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Abstract Context In primary aldosteronism, cosecretion of cortisol may alter cortisol-derived adrenal venous sampling indices. Objective To identify whether cortisol cosecretion in primary aldosteronism alters adrenal venous sampling parameters and interpretation. Design Retrospective case–control study Setting A tertiary referral center Patients 144 adult patients with primary aldosteronism who had undergone both adrenocorticotropic hormone-stimulated adrenal venous sampling and dexamethasone suppression testing between 2004 and 2018. Main Outcome Measures Adrenal venous sampling indices including adrenal vein aldosterone/cortisol ratios and the selectivity, lateralization, and contralateral suppression indices. Results 21 (14.6%) patients had evidence of cortisol cosecretion (defined as a failure to suppress cortisol to ≤50 nmol/L post dexamethasone). Patients with evidence of cortisol cosecretion had a higher inferior vena cava cortisol concentration (P = .01) than those without. No difference was observed between the groups in terms of selectivity index, lateralization index, lateralization of aldosterone excess, or adrenal vein cannulation rate. Conclusions Cortisol cosecretion alters some parameters in adrenocorticotrophic hormone-stimulated adrenal venous sampling but does not result in alterations in patient management.

The purpose of this study was to assess whether portal vein embolization (PVE) using a nitinol vascular plug in combination with histoacryl glue and iodinized oil minimizes the risk of nontarget embolization while obtaining good levels of future liver remnant (FLR) hypertrophy. Between November 2005 and August 2008, 16 patients (8 females, 8 males; mean age, 63 ± 3.6 years), each with a small FLR, underwent right ipsilateral transhepatic PVE prior to major hepatectomy. Proximal PVE was initially performed by placement of a nitinol vascular plug, followed by distal embolization using a mixture of histoacryl glue and iodinized oil. Pre- and 6 weeks postprocedural FLR volumes were calculated using computed tomographic imaging. Selection for surgery required an FLR of 0.5% of the patient’s body mass. Clinical course and outcome of surgical resection for all patients were recorded. At surgery, the ease of hepatectomy was subjectively assessed in comparison to previous experience following PVE with alternative embolic agents. PVE was successful in all patients. Mean procedure time was 30.4 ± 2.5 min. Mean absolute increase in FLR volume was 68.9% ± 12.0% ( p  = 0.00005). There was no evidence of nontarget embolization during the procedure or on subsequent imaging. Nine patients proceeded to extended hepatectomy. Six patients demonstrated disease progression. One patient did not achieve sufficient hypertrophy in relation to body mass to undergo hepatic resection. At surgery, the hepatobiliary surgeons observed less periportal inflammation compared to previous experience with alternative embolic agents, facilitating dissection at extended hepatectomy. In conclusion, ipsilateral transhepatic PVE using a single nitinol plug in combination with histoacryl glue and iodinized oil simplifies the procedure, offering short procedural times with minimal risk of nontarget embolization. Excellent levels of FLR hypertrophy are achieved enabling safe extended hepatectomy.

Primary aldosteronism (PA) due to a unilateral aldosterone-producing adenoma is a common cause of hypertension. This can be cured, or greatly improved, by adrenal surgery. However, the invasive nature of the standard pre-surgical investigation contributes to fewer than 1% of patients with PA being offered the chance of a cure. The primary objective of our prospective study of 143 patients with PA ( NCT02945904 ) was to compare the accuracy of a non-invasive test, [ 11 C]metomidate positron emission tomography computed tomography (MTO) scanning, with adrenal vein sampling (AVS) in predicting the biochemical remission of PA and the resolution of hypertension after surgery. A total of 128 patients reached 6- to 9-month follow-up, with 78 (61%) treated surgically and 50 (39%) managed medically. Of the 78 patients receiving surgery, 77 achieved one or more PA surgical outcome criterion for success. The accuracies of MTO at predicting biochemical and clinical success following adrenalectomy were, respectively, 72.7 and 65.4%. For AVS, the accuracies were 63.6 and 61.5%. MTO was not significantly superior, but the differences of 9.1% (95% confidence interval = −6.5 to 24.1%) and 3.8% (95% confidence interval = −11.9 to 9.4) lay within the pre-specified −17% margin for non-inferiority ( P  = 0.00055 and P  = 0.0077, respectively). Of 24 serious adverse events, none was considered related to either investigation and 22 were fully resolved. MTO enables non-invasive diagnosis of unilateral PA. Comparison of non-invasive [ 11 C]metomidate PET-CT with adrenal vein sampling for predicting biochemical remission of primary aldosteronism showed non-superiority, suggesting that the non-invasive method is suitable for the diagnosis of unilateral primary aldosteronism.

Maternal immune dysregulation is a prenatal risk factor for autism spectrum disorder (ASD). Importantly, a clinically relevant connection exists between inflammation and metabolic stress that can result in aberrant cytokine signaling and autoimmunity. In this study we examined the potential for maternal autoantibodies (aAbs) to disrupt metabolic signaling and induce neuroanatomical changes in the brains of exposed offspring. To accomplish this, we developed a model of maternal aAb exposure in rats based on the clinical phenomenon of maternal autoantibody-related ASD (MAR-ASD). Following confirmation of aAb production in rat dams and antigen-specific immunoglobulin G (IgG) transfer to offspring, we assessed offspring behavior and brain structure longitudinally. MAR-ASD rat offspring displayed a reduction in pup ultrasonic vocalizations and a pronounced deficit in social play behavior when allowed to freely interact with a novel partner. Additionally, longitudinal in vivo structural magnetic resonance imaging (sMRI) at postnatal day 30 (PND30) and PND70, conducted in a separate cohort of animals, revealed sex-specific differences in total and regional brain volume. Treatment-specific effects by region appeared to converge on midbrain and cerebellar structures in MAR-ASD offspring. Simultaneously, in vivo 1 H magnetic resonance spectroscopy ( 1 H-MRS) data were collected to examine brain metabolite levels in the medial prefrontal cortex. Results showed that MAR-ASD offspring displayed decreased levels of choline-containing compounds and glutathione, accompanied by increased taurine compared to control animals. Overall, we found that rats exposed to MAR-ASD aAbs present with alterations in behavior, brain structure, and neurometabolites; reminiscent of findings observed in clinical ASD.

