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PubMed2005

Serum levels of osteoprotegerin and RANKL in patients with ST elevation acute myocardial infarction.

OPG (osteoprotegerin) has been suggested to have an important role in atherogenesis and vascular calcification. In the present study, we have investigated serum OPG and RANKL (receptor activator of nuclear factor kappaB ligand) concentrations in patients with ST elevation AMI (acute myocardial infarction) and established CAD (coronary artery disease). OPG and RANKL were measured in 58 male patients hospitalized in the coronary care unit with ST elevation AMI, in 52 asymptomatic male patients with an established diagnosis of CAD and in 52 healthy male controls. These last two groups were matched with the AMI patients for age and body mass index. OPG was significantly (P<0.05) higher in patients with AMI at 1 h after AMI (8.04+/-4.86 pmol/l) than in both patients with established CAD (4.92+/-1.65 pmol/l) and healthy subjects (3.15+/-1.01 pmol/l). Subjects with established CAD had significantly (P<0.05) increased OPG levels compared with controls. RANKL levels in patients with established CAD (0.02+/-0.05 pmol/l) and with AMI (0.11+/-0.4 pmol/l) were significantly (P<0.05) lower compared with controls (0.32+/-0.35 pmol/l). In the AMI group, OPG decreased significantly (P<0.05) at 1 and 4 weeks after infarction (8.04+/-4.86 compared with 6.38+/-3.87 and 6.55+/-2.6 pmol/l respectively), but OPG levels, either at 1 h or 1-4 weeks after AMI, remained significantly (P<0.05) higher compared with established CAD (4.92+/-1.65 pmol/l) and controls (3.15+/-1.01 pmol/l). Our data show for the first time that OPG levels are increased in ST elevation AMI within 1 h of infarction. Whether the increase in OPG is a consequence or a causal factor of plaque destabilization deserves further investigation.

Aged↗
PubMed2000

Calciphylaxis in a patient without renal failure or elevated parathyroid hormone: possible aetiological role of chemotherapy.

Calciphylaxis is a rare, often fatal disease characterized clinically by progressive cutaneous necrosis and ulceration, and histologically by vascular calcification and thrombosis. It has been described in association with end-stage renal disease, after initiation of dialysis, following renal transplantation, and in patients with hyperparathyroidism. We present the first case of calciphylaxis occurring in a patient with both normal renal function and parathyroid hormone level and discuss the possible aetiological role of chemotherapy-induced functional protein C and protein S deficiency.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed2000

The Charcot foot.

AIMS: To review the clinical manifestations of the Charcot foot in diabetes mellitus, with particular reference to theories concerning aetiology. METHODS: Systematic review of the published literature, searching for the keywords 'Charcot', 'foot and diabetes' and 'neuropathy' on Medline, as well as by examination of the references in recent published reviews. CONCLUSIONS: The Charcot foot of diabetes mellitus is a common problem, and yet is not widely recognized by non-specialists. The failure of professionals to identify the condition in its early phases is probably largely responsible for the gross deformity which follows continued weight-bearing. The condition is confined to those with severe peripheral neuropathy. It is thought to result from three factors: motor neuropathy leading to the development of abnormal forces within the foot, subsequent disorganization of the foot as a result of associated osteopenia and progressive destruction from continued weight-bearing, enabled by reduced pain sensation. The cause of the osteopenia is not known, but it is associated with increased bone blood flow, which may be mainly the result of loss of sympathetic innervation. The importance of increased limb blood flow in the pathogenesis of the Charcot foot has been recognized for over a century. Paradoxically, the increased flow is associated with evidence of macrovascular disease, in that the prevalence of vascular calcification of pedal vessels approaches 90%. After an interval of many months, the condition tends to evolve: the increased blood flow lessens, the osteopenia is reduced and the disorganized bones become sclerotic. This tendency for the condition to evolve remains unexplained, since it would not be expected if the condition was caused solely by progressive denervation. As a result, it is suggested that another factor may be involved in the pathogenesis of the Charcot foot: an abnormal vasomotor reflex, analogous to reflex sympathetic dystrophy, occurring against a background of severe peripheral neuropathy. The resolution of the condition occurs because it is the reflex component of the hyperaemia which proves self-limiting.

