and Long-term Outcome after Open Surgical Suprarenal Aortic Fenestration in Patients with Complicated Acute Type B Aortic Dissection’

Objectives The purpose of this retrospective cohort study was to determine the early and long-term mortality and morbidity as well as to reveal risk factors influencing the long-term prognosis in patients with complicated acute type B aortic dissection (CABAD) undergoing open surgical suprarenal aortic fenestration (OSSAF). Methods Fifty-two patients with CABAD, defined as (impending) rupture, acute enlargement of the false lumen, malperfusion, and/or unrelenting back pain or uncontrollable hypertension despite maximum medical therapy were treated with by surgical repair between 2002 and 2008. Ten patients with (impending) rupture had aortic graft replacement, while 42 (33 men, mean age 55 ± 11 years) had OSSAF. Follow up visits were scheduled at 1, 3–6 and 12 months after the surgery and annually thereafter. Clinical examination and computed tomography angiography findings were investigated at baseline and at subsequent visits. Results The indications for OSSAF were acute enlargement of the false lumen in four (10%), malperfusion in 17 (40%) (11 lower extremity [26%], 6 visceral [14%]), and unrelenting back pain or uncontrollable hypertension in 21 cases (50%). The 30 day mortality was 21.4% (2 multiple organ failure, 2 heart failure, 3 pneumonia, 1 intestinal necrosis, 1 major hemorrhage). The mean follow up was 84 ± 40 months. The 5 year survival was 70.6%. Eight patients (19%) died during the follow up period (6 aortic ruptures, 2 myocardial infarctions). None of the patients became paraplegic after the surgery. Further surgery or stenting was indicated in nine cases (21%). Conclusions OSSAF has been performed with an acceptable early mortality and low paraplegia rate, but late mortality is frequently related to aortic rupture. Stentgraft coverage of the primary entry tear decreases late aortic related deaths, but suprarenal fenestration remains an option for cases not suitable for endovascular techniques.

Less-Tight Versus Tight Control of Hypertension in Pregnancy

Nearly 10% of pregnant women have hypertension, which can increase both perinatal and maternal risk. While there have been several randomized controlled trials examining hypertension in pregnant women, they were not consistent enough to determine blood-pressure targets for pregnant women experiencing hypertension. Current guidelines are debated over treatment goals between less-tight control (blood pressure elevated but not threatening) and tight control. The Control of Hypertension in Pregnancy Study evaluated perinatal and maternal outcomes of nonsevere hypertension in pregnancy by comparing less-tight control and tight control. This study was an open, multicenter, international, randomized controlled trial that included women with nonsevere, nonproteinuric preexisting hypertension/gestational hypertension. All women had gestational periods of 14 weeks 0 days to 33 weeks 6 days with preexisting hypertension with a diastolic blood pressure of 90 mm Hg or higher at 20 weeks. Women were randomized 1:1 to less-tight control group (100 mm Hg) or tight control group (85 mm Hg). Primary outcomes focused on pregnancy loss or need for high-level neonatal care more than 48 hours to 28 days after birth. The secondary outcomes focused on “serious” maternal complications up to 6 weeks after birth and was defined as conditions such as stroke, uncontrollable hypertension, or death. Of the women who met the criteria, 497 women were randomly assigned to the less-tight control group, and 490 were assigned to the tight control group. Results for the primary outcome were found to be similar between the 2 groups, with 31.4% for the less-tight control and 30.7% tight control (adjusted odds ratio [aOR], 1.02; 95% confidence interval, 0.77–1.35). Similarities were also found in the secondary outcomes as well with maternal complications at 3.7% and 2.0% (aOR, 1.74; 95% confidence interval, 0.79–3.84). However, results revealed that less-tight control had higher rates of severe maternal hypertension (40.6%) compared with the tight control (27.5%). In addition, there were more patients in the less-tight control group with thrombocytopenia or elevated transaminases; however, the rate of HELLP syndrome was not statistically significantly increased (aOR, 4.35; 0.93–20.35). With regard to the rate of small-for-gestational-age neonates, this was examined both at the less than the 10th percentile and less than the third percentile. For the less than the 10th percentile, the absolute percentage was lower in the less-tight control group (16.1% vs 19.7%); however, this was not statistically significant, with an aOR of 0.78 (0.56–1.08). Similarly, the less than the third percentile rates were not different with an aOR of 0.92 (0.51–1.63) when comparing the less-tight control group with the tight control group. This randomized trial revealed that there was no significant difference between less-tight control and tight control in regard to the primary perinatal or maternal outcomes examined. However, less-tight control was found to have a higher rate of severe maternal hypertension.

