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Chronic renal failure acutely worsened in a patient with a type B aortic dissection. Aortography revealed an occlusion of the left renal artery without renal intimal tear. Percutaneous recanalization, performed with a self-expandable stent, resulted in improvement in the renal function. This technique offers a new therapeutic choice in patients with visceral complications of aortic dissection.

670BRITISH MEDICAL JOURNAL 2 SEPTEMBER 1978 ventricle and pulmonary artery. Half of all emboli to the right ventricle cause a major complication or death. The use of beta-blocking drugs during pregnancy has been questioned for two main reasons: their possible stimulant action on uterine muscle,1 2 and their pharmacological effects on the fetus.3 In an earlier retrospective study of 10 hypertensive pregnant patients propranolol was used with success.5 We report a prospective study of nine similar high-risk pregnancies followed to term in which propranolol was used to treat hypertension. Method and resultsThree primiparous and six multiparous patients received propranolol for hypertension. In one patient treatment had been started before pregnancy; in five, it was started within three months of the onset of pregnancy; and in three it was started between the fourth and fifth month. Except in case 3, the fetal heart rates were between 120 and 150 beats/ minute. Apgar index at 1 minute was 10 in five cases, but lower in the others (8, 7, 1); Apgars at 5 minutes were 10 in these eight cases. Blood glucose concentrations recorded in seven of these eight infants were normal (>2-2 mmol/l (>40 mg/100 ml)) in five and at the lower limit of normal in the remaining two. In case number 3 the infant was born at 35 weeks by caesarean section for fetal distress (heart rate 110 beats/minute). Infant weight was 1320 g and the Apgar index was 0 at one minute and 8 at five minutes but the plasma glucose concentration was above 2-2 mmol/l. Despite immediate referral to intensive care this child died at three months of hyaline membrane disease with acute on chronic distress. Of four previous pregnancies in this patient, there had been two abortions, one premature delivery of a stillborn child, and one premature delivery of a living child. CommentThe blood pressure was controlled in eight of the nine patients during pregnancy by propranolol with no effect on uterine contractions or increased frequency of abortion and premature labour. No congenital malformations were seen in the six patients started before three months and propranolol did not seem directly responsible for fetal or maternal distress. Of the four patients who had had previous complicated pregnancies including hypertension, three had a much more satisfactory course with propranolol and in the fourth patient no improvement over previous pregnancies was seen. These results need confirmation but indicate that propranolol is effective in reducing high blood pressure in pregnancy without increasing mortality in babies already at risk.

In a double-blind trail in 22 patients with mild to moderate essential hypertension, indapamide was compared with chlorathiazide and placebo. Dosage levels were set at 5 mg. indapamide and 500 mg. chlorothiazide daily, for 5 days out of 7, and patients were treated alternately, in random sequence, with each drug for a month over a 3-month period. Blood pressure readings and blood chemistry investigations were carried out before and after each treatment period and a careful history was kept of subjective symptoms and patients' tolerance of therapy. The results show that both active treatments produced drops in systolic and diastolic pressures, but were only statisically significant and different from placebo in the case of indapamide. Indapamide also produce much greater subjective improvement (74%) in patients with functional symptoms compared with chlorothiazide (15%). In an overall assessment, indapamide produced an excellent to good response to treatment in 57% of patients. Comparable responses for chlorotiazide and placebo were 25% and 20% respectivlely. Using patients as their own controls to compare the relative effectiveness of the three periods of treatment, indapamide was shown to be more effective than placebo in 65% of cases and more effective han chlorothiazide in 60%. Although patient tolerance of indapamide was slightly better, both drugs were well accepted and no significant changes from baseline levels were noted in any of the laboratory parameters investigated.

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