Catheter-directed Thrombolysis of Below-Knee Deep Venous Thrombosis of the Lower Extremities

PURPOSE: To evaluate the technical feasibility and clinical efficacy of the use of local thrombolysis for below-knee deep vein thrombosis (DVT). MATERIALS AND METHODS: From a population of 41 patients with a lower extremity DVT, the prospective clinical trial included 11 patients (7 female, 4 male, average age 61.4 years) treated with catheter-directed thrombolysis with urokinase for below-knee DVT. After removal of the proximal ilofemoral DVT, additional interventional procedures to remove the residual thrombus and restore the venous flow from the below-knee vein were performed in cases of continuous occlusion of venous flow from the popliteal and tibial veins. Under ultrasound (US) guidance, catheter-directed thrombolysis with urokinase was performed through the ipsilateral popliteal vein. After administration of oral anticoagulation therapy, CT and venography were performed to identify patency and the presence of a recurrent thrombosis. RESULTS: Successful removal of the thrombus and restoration of venous flow were achieved in all of the patients (100%). Restoration of flow with a residual thrombus occurred in one case. Focal venous stenosis was discovered in four cases. The duration of urokinase infusion was 1-4 days (average 2.36 days), which was considered long. For 15.2 months, the venous lumen of all cases was preserved without a recurrent thrombosis. CONCLUSION: Catheter-directed thrombolysis is an effective procedure for recanalization of below-knee DVT in patients with a lower extremity DVT.

Primary Hepatic Choriocarcinoma: A Case Report

Choriocarcinoma is one of the most common malignancies associated with pregnancy. The characteristics of this malignancy include abnormal growth of the trophoblastic tissue, direct invasion of adjacent organs, and distant metastasis; however, it rarely presents extragonadally. Recently, we have experienced a case of primary hepatic choriocarcinoma in a middle-aged-man, which was characterized by a solitary large hepatic mass with central necrosis and hemorrhaging, as well as metastases to the lung and lymph nodes along the hepatoduodenal ligament. We report this case with a review of the literature.

Diagnosis of Arteriovenous Fistulas following a Lumbar Discectomy

PURPOSE: To evaluate the relevant clinical and radiographical findings for the diagnosis of an arteriovenous fistula after a lumbar discectomy. MATERIALS AND METHODS: Five patients with an arteriovenous fistula following a lumbar discectomy were preoperatively diagnosed and treated. We retrospectively evaluated the level of surgery, injured vessels, clinical symptoms, physical findings, and the interval between surgery and treatment. Effective and fast diagnostic methods for determining the presence of a postoperative arteriovenous fistula were evaluated. RESULTS: All of the arteriovenous fistulas resulted from operative injuries of the iliac arteries and veins. They were diagnosed after a mean time of 22 months (range 2 months-4 years) in spite of various symptoms and signs shortly after surgery. The arteriovenous fistulas were confirmed with angiography and were treated by surgery for 3 patients and by insertion of a stent-graft in 2 patients. Postoperative CT angiography showed the complete occlusion of the fistula tract and the normal blood flow. CONCLUSION: Essential clinical information and radiological examination, especially CT angiography with 3D reconstruction, is necessary to obtain to diagnose an arteriovenous fistula after a lumbar discectomy.

Intravenous Pyogenic Granuloma (or Lobular Capillary Hemangioma) Developed within the Right External Iliac Vein

A pyogeinc granuloma, also known as a lobular capillary hemangioma, is a benign vascular tumor of the skin and mucous membranes, which is common in infants and children. It usually presents as a rapidly evolving solitary, sessile, or polypoid vascular nodule. An intravenous pyogenic granuloma (IVPG) is a rare form of pyogenic granuloma, in which the whole lesion appears as a single polypoid mass projecting into the lumen of a vein. All reported cases of IVPG have been limited the head, neck, and upper extremity. We report a case of an intravenous pyogenic granuloma located within the iliac vein of a lower extremity.