Early and Long-term Outcome after Open Surgical Suprarenal Aortic Fenestration in Patients with Complicated Acute Type B Aortic Dissection

The purpose of this retrospective cohort study was to determine the early and long-term mortality and morbidity as well as to reveal risk factors influencing the long-term prognosis in patients with complicated acute type B aortic dissection (CABAD) undergoing open surgical suprarenal aortic fenestration (OSSAF). Fifty-two patients with CABAD, defined as (impending) rupture, acute enlargement of the false lumen, malperfusion, and/or unrelenting back pain or uncontrollable hypertension despite maximum medical therapy were treated with by surgical repair between 2002 and 2008. Ten patients with (impending) rupture had aortic graft replacement, while 42 (33 men, mean age 55±11 years) had OSSAF. Follow up visits were scheduled at 1, 3-6 and 12 months after the surgery and annually thereafter. Clinical examination and computed tomography angiography findings were investigated at baseline and at subsequent visits. The indications for OSSAF were acute enlargement of the false lumen in four (10%), malperfusion in 17 (40%) (11 lower extremity [26%], 6 visceral [14%]), and unrelenting back pain or uncontrollable hypertension in 21 cases (50%). The 30 day mortality was 21.4% (2 multiple organ failure, 2 heart failure, 3 pneumonia, 1 intestinal necrosis, 1 major hemorrhage). The mean follow up was 84±40 months. The 5 year survival was 70.6%. Eight patients (19%) died during the follow up period (6 aortic ruptures, 2 myocardial infarctions). None of the patients became paraplegic after the surgery. Further surgery or stenting was indicated in nine cases (21%). OSSAF has been performed with an acceptable early mortality and low paraplegia rate, but late mortality is frequently related to aortic rupture. Stentgraft coverage of the primary entry tear decreases late aortic related deaths, but suprarenal fenestration remains an option for cases not suitable for endovascular techniques.

