Percutaneous angioplasty in clinical management of renovascular hypertension: initial and long-term results.

Between January 1980 and July 1983, percutaneous transluminal angioplasty was attempted on 137 stenotic renal arteries in 100 patients. At termination of follow-up studies (3-39 months, mean of 16 months), 70% of those treated for hypertension had benefited from the procedure. Stenosis secondary to fibromuscular dysplasia responded better than stenosis from arteriosclerosis (85% and 65% of the patients, respectively). Benefit was minimal for those with stenosis of the renal artery ostium or renal insufficiency. Determining levels of renal vein renin before angioplasty is helpful in selecting patients; following angioplasty, this has considerable significance in predicting the success of the procedure.

Varices from portal hypertension: correlation of CT and angiography.

Two hundred abdominal CT and angiographic examinations were performed on 137 patients with portal hypertension. These patients were being evaluated before or after a distal splenorenal shunt. CT increased the detection of umbilical and retroperitoneal varices. Angiography better detected peripancreatic varices and cavernous transformation. Both modalities together added more information than either alone in identification of coronary and/or gastroesophageal, retrogastric, and perisplenic-mesenteric varices. This additional anatomic information helped in the patient's management pre- and postoperatively.

Portaprival collaterals following distal splenorenal shunt. Incidence, magnitude and associated portal perfusion changes.

Collateral venous pathways develop between the high pressure portal vein and low pressure splenic vein following distal splenorenal shunt. This review of angiography in 50 patients with cirrhosis prior to and 1 year after DSRS shows that 98% developed collaterals: 72% transpancreatic, 48% transgastric, and 46% colonic. Multiple pathways developed in 64% of patients. Grading of the size of these collaterals showed that in 74% these exceeded the size of the portal and/or superior mesenteric vein. The effect of these collaterals on portal perfusion showed that 32% lost perfusion at 1 year, but significantly (P less than 0.05) more alcoholics (48%) lost perfusion than nonalcoholics (16%). The size, site and number of collaterals was not different between etiologies. Late follow-up in a subset of 32 of the patients showed no change in the site, and minimal increase in size of the collaterals at 3-11 years, with no further loss of portal perfusion. We conclude that virtually all patients develop collaterals after DSRS, these are along predictable pathways and are of significant size in the majority. However, development of collaterals per se does not equate to loss of portal venous flow, and a stable pattern is set in the first year after shunt. Characterization of these pathways will permit new approaches to minimizing their development.

The computed tomography-guided adrenal biopsy. An alternative to surgery in adrenal mass diagnosis.

A series of 16 patients with adrenal masses were biopsied percutaneously under computed tomography (CT) guidance with 18- to 22-gauge modified Chiba needles. Adrenal adenomas, cysts, metastases, melanoma, and adrenal hemorrhage were identified. Of nine oncologic patients, four had adrenal metastases, while five had other nonmalignant adrenal masses. Thus, an adrenal mass in an oncologic patient is not always metastases. No complications occurred. The diagnostic evaluation of an adrenal mass in selected cases should include CT-guided percutaneous aspiration as a safe and reliable alternative to open surgical biopsy. CT-guided biopsy can be performed as an outpatient procedure, avoiding the cost of hospitalization and the morbidity of surgery.

Varicoceles: a coaxial coil occlusion system.

A modified transfemoral technique for testicular venography and occlusion of the testicular vein (TV) was used to treat 30 patients with a total of 43 varicoceles (17 left-sided and 13 bilateral). Occlusion was satisfactory in all left varicoceles and 90% of right varicoceles. This coaxial technique facilitates subselective catheterization of the TV and its collaterals and enables coils to be placed deep within these vessels, either alone or in combination with detachable balloons.

Percutaneous drainage of multiseptated hepatic abscess.

Thirteen patients with multiseptated, hepatic abscesses were initially treated by percutaneous drainage using computed tomographic guidance. One of these 13 patients required surgery because of failure of percutaneous drainage due to the viscosity of the debris within the multiseptated cavities. Another patient required a second percutaneous drainage procedure due to recurrent hepatic fluid collection. Eleven of the 12 successful drainages were accomplished with one catheter because there was communication between the multiseptated "pockets." Our approach to hepatic abscess drainage is discussed with specific attention to the multiseptated abscess. The multiseptated abscess should not discourage an attempt at percutaneous catheter drainage.

Percutaneous drainage of abdominal abscesses.

Abdominal abscesses carry high morbidity and mortality unless properly drained. In recent years, percutaneous drainage has become an accepted alternative to surgery. A brief overview of diagnostic principles, selection of patients, percutaneous drainage catheters and technique, contraindications, and post-drainage follow-up is presented. In experienced hands, more than 80% of abdominal abscesses can be drained successfully by this method and with lower rates of morbidity, mortality, and complications than by surgery.

Multiple NMR T2 relaxation values in human liver tissue.

Twenty-one human hepatic liver biopsy samples were evaluated by nuclear magnetic resonance spectroscopy. This spectroscopy was performed by obtaining multiple and not single T2 values (T2-long and T2-short). Neoplastic tissue had greater T2-long and T2-short values than diffuse liver disease. The T2-short correlated, r = 0.947 (p less than 0.01), with the percentage of cancer cellularity within the tissue specimens. There was no correlation between the multiple T2 values and the degree of fibrosis and inflammation. Minimal correlation was noted between the T2-long and percentage of fat within the diffuse disease (cirrhotic) specimens, r = 0.636 (p less than 0.05). The possible reasons for the above findings are discussed.

CT directed hepatic biopsies: increased diagnostic accuracy with low patient risk.

