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Katz AE, Gupte T, Ganesh SK. From Atherosclerosis to Spontaneous Coronary Artery Dissection: Defining a Clinical and Genetic Risk Spectrum for Myocardial Infarction. Curr Atheroscler Rep 2024; 26:331-340. [PMID: 38761354 DOI: 10.1007/s11883-024-01208-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2024] [Indexed: 05/20/2024]
Abstract
PURPOSE OF REVIEW Spontaneous coronary artery dissection (SCAD) has been increasingly recognized as a significant cause of acute myocardial infarction (AMI) in young and middle-aged women and arises through mechanisms independent of atherosclerosis. SCAD has a multifactorial etiology that includes environmental, individual, and genetic factors distinct from those typically associated with coronary artery disease. Here, we summarize the current understanding of the genetic factors contributing to the development of SCAD and highlight those factors which differentiate SCAD from atherosclerotic coronary artery disease. RECENT FINDINGS Recent studies have revealed several associated variants with varying effect sizes for SCAD, giving rise to a complex genetic architecture. Associated genes highlight an important role for arterial cells and their extracellular matrix in the pathogenesis of SCAD, as well as notable genetic overlap between SCAD and other systemic arteriopathies such as fibromuscular dysplasia and vascular connective tissue diseases. Further investigation of individual variants (including in the associated gene PHACTR1) along with polygenic score analysis have demonstrated an inverse genetic relationship between SCAD and atherosclerosis as distinct causes of AMI. SCAD represents an increasingly recognized cause of AMI with opposing clinical and genetic risk factors from that of AMI due to atherosclerosis, and it is often associated with complex underlying genetic conditions. Genetic study of SCAD on a larger scale and with more diverse cohorts will not only further our evolving understanding of a newly defined genetic spectrum for AMI, but it will also inform the clinical utility of integrating genetic testing in AMI prevention and management moving forward.
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Affiliation(s)
- Alexander E Katz
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
- Department of Human Genetics, University of Michigan, Ann Arbor, MI, USA
| | - Trisha Gupte
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Santhi K Ganesh
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA.
- Department of Human Genetics, University of Michigan, Ann Arbor, MI, USA.
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Eltabbakh A, Khudair A, Khudair A, Fredericks S. Spontaneous coronary artery dissection and fibromuscular dysplasia: insights into recent developments. Front Cardiovasc Med 2024; 11:1409278. [PMID: 38883987 PMCID: PMC11176522 DOI: 10.3389/fcvm.2024.1409278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Accepted: 05/20/2024] [Indexed: 06/18/2024] Open
Abstract
Spontaneous coronary artery dissection (SCAD), an uncommon cause of acute coronary syndrome, continues to be a poorly understood disease predominantly affecting females. It is characterized by an abrupt separation in the coronary arterial wall due to intramural bleeding. Fibromuscular dysplasia (FMD) is a non-atherosclerotic arteriopathy manifesting in medium and small-sized arteries. It is a concomitant disease found among SCAD patients. In some studies, FMD prevalence in SCAD patients ranges between 25%-86%, which can be explained through varying screening techniques or modalities. The potential association has been elucidated in some studies; notably, not only has a genetic link been recently delineated between SCAD and FMD, but there is data to suggest that FMD not only can predispose to SCAD but can also be a potential predictor of its recurrence. However, a clear-cut correlation between the two has still not been established due to conflicting reports in the literature. To further dive into its pathology, it is crucial to highlight the importance of systematic screening in SCAD in order to identify associated risk factors and to be used as a method of FMD detection in such patients. Together, the two pathologies pose unique challenges in understanding its pathophysiology, diagnosis and management, as there is no clear evidence of a definitive treatment plan for patients with SCAD and FMD. A potentially beneficial modality of management is physical exercise, which is currently understudied in the long-term approach to treatment for patients with concomitant SCAD and FMD. Limited research in this field brings disadvantages to the understanding of the association between these two diseases, in order to give rise to better management recommendations. This mini-review aims to highlight the recent developments in the association between SCAD and FMD, its potential genetic association and some insights in screening, diagnosis, and management.
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Affiliation(s)
- Ayah Eltabbakh
- Department of Medicine, Royal College of Surgeons in Ireland-Bahrain, Busaiteen, Bahrain
| | - Ahmed Khudair
- Department of Medicine, Royal College of Surgeons in Ireland-Bahrain, Busaiteen, Bahrain
| | - Aiman Khudair
- Department of Medicine, Royal College of Surgeons in Ireland-Bahrain, Busaiteen, Bahrain
| | - Salim Fredericks
- Department of Medicine, Royal College of Surgeons in Ireland-Bahrain, Busaiteen, Bahrain
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Cersonsky TE, Roth J. A Midsummer Night's Gene: The familial Neurological Illness of Felix Mendelssohn. JOURNAL OF MEDICAL BIOGRAPHY 2024; 32:264-272. [PMID: 34636685 DOI: 10.1177/09677720211046584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Felix Mendelssohn Bartholdy (1805-1847) is widely regarded as one of the musical geniuses of the Romantic period. A prodigy akin to Mozart, Mendelssohn composed piano works, symphonies, and concertos at an early age but died young, at 38. His death has been attributed to neurological disease, but the mystery of his diagnosis is amplified by the fact that his sisters died under similar circumstances, including the renowned composer, Fanny Mendelssohn Hensel. Mendelssohn died after years of suffering from headaches, earaches, and mood disturbances. In the final year of his life, his acute decline was marked by stepwise, progressive neurologic deficits: gait disturbance, loss of sensation in the hands, partial paralysis, and, finally, loss of consciousness. The similar pattern of disease within his family suggests an underlying genetic link, though this may be multifactorial in nature. We present a thorough, posthumous differential diagnosis for Mendelssohn's illness, given his medical history, the familial pattern, and hints from within his music. Possible diagnoses include ruptured cerebral aneurysm with resultant subarachnoid hemorrhage, familial cerebral cavernous malformation, and cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL). Continued research into Mendelssohn's life may yield more information about his illness, death, and possibly true diagnosis.
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Affiliation(s)
- Tess Ek Cersonsky
- Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Julie Roth
- Warren Alpert Medical School of Brown University, Providence, RI, USA
- Department of Neurology, Rhode Island Hospital, Providence, RI, USA
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Pierce TT, Prabhu V, Baliyan V, Hedgire S. Imaging of Visceral Vessels. Radiol Clin North Am 2024; 62:543-557. [PMID: 38553185 DOI: 10.1016/j.rcl.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
The visceral vasculature is inextricably intertwined with abdominopelvic disease staging, spread, and management in routine and emergent cases. Comprehensive evaluation requires specialized imaging techniques for abnormality detection and characterization. Vascular pathology is often encountered on nondedicated routine imaging examinations, which may obscure, mimic, or confound many vascular diagnoses. This review highlights normal arterial, portal venous, and systemic venous anatomy and clinically relevant variants; diagnostic pitfalls related to image-acquisition technique and disease mimics; and characteristics of common and rare vascular diseases to empower radiologists to confidently interpret the vascular findings and avoid misdiagnosis.
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Affiliation(s)
- Theodore T Pierce
- Department of Radiology, Harvard Medical School, Massachusetts General Hospital, White Building, Room 270, 55 Fruit Street, Boston, MA 02114, USA.
| | - Vinay Prabhu
- Department of Radiology, NYU Langone Health, 660 First Avenue, Third Floor, New York, NY 10016, USA
| | - Vinit Baliyan
- Division of Cardiovascular Imaging, Department of Radiology, Massachusetts General Hospital-Harvard Medical School, 175 Cambridge Street, Boston, MA 02114, USA
| | - Sandeep Hedgire
- Division of Cardiovascular Imaging, Department of Radiology, Massachusetts General Hospital-Harvard Medical School, 175 Cambridge Street, Boston, MA 02114, USA
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Saha MK. Overview of Vasculitides in Adults. Neuroimaging Clin N Am 2024; 34:1-12. [PMID: 37951696 DOI: 10.1016/j.nic.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
Vasculitis is characterized by the inflammation of blood vessels. Vasculitides refers to the different forms of vasculitis, often classified according to the size of the blood vessel that is involved. Vasculitis may occur as a primary process or secondary to many systemic diseases. This topic provides an overview of the clinical features, diagnosis, and classification of the different forms of vasculitides.
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Affiliation(s)
- Manish K Saha
- Division of Nephrology, University of North Carolina, Chapel Hill, NC, USA.
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Al Mubarak HA, Alshalan SM, Alkhunaizi NB, Alorabi AH, Abdulfatah AM. A Case Report on Fibromuscular Dysplasia With Extrarenal Involvement. Cureus 2023; 15:e50358. [PMID: 38213346 PMCID: PMC10781897 DOI: 10.7759/cureus.50358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2023] [Indexed: 01/13/2024] Open
Abstract
Fibromuscular dysplasia is a vascular disorder characterized by nonatherosclerotic, noninflammatory arterial abnormalities, primarily affecting renal arteries. While extrarenal involvement is rare, it poses diagnostic challenges due to diverse clinical presentations. We present the case of a middle-aged female who presented with sudden-onset severe abdominal pain and hypertension. Physical examination revealed tenderness, guarding, and hypertensive urgency. Diagnostic workup, including laboratory investigations and computed tomography, identified multifocal arterial stenosis in both renal and mesenteric arteries, consistent with fibromuscular dysplasia. A multidisciplinary team initiated antihypertensive medications and performed angioplasty to address vascular stenosis. The patient showed significant improvement post intervention, highlighting the efficacy of a comprehensive management strategy. This case underscores the clinical complexities of fibromuscular dysplasia, emphasizing the diagnostic challenges posed by extrarenal manifestations. The successful multidisciplinary intervention highlights the importance of timely and targeted measures in addressing both renal and extrarenal complications.
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Affiliation(s)
| | | | | | - Abdullah H Alorabi
- General Practice, Ibn Sina National College for Medical Studies, Jeddah, SAU
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Katz AE, Ganesh SK. Advancements in the Genetics of Spontaneous Coronary Artery Dissection. Curr Cardiol Rep 2023; 25:1735-1743. [PMID: 37979122 PMCID: PMC10810930 DOI: 10.1007/s11886-023-01989-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/24/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE OF REVIEW Spontaneous coronary artery dissection (SCAD) is a significant cause of acute myocardial infarction that is increasingly recognized in young and middle-aged women. The etiology of SCAD is likely multifactorial and may include the interaction of environmental and individual factors. Here, we summarize the current understanding of the genetic factors contributing to the development of SCAD. RECENT FINDINGS The molecular findings underlying SCAD have been demonstrated to include a combination of rare DNA sequence variants with large effects, common variants contributing to a complex genetic architecture, and variants with intermediate impact. The genes associated with SCAD highlight the role of arterial cells and their extracellular matrix in the pathogenesis of the disease and shed light on the relationship between SCAD and other disorders, including fibromuscular dysplasia and connective tissue diseases. While up to 10% of affected individuals may harbor a rare variant with large effect, SCAD most often presents as a complex genetic condition. Analyses of larger and more diverse cohorts will continue to improve our understanding of risk susceptibility loci and will also enable consideration of the clinical utility of genetic testing strategies in the management of SCAD.
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Affiliation(s)
- Alexander E Katz
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, USA
- Department of Human Genetics, University of Michigan, 7220, MSRB III, 1150 West Medical Center Drive, Ann Arbor, MI, 48109-0644, USA
| | - Santhi K Ganesh
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, USA.
- Department of Human Genetics, University of Michigan, 7220, MSRB III, 1150 West Medical Center Drive, Ann Arbor, MI, 48109-0644, USA.
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Sorber R, Bowen CJ, Radomski SN, Shalhub S. Prevalence and outcomes of select rare vascular conditions in females: A descriptive review. Semin Vasc Surg 2023; 36:571-578. [PMID: 38030331 DOI: 10.1053/j.semvascsurg.2023.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 09/19/2023] [Accepted: 10/04/2023] [Indexed: 12/01/2023]
Abstract
Rare vascular conditions frequently pose a diagnostic and therapeutic dilemma for health care providers. Several of these conditions have distinct relevance to females populations but, due to their infrequency, there has been little reported on the outcomes of rare vascular conditions specifically in females populations. We performed a literature review of a selection of three rare vascular conditions known to either disproportionately affect females (median arcuate ligament syndrome and fibromuscular dysplasia) or have unique manifestations in females populations (vascular Ehlers-Danlos syndrome). We performed a descriptive review of the literature focused on these three vascular conditions and identified aspects of the current available research describing sex-based differences in prevalence, any pathophysiology explaining the observed sex-based differences, and the contribution of sex to outcomes for each disease process. In addition, considerations for pregnant females with respect to each rare vascular disease process are discussed.