Abdominal aortic coarctation in a middle aged adult

A 53-year-old male was being evaluated for endocarditis and mitral valve prolapse. Computed tomography angiography of the thorax and abdomen demonstrated a complete aortic coarctation with a rich network of collateral vessels, arising from the lumbar and inferior mesenteric arteries (Cover and A; see Video, online only). Abdominal aortic coarctation is an uncommon pathology. Fusion of the dorsal embryonic aortas and viral-mediated diseases such as rubella have been identified as possible causes. Most patients present by their early twenties for uncontrollable hypertension, which, if left untreated, results in death at a mean age of 34 years.1Stanley J.C. Criado E. Eliason J.L. Upchurch Jr., G.R. Berguer R. Rectenwald J.E. Abdominal aortic coarctation: surgical treatment of 53 patients with a thoracoabdominal bypass, patch aortoplasty, or interposition aortoaortic graft.J Vasc Surg. 2008; 48: 1073-1082Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar, 2Connolly J.E. Wilson S.E. Lawrence P.L. Fujitani R.M. Middle aortic syndrome: distal thoracic and abdominal coarctation, a disorder with multiple etiologies.J Am Coll Surg. 2002; 194: 774-781Abstract Full Text Full Text PDF PubMed Scopus (134) Google Scholar, 3Hallett Jr., J.W. Brewster D.C. Darling R.C. O'Hara P.J. Coarctation of the abdominal aorta: current options in surgical management.Ann Surg. 1980; 191: 430-437Crossref PubMed Scopus (81) Google Scholar Interestingly, our patient was completely asymptomatic. He never had hypertension nor claudication even while regularly playing soccer in an amateur league until the age of 30 years. This physical athletic activity most likely both led to the development of the extensive network of pelvic collaterals and accounted for his lack of claudication symptoms (B and C; see Video, online only). Consent was obtained from the patient for the publication of this report. Download .doc (1.37 MB) Help with doc files CovereyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJjYzNmZWE5NGZhMjY3OWZlY2ViZTA4MGUyZjAyNjU0OSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc3OTkwNzI2fQ.TFS7Zl1GotOHCXBORH_2oO5O7c99YFXg5VOfAtROsvp5lUBELaCv4DvYH0WPJgb68NxQZSiDMwAlpGqBGiuynUCJ9MXv3HVquj9eC51LjU8BxJZ-4-KiLE-zmZPUGUrPeuFNHc69D2buTDW3I_zVeSQFZUvuLaVLfIp4kmclk13oQBWr5VemhMBeFe5iTS1DDEo42vISGzwg8V8k5Xj-pnMi-G_45xzu8erYL1VO1gySZwmfBEeU6XDfH1bqL5NMv3CTAOuqa05TjHHzYPyaYYdNYm0ZBxUu1VpiHP8XLrcnG37fqGiC5F1DRHf-oJCAy4lK7Il_2YwvBS8w-4M7eA Download .mp4 (6.46 MB) Help with .mp4 files Video, online onlyComputed tomography angiography scan of the patient, transverse view.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiIxOTA5MzIxNWFjYmFhZTUzNDczYjQxMTg2OWQwMWZmZiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc3OTkwNzI2fQ.qoKKzYvtekTNhUUZTjhIwyEG_PNbbn6ircc2m9EZft--txuJIzVTbejnWPeFfjonSiMbWuro0FpLqdm5NYxMy0bo_2lk05HrGYJspUKqOVRdlhlMOFAubnyZW1jwioEi0iQz1jLbkNEkU8bmUy_EOEnSL73Py1N0TdlbTh1kRjj7nmPl3F4pUteqnMbwuC3ux9LO2hx0gW-46CIJ7yV48lUhpEb7nlpTEM3igmFkdWPFdr2m2cx4RVqFUlJHHt8ATta16WZbV3-Z4Iyd3Y86rDAwHm4b8TlwRTNOfH1h_vdf6p9RO-3izNe97RIeKY4S39Y7w5vHXhnTcdpgMP-cdQ Download .mp4 (6.38 MB) Help with .mp4 files Video

Ventriculoperitoneal shunts for treating increased intracranial pressure in cryptococcal meningitis with or without ventriculomegaly.

Cryptococcosis is an opportunistic mycosis, especially in patients that are human immunodeficiency virus (HIV)-positive, and frequently involves the central nervous system. We assessed the potential of ventriculoperitoneal shunting (VPS) in preventing mortality due to uncontrollable intracranial hypertension (ICH) in 15 patients with acquired immunodeficiency syndrome (AIDS)-related cryptococcal meningitis. After 2 weeks of antifungal therapy consisting of amphotericin B deoxycholate with or without fluconazole, patients with persistent ICH underwent VPS, despite having persistent Cryptococcus neoformans infection. In 12 patients, the uncontrollable ICH was resolved by VPS. Patients with cryptococcal meningoencephalitis who have ICH must be considered for VPS even with positive cerebrospinal fluid cultures.

Renoprotective effects of thiazides combined with loop diuretics in patients with type 2 diabetic kidney disease.

Type 2 diabetic kidney disease (DKD) is frequently accompanied by uncontrollable hypertension due to the sodium sensitivity inherent in DKD and to diuretic-resistant edema. In general, diuretics are effective in treating this condition, but thiazide diuretics are thought to be innocuous in advanced chronic kidney disease (CKD). We examined the renoprotective effects of combination therapy with thiazides and loop diuretics in type 2 DKD patients with CKD stage G4 or G5. This study included 11 patients with type 2 DKD and an estimated glomerular filtration rate (eGFR) <30 mL/min/1.73 m(2) who were suffering from severe edema even with loop diuretics. Each patient received additional hydrochlorothiazide (HCTZ) therapy, which was continued for more than 12 months. We examined clinical parameters including blood pressure (BP), proteinuria, and eGFR before and after the addition of HCTZ. Patients received a 13.6 ± 3.8 mg/day dose of HCTZ in addition to loop diuretics (azosemide: 120 mg/day in 6 cases, 60 mg/day in 3 cases and furosemide: 80 mg/day in 1 case, 120 mg/day in 1 case). Side effects of HCTZ were not observed in all patients. After the addition of HCTZ therapy, systolic and diastolic blood pressures (S-BP, D-BP) as well as proteinuria significantly decreased (S-BP: at 6 months, p < 0.05 and 12 months, p < 0.01 vs. 0 month, D-BP: at 12 months, p < 0.05 vs. 0 month, proteinuria: at 6 months, p < 0.05 and 12 months, p < 0.01 vs. 0 month). The annual decline in eGFR was not significantly different before and after HCTZ therapy (-7.7 ± 8.5 and -8.4 ± 4.8 mL/min/1.73 m(2)/year, respectively). Our findings suggest that the combination of HCTZ and loop diuretics improves BP levels, and decreases proteinuria even in advanced stage type 2 DKD patients with severe edema. The addition of HCTZ therapy was not found to negatively affect the change in eGFR in the present study.

