Treatment of fibromuscular dysplasia and renal artery aneurysm with use of a stent-graft.

A Jostent stent-graft was placed in a renal artery with a focal stenosis and an associated aneurysm in a young patient with fibromuscular dysplasia. Arteriographic follow-up at 16 months showed that the stent-graft remained patent and the aneurysm was excluded.

Cost-effectiveness of percutaneous treatment of iliac artery occlusive disease in the United States.

OBJECTIVE: The costs of percutaneous transluminal angioplasty and stent placement for iliac artery occlusive disease in the United States were assessed and the cost-effectiveness was evaluated. MATERIALS AND METHODS: Lifetime costs and quality-adjusted life expectancy were estimated using a Markov decision model for a hypothetic cohort of patients with life-style-limiting claudication caused by an iliac artery stenosis for whom a percutaneous intervention was indicated. Various percutaneous treatment strategies were evaluated, each consisting of an initial intervention followed by a secondary intervention. Procedures considered were angioplasty alone and angioplasty with selective stent placement. RESULTS: From the perspective of the interventional radiology department, angioplasty with selective stent placement costs more than angioplasty alone ($2926 versus $2106). Taking into account follow-up costs and procedures for long-term failures, the cost differential was reduced because of a lower failure rate of selective stent placement ($13,158 versus $12,458, respectively). Treatment strategies using angioplasty with selective stent placement (as an initial procedure or including reintervention) dominated treatment strategies using angioplasty alone (incremental cost-effectiveness ratio was $7,624-8,519 per quality-adjusted life-year gained). CONCLUSION: Angioplasty with selective stent placement is a cost-effective treatment strategy compared with angioplasty alone in the treatment of intermittent claudication in the United States.

Frequency of pulmonary embolism in patients with low-probability lung scan and negative lower extremity venous ultrasound.

STUDY OBJECTIVES: To define the prevalence of pulmonary embolism (PE) in patients who are undergoing pulmonary arteriography because of a high clinical suspicion for PE but who have had a low-probability lung scan and a negative lower extremity venous ultrasound examination. DESIGN: A retrospective review of the medical records of 365 consecutive patients who underwent pulmonary arteriograms for suspected PE was undertaken. RESULTS: Of the 365 pulmonary arteriograms, 62 were performed in patients with suspected PEs despite a low-probability lung scan and a negative lower extremity venous ultrasound examination. In the latter group, five patients (8%; 95% confidence interval, 2.7% to 18%) had PEs revealed on the arteriogram. CONCLUSIONS: In patients whose presentation provokes a high clinical suspicion for PE despite having had a low-probability lung scan, a negative lower extremity venous ultrasound examination is insufficient to preclude proceeding to pulmonary angiography.

Comparative efficacy of pulse-spray thrombolysis and angioplasty versus surgical salvage procedures for treatment of recurrent occlusion of PTFE dialysis access grafts.

PURPOSE: To compare the efficacy of surgery versus pulse-spray thrombolysis and angioplasty in patients with recurrent thrombosis of polytetrafluoroethylene (PTFE) dialysis access grafts. METHODS: We analyzed 96 consecutive interventions for thrombosed PTFE dialysis access grafts in 18 patients. Primary patency after thrombolysis and angioplasty (n = 25) was compared with primary patency following thrombectomy alone (n = 50) or thrombectomy followed by graft revision (n = 21) using life-table analysis. A Cox proportional hazards model that accounted for graft age and number of previous interventions was used to generate the relative risk for recurrent occlusion following therapy. RESULTS: Life-table analysis showed that patency after thrombolysis and angioplasty was greater than that following thrombectomy alone (p = 0.02). After accounting for the age of the graft and the number of previous interventions (average six per patient), the relative risk for recurrent occlusion [3.0; 95% confidence intervals (CI): 1.5, 6.4] was greater for thrombectomy alone than for thrombolysis/angioplasty [0.6; CI = 0.3, 1.3]. The relative risks of repeat occlusion following thrombolysis/angioplasty [0.6; CI = 0.3, 1.3] and thrombectomy/surgical revision [1.0; CI = 0.5, 1.7] were similar. CONCLUSION: Outcome data from our retrospective study on recurrent thrombosis of PTFE dialysis access grafts suggest that thrombolysis/angioplasty is superior to thrombectomy alone, and equivalent to thrombectomy/surgical revision.

