Cardiac valve calcification as an important predictor for all-cause mortality and cardiovascular mortality in long-term peritoneal dialysis patients: a prospective study

Calcification complications are frequent among long-term dialysis patients. However, the prognostic implication of cardiac valve calcification in this population is not known. This study aimed to determine if cardiac valve calcification predicts mortality in long-term dialysis patients. Baseline echocardiography was performed in 192 patients (mean +/- SD age, 55 +/- 12 yr) on continuous ambulatory peritoneal dialysis (mean +/- SD duration of dialysis, 39 +/- 31 mo) to screen for calcification of the aortic valve, mitral valve, or both. Valvular calcification was present in 62 patients. During the mean follow-up of 17.9 mo (range, 0.6 to 33.9 mo), 46 deaths (50% of cardiovascular causes) were observed. Overall 1-yr survival was 70% and 93% for patients with and without valvular calcification (P < 0.0001, log-rank test). Cardiovascular mortality was 22% and 3% for patients with and without valvular calcification (P < 0.0001). Multivariable Cox regression analysis showed that cardiac valve calcification was predictive of an increased all-cause mortality (hazard ratio [HR], 2.50; 95% CI, 1.32 to 4.76; P = 0.005) and cardiovascular death (HR 5.39; 95% CI, 2.16 to 13.48; P = 0.0003) independent of age, male gender, dialysis duration, C-reactive protein, diabetes, and atherosclerotic vascular disease. Eighty-nine percent of patients with both valvular calcification and atherosclerotic vascular disease, 23% of patients with valvular calcification only, 21% of patients with atherosclerotic vascular disease only, and 13% of patients with neither complication died at 1-yr (P < 0.0005). The cardiovascular death rate was 85% for patients with both complications, 13% for patients with valvular calcification only, 14% for patients with atherosclerotic vascular disease only, and 5% for those with neither complication (P < 0.0005). The number of calcified valves was associated with all-cause mortality (P < 0.0005) and cardiovascular death (P < 0.0005). One-year all-cause mortality was 57% for patients with both aortic and mitral valves calcified, 40% for those with either valve calcified, and 15% for those with neither valve calcified. In conclusion, cardiac valve calcification is a powerful predictor for mortality and cardiovascular deaths in long-term dialysis patients. Valvular calcification by itself has similar prognostic importance as the presence of atherosclerotic vascular disease. Its coexistence with other atherosclerotic complications indicates more severe disease and has the worst outcome.

[Arteriosclerosis -- a lifelong challenge]

BACKGROUND

Effective prevention of cardiovascular diseases is of utmost importance in Western civilizations as they are on top of mortality statistics.

PRIMARY PREVENTION

Physical exercise plays an important role in optimizing the individuals cardiovascular risk profile. However in the absence of scientifically based studies the potential benefit of physical exercise is often being discussed. Recently by several population-based studies it has been proven that physical exercise is inversely related to long-term cardiovascular mortality in both man and women of all age groups, even after adjustment for other risk factors.

SECONDARY PREVENTION

Even for secondary prevention in clinical studies and meta-analyses a reduction of all causes and cardiovascular mortality of 20-45% was found after physical exercise.

TYPE OF SPORTS

At present it is being discussed controversially which type of sports would be most beneficial. Recent studies have shown that cardiovascular risk reduction is not only the consequence of vigorous exercise, especially endurance training, but can also be achieved by moderate training programs like walking or increased daily activities.

CONCLUSION

Current epidemiological data reveal the necessity to perform more physical activity/exercise training, which would best be integrated in a health-oriented lifestyle. An early beginning, even in childhood, is important.

Endovascular stent-graft repair of complicated penetrating atherosclerotic ulcers of the descending thoracic aorta

OBJECTIVE

To report our initial experience with endovascular stent-graft repair of complicated penetrating atherosclerotic ulcers as an alternative to surgery in patients with increased risk of perioperative morbidity and mortality.