ABSTRACT 337

Background and aims: The herniation paradoxal is consequence of the trephined syndrome that is a subacute complication of large craniectomies. Aims: We report a case of a 4-year-old male child who presented major trauma brain injury after motor vehicle accident versus pedestrian. Methods: He had a crushing lesion on the right side of the skull. Glasgow Coma Score (GCS) was 11T at the hospital admission. His initial CT scan showed frontal comminuted fracture of the right facial bones, frontal, temporal, parietal and nasal bones. Plus skull base fracture throught the temporal floor, soft tissue edema and large pneumocephalus. TBI guidelines was used and intracranial pressure monitoring. After 4 days he presented an uncontrollable intracranial hypertension and signs of severe infection of the brain. A new CT showed reducing size of the lateral ventricles, sulci and cisterns, mildline shift and transcalvarial herniation of the right temporal lobe. The decompressive craniectomy and dural repair was performed. His skul frontal, temporal and parietal right bones were necrotic and were removed. The ICP was controlled on post injury day 7. After 3 weeks his medical condition deteriorated with tachycardia, tachypnea, fever, worsening of nasal cerebrospinal fluid leak and decerebrate posture. CT scan showed paradoxal herniation with uncal herniation, brainstem compression and midline shift. Results: The medical management was to increase intracranial pressure by placing into Trendelenburg positioning and increasing hydratation. Conclusions: Our proposal was to bring attention to early diagnosis of paradoxal herniation whose outcome is severe acute neurological deterioration and death.

Endovascular management of acute complicated type B aortic dissection: adjunct procedures

Background: This study aims to evaluate the results of endovascular treatment (TEVAR) and the contribution of adjunct procedures in acute complicated type B aortic dissections. Methods: Thirty patients (26 males, 4 females; mean age 55.2±14.7 years, range 24 to 86 years) with acute complicated type B dissection underwent endovascular treatment. The dissection was complicated by malperfusion in eight patients (26.7%), impending rupture in four (13.3%), uncontrollable hypertension in 12 (40%), and severe treatmentresistant pain in six (20%). Self-expanding stent-grafts (Talent® and Valiant®, Medtronic Inc.) were used. Ostium of the left subclavian artery was covered intentionally in 19 patients (63.3%). Additional stenting was necessary in eight patients (26.7%). Of a total of 12 bare metal stents used in these patients, stents were inserted in the renal arteries in six (20%), iliac arteries in three (10%), and celiac arteries in two (6.7%) patients. Median follow-up was 55 months (range, 25 to 99 months). Results: The mean number of stent-grafts implanted was 1.42 (range, 1 to 3). One patient had inadvertent partial closure of the left common carotid artery ostium due to proximal migration of the stent-graft which caused no early neurological complications. Right hemiplegia occurred 15 months later due to his discontinuation of the anticoagulant therapy in the same patient. In another patient with visceral malperfusion, early laparoscopic exploration following the stenting of the celiac and the left renal arteries revealed no ischemia of the bowels. One patient with postoperative angina pectoris required stenting of the right coronary artery. There was no stroke in any patients, while reversal of paraplegia was observed in one patient early after the procedure. The mean lengths of intensive care unit and hospital stays were 3.2±3.4 and 9.8±7.1 days, respectively. There was no 30-day mortality. The one-year survival rate was 96.7%. Conclusion: Although endovascular treatment of complicated type B aortic dissections has a high success rate, TEVAR may not be the sole solution. Findings of malperfusion should be carefully sought in the early postoperative period. The adjunct procedures such as stenting of the visceral arteries or open surgical revascularization should always be considered particularly in young patients.