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Query: UMLS:C0004153 (atherosclerosis)
 77,401 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

In patients with severe atherosclerosis of the abdominal aorta or previous operations on the abdominal aorta, right renal revascularization may be difficult to achieve using aortorenal bypass. An experimental study was performed demonstrating the efficacy of hepatorenal bypass as an alternative operative procedure in this regard. Follow-up studies in these dogs demonstrated no adverse postoperative effects on hepatic function or morphology. In addition, two patients underwent hepatorenal bypass with a saphenous vein graft as surgical treatment for azotemia and hypertension caused by atherosclerotic right renal artery stenosis. Postoperatively, the blood pressure diminished and renal function improved in both patients. No evidence of persistent hepatic dysfunction was observed.
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PMID:Experimental and clinical hepatorenal bypass as a means of revascularization of the right renal artery. 43 70

In elderly patients with uncontrolled hypertension or increasing azotemia caused by renovascular disease, hepatorenal or splenorenal bypass procedures are helpful alternatives. The presence of diffuse atherosclerosis makes aortorenal bypass technically difficult. Surgery of this type can be accomplished with acceptable morbidity and mortality, even in suitably screened elderly patients.
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PMID:Renovascular hypertension in elderly patients. 183 57

Surgery has been used to treat renal vascular hypertension for almost 50 years. The reason for the many apparent discrepancies in the literature on effectiveness and risk have become clear only in the past decade. The results are poorest and the risk is greater, not surprisingly, in patients with advanced atherosclerosis involving many vascular beds. The results are much better in fibromuscular disease, both in terms of effectiveness and risk. Angioplasty has been available for a much shorter time, but a reasonable picture of the short-term effectiveness and the risk is emerging. The risk is substantially lower than that of surgery. The results are again best in fibromuscular disease. In atherosclerotic disease, the results are especially poor for the most common lesion, that involving the renal artery ostium. Medical therapy before the development of captopril was often difficult and often unsatisfactory. Since the development of converting-enzyme inhibition, medical therapy is an important option. In the early experience, reflecting the severity of the hypertension, the frequency with which azotemia was present, and the high dose of captopril used, the adverse reaction rate was substantial. In one study, none of 133 patients with unilateral renal arterial disease and an intact contralateral kidney developed renal failure. Among 136 patients with bilateral disease or a solitary kidney, renal failure occurred in 15 and led to discontinuation of therapy in 12. If surgery or angioplasty are contraindicated, one can modify the therapeutic goal.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:The treatment of renovascular hypertension: surgery, angioplasty, and medical therapy with converting-enzyme inhibitors. 303 90

Sixty-three patients who underwent renal revascularization at the time of aortic surgery were retrospectively reviewed. These patients had significant renal artery stenosis in addition to either severe aortoiliac occlusive disease or aortic aneurysmal disease. Fifty-eight patients were hypertensive, whereas five patients were normotensive and these renal lesions were treated prophylactically. The operative mortality rate was 3%. Despite lack of selectivity in these patients with diffuse atherosclerosis, 60% (35 of 58) of the patients with hypertension could be classified as either "cured" or "improved." Patients with bilateral renal artery involvement and moderate azotemia were noted to improve with respect to renal function postoperatively. No patient has required chronic dialysis at a mean follow-up period of 22.6 months. Simultaneous aortic and renal artery surgery may be performed with low morbidity and mortality rates and produce a gratifying improvement in hypertension. Renal functional improvement and perhaps preservation of renal mass may be anticipated in selected patients.
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PMID:Concomitant renal revascularization in patients undergoing aortic surgery. 399 29

A patient developed azotemia from bilateral ureteral obstruction due to retroperitoneal fibrosis after placement of an aortofemoral bypass graft for atherosclerosis in that region. This complication of abdominal vascular prosthesis may be more common than is presently recognized; especially since the patient may remain asymptomatic till an advanced degree to azotemia supervenes. At that time irreversible damage to the kidney may occur. Furthermore, silent damage in the kidneys may be attributed to other causes in these patients who may also have severe vascular disease or prostatic disease. When a gradually increasing azotemia is seen in a patient who had aortofemoral bypass surgery, ureteral obstruction from retroperitoneal fibrosis should be one of the main considerations in the differential diagnosis. Computed tomography, isotope renography and sonography may be helpful in making an early diagnosis and should be a part of the postoperative follow-up care in these patients.
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PMID:Bilateral ureteral obstruction following aortic bypass surgery. 722 83