Endovascular Management of Deep Venous Thrombotic Diseases of the Lower Extremity

Pulmonary embolism and venous ischemia are acute complications of deep vein thrombosis (DVT) of the lower extremities. Delayed complications include a spectrum of debilitating symptoms referred to as postthrombotic syndrome (PST). Because the early symptoms and patient signs are nonspecific for DVT, careful history taking and radiological evaluation of the extent and migration of thrombus should be used to establish an objective diagnosis and the need for treatment. Anticoagulation therapy is recognized as the mainstay treatment in acute DVT. However, there are few data to suggest any major beneficial effect of the early clearing of massive DVT and PTS. Endovascular, catheter-directed, thrombolysis techniques, used alone or in combination with mechanical thrombectomy devices, have been proven to be highly effective in clearing acute DVT, which may allow the preservation of venous valve function and the prevention of subsequent venous occlusive disease. Definitive management of the underlying anatomic occlusive abnormalities should also be undertaken.

Isolated Spontaneous Dissection of the Superior Mesenteric Artery: Percutaneous Stent Placement in Two Patients

Isolated spontaneous dissection of the superior mesenteric artery (SMA) is a rare cause of acute mesenteric ischemia. Two patients were successfully treated by percutaneous stent placement within the main trunk of the SMA. Emphasis is placed on the feasibility of nonsurgical management with percutaneous stent placement of isolated spontaneous dissection of the SMA.

Blue Digit Syndrome: Treatment with Endarterectomy and Intra-Arterial Stent Placement: 2 Cases Report

Blue digit syndrome, peripheral atheroembolism, and atheromatous embolization, all refer to microembolization and occlusion of the smaller distal arteries. Despite the longstanding recognition that atheroemboli arise from severely degenerative atherosclerotic plaques in the proximal circulation, many questions remain about the pathophysiology and natural history of this disorder. The threat to the survival of a single digit may not appear to be of great consequence, but repeated episodes of atheroembolism with continued destruction of the collateral circulation may portend disaster for the digit. Diagnostic efforts should be promptly concentrated on the location, stabilization and preferably, eradication of the embolic source. We report 2 cases of blue digit syndrome were managed by endarterectomy and intra-arterial stenting. Case 1: A 61-year-old man was presented with the blue toe syndrome at the third, fourth, fifth toes. The bilateral pedal pulses were normally palpable and ankle-brachial pressure indices (ABI) were within normal range. At the findings of duplex ultrasonography and CT angiography, right common femoral artery showed a focal eccentric stenosis with mural thrombus. The right common femoral artery endarterectomy was performed for the athersclerotic ulcerating plaque. Case 2: A 64-year-old man was presented with 11-month history of his left leg pain and 1-week history of his left third, fourth fingers. He had a history of flap operation for his left fourth finger tip due to necrosis. At the findings of angiography, multiple stenosis of left common iliac and left subclavian arteries were found. The lesion of left subclavian artery lesion was presumed to be the source of blue finger syndrome and treated with intra-arterial stent placement after balloon angioplasty.

Catheter-Directed Thrombolytic Therapy

No abstract available.

Catheter-Directed Thrombolytic Therapy

No abstract available.

