Percutaneous transluminal angioplasty of abdominal aortic stenoses.

Percutaneous transluminal angioplasty (PTA) was performed on 25 patients with localized distal abdominal aortic stenoses. All patients were smokers and all complained of bilateral lower limb claudication. Eleven patients had small distal aortas and iliac vessels. Technically successful dilatation was achieved in all patients. Long-term follow-up was available on 17 of the patients. The mean follow-up period was 38 months. Cumulative patency at 5 years was 70%. Thirteen patients remain asymptomatic 15-83 months following PTA. Late failure occurred in 4 patients, 1-38 months following PTA. No complications related to PTA were experienced. PTA of localized aortic stenoses is a safe alternative to surgery and should be the treatment of choice in this condition.

Hepatic venography in the surgical assessment of hepatic tumours.

Hepatic venography was performed on 80 patients with hepatic tumours for the pre-operative assessment of resectability. Sixty-six patients subsequently underwent laparotomy, 27 undergoing hepatic resection. Forty-two patients had metastases from colo-rectal primaries, 19 hepatocellular carcinoma and 19 a variety of other tumours. The type and frequency of the abnormalities shown on venography were noted for each tumour category and for their hepatic segmental distribution. The results of venography were compared with those of arteriography, computed tomography and ultrasound and with the findings at laparotomy. Displacement was the commonest abnormality seen while encasement or obstruction occurred less frequently and tumour invasion was rare. The sensitivity of venography in correctly identifying the segmental distribution of tumour deposits was 41%. Sensitivity was poorest with tumours in the left lobe (31%) and bilobar tumours (0%). Venography was most sensitive in detecting tumour involvement of the major segmental hepatic veins and inferior vena cava (100%). Peripheral colo-rectal metastases frequently produced no venographic abnormality. Hepatic venography provides no additional information to arteriography, computed tomography or ultrasound in patients with peripheral or bilobar tumour deposits. Some additional information may be obtained with central tumours and venography is the most accurate means of detecting tumour involvement of the major segmental hepatic veins.

Intestinal angina: percutaneous transluminal angioplasty of the celiac and superior mesenteric arteries.

Percutaneous transluminal angioplasty (PTA) was performed in ten patients with chronic ischemia of the mesenteric arteries and stenoses of the celiac artery and/or the superior mesenteric artery (SMA). PTA was performed on 14 occasions, with attempted dilation of 19 arteries. PTA was technically unsuccessful in two patients. Seventeen of 19 arteries (90%) were successfully dilated in eight patients, resulting in relief of symptoms that lasted from 6 to 24 months. Symptoms recurred in five patients, and redilation in three of them relieved the symptoms. Three patients, one of them following redilation, remained asymptomatic 7-9 months following PTA. An asymptomatic intimal dissection of the SMA was the only complication attributable to the procedure. PTA of celiac and SMA stenoses is an alternative to surgical revascularization and can be repeated if symptoms recur.

Femoral artery compression device for outpatient angiography.

To avoid late bleeding from the femoral artery puncture site after outpatient femoral angiography, a compression device was designed to exert continuous pressure over the groin, even when the patient is upright. It has been successfully used in more than 2,000 arterial catheter procedures. The device can also help prevent bleeding in patients who are at increased risk because of hypertension or anticoagulant therapy.

5-year results of a prospective study of percutaneous transluminal angioplasty.

This paper presents the results of a prospective study of percutaneous transluminal angioplasty (PTA) for the treatment of patients with peripheral arterial occlusive disease and identifies the variables that are predictive of long-term success. The variables believed to be important prognostically were recorded for 984 consecutive PTAs performed between July 1978 and July 1986. Success or failure was defined using a combination of clinical and objective vascular laboratory criteria. The overall long-term success was estimated by the Kaplan-Meier method and differences between curves of success rate versus time for each variable were determined by the Wilcoxon and log-rank statistics. The combination of variables associated with success were determined by the Cox proportional hazards regression model. For all cases, the initial success rate was 88.6 +/- 1.0% and at 5 years was 48.2 +/- 2.3%. The following variables, when considered individually, were associated with success (p less than 0.05): indication for PTA, site of PTA, severity of lesion, runoff, number of sites dilated, diabetes, and the occurrence of a complication. From the Cox model, by using a stepwise multiple regression procedure, the following combination of variables were found to be predictive of success (p less than 0.05): (1) indication (claudication vs. salvage), (2) site (common iliac vs. other), (3) severity of lesion (stenosis vs. occlusion), and (4) runoff (good vs. poor). For all combinations of these four significant variables, curves of the success rate versus time were calculated. In conclusion, this study has identified the combination of four variables that together predict if PTA is likely to be successful in the management of a patient with peripheral arterial occlusive disease.

Transjugular intrahepatic portosystemic shunt: a nonoperative approach to life-threatening variceal bleeding.