Coexistence of renal cell carcinoma and renal artery disease is an unusual and challenging problem. From 1969 to 1991, 34 patients presented with localized renal cell carcinoma and renal artery disease affecting all of the functioning renal parenchyma. These patients represented 4 categories: 1) a solitary kidney with renal cell carcinoma and renal artery disease (5), 2) bilateral renal cell carcinoma and coexistent renal artery disease (5), 3) unilateral renal cell carcinoma and contralateral renal artery disease (13), and 4) unilateral renal cell carcinoma and bilateral renal artery disease (11). Atherosclerosis was the most common cause of renal artery disease (30), followed by medial fibroplasia (2), renal artery aneurysm (1) and arteriovenous malformation (1). A total of 23 patients (68%) presented with azotemia (serum creatinine 1.5 mg./dl. or more) and 11 (32%) presented with hypertension. All patients underwent complete surgical excision of renal cell carcinoma. A nephron sparing operation was performed preferentially (30 patients) and bilateral renal cancer operations were staged. Eight patients underwent simultaneous partial (6) or radical (2) nephrectomy and surgical renal revascularization. There were no operative deaths. Postoperatively, preservation of renal function was achieved in 33 patients and 1 required chronic dialysis. At mean followup of 47 months 23 patients (68%) were alive with no evidence of malignancy and 2 were alive with recurrent renal cell carcinoma. Three patients died of metastatic renal cell carcinoma, while 6 died of unrelated causes. All of the latter 6 patients were free of renal cell carcinoma at death. Nephron sparing surgery combined occasionally with renal arterial reconstruction can yield gratifying results in this complex patient population.
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PMID:Management of renal cell carcinoma with coexistent renal artery disease. 834 89

Ischemic renal disease is defined as a clinically significant reduction in glomerular filtration rate in patients with hemodynamically significant renal artery stenosis. The most common etiology for this is atherosclerotic renal artery disease. The three major clinical settings in which one must suspect ischemic renal disease include acute renal failure precipitated by the treatment of hypertension particularly with angiotensin-converting enzyme inhibitors; progressive azotemia in a patient with known renal vascular hypertension treated medically; and unexplained progressive azotemia in an elderly patient with refractory hypertension and other evidence of atherosclerotic disease. Prevalence of ischemic renal disease secondary to atherosclerosis can be estimated from the incidence of atherosclerotic renal artery lesions leading to renal vascular hypertension and the natural history of these lesions. Autopsy series, arteriography studies, and review of populations of patients in end-stage renal disease programs all suggest that ischemic renal disease has a high and increasing prevalence in our aging population.
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PMID:The natural history of renal artery stenosis: who should be evaluated for suspected ischemic nephropathy? 872 81

Chronic azotemic renovascular disease is common in patients with atherosclerosis. Its prevalence appears to be increasing in the aging population. How often it is the primary cause of end-stage renal disease (ESRD) is not yet certain. Some studies suggest that 10%-40% of elderly hypertensive patients with newly documented ESRD and no demonstrable primary renal disease have significant renal artery stenosis (RAS). Atherosclerotic vascular occlusive disease of the renal arteries does progress, but current rates of progression and occlusion are lower than those reported a decade ago. Methods of identifying patients whose renal function is at true risk from vascular occlusive disease and determining who will benefit from intervention remain elusive. The presence of RAS in an azotemic patient can be assessed with noninvasive and risk-free radiologic techniques, including Duplex doppler velicometry and magnetic resonance angiography. Functional tests that predict the change in renal function after revascularization are not yet available. However, a renal length of greater than 7.5 cm in the absence of renal cysts and a short history of renal functional deterioration indicate a good prognosis. Patients with recent deterioration in renal function, those with bilateral renal artery stenosis or stenosis to a single functioning kidney, those with flash pulmonary edema, advanced chronic renal failure, or ESRD (who have much to gain), those with reversible azotemia during angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor antagonist (ARB) therapy, and those whose conditions cannot be managed medically should be considered for revascularization. Results from recent controlled clinical trials of the response to percutaneous transluminal renal artery angioplasty (PTRA) and stenting indicate that improvement in blood pressure control or renal function is not a predictable outcome of renal revascularization. In azotemic groups, 25%-30% of patients achieve important recovery of renal function. Thus, significant progress has been made recently in determining whether RAS is a frequent, treatable cause of renal failure. The decision to recommend revascularization remains a difficult balance between the risks and expense of the procedure and the undoubted benefits that accrue if renal function is successfully stabilized.
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PMID:Renal artery stenosis: a common, treatable cause of renal failure? 1116 Jul 87