Long Term Follow-up of Deep Vein Thrombosis in the Lower Extremities

PURPOSE: To learn the long-term prognosis of patients with deep vein thrombosis (DVT), we evaluated the location and extent of thrombotic changes, hemodynamic status and clinical symptoms of patients of more than 12 months after development of acute thrombosis. METHODS: 31 patients (man; 24, female; 7, mean age; 44.7 13.2 years) with phlebograpically documented DVT were followed-up for 13~90 months (mean: 32.6 20.4 months) with Duplex scanning, and photo-plethysmography (PPG), and clinical symptoms. To evaluate the effects of treatment modality, the patients were devided into 3 groups; Group 1 (heparine warfarin, n=17), Group 2 (heparine warfarin catheter directed urokinase, n=10), Group 3 (heparine warfarin systemic urokinase, n=4). But, the size of Group 3 was inappropriate to compare with other groups, we performed analysis of the results of Group 1 and 2. RESULTS: Remained thrombi were detected in 22 patients (70.2%) of 31 patients by Duplex scanning, even 1 year later. Of the 29 patients studied with PPG, 24 patients (83%) revealed valvular incompetence in deep (11 cases, 38%) and superficial venous systems (13 cases, 45%). Thrombolytic rate in Group 2 was much higher than Group 1; complete resolution (40% vs 23%), complete obstruction (0% vs 41%). The statistically significant correlation between resolution degree and symptomatic improvement was shown (p=0.008). CONCLUSION: Residual thrombi and valvular damages after DVT were common. But, thrombolysis by catheter-directed urokinase may be associated with a higher rate of thrombolysis and clinical improvement. Anticoagulation alone may not be a sufficient method for treatment of DVT.

Deep Venous Thrombosis in the Lower Extremity: Catheter-Directed Thrombolysis

PURPOSE: To evaluate the efficacy of catheter-directed thrombolysis in treating symptomatic deep venous thrombosis (DVT) in lower limbs. MATERIALS AND METHODS: Twenty-six consecutive patients (16 male and 10 female; mean age, 55 years) with lower extremity DVT underwent thrombolytic therapy. The duration of symptoms was 1 -90 (mean, 17) days: 20 days or less in 16 cases (acute DVT) and less than 20 days in ten (chronic DVT). Catheter-directed infusions of urokinase were administered via ipsilateral popliteal veins, and angioplasty or stent placement was performed after the thrombolytic procedure. Oral medication of warfarin continued for six months, and for the evaluation of venous patency, follow-up ultrasonography was performed. The total dose of infused urokinase was 1,750,000 -10,000,000 (mean 4, 84,000) IU, and the total procedural time was 25 -115 (mean, 64) hours. RESULTS: Lysis was complete in 16 cases (62%, all acute DVT), partial in five (19%, chronic DVT), and failed in five (19%, chronic DVT). Eight patients with venous stenosis and two with occlusion were treated by means of angioplasty (n=4) or Wallstent placement (n=6). Minor bleeding occurred in six cases and major complications in two (one of pulmonary embolism, and one of multiorgan failure). CONCLUSION: Catheter-directed thrombolysis with urokinase is effective for the treatment of DVT in lower limbs.

Biodistribution of Iodine-131-Iodomisonidazole and Imaging of Tumor Hypoxia in Mice bearing CT-26 Adenocarcinoma / 대한핵의학회잡지

urpose: Misonidazole is a radiosensitizer that binds in hypoxic cells. The purpose of this study was to find out the feasibility of I-131-Iodomisonidazole (IMISO) for imaging of tumor hypoxia. MATERIALS AND METHODS: Tosyl precursor was dissolved in acetonitrile and I-131-NaI was added to synthesize IMISO. Balb/c mice inoculated with CT-26 adenocarcinoma were injected with IMISO. Mice were sacrificed at 1,2,4,24 hr and % of injected dose per gram of tissue (%ID/g) was determined. For scintigraphy and MRI, mouse bearing CT-26 adenocarcinoma was administered with IMISO and imaging was performed 4 hr after. Then, mouse body was fixed and microtomized slice was placed on radiographic film for autoradiography. RESULTS: %ID/g of tumor was 1.64 (1h), 0.98 (2h), 0.85 (4h) and 0.20 (24h), respectively. At 24h, %ID/g of tumor was higher than that of all other tissues except thyroid. Tumor to muscle ratio increased with time and tumor to blood ratio also increased with time and reached 1.53 at 24 hr. On autoradiogram, tumor was well visualized as an increased activity in central hypoxic area of the tumor which corresponds to the area of high signal intensity on T2-weighted MR image. On scintigraphy, tumor uptake was visualized. CONCLUSION:: This RESULTS suggest that IMISO may have a potential for tumor hypoxia imaging in mouse model. However, further study is needed to improve it's localization in tumor tissue and to achieve acceptable images of tumor hypoxia.