METHOD

During a 2-year period, eight patients with complicated penetrating atherosclerotic ulcers of the descending thoracic aorta were treated with the Gore Excluder stent-graft. Patients (mean age, 70.6 years) presented with two to five comorbid conditions causing an increased risk for surgical repair. In addition to painful events, three patients presented with severe hemoptysis, one patient with shortness of breath, and one patient with dysphagia. All patients underwent emergency computed tomography, and diagnosis of contained rupture was confirmed in five patients. Computed tomographic findings included one to three penetrating ulcers per patient (n = 4), pseudoaneurysms (n = 5), additional intramural hematomas (n = 4), mediastinal bleeding (n = 2), and hematothoraces (n = 4). Through an iliac or femoral access site, a total of 11 stent-grafts were implanted under general (n = 5), epidural (n = 2), or spinal (n = 1) anesthesia.

RESULTS

Deployment of stent-grafts was successful in all patients, and all sites of hemorrhage were sealed. The intramural hematoma resolved completely in three cases, and two pseudoaneurysms decreased in size. Intentional occlusion of the origin of left subclavian artery with the stent-graft in one patient was tolerated without left arm or cerebral symptoms. One patient experienced permanent paraplegia immediately after endovascular repair. There were no deaths during the hospital stay (range, 7-35 days; mean, 14.5 days). One patient was lost to follow-up after hospital discharge. The clinical observation period for the remaining seven patients was 38 to 99 weeks (mean, 60 weeks).

CONCLUSIONS

Endovascular stent-graft repair in complicated penetrating atherosclerotic ulcers is an alternative therapeutic option to conventional thoracotomy, especially in patients at high risk of increased morbidity and mortality perioperatively and postoperatively.

Awareness of Austrian physicians of risk factors for the development of atherosclerosis

OBJECTIVE

In industrialised countries, coronary heart- (CHD) and other atherosclerosis-associated diseases (AAD) are, with an increasing incidence, responsible for almost half of the deaths among their respective populations. There is unequivocal evidence that medicine should try to achieve a reduction in manifestations of atherosclerosis by efficient preventive strategies. A variety of guidelines have been published during the last decades; nevertheless there is a gap between established recommendations and its application in everyday practice by Austrian physicians. The aim of this survey was to investigate physicians' knowledge of and attitude towards risk factors, preventive strategies and therapy of CHD and other AAD.

METHODS

The self-administered questionnaire was mailed to 1000 physicians. We obtained an answer from a total of 286 physicians (general practitioners, GP) and specialists in internal medicine, IMS), who were asked about selected items concerning CHD and other AAD and an eventual modification in attitude towards diagnosis and treatment according to their own, personal risk profile.

RESULTS

Risk factors for developing AAD such as elevated CH was identified in 77% (74% GP vs. 84% IMS), hypertension in 77% (76% GP vs. 81% IMS), elevated TG in 37% (40% GP vs. 26% IMS), excess alcohol consumption in 14% of all interrogated physicians (16% GP vs. 9% IMS) respectively. 77% (75% GP vs. 81% IMS) of the physicians considered the CH/HDL-ratio to be important in primary prevention and 83% (81% GP vs. 87% IMS) in secondary prevention; Lipoprotein(a) was considered important in only 9% (8% GP vs. 14% IMS) and 24% (19% GP vs. 41% IMS), respectively.

CONCLUSION

In summary, all mentioned risk factors were heavily underestimated by Austrian physicians, partly leading to insufficient evaluation and therapeutic interventions. Secondary prevention was managed quite satisfactorily by both GP and IMS according to the Austrian guidelines. The knowledge about primary prevention strategies was significantly worse in GP compared to IMS. There is still a great need for information and training-programs for Austrian physicians to make primary and secondary prevention strategies work more effectively.

Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in atherosclerosis

Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) effectively interfere with the renin-angiotensin system and exert various beneficial actions on cardiac and vascular structure and function, beyond their blood pressure-lowering effects. Randomized, controlled clinical trials have shown that ACE inhibitors improve endothelial function, cardiac and vascular remodeling, retard the anatomic progression of atherosclerosis, and reduce the risk of myocardial infarction, stroke, and cardiovascular death. Therefore, these agents are recommended in the treatment of a wide range of patients at risk for adverse cardiovascular outcomes, including those with coronary disease, prior stroke, peripheral arterial disease, high-risk diabetes, hypertension, and heart failure. ARBs are effective blood pressure- lowering and renoprotective agents and can be used in heart failure in patients who do not tolerate ACE inhibitors. The role of ARBs in the prevention of atherosclerosis and its sequelae is currently under investigation. The use of combined ACE inhibitor plus ARB therapy offers theoretical advantages over the use of each of these agents alone and is also under investigation in large, randomized clinical trials.