A technique for computed tomography directed percutaneous liver biopsy using small gauge (18-20) needles is described. In 51 procedures performed on 50 patients tissue specimens adequate for diagnosis were obtained 49 times (96%). There was one false negative diagnosis. The correct diagnosis was made in 48 of 51 (94%) procedures on 48 of 50 (96%) patients. There were no significant complications.

Monitoring the response of lymphoma patients to therapy: correlation of abdominal CT findings with clinical course and histologic cell type.

A review was made of 365 abdominal computed tomographic (CT) examinations in 125 patients with a histologic diagnosis of lymphoma who had undergone CT before and after therapy. Clinical correlation immediately preceding the follow-up CT examination was obtained in 100 patients. In these 100 patients, five distinct subgroups emerged: (a) reduction in extent of disease without changes in internal nodal characteristics; (b) reduction in extent of disease with change in internal nodal characteristics; (c) no change in extent of disease and no change in internal nodal characteristics; (d) no change in extent of disease but change in internal nodal characteristics; and (e) disease progression. Changes in internal nodal architecture consisted of diminished attenuation or mesenteric "stranding." A 91% correlation existed between the CT findings and the clinical course. Of those patients with a worsening clinical course, and follow-up CT studies suggesting a stable or improved response to therapy, relapse in the majority (57%) involved the central nervous system. The authors conclude that limited abdominal CT examination is satisfactory in the posttherapy follow-up of lymphoma patients.

Biopsy of the right adrenal gland by the transhepatic approach.

A transhepatic computed-tomographic-guided biopsy of a right adrenal mass is described. This method is simpler to perform than the usual posterior biopsy carried out with the patient prone and is less likely to cause a complicating pneumothorax. In seven of eight patients with right adrenal masses, adrenal tissue was obtained and an accurate diagnosis was possible. No complications resulted.

Management of stenosis of distal splenorenal shunt by balloon dilation.

Stenosis of a distal splenorenal shunt may lead to inadequate variceal decompression with the risk of rebleeding. We report this complication in three patients at five, 16 and 17 months after DSRS, with successful management by balloon dilation. One patient had rebled from varices and the other two showed roentgenologic evidence of inadequate variceal decompression. All of the shunts were patent but showed a mean pressure gradient of 15 millimeters of mercury which was reduced to a mean of 7 millimeters of mercury by dilation. Angiography at 15 months showed no restenosis and sustained reduction of the pressure gradient in one patient. The other two patients await long term follow-up observation. Rebleeding or reappearance of varices are indications for repeat angiography after DSRS to determine the cause. The risk of dilating a venous anastomosis must be weighed against the risk of rebleeding; the results of this report demonstrate that this can be done with a satisfactory outcome.

Effectiveness of CT in evaluating intrathoracic masses.

To compare the effectiveness of computed tomography (CT) with conventional radiography and conventional tomography for evaluating masses in the thorax, 168 masses, 154 of which were histologically verified, which had been examined with CT were reviewed. In 74 instances (44%) CT provided important additional information compared with conventional radiography. Compared to conventional tomography, CT added important information in 15 (23%) of 65 cases. In no case did CT fail to demonstrate pathology shown with the other two methods. Average radiation dose to the chest was 1.3 rad (0.013 Gy) with CT and 0.4 rad (0.004 Gy) with linear tomography. Although CT is associated with slightly greater radiation dose and cost, this review indicates it should be performed directly after plain film examination instead of conventional tomography when further investigation of an intrathoracic mass is indicated.

The incidence and natural history of thrombus in the portal vein following distal splenorenal shunt.

The incidence of thrombus formation in the portal vein following distal splenorenal shunt was 4% occlusive and 14% nonocclusive from 1974 to 1977, and 6% occlusive and 22% nonocclusive in 1980. The increased incidence was probably due to more aggressive ligation of collaterals on the portal vein. Ten patients with this complication were evaluated prospectively with clinical and biochemical parameters, angiography, and nutrient hepatic perfusion. In this group, one thrombus was occlusive immediately after operation, and nine were nonocclusive: eight of the latter resolved by six months, but one progressed to total thrombosis. There were no demonstrable adverse clinical or biochemical sequelae. Angiography showed continuing portal perfusion in the face of nonocclusive thrombus, but at six months there was increased collateral formation and significant (p less than 0.05) reduction in portal vein diameter, from 20 +/- 4 mm to 14 +/- 5 mm. Nutrient hepatic perfusion at six months, 896 +/- 257 ml/min, was not significantly different from that seen prior to operation, 848 +/- 92 ml/min. It is concluded that the natural history of nonocclusive portal vein thrombus after distal splenorenal shunt is resolution, and management should be expectant.

Liver lesions: comparative accuracy of scintigraphy and computed tomography.

Of 84 cases with both radionuclide and computed tomographic studies of the liver, in 54 the results of the two examinations agreed, in 14 results disagreed, and in 16 cases one of the two tests gave equivocal results. Overall accuracy in detecting or ruling out focal liver disease was 79% for scintigraphy and 98% for computed tomography. In 13 of the 14 patients in whom studies did not agree, the scintigram was falsely negative. In 10 of these 13 false-negative scintigrams, small (less than 2 cm) solitary or multiple lesions were detected on computed tomography in patients who had normal liver function studies. In seven patients in whom both studies agreed, computed tomography provided additional, extrahepatic information that altered clinical management. Scintigraphy was 86% accurate in detecting liver disease when the patient had a gastrointestinal neoplasm, but only 74% accurate for nongastrointestinal neoplasm. Computed tomography was over 94% accurate in both situations. These data indicate an advantage of computed tomography as the initial screening examination for space-occupying lesions of the liver, especially in patients with a primary diagnosis of nongastrointestinal neoplasm.