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Affiliation(s)
- Rebecca Sorber
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Medical Institutions, Halsted 668, 600 N Wolfe Street, Baltimore, MD, 21287.
| | - Caitlin J Bowen
- Division of Pediatrics, Boston Children's Hospital, Boston, MA
| | - Shannon N Radomski
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Medical Institutions, Halsted 668, 600 N Wolfe Street, Baltimore, MD, 21287
| | - Sherene Shalhub
- Division of Vascular Surgery, University of Oregon Health Sciences University, Portland, OR
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El-Masri S, Wilson MM, Kleinig T. Systematic review and meta-analysis of ipsilateral and contralateral carotid web prevalence in embolic supratentorial strokes of undetermined source. J Clin Neurosci 2023; 107:118-123. [PMID: 36535218 DOI: 10.1016/j.jocn.2022.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 11/06/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVES A carotid web isdefined as an abnormal shelf-like projection of intimal fibrous tissue into the carotid bulb. Its presence may be an under-recognised source of embolic stroke of undetermined source (ESUS). The aim of this study was to investigate its prevalence in previously reported studies. MATERIALS AND METHODS A systematic literature review of Pubmed, EMBASE, and Scopus was conducted up until the 4/12/2021 using variations of the search terms - 'carotid web' and 'ischemic stroke'. Inclusion criteria were studies reporting carotid web prevalence in an ESUS cohort aged >18 years with adequate imaging. Secondary measures such as age, gender, ethnicity, and laterality were recorded. A meta-analysis of proportions was used to summarise the prevalence of webs along with a random-effects model to calculate the relative risk of ipsilateral and contralateral webs in ESUS. RESULTS The initial search yielded 361 articles, with 11 remaining post the inclusion and exclusion criteria. A meta-analysis of allage groups yielded a total carotid web prevalence among patients with stroke of unknown cause of 9.58 % (95 % CI 5.62 - 15.85). Carotid webs were more often detected in females (76.5 % ± 22.3 %), and in those of African heritage (58 % ± 39 %). In comparison with patients without an ischemic stroke, there was a significant association found for an ipsilateral carotid web (risk ratio of 2.74 (95 % CI: 2.14 - 3.51)) but no association found for contralateral webs (risk ratio of 1.50 (95 % CI: 0.94 - 2.40)). CONCLUSION The prevalence of ipsilateral carotid webs associated with ESUS is substantial, and may be more common in females and in individuals of African descent.
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Affiliation(s)
- Shaddy El-Masri
- Department of Medicine, Royal Melbourne Hospital, Melbourne, Australia.
| | | | - Timothy Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, Australia
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Lu YT, Zhou ZM, Zhang D, Sun L, Liu XC, Yang YK, Jiang XJ, Zhou XL. Percutaneous Transluminal Renal Angioplasty for Fibromuscular Dysplasia and Prognostic Risk Factors: A Retrospective Chinese Cohort Study. J Clin Med 2022; 12:jcm12010023. [PMID: 36614824 PMCID: PMC9821653 DOI: 10.3390/jcm12010023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 12/06/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022] Open
Abstract
Fibromuscular dysplasia (FMD) is a non-atherosclerotic, non-inflammatory vascular disease involving small-to-medium-sized arteries. The characteristics of Chinese patients with FMD remain unclear. We retrospectively analyzed the data of patients with renal FMD who underwent percutaneous transluminal renal angioplasty (PTRA) for the first time at Fuwai Hospital between 2010 and 2021. The variables were selected through least absolute shrinkage and selection operator regression (LASSO), and logistic regression models were constructed to identify independent risk factors. A total of 116 patients (52 males, median age at diagnosis, 25.0 years) were enrolled. Elevated blood pressure was the leading complaint. After a median follow-up period of 18.0 months (interquartile range: 6.0-48.0 months), hypertension recurred in 34 patients and restenosis in nine patients, among whom four patients underwent secondary intervention and one patient underwent surgical revascularization. Bilateral renal artery involvement (odds ratio [OR]: 2.61, 95% confidence interval [CI]: 1.11-6.15; p = 0.028) and age at hypertension onset (OR: 0.93, 95% CI: 0.88-0.99; p = 0.018) were independent prognostic factors for adverse outcomes. The results indicate that patients with bilateral renal artery involvement and younger age at hypertension onset are more likely to have poorer clinical outcomes after PTRA, and should be more closely monitored.
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Affiliation(s)
- Yi-Ting Lu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Ze-Ming Zhou
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Di Zhang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Lin Sun
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Xin-Chang Liu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Yan-Kun Yang
- Department of Cardiology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Xiong-Jing Jiang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Xian-Liang Zhou
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
- Correspondence: ; Tel.: +86-10-8839-2162
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Katz AE, Yang ML, Levin MG, Tcheandjieu C, Mathis M, Hunker K, Blackburn S, Eliason JL, Coleman DM, Fendrikova-Mahlay N, Gornik HL, Karmakar M, Hill H, Xu C, Zawistowski M, Brummett CM, Zoellner S, Zhou X, O'Donnell CJ, Douglas JA, Assimes TL, Tsao PS, Li JZ, Damrauer SM, Stanley JC, Ganesh SK. Fibromuscular Dysplasia and Abdominal Aortic Aneurysms Are Dimorphic Sex-Specific Diseases With Shared Complex Genetic Architecture. CIRCULATION. GENOMIC AND PRECISION MEDICINE 2022; 15:e003496. [PMID: 36374587 PMCID: PMC9772208 DOI: 10.1161/circgen.121.003496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 08/26/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND The risk of arterial diseases may be elevated among family members of individuals having multifocal fibromuscular dysplasia (FMD). We sought to investigate the risk of arterial diseases in families of individuals with FMD. METHODS Family histories for 73 probands with FMD were obtained, which included an analysis of 463 total first-degree relatives focusing on FMD and related arterial disorders. A polygenic risk score for FMD (PRSFMD) was constructed from prior genome-wide association findings of 584 FMD cases and 7139 controls and evaluated for association with an abdominal aortic aneurysm (AAA) in a cohort of 9693 AAA cases and 294 049 controls. A previously published PRSAAA was also assessed among the FMD cases and controls. RESULTS Of all first degree relatives of probands, 9.3% were diagnosed with FMD, aneurysms, and dissections. Aneurysmal disease occurred in 60.5% of affected relatives and 5.6% of all relatives. Among 227 female first-degree relatives of probands, 4.8% (11) had FMD, representing a relative risk (RR)FMD of 1.5 ([95% CI, 0.75-2.8]; P=0.19) compared with the estimated population prevalence of 3.3%, though not of statistical significance. Of all fathers of FMD probands, 11% had AAAs resulting in a RRAAA of 2.3 ([95% CI, 1.12-4.6]; P=0.014) compared with population estimates. The PRSFMD was found to be associated with an AAA (odds ratio, 1.03 [95% CI, 1.01-1.05]; P=2.6×10-3), and the PRSAAA was found to be associated with FMD (odds ratio, 1.53 [95% CI, 1.2-1.9]; P=9.0×10-5) as well. CONCLUSIONS FMD and AAAs seem to be sex-dimorphic manifestations of a heritable arterial disease with a partially shared complex genetic architecture. Excess risk of having an AAA according to a family history of FMD may justify screening in family members of individuals having FMD.
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Affiliation(s)
- Alexander E Katz
- Department of Internal Medicine, Division of Cardiovascular Medicine (A.E.K., M.-L.Y., K.H., H.H., S.K.G.), University of Michigan, Ann Arbor
- Department of Human Genetics (A.E.K., M.-L.Y., K.H., H.H., J.A.D., J.Z.L., S.K.G.), University of Michigan, Ann Arbor
- Medical Genomics & Metabolic Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD (A.E.K.)
| | - Min-Lee Yang
- Department of Internal Medicine, Division of Cardiovascular Medicine (A.E.K., M.-L.Y., K.H., H.H., S.K.G.), University of Michigan, Ann Arbor
- Department of Human Genetics (A.E.K., M.-L.Y., K.H., H.H., J.A.D., J.Z.L., S.K.G.), University of Michigan, Ann Arbor
- Department of Computational Medicine and Bioinformatics (M.-L.Y.), University of Michigan, Ann Arbor
| | - Michael G Levin
- Corporal Michael J. Crescenz Philadelphia VA Medical Center (M.G.L., S.M.D.)
- Division of Cardiovascular Medicine, Department of Medicine (M.G.L.)
| | - Catherine Tcheandjieu
- Gladstone Institute of data science and Biotechnology, Gladstone Institutes; and Department of epidemiology and biostatistics, University of California at San Francisco, CA. (C.T.)
| | - Michael Mathis
- Department of Anesthesiology, Michigan Medicine (M.M., C.M.B.), University of Michigan, Ann Arbor
| | - Kristina Hunker
- Department of Internal Medicine, Division of Cardiovascular Medicine (A.E.K., M.-L.Y., K.H., H.H., S.K.G.), University of Michigan, Ann Arbor
- Department of Human Genetics (A.E.K., M.-L.Y., K.H., H.H., J.A.D., J.Z.L., S.K.G.), University of Michigan, Ann Arbor
| | - Susan Blackburn
- Department of Surgery, Section of Vascular Surgery (S.B., J.L.E., D.M.C., M.K., J.C.S.), University of Michigan, Ann Arbor
| | - Jonathan L Eliason
- Department of Surgery, Section of Vascular Surgery (S.B., J.L.E., D.M.C., M.K., J.C.S.), University of Michigan, Ann Arbor
| | - Dawn M Coleman
- Department of Surgery, Section of Vascular Surgery (S.B., J.L.E., D.M.C., M.K., J.C.S.), University of Michigan, Ann Arbor
| | | | - Heather L Gornik
- Harrington Heart and Vascular Institute, University Hospitals, Cleveland, OH (H.L.G.)
| | - Monita Karmakar
- Department of Surgery, Section of Vascular Surgery (S.B., J.L.E., D.M.C., M.K., J.C.S.), University of Michigan, Ann Arbor
| | - Hannah Hill
- Department of Internal Medicine, Division of Cardiovascular Medicine (A.E.K., M.-L.Y., K.H., H.H., S.K.G.), University of Michigan, Ann Arbor
- Department of Human Genetics (A.E.K., M.-L.Y., K.H., H.H., J.A.D., J.Z.L., S.K.G.), University of Michigan, Ann Arbor
| | - Chang Xu
- Department of Biostatistics and Center for Statistical Genetics, University of Michigan School of Public Health, Ann Arbor (C.X., M.Z., S.Z., X.Z.)
| | - Matthew Zawistowski
- Department of Biostatistics and Center for Statistical Genetics, University of Michigan School of Public Health, Ann Arbor (C.X., M.Z., S.Z., X.Z.)
| | - Chad M Brummett
- Department of Anesthesiology, Michigan Medicine (M.M., C.M.B.), University of Michigan, Ann Arbor
| | - Sebastian Zoellner
- Department of Biostatistics and Center for Statistical Genetics, University of Michigan School of Public Health, Ann Arbor (C.X., M.Z., S.Z., X.Z.)
| | - Xiang Zhou
- Department of Biostatistics and Center for Statistical Genetics, University of Michigan School of Public Health, Ann Arbor (C.X., M.Z., S.Z., X.Z.)
| | - Christopher J O'Donnell
- VA Boston Healthcare System (C.O.)
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA (C.O.)
| | - Julie A Douglas
- Department of Human Genetics (A.E.K., M.-L.Y., K.H., H.H., J.A.D., J.Z.L., S.K.G.), University of Michigan, Ann Arbor
| | - Themistocles L Assimes
- VA Palo Alto Health Care System (T.L.A., P.S.T.)
- Division of Cardiovascular Medicine, Department of Medicine (T.L.A.), Stanford University School of Medicine, CA
| | | | - Jun Z Li
- Department of Human Genetics (A.E.K., M.-L.Y., K.H., H.H., J.A.D., J.Z.L., S.K.G.), University of Michigan, Ann Arbor
| | - Scott M Damrauer
- Corporal Michael J. Crescenz Philadelphia VA Medical Center (M.G.L., S.M.D.)