Selective stenting and the course of atherosclerotic renovascular nephropathy

BACKGROUND

The effectiveness of percutaneous revascularisation (PTRA) in the treatment of atherosclerothic renovascular nephropathy (ARN), a leading cause of progressive renal failure, is still a matter of debate.

METHODS

we reviewed 52 patients submitted to selective stenting from 1991 to 2000 because of ARN, followed for a mean of 22.3 months before and 24.6 after the procedure, looking for complications, re-stenosis rates, blood pressure, renal function and survival.

RESULTS

Arterial patency was achieved in 97.1% of procedures (71.6% by stent deployment); complications occurred in 42% of patients, and re-stenoses in 17.3% of vessels, most often in those without a stent (31.6% vs 8.3%). No effect was detectable on hypertension and renal failure in the whole group, but in the subgroup without technical failure or early dialysis start PTRA reduced the creatinine clearance (BCRC) decline from 0.9 to 0.19 mL/min/month. At univariate analysis, BCRC outcome was better in bilateral or single kidney stenoses, proteinuria < 1 g/day, serum creatinine < 4 mg/dL and resistance index < 0.8. Survival was 68.9% at five years, with a mortality rate of 4.5/100 person-years.

CONCLUSIONS

Renal outcome of successful PTRA differs from case to case, but efficacy is substantial. Primary stenting in ostial stenosis and selection of patients based on prognostic factors seem likely to improve the effectiveness.

Oxidative stress, alpha-tocopherol therapy, and atherosclerosis

Atherosclerosis is the leading cause of morbidity and mortality in the United States. Evidence suggests that antioxidants, especially alpha-tocopherol (AT), have potential benefits with respect to cardiovascular disease. AT has been shown to decrease lipid peroxidation, to inhibit platelet adhesion, aggregation, and smooth muscle cell proliferation, to exert anti-inflammatory effects on monocytes, and to improve endothelial function. Low levels of AT are related to a higher incidence of cardiovascular disease and increased intakes appear to afford protection against cardiovascular disease. Although clinical trials with AT supplementation to date have been conflicting, the majority of evidence supports a benefit for AT supplementation in patients with pre-existing cardiovascular disease. Clearly, more clinical trials are required in individuals with increased oxidative stress before a definitive recommendation can be made with respect to AT supplementation in atherosclerosis.

Subclinical atherosclerosis and estimated glucose disposal rate as predictors of mortality in type 1 diabetes

PURPOSE

To investigate the usefulness of ischemic resting electrocardiogram (ECG), ankle brachial index (ABI) <0.8, ankle brachial difference (ABD) > or = 75 mm Hg (a marker of peripheral medial arterial wall calcification), and estimated glucose disposal rate (eGDR) (a marker for insulin resistance) for predicting mortality risk in the context of standard risk factors.

METHODS

Data are from participants in the Pittsburgh Epidemiology of Diabetes Complications Study of 658 subjects with childhood onset Type 1 diabetes of mean age 28 years (range 8-48) and duration of diabetes 19 years (range 7-37) at baseline. Deaths were confirmed by death certificates.

RESULTS

There were 68 deaths from all causes during 10 years follow-up. In univariate analysis, the mortality hazard ratios and 95% confidence intervals associated with ischemic ECG (6.7, 3.7-12.1), the lowest quintile of eGDR (i.e., the most insulin resistant) (6.7, 4.1-10.9), ABI <0.8 (2.5, 1.1-5.9), and ABD > or = 75 mm Hg (6.7) were only marginally less than those conveyed by pre-existing coronary artery disease (8.4, 4.7-15.2) or overt nephropathy (7.6, 4.5-12.9). Ischemic ECG and eGDR were independent mortality predictors, together with duration of diabetes, coronary artery disease, overt nephropathy, nonhigh density lipoprotein cholesterol, and smoking history. If serum creatinine was available, it entered, and glycosylated hemoglobin replaced eGDR.

