Overview of endovascular and open abdominal aortic aneurysm repair.
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Aortic Aneurysm, Abdominal↗
Biomedical subjects
A B Lumsden
Publications and source records attributed to A B Lumsden.
Effects of homocysteine on smooth muscle cell proliferation in both cell culture and artery perfusion culture models.
BACKGROUND: Hyperhomocysteinemia is associated with increased risk for vascular disease. However, the pathogenic mechanisms of homocysteine are largely unknown. We evaluated the effects of homocysteine on smooth muscle cell (SMC) and endothelial cell proliferation in cell culture and on SMC proliferation of balloon angioplasty-injured arteries in a perfusion culture model. METHODS: Human and pig SMCs and endothelial cells were cultured with variable amounts of homocysteine for 72 h and the total cells were counted using a hemocytometer. Fresh pig carotid arteries were harvested from a local slaughterhouse and cultured in a newly designed artery perfusion culture system. Five groups of arteries (six per group) were cultured for 48 h under different conditions: normal control, balloon angioplasty injury alone, and injury with three different doses of homocysteine. Vessel viability was evaluated. SMC proliferation was assayed by bromodeoxyuridine (BrdU) DNA labeling. RESULTS: At concentrations equivalent to those in human hyperhomocysteinemia, homocysteine significantly stimulated both cultured human and pig SMC proliferation with a dose-dependent effect, while it inhibited cultured endothelial cell growth. Perfusion-cultured pig carotid arteries remained contractile in response to norepinephrine and relaxant to nitroglycerine, and viable cells were also isolated from the cultured arteries. SMC proliferation (BrdU index) showed significant differences among the groups. SMC proliferation was stimulated by vascular injury and further enhanced by homocysteine in a dose-dependent manner. The proliferative response occurred strongly on the luminal side of the vessel wall, with the effects tapering toward the adventitia. CONCLUSIONS: Homocysteine had a mitogenic effect on vascular SMCs and a cytotoxic effect on endothelial cells. This differential effect of homocysteine on vascular cells may represent a pathogenic mechanism of vascular lesion formation in patients with hyperhomocysteinemia.
Angioplasty, Balloon↗
A new perfusion culture system used to study human vein.
BACKGROUND: Cell culture studies, ring studies, and indirect physiologic studies are the predominant models used to study human vascular tissue. Such studies are limited in their capacity to permit physiologic single-factor changes or to provide the proper mechanical stress or extracellular matrix present in normal tissues. We present a newly devised organ culture system that addresses these issues and permits survival of intact segments of human vascular tissue in a perfused environment. Our experience culturing human saphenous vein with this system is detailed. METHODS: Perfusion culture chambers were designed and constructed in our laboratory. Excess saphenous vein segments were collected from coronary artery bypass graft cases at our hospital and then mounted into our perfusion culture system for 0, 24, 48, 72, or 96 h. Vasomotor assays, hematoxylin and eosin staining, bromodeoxyuridine staining, and factor VIII staining were performed to assess tissue survival. RESULTS: A total of 24 veins were cultured. Average vessel length was 5 cm. The vessels contracted and relaxed the following amounts: time 0 (6.7% contraction, 5.0% relaxation), 24 h (5.7%, 5.3%), 48 h (5.2%, 2.8%), 72 h (4.8%, 5.3%), 96 h (4.8%, 3.8%). Hematoxylin and eosin staining, bromodeoxyuridine staining, and factor VIII staining support the viability of the tissue segments. CONCLUSION: A new perfusion organ culture system has been devised that permits survival of intact human venous tissue for periods up to 96 h. Studies that permit physiologic single-factor changes along with precise control of the hemodynamic environment are possible with this system.
Humans↗
Local infusion of heparin reduces anastomotic neointimal hyperplasia in aortoiliac expanded polytetrafluoroethylene bypass grafts in baboons.