- Department of Surgery and Department of Genetics, University of Pennsylvania Perelman School of Medicine, Philadelphia (S.M.D.)
| | - James C Stanley
- Department of Surgery, Section of Vascular Surgery (S.B., J.L.E., D.M.C., M.K., J.C.S.), University of Michigan, Ann Arbor
| | - Santhi K Ganesh
- Department of Internal Medicine, Division of Cardiovascular Medicine (A.E.K., M.-L.Y., K.H., H.H., S.K.G.), University of Michigan, Ann Arbor
- Department of Human Genetics (A.E.K., M.-L.Y., K.H., H.H., J.A.D., J.Z.L., S.K.G.), University of Michigan, Ann Arbor
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Mehkri Y, Poe J, Murshid M, Hernandez J, Singh P, Sinha VN, Shuhaiber H. Retinal Artery Occlusion in Fibromuscular Dysplasia: A Case Report. Cureus 2022; 14:e31462. [DOI: 10.7759/cureus.31462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2022] [Indexed: 11/15/2022] Open
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13
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Meltzer AZ, Fintha A, Cseprekál O, Somogyi D, Szabó J, Kóbori L, Rózsa B, Piros L, Huszty G. Graft Arterial Dissection and Thrombosis After Kidney Transplantation With Undiagnosed Fibromuscular Dysplasia From a Deceased Donor: Case Report and Review. Transplant Proc 2022; 54:2603-2607. [DOI: 10.1016/j.transproceed.2022.10.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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14
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The complex genetic basis of fibromuscular dysplasia, a systemic arteriopathy associated with multiple forms of cardiovascular disease. Clin Sci (Lond) 2022; 136:1241-1255. [PMID: 36043395 PMCID: PMC9434409 DOI: 10.1042/cs20210990] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 07/28/2022] [Accepted: 08/16/2022] [Indexed: 12/03/2022]
Abstract
Artery stenosis is a common cause of hypertension and stroke and can be due to atherosclerosis accumulation in the majority of cases and in a small fraction of patients to arterial fibromuscular dysplasia (FMD). Artery stenosis due to atherosclerosis is widely studied with known risk factors (e.g. increasing age, male gender, and dyslipidemia) to influence its etiology, including genetic factors. However, the causes of noninflammatory and nonatherosclerotic stenosis in FMD are less understood. FMD occurs predominantly in early middle-age women, a fraction of the population where cardiovascular risk is different and understudied. FMD arteriopathies are often diagnosed in the context of hypertension and stroke and co-occur mainly with spontaneous coronary artery dissection, an atypical cause of acute myocardial infarction. In this review, we provide a comprehensive overview of the recent advances in the understanding of molecular origins of FMD. Data were obtained from genetic studies using complementary methodological approaches applied to familial, syndromic, and sporadic forms of this intriguing arteriopathy. Rare variation analyses point toward mechanisms related to impaired prostacyclin signaling and defaults in fibrillar collagens. The study of common variation, mainly through a recent genome-wide association study, describes a shared genetic link with blood pressure, in addition to point at potential risk genes involved in actin cytoskeleton and intracellular calcium homeostasis supporting impaired vascular contraction as a key mechanism. We conclude this review with future strategies and approaches needed to fully understand the genetic and molecular mechanisms related to FMD.
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Hicks CW, Clark TW, Cooper CJ, de Bhailís ÁM, De Carlo M, Green D, Małyszko J, Miglinas M, Textor SC, Herzog CA, Johansen KL, Reinecke H, Kalra PA. Atherosclerotic Renovascular Disease: A KDIGO (Kidney Disease: Improving Global Outcomes) Controversies Conference. Am J Kidney Dis 2022; 79:289-301. [PMID: 34384806 PMCID: PMC9834909 DOI: 10.1053/j.ajkd.2021.06.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 06/23/2021] [Indexed: 02/03/2023]
Abstract
The diagnosis and management of atherosclerotic renovascular disease (ARVD) is complex and controversial. Despite evidence from the ASTRAL (2009) and CORAL (2013) randomized controlled trials showing that percutaneous renal artery revascularization did not improve major outcomes compared with best medical therapy alone over 3-5 years, several areas of uncertainty remain. Medical therapy, including statin and antihypertensive medications, has evolved in recent years, and the use of renin-angiotensin-aldosterone system blockers is now considered the primary means to treat hypertension in the setting of ARVD. However, the criteria to identify kidneys with renal artery stenosis that have potentially salvageable function are evolving. There are also data suggesting that certain high-risk populations with specific clinical manifestations may benefit from revascularization. Here, we provide an overview of the epidemiology, diagnosis, and treatment of ARVD based on consensus recommendations from a panel of physician experts who attended the recent KDIGO (Kidney Disease: Improving Global Outcomes) Controversies Conference on central and peripheral arterial diseases in chronic kidney disease. Most focus is provided for contentious issues, and we also outline aspects of investigation and management of ARVD that require further research.
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16
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Yagmurov OD, Fedotova EP, Davydova ZV, Kalinina EY, Anichkov NM. [Arterial fibromuscular dysplasia as a factor in sudden cardiac death in young adults]. Sud Med Ekspert 2022; 65:57-60. [PMID: 35947412 DOI: 10.17116/sudmed20226504157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The objective of the study is to consider the problem of diagnostics of a rare vasculopathy, fibromuscular dysplasia of coronary arteries, by the case study of a 19-year-old serviceman, an athlete with sudden death occurred during slight physical exertion. After repeated histological examination as part of the forensic medical examination, the diagnosis was made: «multifocal fibromuscular dysplasia of the coronary arteries and ascending aortic arch, complicated by acute left ventricular failure.» This disease often manifests with the acute coronary syndrome in people of young age. Therefore, special attention was given to the macroscopic and histological features of fibromuscular dysplasia of arteries.
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Affiliation(s)
- O D Yagmurov
- Bureau of forensic medicine, St. Petersburg, Russia
| | - E P Fedotova
- St. Petersburg State Pediatric Medical University, St. Petersburg, Russia
| | - Z V Davydova
- St. Petersburg State Pediatric Medical University, St. Petersburg, Russia
| | - E Yu Kalinina
- St. Petersburg State Pediatric Medical University, St. Petersburg, Russia
| | - N M Anichkov
- St. Petersburg State Pediatric Medical University, St. Petersburg, Russia
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17
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Sharashidze V, Nogueira RG, Al-Bayati AR, Bhatt N, Nahab FB, Yun J, Allen JW, Frankel M, Haussen DC. Carotid Web Phenotype Is Uncommonly Associated With Classic Fibromuscular Dysplasia: A Retrospective Observational Study. Stroke 2021; 53:e33-e36. [PMID: 34965739 DOI: 10.1161/strokeaha.121.036188] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Carotid web (CaW) is an intimal form of fibromuscular dysplasia (FMD) involving the carotid bulb which has been increasingly recognized as a potential cause of recurrent ischemic strokes. It is overlooked as a separate entity and often dismissed if no coexistent signs of classic FMD changes are observed. We aim to evaluate the frequency of classic FMD in high-yield vascular territories in patients with symptomatic CaW. METHODS This was a retrospective analysis of a symptomatic CaW database of 2 comprehensive stroke centers (spanning September 2014-October 2020). The diagnosis of a CaW during a stroke workup was defined as the presence of a shelf-like linear filling defect in the posterior aspect of the carotid bulb on computed tomography angiography in patients with acute ischemic stroke or transient ischemic attack of undetermined cause after a thorough evaluation. Neck computed tomography angiography and renal conventional angiography images were independently evaluated by two readers blinded to the laterality and clinical details to inspect the presence of underlying classic FMD. RESULTS Sixty-six patients with CaW were identified. Median age was 51 years (interquartile range, 42-57), and 74% were women. All patients had neck computed tomography angiography (allowing for bilateral vertebral and carotid evaluation), whereas 47 patients had additional digital subtraction angiography (which evaluated 47 carotids ipsilateral to the stroke and 10 contralateral carotids). Internal carotid artery classic FMD changes were noted in only 6 out of 66 (9%) in the ipsilateral carotids. No contralateral carotid or vertebral artery classic FMD changes were observed. Renal artery catheter-based angiography was obtained in 16 patients/32 arteries and only 1 patient/2 renal arteries demonstrated classic FMD changes. CONCLUSIONS CaW phenotype is uncommonly associated with classic FMD changes. Coexistent classic FMD does not constitute a useful marker to corroborate or exclude CaW diagnosis.
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Affiliation(s)
- Vera Sharashidze
- Department of Neurology, Emory University/Grady Memorial Hospital, Atlanta, GA. (V.S., R.G.N., A.R.A-B., N.B., F.B.N., J.Y., M.F., D.C.H.)
| | - Raul G Nogueira
- Department of Neurology, Emory University/Grady Memorial Hospital, Atlanta, GA. (V.S., R.G.N., A.R.A-B., N.B., F.B.N., J.Y., M.F., D.C.H.)
| | - Alhamza R Al-Bayati
- Department of Neurology, Emory University/Grady Memorial Hospital, Atlanta, GA. (V.S., R.G.N., A.R.A-B., N.B., F.B.N., J.Y., M.F., D.C.H.)
| | - Nirav Bhatt
- Department of Neurology, Emory University/Grady Memorial Hospital, Atlanta, GA. (V.S., R.G.N., A.R.A-B., N.B., F.B.N., J.Y., M.F., D.C.H.)
| | - Fadi B Nahab
- Department of Neurology, Emory University/Grady Memorial Hospital, Atlanta, GA. (V.S., R.G.N., A.R.A-B., N.B., F.B.N., J.Y., M.F., D.C.H.)
| | - Johanna Yun
- Department of Neurology, Emory University/Grady Memorial Hospital, Atlanta, GA. (V.S., R.G.N., A.R.A-B., N.B., F.B.N., J.Y., M.F., D.C.H.)
| | - Jason W Allen
- Department of Radiology, Emory University/Grady Memorial Hospital, Atlanta, GA. (J.W.A.)
| | - Michael Frankel
- Department of Neurology, Emory University/Grady Memorial Hospital, Atlanta, GA. (V.S., R.G.N., A.R.A-B., N.B., F.B.N., J.Y., M.F., D.C.H.)
| | - Diogo C Haussen
- Department of Neurology, Emory University/Grady Memorial Hospital, Atlanta, GA. (V.S., R.G.N., A.R.A-B., N.B., F.B.N., J.Y., M.F., D.C.H.)
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18
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Fibromuscular dysplasia and hypertension-a statement on behalf of the British and Irish Hypertension Society. J Hum Hypertens 2021; 35:1051-1053. [PMID: 33262434 DOI: 10.1038/s41371-020-00456-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 11/06/2020] [Accepted: 11/16/2020] [Indexed: 02/03/2023]
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19
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Georges A, Yang ML, Berrandou TE, Bakker MK, Dikilitas O, Kiando SR, Ma L, Satterfield BA, Sengupta S, Yu M, Deleuze JF, Dupré D, Hunker KL, Kyryachenko S, Liu L, Sayoud-Sadeg I, Amar L, Brummett CM, Coleman DM, d’Escamard V, de Leeuw P, Fendrikova-Mahlay N, Kadian-Dodov D, Li JZ, Lorthioir A, Pappaccogli M, Prejbisz A, Smigielski W, Stanley JC, Zawistowski M, Zhou X, Zöllner S, Amouyel P, De Buyzere ML, Debette S, Dobrowolski P, Drygas W, Gornik HL, Olin JW, Piwonski J, Rietzschel ER, Ruigrok YM, Vikkula M, Warchol Celinska E, Januszewicz A, Kullo IJ, Azizi M, Jeunemaitre X, Persu A, Kovacic JC, Ganesh SK, Bouatia-Naji N. Genetic investigation of fibromuscular dysplasia identifies risk loci and shared genetics with common cardiovascular diseases. Nat Commun 2021; 12:6031. [PMID: 34654805 PMCID: PMC8521585 DOI: 10.1038/s41467-021-26174-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 09/17/2021] [Indexed: 12/23/2022] Open
Abstract
Fibromuscular dysplasia (FMD) is an arteriopathy associated with hypertension, stroke and myocardial infarction, affecting mostly women. We report results from the first genome-wide association meta-analysis of six studies including 1556 FMD cases and 7100 controls. We find an estimate of SNP-based heritability compatible with FMD having a polygenic basis, and report four robustly associated loci (PHACTR1, LRP1, ATP2B1, and LIMA1). Transcriptome-wide association analysis in arteries identifies one additional locus (SLC24A3). We characterize open chromatin in arterial primary cells and find that FMD associated variants are located in arterial-specific regulatory elements. Target genes are broadly involved in mechanisms related to actin cytoskeleton and intracellular calcium homeostasis, central to vascular contraction. We find significant genetic overlap between FMD and more common cardiovascular diseases and traits including blood pressure, migraine, intracranial aneurysm, and coronary artery disease.