Diabetic Foot↗
PubMed2001

Calciphylaxis in two patients with end-stage renal disease.

Fatal calciphylaxis (CPX) occurred in two 71-year-old females both requiring haemodialysis for end-stage renal disease. Case 2 also had an associated follicular lymphoplasmocytoid lymphoma. Although laboratory tests disclosed normal coagulation parameters, this woman had a striking cutaneous histological picture of vessel thrombosis and finally died of disseminated intravascular coagulation. CPX is a rare but potentially life-threatening complication of renal failure. The clinical picture is primarily characterized by livedoid purpura with subsequent cutaneous ischaemia and painful ulcerations. Cutaneous ischaemic phenomena are sustained by a progressive process of vascular calcification and thrombosis involving small to medium size arteries of the dermis and subcutis. Although not yet clearly explained, the pathogenetic role of a predisposing hypercoagulability state is currently the most frequently considered hypothesis.

Aged↗
PubMed2003

Total hip bone mass predicts survival in chronic hemodialysis patients.

BACKGROUND: Bone mass measurements are widely used to diagnose osteoporosis and identify patients at risk for fractures. Recent studies have shown that reduced bone mass is also predictive of all-cause and cardiovascular mortality in healthy postmenopausal women. Among chronic hemodialysis patients reduced bone mass resulting from the combined effects of age-related factors and renal osteodystrophy has been associated with vascular calcification. In this prospective study, we investigated the ability of bone mass measurements to predict mortality in chronic hemodialysis patients. METHODS: Eighty eight patients underwent hip bone mass measurements by dual energy x-ray absorptiometry (DEXA) and were followed up for a mean of 3.5 years. Eleven patients received renal transplants and were therefore excluded. Forty of the remaining patients died, predominantly due to cardiovascular causes (43%). RESULT: Cox regression analysis showed patient age, osteoporosis or osteopenia, and baseline average calcium x phosphate product (Ca x P) to be independently predictive of increased mortality. Patients with osteopenia or osteoporosis had a 3.3- and 4.3-fold increased risk of death, respectively. A Ca x P of >or=5.0 mmol2/L2 predicted a threefold increased risk of death. Previous renal transplantation predicted a lower mortality. CONCLUSIONS: This study has shown for the first time that reduced total hip bone mass is an independent predictor of all-cause mortality among chronic hemodialysis patients. Our findings suggest that reduced bone mass and elevated Ca x P may be involved in the pathogenesis of cardiovascular disease in these patients but further research is required to investigate the possible mechanisms for these associations.

Absorptiometry, Photon↗
PubMed2003

The impact of calcimimetics on mineral metabolism and secondary hyperparathyroidism in end-stage renal disease.

The impact of calcimimetics on mineral metabolism and secondary hyperparathyroidism in end-stage renal disease. Secondary hyperparathyroidism is often complicated by elevations in calcium and phosphorus either as a result of the disease per se or due to toxicity from current therapeutic options. These disturbances in mineral metabolism limit the successfulness of therapy and have been implicated as contributing to the development and progression of vascular calcification, an important and often overlooked component of cardiovascular disease in patients on dialysis. Phosphorus, active vitamin D, and calcium all play important roles in the pathogenesis of secondary hyperparathyroidism; however, serum calcium is the primary regulator of minute-to-minute parathyroid hormone secretion. Small changes in serum calcium are detected by a cell surface calcium sensing receptor that has recently been cloned. Calcimimetic agents modulate the activity of the calcium-sensing receptor and result in profound reductions in levels of circulating parathyroid hormone. Additionally, these agents result in decreases in serum calcium, phosphorus, and calcium-phosphorus product. Recently completed phase 2 clinical trials with the second-generation calcimimetic agent cinacalcet HCl confirm that this agent represents a safe and effective novel therapeutic agent which has the potential to dramatically alter the treatment and complications associated with secondary hyperparathyroidism in patients on dialysis.

