Assessment of internal carotid artery stenosis and results of carotid stenting by angiography compared with intravascular ultrasound

Background/Introduction

Intravascular imaging is commonly used in coronary interventions and improves outcomes. On the contrary, it is almost unrecognized for the guidance of carotid stenting (CAS).

Purpose

The aim of this study was to compare quantitative angiography (QA) and intravascular ultrasound (IVUS) in the assessment of the severity of carotid stenosis and residual stenosis in patients undergoing CAS and to provide reference values for IVUS measurements of the internal carotid artery (ICA) in the European population.

Methods

IVUS imaging was performed during 151 CAS procedures in 140 patients from April 2013 to December 2019. In total 162 self-expanding stents of different design were implanted (66% closed-cell, 22% open-cell, 8% hybrid, 4% double layer micromesh stents). IVUS was used to measure distal reference diameter and area of ICA, minimal luminal diameter (MLD) and minimal luminal area (MLA) before and after CAS. IVUS and QA were used to measure relative stenosis area (stenosis) at baseline and relative residual stenosis area (residual stenosis) after CAS. Relative stenosis area was calculated as [1 − (MLA / distal reference area)] x 100.

Results

Mean (±SD) distal reference diameter of ICA was 4.5±0.8 mm. MLD increased from 1.9±0.4 mm to 3.6±0.6 mm after CAS (p<0.001). MLA increased from 3.9±1.7 mm2 to 12.0±3.4 mm2 after CAS (p<0.001). Stenosis measured by QA and IVUS was 84±9% and 76±13% respectively (p=0.01). There was a moderate correlation (Pearson's correlation coefficient r=0.575; p=0.01) between QA and IVUS measurement of ICA stenosis severity. Residual stenosis measured by QA and IVUS was 12±10% and 40±16% (p<0.001) respectively with only weak correlation (r=0.433; p<0.001) between the two methods.

Conclusion

Angiography slightly overestimates stenosis of internal carotid artery and substantially underestimates residual stenosis after CAS compared to IVUS. Angiography alone is inaccurate in the assessment of ICA stenosis and results of carotid stenting.

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): University Hospital Motol

Occurrence of malignancies after kidney transplantation in adults: Slovak multicenter experience

Malignancies are one of the three major causes of renal recipient´s death with a functioning graft after cardiovascular diseases and infections. Among the variety of risk factors, including conventional and specific to transplant recipients, the duration of immunosuppressive therapy, the intensity of therapy, and the type of immunosuppressive agent all have an impact on development of post-transplant malignancy. The aim of our retrospective study was to document the incidence, the type of malignancies, the patient/graft survival in the group of kidney transplant recipients in Slovak Republic, and to identify the factors which influenced the outcome. We analyzed the data of 1421 patients who underwent renal transplantation from deceased or living donors in the period from 2007 to 2015 in the Slovak transplant centers. The incidence of malignant tumors was 6%, the malignancy was diagnosed in 85 patients at the age of 54.1 ± 9.8 years, more frequently in men (68.2 %; P < 0.0001). The mean time of malignancy occurrence was 45 months after transplantation. The most frequent malignancies were skin cancers- basal cell carcinoma (BCC) in 17.6%, squamous cell carcinoma (SCC) in 8.2%, and malignant melanoma (MM) in 2.4% of patients, followed by non-skin tumors such as renal cell carcinoma (RCC) in 16.5%, cancer of colon in 12.9%, prostatic cancer in 9.4%, breast cancer in 9.4%, cancer of lung in 7.1%, post-transplant lymphoproliferative disease (PTLD) in 2.4%, cancer of urine bladder in 2.4%, and cancer of sublingual gland in 1.17% of patients. Surgical treatment was used in 40% of patients, chemotherapy in 7.1%, radiotherapy in 2.4%, treatment with biological agents in 15.3%, combined therapy in 29.4% and palliative treatment in 5.9% of patients. 55.3% of patients underwent conversion from other immunosuppressive agents into mTORi at the time of malignancy occurrence. The remission was achieved in 48.2% of patients, 28.2% of patients were in the oncology treatment in the end of the year 2015, and 23.5% of patients died. There was no difference in the kidney function at the time of malignancy occurrence (s-creat 133.7 ± 59.8 µmol/l) and one year later (s-creat 131.1 ± 47.9 µmol/l) (P = 0.7768). The patients after successful treatment more frequently suffered from BCC (P = 0.0140), did not undergo palliative treatment (P = 0.0033), but were more frequently treated surgically (P < 0.0001).