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Affiliation(s)
- Adrien Georges
- grid.508487.60000 0004 7885 7602PARCC, INSERM, Université de Paris, F-750015 Paris, France
| | - Min-Lee Yang
- grid.214458.e0000000086837370Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI USA ,grid.214458.e0000000086837370Department of Human Genetics, University of Michigan Medical School, Ann Arbor, MI USA
| | - Takiy-Eddine Berrandou
- grid.508487.60000 0004 7885 7602PARCC, INSERM, Université de Paris, F-750015 Paris, France
| | - Mark K. Bakker
- grid.5477.10000000120346234Department of Neurology and Neurosurgery, University Medical Center Utrecht Brain Center, Utrecht University, Utrecht, The Netherlands
| | - Ozan Dikilitas
- grid.66875.3a0000 0004 0459 167XDepartment of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55902 USA
| | - Soto Romuald Kiando
- grid.508487.60000 0004 7885 7602PARCC, INSERM, Université de Paris, F-750015 Paris, France
| | - Lijiang Ma
- grid.59734.3c0000 0001 0670 2351Icahn Institute for Genomics and Multiscale Biology, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Benjamin A. Satterfield
- grid.66875.3a0000 0004 0459 167XDepartment of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55902 USA
| | - Sebanti Sengupta
- grid.214458.e0000000086837370Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI USA
| | - Mengyao Yu
- grid.508487.60000 0004 7885 7602PARCC, INSERM, Université de Paris, F-750015 Paris, France
| | - Jean-François Deleuze
- grid.418135.a0000 0004 0641 3404Centre National de Recherche en Génomique Humaine, Institut de Génomique, CEA and Fondation Jean Dausset-CEPH, Evry, France
| | - Delia Dupré
- grid.508487.60000 0004 7885 7602PARCC, INSERM, Université de Paris, F-750015 Paris, France
| | - Kristina L. Hunker
- grid.214458.e0000000086837370Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI USA ,grid.214458.e0000000086837370Department of Human Genetics, University of Michigan Medical School, Ann Arbor, MI USA
| | - Sergiy Kyryachenko
- grid.508487.60000 0004 7885 7602PARCC, INSERM, Université de Paris, F-750015 Paris, France
| | - Lu Liu
- grid.508487.60000 0004 7885 7602PARCC, INSERM, Université de Paris, F-750015 Paris, France
| | - Ines Sayoud-Sadeg
- grid.508487.60000 0004 7885 7602PARCC, INSERM, Université de Paris, F-750015 Paris, France
| | - Laurence Amar
- grid.508487.60000 0004 7885 7602PARCC, INSERM, Université de Paris, F-750015 Paris, France ,grid.414093.b0000 0001 2183 5849Hypertension Unit, Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, F-75015 Paris, France
| | - Chad M. Brummett
- grid.214458.e0000000086837370Department of Anesthesiology, Michigan Medicine, University of Michigan, Ann Arbor, MI USA
| | - Dawn M. Coleman
- grid.214458.e0000000086837370Vascular Surgery Section, Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109 USA
| | - Valentina d’Escamard
- grid.59734.3c0000 0001 0670 2351Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Peter de Leeuw
- grid.412966.e0000 0004 0480 1382Department of Internal Medicine, Division of General Internal Medicine, Section Vascular Medicine, Maastricht University Medical Centre, Maastricht University, Maastricht, the Netherlands ,grid.5012.60000 0001 0481 6099CARIM School for Cardiovascular Diseases, Maastricht University Medical Centre, Maastricht University, Maastricht, the Netherlands
| | - Natalia Fendrikova-Mahlay
- grid.239578.20000 0001 0675 4725Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH 44195 USA
| | - Daniella Kadian-Dodov
- grid.59734.3c0000 0001 0670 2351Zena and Michael A. Wiener Cardiovascular Institute and Marie-Josée and Henry R, Kravis Center for Cardiovascular Health Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Jun Z. Li
- grid.214458.e0000000086837370Department of Human Genetics, University of Michigan Medical School, Ann Arbor, MI USA
| | - Aurélien Lorthioir
- grid.508487.60000 0004 7885 7602PARCC, INSERM, Université de Paris, F-750015 Paris, France ,grid.414093.b0000 0001 2183 5849Hypertension Unit, Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, F-75015 Paris, France
| | - Marco Pappaccogli
- grid.7942.80000 0001 2294 713XDivision of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, 1200 Brussels, Belgium ,grid.7605.40000 0001 2336 6580Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Aleksander Prejbisz
- grid.418887.aDepartment of Hypertension, National Institute of Cardiology, Warsaw, Poland
| | - Witold Smigielski
- grid.10789.370000 0000 9730 2769Department of Demography, University of Lodz, Lodz, Poland
| | - James C. Stanley
- grid.214458.e0000000086837370Vascular Surgery Section, Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109 USA
| | - Matthew Zawistowski
- grid.214458.e0000000086837370Department of Biostatistics and Center for Statistical Genetics, University of Michigan School of Public Health, Ann Arbor, MI USA
| | - Xiang Zhou
- grid.214458.e0000000086837370Department of Biostatistics and Center for Statistical Genetics, University of Michigan School of Public Health, Ann Arbor, MI USA
| | - Sebastian Zöllner
- grid.214458.e0000000086837370Department of Biostatistics and Center for Statistical Genetics, University of Michigan School of Public Health, Ann Arbor, MI USA
| | | | | | | | - Philippe Amouyel
- grid.503422.20000 0001 2242 6780Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1167 - RID-AGE - Labex DISTALZ - Risk factors and molecular determinants of aging-related disease, F-59000 Lille, France
| | - Marc L. De Buyzere
- grid.5342.00000 0001 2069 7798Department of Cardiovascular Diseases, Ghent University and Ghent University Hospital, Ghent, Belgium
| | - Stéphanie Debette
- grid.42399.350000 0004 0593 7118Department of Neurology, Bordeaux University Hospital, Inserm U1219, Bordeaux, France
| | - Piotr Dobrowolski
- grid.418887.aDepartment of Hypertension, National Institute of Cardiology, Warsaw, Poland
| | - Wojciech Drygas
- grid.418887.aDepartment of Epidemiology, Cardiovascular Disease Prevention, and Health Promotion, National Institute of Cardiology, Warsaw, Poland
| | - Heather L. Gornik
- grid.239578.20000 0001 0675 4725Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH 44195 USA
| | - Jeffrey W. Olin
- grid.59734.3c0000 0001 0670 2351Zena and Michael A. Wiener Cardiovascular Institute and Marie-Josée and Henry R, Kravis Center for Cardiovascular Health Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Jerzy Piwonski
- grid.418887.aDepartment of Epidemiology, Cardiovascular Disease Prevention, and Health Promotion, National Institute of Cardiology, Warsaw, Poland
| | - Ernst R. Rietzschel
- grid.5342.00000 0001 2069 7798Department of Cardiovascular Diseases, Ghent University and Ghent University Hospital, Ghent, Belgium
| | - Ynte M. Ruigrok
- grid.66875.3a0000 0004 0459 167XDepartment of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55902 USA
| | - Miikka Vikkula
- grid.7942.80000 0001 2294 713XHuman Molecular Genetics, de Duve Institute, Université Catholique de Louvain, 1200 Brussels, Belgium
| | - Ewa Warchol Celinska
- grid.418887.aDepartment of Hypertension, National Institute of Cardiology, Warsaw, Poland
| | - Andrzej Januszewicz
- grid.418887.aDepartment of Hypertension, National Institute of Cardiology, Warsaw, Poland
| | - Iftikhar J. Kullo
- grid.66875.3a0000 0004 0459 167XDepartment of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55902 USA ,grid.66875.3a0000 0004 0459 167XGonda Vascular Center, Mayo Clinic, Rochester, MN 55902 USA
| | - Michel Azizi
- grid.414093.b0000 0001 2183 5849Hypertension Unit, Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, F-75015 Paris, France ,grid.512950.aUniversité de Paris, Inserm, Centre d’Investigation Clinique 1418, F-75006 Paris, France
| | | | - Xavier Jeunemaitre
- grid.508487.60000 0004 7885 7602PARCC, INSERM, Université de Paris, F-750015 Paris, France ,grid.414093.b0000 0001 2183 5849Department of Genetics, Assistance-Publiques-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, F-75015 Paris, France
| | - Alexandre Persu
- grid.7942.80000 0001 2294 713XDivision of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, 1200 Brussels, Belgium ,grid.7942.80000 0001 2294 713XPole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, 1200 Brussels, Belgium
| | - Jason C. Kovacic
- grid.59734.3c0000 0001 0670 2351Zena and Michael A. Wiener Cardiovascular Institute and Marie-Josée and Henry R, Kravis Center for Cardiovascular Health Icahn School of Medicine at Mount Sinai, New York, NY USA ,grid.1057.30000 0000 9472 3971Victor Chang Cardiac Research Institute, Darlinghurst, NSW Australia ,grid.1005.40000 0004 4902 0432St. Vincent’s Clinical School, University of New South Wales, Sydney, NSW Australia
| | - Santhi K. Ganesh
- grid.214458.e0000000086837370Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI USA ,grid.214458.e0000000086837370Department of Human Genetics, University of Michigan Medical School, Ann Arbor, MI USA
| | - Nabila Bouatia-Naji
- grid.508487.60000 0004 7885 7602PARCC, INSERM, Université de Paris, F-750015 Paris, France
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20
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Vanzin JR, Martio AE, Manzato LB, Abud DG. Casper stent in the treatment of pulsatile tinnitus in fibromuscular dysplasia: Therapeutic review and case report. Brain Circ 2021; 7:281-284. [PMID: 35071846 PMCID: PMC8757508 DOI: 10.4103/bc.bc_35_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 05/11/2021] [Accepted: 06/11/2021] [Indexed: 11/17/2022] Open
Abstract
Fibromuscular dysplasia (FMD) is a known cause of pulsatile tinnitus that can, on rare occasion, evolve into an incapacitating condition. It is a noninflammatory and nonatherosclerotic arteriopathy of unknown cause that affects medium-sized vessels, such as the carotid and renal arteries, occurring mainly in women. We describe a 72-year-old woman suffering from pulsatile tinnitus refractory to medical treatment who was successfully treated with Casper stent in the carotid artery. The different treatment strategies published in the literature were reviewed.
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Affiliation(s)
- José Ricardo Vanzin
- Division of Interventional Neuroradiology, Medical School of Passo Fundo, Federal University of South Frontier, Brazil
| | - Artur Eduardo Martio
- Division of Interventional Neuroradiology, Medical School of Passo Fundo, Federal University of South Frontier, Brazil
| | - Luciano Bambini Manzato
- Division of Interventional Neuroradiology, Medical School of Passo Fundo, Federal University of South Frontier, Brazil
| | - Daniel Giansante Abud
- Division of Interventional Neuroradiology, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil
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21
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Tian Y, Yuan B, Zhang N, Huang Z. Outcomes Following the Endovascular Treatment of Renal Artery Stenosis Caused by Fibromuscular Dysplasia: A Systematic Review and Meta-Analysis. Ann Vasc Surg 2021; 78:362-372. [PMID: 34543714 DOI: 10.1016/j.avsg.2021.06.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 05/31/2021] [Accepted: 06/24/2021] [Indexed: 11/01/2022]
Abstract
OBJECTIVE Renal artery revascularization has been performed to improve blood pressure control and to cure hypertension in patients with renal artery fibromuscular dysplasia (RAFMD). We herein conducted a systematic review and meta-analysis of studies assessing outcomes associated with the treatment of hypertensive RAFMD patients via endovascular angioplasty in order to offer an up-to-date overview of the relative costs and benefits of this approach to revascularization in RAFMD patients. METHODS We systematically searched the PubMed and Embase databases and the Cochrane Central Register for Controlled Trials to identify relevant studies published as of January 15, 2020. Key outcomes of interest in these studies included technical success, the incidence of perioperative complications, cure rates, and overall improvement rates. RESULTS In total, we identified 36 relevant studies of 1916 total repairs conducted in 1191 patients. Of these included studies, 33 were retrospective, while 3 were prospective. The overall technical success rate across these studies was 94.3%. Rates of total, major, and minor complications in these pooled studies were 12.9%, 4.6%, and 7.4%, respectively. Pooled rates of cured hypertension and improved hypertension following angioplasty, defined according to study-specific criteria, were 37.0% [95% CI: 27.0%-47.0%] and 80.0% [95% CI: 75.0% to 84.0%], respectively, although these rates varied highly among studies. Cure rates for studies used current clinical definitions for substantial variations across studies. Cure rates in studies using current definitions of cured hypertension (blood pressure <140/90 mm Hg without treatment) were just 18.1% following angioplasty. Cure rates fell markedly with increasing mean patient age (OR associated with an increase in mean age of 10 years: -0.24 [95% CI: -0.44 to -0.04, P = 0.019] and with mean known duration of hypertension (OR associated with an increase in mean hypertension duration of 5 years: -0.09 [95% CI: -0.12 to -0.05, P = 0.001]). CONCLUSIONS These findings suggest that endovascular treatment yielded moderate benefits to RAFMD patients, with substantial variation across studies. The blood pressure outcome was strongly influenced by patient age.
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Affiliation(s)
- Yu Tian
- Department of Vascular Surgery, The 3rd Affiliated Hospital of Shenzhen University, Shenzhen, Guangdong Province, China
| | - Biao Yuan
- Department of Vascular Surgery, Beijing Chao Yang Hospital, Affiliate of Capital Medical University, Beijing, People's Republic of China.
| | - Ning Zhang
- Department of Vascular Surgery, The 3rd Affiliated Hospital of Shenzhen University, Shenzhen, Guangdong Province, China
| | - Zhiyong Huang
- Department of Vascular Surgery, The 3rd Affiliated Hospital of Shenzhen University, Shenzhen, Guangdong Province, China
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22
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Dicks AB, Gornik HL, Gu X, Bacharach JM, Fendrikova Mahlay N, Froehlich JB, Gupta K, Gray BH, Kim ESH, Mahmood R, Sharma AM, Wells BJ, Olin JW, Weinberg I. Association of Fibromuscular Dysplasia and Pulsatile Tinnitus: A Report of the US Registry for Fibromuscular Dysplasia. J Am Heart Assoc 2021; 10:e021962. [PMID: 34459232 PMCID: PMC8649251 DOI: 10.1161/jaha.121.021962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Fibromuscular dysplasia (FMD) is a nonatherosclerotic arterial disease that has a variable presentation including pulsatile tinnitus (PT). The frequency and characteristics of PT in FMD are not well understood. The objective of this study was to evaluate the frequency of PT in FMD and compare characteristics between patients with and without PT. Methods and Results Data were queried from the US Registry for FMD from 2009 to 2020. The primary outcomes were frequency of PT among the FMD population and prevalence of baseline characteristics, signs/symptoms, and vascular bed involvement in patients with and without PT. Of 2613 patients with FMD who were included in the analysis, 972 (37.2%) reported PT. Univariable analysis and multivariable logistic regression were performed to explore factors associated with PT. Compared with those without PT, patients with PT were more likely to have involvement of the extracranial carotid artery (90.0% versus 78.6%; odds ratio, 1.49; P=0.005) and to have higher prevalence of other neurovascular signs/symptoms including headache (82.5% versus 62.7%; odds ratio, 1.82; P<0.001), dizziness (44.9% versus 22.9%; odds ratio, 2.01; P<0.001), and cervical bruit (37.5% versus 15.8%; odds ratio, 2.73; P<0.001) compared with those without PT. Conclusions PT is common among patients with FMD. Patients with FMD who present with PT have higher rates of neurovascular signs/symptoms, cervical bruit, and involvement of the extracranial carotid arteries. The coexistence of the 2 conditions should be recognized, and providers who evaluate patients with PT should be aware of FMD as a potential cause.
