[os 213] Lec 15 Surgery For Peripheral Vascular Diseases I (b)

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OS 213: Human Disease and Treatment 3 (Circulation and Respiration) : OUT%#'E Aneurysmal Diseases A. Aneury Aneurysm sm B. Risk Factors Factors C. Natural Natural History History D. Diagnosis Diagnosis E. Inications Inications o! Re"air Re"air F. #reatment reatment $"tions II. Caroti Artery Diseases A. Introuctio Introuction n B. Clinical Clinical %ynromes %ynromes C. Natural Natural History History D. Diagnosis Diagnosis E. Inications Inications o! Re"air Re"air F. #reatment reatment &. Com"lication Com"lications s H. Inter'entio Inter'ention n I. %umm %ummar ary y =. III.Reno'ascula III. Reno'ascularr Hy"ertension A. Introucti Introuction on B. (at)o") (at)o")ysiol ysiology ogy C. Clinical Clinical Clues Clues D. Diagnostic Diagnostics s E. #reatment reatment F. %urgery %urgery 's. %tenting %tenting &. %ummary %ummary '$TUR$% '$TUR$% H#STOR  #'TRODUCT#O' • • $*+ecti'es:  #o iscuss t)e clinical "resentation, "resentation, iagnosis an treatment o! common iseases in'ol'ing t)e aorta an its *ranc)es, as seen in clinical "ractice • • •  #o re'ie- clinical ata su""orting su""orting use o! o! t)ese iagnostic strategies •  #)is trans trans is co"ie co"ie entirely !rom Class Class /15 trans trans an eite eite to our class trans !ormat. %us"ension o! classes ang salarin000  $'EURS$% D#SE$SES $'EURS • • • • Hig Hig) Bloo loo (ressu essurre 2B(4 2B(4:: Can acce accele lerrate kno-n aneurysms aneurysms an contri*ute contri*ute to !ormation !ormation o! ne- ones  #)e a'erage gro-t) rate o! an AAA is ;.; to < mm e'ery year ye ar.. >? AAA screening 21@<8//64 eian AAA iameter ;5 mm ○ eian gro-t) 2;. yrs4 @ mm ○ Aneur Aneurysm ysms s are are like like *alloo *alloons ns99 as t)e t)e iame iameter ter increases, t)e -all *ecomes t)inner an -eaker. T.e increa increase se in diamet diameter er 0ill 0ill increa increase se t.e ris o/ rupture, In "rac "racti tice ce,, -)en -)en t)e t)e aneu aneury rysm sm is 5 cm in iameter, surgery can *e inicate. #)is 'alue is true !or Fili"inos 2/1<4. ORT$%#T  • =7 o! "atients -it) ru"ture AAA ne'er reac) t)e )os"ital ali'e9 <7 o! t)ose -)o reac) t)e )os"ital on3t get out ortalit* 49 o! t)e )os"ital ali'e 2Operatie 2 Operatie ortalit*49 it)o it)out ut surg surgery ery,, t)e o'eral o'eralll morta mortalit lity y rate rate is roug)ly /79 ortality !or electi'e re"air is 8579  #)us, Early Diagnosis Diagnosis an e"eitious e"eitious electi'e re"air o! intact AAA "ro'ies t)e *est c)ance !or goo outcome. • Dene as a "at)ologic ilatation o! a segment o! a *loo 'essel 2!rom Harrison3s4  ost commonly locate in t)e a*ominal aorta 26174 s"ecically aorto8iliac area 657 o! at)erosclerotic aneurysms occur in t)e distal adominal aorta *eloaorta *elo- t)e renal arteries.  #)e !ocus o! t)is iscussion -ill *e on adominal aortic aneur*sms ($$$), ($$$), also calle aorto8iliac aneurysms • • • D#$G'OS#S H#STOR  •  o o o o o o !i+ure 1, $dominal aortic aneur*sm ($$$),  #rue  #rue aneurysm: aneurysm: in'ol'es in'ol'es all t)ree t)ree layers o! t)e 'essel 'essel -all (seuoaneurysm: intimal an meial layers are isru"te an t)e ilatation is line *y a'entitia only an sometimes *y "eri'ascular clot "HS#C$% E$#'$T#O' • • R#S- !