CT Findings and Clinical Characteristics of Colorectal Mucinous Adenocarcinoma

PURPOSE: To establish the CT findings and clinical characteristics of colorectal mucinous adenocarcinoma. MATERIALS AND METHODS: The CT features of 26 surgically proven cases of colorectal mucinous adenocarcinoma were reviewed. The subjects were selected from among 262 patients with colorectal cancer, of whom 40 with non-mucinous adenocarcinoma were included as a control group. Contrast-enhaneed CT images were analyzed for tumor location, the presence or absence of tumoral calcification, tumor shape (circumferential or eccentric, polypoid or infiltrative), tumor thickness-to-length ratio, and attenuation and homogeneity. In each group, the TNM stage of pathologic specimens was compared. During follow-up, the incidence of recurrence, and outcome, were also compared. RESULTS: CT images of mucinous adenocarcinoma revealed intratumoral calcification in three patients (12%, p < 0.01). Tumors were eccentric and polypoid-shaped, with a high tumoral thickness/length ratio (p < 0.01). On contrast-enhanced images, most were seen as a heterogenous hypoattenvuted mass. No differences in T-NM stage were found in surgical specimens. In patients with mucinous adenocarcinoma, recurrence during the early follow-up period is more common than in patients with non-mucinous cancer. CONCLUSION: Contrast-enhanced CT reveals mucinous adenocarcinoma as an eccentric polypoid mass with heterogeneous hypoattenuation. In patients with mucinous colorectal cancer, careful follow-up is required because tumors tend to recur early in the follow-up period.

CT Findings and Clinical Characteristics of Colorectal Mucinous Adenocarcinoma

PURPOSE: To establish the CT findings and clinical characteristics of colorectal mucinous adenocarcinoma. MATERIALS AND METHODS: The CT features of 26 surgically proven cases of colorectal mucinous adenocarcinoma were reviewed. The subjects were selected from among 262 patients with colorectal cancer, of whom 40 with non-mucinous adenocarcinoma were included as a control group. Contrast-enhaneed CT images were analyzed for tumor location, the presence or absence of tumoral calcification, tumor shape (circumferential or eccentric, polypoid or infiltrative), tumor thickness-to-length ratio, and attenuation and homogeneity. In each group, the TNM stage of pathologic specimens was compared. During follow-up, the incidence of recurrence, and outcome, were also compared. RESULTS: CT images of mucinous adenocarcinoma revealed intratumoral calcification in three patients (12%, p < 0.01). Tumors were eccentric and polypoid-shaped, with a high tumoral thickness/length ratio (p < 0.01). On contrast-enhanced images, most were seen as a heterogenous hypoattenvuted mass. No differences in T-NM stage were found in surgical specimens. In patients with mucinous adenocarcinoma, recurrence during the early follow-up period is more common than in patients with non-mucinous cancer. CONCLUSION: Contrast-enhanced CT reveals mucinous adenocarcinoma as an eccentric polypoid mass with heterogeneous hypoattenuation. In patients with mucinous colorectal cancer, careful follow-up is required because tumors tend to recur early in the follow-up period.