Transcatheter endovascular procedures are increasingly used to treat symptomatic peripheral atherosclerosis. This two-part review identifies the existing evidence supportive of the application of transcatheter treatments for peripheral atherosclerotic lesions. The first part addresses the treatment of obstructive lesions that cause limb claudication and critical ischemia, renovascular hypertension and azotemia, and mesenteric ischemia. Studies were identified via a search of MEDLINE (January 1993 through April 1999) and reference lists of identified articles. When multicenter prospective randomized trials or other high-quality studies were unavailable, a preference was given to studies with at least 50 patients per treated group and a minimum mean follow-up duration of 6 months. Data presented in tables are proportionally weighted averages from included studies. For each application, the authors assessed the quality of evidence (QOE; efficacy, safety, and, where available, cost-effectiveness) and made recommendations with appropriate caveats. There is higher QOE supporting the more established treatments such as lower limb percutaneous transluminal angioplasty (PTA) with stent placement and thrombolysis. Treatments such as renal artery PTA and stent placement and mesenteric and brachiocephalic PTA are in wide use, but high QOE supporting general application is lacking. Blanket recommendations based on established efficacy and cost-effectiveness cannot be made. However, the use of transcatheter therapies can be supported in specific circumstances based on an expected reduction in procedure-related morbidity and/or mortality rates. It is hoped that the identification of deficiencies in the literature will inform and inspire critically needed research in this area.
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PMID:Transcatheter interventions for the treatment of peripheral atherosclerotic lesions: part I. 1138 19

The clinical diagnosis of renal artery stenosis relies on a high index of suspicion and confirmation by noninvasive imaging modalities. There are three distinct clinical syndromes associated with renal artery stenosis: renin-dependent hypertension, essential hypertension, and ischemic nephropathy. Clinical features that should heighten suspicion for renal artery stenosis include abrupt-onset or accelerated hypertension at any age, unexplained acute or chronic azotemia, azotemia induced by angiotensin-converting enzyme (ACE) inhibitors, asymmetric renal dimensions, and congestive heart failure with normal ventricular function. Patients with true renin-dependent (renovascular) hypertension are typically young or middle-age women with renal fibromuscular dysplasia (FMD). Initial therapy for renovascular hypertension associated with FMD is an ACE inhibitor; refractory hypertension responds readily to balloon angioplasty without stenting. Elderly patients with generalized atherosclerosis and hypertension often have atherosclerotic renal artery stenosis (ARAS); hypertension in these patients is usually not renin dependent (ie, essential hypertension). Hypertension alone, even if treated with multiple medications, is not a compelling indication for renal artery revascularization; these patients should be treated aggressively with antihypertensive medical therapy. Renal artery revascularization with stenting may be considered for refractory severe hypertension, and would be expected to improve blood control and modestly reduce medication requirements. Renal revascularization rarely cures hypertension in patients with ARAS. Patients with ARAS, hypertension, and end-organ injury should be considered for renal revascularization. Manifestations of end-organ injury include nonischemic pulmonary edema; hypertensive crisis associated with acute coronary syndrome, aortic dissection, or neurologic impairment; and renal insufficiency. Ischemic nephropathy is best treated before the development of advanced renal failure. The best candidates for revascularization are those with baseline serum creatinine less than 2.0 mg/dL, bilateral renal artery stenosis, normal renal resistive indices, no proteinuria, and one or more manifestations of end-organ injury. In these patients, renal revascularization is best accomplished by stenting, although surgical revascularization may be considered in patients with concomitant severe aortic aneurysmal or occlusive disease.
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PMID:Atherosclerotic Renal Artery Stenosis. 1268 6


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