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Affiliation(s)
- Andrew B Dicks
- Fireman Vascular Center Massachusetts General Hospital Boston MA
| | - Heather L Gornik
- Harrington Heart and Vascular InstituteUniversity Hospitals Cleveland OH
| | - Xiaokui Gu
- Division of Cardiovascular Medicine Department of Medicine University of Michigan Health System Ann Arbor MI
| | | | - Natalia Fendrikova Mahlay
- Department of Cardiovascular Medicine Cleveland Clinic Heart, Vascular and Thoracic Institute Cleveland OH
| | - James B Froehlich
- Harrington Heart and Vascular InstituteUniversity Hospitals Cleveland OH
| | - Kamal Gupta
- University of Kansas School of Medicine Kansas City KS
| | - Bruce H Gray
- Department of Surgery Prisma Health SystemUniversity of South Carolina School of Medicine Greenville SC
| | - Esther S H Kim
- Division of Cardiovascular Medicine Department of Medicine Vanderbilt University Medical Center Nashville TN
| | | | - Aditya M Sharma
- Division of Cardiovascular Medicine University of Virginia Charlottesville VA
| | | | - Jeffrey W Olin
- Zena and Michael A. Wiener Cardiovascular Institute and Marie-Joseé and Henry R. Kravis Center for Cardiovascular Health Icahn School of Medicine at Mount Sinai New York NY
| | - Ido Weinberg
- Fireman Vascular Center Massachusetts General Hospital Boston MA
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23
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Song Y, Kwon B, Al-Abdulwahhab AH, Nam YK, Ahn Y, Jeong SY, Seo EJ, Lee JK, Suh DC. Rare Neurovascular Diseases in Korea: Classification and Related Genetic Variants. Korean J Radiol 2021; 22:1379-1396. [PMID: 34047503 PMCID: PMC8316781 DOI: 10.3348/kjr.2020.1171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 12/07/2020] [Accepted: 01/23/2021] [Indexed: 01/19/2023] Open
Abstract
Rare neurovascular diseases (RNVDs) have not been well-recognized in Korea. They involve the central nervous system and greatly affect the patients' lives. However, these diseases are difficult to diagnose and treat due to their rarity and incurability. We established a list of RNVDs by referring to the previous literature and databases worldwide to better understand the diseases and their current management status. We categorized 68 RNVDs based on their pathophysiology and clinical manifestations and estimated the prevalence of each disease in Korea. Recent advances in genetic, molecular, and developmental research have enabled further understanding of these RNVDs. Herein, we review each disease, while considering its classification based on updated pathologic mechanisms, and discuss the management status of RNVD in Korea.
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Affiliation(s)
- Yunsun Song
- Division of Neurointervention Clinic, Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Boseong Kwon
- Division of Neurointervention Clinic, Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Abdulrahman Hamed Al-Abdulwahhab
- Department of Diagnostic and Interventional Radiology, Imam Abdulrahman Bin Faisal University, King Fahd Hospital of the University, Al-Khobar City, Eastern Province, Saudi Arabia
| | - Yeo Kyoung Nam
- Division of Neurointervention Clinic, Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yura Ahn
- Division of Neurointervention Clinic, Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - So Yeong Jeong
- Division of Neurointervention Clinic, Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eul Ju Seo
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jong Keuk Lee
- Asan Institute of Life Sciences, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dae Chul Suh
- Division of Neurointervention Clinic, Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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24
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Wheat HL, Alencherry BP, Carman TL, Shishehbor MH, Gornik HL. Fibromuscular dysplasia in a middle-aged transgender man: The role of hormones in disease pathogenesis. SAGE Open Med Case Rep 2021; 9:2050313X211025922. [PMID: 34178356 PMCID: PMC8207260 DOI: 10.1177/2050313x211025922] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 05/30/2021] [Indexed: 01/24/2023] Open
Abstract
Fibromuscular dysplasia is an uncommon non-inflammatory arteriopathy. Hormonal factors are believed to play a role in disease pathogenesis given the overwhelming female predominance of this disease. We describe a case of a 56-year-old transgender man on prolonged testosterone therapy diagnosed with renal fibromuscular dysplasia after presenting with hypertensive urgency.
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Affiliation(s)
- Heather L Wheat
- Department of Internal Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Ben P Alencherry
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Teresa L Carman
- Department of Cardiovascular Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Mehdi H Shishehbor
- Department of Cardiovascular Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Heather L Gornik
- Department of Cardiovascular Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
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25
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Kim ESH, Saw J, Kadian-Dodov D, Wood M, Ganesh SK. FMD and SCAD: Sex-Biased Arterial Diseases With Clinical and Genetic Pleiotropy. Circ Res 2021; 128:1958-1972. [PMID: 34110898 DOI: 10.1161/circresaha.121.318300] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Multifocal fibromuscular dysplasia (FMD) and spontaneous coronary artery dissection are both sex-biased diseases disproportionately affecting women over men in a 9:1 ratio. Traditionally known in the context of renovascular hypertension, recent advances in knowledge about FMD have demonstrated that FMD is a systemic arteriopathy presenting as arterial stenosis, aneurysm, and dissection in virtually any arterial bed. FMD is also characterized by major cardiovascular presentations including hypertension, stroke, and myocardial infarction. Similar to FMD, spontaneous coronary artery dissection is associated with a high prevalence of extracoronary vascular abnormalities, including FMD, aneurysm, and extracoronary dissection, and recent studies have also found genetic associations between the two diseases. This review will summarize the relationship between FMD and spontaneous coronary artery dissection with a focus on common clinical associations, histopathologic mechanisms, genetic susceptibilities, and the biology of these diseases. The current status of disease models and critical future research directions will also be addressed.
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Affiliation(s)
- Esther S H Kim
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (E.S.H.K.)
| | - Jacqueline Saw
- Division of Cardiology, Vancouver General Hospital, University of British Columbia Canada (J.S.)
| | - Daniella Kadian-Dodov
- Zena and Michael A. Wiener Cardiovascular Institute, Marie-Joseé and Henry R. Kravis Center for Cardiovascular Health, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY (D.K.-D.)
| | - Malissa Wood
- Division of Cardiology, Harvard Medical School, Massachusetts General Hospital, Boston (M.W.)
| | - Santhi K Ganesh
- Division of Cardiovascular Medicine, Department of Internal Medicine (S.K.G.), University of Michigan Medical School, Ann Arbor.,Department of Human Genetics (S.K.G.), University of Michigan Medical School, Ann Arbor
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26
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Woods DJ, Woods ZJ, Alter K, Choudhury AZ. Fibromuscular dysplasia with unilateral renal agenesis. BMJ Case Rep 2021; 14:e240311. [PMID: 33827872 PMCID: PMC8030670 DOI: 10.1136/bcr-2020-240311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2021] [Indexed: 11/03/2022] Open
Abstract
Fibromuscular dysplasia (FMD) is predominantly diagnosed in women and is a congenital malformation damaging the arterial cell walls of numerous arteries, most prominently impacting the renal arteries. Although previously believed to be a disease of young women, older patients have been shown to make up a large percentage of this patient population as well. FMD is underdiagnosed, and the misdiagnosis of this disease has life-threatening consequences. Here, we present the case of a 24-year-old woman with hypertension who did not receive adequate workup until her symptoms were unrelenting. Her hypertension was presumed to be a result of her generalised anxiety disorder. However, once she began to experience vision changes and significant headaches, further workup ensued. This case exemplifies the importance of performing a thorough evaluation of all patients that present with hypertension of unknown origin, especially young women. To decrease the risk of permanent consequences such as strokes, renal failure and even death, the correct diagnosis of FMD is vital.
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Affiliation(s)
- Demi Jordan Woods
- Medicine, University of Missouri Kansas City, Kansas City, Missouri, USA
| | | | - Kevin Alter
- Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Adnan Z Choudhury
- Internal Medicine, University of Missouri Kansas City, Kansas City, Missouri, USA
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27
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Kronzer VL, Tarabochia AD, Lobo Romero AS, Tan NY, O'Byrne TJ, Crowson CS, Turley TN, Myasoedova E, Davis JM, Raphael CE, Gulati R, Hayes SN, Tweet MS. Lack of Association of Spontaneous Coronary Artery Dissection With Autoimmune Disease. J Am Coll Cardiol 2021; 76:2226-2234. [PMID: 33153582 DOI: 10.1016/j.jacc.2020.09.533] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 09/08/2020] [Accepted: 09/09/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Case reports and referral-based studies suggest spontaneous coronary artery dissection (SCAD) is associated with autoimmune diseases and causes 2% to 4% of acute coronary syndromes. OBJECTIVES This study determined the association of SCAD with autoimmune diseases, together with incidence and recurrence, in a population-based study. METHODS This case-control study took place from 1995 to 2018 within the Rochester Epidemiology Project. The study identified cases with SCAD from diagnosis codes and verified them using coronary angiography images, matching each case to 3 control subjects on age, sex, county, and years of medical history. Autoimmune disease history came from a validated, code-based definition. A multivariable logistic regression model calculated the odds ratio (OR) for SCAD among patients with a history of autoimmune disease, adjusting for race and body mass index. RESULTS The study identified 114 cases with SCAD (mean age 51 years and 90% women) and 342 matched control subjects. Autoimmune disease occurred in 13 (11%) cases with SCAD and 40 (12%) control subjects (p = 0.93). Even after adjustment, autoimmune diseases were not associated with SCAD (OR: 0.81; 95% confidence interval [CI]: 0.40 to 1.66). SCAD incidence between 2010 and 2018 (2.7 per 100,000; 95% CI: 1.7 to 3.7) was 10-fold higher than the incidence between 1995 and 2009 (0.3 per 100,000; 95% CI: 0.0 to 0.6). SCAD recurrence was 10% (95% CI: 3% to 16%) at 5 years. CONCLUSIONS These findings suggested SCAD pathogenesis is noninflammatory and screening for autoimmune diseases based on SCAD alone is not warranted. The code-based incidence of SCAD has increased over time, highlighting the importance of considering SCAD among patients with acute coronary syndromes.
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Affiliation(s)
- Vanessa L Kronzer
- Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | | | | | - Nicholas Y Tan
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Thomas J O'Byrne
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Cynthia S Crowson
- Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota; Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Tamiel N Turley
- Molecular Pharmacology and Experimental Therapeutics Track, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, Minnesota; Cardiovascular Genetics Research Laboratory, Mayo Clinic, Rochester, Minnesota
| | - Elena Myasoedova
- Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - John M Davis
- Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Claire E Raphael
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Rajiv Gulati
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Sharonne N Hayes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Marysia S Tweet
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
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28
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Shah KP, Peruri A, Kanneganti M, Gorsch L, Ramcharitar R, Williams C, Clouse D, Thomas M, Norton PT, Hagspiel KD, Taylor A, Southerland A, Matsumoto AH, Angle JF, Mace P, Khaja MS, Sharma AM. Fibromuscular dysplasia: A comprehensive review on evaluation and management and role for multidisciplinary comprehensive care and patient input model. Semin Vasc Surg 2021; 34:89-96. [PMID: 33757641 DOI: 10.1053/j.semvascsurg.2021.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Fibromuscular dysplasia is a nonatherosclerotic, under-recognized disorder primarily seen in middle-aged women. It can lead to several complications, such as hypertension, headaches, dissections, aneurysms, myocardial infarctions, and cerebrovascular accidents, to name a few. This article provides a comprehensive review of current literature on epidemiology, etiology, diagnosis, treatment, and long-term surveillance and fibromuscular dysplasia management. In addition, it renders the role of education and prevention for patients living with this condition and family screening. Lastly, it emphasizes the importance of a comprehensive multidisciplinary care model and patient input, given the complexity of this disease and its systemic presence and protean manifestations.