Transcatheter Arterial Embolization for Control of Hemoptysis in Pulmonary Tuberculosis: Analysis of Prognostic Factors

PURPOSE: To evaluate the effectiveness of transcatheter arterial embolization(TAE) and the relationshipbetween therapeutic effect and prognostic factors after this procedure. MATERIALS AND METHODS: Fifty-fivepatients with hemoptysis caused by pulmonary tuberculosis(TB) underwent TAE. We reviewed medical records of thehistory and activity of pulmonary TB, and the extent of treatment, and assessed plain chest PA for the extent oflesions ; we also evaluated the angiographic findings of embolized arteries, and embolic agents. The initialsuccess rate, as shown by immediate response, and recurrence during follow-up, were then observed. Using theChi-square test, differences in these findings were analysed. RESULTS: Immediate control of hemoptysis wasachieved in 46 of 55 patients(84%); 24 of 46(52.2%), experienced recurrence. Initial failure and partial responserates were higher in patients with active pulmonary TB(p<0.05) than in those in whom the condition was inactive.The recurrence rate was higher among those who had had pulmonary TB for between one and ten years (p<0.05). Therewas, however, no significant correlation between therapeutic effect and the extent of anti-TB treatment, theextent of lesions seen on plain chest PA, angiographic findings, embolized arteries, and embolic agents. CONCLUSION: The initial success rate of TAE was 84% and the recurrence rate was as high as 52.2%. Both activityand duration of pulmonary TB were prognostic factors in immediate response and recurrence.

Clinical Review of Acute Arterial Occlusive Disease in Lower Extremities

Despite various methods of treating acute lower limb ischemia, the reported mortality continues to be in the 10% to 30% range. To evaluate the results according to etiology, location, time interval before starting treatment of acute lower extremities occlusive lesion, this study was done for 38 patients with acute arterial occlusive disease. The causes of acute lower limb occlusion were embolism (n=18, 47.4%) and thrombosis (n=20, 52.6%). The mortality rate was 11.1% (2/18) in embolism and 10% (2/20) in thrombosis. All the patients with embolic occlusion were treated by thromboembolectomy with Fogarty catheter, and thrombotic occlusive lesion were treated by intraarterial thrombolytic therapy only (n=3), followed by corrective procedure such as PTA only for short iliac arterial lesion (n=1), PTA and stent for long iliac arterial lesion (n=5), bypass operation (n=5). The amputation rate was higher (p,24 hr, 7/20, 35.0%) than in shorter duration (<24 hr, 1/18, 5.6%), and in multiple lesion (7/13, 53.7%) than single lesion (1/25, 10.0%). Even though advanced therapeutic modality for acute lower limb occlusive disease, mortality is still high, and limb salvage is dependent on various factors such as status of patients, etiology and number of lesion site, time interval before starting treatment.

Arterial Occlusive Disease of Lower Extremity: Comparison of Spiral CT Angiography with ConventionalAngiography

PURPOSE: To evaluate and compare effectiveness of single acquisition CT and conventional angiography (CA) in grading stenosis in an artery of the lower extremity . MATERIALS AND METHODS: CA and CTA were performed in 12 patients with acclusive arterial disease of the lower extremity. CA extended from the bifurcation site of the abdominal aorta to the popliteal artery, 25-30 seconds after the injection of 120-150ml contrast media by a power injector at the rate of 2.5-3ml/sec via the antecubital vein. Using SSD and MIP methods, the data was reconstructed three-dimensionally. The artery was divided into five segments and the degree of lesion was definedas normal or mild (1-49%), moderate (50-74%), or severe stenosis (75-99%), or occlusion (100%). We retrospectively evaluated and compared the effectiveness of CTA and CA in the detection of each vessel and the grading ofstenosis. RESULTS: Although 11 segments were graded by CA as occluded, only five of these were similarly graded by CTA, and the remaining six were undergraded. The ratio of consistency for grading was 88.5% (46/52) in less thanmild stenosis, and 63.6% (7/11) in moderate or severe stenosis ; if the 11 segments detected only by CTA wereexcluded, the ratio of consistency for occlusion was 100%. Overall diagnostic accuracy was 84.2% (85/101) and whenthe 11 segments were excluded, this was 88.9% (80/90). Because of the capacity of CTA to distinguish vessles with greater than 50% stenosis from those with less than mild stenosis, sensitivity of 86.0%, specificity of 93.2% and accuracy of 89.1% were recorded. If the 11 vessels detected only by CTA were excluded, sensitivity and accuracy would be 91.3% and 92.2%, respectively. CONCLUSION: For detecting and grading stenosis in an artery of the lowerextremity, single acquisition CTA is more accurate than its conventional counter part, and we believe that CTA is a useful modality in the planning and follow-up of treatment.

