Chap 102/147 FMD

Question 1

What is FMD?

Answer 1

Non-athersclerotic noninflamm angiopathy of unknown cause. Medium sized vessels

Question 2

What are complication of carotid FMD and how many get comps?

Answer 2

10%

Decreased lumen size
Formation distal embolization of thrombus
Dissection/rupture

Question 3

What is the most common pathophys for cFMD?

Answer 3

medial fibroplasia 90%

Question 4

What are most common concurrent lesion with cFMD?

Answer 4

ipsi bifurcation 20%
extracranial CA anerusy.
CA dissection
vert artery FMD
intracranial aneurysm/occlusive
RA FMD

Question 5

What are diagnostic methods?

Answer 5

duplex-may miss distal dz
angio–best, string of beads
CT-better then MRA
MRA-signal dropout may appear to be beads

Question 6

What are therapeutic challenges for cFMD?

Answer 6

Difficult to quantify severity of disease
If concurrent lesion, difficult to determine which is causing symptoms
If ipsi sympto and contra asympto, difficult to know what to do with contra side
May have nonfocal symptoms due to global ischemia
Intracranial aneurysms may alter surgical approach
HTN from RA FMD may complicate sx on carotid FMD

Question 7

What is conservative therapy for cFMD?

Answer 7

Antiplt
Monitor q6 months
Rule out involvement in other arterial beds
Avoid chiro

Question 8

What are invasive treatment strategies?

Answer 8

Open surgical dilatation
Rigid dilators disrupt obstructive webs
May need to ivied belly of digastric muscle
Start with 1.5mm
Back bleed
Stroke 3%
10 year patency, stroke-free and survival all about 90%

Dilatation mainstay of treatment
Stenting
Durability of PTA/stent unknown
May need to use external to get sheath/balloon up
Balloon should cover entire lesion and be slightly undersized to avoid dissection
Stent only if needed

Question 9

What is the classification of FMD?

Answer 9

intimal fibroplasia

medial dysplasia
medial fibrosis
perimedial
medial hyperplasia

adventitial fibroplasia

Question 10

What is the most common type of FMD?

Answer 10

medial

Question 11

What are proposed cause of FMD?

Answer 11

May be hormonal factors
Occlusion of vaso vasorum
Long straight segs without branches are affected
CA and RA also get a lot of motion damaging VV.
Right renal longer so this may be why its affected more
Smoking
Familial
EDS

Question 12

What are most common patterns of involvement?

Answer 12

Uni Right
Bilat renal
Uni left
Carotid/vert
Multiple

Question 13

How common a cause of HTN is r FMD

Answer 13

2nd most common cause

Question 14

What is the natural hx of r FDM?

Answer 14

About 25% of asympto devel HTN within 4 years
40% angio progression
decrease of renal funcition less frequent then with athererosclerotic

Question 15

What are best tools for diagnosis?

Answer 15

DUS/CT/MRA are screening only because limited resolution for distal renal vessels
angio for diagnosis

Question 16

What are indication for interventions for rFMD?

Answer 16

renal to aortic P gradient of 0.9
change in kidney size of 1 cm
refractory HTN
impaired renal function
size difference of >1.5cm
pressure gradient across stenosis of 10mmhg

Question 17

What are indications for evaluation of secondary HTN?

Answer 17

>3 anti-HTN
sudden acceleration of CR or HTN
increased CR with ACEi
<30 yo
spontaneous hypoK
unexplained pulm edema
bruit

Question 18

What are medical treatments for rFMD?

Answer 18

ASA, statins

Anti-htn treatment <140/90

Question 19

What are surgical options for rFMD?

Answer 19

aortorenal bypass

autotransplantation

Question 20

When to consider autotransplantation in rFMD?

Answer 20

if reop
failed endo
multiseg
single kidney with stenosis in several RA