Pulmonary administration of activated recombinant factor VII

Diffuse alveolar haemorrhage (DAH) is a serious pulmonary complication seen in patients with autoimmune disorders and patients treated with chemotherapy or after hematopoietic stem cell transplantation. The clinical management of DAH is complex and the condition has a high mortality rate. During inflammation, tissue factor is expressed in the lung alveoli and therefore pulmonary administration of human recombinant activated factor VIIa (rFVIIa) could be a rational treatment option (4.1). A case report of the patient with an acute, bronchoscopically confirmed DAH from intensive care unit university hospital is described. The patient was treated by the intrapulmonary administration of 50 microg/kg rFVIIa in 50 ml of 0.9% sodium chloride; 25 ml into each of the main bronchi. An excellent response, defined as complete and sustained haemostasis after a single dose of rFVIIa was achieved. The oxygenation capacity, as reflected by the paO2/FiO2 (arterial oxygen pressure/inspiratory fractional oxygen content) ratio, decreased immediately after the bronchoscopy and the local rFVIIa instillation, but the following course of the patient's illness was favourable. Symptomatic therapy--intrapulmonary administration of one dose of rFVIIa was found to have an excellent haemostatic effect in the patient with DAH. The intrapulmonary administration of rFVIIa seemed to have a high benefit-to-risk ratio. These findings warrant further exploration (Ref. 12).

[BNP and echocardiographic parameters in patients with chronic kidney disease and dialyzed patients]

We assessed the relation between BNP levels and some echocardiographic parameters of systolic and diastolic function of the left ventricle in 49 patients (mean age 69.39 +/- 8.47 years) with chronic kidney disease in different stages of chronic renal failure according to K/DOQI and in 45 subjects (mean age 52.6 +/- 14.85 years) on dialysis. Median for BNP in the group of patients with chronic renal failure was 132 pg/ml, and in dialysis subjects 320 pg/ml. None of our patients had clinical signs of heart failure during the last six months. Using a method of correlation matrix we found the left ventricular mass and its indexed value as a common indicator of increased BNP level in both groups of patients (dialysis patients, p = 0.0003, and p = 0.0005, respectively; patients with chronic renal failure, p = 0.03, and p = 0.04, respectively). Further analysis proved that in the group of dialysis patients the main determinants of increased BNP level were volumes of the left heart side: left ventricular end diastolic volume (p = 0.004), endsystolic volume (p = 0.01), and left atrial volumes (maximal, minimal, and total atrial stroke volume; p = 0.004, p = 0.009 and p = 0.04, respectively). In the group of patients with chronic renal failure the major contributors to increased BNP level were echocardiographic parameters of diastolic filling assessed from transmitral and pulmonary venous flow: E wave (p = 0.001), A wave (p = 0.01), E/A (p < 0.001), IVRT (p = 0.004), E/EDT (p < 0.0001), S wave (p = 0.01), D wave (p = 0.0003), S/D (p = 0.001), Ar duration (p = 0.02), and E/Vp (p = 0.003). No significant relation to left ventricular ejection fraction was found in both groups of patients. Our results suggest that the main determinant of increased BNP level in patients with different stages of chronic renal failure is diastolic dysfunction, whereas in dialysis patients high left heart volumes due to volume overload. The common denominator of high BNP level in both groups of patients is especially the left ventricular mass.

Severe limb necrosis: primary thrombotic microangiopathy or “seronegative” catastrophic antiphospholipid syndrome? A diagnostic dilemma

An episode of gastroenteritis triggered severe necrosis of all extremities in a previously asymptomatic male. Hepatic and renal involvement were also manifest, while the hematological picture was one of thrombotic microangiopathic hemolytic anemia. Antiphospholipid antibodies were negative. He responded well to a combination of plasma exchange, anticoagulation (heparin), parenteral steroids, and antibiotics, as well as vasodilators (prostacycline) and hyperbaric oxygen, but died because of a cerebral hemorrhage. The differential diagnosis included thrombotic thrombocytopenic purpura/hemolytic-uremic syndrome, or seronegative catastrophic antiphospholipid (Asherson's) syndrome. The dangers of administering such a combination of therapies with anticoagulation, as well as vasodilatation (prostacycline) and hyperbaric oxygen, are highlighted by the case report and emphasized.