MR Imaging of the Denvervated Skeletal Muscles in Rabbits

PURPOSE: To determine the time of magnetic resonance(MR) signal intensity changes in denervated skeletal muscle and to compare MR imaging with electromyography(EMG) in the evaluation of peripheral nerve injury. MATERIALS AND METHODS: We evaluated MR imagings of denervated muscles after experimental transection of the sciatic nerve in five rabbits using 1.0T MR unit. MR imaging and EMG were performed 3 days and 1, 2 and 3 weeks after denervation. T1-weighted images(T1-WI), T2-WI and Short Tau Inversion Recovery(STIR) images were obtained. The signal intensity (SI) of muscles in the denervated and normal sides were visually and quantitatively compared. After measuring the SI of the normal and abnormal areas, the time of SI change was determined when there was significant difference (P<0.05) of SI between the normal and denervated sides. RESULTS: On STIR images, two of the five rabbits showed significant SI changes at the third day(P<0.05) and all showed significant changes(P<0.05)at the first week. On T2-WI, one rabbit showed significant SI changes at the third day, and all showed significant SI changes at the first week. On T1-WI, significant SI changes were seen in one rabbit at the second week and in one at the third. One week after denervation, all showed denervation potential on EMG. CONCLUSION: This study suggests that MR imaging using STIR images is a useful method in the evaluation of denervated muscle, and that MR signal changes of denervated muscle may precede EMG changes after denervation. To localize and to determine the severity of the peripheral nerve injury, future analysis of the distribution of abnormal MR SI in denervated muscles would be helpful.

Surgical Treatment of 3 cases of Takayasu Arteritis with Renovascular Hypertension

Renovascular hypertension secondary to renal artery vascular disease is the most common form of surgically correctable hypertension. The common causes of renovascular hypertension are atherosclerosis, fibromuscular dysplasia, and Takayasu arteritis. Takayasu arteritis is a chronic nonspecific arteritis of unkown cause that is relatively prevalant in young female subjects. It has been well known that the pathologic feature of the disease consist predominantly of occulsive changes in the aorta and the origin of its major branches. The most important pathogenetic mechanism of hypertension seems to be through renal artery stenosis. We have experimented three hypertensive patients with Takayasu arteritis experienced. Basic diagnosis was established by angiographic study. This article presents surgical treatment methods of Takayasu arteritis with renovascular hypertension and brief review of literatures.

Percutaneous Drainage of Abscess in the Treatment of Emphysematous Pyelonephritis

PURPOSE: To assess the usefulness of percutaneous drainage of abscess in the treatment of emphysematous pyelonephritis. MATERIALS AND METHODS: Ten cases of nine patients with emphysematous pyelonephritis were percutaneously drained. All were suffering from diabetes mellitus. The procedure was performed under fluoroscopic guidance in nine cases and US guidance in one case in which bilateral multiloculated abscesses were present in the perirenal spaces. The results were classified as cure, partial success, recurrence, or failure. The mean drainage period and complication were analyzed. RESULTS: Eight cases were cured, and there was one partial success. In one case, who had diffuse renal parenchymal destruction without perirenal fluid collection, the treatment failed. The longest drainage period was 45 days, in a case of re-insertion due to incidental catheter removal ; the mean was 23 days. Bacteremia in one case was cured with antibiotic therapy which lasted two days. CONCLUSION: In diabetic patients, percutaneous drainage of abscess is thought to be a safe and effective method for the treatment of emphysematous pyelonephritis, and is one that does not involve diffuse destruction of renal parenchyma.