Portosystemic venous shunts may be created nonoperatively with a Grüntzig balloon dilatation catheter using the transjugular route. The authors achieved technical success with this shunt in 15 of 20 patients with life-threatening gastrointestinal bleeding from variceal hemorrhage. All patients but one were considered at high risk for surgery because of end-stage liver disease; the exception was a patient in whom two previous operative portosystemic shunts had failed. An average decrease of 5.9 mm Hg in portal vein pressure was measured in 11 patients for whom sequential pressures could be obtained. Two patients survived longer than 12 months without subsequent operative procedures, and the shunt helped temporize in three other patients who later underwent operation. Nine patients with successful shunts died within 30 days of the procedure, comparing favourably with reported operative death rates of 40% to 80% in emergency shunt procedures. Follow-up portal venograms demonstrated shunt patency in six of nine patients, in one after 8 months. Tract patency was determined in four of seven patients on whom autopsy was performed, up to 6 months after the transjugular intrahepatic portosystemic shunt was created.

Transluminal angioplasty of complete iliac obstructions.

Of 64 complete iliac obstructions, 50 (78%) were recanalized using the Gruntzig balloon catheter. Life-table analysis of the patency rate over a 4-year period gives a cumulative success rate of 78%. Only three of eight obstructions that involved both the common and external iliac arteries were successfully dilated. The only serious complication was distal embolization, which occurred in two cases (3.1%). Although the procedure is difficult, with a relatively low technical success rate, the high cumulative patency rate should make it an option in the treatment of all patients with totally occluded iliac artery segments.

Transjugular liver biopsy: a review of 461 biopsies.

Transjugular liver biopsy was performed in a large series of patients for whom routine percutaneous biopsy was contraindicated; most of the patients had severe liver disease associated with coagulopathies or massive ascites. Of the 461 biopsies performed over a 7-year period, adequate specimens for histologic diagnosis were obtained in 425; in 14 (3.3%), the biopsy provided a false-negative result. Minor complications such as neck pain, hematoma at the puncture site, or pyrexia occurred in 79 patients (17.1%). Serious complications were encountered in six patients (1.3%) (two with cardiac arrhythmias; four with intraperitoneal hemorrhage following capsular perforation), with an overall mortality rate for the series of 0.22%. Modification of the technique--taking the biopsy with the catheter positioned centrally rather than wedged peripherally--has reduced the occurrence of capsular perforation without affecting the success rate. Transjugular liver biopsy is a valuable technique that provides diagnostic information in a high proportion of cases in which conventional percutaneous biopsy is contraindicated.

Transjugular biopsy of the liver.

Percutaneous liver biopsy is the procedure of choice for most patients because of its simplicity and the high percentage of adequate biopsies obtained. It is a bedside procedure that does not require specialized equipment or the services of a highly trained angiographer. Nevertheless, complications are not uncommon unless strict contraindications are observed. It is usually recommended that patients be excluded who present with ascites, a prothrombin time less than 50%, a partial thromboplastin time greater than 10 s, or a platelet count less than 50 000. Mahal et al (1979) cite lack of attention to the contraindications as the most important factor in 22 bleeding episodes which occurred following 3800 percutaneous biopsies (0.7%). It is these contraindications that are the main indication for transjugular biopsy. Despite the highly selective nature of the patients who have undergone transjugular biopsy, the frequency of post-biopsy bleeding is only 0.35% and of death 0.13% (Table 1). These figures include the earliest experiences with this technique and can be expected to improve with increased experience and the development of new instruments that make the procedure safer and easier. Transjugular liver biopsy should be an essential procedure in every hospital that is involved in treating patients with liver disease. Unfortunately, although Lebrec et al (1982) estimated that approximately 30% of patients are rejected for percutaneous biopsy because of the presence of contraindications, relatively few centres have adopted this technique. This may be in part due to the reluctance of clinicians to subject their patients to a procedure they perceive as stressful, although a study by Poynard and Lebrec (1982) showed patients rated transjugular biopsy as less painful and inconvenient than percutaneous biopsy.

Results and hemodynamic changes after interposition mesocaval shunt.

Forty-seven patients have been treated by interposition mesocaval shunting for portal hypertension and variceal bleeding between December 1973 and March 1980. The average age was 55 years. The underlying diseases were alcoholic cirrhosis in 26 patients (56%), macronodular cirrhosis in 11 patients (23%), and other causes in 10 patients (21%). Thirty-five operations (75%) were performed on an emergency basis for patients who continued to bleed after failure of conservative management. In these patients, the early mortality rate was 43%. Overall survival, rebleeding, and postshunt encephalopathy rates are correlated with the preoperative Child's classification. These figures are similar to those reported for end-to-side portocaval shunts. The improvement in postshunt encephalopathy rates as reported by Drapanas is not borne out by our results. Postshunt angiography was performed in 31 patients and shunt patency was confirmed in 28 (90%). In 26 patients, selective studies to determine portal flow patterns were carried out, and in only three patients was there any evidence of hepatopedal flow. In each of these patients, some kinking of the shunt was noted. Mesocaval shunting is a reasonable alternative to end-to-side portocaval shunts and is associated with similar rates of patency, rebleeding, mortality, and late postoperative encephalopathy. A well-constructed, patent mesocaval shunt totally diverts portal flow.