Bone Density↗
PubMed2001

Role of phosphorus in the pathogenesis of secondary hyperparathyroidism.

Secondary hyperparathyroidism (SH) and hyperplasia of the parathyroid glands (PTG) are universal complications in patients with CRF. In early renal failure, reduction in serum calcitriol and moderate decreases in ionized calcium contribute to greater synthesis and secretion of PTH. As renal disease progresses, a reduction in parathyroid expression of vitamin D receptor and calcium receptor renders the PTG more resistant to both calcitriol and calcium. High dietary phosphorus (P), independent of calcium and calcitriol, further enhances uremia-induced PTG hyperplasia and PTH synthesis and secretion, the latter by posttranscriptional mechanisms. Once SH develops, dietary P restriction can return the high serum PTH levels toward normal, however, parathyroid hyperplasia persists. Studies in our laboratory identified 2 of the mechanisms involved in the opposing effects of high and low dietary P content on PTG growth. Whereas high dietary P increases parathyroid expression of transforming growth factor alpha (TGFalpha), a growth promoter, P restriction induces the cyclin-dependent kinase inhibitor p21, an inducer of growth arrest. Both effects of P are specific for the PTG. No increase in either protein was observed in liver or intestine. TGFalpha induction of hyperplasia involves binding to the epidermal growth factor receptor and activation of mitogen activated protein (MAP) kinases cascades. p21 blocks progression through the cycle and cell division by inactivating cyclin/cyclin-dependent kinase complexes. Preventing hyperphosphatemia and elevated Ca x P product in renal failure not only ameliorates the progression of SH and bone disease but also the morbidity and mortality resulting from vascular calcification.

Animals↗
PubMed2007

Bone health in chronic kidney disease-mineral and bone disease.

Chronic kidney disease (CKD) is accompanied by disturbances in calcium, phosphate, vitamin D, and parathyroid hormone (PTH) homeostasis that play an important role in the pathophysiology of renal bone disease. The increased cardiovascular morbidity and mortality observed among patients with CKD has recently been recognized to be associated with these disturbances in mineral metabolism. Thus, disturbances in mineral metabolism observed in renal failure results in a multisystem disorder, making the development of a standardized definition of these disorders a top priority. Therefore, the Board of Directors of Kidney Disease: Improving Global Outcomes proposed to define the broader category of mineral disorders associated with CKD as CKD-mineral and bone disorder (CKD-MBD). This newly proposed definition will include the disorders of mineral metabolism, bone histology (renal osteodystrophy), and the extraskeletal manifestations such as vascular calcification. This new definition and stratification of disease should result in improvement not only in the clinical management of patients but also will facilitate the interpretation and translation of clinical research. Renal osteodystrophy is now considered as 1 component of this disorder and will be defined as a morphologic alteration only, based on unification of the histomorphometric definitions that will include parameters of turnover, mineralization, and volume. An internationally accepted classification system will enable the consensus for bone biopsy evaluation as well as for the role of biomarkers. This article will focus on the newly proposed definitions of bone disease as part of CKD-MBD, based on the complex pathophysiologic process underlying bone disease in CKD stages 2 to 5.

Biomarkers↗
PubMed2005

Cross-sectional association of serum phosphate with carotid intima-medial thickness in hemodialysis patients.