$CTORS $t.erosclerosis is t.e leadin+ cause o/  aneur*sms, 1. Age: Age: increas increase e incien incience ce in elerl elerly y "o"u "o"ulat lation ion usua usuall lly y ue ue to at)e at)ero rosc scle lero rosi sis9 s9 in youn young g "ati "atien ents ts  t)in t)ink k o! ot)e ot)err etio etiolo logy gy suc) suc) as ar!an synrome an sy")ilis . %moking: %moking: Incien Incience ce incre increases ases muc) muc) )ig)er )ig)er -it) -it) age in smokers ;. Famil amily y )ist )istor ory: y: 158 158/7 /7 o! "ati "atien ents ts )a'e )a'e a !amily )istory o! aortic aneurysm <. C$(D C$(D:: Asso Associ ciat ate e elas elasti tin n egr egra aat atio ion n an an smoking 5. Hig) Hig) C)o C)ole lest ster erol ol 4ea5 $nna5 67C8 sa*s frequently asymptomatic %ym" %ym"tom toms s -)ic -)ic) ) may may *e *e sign signs s o! *egin *eginnin ning g ru"ture inclue: a*ominal mass or !ullness (ainG tenerness raiating to t)e groin, *ack legs Lo- *ack "ain A*ominal rigiity FaintingG lig)t8)eaeness Ecessi'e t)irst an 'omiting o o • pulsatile ile mass mass on >sually "resents as a pulsat a*omin a*ominal al eaminat eamination ion 2Dicul 2Dicultt to iagnose iagnose in o*ese "atients. ay *e con!use -it) a transmitte "ulse.4 "ulsatile mass: mass : usually ce")ala to t)e um*ilicus an -)en ngers are "lace on its lateral -alls, it -ill -ill emo emons nstr trat ate e late latera rall an an ante antero ro"o "ost ster erio iorr mo'ement mo'ement to ieren ierentiate tiate it !rom !rom a soli soli tumor tumor transmitting t)e "ulsation. 2De &o-in4 "ulsatile "ulsatile mass  mass  e)i* e)i*its its horiz horizont ontal al mo'ement. 2Fingers -ill mo'e u" an o-n an a-ay !rom eac) ot)er4 Transmitted pulses  pulses  e)i*it vertical mo'ement. 2Bot) ngers -ill mo'e u" an o-n4 it) o! t)e "ulsatile mass an not t)e egree o!  "ulsatility s)oul *e measure pulsation, )o-e'er !orci*le9 no I($R#AN#: No pulsation, t.rill, t.rill, )o-e'er intense9 no ruit, ruit, )o-e'er lou, U"C 291: JKI, alang ?a"antay0 1 o/ ; OS 213: Human Disease and Treatment 3 (Circulation and Respiration) : singly or toget)er can +usti!y t)e iagnosis o! an aneurysm o! t)e a*ominal aorta T.e presence o/ a palpale e) • o o o o o o o o o  $danta+es: Hi+.l* accurate5 cost=e?ectie5 no radiation and is readil* aailale &i'es t)e !ollo-ing in!ormation 2/1<4: In'ol'ement o! iliac artery A*solute iameter o! t)e aneurysm can *e etermine Eecti'e lumen can *e measure  #)rom*i may *e 'isualie Relations)i" o! aneurysm -it) near*y 'essels 2iliac an renal arteries4, organs an lesions can *e 'isualie 8 use!ul !or "reo"erati'e "lanning Disadanta+es: Operator dependent %ome aneurysms may *e etremely icult to etect Contrainicate in oese ini'iuals an "atients -it) a !ull stomac) Dicult to get measurements !or tortuous essels  D#$G'OST#C TESTS=CO"UTER TOOGR$"H SC$' (CT SC$') • • • • Gold standard /or detectin+ $$$s Also "ro'ies all t)e in!ormation "ro'ie *y an ultrasoun  #)e ierence: it can use t)is in!ormation to reconstruct t)e aneurysm an its relations in ;D Can also s)o- neig)*oring structures t)at can )el" tell -)at t)e "atient is !eeling Kersus t)e ultrasoun: o Deli'ers a more anatomically accurate image %ess prone to reader error o ore e% >? %mall Aneurysm #rial 2U-S$T4 o! t)e >?  o RC# Results an Finings o Designs are *asically t)e same (atients em"loye -ere iagnose cases o!  AAA3s -)ic) are <./8 5.