A renal transplant patient with intractable hiccups and review of the literature

Intractable hiccups in transplanted patients may be caused by various medical conditions including infections. We report a case of a 44-year-old man who suffered from intractable hiccups after cadaveric kidney transplantation. We identified 3 different hiccup periods with different causes: 1) steroid and anesthetics use, 2) severe ulcerose herpetic and mycotic esophagitis, and 3) pleuropneumonia caused by nosocomial methicillin-resistant Staphylococcus epidermidis and pulmonary abscess requiring thoracic surgery.

[Gastrointestinal surgical complications after kidney transplantation]

BACKGROUND AND OBJECTIVE

Clinical spectrum of gastrointestinal (GI) complication in renal transplant recipients ranges from nonspecific signs of abdominal discomfort to life-threatening surgical emergencies. The manifestation of such complications is modified by antirejection therapy with resulting risk of diagnostic and therapeutic error. The present study analyses the incidence of serious GI complications after renal transplantation and their treatment.

METHODS

Retrospective analysis in a university transplant center in years 1988-2000. There was 239 renal transplants performed in 234 patients (age 42 +/- 14). Male to female ratio was 140.99. Polycystic kidney disease patients comprised 9% (n = 22).

RESULTS

Five serious GI complications resulting in death were recorded (2x upper GI bleed, 1x acute pancreatitis, 1x bowel obstruction in sclerotizing peritonitis, 1x diffuse purulent peritonitis of unknown origin). There was no case of diverticulitis. The average time onset of lethal GI complication was 2.8 +/- 1.4 years after renal transplantation. There was no statistically significant relation to underlying diagnosis of renal failure, warm and cold ischemia time, and time elapsed after transplantation.

CONCLUSION

GI complications have increased incidence in patients after renal transplantation. The incidence of complications has no relationship to underlying diagnosis of renal failure, warm and cold ischemia time, and time elapsed after transplantation. Patients involved in transplant program should be carefully followed and thoroughly examined with any new GI symptomatology. Further studies are necessary to evaluate potential of pre-transplant screening programs.

[Controlled clinical study of Consupren versus cyclophosphamide in chronic glomerulonephritis. II. Adverse effects]

BACKGROUND

The second part of the study was designed to assess Consupren side effects.

METHODS AND RESULTS

The groups of patients studied were described in Part I. Side affects typical of Cy-A were evaluated only in the CS group. Gastrointestinal intolerance, only mild and temporary, was observed in 31%, neurotoxicity in 44%, hypertrichosis in 37%, nephrotoxicity in 25%, and gingival hypertrophy in 19%. Mean values of systolic and diastolic blood pressure did not change significantly in the course of treatment. When changes in blood pressure were individually investigated in particular patients, they were found in 31% in the CS group and in none in the K group. Mean values of uric acid non-significantly increased in the CS group and, on individual investigation, hyperuricaemia was observed in 31%. Mean values of serum potassium did not alter significantly. Signs of possible hepatotoxicity were found in 37% patients of the CS group. In this group, there was a significant decrease in haemoglobin mean values and a decrease in haemoglobin of more than 25 g/l was observed in 44% of CS group patients. In the K group significant decrease in mean leukocyte count was noted, but no patient developed real leukopenia.

CONCLUSIONS

The occurrence of side effects was comparable to data known from the literature.

[A controlled clinical trial of Consupren versus cyclophosphamide in chronic glomerulonephritis]

BACKGROUND

Experience gained from recent studies shows, that Cyclosporine-A (Cy-A) may decrease proteinuria (PU) in some forms of chronic glomerulonephritis (GN) with the nephrotic syndrome. The aim of this study was to test the efficacy of Czech-made Cy-A, Consupren.

METHODS AND RESULTS

30 patients with chronic GN, confirmed by biopsy and PU higher than 3 g/d, corticodependent or corticoresistant, were randomized according to the month of birth to either therapy with Consupren at an initial dose of 5 mg/kg/d (CS group, after dropout of 3 patients who did not finish the treatment, n = 16) or Cyclophosphamide at a dose of 1.5 mg/kg/d (K group, n = 11), and prednisone maintained at the original dose in both groups. The treatment was stopped after six months or after achieving remission. The main criterion of efficacy was PU. The decrease in mean values, statistically evaluated by Holm's procedure was highly significant in the CS group and non-significant in the K group. A similar evaluation of PU corrected by glomerular filtration rate was significant in both groups. Partial or complete remission was reached in 50% of CS group patients and in 34% of K group patients (NS). In the CS group a significant increase in the mean values of albumin and gama-globulin, and a decrease in cholesterol levels were observed. In the K group, these changes were non-significant.

