Selection of patients with infrainguinal arterial occlusive disease for percutaneous transluminal angioplasty with duplex scanning.

AIM: To evaluate the role of duplex scanning in the selection of patients with infrainguinal arterial occlusive disease for percutaneous transluminal angioplasty (PTA). MATERIAL AND METHODS: From January 1995 through May 2000, 702 patients (952 limbs), with chronic lower extremity ischemia due to infrainguinal atherosclerotic disease diagnosed by duplex scanning, were retrospectively studied. Diagnostic angiography (130 limbs) or infrainguinal PTA (108 limbs) was performed in 238 limbs. Two investigators retrospectively analyzed the duplex examinations and angiographies in a blinded manner and used similar criteria for the interpretation of lesions suitable or not suitable for PTA. RESULTS: The superficial femoral, popliteal and crural artery lesions were correctly selected for PTA in 85%, 66% and 32%, respectively. The accuracy, sensitivity, specificity, negative predictive value and positive predictive value of duplex scanning to appropriately categorize femoropopliteal lesions as suitable or unsuitable for PTA were 89%, 83%, 92%, 94% and 78%, respectively. The accuracy of duplex scanning for predicting the performance of infrainguinal PTA was 83%. CONCLUSION: Duplex scanning has an important impact on the selection of treatment modalities in limbs with infrainguinal arterial occlusive disease. Femoropopliteal lesions can be reliably selected to PTA according to duplex scan findings.

Distal percutaneous transluminal angioplasty through infrainguinal bypass grafts.

AIM: to evaluate the results of transluminal angioplasty (PTA) performed through infrainguinal bypass grafts for stenotic or occlusive lesions at the distal anastomosis and/or in the runoff arteries. DESIGN: retrospective clinical study. MATERIAL AND METHODS: forty-one patients underwent 57 procedures at the distal anastomosis (n=13), in the runoff arteries (n=32) or at both locations (n=12) at a median of 9.6 months (range, 2-76 months) after infrainguinal bypass grafting. Nineteen procedures were on the popliteal artery, the rest on the crural arteries. Eleven procedures related to occlusions less than 5 cm in length. RESULTS: technical success was achieved in 91%. Primary and primary assisted graft patency rates at 3 years were 32% and 53%, respectively. There were no significant differences in patency rates with regard to the graft material, the type of lesion, the level of PTA, the status of runoff and the use of thrombolysis before PTA. No patients underwent amputation as a direct consequence of failed PTA or graft occlusion. One patient underwent acute surgical intervention due to graft occlusion at the time of attempted PTA. CONCLUSION: the results of PTA at the distal anastomosis and/or in the runoff arteries in limbs with infrainguinal bypass seemed to be inferior to the results of surgical revisions reported in literature. However, as failed PTA did not jeopardise vein-patch angioplasty or jump grafting, it is a reasonable alternative to surgical intervention in selected cases.

Percutaneous transluminal angioplasty of the femoropopliteal arteries in limbs with chronic critical lower limb ischemia.

PURPOSE: The aim of the study was to evaluate the results of percutaneous transluminal angioplasty (PTA) of femoropopliteal arteries in patients with subcritical or critical lower limb ischemia. MATERIALS AND METHODS: Ninety-two patients underwent 121 PTA procedures, 68 were of the superficial femoral artery (SFA), 13 of the popliteal and 40 of both arteries. Fifty-seven procedures were performed for treatment of occlusions. Eighty-four patients (94 procedures) were monitored with duplex scanning. RESULTS: Technical success rate was 88%. Primary success rates at 12 and 60 months in the whole series were 40% and 27%, respectively. The primary success rate in limbs with SFA occlusion of longer than 5 cm was only 12% after 5 years compared with 32% if the occlusion was

Selection of patients with lower limb arterial occlusive disease for endovascular treatment of the iliac arteries with duplex scanning.