CONCLUSIONS

Estimated GDR and ECG ischemia are strong predictors of mortality in type 1 diabetes and may be useful in the identification of those at risk.

[Arteriosclerotic renal artery stenosis. Significance, diagnosis and therapy options]

BACKGROUND

Renal artery stenosis (RAS) can cause arterial hypertension and can lead to renal insufficiency. In 1999 16% of patients starting dialysis in Germany suffered from ischemic nephropathy.

SCREENING

Cost-effective screening for RAS should be done by Doppler sonography or captopril renography. Doppler sonographic findings can be predictive in respect to progression of stenosis, renal atrophy and postinterventional course of hypertension and kidney survival.

TREATMENT

The results of recent studies are helpful to select patients for preferential drug treatment or for interventional treatment.

The effect of decision rules on the choice of a body mass index cutoff for obesity: examples from African American and white women

BACKGROUND

Ethnic differences in the relation of body mass index (BMI; in kg/m2) to morbidity and mortality have led investigators to question whether a single cutoff for obesity should be applied to all ethnic groups.

OBJECTIVE

The effects of using 4 different outcomes and 3 different measures of effect as criteria for comparing BMI cutoffs were shown with the use of data from 45- to 64-y-old African American and white women.

DESIGN

Data were from the Cancer Prevention Study I (CPS-I) and the Atherosclerosis Risk in Communities (ARIC) Study. The outcomes were mortality (9211 deaths), diabetes (757 cases), hypertension (1518 cases), and hypertriglyceridemia (1264 cases). The measures of effect were incidence rate, rate ratio, and rate difference. The BMI in African American women that was associated with a risk equivalent to that of white women with a BMI of 30 was estimated.

RESULTS

There was no significant association between BMI and mortality in African American women. The BMI in African American women that was associated with a risk of diabetes equivalent to that of white women with a BMI of 30 was 28.0-34.5, depending on the measure of effect. For hypertension, the equivalent risk in African American women occurred at a BMI of <18-38, depending on the measure of effect. There was no BMI at which African American women had an incidence rate or rate ratio for hypertriglyceridemia that was as high as that of white women with a BMI of 30.

CONCLUSION

BMI cutoffs associated with equivalent risk across ethnic groups differ widely depending on the outcome and the risk estimate.

PAD. Epidemiology and pathophysiology

The real prevalence of Peripheral Arterial Disease (PAD) is considerably underestimated if only symptomatic patients (i.e those with Intermittent Claudication) are taken into account instead of subjects with instrumental abnormalities such as a low Ankle-Branchial Index (ABI). The risk of both-fatal and non-fatal-cardiovascular events is particularly high in these patients either presenting with symptoms or asymptomatic. On the contrary the tendency to local worsening (need of revascularization or amputation of leg) is reduced. PAD is markedly prevailing in elderly, with a peak of incidence after the fifth decade of life. Owing to this, the prevalence is not significantly different in men compared to women. The risk factors related to PAD are the same as those observed in the other locations of atherosclerosis but cigarette smoking and diabetes seem to be more often associated to PAD than the remaining factors.

A prospective study of the determinants of renal functional outcome and mortality in atherosclerotic renovascular disease

Atherosclerotic renovascular disease (ARVD) commonly causes renal failure and hypertension and is accompanied by high cardiovascular comorbidity and mortality. Interrelationships between these factors remain poorly understood. Patients with ARVD presenting to a single center between 1995 and 1999 were followed up, with prospective collection of clinical and biochemical data. Fifty men and 48 women were identified. Mean age at entry was 68.7 +/- 8.3 (SD) years, and baseline creatinine clearance (CrCl) was 35.5 +/- 20.7 mL/min. During follow-up (27.7 +/- 18.7 months), 10 patients required dialysis therapy, 11 patients underwent revascularization, and 35 patients (36%) died. Patients in whom renal function deteriorated during follow-up (n = 61) had similar ages, baseline CrCls, blood pressures, and comorbidities compared to patients with stable function. Mortality (55.7% versus 27.0%; P < 0.01) and proteinuria (protein, 1.3 +/- 1.6 versus 0.3 +/- 0.4 g/24 h; P < 0.001) were greater in patients with declining function. Baseline renal function was not significantly related to blood pressure, proteinuria, or change in renal function during follow-up (change in CrCl), but patients with a lower CrCl had increased mortality. There was no increase in cardiovascular comorbidity in groups with lower renal function. Patients with the most severe anatomic ARVD had worse hypertension and increased mortality, but severity of ARVD was unrelated to extent of renal dysfunction and proteinuria at baseline. Lack of correlation between renal artery anatomy and baseline renal function or functional outcome and correlation between renal functional outcome and proteinuria suggest that renal parenchymal damage is a major determinant of renal dysfunction and outcome in ARVD.