PURPOSE: Recently, we designed and characterized a novel expanded polytetrafluoroethylene (ePTFE)-based local drug delivery approach that selectively concentrates infused pharmacologic agents specifically within those blood layers adjacent to the graft wall and at downstream anastomotic sites. In this study, we locally administrated standard heparin therapy and evaluated its effects on neointimal hyperplasia formation in a baboon model of aortoiliac bypass graft placement. METHODS: Six adult male baboons underwent bilateral aortoiliac bypass grafting with ringed ePTFE (4 mm internal diameter x 5 cm length). In each animal, the distal anastomosis of one graft was continuously infused with heparin (50 U/h) and the distal anastomosis of the contralateral graft was infused with saline solution at the same rate (2.5 microL/h), with osmotic pumps implanted for 4 weeks. Platelet counts and activated partial thromboplastin time measurements were performed weekly. The specimens were harvested at 4 weeks and were subjected to morphometric analysis. Cell proliferation was assessed with bromodeoxyuridine immunostaining. RESULTS: All the harvested grafts were patent except for one control graft. There were no significant differences in platelet counts or activated partial thromboplastin time measurements taken before and during heparin infusion. As expected, there were no significant differences in graft neointimal hyperplasia and cell proliferation at the proximal anastomoses between the heparin-infused and control grafts. In contrast, at the treated distal anastomoses, heparin infusion significantly reduced the graft neointimal area by 65% and the cell proliferation index by 47% as compared with the untreated control distal anastomoses. CONCLUSION: These results show that local infusion of heparin significantly reduces distal anastomotic neointimal hyperplasia and cell proliferation without measurable systemic anticoagulation or other side effects. Thus, this approach may represent an attractive strategy for prolonging ePTFE bypass graft patency.
Anastomosis, Surgical↗
Evaluation of thrombolysis and angioplasty in a porcine iliac artery thrombosis model: application of endovascular stent-graft-induced thrombosis.
PURPOSE: To develop a novel endovascular thrombosis model in the porcine iliac artery for the evaluation of thrombolysis and angioplasty. MATERIALS AND METHODS: A stent-inversion-graft (SIG) model combining either a 3-mm or 5-mm tapered expandable polytetrafluoroethylene (ePTFE) graft attached within a self-expandable, 10-mm nitinol stent was placed in the left common iliac artery via an ipsilateral common femoral artery approach in 24 pigs. When the iliac artery was thrombosed, urokinase (250,000 IU) plus heparin (1,000 units) were pulse sprayed via a contralateral femoral approach (n = 12). Saline pulse-spray was used as a control group (n = 12). Balloon angioplasty was performed to eliminate the stenotic tapered graft within the stent after successful thrombolysis. The efficacy of the thrombolysis was assessed with use of intravascular ultrasound (IVUS) and arteriogram. RESULTS: Both the 3-mm tapered and 5-mm tapered SIG models caused iliac artery occlusion in 22 +/- 5 and 41 +/- 9 minutes, respectively, after the deployment. Luminal patency was re-established successfully in all occluded arteries after urokinase infusion. Angioplasty was successful in eliminating the tapered stenosis and restoring the normal diameter in all iliac arteries treated with urokinase. Complete thrombolysis was achieved in both models treated with urokinase. CONCLUSION: This novel endovascular approach of inducing arterial thrombosis is simple to perform and reliably produces arterial thrombosis. The intraluminal stenosis is also amenable to angioplasty. This model is useful for the evaluation of antithrombotic treatment modality and adjunctive endovascular interventions.
Alloys↗
Subclavian artery disruption resulting from endovascular intervention: treatment options.