Percutaneous venous interventions.

Percutaneous procedures by interventional radiologists are becoming an increasingly frequent part of the overall care of patients with complex venous thrombotic diseases. Inferior vena caval filters are used in the setting of failed or contraindicated anticoagulation. Catheter-directed thrombolysis is considered for patients with extensive iliofemoral deep venous thrombosis. Venous angioplasty is often indicated for patients with dialysis shunt venous stenoses, upper extremity venous stenoses and for stenoses within venous bypass grafts. Venous stenting is often employed following angioplasty to ensure long-term procedural success. Finally, suction and mechanical thrombectomy and embolectomy are relatively new procedures that are available to optimize patient management.

Pulmonary embolism: comparison of cut-film and digital pulmonary angiography.

PURPOSE: To compare "cut-film" (film hard-copy) angiography (CFA) with digital pulmonary angiography in the detection of pulmonary embolism (PE). MATERIALS AND METHODS: Thirty-six adult patients (39 lungs) underwent selective digital pulmonary angiography for suspected PE. Imaging was repeated in one selected projection by using cut film. The standard was consensus interpretation of both CFA and digital angiographic images and clinical course. Three vascular radiologists subsequently reviewed the digital and cut-film images in a blinded fashion and ranked the likelihood of the presence of PE on a five-point scale. The two modalities were compared by means of receiver operating characteristic (ROC) analysis. Image quality (i.e., sharpness, opacification of subsegmental vessels, and exposure) was judged on a three-point scale. The highest-order pulmonary artery branch seen on each study was recorded. RESULTS: ROC curve analyses for all three operators showed similar diagnostic performance for digital pulmonary angiography and CFA, with one operator showing better performance with digital subtraction angiography than with CFA (P = .04). Compared with the final diagnosis, single-plane digital pulmonary angiography had higher sensitivity for the detection of PE than had CFA. The specificity was 100% for both modalities. The mean score in patients with findings positive for PE was higher in the digital pulmonary angiography group than in the CFA group (P < .005). There was no difference in the mean score in patients who did not have a PE. There also was no difference in the smallest detectable subsegmental branch (P = .87) or in the average estimate of image quality. CONCLUSION: Selective digital pulmonary angiography and CFA offer similar diagnostic performance and image quality. Digital pulmonary angiography is a reasonable alternative to CFA in the diagnosis of PE.

Removal of the protruding retention wire via a femoral approach while leaving the active-fixation atrial "J" lead in situ: a technique for the management of class III atrial "J" leads.

The Telectronics Accufix Atrial "J" pacing lead poses a mechanical risk to patients of retention wire fracture and protrusion. Standard lead extraction techniques include percutaneous approaches, which are associated with significant risk of morbidity and mortality, and open procedures, which necessitate thoracotomy. In nine patients referred with Class III retention wire fractures, attempts were made to snare the protruding retention wire from a femoral approach using snare devices and bioptomes. In six cases, the retention wire was successfully removed, leaving the lead body in place. In four patients with lead function that was able to be evaluated, the atrial lead remained functional after the procedure. There were no complications. Snare removal of the protruding retention wire via a femoral approach should be considered as an option in the management of patients with Class III Accufix leads.

Drug variables in thrombolytic therapy.

Fibrinolytic therapy has become an accepted treatment modality for recent peripheral arterial and bypass graft occlusions and, in some cases, for chronic arterial occlusions. Streptokinase, urokinase, and tissue plasminogen activator have all been used for intraarterial infusion with varying protocols and results. This review focuses on dosing variables and clinical results for the various thrombolytic agents in peripheral arterial and bypass graft occlusions. Also discussed are new thrombolytic agents and the effects of concomitant use of other drugs as part of the treatment regimen.

Thrombolytic therapy compared with mechanical recanalization in non-acute peripheral arterial occlusions: a randomized trial.