Characteristics of intact and ruptured atherosclerotic plaques in brachiocephalic arteries of apolipoprotein E knockout mice

The brachiocephalic arteries of fat-fed apolipoprotein E knockout mice develop plaques that frequently rupture and form luminal thromboses. The morphological characteristics of plaques without evidence of instability or with healed previous ruptures (intact) and vessels with acutely ruptured plaques (ruptured) have now been defined, to understand the process of plaque destabilization in more detail. Ninety-eight apolipoprotein E knockout mice were fed a diet supplemented with 21% lard and 0.15% cholesterol, for 5 to 59 weeks. Of these 98 mice, 51 had an acutely ruptured plaque in the brachiocephalic artery. Ruptured and intact plaques differed in terms of plaque cross-sectional area (intact, 0.109+/-0.016 mm2; ruptured, 0.192+/-0.009 mm2; P=0.0005), luminal occlusion (intact, 35.3+/-3.3%; ruptured, 57.7+/-1.9%; P<0.0001), the number of buried caps within the lesion (intact, 1.06+/-0.12; ruptured, 2.66+/-0.16; P<0.0001), fibrous cap thickness (intact, 4.7+/-0.6 microm; ruptured, 2.0+/-0.3 microm; P=0.0004), and lipid fractional volume (intact, 35.9+/-3.0%; ruptured, 50.7+/-2.2%; P=0.0019). This study confirms that plaque rupture is a frequent occurrence in the brachiocephalic arteries of apolipoprotein E knockout mice on a high-fat diet. The data also show that ruptured plaques in these mice show many of the characteristics of vulnerable plaques in humans. This supports the use of this model in studies of the mechanisms and therapy of plaque rupture.

[Manifestations of atherosclerosis in various vascular regions. Similarities and differences regarding epidemiology, etiology and prognosis]

Pathologic studies have demonstrated that atherosclerosis involves the whole arterial vessel tree. In the Framingham study, cardiovascular risk factors could be defined with different prognostic value for the development of atherosclerosis in various vascular regions. The prognosis of patients with atherosclerosis in coronary, carotid or leg arteries is worse compared to a normal population. Moreover, patients with symptomatic lesions in one vascular bed often have additional asymptomatic atherosclerotic lesions in other vascular regions. Patients with atherosclerosis in multiple vascular regions have a worse prognosis than patients with atherosclerosis in one vascular bed only. In a study of 804 patients, we could show a significantly higher incidence of cardiovascular events (death, myocardial infarction, stroke) in patients with coronary artery disease (CAD) and additional lesions in peripheral arteries (leg, carotid) during a 3.2-year follow-up compared to those with CAD only. Local and systemic inflammatory processes in the arterial vessel wall are considered to play an important role with regard to plaque instability. It has been suggested, that besides the symptomatic atherosclerotic lesion, multiple stable or unstable lesions are present in the whole arterial vessel tree predicting the patient's prognosis. Chronic infections with multiple pathogens ("concept of infectious burden") probably play an important role by triggering these inflammatory processes. Therefore, systemic therapeutic regimes are necessary for the treatment of patients with atherosclerosis. The platelet aggregation inhibitors improve the prognosis of patients with atherosclerosis in all vascular areas. Another important therapeutic regime is the use of statins, which seem to be not only effective in lipid lowering but also in plaque stabilization.