Endovascular intervention is a commonly accepted form of treatment in patients with subclavian artery stenosis. Complications will undoubtedly occur as the utility of catheter-based intervention continues to rise. We report two cases of subclavian artery disruption as a result of endovascular intervention. One patient had contrast extravasation after the deployment of a balloon-expandable stent in a stenotic subclavian artery, and the arterial injury was successfully treated with balloon tamponade. A second patient had a large subclavian pseudoaneurysm 4 months after a balloon-expandable stent placement. Successful repair was achieved in this patient by means of arterial reconstruction with a prosthetic bypass graft. These cases illustrate different therapeutic methods of treating subclavian artery rupture due to endovascular intervention.
Aged↗
A porcine model of carotid artery thrombosis for thrombolytic therapy and angioplasty: application of PTFE graft-induced stenosis.
PURPOSE: To develop a porcine carotid artery thrombosis model for the evaluation of thrombolytic therapy and adjunctive angioplasty procedures. METHODS: Bilateral carotid thrombosis was induced in 16 pigs using endothelial crush injury followed by external polytetrafluoroethylene (PTFE, 5 x 2 cm2) wrap placement to create segmental carotid stenosis. Light microscopy was used to examine thrombus composition. Selective carotid catheterization was performed via a femoral approach. Two hours following carotid artery occlusion, a urokinase (250,000 IU) and heparin (1000 U) solution was pulse-sprayed in 1 carotid artery while the contralateral vessel received the control saline vehicle. The efficacy of thrombolytic therapy was assessed using carotid arteriography and intravascular ultrasound. The feasibility and technical efficacy of balloon angioplasty within the carotid stenosis model were also evaluated. RESULTS: Carotid artery occlusion occurred in 30 +/- 6 minutes following endothelial injury plus PTFE wrap placement. Histological examination of carotid arteries showed endothelial irregularity with fibrin-rich and platelet-rich thrombus. Urokinase was effective in recanalizing all occluded arteries (100%), while the control saline vehicle showed no effective thrombolysis (p < 0.001). Angioplasty was successful in restoring normal diameter in all arteries (100%). CONCLUSIONS: This carotid artery thrombosis model, which incorporates intimal injury with segmental stenosis, is simple to create and reproducible. It provides not only a model for the evaluation of thrombolytic therapy but also a practical training tool for adjunctive endovascular interventions.
Angiography↗
An endovascular model of carotid stenosis for the evaluation of thrombolysis and angioplasty.
PURPOSE: To develop a porcine carotid artery thrombosis model using a novel stent-graft device to evaluate the efficacy of thrombolytic therapy and angioplasty procedures. METHODS: An endovascular device made from a tapered polytetrafluoroethylene graft inverted in a self-expanding nitinol stent was delivered to bilateral carotid arteries via a right femoral approach in 16 pigs. Carotid thrombotic occlusion ensued from flow stasis created by the intrastent stenosis. Via selective carotid catheterization from a femoral approach, urokinase (250,000 IU) was pulse-sprayed in one carotid artery while a control saline solution was infused in the contralateral vessel; delivery times were 1 hour, 8 hours, 3 days, or 6 days after carotid occlusion (4 animals per time period). After thrombolysis, balloon angioplasty was performed to maintain carotid patency. Arteriography and intravascular ultrasound were used to evaluate the efficacy of thrombolysis. Light microscopy was used for histological analysis of the thrombus. RESULTS: Carotid artery occlusion occurred in 15+/-8 minutes after stent-graft placement in all animals. Urokinase was effective in recanalizing all occluded arteries in the 1-hour, 4-hour, and 3-day groups (100%) but was effective in only 2 of 4 animals in the 6-day group (p < 0.05). Overall thrombolytic efficacy was 78%+/-7%. Control saline solution showed no thrombolytic effect (p < 0.001). Angioplasty successfully restored normal luminal diameter in all fully lysed arteries (100%). Histological analysis showed fibrin-predominant thrombus with a varying degree of platelet deposition. CONCLUSIONS: This endovascular approach, which creates a carotid stenosis using this novel stent-graft device, is reliable in producing carotid thrombosis. In our model, thrombolytic therapy was effective in restoring luminal patency, and the intraluminal stenosis is amenable to balloon angioplasty. The model is useful for the evaluation of antithrombotic therapy and adjunctive endovascular interventions.