PURPOSE: To evaluate whether thrombolytic therapy followed by angioplasty has any added benefit compared with angioplasty alone for the treatment of chronic peripheral arterial occlusions. PATIENTS AND METHODS: Twenty patients with claudication or limb-threatening ischemia of at least 3 weeks duration due to iliac or femoropopliteal artery occlusions were randomized either to thrombolytic therapy with recombinant tissue-type plasminogen activator for up to 4 hours (n = 11) followed by angioplasty or to angioplasty alone (n = 9). Clinical follow-up was obtained for 1 year. RESULTS: Life-table analysis revealed a significant improvement in the cumulative primary patency rate for patients with claudication treated initially with thrombolysis followed by angioplasty (n = 7; 86% at 6 months; 51% at 1 year) compared with angioplasty alone (n = 9; 11% at 6 months and 1 year) (P < .02). All four patients with limb-threatening ischemia were randomized to thrombolytic therapy, and none exhibited continued patency at 1 year. The most common complication in the thrombolysis group was peripheral embolization; three of these four patients were among those who had limb-threatening ischemia as the indication for entry into this study. There was no increased incidence of bleeding with thrombolytic therapy. CONCLUSIONS: A short course of thrombolytic therapy prior to angioplasty appears to improve the 1-year patency rate for claudication due to iliac or femoropopliteal occlusions. However, patients with limb-threatening ischemia have a high prevalence of peripheral embolization and dismal patency rates with this form of therapy. A larger scale study is necessary to confirm these findings.

Revascularization for femoropopliteal disease. A decision and cost-effectiveness analysis.

OBJECTIVE: To evaluate the relative benefits and cost-effectiveness of revascularization for femoropopliteal disease using percutaneous transluminal angioplasty or bypass surgery. DESIGN: Decision analysis using a multistate transition simulation model (Markov process) and cost-effectiveness analysis from the perspective of the health care system. SETTING: Based on mortality, morbidity, patency, and cost data from a literature review. PATIENTS: Hypothetical cohort of patients with chronic femoropopliteal disease who desire revascularization. Subgroup analysis for patients defined by age, sex, indication, lesion type, and graft type. INTERVENTIONS: Percutaneous transluminal angioplasty, bypass surgery, and a strategies combining the two treatments. MAIN OUTCOME MEASURES: Five-year patency results, quality-adjusted life expectancy, lifetime costs, and incremental cost-effectiveness ratios. RESULTS: For 65-year-old men with disabling claudication and a femoropopliteal stenosis or occlusion and for 65-year-old men with chronic critical ischemia and a femoropopliteal stenosis, initial angioplasty increased quality-adjusted life expectancy by 2 to 13 months and resulted in decreased lifetime expenditures compared with bypass surgery. For patients with chronic critical ischemia and a femoropopliteal occlusion, initial bypass surgery increased quality-adjusted life expectancy by 1 to 4 months and resulted in decreased lifetime expenditures compared with angioplasty. Sensitivity analysis demonstrated that angioplasty would always be the preferred initial treatment if the angioplasty 5-year patency rate exceeds 30%. CONCLUSION: Angioplasty is the preferred initial treatment in patients with disabling claudication and a femoropopliteal stenosis or occlusion and in those with chronic critical ischemia and a stenosis. Bypass surgery is the preferred initial treatment in patients with chronic critical ischemia and a femoropopliteal occlusion.

Patency results of percutaneous and surgical revascularization for femoropopliteal arterial disease.

To estimate the patency results of percutaneous transluminal angioplasty and bypass surgery in the treatment of femoropopliteal arterial disease, a Medlars search of the English-language medical literature was performed. Inclusion required that studies 1) report original data, 2) report patency with a life table or Kaplan-Meier analysis with the number at risk or standard errors, 3) define patency as hemodynamic improvement, 4) report the distribution of covariates, and 5) not duplicate other published material. Using a method based on the proportional-hazards model and the actuarial life-table approach, the results were adjusted for differences in case-mix of the study populations and patency was predicted for subgroups at various levels of risk for failure. The unadjusted pooled life tables yielded five-year patencies of 45% (+/- 2%) for angioplasty, 73% (+/- 2%) for bypass surgery using a vein graft, and 49% (+/- 3%) for bypass surgery using a polytetrafluoroethylene graft. Adjusted five-year primary patencies after angioplasty varied from 12% to 68%, the best results being for patients with claudication and stenotic lesions. Adjusted five-year primary patencies after surgery varied from 33% to 80%, the best results being for saphenous vein bypass performed for claudication. The authors conclude that pooling life-table data without adjustment for covariates can be misleading. Indication, lesion type, vein graft availability, and site of the distal graft anastomosis need to be considered in predicting patency results of revascularization for femoropopliteal arterial disease.