< cm in iameter !i+ure 2, $l+orit.m /or ealuation and mana+ement o/ adominal aortic aneur*sm, TRE$TE'T O"T#O'S O"E' SURGER  • • • • • •   • 4ea5 $nna5 67C8 sa*s iline la"arotomy Retro"eritoneal La"arosco"y assiste ini la"arotomy ost common !orms o! surgical inter'ention 2/1<4 (roceure 1. %tarts -it) a miline la"arotomy 2most common9 incision !rom i")oi "rocess to sym")ysis "u*is4 . Aorta is e"ose ;. Aneurysm is locate <. Aorta is clam"e on eit)er en o! t)e aneurysm 5. Aorta is o"ene to e"ose t)e aneurysm =. Lesion is taken out an t)e 'essel is re"aire -it) a gra!t A ma+or o"eration one *y a 'ascular surgeon U"C 291: JKI, alang ?a"antay0 2 o/ ; OS 213: Human Disease and Treatment 3 (Circulation and Respiration) : • • •  • • • • !i+ure B, Endoascular Sur+er* ## The catheter has now reached the  and the graft  is deployed. a+or o"eration -)ic) entails at least one -eek in t)e )os"ital an may e'en in'ol'e a stay in t)e IC> %tatistics 1/7 mor*iity rate o o 857 mortality rate Note, however, that most patients who undergo the surgery are elderly; hence, the mortality & morbidity are high Co8mor*iities i! "resent, -ill com"licate t)e surgery (ro'ie "roimal control o! t)e AAA Bloo loss in surgery   Liters Hos"ital stay8 1 -eek  #-o o"tions: &RAF# or CLA( re"lacement !i+ure 3, Open Sur+er* • !i+ure , Common Gra/ts in Current Use !i"erent mechanisms entail variations in characteristics and speci#cations In ()il., #alent gra!t most commonly use /1< says: $natomic and deice constraints o Diameter 2De"ening on t)e neck o!  aneurysm, gra!t is o'ersie *y 1/8157  can *e a Poating gra!t4 o Raial !orce ec.anism o %ince aneurysm is ue to systolic Po-, i! you *lock t)e Po- a*o'e t)e aneurysm, it -ill e'entually s)rink o Instances -)en t)e aneurysm oesn3t s)rink: Bloo Po- !rom lum*ar 'essels is not eclue 2usually t)is is some)o- *locke in o"en surgeries4 8 ty"e II enoleak (oor seal 8 ty"e I enoleak $danta+es (S.ort Outcome) RelatieTerm Contraindications E'DO&$SCU%$R SURGER  • • • • • Relati'ely no'el -ay o! treating AAA3s No miline incision9 only  small incisions Has *een increasingly use in t)e "ast 1/ years  #alent gra!t  most commonly use in t)e ()ils. • (roceure 1. A small incision is mae in t)e groin area . #)e !emoral artery is locate an "uncture ;. A cat)eter -)ic) contains t)e gra!t in an enclose 'essel is inserte t)roug) t)e !emoral artery. <. &uie *y an angiogram, t)e cat)eter enters t)e site o! t)e aneurysm. 5. #)e gra!t is e"loye an t)e cat)eter is taken out.   o o o o o o o !i+ure A, Endoascular Sur+er* Note the site of catheter insertion. Exclude the aneurysm sac. o Less *loo loss Faster reco'ery, s)orter IC> stay Reuction in early ma+or a'erse e'ents %ignicantly reuce ;/ ay mortality 2usually ue to cariac "ro*lems4 EKAR 1 #rial Lancet //< DREA #rial N Eng O e //< $KER #rial OAA //@ %on+ Term Outcome eian !ollo-8u": 1. yrs 2$KER4 =./ yrs 2EKAR 4 No signicant ierence in ma+or mor*iity an mortality Hig)er gra!t relate com"lications an reinter'entions -it) eno'ascular re"air $KER #rial OAA //@ EKAR  #rial N Eng O e /1/ Earl* Repair /or Small $$$ AAA <./85./ cm in iameterM (IK$#AL trial 2$uriel et al., /1/ 2"ositi'e #m"act o! Eno&ascular O"tions !or Treating $neurysm ear%y4 CAE%AR trial 2Cao et al., /114 $ortic 2Com"arison o! %ur'eillance 's Enogra!ting !or Small $neurysm Re"air4 No signicant ierence in mortality 1G= E&$R "atients lose !easi*ility !or (Endoascular repair)   4ea5 $nna5 67C8 sa*s U"C 291: JKI, alang ?a"antay0 3 o/ ; OS 213: Human Disease and Treatment 3 (Circulation and Respiration) : Not all "atients -it) AAA are caniates !or EKAR 21/,/// ollars  cost o! eno'ascular re"air gra!t4 $natomic Criteria Not all patients are candidates for EVAR o  A criterion is use to ascertain -)et)er a "erson o  is a "ossi*le caniate !or EKAR. Access 8 %mallest gra!t )as Frenc) 1, -)ose outer iameter is = mm 8 Hence, essel must e at least F mm !or t)e e'ice to enter 2*ecause a 'ery t)ick eli'ery s)eat) is going to *e use into t)e aorta, = mm 'essel to accommoate eli'ery 'essel4 8 Not !or kis an -omen 8 No calcie or stenotic arteries Iliac Kessels $  #)e angle *et-een aorta an common iliac arteries s)oul e at least 9, i! less t)an it is a relati'e contrainication (resence o! a*errant 'essels = %ar+e #n/erior esenteric $rter* (#$) $ccessor* Renal $rter* 2i! t)ere are 8 accessory renal arteries an you *lock t)e aortic aneurysm, you -ill also eclue *loo Po- to t)ese arteries an cause in!arcts 8 colonic isc)emia 8 to areas su""lie *y t)em, /1;4 Neck angulate 8 Dicult to maneu'er t)e e'ice i/ less t.an 69S, also anot)er relati'e contrainication. 8 =/S angle is necessary to create a goo "roimal seal 8 Lengt) s)oul *e at least 1,B cm 8 Diameter s)oul *e at least 2; mm 8 Ha'ing a re'erse cone s)a"e neck is also a RC 'o t.romus5 at.eroma5 8 or calcications 2to allo- t)e gra!t to attac) an to a'oi leakage into t)e aneurysm4 •    • • • • • • • C%#'#C$% S"TOS •  SU$R  • • • • • • Early iagnosis is *enecial Risk !or ru"ture -)en t)e AAA 25 mm4 is lo-. ortality o! electi'e re"air is lo- 2;857 in ()ils4 Decision !or re"air must *e ini'iualie EKAR is a 'ia*le alternati'e treatment o! AAA 2Al-ays take note o! t)e anatomical criteria.4 Anatomic selection criteria a*solutely im"ortant !or EKAR Not all "atients -it) AAA are caniates !or EKAR Stroe5 or a cereroascular accident5 is dened * t.is arupt onset o/ a neurolo+ic decit t.at is attriutale to a /ocal ascular cause, T.e denition o/ stroe is clinical5 and laorator* studies includin+ rain ima+in+ are used to support t.e dia+nosis, 2Harrison3s4 %troke is t)e leaing cause o! serious long8term isa*ility9 it is a 'ery costly isease.  #)e risk o! getting stroke increases -it) a )istory o!  stroke incients ortality !rom initial stroke is 1B=3B, Caroti artery at)erosclerosis is a ma+or !actor in caroti artery isease Risk !or recurrence is A,; I 29 39 o! "atients ie 39 sur'i'e -it)out seTuelae 39 sur'i'e an are le!t -it) a isa*ility t)at amounts to a )ig) cost • • &enerally, "atients are asym"tomatic Transient #sc.emic $ttacs (T#$Js) are common o !e#nition: !ocal neurologic ecit -)ic) isa""ears -it)in < )ours %athophysiology : #IA results !rom a !ailure o!  o "er!usion ue to )emoynamic causes or microem*olism. Less common causes are in situ arterial t)rom*osis, arterial issection an 'enous sinus t)rom*osis. #)e sym"toms rePect t)e area o!  isc)emia. 2De &o-in4  #)e "atient returns to "re8#IA neurological state o -it)in t)e ay Reersile #sc.emic 'eurolo+ic Decit (R#'D) o Lasts more t)an < )ours o  #akes at least a -eek !or t)e "atient to return to )is or )er "re8isc)emic neurological