Angioplasty, Balloon↗
Oral administration of L-arginine reduces intimal hyperplasia in balloon-injured rat carotid arteries.
Endogenous nitric oxide (NO) is produced from L-arginine by NO synthase. We evaluated the effect of oral administration of L-arginine on intimal hyperplasia in balloon-injured rat carotid arteries. Thirty Sprague-Dawley rats underwent balloon denudation on the left common carotid artery. Fifteen rats were treated with L-arginine in drinking water (2.5 mg/mL) two days before injury and were continued for 2 weeks. Another 15 rats served as controls. All animals survived without complications or body weight loss. In the treated group, daily intake of L-arginine was 170 +/- 43 mg/day. Plasma arginine levels were 130 +/- 32 micromol/L prior to L-arginine intake, 165 +/- 42 micromol/L at the day of injury, and 162 +/- 26 micromol/L at sacrifice. Intimal hyperplasia developed in all balloon-injured arteries in both control and L-arginine-treated animals. However, L-arginine-treated animals showed a 65% reduction of the intima/media area ratio and a 26% reduction of the intimal cell proliferation compared with control animals. These data indicate that adequate amounts of L-arginine were ingested by the rats and that oral administration of L-arginine significantly reduced intimal hyperplasia of balloon-injured arteries without any detectable toxicity.
Administration, Oral↗
Minimally invasive vascular surgery: review of current modalities.
The concept of a minimally invasive approach to the treatment of vascular pathology was realized nearly 30 years ago when Charles Dotter described dilatation of atherosclerotic stenoses. Since that time biotechnology and therapeutic innovation have progressed to the point where entire medical subspecialties are based on the endoluminal treatment of diseases of the blood vessels. The most rapid progress has been made in the area of endoluminal treatment of vascular lesions, with angioplasty, stent, and stent graft deployment becoming an increasingly common method of treating various vascular lesions. Extraluminal endoscopic treatment of vascular disease has been gaining popularity, particularly for management of perforator vein incompetence associated with venous stasis disorders. Endoscopic saphenous vein harvest has become an accepted method for minimizing the length of incision required for saphenectomy. Vascular imaging has followed similar trends, with more detailed information being derived from tiny intravascular ultrasonic catheters. This article summarizes the current state of minimally invasive vascular surgery to provide the reader with an understanding of the efficacy of the various modalities. It also discusses future directions in the field.
Angiography↗
Prophylactic angioplasty reduces thrombosis in virgin ePTFE arteriovenous dialysis grafts with greater than 50% stenosis: subset analysis of a prospectively randomized study.
PURPOSE: To determine if prophylactic percutaneous transluminal balloon angioplasty (PTA) can extend patency in functioning virgin ePTFE arteriovenous hemodialysis grafts. MATERIALS AND METHODS: The results of a prospectively randomized study of 64 patients with greater than 50% stenosis of functioning ePTFE arteriovenous hemodialysis grafts who were blindly assigned to be treated with PTA (treatment group) or observed without treatment (control group) were subjected to statistical subset analysis. Within this group were 21 patients (virgins) who had never undergone surgery, PTA, or thrombolysis. Eight patients had been assigned to the treatment group and 13 to the control group. The virgin groups were well matched as to age, sex, and risk factors. The virgin treatment group versus virgin control group had 1.63 versus 1.46 stenoses per patient and 61.3% versus 63.3% average percentage stenosis per lesion, respectively. Stenoses were treated with PTA 27 times (average, 3.4 per patient) in the virgin treatment group. Primary study patency began at the time of randomization and ended with graft thrombosis or nonfunction. RESULTS: Among the 32 patients randomized to treatment with PTA, study patency was significantly increased (P > .0001) and the incidence of graft thrombosis significantly decreased (P = .0151) in the eight-patient virgin subset when compared with the 24-patient nonvirgin subset of the treatment group. During the 81.3 patient-dialysis-year study period, patency in the virgin-treatment versus virgin-control groups, respectively, was terminated by thrombosis in two versus nine, by death in two versus two, and cadaveric renal transplant in one versus zero. There was a statistically significant prolongation of study patency (P = .0349) and a reduction of graft thromboses, 0.10 versus 0.44 thromboses per patient-dialysis year, in the virgin-treatment group compared to the virgin-control group. CONCLUSION: Patency after PTA of ePTFE hemodialysis grafts is significantly affected by previous interventions. Prophylactic PTA of stenoses greater than 50% in functioning virgin ePTFE arteriovenous hemodialysis grafts can significantly extend their patency. PTA should be included as an important treatment option in this patient population.