[Long-term results of aortic arch replacement using combination of deep hypothermic circulatory arrest and retrograde cerebral perfusion; comparison of result for atherosclerotic aneurysm and aortic dissection]

Between 1992 and 2001, 73 patients with aortic arch lesion underwent surgical treatment. The aneurysm was characterized by atherosclerosis in 54 patients (TAA) and by aortic dissection in 19 patients (DAA). All patients received graft replacement under combination of deep hypothermic circulatory arrest and retrograde cerebral perfusion. The hospital mortality rate for all patients was 15.6%. The follow-up period of 61 survival patients ranged from 2 to 90 months (mean 33.2 months). The actuarial survival rate was 93.2%, 83.5%, and 79.7% at 1, 3, and 5 years, respectively. No significant difference was noted between TAA and DAA in the actuarial survival rate. The freedom from vascular complication was 97.9%, 95.8%, and 95.8% at 1, 3, and 5 years, respectively. The rate was significant higher in the patients of DAA than in those of TAA (TAA: 100%, 100%, and 100%, DAA: 90.9%, 81.8%, and 81.8%). The freedom from cardiac complication was 96.4%, 89.7%, and 84.1% at 1, 3, and 5 years, respectively. There was no significant difference between TAA and DAA. The freedom from cerebrovascular complication was 100%, 97.6%, and 83.4% at 1, 3, and 5 years, respectively. No significant difference was noted between TAA and DAA. The late result of surgical treatment for the aortic arch using combination of deep hypothermic circulatory arrest and retrograde cerebral perfusion was satisfied. The long-term survival rate was higher in TAA patient than in DAA one. The possibility remained that fatal vascular complication affected the long-term survival rate.

Outcome of conservative versus interventional treatment of subclavian artery stenosis

PURPOSE

To compare the outcome of conservative treatment versus percutaneous transluminal angioplasty (PTA) of subclavian artery stenosis in terms of long-term hemodynamic and symptomatic outcome in a retrospective, nonrandomized study.

METHODS

Within a 14-year period, 295 consecutive inpatients were treated for subclavian artery stenosis. Excluding 21 (7%) surgical cases, the remaining 274 patients were treated either conservatively (n = 165) or with PTA (n = 109). Medical history, physical findings, and sonographic and angiographic data were recorded from the medical records of the 223 (81%) patients who were followed until the year 2000; 166 patients were then reinvestigated with oscillography, Doppler measurements, and duplex sonography. Outcomes of conservative versus interventional therapy were analyzed based on the intention to treat principle.

RESULTS

After a median 42-month follow-up (interquartile range 18-85), patients treated with PTA had a 60% risk reduction for hemodynamic subclavian stenosis compared to conservative treatment (adjusted hazard ratio 0.4, 95% confidence interval 0.2-0.6, p<0.0001). However, the risk of having a symptomatic stenosis at the time of follow-up did not differ between the treatment groups (p=0.3).

CONCLUSIONS

Endovascular revascularization improves the long-term hemodynamic outcome in patients with subclavian stenosis, but many conservatively treated patients become asymptomatic during follow-up. Interventional treatment may be considered primarily for patients with severe symptoms of vertebrobasilar insufficiency, critical ischemia, or peripheral emboli.

[Early and late survival of total aortic arch replacement in patients with dissecting or atherosclerotic aneurysm]

Forty-seven patients (pts) were underwent total aortic arch replacement (TAAR) were studied to compare the early and late results between atherosclerotic (AA) and dissecting aneurysm (DA). There were 23 pts with AA and 24 pts with 24 pts. Preoperative risk were observed with shock in 12 pts (26%), major organ ischemia in 2 pts (4%), rupture in 8 pts (17%), stroke in 8 pts (17%) and coronary artery disease in 4 pts (9%). Operative procedure was TAAR in 22 pts, TAAR with ascending aorta replacement in 14 pts, and TAA with descending aorta replacement in 11 pts. Hospital mortality was 21 pts (45%) and late mortality was a surgical death after thoracoabdominal aneurysm in 1 pts. There was no difference in early and late survival rate, however early mortality was higher in pts with ruptured AA and with DA suffered from preoperative shock. There were 19 of early death in recent pts without rupture in AA and preoperative shock in DA.

Repair of the thoracic aorta by transaortic stent grafting (open stenting)

BACKGROUND

The late results of direct open stent grafting of the aortic arch for aortic arch repair have not been reported previously.