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Affiliation(s)
- Kajal P Shah
- Department of Medicine, University of Virginia, PO Box 100058, 1215 Lee Street, Charlottesville, VA 22908
| | - Adithya Peruri
- Department of Medicine, University of Virginia, PO Box 100058, 1215 Lee Street, Charlottesville, VA 22908
| | | | - Lindsey Gorsch
- Department of Medicine, University of Virginia, PO Box 100058, 1215 Lee Street, Charlottesville, VA 22908
| | - Randy Ramcharitar
- Department of Medicine, University of Virginia, PO Box 100058, 1215 Lee Street, Charlottesville, VA 22908
| | - Carlin Williams
- Department of Surgery, University of Virginia, Charlottesville, VA
| | - Darrin Clouse
- Department of Surgery, University of Virginia, Charlottesville, VA
| | - Matthew Thomas
- Department of Pediatrics, University of Virginia, Charlottesville, VA
| | - Patrick T Norton
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA
| | - Klaus D Hagspiel
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA
| | - Angela Taylor
- Department of Medicine, University of Virginia, PO Box 100058, 1215 Lee Street, Charlottesville, VA 22908
| | | | - Alan H Matsumoto
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA
| | - John F Angle
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA
| | - Pamela Mace
- Executive Director, Fibromuscular Dysplasia Society for America, North Olmsted, OH
| | - Minhaj S Khaja
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA
| | - Aditya M Sharma
- Department of Medicine, University of Virginia, PO Box 100058, 1215 Lee Street, Charlottesville, VA 22908.
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29
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Klinkhammer B, Vadali S, Albulushi A, Burdorf A. A Fibromuscular Dysplasia Clinical Tetrad of Coronary Artery Dissection, Cardiogenic Shock, Carotid Dissection, and Stroke. Oman Med J 2021; 36:e230. [PMID: 33628465 PMCID: PMC7897354 DOI: 10.5001/omj.2021.22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 03/01/2020] [Indexed: 11/03/2022] Open
Abstract
Spontaneous coronary artery dissection is a serious and underreported clinical entity strongly associated with fibromuscular dysplasia (FMD). The female predominance of FMD may predispose many women to coronary artery dissection or other similar vascular pathologies. We present a case of a young woman who presented with a clinical tetrad of spontaneous coronary artery dissection, cardiogenic shock requiring extracorporeal membrane oxygenation, internal carotid dissections, and subacute cerebellar infarct secondary to underlying FMD. The patient's clinical course and vascular pathology are discussed. A review of the relevant literature of previously published similar cases, the incidence of spontaneous coronary artery dissection, and issues in the clinical management of spontaneous coronary artery dissection are also included.
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Affiliation(s)
- Brent Klinkhammer
- Division of Cardiology, University of Nebraska Medical Center, Nebraska, USA
| | - Sirisha Vadali
- Division of Cardiovascular Medicine, University of Missouri-School of Medicine, Missouri, USA
| | - Arif Albulushi
- Division of Cardiology, University of Nebraska Medical Center, Nebraska, USA
| | - Adam Burdorf
- Division of Cardiology, University of Nebraska Medical Center, Nebraska, USA
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30
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Bonacina S, Locatelli M, Mazzoleni V, Pezzini D, Padovani A, Pezzini A. Spontaneous cervical artery dissection and fibromuscular dysplasia: Epidemiologic and biologic evidence of a mutual relationship. Trends Cardiovasc Med 2021; 32:103-109. [PMID: 33524506 DOI: 10.1016/j.tcm.2021.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/18/2021] [Accepted: 01/24/2021] [Indexed: 12/15/2022]
Abstract
Cervical artery dissection (CeAD) is the most common cause of ischemic stroke in young and middle-aged adults. Over the last decade, a relation between CeAD and fibromuscular dysplasia (FMD), an idiopathic, segmental, non-atherosclerotic and non-inflammatory arterial disease, has been suggested based on a number of epidemiologic observations, while preliminary data support the idea that the two conditions may share common biologic mechanisms. In this article, we review the literature on the relation between CeAD and FMD, focus on the potential pathogenetic mechanisms common to the two conditions, summarize clinical features, management and outcome, and provide support to the hypothesis that the coexistence of the two diseases in one individual might be conceptualized as a distinct non-atherosclerotic non-inflammatory arteriopathy.
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Affiliation(s)
- Sonia Bonacina
- Dipartimento di Scienze Cliniche e Sperimentali, Clinica Neurologica, Università degli Studi di Brescia, P.le Spedali Civili, 1, 25123 Brescia, Italia
| | - Martina Locatelli
- Dipartimento di Scienze Cliniche e Sperimentali, Clinica Neurologica, Università degli Studi di Brescia, P.le Spedali Civili, 1, 25123 Brescia, Italia
| | - Valentina Mazzoleni
- Dipartimento di Scienze Cliniche e Sperimentali, Clinica Neurologica, Università degli Studi di Brescia, P.le Spedali Civili, 1, 25123 Brescia, Italia
| | - Debora Pezzini
- Dipartimento di Scienze Cliniche e Sperimentali, Clinica Neurologica, Università degli Studi di Brescia, P.le Spedali Civili, 1, 25123 Brescia, Italia
| | - Alessandro Padovani
- Dipartimento di Scienze Cliniche e Sperimentali, Clinica Neurologica, Università degli Studi di Brescia, P.le Spedali Civili, 1, 25123 Brescia, Italia
| | - Alessandro Pezzini
- Dipartimento di Scienze Cliniche e Sperimentali, Clinica Neurologica, Università degli Studi di Brescia, P.le Spedali Civili, 1, 25123 Brescia, Italia.
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31
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Rana MN, Al-Kindi SG. Prevalence and manifestations of diagnosed fibromuscular dysplasia by sex and race: Analysis of >4500 FMD cases in the United States. Heart Lung 2020; 50:168-173. [PMID: 33069453 DOI: 10.1016/j.hrtlng.2020.09.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 09/25/2020] [Accepted: 09/30/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Fibromuscular Dysplasia (FMD) is a rare non-atherosclerotic non-inflammatory vascular disease associated with arterial aneurysms and dissections. The epidemiology of FMD is not well understood. We sought to characterize the epidemiology of FMD utilizing a large aggregated electronic medical record database. METHODS We used a commercial database (Explorys, IBM Watson), which aggregates data from electronic health records from 26 major integrated healthcare systems in the United States. Fibromuscular dysplasia cases were identified using a unique systemized nomenclature of medical terminology (SNOMED CT) term. We calculated the overall and age-, race-, and sex-based prevalence of FMD, and evaluated sex and race-specific differences in manifestations. RESULTS A total of 40,566,670 individuals were active in the database from January 2015 to January 2020. Of these, 4860 had a diagnosis of FMD with an overall prevalence of 12.0 cases per 100,000 individuals. The majority of patients with FMD were female (n=4130, 85.0%), Caucasian (n=3960, 80.5%) and adults aged 18 to 65 years (n=2610, 53.7%). FMD was more common in women (prevalence 18.4 per 100,000) than men (4.0 per 100,000) and among Caucasians (15.8 per 100,000) than African Americans (11.2 per 100,000). Men and African Americans with FMD were more likely to have traditional atherosclerotic risk factors (hypertension, diabetes mellitus type 2, smoking, obesity, hyperlipidemia, chronic kidney disease), and vascular manifestations (stroke, renal infarction, claudication), compared with women and Caucasians. Men with FMD were more likely to have dissection of aorta and renal artery as well as aneurysm of vertebral artery, coronary artery, aorta and iliac artery. African-Americans were more likely to have ruptured aortic aneurysms than Caucasians. CONCLUSIONS The overall prevalence of FMD in this large aggregated electronic medical record study is estimated at 12.0 per 100,000 persons. FMD is more common in women and Caucasians, with variable characteristics and manifestations.
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Affiliation(s)
| | - Sadeer G Al-Kindi
- Department of Medicine, University Hospitals, Cleveland, OH USA; School of Medicine, Case Western Reserve University, Cleveland, OH USA; Harrington Heart and Vascular Institute, University Hospitals, Cleveland, OH USA.
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32
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Matsushita Y, Motoyama D, Ito T, Sugiyama T, Otsuka A, Sano M, Inuzuka K, Miyake H. Kidney transplantation from a living donor with renal artery fibromuscular dysplasia: A case report on arterial grafting of the donor renal artery. IJU Case Rep 2020; 3:201-203. [PMID: 32914075 PMCID: PMC7469844 DOI: 10.1002/iju5.12188] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 06/11/2020] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION Renal artery fibromuscular dysplasia is generally considered a contraindication of kidney transplantation, since fibromuscular dysplasia occasionally induces hypertension or renal insufficiency in the recipient and/or donor. To date, limited information remains available with respect to whether kidneys with renal arterial fibromuscular dysplasia can be successfully transplanted. CASE PRESENTATION A 53-year-old potential donor was diagnosed with fibromuscular dysplasia of the right renal artery. Laparoscopic right nephrectomy was performed, and the affected portion was resected and reconstructed using the harvested internal iliac artery. Transplantation was successful and the serum creatinine level was <2 mg/dL for 3 years after surgery. CONCLUSION If reconstruction of the diseased artery could be safely performed, transplantation using a kidney from a donor with renal artery fibromuscular dysplasia may be considered.
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Affiliation(s)
- Yuto Matsushita
- Department of Urology Hamamatsu University School of Medicine Hamamatsu Shizuoka Japan
| | - Daisuke Motoyama
- Department of Urology Hamamatsu University School of Medicine Hamamatsu Shizuoka Japan
| | - Toshiki Ito
- Department of Urology Hamamatsu University School of Medicine Hamamatsu Shizuoka Japan
| | - Takayuki Sugiyama
- Department of Urology Hamamatsu University School of Medicine Hamamatsu Shizuoka Japan
| | - Atsushi Otsuka
- Department of Urology Hamamatsu University School of Medicine Hamamatsu Shizuoka Japan
| | - Masaki Sano
- Department of Vascular Surgery Hamamatsu University School of Medicine Hamamatsu Shizuoka Japan
| | - Kazunori Inuzuka
- Department of Vascular Surgery Hamamatsu University School of Medicine Hamamatsu Shizuoka Japan
| | - Hideaki Miyake
- Department of Urology Hamamatsu University School of Medicine Hamamatsu Shizuoka Japan
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33
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Subbotin VM. Pattern of organ remodeling in chronic non-communicable diseases is due to endogenous regulations and falls under the category of Kauffman's self-organization: A case of arterial neointimal pathology. Med Hypotheses 2020; 143:110106. [PMID: 32759005 DOI: 10.1016/j.mehy.2020.110106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 06/07/2020] [Accepted: 07/11/2020] [Indexed: 01/10/2023]
Abstract
Clinical diagnosis is based on analysis of pathologic findings that may result in perceived patterns. The same is true for diagnostic pathology: Pattern analysis is a foundation of the histopathology-based diagnostic system and, in conjunction with clinical and laboratory findings, forms a basis for the classification of diseases. Any histopathology diagnosis is based on the explicit assumption that the same diseased condition should result in formation of the same (or highly similar) morphologic patterns in different individuals; it is a standard approach in microscopic pathology, including that of non-communicable chronic diseases with organ remodeling. During fifty years of examining diseased tissues under microscopy, I keep asking the same question: Why is a similarity of patterns expected for chronic organ remodeling? For infection diseases, xenobiotic toxicity and deficiencies forming an identical pathologic pattern in different individuals is understandable and logical: The same infection, xenobiotic, or deficiency strikes the same target, which results in identical pathology. The same is true for Mendelian diseases: The same mutations lead to the same altered gene expressions and the same pathologic pattern. But why does this regularity hold true for chronic diseases with organ remodeling? Presumable causes (or risk factors) for a particular chronic disease differ in magnitude and duration between individuals, which should result in various series of transformations. Yet, mysteriously enough, pathological remodeling in a particular chronic disease always falls into a main dominating pattern, perpetuating and progressing in a similar fashion in different patients. Furthermore, some chronic diseases of different etiologies and dissimilar causes/risk factors manifest as identical or highly similar patterns of pathologic remodeling. HYPOTHESIS: I hypothesize that regulations governing a particular organ's chronic remodeling were selected in evolution as the safest response to various insults and physiologic stress conditions. This hypothesis implies that regulations directing diseased chronic remodeling always preexist but normally are controlled; this control can be disrupted by a diverse range of non-specific signals, liberating the pathway for identical pathologic remodeling. This hypothesis was tested in an analysis of arterial neointimal formation, the identical pathology occurring in different diseases and pathological conditions: graft vascular disease in organ transplantation, in-stent restenosis, peripheral arterial diseases, idiopathic intimal hyperplasia, Kawasaki disease, coronary atherosclerosis and as reaction to drugs. The hypothesis suggests that arterial intimal cells are poised between only two alternative pathways: the pathway with controlled intimal cell proliferation or the pathway where such control is disrupted, ultimately leading to the progressive neointimal pathology. By this property the arterial neointimal formation constitutes a special case of Kauffman's self-organization. This new hypothesis gives a parsimonious explanation for identical pathological patterns of arterial remodeling (neointimal formation), which occurs in diseases of different etiologies and due to dissimilar causes/risk factors, or without any etiology and causes/risk factors at all. This new hypothesis also suggests that regulation facilitating intimal cell proliferation cannot be overwritten or annulled because this feature is vital for arterial differentiation, cell renewal, and integrity. This hypothesis suggests that studying numerous, and likely interchangeable, non-specific signals that disrupt regulation controlling intimal cell proliferation is unproductive; instead, a study of the controlling regulation(s) itself should be a priority of our research.
