Surgical Hypertension by Dr. Edward N. Nyimbili - UTH - Surgery

Surgical Hypertension Presenter: Dr. Edward N. Nyimbili Date: 13-03-2020 UTH Background HTN affects approx. 60 m people in U.S . Long-term sequelae include: cardiac arterial disease, congestive heart failure left ventricular hypertrophy, renal disease, cerebral vascular accidents retinopathy. Background The vast majority of people with hypertension have primary or essential hypertension HTN that develops as a result of an identifiable cause, it is termed “secondary” hypertension Suspect 2°HTN in Pt. with medically refractory HTN An Acute Raise in BP over a Short Period of time. <30yrs at onset of HTN & with no family Hx. Severe HTN Secondary HTN Surgical Causes Renal Renovascular Disease Coarctation of the Aorta Primary Hyperaldosteronism Phoechromocytoma Hyperthyroidism Hyperparathyroidism ACTH secreting Tumour Non Surgical Causes Polycythemia vera Chronic Sleep Aponea Renal Parenchymal Disease Medications Secondary hypertension can be divided into surgical and nonsurgical causes. Renal Renovascular Disease Present in 1% of general population Suspect in PT. with Hypertension and upper Abd. Bruit. Caused by Renal Artery Stenosis Two main causes Atherosclerosis, 75% of cases, affects men over the age of 45yrs mostly Fibromuscular dysplasia, 25% of cases, affects more women than men. Renal Renovascular Disease 3 anatomical types described Unilateral Art. Stenosis Bilateral renal Art. Stenosis Stenosis in solitary Kidney Determining the type may be important for therapy. ACE inhibitors are useful in patient with unilateral Stenosis but contraindicated in the other 2 types. Renal Renovascular Disease Renal Renovascular Disease Work up. Duplex Doppler U/S CT angiography MRI Arteriography; necessary to delineate subtle anomalies. Still considered a gold standard. Renal Renovascular Disease Treatment Angioplasty Endarterectomy Bypass Coarctation of the Aorta Narrowing of the medial layer of the vessel. Aetiology: Commonly congenital Acquired- 2°to Takayasu arteritis Severe atherosclerosis May affect neonates, infants, children & adults Commonly affects Aorta distal subclavian artery. Coarctation of the Aorta Coarctation of the Aorta Physical Findings BP differences between Rt. & Lt. Arms or between Arms & legs. ECG-LV hypertrophy(voltage & ST&T wave changes) CXR- Normal or enlarged Heart. -notching of the posterior 1/3 of the 3rd to 8th ribs. Coarctation of the Aorta rRib Notching Coarctation of the Aorta Diagnosis Transthoracic echo with suprasternal notch view. CT MRI CT & MRI help delineate anatomy. Coarctation of the Aorta Definitive Management Percutaneous catheterization Repair (Angioplasty & Stent) Surgical Repair. Indications Significant Coarctation or collateral flow Peak to Peak coarctation Gradient of > 20mmHg. Primary Hyperaldosteronism Dfn. Pathologic secretion of aldosterone, independent of renin plasma levels, from unilateral or bilateral adrenal glands. Causes Conn’s syndrome-unilateral or bilateral adenomas Bilateral adrenal hyperplasia Adrenal Ca. Ectopic Aldosterone producing tumours Primary Hyperaldosteronism Primary aldosteronism is the most common cause of surgically correctable HTN. Suspect P° Hyperaldosteronism in patient with HTN; family Hx. of early onset HTN Hyperaldosteronism, concurrent HypoK⁺, HyperN⁺ adrenal incidentaloma Pt. with drug resistant hypertension Primary Hyperaldosteronism Work up. Plasma aldo./renin ratio if elevated >50 times. Aldosterone suppression test(oral or IV) & measure urine excretion / plasma levels of aldosterone . CT to localise lesion Bilateral adrenal vein sampling Primary Hyperaldosteronism Primary Hyperaldosteronism Goals of treatment Normalise HTN & hypoK⁺ Unilateral disease – surgical resection Bilateral benign disease – medical Treatment Pheochromocytoma Dfn: catecholamine secreting tumour of the neural crest origin. 90% arise in the adrenal medulla Most are benign 10% are malignant Seen commonly in young to mid adult life Screen all Pt. for MEN type 2. Secretion of catecholamines maybe precipitated by anxiety, trauma, drugs, food, surgery & anaesthesia. Pheochromocytoma Potential sites for Pheochromocytoma Pheochromocytoma Symptoms Paroxysmal HTN Chronic Hypertension resistant to anti-HTN Heart palpitation Headache Sweating 50 % diagnosed with Pheo. are asymptom. Other Symptoms Visual blurring Weight loss Polyuria Polydipsia Constipation diarrhoea Pheochromocytoma Work up 24 hrs measurement of urine normetanephrines/metanephrines & urinary vanillyl-mendilic acid. Plasma catecholamine levels CT/MRI can localise tumour 123-I- metaiodobenylguanidine(MIBG) scintigraphy if CT/MRI –ve but biochemically proven disease Pheochromocytoma Treatment Preoperative control of BP is necessary with Pheoxybenzamine -B-blockers maybe used for tachycardia & HTN Pt. with MEN 2 & evidence of bilateral disease on imagine undergo bilateral adrenalectomy. Miscellaneous Surgical Disease that Contribute to HTN Pt. with HTN and concurrent; Hyperthyroidism Hyperparathyroidism ACTH secreting tumours May have their HTN lessened after surgical cure. However most of these patient have primary HTN with these secondary disease. …