Adult↗
Endoscopic vein harvest techniques for coronary and infrainguinal bypass.
Endoscopic saphenous vein harvest represents a minimally invasive approach to obtain a suitable bypass conduit for coronary or extremity revascularization. Endoscopic vein harvest has been designed to reduce wound complications in a population typically at risk for problematic wound healing. Most studies have shown a reduction in such wound healing complications and improved patient comfort, which may result in fewer postoperative visits. The technique of endoscopic saphenous vein harvest is described, and the current limitations of the procedure are discussed.
Angioscopes↗
Phosphorylcholine coating of ePTFE reduces platelet deposition and neointimal hyperplasia in arteriovenous grafts.
In an attempt to reduce platelet deposition and inhibit neointimal hyperplasia, we evaluated the effect of coating expanded polytetrafluoroethylene (ePTFE) grafts with phosphorylcholine (PC), a lipid found in animal cell membranes, in a dog model of femoral arteriovenous (AV) grafts. Eight mongrel dogs underwent placement of a PC-coated femoral AV graft on one side and an untreated control graft on the contralateral side. Platelet deposition was measured by autologous 111Indium-labeling and scintillation camera imaging analysis. Platelet deposition on the PC-coated grafts at 30 and 90 min. was 9.32 +/- 4.35 x 10(9) and 10.00 +/- 4.38 x 10(9), respectively, as compared with 10.26 +/- 4.36 x 10(9) and 11.64 +/- 5.08 x 10(9) platelet deposition on control grafts (P < 0.05). All grafts were patent at 4 weeks. There was a significant reduction of neointimal area at both arterial (0.07 +/- 0.05 mm2) and venous (0. 18 +/- 0.09 mm2) anastomoses in the treated grafts as compared with arterial (0.15 +/- 0.05 mm2) and venous (0.43 +/- 0.22 mm2) anastomoses in the control grafts (P < 0.05). In addition, neointimal cell proliferation assayed by bromodeoxyuridine (BrdU) incorporation was reduced in both arterial (2.05 +/- 0.81%) and venous (3.25 +/- 0.17%) anastomoses of treated grafts compared with arterial (3.12 +/- 1.23%) and venous (5.36 +/- 1.18%) anastomoses of control grafts (P < 0.05). These data demonstrated that PC coating of ePTFE grafts significantly reduced platelet deposition, anastomotic neointimal hyperplasia, and neointimal cell proliferation in a dog model of AV grafts. This may represent a new strategy for prolonging hemodialysis graft patency.
Anastomosis, Surgical↗
Cytotoxic effects of basic FGF and heparin binding EGF conjugated with cytotoxin saporin on vascular cell cultures.
