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Treatment of Renal Artery Disease

The treatment of renal artery disease should be guided by the cause of the arterial obstruction and the health consequence(s) of the obstruction. A renal artery stenosis (RAS) of any cause that has no sequelae, such as hypertension or functional kidney impairment, generally requires no treatment. Although this circumstance might seem unusual, it is becoming more commonplace as imaging of the abdominal aorta becomes more frequent…

Clinical Evaluation of Renal Artery Disease

Approximately 46% of individuals age 20 and older have high blood pressure. In those age 75 and older, 79% of men and 85% of women have hypertension. Most have primary (essential) hypertension; however, there are a number of different causes of secondary hypertension, including those related to lifestyle or medications, such as obesity, excess alcohol ingestion, drug abuse, and oral contraceptive agents. Among other secondary causes,…

Pathophysiology of Renal Artery Disease

Vascular disease affecting the renal arteries presents complex challenges to clinicians. Partly due to advances in vascular imaging, more patients than ever before are being identified with some degree of atherosclerotic or fibromuscular renovascular disease. Many of these lesions are of minor hemodynamic importance at the time of detection. Some reach a degree at which perfusion pressures and intrarenal hemodynamics are altered, leading to changes in…

Reconstructive Surgery for Peripheral Artery Disease

The clinical manifestations and complications of atherosclerosis are the most common therapeutic challenges encountered by vascular surgeons. The tendency for lesions to develop at specific anatomic sites and to follow recognizable patterns of progression was appreciated as long ago as the late 1700s by the extraordinary British anatomist and surgeon John Hunter. Considered one of the forefathers of vascular surgery, his dissections of atherosclerotic aortic bifurcations…

Endovascular Treatment of Peripheral Artery Disease

The concept of percutaneous catheter-based peripheral vascular intervention (PVI) was first described by Charles Dotter and further advanced with the development of balloon dilation catheters by Andreas Gruentzig. Catheter-based revascularization has largely replaced conventional open surgery as the treatment of first choice in selected patients treated for lower-extremity ischemia. No single specialty program (cardiology, radiology, or surgery) offered training that satisfied the entire skill set needed…

Medical Treatment of Peripheral Artery Disease

Medical treatment of patients with peripheral artery disease (PAD) is targeted at preventing adverse cardiovascular and limb outcomes and improving limb function. Atherothrombotic complications such as myocardial infarction (MI), ischemic stroke, and cardiovascular death are referred to as major adverse cardiovascular events (MACE), with risk related to the systemic nature of atherosclerosis (see Chapter 16 ). In addition, patients with PAD are at risk of major…

Peripheral Artery Disease: Clinical Evaluation

The least often recognized of the commonly occurring manifestations of atherosclerosis is peripheral artery disease (PAD). Epidemiological studies suggest that approximately 7.1 million people in the United States have PAD. Among 7458 participants aged 40 years and older from the 1999 to 2004 National Health and Nutrition Examination Survey (NHANES), the prevalence of PAD was 5.9%. Despite its relative frequency, predictable patient population, and prognostic implications…

Pathophysiology of Peripheral Artery Disease

Peripheral artery disease (PAD) has a considerable and growing impact on cardiovascular health worldwide. , PAD represents systemic atherosclerosis in the lower extremities that elevates the risk for cardiovascular events including myocardial infarction and stroke (see Chapter 16 ). Patients with PAD experience limb manifestations that lead to substantial suffering. Limb ischemia induces leg pain, limits walking ability, and may progress to amputation (see Chapter 18…

The Epidemiology of Peripheral Artery Disease

Peripheral artery disease (PAD) is one of several terms referring to a partial or complete obstruction of one or more arteries that supply blood to the limbs. Although the term PAD is sometimes inclusive of all peripheral arteries and/or any etiology, in this chapter PAD refers to atherosclerotic occlusive disease of lower extremity arteries. Other terms used for this condition in the literature are “peripheral vascular…

Catheter-Based Peripheral Angiography

Catheter-based invasive contrast angiography is the standard method for diagnosing peripheral artery disease (PAD), and against which all other methods are compared for accuracy. Angiography provides the “road map” on which therapeutic decisions are based. Knowledge of the vascular anatomy and its normal variations is a core element in the skill set required to safely perform peripheral vascular angiography and interventions. Imaging equipment There are many…