BACKGROUND: Although an increased serum phosphate concentration is a significant risk factor for vascular calcification, it is unclear whether serum phosphate level is a risk factor for increased arterial wall thickness in hemodialysis patients. METHODS: Using B-mode ultrasonography, we examined intima-medial thickness (IMT) of the carotid artery of hemodialysis patients and analyzed risk factors for increased IMT with regard to the effect of serum phosphate. Seven hundred sixteen hemodialysis patients were enrolled (547 patients without diabetes, 169 patients with diabetes; 441 men, 275 women; age, 60 +/- 8.5 years). RESULTS: IMT of patients with diabetes was significantly greater than that of patients without diabetes (0.859 +/- 0.250 versus 0.783 +/- 0.178 mm; P < 0.0001). For the group of all patients, IMT correlated weakly, but significantly, with serum phosphate level (r = 0.093; P = 0.0127). In multiple regression analysis of the group of all patients, greater serum phosphate level (beta = 0.166; P < 0.0001) was shown to be a significant independent risk factor for increased carotid IMT, in addition to other significant independent risk factors, including advanced age, higher blood pressure, greater non-high-density lipoprotein cholesterol level, and the presence of diabetes (R2 = 0.1119; P < 0.00001). In multiple regression analyses performed separately for hemodialysis patients without and with diabetes, greater phosphate level and advanced age were significant independent risk factors for increased IMT, independent of other confounding risk factors. CONCLUSION: These results show that in addition to advanced age, greater serum phosphate level is a significant and independent factor associated with advanced arteriosclerosis in hemodialysis patients with and without diabetes, suggesting that phosphate levels should be controlled appropriately to prevent an increase in arterial wall thickness in hemodialysis patients.

Adult↗
PubMed2005

Metabolic acidosis of CKD: diagnosis, clinical characteristics, and treatment.

Metabolic acidosis is noted in the majority of patients with chronic kidney disease (CKD) when glomerular filtration rate (GFR) decreases to less than 20% to 25% of normal, although as many as 20% of individuals can have acid-base parameters close to or within the normal range. Acidosis generally is mild to moderate in degree, with plasma bicarbonate concentrations ranging from 12 to 22 mEq/L (mmol/L), and it is rare to see values less than 12 mEq/L (mmol/L) in the absence of an increased acid load. Degree of acidosis approximately correlates with severity of renal failure and usually is more severe at a lower GFR. The metabolic acidosis can be of the high-anion-gap variety, although anion gap can be normal or only moderately increased even with stage 4 to 5 CKD. Several adverse consequences have been associated with metabolic acidosis, including muscle wasting, bone disease, impaired growth, abnormalities in growth hormone and thyroid hormone secretion, impaired insulin sensitivity, progression of renal failure, and exacerbation of beta 2 -microglobulin accumulation. Administration of base aimed at normalization of plasma bicarbonate concentration might be associated with certain complications, such as volume overload, exacerbation of hypertension, and facilitation of vascular calcifications. Whether normalization of plasma bicarbonate concentrations in all patients is desirable therefore requires additional study. In the present review, we describe clinical and laboratory characteristics of metabolic acidosis, discuss potential adverse effects, and address benefits and complications of therapy.

Acidosis↗
PubMed2006

Serum albumin, C-reactive protein, interleukin 6, and fetuin a as predictors of malnutrition, cardiovascular disease, and mortality in patients with ESRD.