state Crescendo T#$ o ulti"le #IA3s occurring in a s)ort "erio o! time o Connotati'e o! )ig) grae stenoses $maurosis /u+a< o %athophysiology : C)olesterol em*oli !rom ru"ture at)erosclerotic "laTues in t)e common or internal caroti artery transiently occlue Po- to t)e retinal artery 2De &o-in4 o E'ience o! isc)emia seen in t)e o")t)almic arteries (resents as Peeting *linness or monocular loss o!  o 'ision9 escri*e as Ucurtain !allV o'er eyes o Due to em*oli 2usually c)olesterol em*oli4 -)ic) go into o")t)almic artery an may cause calcication Stroe '$TUR$% H#STOR  • Ris o/ Stroe • $DD#T#O'$% #'!O o o o o Is t)e 5 mm t)res)ol a""lica*le !or all aneurysmsM 'O, 5 mm  +ust !or a*ominal aorta (o"liteal: .5 mm Iliac: .5 mm  #)oracic: = mm C$ROT#D $RTER D#SE$SES #'TRODUCT#O' 4ea5 $nna5 67C8 sa*s • • (resence o! sym"toms Degree o! stenosis 2)ig)er egree o! stenosis, t)e )ig)er risk o! stroke4 (laTue ensity o For as*mptomatic patients, risk increases -it) t)e "laTue ensity Accoring to increase risk o! #IA W stroke: o Calcied 6 Dense 6 So/t "laKue  #)ere!ore: so/t plaKue is @ORSE t.an calcied plaKue  #)ere is al-ays !or-ar *loo Po-. %o!t "laTues o may *e isloge an em*olie. U"C 291: JKI, alang ?a"antay0 A o/ ; OS 213: Human Disease and Treatment 3 (Circulation and Respiration) : Ris o/ neurolo+ic eent and c.aracteristics Du"le %tenosi n c)arc. s Calcie 657 ;6  657 5; Dense 657 < %o!t 657 657 6= < 657 <= carotid plaKue #IA %troke <21174 / ; 25574 6 2@74 ; 26=74 1/ 2174 12;74 / < 21/74 1 2174 @ 2174 < 2@74 $sence o/ Carotid "ulse Rare 8 t)e eternal caroti artery is almost al-ays o "atent $ccurs only -)en t)ere is common caroti artery o occlusion Emolic aterial $!ten !oun in t)e retinal artery an its *ranc)es o Hollen.orst plaKue 8 c)olesterol em*olus o Dia+nostics For s*mptomatic patients (ris increases 0it. increasin+ seerit* o/ stenosis) .as: o Intra"laTue )emorr)age o Large su"ercial li"i core o Lo- intra"laTue calcication Those who have intraplaue hemmorhage, calci#cation, lipid core, soft and ulcerated plaues have higher ris'. /1< says: OUTCOES (rogression o! t)e Disease o Increase in t)e egree o! stenosis -)ic) may lea to !ull occlusion o! t)e artery Ru"ture Em*oliation o! t)rom*osis may ensue causing o transient isc)emic attack an stroke o Neurologic ecits may also "resent as a conseTuence o! em*oli reac)ing t)e *rain • • • • Carotid Duple< easures t)e egree o! *loo Po- 2'elocity4 going o t)roug) t)e artery 2e.g. caroti4 Com*ines t)e ultrasoun -it) t)e Do""ler to o "rouce a ;D image -it) soun Has t-o com"onents: o 4 ode8 "ro'ies anatomic in!ormation9 s)o-s Po- irregularities an e'iences o! *lockage Doppler= deried Data8 "ro'ies !unctional in!ormation Data otained: o egree o! stenosis, "laTue ensity, ot)er mor")ological c)aracteristics 2like ulcerations4  #o etermine t)e "laTue ensity 2i.e. egree o!  stenosis4, -e look at t)e elocit* o/ lood Lo0 t)roug) t)e 'essel not at )o- *roa t)e lesion a""ears on t)e ultrasoun 2not at anatomic criteria, >ni'ersity o! as)ington Criteria4 Determine *y t)e Do""ler com"onent I! t)ere is increase 'elocity in t)e area "roimal to t)e caroti *ul*, t)ere is a signicant lesion in t)e area o! t)e caroti artery A*le to )el" t)e eaminer 'isualie ot)er mor")ologic c)aracteristics o! t)e lesion %imitations: o Operator dependent Cannot proide an ima+e o/ t.e carotid arc. and t.e intracranial circulation 2recall how important this is for the uniue  pathophysiology of stro'e in )ilipinos Dierent la*s )a'e ierent "arameters Hence, reTuest !or an RI or C# Angiogra")y Largely o"erator8e"enent Limite access area a+netic Resonance #ma+in+ (R#) and CT $n+io+rap.