Computed Tomographic Angiography

Volumetric data acquisition with multidetector computed tomography (MDCT) has enabled the development of computed tomographic angiography (CTA), a diagnostic modality that has revolutionized the diagnosis of vascular disorders. Adequate imaging of the peripheral vascular system during a single acquisition and a single injection of contrast medium became feasible with the introduction of a 4-slice computed tomography (CT) system with a 0.5 second gantry rotation (thinnest collimation…

Magnetic Resonance Imaging

Acknowledgment Drs. Pollak and Kramer acknowledge the prior contributions of Dr. Cihan Duran, Dr. Piotr S. Sobieszczyk, and Dr. Frank J. Rybicki to the sections on principles of MRI and image analysis. Magnetic resonance imaging (MRI) is a valuable vascular imaging tool and is a modality of choice for many indications, including peripheral and renal arteriography. Gadolinium-based contrast-enhanced magnetic resonance angiography (CE-MRA) yields high-quality spatial resolution…

Vascular Laboratory Testing

Vascular laboratory technology offers many cost-effective applications in the practice of vascular medicine. Vascular testing includes both physiological testing and duplex ultrasonography. Physiological testing includes segmental pressure measurements, pulse volume recordings (PVRs), continuous wave (CW) Doppler, and plethysmography. These tests use sphygmomanometric cuffs, Doppler instruments, and plethysmographic recording devices. Duplex ultrasonography combines gray-scale and Doppler imaging with spectral and color Doppler and is used for the…

The History and Physical Examination

The ubiquitous nature of arteries, veins, and lymphatic vessels allows for any region of the body to develop vascular disease. This chapter describes the vascular medical history and physical examination—the core components of evaluating patients with vascular diseases. Application of these methods and tailored use of special examination maneuvers facilitate the diagnosis of vascular disease, especially when used in conjunction with vascular tests described elsewhere in…

Pathobiology of Vasculitis

The term “vasculitis” encompasses diseases that share the feature of inflammatory destruction of blood vessels but otherwise include diverse clinical phenotypes and pathophysiologies. The rarity of the vasculitides and the paucity of animal models means that their pathophysiologies are not as well understood as in many other inflammatory diseases. However, a combination of genetic, epidemiologic, and laboratory-based studies has provided insight into ways that the vasculitides…

Pathobiology and Assessment of Cardiovascular Fibrosis

Fibrosis refers to the reorganization of loose extracellular matrix (ECM) and proliferation of fibroblasts that causes connective tissue thickening. Upregulation of profibrotic signaling pathways occurs in response to tissue destruction as a compensatory mechanism when parenchymal cells are unable to restore the normal structural integrity of affected organs. Recruitment of ECM proteins such as collagens, elastin, fibrillin, adhesive glycoproteins, integrins, and other secreted matricellular proteins is…

Pathobiology of Thrombosis

Overview of thrombosis Abnormal hemostasis leads to thrombus formation. Thrombosis in either the arterial or the venous system is a leading cause of significant morbidity and mortality. When thrombosis occurs in the arterial system, myocardial infarction and stroke may occur, whereas thrombosis in the venous system results in venous thromboembolic disease. Thrombosis and thrombotic-related events are among the most common causes of mortality in the Western…

Pathobiology of Aortic Aneurysms

Aortic aneurysms (AAs) can develop in either the thoracic or the abdominal aorta, termed thoracic aortic aneurysm (TAA) ( Fig. 7.1 ) or abdominal aortic aneurysm (AAA) ( Fig. 7.2 ), respectively. AAs are further subclassified according to their specific location in the thoracic (ascending aorta, aortic arch, descending aorta) or abdominal (suprarenal or infrarenal) aortic segments ( Fig. 7.3 ). Although this classification may appear…

Pathobiology of Atherosclerosis

Knowledge of the pathobiology of atherosclerosis has continued to evolve at a rapid pace. Previously regarded as a mainly segmental disease, we now increasingly appreciate the condition’s diffuse nature. The traditional clinical focus on atherosclerosis has emphasized coronary artery disease. The attention of physicians in general and of cardiovascular specialists in particular now embraces other arterial beds, including the peripheral and cerebrovascular arterial circulations. Formerly considered…

Vascular Pharmacology

Therapeutic intervention is optimized when we understand the normal physiological signaling processes that are disrupted by a disease process, the abnormal molecular and cellular mechanisms driving disease pathogenesis, and the pharmacological profile of the intervention. Indeed, the majority of vascular drugs act as replacement therapy to augment endogenous protective signaling processes or as reversal therapy to block or reduce the abnormal activity of pathological mediators or…