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Affiliation(s)
- Vladimir M Subbotin
- University of Pittsburgh, Pittsburgh, PA 15260, USA; University of Wisconsin, Madison, WI 53705, USA; Arrowhead Parmaceuticals, Madison, WI 53719, USA.
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Abstract
This article is a comprehensive document on the diagnosis and management of fibromuscular dysplasia (FMD) which was commissioned by the Working Group 'Hypertension and the Kidney' of the European Society of Hypertension (ESH) and the Society for Vascular Medicine (SVM). This document updates previous consensus documents/scientific statements on FMD published in 2014 with full harmonization of the position of European and US experts. In addition to practical consensus-based clinical recommendations, including a consensus protocol for catheter-based angiography and percutaneous angioplasty for renal FMD, the document also includes the first analysis of the European/International FMD Registry and provides updated data from the US Registry for FMD. Finally, it provides insights on ongoing research programs and proposes future research directions for understanding this multifaceted arterial disease.
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Bagh I, Olin JW, Froehlich JB, Kline-Rogers E, Gray B, Kim ESH, Sharma A, Weinberg I, Wells BJ, Gu X, Gornik HL. Association of Multifocal Fibromuscular Dysplasia in Elderly Patients With a More Benign Clinical Phenotype: Data From the US Registry for Fibromuscular Dysplasia. JAMA Cardiol 2019; 3:756-760. [PMID: 29926082 DOI: 10.1001/jamacardio.2018.1638] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Fibromuscular dysplasia (FMD) is a nonatherosclerotic arterial disease that predominately affects women and is most commonly diagnosed in middle age. The natural history of FMD among patients diagnosed at an older age is not well understood. Objective To examine the differences in clinical presentation, arterial bed involvement, vascular events, and need for vascular procedures between younger and older patients with FMD. Design, Setting, and Participants Analysis of baseline data for patients enrolled in the US Registry for FMD as of December 15, 2016, at referral centers participating in the US Registry for FMD. Patients 18 years and older at the time of enrollment and those with only confirmed multifocal (string of beads type) FMD were included. Patients were categorized according to age at the time of diagnosis (≥65 years vs <65 years). Main Outcomes and Measures Prevalence of specific symptoms, vascular events, and prior vascular procedures at the time of enrollment in the registry. Results A total of 1016 patients were included in the analysis, of whom, 170 (16.7%) were 65 years or older at the time of diagnosis. Older patients with FMD were more likely to be asymptomatic at the time of diagnosis (4.2% vs 1.4%; P = .02). Headache and pulsatile tinnitus, both common manifestations of FMD, were less common in older patients (40.5% vs 69.1%; P < .001 and 30% vs 44.6%; P < .001, respectively). Extracranial carotid arteries were more commonly involved in patients 65 years or older at time of diagnosis (87% vs 79.4%; P = .03). There was no difference in prevalence of renal artery involvement, number of arterial beds involved, or diagnosis of any aneurysm. Patients 65 years or older were less likely to have had a major vascular event (37.1% vs 46.1%; P = .03) and fewer had undergone a therapeutic vascular procedure (18.5% vs 33.1%; P < .001). Conclusions and Relevance In the US Registry for FMD, patients 65 years or older at the time of diagnosis of multifocal FMD were more likely to be asymptomatic, had lower prevalence of major vascular events, and had undergone fewer therapeutic vascular procedures than younger patients. Patients with multifocal FMD diagnosed at an older age may have a more benign phenotype and fewer symptoms.
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Affiliation(s)
- Imad Bagh
- Vascular Medicine Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Jeffrey W Olin
- Zena and Michael A. Wiener Cardiovascular Institute, Mt Sinai Medical Center, New York, New York
| | - James B Froehlich
- Michigan Cardiovascular Outcomes Research and Reporting Program, University of Michigan, Ann Arbor
| | - Eva Kline-Rogers
- Michigan Cardiovascular Outcomes Research and Reporting Program, University of Michigan, Ann Arbor
| | - Bruce Gray
- Department of Surgery, Greenville Health System, Greenville, South Carolina
| | - Esther S H Kim
- Cardiovascular Division, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Aditya Sharma
- Division of Cardiovascular Medicine, University of Virginia, Charlottesville
| | - Ido Weinberg
- Vascular Center, Massachusetts General Hospital, Boston
| | - Bryan J Wells
- Divison of Cardiology, Emory University, Atlanta, Georgia
| | - Xiaokui Gu
- Michigan Cardiovascular Outcomes Research and Reporting Program, University of Michigan, Ann Arbor
| | - Heather L Gornik
- Vascular Medicine Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
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Chen S, Merchant M, Mahrer KN, Lundstrom RJ, Naderi S, Goh AC. Spontaneous Coronary Artery Dissection: Clinical Characteristics, Management, and Outcomes in a Racially and Ethnically Diverse Community-Based Cohort. Perm J 2019; 23:18.278. [PMID: 31926571 DOI: 10.7812/tpp/18.278] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
CONTEXT Spontaneous coronary artery dissection (SCAD) is a cause of acute coronary syndrome, which predominantly affects healthy women; however, few data define this vulnerable population. OBJECTIVE To identify demographic and clinical characteristics of patients with SCAD and determine outcomes in a community-based cohort. DESIGN Retrospective cohort study of patients with SCAD at Kaiser Permanente Northern California during a 10-year period. We compared 111 SCAD cases with 333 healthy, matched controls. MAIN OUTCOME MEASURES Predisposing factors, treatment modalities, and inhospital and late outcomes. RESULTS Patients with SCAD had a mean age (standard deviation) of 48.1 (11) years; 92.8% were women, and 49.5% were nonwhite. Of women, 9% were peripartum. Fibromuscular dysplasia was identified in 21.8% of femoral angiograms obtained. With conditional logistic regression, only pregnancy and hyperlipidemia were associated with SCAD compared with controls. Fifty-five patients (49.5%) were successfully treated without revascularization; of the 54 who had urgent percutaneous coronary intervention, 2 required coronary artery bypass grafting for SCAD extension. During a median follow-up of 2.6 years, major adverse cardiovascular events occurred in 8.1% of patients. Pregnancy-related SCAD was not associated with worsened outcomes. However, Emergency Department visits or hospitalizations because of recurrent chest pain occurred frequently for 54% of patients with SCAD. CONCLUSION The study cohort is comparable to published SCAD cohorts, but notable for a racially and ethnically diverse population. Compared with the controls, only pregnancy and hyperlipidemia were associated with SCAD. For the SCAD cases, major adverse cardiovascular events occurred in 8.1%, and race did not influence outcomes.
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Affiliation(s)
| | | | | | | | - Sahar Naderi
- Kaiser Permanente San Francisco Medical Center, CA
| | - Anne Ch Goh
- Kaiser Permanente San Francisco Medical Center, CA
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Trisvetova EL. Modern Concepts of Fibromuscular Dysplasia of the Coronary Arteries. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2019. [DOI: 10.20996/1819-6446-2019-15-3-431-438] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Fibromuscular dysplasia of the coronary arteries is a rare non-atherosclerotic and non-inflammatory vascular lesion that is asymptomatic until serious complications develop: stenosis, dissection, rupture, sudden cardiac death. Since there are no long-term numerous clinical observations of patients with fibromuscular dysplasia of the coronary arteries, recommendations have not been developed for diagnosing and treating the disease, which often manifests with acute coronary syndrome. In 2014, the European Consensus was published, and in 2019, the first international consensus document on the diagnosis and treatment of fibromuscular dysplasia with lesions of vessels from different regions (renal, cerebrovascular, coronary, and others). The documents state that the development of fibromuscular dysplasia of the coronary arteries considers the participation of the PHACTR1 gene mutation and the transcriptional activity of the EDN1 gene, smoking, prolonged exertion of the vascular wall, and possibly female sex hormones. In the case of acute coronary syndrome, the most informative diagnostic method is computed tomography with angiography, which reveals a smooth narrowing of the lumen in the middle or distal section in the epicardial artery, often due to intramural hematoma, and also finds dissection, spasm, and tortuous vessel. Additional diagnostic methods ‒ intravascular ultrasound and optical coherence tomography allow differentiation of fibromuscular dysplasia with atherosclerosis of the coronary artery, vasculitis, and other diseases. The choice of treatment tactics for fibromuscular dysplasia of the coronary arteries depends on the severity of the clinical manifestations ‒ conservative medical treatment and interventional methods are used.
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Ly VK, Manesh R, Raghavan K, Geha RM. Follow the Beads: Fibromuscular Dysplasia. Am J Med 2019; 132:329-332. [PMID: 30290190 DOI: 10.1016/j.amjmed.2018.09.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 09/12/2018] [Accepted: 09/13/2018] [Indexed: 11/24/2022]
Affiliation(s)
- Vy K Ly
- Department of Medicine, University of California, San Francisco.
| | - Reza Manesh
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Kesav Raghavan
- Department of Radiology, University of California, San Francisco
| | - Rabih M Geha
- Department of Medicine, University of California, San Francisco; Medical Service, VA Medical Center, San Francisco, Calif
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Fibromuscular Dysplasia: Recognition and Management. J Nurse Pract 2019. [DOI: 10.1016/j.nurpra.2018.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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40
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Gornik HL, Persu A, Adlam D, Aparicio LS, Azizi M, Boulanger M, Bruno RM, de Leeuw P, Fendrikova-Mahlay N, Froehlich J, Ganesh SK, Gray BH, Jamison C, Januszewicz A, Jeunemaitre X, Kadian-Dodov D, Kim ESH, Kovacic JC, Mace P, Morganti A, Sharma A, Southerland AM, Touzé E, van der Niepen P, Wang J, Weinberg I, Wilson S, Olin JW, Plouin PF. First International Consensus on the diagnosis and management of fibromuscular dysplasia. Vasc Med 2019; 24:164-189. [DOI: 10.1177/1358863x18821816] [Citation(s) in RCA: 151] [Impact Index Per Article: 30.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
This article is a comprehensive document on the diagnosis and management of fibromuscular dysplasia (FMD), which was commissioned by the working group ‘Hypertension and the Kidney’ of the European Society of Hypertension (ESH) and the Society for Vascular Medicine (SVM). This document updates previous consensus documents/scientific statements on FMD published in 2014 with full harmonization of the position of European and US experts. In addition to practical consensus-based clinical recommendations, including a consensus protocol for catheter-based angiography and percutaneous angioplasty for renal FMD, the document also includes the first analysis of the European/International FMD Registry and provides updated data from the US Registry for FMD. Finally, it provides insights on ongoing research programs and proposes future research directions for understanding this multifaceted arterial disease.
