Ochsner Case Studies

MEDICAL CASE STUDY

Hugo Quintana, MD

A 72-year-old man with a history of hypertension, diabetes, and coronary artery disease, was admitted to the hospital with unstable angina. His blood pressure had been difficult to control despite therapy with four antihypertensive medications (diltiazem, hydroclorothiazide, metoprolol, and losartan). Creatinine clearance was 65 mL/min. Selective renal angiography was performed at the time of the coronary angiogram. The angiographic findings are shown below.

Questions:

What is the diagnosis?
In which patients should the diagnosis be suspected?
What other vascular studies are available to make this diagnosis?
What are the treatment options?
What are the clinical outcomes of renal artery revascularization therapy?

SURGICAL CASE STUDY

Aditya K. Kaza MD, George M. Fuhrman MD

Department of Surgery, Ochsner Clinic Foundation, New Orleans, LA

A 76-year-old female was treated with breast conservation therapy for right breast cancer 4 years ago. She underwent a segmental mastectomy with axillary node dissection and whole-breast radiotherapy postoperatively. She recently came to the clinic with breast ecchymosis and induration and denies any history of trauma. On examination, the right breast is ecchymotic with thickened skin consistent with prior radiotherapy (Figure 1). An H&E stained slide was produced from punch biopsy (Figure 2).

Figure 1.

Figure 2.

Question:

What is the underlying pathology?

pg 40 Answers:

The picture depicts a selective angiogram of the left renal artery. It demonstrates the presence of both atherosclerotic renal artery stenosis (ARAS) at the ostium and fibromuscular dysplasia (FMD) in the vessel mid-third. By far, these are the two most common causes of renal artery stenosis. The simultaneous occurrence of both (ARAS and FMD) is rare.
Patients at risk of renal artery stenosis include:
a. Abdominal bruit (systolic and diastolic)
b. Onset of hypertension < 20 yrs or > 55 yrs
c. Malignant hypertension
d. Refractory or difficult to control hypertension
e. Azotemia with ACE inhibitors
f. Atrophic kidney
g. Hypertension and associated atherosclerotic disease
h. Elderly with renal insufficiency
i. Flash pulmonary edema
Other noninvasive tests available to make this diagnosis include renal Doppler ultrasound, magnetic resonance angiography, and computed tomographic angiography. More cumbersome physiological studies available to assess the renin-angiotensin system include plasma, renal vein, and captopril-stimulated renin levels. Functional studies to evaluate the overall renal function include urinalysis, serum creatinine, and nuclear imaging with diethylenetriamine pentaacetic acid (DTPA).
There is no consensus about which patients should undergo renal artery revascularization (surgical or percutaneous). However, it should be considered in patients with ARAS or FMD with associated clinical findings such as:
a. Hypertension (new onset, malignant, accelerated, and refractory).
b. Renal abnormalities (unexplained or ACE-inhibitor-induced azotemia, hypokalemia, and unilateral small kidney).
c. Other findings (CHF – pulmonary edema, hypertensive end-organ damage, and other peripheral vascular disease)
Due to its low associated morbidity and equal efficacy, the current method of choice is percutaneous angioplasty (PTA). PTA alone is the treatment of choice for patients with FMD, while stenting is used for patients with FMD and a suboptimal PTA result. Primary renal artery stenting is preferred for patients with ARAS.
Renal artery revascularization results in stabilization or improvement of the renal filtration function (as determined by serum creatinine) in about 60% – 92% of the patients and deterioration in 8% – 28 %. Renal artery stent placement in patients with refractory hypertension, unstable angina, or heart failure and unilateral or bilateral renal artery stenosis results in improved blood pressure control in 74% of patients at 6 months. Percutaneous balloon angioplasty is the treatment of choice in hypertensive patients with renal FMD refractory to maximal medical therapy. The reported cure rates exceed 75%.

Pg 41 Answer:

The punch biopsy of the skin reveals malignant changes in the dermis consistent with angiosarcoma (Stewart-Treves Syndrome). Studies have shown association between radiotherapy and lymphedema resulting in soft tissue sarcomas. Stewert-Treves in 1946 described six patients who developed vascular sarcomas in the presence of lymphedema after radical mastectomy and hence the eponym. Patient in this case underwent a simple mastectomy with removal of all involved skin.