BACKGROUND: Serum albumin (S-Alb), C-reactive protein (CRP), and interleukin 6 (IL-6) predict malnutrition, atherosclerotic cardiovascular disease (CVD), and mortality in patients with end-stage renal disease (ESRD). Fetuin A, an inhibitor of vascular calcification, also is associated strongly with clinical outcome in patients with ESRD. In this study, multivariate analyses were performed to assess these 4 biomarkers as predictors of malnutrition, CVD, and mortality in patients with ESRD. METHODS: One hundred seventy-six patients with ESRD (54 +/- 12 years) underwent measurements of S-Alb, high-sensitivity CRP (hs-CRP), plasma IL-6, and fetuin A close to the start of dialysis therapy and were followed up for a median of 26 months (range, 1 to 66 months). Nutritional status was evaluated by means of subjective global assessment. CVD was defined based on medical history. Associations between biomarker levels and malnutrition, CVD, and mortality were evaluated by means of receiver operating characteristic curve, logistic regression analysis, and Cox proportional hazards model. RESULTS: All 4 biomarkers predicted malnutrition, CVD, and mortality. Multivariate analysis, according to receiver operating characteristic analysis, showed that malnutrition was predicted best by hs-CRP and IL-6 levels; CVD, by IL-6 level; and mortality, by albumin and IL-6 levels. When using the cutoff levels derived from receiver operating characteristics, logistic regression analysis showed that only hs-CRP level (odds ratio [OR], 3.6) was associated with malnutrition, and only IL-6 level (OR, 3.7) was associated with CVD. Levels of S-Alb, IL-6, and fetuin A, but not hs-CRP, were associated with increased relative risk for mortality as assessed by Cox in a model adjusting for age, sex, and diabetes mellitus. CONCLUSION: Multivariate analyses show that in patients with ESRD, malnutrition is predicted best by hs-CRP and IL-6 levels; CVD, by IL-6 level; and mortality, by S-Alb, IL-6, and fetuin A levels, but not by hs-CRP level. This comparative analysis indicates that of these biomarkers, IL-6 level may be the most reliable predictor of CVD and mortality in patients with ESRD.

Adult↗
PubMed2006

Calcium exposure and removal in chronic hemodialysis patients.

The risks associated with calcium exposure in chronic hemodialysis (HD) patients are becoming increasingly apparent. Current K/DOQI guidelines recommend an absolute maximum elemental calcium load of 2,000 mg/d, including calcium-containing medication and a maximum dialysate calcium concentration of 1.25 mmol/L (to avoid intradialytic calcium loading). The goal of this study was to characterize the total exposure to calcium from all sources that chronic HD patients are exposed to. We studied 52 patients. Each was requested to complete a 3-day food diary for analysis of daily calcium intake; 24-hour urine collections were taken and analyzed for calcium content. All patients underwent HD using Hospal Integra (Lyon, France) dialysis monitors, bicarbonate buffering, and dialysate sodium and calcium concentrations of 134 mmol/L and 1.25 mmol/L, respectively. Blood was sampled before and after HD for total serum calcium, albumin, bicarbonate, and phosphate, in addition to ionized calcium level measured at the bedside using a portable electrolyte analyzer. Calcium flux was determined from measurements of ionized calcium levels in dialyzer inlet samples and those in continuous partial waste dialysis collection (with reference to total waste dialysate and ultrafiltration volumes). There was marked interpatient variability of total calcium exposure; the mean was 2,346 +/- 293 mg (range, 230 to 7,309 mg) per day. The majority of enteral calcium exposure was from calcium-containing phosphate binders, with diet providing only a mean load of 581 +/- 34 mg (range, 230 to 1,309 mg). Calcium removal was evident in 83% of patients. Mean calcium flux was -187 +/- 232 mg (range, -486 to 784 mg). There was a linear correlation observed between the amount of calcium removed during dialysis and the predialysis ionized plasma calcium concentration, r2 = 0.42, P < .001 (calculated from actual measured dialysate ionized calcium concentration). This shows that calcium flux across the dialysis membrane is determined by the diffusion gradient. The amount of calcium removed during dialysis was found to be independent of exogenous calcium load. These results support previous reported data showing that the majority of HD patients are continually experiencing calcium overload. This may have a contributory role in the development of vascular calcification. In contrast to recent K/DOQI recommendations, an upper dialysate concentration of 1.25 mmol/L may not be ideal for every patient. To minimize the effects of exogenous calcium overload, dialysate concentrations should be prescribed with reference to plasma calcium levels.

Adult↗
PubMed2002

Hyperphosphatemia in end-stage renal disease.