Liver biopsy through the transjugular approach. Modification of instruments.

Two modifications of the needle to facilitate transjugular biopsy of the liver are described. The bevel is reversed to prevent perforation of the catheter by the needle, and a stylet is placed within the needle to prevent aspiration of fragmented specimens into the syringe.

Formation of intrahepatic portosystemic shunts using a balloon dilatation catheter: preliminary clinical experience.

Six patients with advanced cirrhosis and portal hypertension had life-threatening upper gastrointestinal hemorrhage from esophageal varices. The varices were obliterated angiographically, using the transjugular approach, after which an intrahepatic portosystemic shunt was created in each case by inflating the balloon of a Grüntzig dilatation catheter in the needle tract between the portal and hepatic veins. All of the patients were expected to succumb quickly to their severe liver disease and massive variceal bleeding, but three of the six survived the initial hemorrhage, and two of these were discharged from hospital. There was an initial reduction of portal venous pressure of 10-15 mm Hg in all patients. All six shunts were patent angiographically 12 hr after the procedure. Two patients had venograms 5 days later and both shunts were patent. All six patients died within 6 months, but in three of the four postmortem examinations the shunts were easily identified and shown to be patent, the last of these 6 weeks after the procedure. These findings suggest that the technique could be of therapeutic value in the management of patients with portal hypertension.

Transluminal dilation. An alternative?

In a prospective study, 384 peripheral arterial transluminal dilations were evaluated, using clinical and vascular laboratory criteria, and analyzed by the life-table method. The overall cumulative success rate was 58.9 +/- 3.3% (mean +/- SEM) after two years but was higher if the iliac segment was dilated, only one site was dilated, the clinical indication was claudication, the distal vessels were normal, the ankle-brachial BP ratio was more than 0.35, or if the patient was younger than 55 years. The complication rate was 3.9%. If the dilation failed, the symptoms were worse in 8% and the ankle-brachial BP ratio fell in 23%. After successful dilation in patients with normal distal vessels, residual claudication persisted in 34%, and the ankle-brachial BP ratio remained abnormal in 40%. Although the overall success rate of transluminal dilation was lower than for a comparable surgical procedure, dilation does have a role in the management of localized peripheral vascular disease.

Percutaneous transluminal dilatation of the renal artery: follow-up studies on renovascular hypertension.

Percutaneous transluminal dilatation of 80 renal artery stenoses was attempted in 68 patients. The procedure was technically successful in 58 (85%) patients. Fifty (86%) of the 58 patients were initially cured or improved. Life-table analysis of this group gives a cumulative success rate of 81% for a 3 year period. Hypertension recurred in only seven patients. There were no deaths related to the procedure, but four major complications occurred, including two secondary nephrectomies.

Peripheral arterial transluminal dilatation: early results.

Over a 3-year period, 275 transluminal dilatations were performed for the treatment of peripheral arterial occlusive disease. The results have been evaluated prospectively using radiologic, clinical and noninvasive criteria. The cumulative success rates for all dilatations were 63 +/- 4% (mean +/- 1 standard error) at 1 year and 53 +/- 5% at 2 years, but varied depending upon the site of the dilatation and the extent of the arteriosclerosis. The results are best in patients who have short, localized stenoses or occlusions, especially in the iliac arteries.

Transluminal dilatation in the management of mesenteric angina: a report of two cases.

Two patients with typical clinical and angiographic findings of mesenteric angina are reported. Both remain asymptomatic seven and 11 months respectively, after transluminal dilatation of superior mesenteric artery stenoses.

Difficulty in assessing the severity of aorto-iliac disease by clinical and arteriographic methods.

Accurate hemodynamic assessment of the severity of aorto-iliac disease has important implications in the management of patients with symptomatic peripheral arterial occlusive disease. This study has documented that history, clinical examination, and single-plane angiography are often unsatisfactory for assessing the hemodynamic significance of an aorto-iliac lesion. The use of oblique angiographic views, certain noninvasive methods, such as quantitative Doppler waveform analysis, and direct pressure measurements will be of benefit in difficult cases and lead to a more accurate diagnosis.

Percutaneous transluminal recanalization of complete iliac artery occlusions.

Percutaneous transluminal recanalization of ten complete iliac artery occlusions were attempted using the Grüntzig balloon catheter. The procedure was successful in eight of the ten occlusions, including all seven in which only one of the common or external iliac arteries was obstructed. Follow-up for periods of three to 13 months (average, eight months) showed continued patency in all cases. Although the long-term results remain to be determined, our preliminary results suggest that transluminal recanalization of complete obstruction of the iliac arteries is an alternative to surgery.