* o A*le to is"lay anatomical in!ormation a*out t)e lesion Also a*le to let t)e eaminer 'isualie t)e o relations)i" o! t)e isease -it) ot)er organs or 'essels o Com"ensate !or s)ortcomings o! Du"le CT an+io+rap.* Contrast $n+io+rap.* Gold Standard o Eaminer is a*le to 'isualie t)e egree o! t)e o stenosis Also "ro'ies com"arisons an "ercentages o • • Healing W Re"air  D#$G'OS#S Goals • • • • •  #o ascertain -)et)er or not caroti isease is "resent  #o asses t)e se'erity o! t)e isease  #o etermine -)et)er or not t)e caroti lesion is res"onsi*le !or t)e "t3s sym"toms  #o assess t)e "otential !or o"era*ility Remember! (tro'e in )ilipinos stems from intracranial carotids, while in *aucasians it is from the extracranial carotids Histor* and ".*sical E% RIGRA 2magnetic resonance angiography 4 Angiogra")y !unctional studies Ca"to"ril renogra")y Renal 'ein rennin assay TRE$TE'T SU$R  • • Coronary artery isease is a ma+or risk !actor !or stroke %urgical inter'ention in sym"tomatic "atients "ro'e to ecrease t)e risk Caroti artery stenting is emerging as a 'ia*le alternati'e to CEA, es". in sym"tomatic, )ig) risk "atients RE'O&$SCU%$R H"ERTE'S#O' #'TRODUCT#O' (291A) o o o o o   #)is is a synrome o! ecrease kiney "er!usion ue to increase arterial *loo "ressure Also kno-n as renal artery occlusi'e isease an *roys"lastic isease o! t)e renal arteries ost common !orm o! seconary )y"ertension /7 o! cases is cause *y at)erosclerosis • • • • "$THO"HS#O%OG (291A)  o  #)e )y"o"er!use kiney res"ons as t)oug) uner conitions o! lo- *loo "ressure, releasing renin an acti'ating t)e Renin8Angiotensin8 Alosterone %ystem 2R$$S) o o     #)e RAA% -ill inuce soium an -ater retention  #)is retention may inuce ot)er !orms o! )y"ertension   C%#'#C$% C%UES O'SET • • • • • • • $nset *e!ore age ;/ -it)out risk !actors or onset o! sig. H#N a!ter age 55 (resence o! an a*ominal *ruit Accelerate H#N o'er "re'. sta*le *aseline or resistant H#N es"ite multirug t)era"y Renal !ailure o! uncertain etiology Recurrent Pas) eema Coeisting iuse at)erosclerotic 'ascular isease ARF "reci"itate *y ACEI or ARBs /1< says: S#G'S $'D S"TOS A*ominal *ruit %igns o! renal !ailure o! uncertain etiology No "roteinuria No seiments in urine Recurrent Pus) eema $CUTE RE'$% !$#%URE  cute 2enal )ailure 02) precipitated by *E 0ngiotensin *onverting Enzyme nhibitors or ngiotensin 2eceptor 4ea5 $nna5 67C8 sa*s 8loc'ers 0289s o o  o  o •  • • • I! t)ere is com"romise *loo Po- to t)e kineys, sus ect renal stenosis i! a!ter aministerin ACE Endoascular and ed Treatment Hy"ertension %lig)t reuction in B( or rug meication is t)e *est t)at can *e )o"e !or Hy"ertension is rarely cure Renal Function E'ience less clear cut Angio"lasty 's eical treatment !or Hy"ertension 0!utch 2enal rtery (tenosis *ooperative (tudy no signicant ierence in systolic an iastolic *loo "ressures, aily rug oses, an renal !unction Re'asculariation 's eical treatment !or RA%  • • Goals Control H(N 2)y"ertension4 (reser'e renal !unction Options edical