Hyperphosphatemia occurs universally in end-stage renal disease (ESRD) unless efforts are made to prevent positive phosphate balance. Positive phosphate balance results from the loss of renal elimination of phosphate and continued obligatory intestinal absorption of dietary phosphate. Increased efflux of phosphate from bone because of excess parathyroid hormone-mediated bone resorption can also contribute to increased serum phosphate concentrations in the setting of severe hyperparathyroidism. It is important to treat hyperphosphatemia because it contributes to the pathogenesis of hyperparathyroidism, vascular calcifications, and increased cardiovascular mortality in ESRD patients. Attaining a neutral phosphate balance, which is the key to the management of hyperphosphatemia in ESRD, is a challenge. Control of phosphorus depends on its removal during dialysis and the limitation of gastrointestinal absorption by dietary phosphate restriction and chelation of phosphate. Knowledge of the quantitative aspects of phosphate balance is useful in optimizing our use of phosphate binders, dialysis frequency, and vitamin D sterols. The development of new phosphate binders and efforts to find new ways to inhibit gastrointestinal absorption of phosphate will lead to improvements in the control of serum phosphate levels in ESRD.

Humans↗
PubMed1978

[Arteriography in old age--an assessment of the risks and technique (author's transl)].

Of 1,263 arteriograms performed over a period of two and a half years, there were 166 patients aged 70 years or more. The indications, angiographic findings and results have been examined retrospectively. In seven patients only was it impossible to carry out the examination because of advanced vascular disease in the pelvis. Most examinations could be performed as planned. In three patients there were minor complications without consequence. In one patient the external iliac artery was occluded following catheter angiography, but this was disobliterated during a subsequent operation which would have been carried out in case. The severity of vascular calcification as seen on plain films gives no indication regarding the difficulties during catheterisation. If aortography by catheter is impossible, we demonstrate the aorta retrogradely by a counter-current technique, using the Hettler instrument. The Hettler technique does not increase the risk and has certain advantages for the examination of older patients.

Abdomen↗
PubMed2000

[Diagnosis of pre-occlusive stenosis of the internal carotid artery by power mode ultrasound].

PURPOSE: To evaluate the accuracy of power mode (PM) vascular ultrasound in preocclusive (> 90%) stenosis of the extracranial internal carotid artery (ICA) compared to other diagnostic methods and to operative findings. MATERIAL AND METHODS: 50 patients with preocclusive stenosis have been examined in a prospective study by power mode and color flow duplex ultrasound, by triplane aortic arch and four plane selective DSA. In 11 cases a MR angiography (time-of-flight) was available. Diagnostic findings were compared to operative results. RESULTS: There was an agreement in findings in 50/50 patients (100%) for selective DSA, in 47/50 (94%) for power mode ultrasound, in 38/50 (76%) for aortic arch DSA, in 31/50 (62%) for color flow duplex ultrasound, and in 5/11 for MR angiography. In contrast to all other methods, ultrasound showed best the true extent of non-calcified atheromatous plaques. In extended vascular calcifications or kinking, however, only parts of the lumen of the vessel could be demonstrated. CONCLUSION: Power mode ultrasound shows preocclusive stenosis of the ICA in a faster and more simple way than color flow duplex ultrasound and has diagnostic results near to those of selective DSA. It improves preoperative diagnostic screening.

Aortic Valve Stenosis↗
PubMed2002

[B-flow and contrast medium-enhanced power Doppler (Optison(R))--preoperative diagnosis of high-grade stenosis of the internal carotid artery].