The aim of this study was to evaluate the role of duplex scanning in selection of patients with lower limb arterial occlusive disease for endovascular treatment of the iliac arteries. From January 1995 through May 2000, 183 patients having chronic lower limb arterial insufficiency who underwent duplex scanning of the lower extremity arteries with available aortoiliac scans within 3 months before conventional aortoiliac diagnostic angiography and/or endovascular intervention of the iliac arteries were studied retrospectively. The findings obtained from duplex scanning and angiography were analyzed in a blinded manner by 2 investigators. Limbs having category 1, 2, and 3 lesions according to duplex scan findings were interpreted as being suitable for endovascular intervention. The comparison between duplex scan findings and angiography was analyzed by the third investigator. During 93 percutaneous transluminal angioplasty (PTA) procedures, 133 arterial segments, common or external iliac, were dilated with stent placement in 70. Bilateral interventions were performed in 25 cases, and of 68 unilateral interventions, 57 were at only 1 arterial segment. The accuracy, sensitivity, specificity, and negative and positive predictive values of duplex scanning to appropriately categorize the iliac artery lesions into suitable or unsuitable for endovascular intervention were 90%, 95%, 83%, 90%, and 92%, respectively when the inconclusive duplex scans were excluded (11%). In 6 patients with lesions suitable for PTA according to duplex scanning and angiography, PTA was not performed owing to clinical reasons. The accuracy of duplex scanning in predicting the performance of endovascular intervention was 88%. It is concluded that iliac artery endovascular procedures in limbs with chronic occlusive disease can be reliably planned according to duplex scan findings.

The role of duplex scanning in the selection of patients with critical lower-limb ischemia for infrainguinal percutaneous transluminal angioplasty.

PURPOSE: To investigate the role of duplex scanning in the selection of patients with critical lower-limb ischemia (CLI) for infrainguinal percutaneous transluminal angioplasty (PTA). METHODS: One hundred and sixty-two limbs with CLI (150 patients) that underwent duplex scanning within 3 months prior to conventional diagnostic angiography (n = 88) or infrainguinal PTA (n = 74) were retrospectively studied. The findings obtained from duplex scanning and angiography were analyzed in a masked fashion by two different investigators. RESULTS: The accuracy, sensitivity, specificity, and negative and positive predictive values of duplex scanning in the selection of patients for infrainguinal PTA were 86%, 84%, 89%, 86%, and 87% respectively. Forty-two procedures (57%) were performed at multiple arterial segments. The accuracy of duplex scanning in the selection of femoropopliteal and crural lesions for PTA was over 85%. However, the sensitivity of duplex scanning in the selection of popliteal and crural lesions for PTA was 49% and 38% respectively, compared with 80% for superior femoral artery lesions. In 39% of patients who were correctly selected for PTA, duplex scanning misdiagnosed one of the multiple lesions treated by PTA. CONCLUSION: Duplex scanning can safely be used for the selection of patients for infrainguinal PTA. The sensitivity of duplex scanning in the selection of lesions for PTA was less satisfactory in the popliteal and crural arteries compared with the femoropopliteal arteries.

Gadolinium-enhanced magnetic resonance angiography, digital subtraction angiography and duplex of the iliac arteries compared with intra-arterial pressure gradient measurements.

PURPOSE: to compare gadolinium-enhanced magnetic resonance angiography (Gd-MRA), digital subtraction angiography (DSA) and duplex of the iliac arteries with intra-arterial pressure gradient measurement as the reference method. MATERIALS AND METHODS: Gd-MRA, DSA and duplex examinations of the iliac arteries were performed in 30 patients (60 arteries) with lower-limb arterial occlusive disease. In 29 arteries, pressure measurements were made (n=25) or the artery was found to be occluded on catheterisation (n=4). An aortofemoral peak systolic pressure gradient of 20 mmHg or more was regarded as haemodynamically significant. Stenoses with a diameter reduction of 50% or more on MRA or DSA, or an increase in peak systolic velocity greater than 150% (duplex) were considered significant. MRA examinations were evaluated by means of maximum intensity projections (MRA-MIP) and using source images and curved multiplanar reconstruction (MRA-MPR). RESULTS: the sensitivity (specificity) for a significant iliac artery stenosis were 81% (75%) for MRA-MIP, 76% (75%) for MRA-MPR, 86% (88%) for DSA, and 72% (88%) for duplex. CONCLUSION: with intra-arterial pressure measurements as the reference method, similar results were achieved with Gd-MRA, DSA and duplex concerning the detection of haemodynamically significant iliac artery stenoses. The use of source images and multiplanar reconstructions resulted in higher accuracy for the detection of occlusions.

Intraarterial chemoembolisation with lipiodol and epirubicin in hepatocellular cancer--improved survival in some patients?