Efficacy and safety of repeated boluses of urokinase in the treatment of deep venous thrombosis.

The only Food and Drug Administration-approved thrombolytic regimen for treatment of deep venous thrombosis (DVT) is a 24- to 72-hour continuous infusion of intravenous streptokinase. This approach to DVT thrombolysis is not entirely satisfactory because of the bleeding complications that may accompany this therapy. In the current study, we treated 27 patients with DVT with a novel dosing regimen of urokinase: 1,000,000 U administered as a 10-minute bolus, with a total of 3 boluses given over approximately 24 hours. Patients were given heparin overnight between bolus urokinase doses. Efficacy was assessed by comparing baseline and prehospital discharge vascular imaging studies, which constituted either venous ultrasound or contrast venography. A vascular-imaging panel of physicians, unaware of the sequence of paired studies, found that 14 patients (52%) had clot lysis (6 slight, 6 moderate and 2 marked), 9 (33%) had no change, and 4 (15%) had more extensive thrombosis after treatment (1 slight, 2 moderate and 1 marked). There were no bleeding complications. At 48 hours after starting urokinase, mean plasma fibrinogen levels had decreased 61% from baseline, and the mean bleeding time had increased 28% from baseline (but remained within the normal range). Because of the promising efficacy and safety that were found in this case series, it is concluded that further testing of bolus urokinase is warranted against anticoagulation alone.

Influence of variability of interpretation of contrast venography for screening of postoperative deep venous thrombosis on the results of a thromboprophylactic study.

To assess interobserver variability of venography for screening for postoperative deep venous thrombosis (DVT), we used 185 bilateral ascending contrast venograms (366 lower limbs) which were performed using the long-leg film technique, in the frame of a trial of the efficacy of two low-molecular-weight-heparin fractions (initial evaluation). These venograms were submitted in a multicenter setting to three further readers who performed a serial scoring as DVT, no DVT or non-evaluable. DVTs were diagnosed in 78, 55 and 59/366 limbs (initial evaluation: 58). The proximal locations of DVTs were 16, 9 and 16 (initial evaluation: 15) and the non evaluable limbs 3, 5 and 18 (initial evaluation: 0). Apparent pairwise agreement between the three readers ranged from 87 to 90% (true coefficient of agreement Kappa 0.63-0.70). It ranged from 89 to 93% (Kappa 0.63-0.74) for the comparison between the readers and the initial evaluation. This considerable degree of disagreement among experienced readers should be taken into account in calculating sample sizes in prospective thromboprophylactic studies. Indeed, one of the two prophylactic regimens proved to be significantly (p = 0.012, p = 0.031, p = 0.049) or non-significantly (p = 0.073) superior to the other one depending upon the reading of venograms.

Intraarterial thrombolysis of lower extremity occlusions: prospective, randomized comparison of forced periodic infusion and conventional slow continuous infusion.

A prospective randomized controlled trial compared forced infusion (FI) of urokinase (UK) with conventional slow continuous infusion (CI) in 25 patients with 25 acutely ischemic lower limbs. Demographics, ischemia categories, and infusion rates and doses were similar for both groups. A preliminary single-pass bolus of UK was injected into the thrombus in all patients with a pulsed-spray technique, and heparin was administered. UK was then infused with a CI pump (n = 13) or a prototype pulsed-spray pump (n = 12). The primary end point was patency, defined as at least 95% thrombolysis by volume, with brisk antegrade flow occurring within 4 hours. Eleven of the 12 patients (92%) who underwent FI and nine of the 13 (70%) who underwent CI had patency within 4 hours. However, 10 patients who underwent FI and nine who underwent CI had residual thrombi prolonging infusion. No significant differences between the two groups were apparent in speed of lysis, initial success rates, complication rates, or 30-day clinical outcome. Lytic therapy, however, was completed within 24 hours in 18 of 23 (78%) successfully treated patients (P = .01).

Risks and benefits of femoropopliteal percutaneous balloon angioplasty.

