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Principles of arteriography
Published in Peter A. Schneider, Endovascular Skills: Guidewire and Catheter Skills for Endovascular Surgery, 2019
Cardiac and pulmonary insufficiency may also present difficulties in performing arteriography. The patient must be able to lie in a supine position for a lengthy period of time. Breath holds are often required to obtain reasonable images of any part of the body cavities. Patients with severe congestive heart failure, poor cardiac output, diastolic dysfunction, or a history of flash pulmonary edema may not be able to tolerate the osmotic load presented by the contrast.
Renal and mesenteric artery interventions
Published in Debabrata Mukherjee, Eric R. Bates, Marco Roffi, Richard A. Lange, David J. Moliterno, Nadia M. Whitehead, Cardiovascular Catheterization and Intervention, 2017
Sumit Baral, Robert A. Lookstein, John H. Rundback
RAS is a common clinical problem. The safety of renal inter- ventions has improved with evolving techniques, and there is strong, albeit predominantly observational data, support- ing clinical value for the treatment of associated hyperten- sion, renal failure, or pulmonary edema. Demonstration of a cardiovascular survival benefit will be a critical deter- minant of long-term acceptability and is currently the sub- ject of a large, international multicenter prospective trial. Currently, the only class I indication for RAST is in patients with hemodynamically significant RAS with recurrent, unexplained HF or sudden unexplained episodes of “flash” pulmonary edema.89 Patients with accelerated or resistant hypertension (defined as failure of >3 maximally toler- ated medications including a diuretic), global renal isch- emia (bilateral RAS or severe RAS in a solitary functioning kidney), or hypertension with medication intolerance also generally benefit from RAST after a trial of optimal medical therapy, and are considered class IIa indications for stenting.90
Endovascular intervention for renal artery occlusive disease
Published in Sachinder Singh Hans, Alexander D Shepard, Mitchell R Weaver, Paul G Bove, Graham W Long, Endovascular and Open Vascular Reconstruction, 2017
Jason Q. Alexander, Derrick Green, Timothy M. Sullivan
The completion of the CORAL (Cardiovascular Outcomes in Renal Atherosclerotic Lesions) trial has significantly decreased the indications for percutaneous intervention of the RAs for stenosis secondary to atherosclerotic disease.1 The CORAL trial did not show a statistically significant reduction in blood pressure (BP) following percutaneous treatment of RA stenosis when compared with best medical management. Studies evaluating the use of percutaneous RA interventions for preservation of renal function have been even less promising. Thus, until new trials demonstrate significant benefit, indications for either open or endovascular revascularization of RAs due to atherosclerotic disease are limited. However, this does not mean that there are not indications for treatment. While traditional indications for RA intervention due to atherosclerotic disease may be less clear, the rapid expansion of new endovascular interventions including complex branched and fenestrated endograft placement or “chimney” endovascular aneurysm repair (chEVAR) procedures for abdominal aortic aneurysm (AAA) means that practitioners must still know how to obtain access and treat RA stenosis. Further, in the face of BP that cannot be controlled despite maximal management with four or more antihypertensive medications, treatment of RA stenosis may still be warranted if for no other reason than a lack of other options. Similar statements can likely be made for patients with poor BP control and episodes of flash pulmonary edema. Controversy will probably continue to present itself when practitioners are faced with the question of worsening RA stenosis in patients with single-functioning kidneys and progressive renal dysfunction.
Impact of end-stage renal disease on in-hospital outcomes of hypertensive emergency from the National Inpatient Sample, 2016 to 2018
Published in Baylor University Medical Center Proceedings, 2022
Dae Yong Park, Seokyung An, Marie-Anjeliese Rodriguez, Raghad Odeh, Hasan Hammo, Mahaim Haque, Abdul Wahab Arif
We also found higher odds of acute pulmonary edema in ESRD patients. This is not a surprising finding, as these patients have little, if any, urine output and are thus much more likely to retain volume. Pulmonary edema can also be explained by the association of ESRD with heart failure.14 Ineffective diuresis and preexisting volume expansion in conjunction with increased left ventricular afterload in hypertensive emergency can acutely worsen volume overload, leading to flash pulmonary edema. In addition, concomitant structural heart disease is common in ESRD patients, which predisposes them to systolic and diastolic dysfunction.15,16 All of these factors put patients with ESRD at a higher risk of clinically significant pulmonary congestion. An epidemiological study also found that 59% of patients with ESRD had moderate to very severe pulmonary congestion.17 Given these findings, improved blood pressure control along with outpatient monitoring of pulmonary congestion may be beneficial in preventing clinical congestion, which is a stronger driver of hospitalization in this population.18
Recognition and management of idiopathic systemic capillary leak syndrome: an evidence-based review
Published in Expert Review of Cardiovascular Therapy, 2018
Noor Ul-Ain Baloch, Marvi Bikak, Abdul Rehman, Omar Rahman
A number of complications of SCLS have been reported in the literature. Development of limb compartment syndromes requiring fasciotomies and/or limb amputations is one of the most widely recognized complications. Flash pulmonary edema during the reversal phase of SCLS, which may even prove fatal, is another dreaded complication of this disease. Moreover, the occurrence of pleural and pericardial effusions (sometimes necessitating repeated thoracenteses and pericardiocenteses) has also been reported. Acute renal failure requiring hemodialysis was noted in two patients in the cohort of Kapoor et al. [9] as mentioned previously; increased vascular permeability during the leak phase can result in marked polycythemia and tremendously increased blood viscosity. This can lead to a hypercoagulable state which may lead to deep venous thrombosis and even ischemic stroke. A few patients with SCLS may develop cerebral edema during the reversal phase and may lead to generalized tonic–clonic seizures [44]. Progression of MGUS to multiple myeloma (MM) in patients with SCLS is well-documented, although the rate of progression to MM is the same as that for other patients with MGUS. In the study of Amoura et al., 3 out of 13 patients died, of whom 2 patients had a progression of MGUS to MM [38].
The PHACES syndrome: Multiple episodes of reproliferation of subglottic hemangioma
Published in Baylor University Medical Center Proceedings, 2018
Randall W. Holdgraf, Melissa Kress
At 48 months of age, a DLB showed almost complete regression of subglottic hemangiomas, and her tracheostomy was decannulated successfully at 51 months of age. Propranolol was then weaned off at 61 months of age. Two months later, she was found to have worsening ear disease with hemangioma present in both middle ears with a bilateral 40 dB conductive hearing loss. At 63 months of age, another DLB showed a grade two subglottic stenosis with recurrence of the subglottic hemangiomas requiring balloon dilation, topical mitomycin C application, and injection of Kenalog-40/celestone solution. She required re-intubation after the procedure was concluded and was admitted to the pediatric intensive care unit due to flash pulmonary edema. The decision was made to restart propranolol at 2.0 mg/kg/day. Over the next 3 months, she required two more DLB procedures including balloon dilation with application of mitomycin C topically and injection with Kenalog-40/celestone. At 66 months, she had a mild grade 2 subglottic stenosis but no visible recurrence of the subglottic hemangiomas and propranolol was weaned down to 1.67 mg/kg/day. At 73 month of age, a DLB revealed a grade 2 subglottic stenosis with recurrence of the subglottic hemangiomas.