BACKGROUND AND AIMS: Arterial chemoembolisation with lipiodol and a cytotoxic drug is reported to give equivocal results in irresectable primary hepatocellular cancer (HCC). In order to further elucidate the possible response to this treatment, we analysed the results of all patients with irresectable HCC treated with chemoembolisation at our hospital. MATERIAL AND METHODS: 58 consecutive patients with HCC were treated with lipiodolepirubicin chemoembolisation between February 1988 - October 1994 and followed until death or October 1998. RESULTS: The average survival was 11.7 months and median survival was 6 months. 17 patients had only one treatment mostly due to death within 6 weeks after the first treatment. Patients with an open portal system at inclusion (50% of all) were found to have significantly increased survival after 6 and 12 months compared to those with portal obstruction. The subgroup of patients displaying a decrease in tumour size as judged by repeated CT scan 6 months after inclusion had significantly increased survival; all survived more than 12 months (median survival 30 months). CONCLUSIONS: Chemoembolisation with lipiodol-epirubicin may have an impact on survival on selected patients with irresectable hepatocellular cancer. The treatment may justifiably be offered patients with an open portal venous system and without liver failure.

Liver embolizations of patients with malignant neuroendocrine gastrointestinal tumors.

BACKGROUND: Patients with neuroendocrine gastrointestinal tumors usually present with inoperable metastatic disease and severe hormonal symptoms. Specific chemotherapy, interferon-alpha (IFN), and somatostatin analogs are established therapies for these patients, but all of them eventually fail. Hepatic arterial embolization can provide reduction of both hormonal symptoms and tumor burden in these patients. METHODS: Between 1981 and 1995, a total of 55 liver embolizations with gel foam powder were performed on 41 patients with histopathologically verified neuroendocrine tumors; 29 had carcinoid tumors and 12 had endocrine pancreatic tumors (EPTs). All patients had received medical treatment, including chemotherapy (n = 18), IFN (n = 31), and octreotide (n = 19), and were experiencing treatment failure when liver embolization was performed at a median of 37 months after diagnosis of liver metastases. Medical treatment was continued after embolization. RESULTS: An overall objective response was noted in 15 of 29 patients with carcinoid tumors (52%). The median duration of effect was 12 months in patients with midgut carcinoid tumors. An overall objective response was observed in 6 of 12 patients with EPTs (50%), with a median duration of effect of 10 months. Adverse events were observed, and, in agreement with earlier reports, the rate of serious complications was 10%. Survival analyses showed a median survival of 80 months and a 5-year survival rate of 60% from the performance of embolization on patients with midgut carcinoid tumors, whereas for patients with EPTs the median survival from embolization was only 20 months. CONCLUSIONS: Liver embolizations performed relatively late in the clinical course in our series appeared to be as effective as "early" embolizations in other series of patients with carcinoid tumors. The results for those with EPTs were poorer, and earlier embolizations may result in better outcomes for these patients. Considering the morbidity associated with the procedure, it is imperative to select patients according to extent of liver involvement, severity of carcinoid heart disease, and somatostatin receptor status.

Magnetic resonance angiography in the resectability assessment of suspected pancreatic tumours.

The aim of this prospective study was to evaluate MRI, including MR angiography (MRA), in the preoperative assessment of the resectability of suspected malignancy of the pancreas. A total of 17 patients with suspected pancreatic carcinoma and planned surgery were investigated with conventional angiography, ultrasonography with Doppler technique, MRI and MRA. The MRA protocol included both 2D inflow angiography and 3D phase-contrast angiography. Surgery was carried out in 13 patients. The image quality of MRA was judged satisfactory in all cases. The findings with respect to vascular involvement agreed between the radiological methods in all but 3 cases. When the findings were correlated with the final diagnosis, one false-negative case was found for each of the three methods. The results suggest that MRI with MRA, including both the phase-contrast and inflow techniques, has a similar diagnostic value to that of conventional angiography and ultrasonography in the preoperative assessment of the portal venous system in patients with pancreatic carcinoma. Further studies are needed to establish the optimal diagnostic procedure.

Value of duplex scanning in evaluation of crural and foot arteries in limbs with severe lower limb ischaemia--a prospective comparison with angiography.

OBJECTIVES: To compare Duplex scanning with angiography for evaluation of crural and pedal arteries in limbs with lower limb ischaemia. DESIGN: The findings obtained during Duplex scanning and angiography were prospectively compared in a blinded manner. SETTING: Departments of Surgery, Diagnostic Radiology and Clinical Physiology, University Hospital. MATERIALS: Duplex scanning and selective angiography of femoropopliteal, crural and foot arteries were performed in 40 limbs (38 patients, 480 segments) with intermittent claudication (n = 6), rest pain (n = 13) and ulcer/gangrene (n = 19). Each arterial segment were graded into four categories: normal, < or = 50% diameter reduction, > 50% diameter reduction and occlusion. Pedal arteries were evaluated as patency or occlusion of dorsal pedal artery and plantar arch. CHIEF OUTCOME MEASURES: Accuracy (AC), sensitivity (SE), specificity (SP), positive predictive (PPV), negative predictive (NPV) and kappa values. MAIN RESULTS: The Duplex scanning of the tibioperoneal trunk, crural and pedal arteries had an accuracy of 80% (kappa = 0.6). The SE, SP, PPV and NPV values were 83%, 77%, 79% and 81%, respectively. The SP was relatively low for the peroneal artery (58%) compared to the others. CONCLUSIONS: The results demonstrate the feasibility and reliability of Duplex scanning in detecting crural and pedal artery lesions in lower limbs with severe ischaemia.