CONCLUSIONS

In patients with chronic GN and the nephrotic syndrome, the efficacy of Consupren treatment gives comparable, or even better results versus treatment with Cyclophosphamide.

Type IV renal tubular acidosis associated with Alport's syndrome

A case of hereditary nephritis with mild reduction of renal function associated with renal tubular acidosis type IV is described. The patient was admitted with life-threatening hyperkalaemia. To our knowledge, type IV renal tubular acidosis has not been reported previously in association with Alport's syndrome in an adult patient.

[Are dietetic and non-immunologic therapies becoming deciding factors in the treatment of autoimmune diseases?]

Authors call attention to non-immunological therapy and its determining role for fate and final prognosis in patients with autoimmune diseases. A stress importance of the timely and rigorous antihypertensive and antiinfectious treatment. From the dietary measures is best known favourable effect of the low protein diet and pharmacological limitation of the phosphorus supply. A new therapeutical aspect is the influence of the lipids on the autoimmune diseases activity and efficiency of the omega-3 unsaturated fatty acids. Non-immunological methods of the treatment are particularly valuable for the general practitioners and pediatricians, because enable them essentially to influence the course of the autoimmune diseases.

[New views on the pathophysiology of the nephrotic syndrome]

The authors draw attention to new pathophysiological aspects of some symptoms of the nephrotic syndrome (NS), in particular proteinuria, hypoalbuminaemia and oedema. In proteinuria they focus attention on the formation of a new population of heteropores in severe morphological forms of NS with penetration of high molecular proteins into urine. In hypoalbuminaemia the authors emphasize the importance of an inadequately increased albumin synthesis in the liver. In case of oedema in the majority of patients hypovolaemia is not present, as was assumed so far. In the pathogenesis of oedema primary Na retention in the kidneys is important caused by the glomerulonephritic process. New findings in the pathophysiology of NS lead to changes of several clinical approaches. The authors draw attention e.g. to the need of dietary protein restriction in NS, on altered effects of drugs in NS, new approaches to diuretic treatment etc.

[Personal experience with the use of human recombinant erythropoietin in the treatment of anemia in children with chronic renal insufficiency]

The authors analyze the course of treatment with human recombinant erythropoietin (rHuEPO) in five children in the preterminal stage of chronic renal insufficiency and one premature infant with a low birth weight and anaemia and acute renal insufficiency. rHuEPO was administered, 50-100 u./kg, by the s.c. route 2-3X per week. During the first month of treatment the haemoglobin rose from 7.0 dag/l to 8.2 dag/l and persisted at this level approximately to the third month of treatment. The haematocrit reached values of 0.30 during the 4th month of therapy when the authors observed also the maximum increase of reticulocytes (20%). The authors did not find a marked decline of iron and ferritin concentrations. In the child with a low birth weight treatment with rHuEPO was started at the age of six weeks and the age haemogram was favourably influenced already after four weeks of treatment with rHuEPO.

[Recombinant erythropoietin--a fundamental change in the treatment of anemia?]

The authors summarize in the submitted review recent findings on erythropoietin (EPO) and recombinant EPO (rHuEPO), a new therapeutic preparation which changed fundamentally the clinical picture of many diseases associated with anaemia. The authors discuss the physiology of EPO, regulation of its secretion, mechanism of action on bone marrow and its importance in the pathogenesis of polycythaemia and in particular anaemia. They emphasize in particular the use of rHuEPO in the treatment of different forms of anaemia. They analyze the pathogenesis of renal anaemia and the importance of treatment with rHuEPO for improvement of the haemogram as well as the general condition of the patients, their adaptability, improved psychic condition and reduced need of transfusions. The authors draw attention to the great importance of treatment with rHuEPO in the treatment of anaemias associated with inflammatory diseases (rheumatoid arthritis, AIDS, Crohn's disease and others), anaemia associated with malignancies, in the treatment of surgical diseases and in autotransfusions, in anaemias of premature infants and in some congenital heart diseases. The introduction of rHuEPO into the treatment of anaemia is a great advance of modern pharmacotherapy, which moreover opened new vistas on the role of anaemia in the clinical picture of many diseases.

[Axial osteosclerosis with autosomal dominant transmission: a new entity?]

The authors report on the case of a 26-year-old woman and three members of her family suffering from a benign condensing osteopathy, of dominant autosomic transmission, characterized mainly by a non homogenous hyperopacity of the spine and the pelvis, without alcaline hyperphosphatasemia, and which seems to them different from the condensing ostepathies described up to now.