METHODS

Between September 1997 and December 2000 19 patients underwent open stent grafting with carotid artery bypass for thoracic arteriosclerotic aneurysms (TAA) of the distal aortic arch. In addition, 21 patients underwent open stent grafting with total aortic arch replacement for Stanford type A acute aortic dissection and 7 patients underwent stenting with carotid bypass for Stanford type B chronic aortic dissection.

RESULTS

The early mortality rate was 11% for TAA, 10% for type A dissection, and 0% for type B dissection. Whereas none of the TAA or type A dissection required a second operation on the thoracic aorta, 1 TAA patient died 6 months postoperatively after sudden aortic rupture and 1 type B patient required descending aortic replacement because of ulceration caused by the stent graft at 11 months postoperatively. On follow-up computed tomography scan, in TAA patients, true aneurysms excluded by the stent graft showed early thrombosis, but the absorption of thrombosed aneurysms started from 1 to 6 months postoperatively and gradually progressed. In patients with type B chronic dissection, the false lumen showed early thrombosis and the true lumen was dilated at the central portion of the graft, which might increase turbulent flow by interaction with the stent. In patients with type A acute dissection, the false lumen showed both early thrombosis and early absorption.

CONCLUSIONS

Early and late results of open stenting are acceptable and follow-up computed tomography scan may be able to predict late results of open stenting.

Surgical management of atherosclerotic renovascular disease

OBJECTIVE

This review describes the clinical outcome of surgical intervention for atherosclerotic renovascular disease in 500 consecutive patients with hypertension.

METHODS

From January 1987 to December 1999, 626 patients underwent operative renal artery (RA) repair at our center. A subgroup of 500 patients (254 women and 246 men; mean age, 65 plus minus 9 years) with hypertension (mean blood pressure, 200 plus minus 35/104 plus minus 21 mm Hg) and atherosclerotic RA disease forms the basis of this report. Hypertension response was determined from preoperative and postoperative blood pressure measurements and medication requirements. Change in renal function was determined with estimated glomerular filtration rates (EGFRs) calculated from serum creatinine levels. Proportional hazards regression models were used for the examination of associations between selected preoperative parameters, blood pressure and renal function response, and eventual dialysis-dependence or death.

RESULTS

Two hundred three patients underwent unilateral RA procedures, 297 underwent bilateral RA procedures, and 205 patients underwent combined renal and aortic reconstruction. After surgery, there were 23 deaths (4.6%) in the hospital or within 30 days of surgery. Significant and independent predictors of perioperative death included advanced age (P <.0001; hazard ratio [HR], 3.23; 95% confidence interval [CI], 1.85 to 5.70) and clinical congestive heart failure (P =.013; HR, 3.05; 95% CI, 1.26 to 7.34). Among the patients who survived surgery, hypertension was considered cured in 12%, improved in 73%, and unchanged in 15%. For the entire group, renal function increased significantly after operation (preoperative versus postoperative mean EGFR, 41.1 plus minus 23.9 versus 48.2 plus minus 25.5 mL/min/m(2); P <.0001). For individual patients, with a 20% or more change in EGFR considered significant, 43% had improved renal function (including 28 patients who were removed from dialysis-dependence), 47% had unchanged function, and 10% had worsened function. Preoperative renal insufficiency (P <.001; HR, 2.35; 95% CI, 1.86 to 2.98), diabetes mellitus (P =.007; HR, 2.14; 95% CI, 1.15 to 3.97), prior stroke (P =.042; HR, 1.50; 95% CI, 1.02 to 2.22), and severe aortic occlusive disease (P =.003; HR, 1.69; 95% CI, 1.19 to 2.31) showed significant and independent associations with death or dialysis during the follow-up examination period. After operation, blood pressure cured (P =.014; HR, 0.52; 95% CI, 0.30 to 0.88) and improved renal function (P =.011; HR, 0.40; 95% CI, 0.19 to 0.81) showed significant and independent associations with improved dialysis-free survival rate. All categories of function response and time to death or dialysis showed significant interactions with preoperative EGFR.

CONCLUSION

The surgical correction of atherosclerotic renovascular disease resulted in blood pressure benefit and retrieval of renal function in selected patients with hypertension. The patients with cured hypertension or improved EGFR after operation showed increased dialysis-free survival as compared with other patients who underwent surgery.