treatment to control )y"ertension "ercutaneous Transluminal renal Angio"lasty -it)out stenting Sur+ical to ra- renal inPo- !rom aortaGs"lenic artery $ortorenal *pass Splenorenal *pass 8 La"arotomy e"ose renal 'essels  aortorenalG s"lenorenal *y"ass  take out "laTue  close u" -it) "atc) 8 Kery g oo res"onse t o surgery Endoascular (Endarterectom*) Treatment >se to re"air o*structeGstenose renal arterial su""ly >ses a stent8 or *alloon cat)eter 2i! *alloon: Fogarty cat)eter4 %tenting is sa!er, )as lo-er mortality an is "rescri*e *y most octors &uie *y eit)er u"le ultrasoun or angiogram Results: rare cure o!   )y"ertension, reuction in num*er o!  meications to *e taken Transaortic Endarterectom* (recommene !or etensi'e aortic lesions4 o U"C 291: JKI, alang ?a"antay0 F o/ ; OS 213: Human Disease and Treatment 3 (Circulation and Respiration) :  o    0ngioplasty and (tenting for 2enal rtery  :esions re'asculariation carrie su*stantial risks *ut )a N$ *enet in renal !unction an *loo "ressure %tent 's eical treatment !or Renal Function "rimary en"oint is /7 or greater ecrease in creatinine clearance Conclusion: stent "lacement )a no clear eect on "rogression o! im"aire renal !unction *ut -as associate -it) signicant "roceure relate com"lications Recommenation: !ocus on cario'ascular risk !actor management an a'oi stenting !i+ure 1, Splenorenal *pass (enous in t.is case) +c says: Hi e'eryone0 No greetings !rom my trans8 mates, so ako na lang0  >na sa la)at, I -anna in'ite you all to Aga"e3s %eries on #tJs 'ot $out e 2a Lucao4, e'ery #uesays starting t)is August 6 until %e"tem*er 5, /1, 586"m at %> n Pr. #)is is o"en to $%% >(C stuents, an it3s !REE0 e )o"e to see you.  &usto ko rin i8greet ang aking mga researc) grou"mates 2Ho8%ia grou"4, #ricia Isaa to Ale artine.  %alamat at )ini na ako 2"ati si Ru*y4 mag8isa sa "ananaliksik )e)e Hello rin sa Class /160  &o *less e'eryone0    SURGER &S STE'T#'G • • • %urgical inter'entions are really su"erior an 'ery eecti'e *ut t)e mortality W mor*iity 'ery )ig) %urgery )as more com"lications  #)ere!ore, i! gi'en t)e o"tion, one s)oul really consier oing an eno'ascular inter'ention instea. SU$R  • • Reno'ascular iseases are a kno-n cause o! )y"ertension an renal insuciency Re'asculariation is an o"tion to cure or *etter control t)e reno'ascular isease E'D N8 championship teams have something in common+ they play with one goal in mind. Each  player contributes his own gifts and e"orts so that  the greater goal 4 winning 4 can be reached. 8ut   players who see' their own glory at the sacri#ce of  the team9s glory drive the team away from success. (o it is with life. The goal is not our own glory. n fact, trying to ma'e life all about us< pushes happiness further out of reach. The 8ible is full of men and women who struggled with me$centric< thin'ing, so our generation is not  alone. f we would learn from them, we could live in freedom. =e would be able to en-oy successes without ta'ing the credit. =e could bear up under  troubles with con#dence in >od. 8y letting go of our  own agendas and time$tables, we would discover  that >od9s plans are mind$blowing. n the end, a >od$centric< lifestyle would free us to live life to the fullest?<  [Da'i Ro*inson, !ormer NBA "layer\ 4ea5 $nna5 67C8 sa*s U"C 291: JKI, alang ?a"antay0 ; o/ ;