PURPOSE: The purpose of this study was to evaluate the efficacy of angioplasty in the treatment of femoropopliteal arterial disease. METHODS: From 1980 to 1991, 126 angioplasty procedures were performed in 131 limbs of 106 patients with 175 femoropopliteal lesions (26 common femoral, 118 superficial femoral, and 31 popliteal). Critical ischemia was present in 55 limbs (42%), and claudication was present in 76 (58%). Angioplasty was performed for a single lesion in 87 limbs (66%) and for multiple lesions in 44 (34%). In 13 limbs (10%) the most severe lesion was an occlusion; in 118 (90%) all lesions were stenoses. Distal runoff was good (2 or 3 vessels patent) in 72 limbs (55%) and poor (0 or 1 vessel patent) in 59 (45%). RESULTS: Death within 30 days occurred in 0.8%, nonfatal systemic morbidity in 7.1%, and local morbidity in 1.6% of procedures. Multivariate analysis revealed that indication and age were predictive of increased morbidity and mortality rates. Immediate success was achieved in 95% of limbs treated. Mean follow-up time was 2.0 years. The overall 5-year cumulative primary patency rate was 45% (+/- 5%). In a proportional hazards model indication and lesion type were predictive (p < 0.01) of long-term failure, with relative risks of 2.0 (1.2 to 3.3) and 2.7 (1.3 to 5.6), respectively. The 5-year primary patency rate after angioplasty for stenoses and claudication was 55% (+/- 7%), for stenoses and critical ischemia it was 29% (+/- 11%), and for occlusions it was 36% (+/- 14%). CONCLUSION: These results suggest that femoropopliteal angioplasty is a low-risk procedure with acceptable long-term results in patients with claudication and stenoses.

Short-term response to thrombolytic therapy in deep venous thrombosis: predictive value of venographic appearance.

To determine whether the response to thrombolytic therapy for lower-extremity deep venous thrombosis (DVT) can be predicted from the venographic appearance, 139 thrombosed venous segments were analyzed. Initial and follow-up venograms were obtained in 62 patients randomized to 24-hour infusions of recombinant human-tissue-type plasminogen activator (rTPA) (n = 34), rTPA plus heparin (n = 16), or heparin alone (n = 12). Segmental response to therapy was evaluated by means of blinded review of the paired venograms. The response (50%-100% lysis) to rTPA alone was significantly greater in venous segments involved with nonobstructive thrombi than in those with obstructive thrombi (12 of 23 vs five of 51; P less than .005). Results were similar for the combination of rTPA and heparin (five of six vs six of 30, P less than .01). No significant difference was seen in the response of either obstructive or nonobstructive thrombus to heparin alone. Thrombotic tails responded substantially (greater than 50% decrease in size) to rTPA with or without heparin in 22 of 24 patients. The venographic appearance of DVT appears to help in predicting the therapeutic response to thrombolytic therapy.

Hysterosalpingography and fallopian tube cannulation: use of a double-balloon introducing catheter.

A double-balloon introducing catheter for cervical cannulation is described. The catheter can be used for hysterosalpingography and allows coaxial passage of a 5-F curved catheter to selectively catheterize the fallopian tubes. The device has been used successfully in eight patients and may offer several advantages over other currently available equipment.

Accuracy of color Doppler flow mapping for evaluation of the severity of femoropopliteal arterial disease: a prospective study.

The usefulness of color Doppler flow mapping for estimating the severity of femoropopliteal lesions was compared with that of angiography in 35 patients (70 extremities). Sonography depicted significant (greater than 40% luminal narrowing) arterial lesions in 45 of 47 lower extremities in which such lesions were present (sensitivity, 0.96 [95% confidence limits; 0.86, 0.99]). The absence of significant segmental stenosis or occlusion was confirmed in 15 of the 23 normal extremities (specificity, 0.65 [0.45, 0.81]). Occlusions amenable to bypass surgery were correctly predicted in 25 of 26 (sensitivity, 0.96 [0.81, 0.99]) and were excluded in 41 of 44 extremities (specificity, 0.93 [0.82, 0.98]). Lesions amenable to angioplasty were detected in 16 of 21 instances, with overestimation of severity in three lesions that were judged suitable for bypass surgery; two lesions were missed. Preangiographic screening with color Doppler flow mapping is an accurate method for predicting the presence of femoropopliteal artery occlusions amenable to bypass surgery. It is also a sensitive method for predicting the presence of peripheral arterial disease.