PURPOSE: To improve sonographic diagnosis of high-grade stenosis of the internal carotid artery (ICA) by vascular sonography in "B-flow"-mode and in contrast medium (Optison(R))-enhanced power Doppler (PD). MATERIAL AND METHODS: 88 patients suspected of a high-grade stenosis of the extracranial ICA were examined by independent examiners with color-coded Doppler (CCD), B-flow and PD to compare the methods for morphology and degree of stenosis. In 21 cases contrast medium was used in PD. Sonographic results of all 88 patients were compared with selective angiography (DSA), in 53 cases with operative findings. RESULTS: A complete occlusion was found in 9 patients and a 50 - 70 % degree non-exulcerated stenosis in 26 cases. 53 of 88 patients presented findings in both sonography and DSA leading to operation of the ICA. Among these 47 had a stenosis > 70 % and 6 a stenosis of 60 - 70 % with exulcerated plaques. Even a small dose of contrast medium (0.3 ml) gave a significant signal increase in PD improving flow detection even in extensive vascular calcification. In both the early phase (up to the first minute p. i.) flow contrast was optimal and without significant artifacts. Thus, the extent and the morphology of the stenosis was better appreciated. Hypoechogenic plaques, ulcerations and thrombi are as easily recognized by B-flow as flow in preocclusive stenosis, free of vibration and blooming artifacts. This gave a better correlation with DSA and a higher diagnostic accuracy in grading a stenosis than CCD and PD. Circular calcifications or vessel kinking made diagnosis of flow more difficult. CONCLUSION: B-flow allows a reliable diagnosis of the degree of stenosis of ICA and a better appreciation of plaque morphology than CCD. In some cases with extensive calcifications contrast medium-enhanced PD is able to detect better intrastenotic flow. Only small quantities of contrast medium (Optison(R)) are required.

Aged↗
PubMed1994

[CT angiography and arterial DSA in the evaluation of occlusive processes in pelvic arteries. Initial results].

UNLABELLED: 32 patients with iliac artery stenosis and occlusion were studied by means of CT angiography. The results were compared with the results of intraarterial digital subtraction angiography (DSA). Postprocessing was performed with Maximum Intensity Projection (MIP) and 3-D-display. RESULTS: 1. MIP: 27/37 stenoses/occlusions were correctly assessed, underestimation of 5 stenoses/occlusions (4 stenoses, one occlusion), overestimation of 5 stenoses. 2. 3-D-Display: 22/37 stenoses/occlusions were correctly assessed, underestimation of 9/37 (8 stenoses, one occlusion), two false negative results (one stenosis, one occlusion), overestimation of 4/37 stenoses. The MIP technique proved to be the only method to display the localisation of vascular calcifications with their exact topographical relationship to the stenoses and occlusions. MIP also proved to be valuable in controlling the position of intravascular stents. Complementary to DSA, the MIP method therefore seems to be a clinically valuable technique for calcified and noncalcified stenoses.

Adult↗
PubMed2006

Tissue reactions induced by different embolising agents in cerebral arteriovenous malformations: a histopathological follow-up.

AIMS: Comparative histopathological analysis was performed in 47 incompletely embolised and resected cerebral arteriovenous malformations (AVMs). METHODS: Thirty-three AVMs were embolised with n-butyl-cyanoacrylate (NBCA), four with iso-butyl-cyanoacrylate (IBCA), seven with polyvinyl alcohol particles (PVA), one with a fibrin mixture, one with silicon pellets, and one with microcatheter balloons. Maximum exposure time (MET) of the embolising agent (interval between embolisation and surgery) ranged from <24 hours to 80 months. All AVMs were investigated regarding angionecrosis, angiofibrosis, acute inflammation, chronic inflammation, foreign-body reactions, vascular calcification, blood admixture to embolising cast, and capillary recanalisation within the AVMs. These parameters were correlated with MET, comparing different embolising agents, age, and sex. RESULTS: A typical sequence of events depending on MET is observed in all embolised AVMs: acute inflammation with mural angionecrosis is soon replaced by prominent chronic granulomatous vasculitis, which remains stable and is detectable for a very long time, even in AVMs with a MET of more than 6 years. CONCLUSION: Capillary recanalisation is always present in incompletely embolised AVMs, detectable after 3 months of MET, irrespective of the embolising agent used. Age and sex does not influence pattern and time course of tissue lesions and recanalisation in incompletely embolised AVMs.

Adolescent↗