The use of below-knee percutaneous transluminal angioplasty in arterial occlusive disease causing chronic critical limb ischemia.

PURPOSE: To determine the efficacy, safety and long-term results of crural artery percutaneous transluminal angioplasty (PTA) in limbs with chronic critical limb ischemia (CLI). METHODS: Patients undergoing crural artery PTA due to CLI were followed at regular clinic visits with ankle brachial pressure index (ABPI) measurements. PTA of the crural arteries was attempted either alone (n = 39) or in combination with PTA of the superficial and/or popliteal artery (n = 55) in 86 limbs (82 patients and 94 procedures) presenting with CLI. The ages of patients ranged from 37 to 94 years (mean 72 years). The indications for PTA were rest pain in 10 and ulcer/gangrene in 84 limbs. RESULTS: A technically successful PTA with at least one crural level was achieved in 88% of cases (n = 83). Cumulative primary clinical success rates at 6, 12, 24, and 36 months were 55%, 51%, 36%, and 36%, respectively. Cumulative secondary clinical success and limb salvage rates at 36 months were 44% and 72%, respectively. CONCLUSION: PTA of the crural arteries might be considered the primary choice of treatment in patients with CLI and distal lesions with localized stenosis or segmental short occlusions.

Duplex ultrasound scanning for diagnosis of aortoiliac and femoropopliteal arterial disease.

Forty patients with symptomatic aortoiliac and/or femoropopliteal occlusive arterial disease subjected to angiography were studied with duplex ultrasonography. The duplex scanning of the aortic, iliac, femoral and popliteal segments had a sensitivity of 93% in detecting significant stenoses and a specificity of 91%. The positive and negative predictive values were 75% and 98%, respectively. The sensitivity was relatively low in low-flow segments distal to total occlusions especially in patients with severe iliac disease and multiple distal femoropopliteal lesions. The results demonstrate the reliability of duplex scanning in detecting aortoiliac and femoropopliteal lesions.

Ultrasound monitored laser-induced local hyperthermia in the liver. An experimental study on pigs.

Ultrasound (US) was used to monitor the size of tissue necrosis generated by Nd-YAG laser-induced local interstitial hyperthermia and tissue coagulation in 8 normal pig livers. Four treatments were done in each liver with 4 different energy settings. The size of the tissue necrosis measured on specimens was compared to the size measured on US. The laser energy caused a round tissue necrosis with some charring in the centre surrounded by a zone of white necrosis and a thin border of hyperaemia. A good correlation was found between the true and US-measured size of the necrosis diameters. It therefore seems possible to safely guide and monitor local laser hyperthermia in the liver with real-time US. The water-cooled quartz fibre used in this study has, however, some limitations.

Embolization of spinal metastases reduces peroperative blood loss. 21 patients operated on for renal cell carcinoma.

We evaluated the peroperative blood loss in 21 patients who were treated with 29 operative procedures for thoracolumbar spinal renal cell carcinoma metastases. Embolization was undertaken prior to 11 operations. At posterior surgery the average blood loss was one third after embolization compared with when embolization had not been performed. The blood loss was also lower during anterior surgery, although this difference was smaller. We recommend that preoperative embolization should precede surgical treatment of spinal metastases of renal cell carcinoma where it can be anticipated that the operation will extend into the pathological tissue.

The Swedish experience with Salter's innominate osteotomy in the treatment of congenital subluxation and dislocation of the hip.

The results of 83 Salter's innominate osteotomies (i.o.) performed to correct congenital subluxation and dislocation of the hip joint in 76 patients were reviewed. The overall radiographic results were classified as excellent or good in 34 hips (41%) and as fair or failure in 49 hips (59%). The best results were obtained in subluxated hips, previously not treated or treated only with closed reduction, prior to i.o. in patients operated on before the age of 5 years. In that group of hips, excellent or good results were obtained in 18 of 20 hips (90%). The poorest results were obtained in hips with residual subluxation or dislocation after previous operation with a result of fair or failure obtained in 26 of 28 hips (93%).