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Affiliation(s)
- Heather L Gornik
- Division of Cardiovascular Medicine, University Hospitals Cleveland Medical Center and UH Harrington Heart and Vascular Institute, Cleveland, OH, USA
| | - Alexandre Persu
- Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires Saint-Luc and Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - David Adlam
- Department of Cardiovascular Sciences, Glenfield Hospital, Leicester, UK
- NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Lucas S Aparicio
- Hypertension Section, Internal Medicine Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Michel Azizi
- Paris Descartes University, Paris, France
- Assistance-Publique Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Hypertension Unit, Paris, France
- Institut national de la santé et de la recherche médicale, Centre d’Investigation Clinique 1418, Paris, France
| | - Marion Boulanger
- Normandie Université, UNICAEN, Inserm U1237, CHU Caen Normandie, Caen, France
| | - Rosa Maria Bruno
- Department of Clinical and Experimental Medicine University of Pisa, Pisa, Italy
| | - Peter de Leeuw
- Department of Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Natalia Fendrikova-Mahlay
- Department of Cardiovascular Medicine, Cleveland Clinic Heart and Vascular Institute, Cleveland, OH, USA
| | - James Froehlich
- Department of Internal Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
| | - Santhi K Ganesh
- Department of Internal Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
| | - Bruce H Gray
- University of South Carolina School of Medicine/Greenville, Greenville, SC, USA
| | - Cathlin Jamison
- Association belge de patients atteints de Dysplasie Fibromusculaire/FMD Groep België (FMD-Be), Brussels, Belgium
| | | | - Xavier Jeunemaitre
- APHP, Department of Genetics and Centre for Rare Vascular Diseases, Hôpital Européen Georges Pompidou, Paris, France
- INSERM, U970 – PARCC, University Paris Descartes, Sorbonne Paris
Cité, Paris, France
| | - Daniella Kadian-Dodov
- Zena and Michael A Wiener Cardiovascular Institute and Marie-Josée and Henry R. Kravis Center for Cardiovascular Health; Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Esther SH Kim
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jason C Kovacic
- Zena and Michael A Wiener Cardiovascular Institute and Marie-Josée and Henry R. Kravis Center for Cardiovascular Health; Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Pamela Mace
- Fibromuscular Dysplasia Society of America (FMDSA), North Olmsted, OH, USA
| | - Alberto Morganti
- Centro Fisiologia Clinica e Ipertensione, Policlinico Hospital, University of Milan, Milan, Italy
| | - Aditya Sharma
- Department of Medicine, Cardiovascular Medicine Division, University of Virginia, Charlottesville, VA, USA
| | | | - Emmanuel Touzé
- Normandie Université, UNICAEN, Inserm U1237, CHU Caen Normandie, Caen, France
| | - Patricia van der Niepen
- Department of Nephrology & Hypertension Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Jiguang Wang
- Shanghai Institute of Hypertension and Center for Epidemiological Studies and Clinical Trials, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ido Weinberg
- Vascular Medicine Section and Vascular Center, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Scott Wilson
- Monash University (Central Clinical School of Medicine), Melbourne, VIC, Australia
- Department of Renal Medicine, Alfred Health, Melbourne, VIC, Australia
| | - Jeffrey W Olin
- Zena and Michael A Wiener Cardiovascular Institute and Marie-Josée and Henry R. Kravis Center for Cardiovascular Health; Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Pierre-Francois Plouin
- Paris Descartes University, Paris, France
- Assistance-Publique Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Hypertension Unit, Paris, France
- Institut national de la santé et de la recherche médicale, Centre d’Investigation Clinique 1418, Paris, France
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Rath M, Spiegler S, Strom TM, Trenkler J, Kroisel PM, Felbor U. Identification of pathogenic YY1AP1 splice variants in siblings with Grange syndrome by whole exome sequencing. Am J Med Genet A 2018; 179:295-299. [PMID: 30556293 PMCID: PMC6590215 DOI: 10.1002/ajmg.a.60700] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 10/23/2018] [Accepted: 10/27/2018] [Indexed: 01/23/2023]
Abstract
Grange syndrome is an autosomal recessive condition characterized by arterial occlusions and hypertension. Syndactyly, brachydactyly, bone fragility, heart defects, and learning disabilities have also been reported. Loss‐of‐function variants in YY1AP1 have only recently been associated with Grange syndrome. YY1AP1 encodes for the transcription coactivator yin yang 1‐associated protein 1 which regulates smooth muscle cell proliferation and differentiation. We here report on three siblings with steno‐occlusive arterial disorder and syndactyly in two of them. Whole exome sequencing including near‐splice regions led to the identification of two intronic YY1AP1 variants which were predicted to interfere with normal splicing. Sanger sequencing demonstrated compound‐heterozygosity in all affected siblings. RT‐PCR analyses confirmed skipping of exon 6 on one allele and exonization of 22 bp in intron 6 on the other. This is the first report of biallelic YY1AP1 variants in noncoding regions and just the second family with multiple affected siblings. Therefore, our report further delineates the phenotypic spectrum of Grange syndrome.
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Affiliation(s)
- Matthias Rath
- Department of Human Genetics, University Medicine Greifswald, and Interfaculty Institute of Genetics and Functional Genomics, University of Greifswald, Greifswald, Germany
| | - Stefanie Spiegler
- Department of Human Genetics, University Medicine Greifswald, and Interfaculty Institute of Genetics and Functional Genomics, University of Greifswald, Greifswald, Germany
| | - Tim M Strom
- Institute of Human Genetics, Technische Universität München, Munich, Germany.,Institute of Human Genetics, Helmholtz Zentrum München, Neuherberg, Germany
| | - Johannes Trenkler
- Institute of Neuroradiology, Kepler University Hospital, Linz, Austria
| | | | - Ute Felbor
- Department of Human Genetics, University Medicine Greifswald, and Interfaculty Institute of Genetics and Functional Genomics, University of Greifswald, Greifswald, Germany
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Rooke T. From the Masters: Lumper? Or splitter? Vasc Med 2018; 24:3-5. [PMID: 30428783 DOI: 10.1177/1358863x18808903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Thom Rooke
- Krehbiel Professor of Vascular Medicine, Mayo Clinic, Rochester, MN, USA
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Abstract
RATIONALE Fibromuscular dysplasia (FMD) is a rare vascular disorder that causes abnormal cell growth in arterial walls. The classic "string of beads" sign has been reported in many cases, whereas the appearance of tubular stenosis and distal tapering of renal arteries with multiple renal infarctions, as well as left kidney atrophy occurring in one patient, has not been precisely described. PATIENT CONCERNS A 19-year-old woman presented to us with a history of elevated blood pressure without any symptoms for the past 1 month. Routine laboratory tests indicated a moderately impaired renal function, and ultrasound examination demonstrated a small-sized left kidney and seriously decreased blood flow of the left renal artery and its branches. DIAGNOSIS Subsequent contrast-enhanced computed tomographic angiography (CTA) demonstrated multiple ischemic infarctions in the bilateral kidneys, and FMD was suggested at that time. Thereafter, we performed selective reno-angiography, which confirmed that the all left renal arteries had tubular stenosis and that right renal arterial branches presented distal tapering. INTERVENTION Antihypertensive drugs were prescribed conservatively, including nifedipine 60 mg/d and prazosin 4 mg/d, to lower the patient's blood pressure. OUTCOMES The patient had a well-controlled blood pressure and an improved renal function at her 6-month follow-up. LESSONS We should take the diagnosis of FMD into account if young women develop asymptomatic hypertension. To our knowledge, this is the first case that exhibited renal artery FMD manifesting as tubular stenosis and distal tapering, especially followed by bilateral renal infarctions and significant atrophy of the left kidney. In addition, CTA combined with digital subtraction angiography (DSA) may be more sensitive than other tests with respect to the detection of intrarenal infarctions and arterial variants of FMD.
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Hua X, Chen X, Chen K, Lai S, Gao R, Hu Y, Song J. Comparing coronary artery fibromuscular dysplasia with coronary atherosclerosis: from clinical to histopathological characteristics. Cardiovasc Pathol 2018; 35:57-63. [DOI: 10.1016/j.carpath.2018.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 03/25/2018] [Accepted: 04/23/2018] [Indexed: 10/17/2022] Open
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Agrawal V, Kim ESH. Spontaneous Coronary Artery Dissection: Cardiac Manifestations of Vascular Disease. Prog Cardiovasc Dis 2018; 60:629-634. [PMID: 29630904 DOI: 10.1016/j.pcad.2018.04.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Accepted: 04/01/2018] [Indexed: 01/24/2023]
Abstract
Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of acute coronary syndrome (ACS) in young women who otherwise do not have traditional risk factors for coronary artery disease. Though previously considered to be a rare occurrence and primarily associated with pregnancy, contemporary series have demonstrated that SCAD may account for 35% of ACS in women under the age of 50 years, and peripartum SCAD accounts for the minority of cases. Importantly, an association between SCAD and arterial abnormalities in non-coronary arterial distributions has been described. The most common of these arterial abnormalities is fibromuscular dysplasia. This manuscript will briefly review the epidemiology, diagnosis, and treatment of SCAD and provide an overview of how SCAD may be a cardiac manifestation of an underlying vascular disease in the majority of patients.
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Affiliation(s)
- Vineet Agrawal
- Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Esther S H Kim
- Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
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Abstract
OPINION STATEMENT Takayasu arteritis, fibromuscular dysplasia (FMD), spontaneous arterial dissection, Raynaud's phenomenon, and chilblains are vascular conditions that are associated with an increased predisposition in women and are often underdiagnosed. Takayasu arteritis has an incidence rate of 2.6 cases per million individuals per year in the USA and predominantly affects women of childbearing age. HLA-B5 genetic locus is linked with Takayasu arteritis susceptibility. Methods to determine active disease are limiting; currently utilized clinical and imaging findings and laboratory tests are of limited value for this purpose. Pregnancy poses risks for maternal and fetal complications, and these patients need additional monitoring and care before and after conception. Controlling hypertension and immunosuppression using steroids, biological and non-biological immunosuppressants, are key components of managing patients with this arteritis. FMD commonly affects middle-aged, white females. Its true prevalence is unknown. Renal and cerebrovascular beds are the most frequently involved vascular beds. Its clinical presentation varies from no symptoms to catastrophic events. Controlling vascular risk factors, periodic surveillance, and revascularization when indicated are important factors in FMD management. Spontaneous arterial dissections are less common, but are an important cause of morbidity and mortality in specific populations. Cervicocephalic dissection causes 10-20% of the strokes in young adults, and coronary artery dissection is the culprit in almost one fourth of young women presenting with acute myocardial infarction. Early diagnosis is key to improving prognosis in these patients, as the majority of patients have spontaneous resolution of the dissection with conservative management alone. Increased clinician awareness of the presentation features and angiographic findings are imperative for early diagnosis. Raynaud's phenomenon and chilblains are cold- or stress-induced cutaneous lesions, commonly involving distal extremities. Secondary causes such as connective tissue diseases and malignancies must be thoroughly excluded during evaluation of these conditions. Cold avoidance, systemic and local warming, and oral vasodilator therapy are the mainstays of therapy.
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Affiliation(s)
- Marianne H Khoury
- Vascular Medicine Section, Department of Cardiovascular Medicine, Cleveland Clinic Heart and Vascular Institute, Cleveland, OH, USA
| | - Heather L Gornik
- Vascular Medicine Section, Department of Cardiovascular Medicine, Cleveland Clinic Heart and Vascular Institute, Cleveland, OH, USA
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Jin C, Hu Z, He Y. A wide-necked extracranial internal carotid artery saccular aneurysm with ipsilateral proximal compression. JOURNAL OF CLINICAL ULTRASOUND : JCU 2017; 45:116-120. [PMID: 27492650 DOI: 10.1002/jcu.22385] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 07/01/2016] [Indexed: 06/06/2023]
Abstract
Extracranial internal carotid artery aneurysms (EICAA) are rare and can elicit various neurologic symptoms. Here, we present a case of a saccular EICAA compressing its proximal parent internal carotid artery (ICA). Ultrasonography demonstrated the proximal ICA stenosis and the "tardus-parvus" Doppler waveform downstream. The patient underwent aneurysmectomy and graft interposition. The histologic analysis highly supported an atypical fibromuscular dysplasia. Although this patient only showed a neck mass, the reduced ipsilateral cerebral blood supply was a potential cause for neurologic symptoms. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:116-120, 2017.
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Affiliation(s)
- ChunXiang Jin
- Department of Ultrasound, The Third Hospital of JiLin University, 126 XianTai street, 130033, ChangChun, China
| | - ZhenZhen Hu
- Department of Radiology, The Third Hospital of JiLin University, 126 XianTai street, 130033, ChangChun, China
| | - Yu He
- Department of Ultrasound, The Third Hospital of JiLin University, 126 XianTai street, 130033, ChangChun, China
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Xu X, Tsai M, Xiao N, Tan X, Zhang F, Yu Y, Wang Q, Xie W, Wang H, Li D. Fatal spontaneous rupture of common iliac artery associated with fibromuscular dysplasia. Forensic Sci Res 2017; 4:358-363. [PMID: 32002496 PMCID: PMC6968554 DOI: 10.1080/20961790.2016.1274467] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 12/15/2016] [Indexed: 11/26/2022] Open
Abstract
A previously healthy 25-year-old man with no known risk factors was presented at the emergency room with a 3 h history of abdominal and loin pain. Physical examination and lab data showed no specific findings except tenderness, slight white cell count elevation and decreased haemoglobin level. The patient's condition deteriorated over the following hours and he died despite resuscitation attempts. Autopsy revealed a 2.5-cm longitudinal tear in the intima of the right common iliac artery, which formed a thrombosed false lumen extending to the abdominal aorta proximally and to the left common iliac artery. Histopathologic examination revealed the characteristic changes of fibromuscular dysplasia (FMD). FMD involving the common iliac arteries is extremely rare; only six cases have been reported previously, and only two of those included forensic findings. The presented case is the first case of FMD with intimal tearing in the right common iliac artery, with propagation to the left common iliac artery and abdominal aorta. When a previously healthy young adult without hypertension or other risk factors presents with acute abdominal and loin pain, systemic vascular disease should be on the list of differential diagnoses. Careful and complete evaluation of multiple arteries can be critical.
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Affiliation(s)
- Xiang Xu
- School of Forensic Medicine, Southern Medical University, Guangzhou, China.,School of Forensic Medicine, Wannan Medical College, Wuhu, China
| | - Mengchen Tsai
- Department of Forensic Medicine, College of Medicine, National Taiwan University, Taipei, China
| | - Ning Xiao
- School of Forensic Medicine, Southern Medical University, Guangzhou, China
| | - Xiaohui Tan
- School of Forensic Medicine, Southern Medical University, Guangzhou, China
| | - Fu Zhang
- Guangdong Public Security Department, Key Lab of Forensic Pathology, Guangzhou, China
| | - Yangeng Yu
- Guangdong Public Security Department, Key Lab of Forensic Pathology, Guangzhou, China
| | - Qi Wang
- School of Forensic Medicine, Southern Medical University, Guangzhou, China
| | - Weibing Xie
- School of Forensic Medicine, Southern Medical University, Guangzhou, China
| | - Huijun Wang
- School of Forensic Medicine, Southern Medical University, Guangzhou, China
| | - Dongri Li
- School of Forensic Medicine, Southern Medical University, Guangzhou, China
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