Vascular smooth muscle cell (SMC) proliferation is an integral component of intimal lesion formation. In this study we compared the mitogenic effects of basic fibroblast growth factor (bFGF) and heparin binding epidermal growth factor (HBEGF) and the cytotoxic effects of bFGF and HBEGF conjugated with plant cytotoxin saporin (SAP) on vascular cell cultures. Human vascular SMCs and endothelial cells were cultured and FGF receptor-1 (FGFR-1) and EGF receptor (EGFR) expression were detected by immunohistochemical staining. Cells were grown in 24-well plates. Variable amounts of testing drugs (bFGF, HBEGF, SAP, bFGF-SAP, or HBEGF-SAP) were added to quadruplicate wells after 24 h. Cells without drugs were used as control. The total number of cells was counted at 72 h using a hemocytometer. The cultured human vascular SMCs and endothelial cells expressed both FGFR-1 and EGFR with predominant perinuclear localization. bFGF and HBEGF demonstrated equally potent mitogenic effects on SMC proliferation. SAP alone showed a limited cytotoxic effect on both SMCs and endothelial cells. bFGF had a more potent effect on endothelial cell proliferation than HBEGF. bFGF-SAP was equally cytotoxic for both SMCs and endothelial cells, while HBEGF-SAP had a more selectively cytotoxic effect on SMCs than on endothelial cells. These data suggest that the mitogenic effects of bFGF and HBEGF and the cytotoxic effects of bFGF-SAP and HBEGF-SAP may both be mediated by their corresponding growth factor receptors. Because of its selective cytotoxic effect on SMCs, HBEGF-SAP may become a more attractive agent for controlling intimal lesion formation.
Aorta↗
Incidence and characteristics of patients with hand ischemia after a hemodialysis access procedure.
The purpose of this study was to determine the clinical characteristics of chronic renal failure patients who developed hand ischemia in the limb carrying the dialysis angioaccess. A retrospective review of the charts of 352 patients who underwent 409 upper extremity arteriovenous access, and who were subsequently diagnosed as steal syndrome, was performed at the Emory University Hospital between February 1992 and January 1997. Hand ischemia occurred after 13 of 299 arteriovenous grafts (4.3%) and after 2 of 110 direct forearm arteriovenous fistulas (1.8%). Six patients developed ischemic manifestations immediately postoperatively, 2 in the first week, 4 after 1 month, and 1 after 1 year. Thirteen occurred in association with the primary access procedure. Two cases occurred following graft thrombectomy and outflow dilatation. Seven patients were mildly symptomatic with dialysis-induced pain, coldness, or numbness; 8 patients developed severe ischemic manifestations in the form of sensory loss in 3, severe intolerable pain with impalpable pulse in 3, and digital gangrene and amputation in 2, one of whom developed an unhealed amputation stump and required a higher amputation level with satisfactory healing of the revised stump. Three patients were treated conservatively, 6 by banding, 4 by ligation, 1 by embolization, and 1 by distal ligation and bypass operation. Clinical characteristics of patients with hand ischemia included long-standing insulin-dependent diabetes (10), chronic hypertension (12), peripheral arterial disease (14; 93.3%), coronary artery disease (8), and systemic lupus erythematosis (1). Severe peripheral arterial diseases are commonly found and may be markers for risk of hand ischemia after access surgery.
Amputation, Surgical↗
Subfascial hemorrhage after endoscopic perforator vein ligation. Control with balloon tamponade.
Ligation of perforator veins in the lower extremity for the treatment of venous ulceration can be performed using a minimally invasive technique with endoscopic instruments. Several studies have documented that the endoscopic technique has a lower wound-related complication rate compared to open perforator vein ligation. We report the complication of postoperative subfascial hemorrhage requiring reexploration after subfascial endoscopic perforator vein ligation and describe a minimally invasive method for its control using balloon tamponade.
Adult↗
Cost efficacy of duplex surveillance and prophylactic angioplasty of arteriovenous ePTFE grafts.