Aortic coarctation presents in adult life in a significant number of patients. The preferred treatment in this age group is percutaneous stent implantation without which life expectancy is reduced due to the complications of uncontrolled hypertension. We present the first case of an “uncrossable” aortic coarctation transversed using the BEACON (Brief Electrification of a guidewire to assist in crossing an Aortic CoarctatiON) technique, a novel approach incorporating the electrification of a guidewire. It requires standard transcaval equipment and techniques but crosses from aortic lumen-to-lumen instead of cava-to-aorta, thus creating a rail for successful stent delivery.

Improved and durable control of hypertension is a global priority for healthcare providers and policymakers. There are several lifestyle measures that are proven to result in improved blood pressure (BP) control. Moreover, there is incontrovertible evidence from large scale randomised controlled trials (RCTs) that antihypertensive drugs lower BP safely and effectively in the long-term resulting in substantial reduction in cardiovascular morbidity and mortality. Importantly, however, evidence is accumulating to suggest that patients neither sustain long-term healthy behaviours nor adhere to lifelong drug treatment regimens and thus alternative measures to control hypertension warrant further investigation. Endovascular renal denervation (RDN) appears to hold some promise as a non-pharmacological approach to lowering BP and achieves renal sympathectomy using either radiofrequency energy or ultrasound-based approaches. This treatment modality has been evaluated in clinical trials in humans since 2009 but initial studies were compromised by being non-randomised, without sham control and small in size. Subsequently, clinical trial design and rigour of execution has been greatly improved resulting in recent sham-controlled RCTs that demonstrate short-term reduction in ambulatory BP without any significant safety concerns in both medication-naïve and medication-treated hypertensive patients. Despite this, the joint UK societies still feel that further evaluation of this therapy is warranted and that RDN should not be offered to patients outside of the context of clinical trials. This document reviews the updated evidence since our last consensus statement from 2014 and provides a research agenda for future clinical studies.

Purpose Endovascular aortic repair (EAR) interventions, endovascular abdominal aortic repair (EVAR) and thoracic endovascular aortic repair (TEVAR), are associated with significant radiation exposures. We aimed to investigate the radiation doses from real-world practice and propose diagnostic reference level (DRL) for the UK. Materials and Methods Radiation data and essential demographics were retrospectively collected from 24 vascular and interventional radiology centres in the UK for all patients undergoing EAR—standard EVAR or complex, branched/fenestrated (BEVAR/FEVAR), and TEVAR—between 2018 and 2021. The data set was further categorised according to X-ray unit type, either fixed or mobile. The proposed national DRL is the 75th percentile of the collective medians for procedure KAP (kerma area product), cumulative air kerma (CAK), fluoroscopy KAP and CAK. Results Data from 3712 endovascular aortic procedures were collected, including 2062 cases were standard EVAR, 906 cases of BEVAR/FEVAR and 509 cases of TEVAR. The majority of endovascular procedures (3477/3712) were performed on fixed X-ray units. The proposed DRL for KAP was 162 Gy cm 2 , 175 Gy cm 2 and 266 Gy cm 2 for standard EVAR, TEVAR and BEVAR/FEVAR, respectively. Conclusion The development of DRLs is pertinent to EAR procedures as the first step to optimise the radiation risks to patients and staff while maintaining the highest patient care and paving the way for steps to reduce radiation exposures.

Four women with symptomatic uterine fibroids were treated by uterine artery embolization (UAE). In all cases both uterine arteries were embolized via a single femoral puncture with polyvinyl alcohol using a selective catheter technique. In three cases, the ovarian artery was not visible on the initial angiogram before embolization, but appeared after the second uterine artery had been treated. In one case of clinical failure following UAE, a repeat angiogram demonstrated filling of the fibroids from the ovarian artery. Anastomoses between uterine and ovarian arteries may cause problems for radiologists performing UAE and are a potential cause of treatment failure.

Resistant hypertension continues to pose a major challenge to clinicians worldwide and has serious implications for patients who are at increased risk of cardiovascular morbidity and mortality with this diagnosis. Pharmacological therapy for resistant hypertension follows guidelines-based regimens although there is surprisingly scant evidence for beneficial outcomes using additional drug treatment after three antihypertensives have failed to achieve target blood pressure. Recently there has been considerable interest in the use of endoluminal renal denervation as an interventional technique to achieve renal nerve ablation and lower blood pressure. Although initial clinical trials of renal denervation in patients with resistant hypertension demonstrated encouraging office blood pressure reduction, a large randomised control trial (Symplicity HTN-3) with a sham-control limb, failed to meet its primary efficacy end point. The trial however was subject to a number of flaws which must be taken into consideration in interpreting the final results. Moreover a substantial body of evidence from non-randomised smaller trials does suggest that renal denervation may have an important role in the management of hypertension and other disease states characterised by overactivation of the sympathetic nervous system. The Joint UK Societies does not recommend the use of renal denervation for treatment of resistant hypertension in routine clinical practice but remains committed to supporting research activity in this field. A number of research strategies are identified and much that can be improved upon to ensure better design and conduct of future randomised studies.