Poor patency of arteriovenous ePTFE grafts remains a major clinical problem. Prophylactic balloon angioplasty of stenoses has been claimed to prolong graft patency and has been widely introduced into practice. In this manuscript we report the cost incurred in application of such a program involving graft surveillance and prophylactic angioplasty of ePTFE graft stenoses >50% diameter. All patients in a single dialysis unit with ePTFE bridge grafts were subject to a surveillance duplex ultrasound and those with a perigraft stenosis of >50% then underwent angiography. Those patients confirmed to have a stenosis >50% within the graft, were randomized to prophylactic percutaneous transluminal angioplasty (PTA) versus no intervention (observation). Patients were followed every 3 months with ultrasound and those in the treatment group with recurrent stenosis (>50%) were subject to repeat PTA. The outcome was thrombosis. Relevant charges were considered to be: initial duplex screening of the entire ePTFE dialysis group; professional and technical fees for angiography and angioplasty; follow-up duplex scanning; repeat angioplasty; and costs of lytic therapy for an intraprocedure lysis. In the treatment and observation group the 6-month patencies were 69% +/- 7% and 70% +/- 7%, respectively. Twelve-month patencies for the treatment and observation groups were 51% +/- 6% and 47% +/- 4%. There was no significant difference between these two groups (p = 0.97), with an 80% confidence limit for detection of a difference >20%. Cost for duplex screening of all patients in the dialysis unit with ePTFE grafts was $40,440 (@ $337 each x 120 patients). Total charges for initial angiography was $178. Angioplasty charges were $143,040. Cost of the follow-up duplex ultrasound scanning in the treated group was $32,352. Charges for repeat angiograms in those with recurrent stenoses were $83,682 (professional fee $1733 + $229; technical fee + $820; equipment charges x 32 x 0.94). One patient required urokinase therapy for an occlusion following PTA. The overall charge for treating the 32 patients in the treatment arm of this study was $440,834, there was net improvement in patency. A policy of generic graft surveillance and prophylactic is expensive and does not lead to improved patency. Until an effective intervention is defined by prospective randomized trial, surveillance duplex scanning cannot be justified.
Angioplasty, Balloon↗
Concomitant aortic and renal artery reconstruction in patients on an intensive antihypertensive medical regimen: long-term outcome.
A beneficial effect in blood pressure control is presumed for patients on an intensive preoperative antihypertensive regimen who undergo empiric renal revascularization. Nonetheless, a noticeable decline in surgical cure rates for hypertension has been recently observed in patients with generalized atherosclerosis. The outcome of patients on multiple preoperative antihypertensive agents who underwent combined aortic and renal artery reconstruction was reviewed. The study population comprised 43 patients who underwent concomitant renal artery and aortic reconstruction for atherosclerotic disease between 1983 and 1995 and who were taking two or more antihypertensive medications and had a serum creatinine of less than or equal to 1.7 mg/dL. Operative management included an aortic reconstruction with either unilateral (n = 22) or bilateral (n = 19) aortorenal bypass or renal endarterectomy (n = 2). Operative mortality was 4.7% (2 of 43). The estimated 5-yr probability of survival was 83% (95% C.I. 0.70, 0.99). Late follow-up data on blood pressure control were available for review in 32 patients at a median follow-up of 37 months. Hypertension was cured in 1 (3%) and improved in an additional 15 (47%) patients. The numbers of antihypertensive medications taken preoperatively (mean = 2.7) declined at late follow-up (mean = 1.6). Notably, the largest reduction was observed with beta blockers (p = 0.006), central sympatholytics (p = 0.041), and angiotensin converting enzyme (ACE) inhibitors (p = 0.052). The number of preoperative antihypertensive medications was not significantly related to survival or to blood pressure improvement. However, uncontrolled preoperative hypertension despite antihypertensive therapy was associated with a favorable blood pressure response to operation (p < 0.001). Patients on an intensive antihypertensive regimen can safely undergo concomitant renal artery and aortic reconstruction for the empiric management of hypertension. Poorly controlled preoperative hypertension in the presence of multiple antihypertensive agents is a favorable marker for improved postoperative blood pressure control.
Aged↗