Hypogastric artery coil embolization prior to endoluminal repair of aneurysms and fistulas: buttock claudication, a recognized but possibly preventable complication.

PURPOSE: Hypogastric artery embolization is considered to be necessary to prevent retrograde flow and potential endoleaks when a stent-graft crosses the origin of the hypogastric artery. The authors assess the incidence of buttock claudication, which is the primary complication encountered. The effect of coil location and the presence of antegrade flow at the completion of embolization are evaluated. MATERIALS AND METHODS: Hypogastric artery embolization and endoluminal repair of aneurysms and fistulas was performed in 34 patients (30 men; four women) aged 27-91 years (mean, 76 years). Ten patients were being treated for solitary abdominal aortic aneurysms, 13 were being treated for aortoiliac aneurysms, and six patients were being treated for isolated common iliac aneurysms, three for hypogastric artery aneurysms and two for iliac arteriovenous fistulas. Eleven patients had coils placed completely above the bifurcation of the hypogastric artery and 23 patients had coils placed at the bifurcation, or within the branches of the hypogastric artery. Preservation of antegrade flow after embolization was noted in 14 of 34 patients. RESULTS: Thirty-four patients underwent stent-graft repair after hypogastric artery embolization. There were two perioperative deaths, three proximal leaks, and one collateral leak. Of the 32 patients who survived the procedure, there was one retrograde leak, even though 13 of 32 (41%) patients had continued antegrade flow at completion of the hypogastric artery embolization. When coils were placed at or in the bifurcation of the hypogastric artery, 12 of 22 (55%) experienced claudication. When coils were placed in the proximal hypogastric artery, one of 10 (10%) claudicated. CONCLUSION: It is probably not necessary to completely occlude antegrade flow in the hypogastric artery to prevent a distal endoleak. Buttock claudication is rare when coils are placed in the proximal hypogastric artery rather than at its bifurcation or in its branches.

Reengineering a radiology department in an academic institution.

OBJECTIVE: A 1-year program was undertaken in conjunction with an outside consultant to cut nonphysician labor expenses by 15%, cut nonlabor expenses by 10%, and improve all service parameters in an academic radiology department. MATERIALS AND METHODS: A steering committee decided on five major goal teams: improve report turnaround time and improve patient throughput, increase the efficiency of performance and improve the quality of radiologic examinations, decrease the cost of each examination, improve charge capture, and improve the perception of the department. The goal teams met at least every 2 weeks, made presentations to the steering committee at midyear, and were then disbanded. The steering committee implemented changes in the second half of the year and continues to meet every 2 weeks. Data were obtained from the radiology information system, financial statements, and surveys. RESULTS: In the first year, report turnaround time decreased from 157 hr to 83 hr (and to 46 hr at 2 years), the efficiency of performing examinations (according to our criteria) improved from 64% to 80%, the quality of examinations improved, labor costs were reduced by 5% (and by 11% at 2 years), nonlabor costs were reduced by 14% (and by 31% at 2 years), cost per examination was reduced by 10% (and by 16% at 2 years), increased charge capture resulted in an annual increase in professional fees of at least $110,000, and the perception of the department by referring clinicians improved. CONCLUSION: It is possible to simultaneously cut expenses and improve service. To gauge progress, objective parameters that can be measured easily are necessary.

Stent-graft repair of aorto-iliac occlusive disease coexisting with common femoral artery disease.

PURPOSE: Significant disease or occlusion of the common femoral artery may preclude percutaneous therapy for aorto-iliac occlusive disease. In addition, aorto-iliac angioplasty may not reverse the ischemic symptoms when common femoral artery disease exists. The authors describe the feasibility of endoluminal stent-grafts to treat multilevel aortoiliofemoral occlusive disease. MATERIALS AND METHODS: The authors placed 18 stent-grafts for aorto-iliac occlusive disease in 17 patients with limb-threatening ischemia and significant common femoral artery disease. These procedures were performed as a joint effort between vascular surgery and interventional radiology staff in the operating room. The common femoral artery was occluded in 10 or severely diseased in eight, necessitating endoluminal bypass to the superficial femoral or popliteal artery (n = 7) or to the deep femoral artery (n = 7), or necessitating patch angioplasty of the common femoral artery (n = 4). Stent-grafts were fabricated from 6-mm polytetrafluoroethylene and 29-mm Palmaz stents. RESULTS: All 18 grafts were placed successfully. Follow-up ranged from 3 to 38 months (mean, 21 months). Seven patients died of myocardial infarction; two grafts occluded and one required angioplasty during follow-up, resulting in a primary patency rate of 81% at 2 years. CONCLUSION: Endoluminal stent-graft placement is a useful method of treatment for advanced atherosclerotic aorto-iliac disease, particularly in the presence of common femoral artery disease. This approach avoids an extra-anatomic bypass or a major transabdominal aortic bypass procedure. Longer follow-up with a larger series is needed to ensure the safety and late graft patency comparable to the traditional aortofemoral and iliofemoral bypass grafts.

Infrapopliteal percutaneous transluminal angioplasty: what we know.

We believe that a substantial experience demonstrating the effectiveness and safety of infrapopliteal artery PTA has been accumulated. It is clear that the results of tibial PTA and femoropopliteal PTA are closely associated for most patients undergoing limb salvage procedures. Anatomic selection is most important; patients with focal disease and restorable runoff will generally benefit, and interventional radiologists should concentrate on treating this group of patients. PTA and surgery for limb salvage patients are indeed complementary procedures, and patients will benefit most by a methodical team approach to treatment. Problems with reporting of data in the literature have obscured the true effectiveness of distal PTA, with such deficiencies leading to both overestimation and underestimation of clinical utility. Nevertheless, the preponderance of evidence (as we see it) suggests a clinical effectiveness of about 80% at 2 years in appropriately selected patients. Like Dr. Fraser and his co-authors, we would welcome randomized trials of tibial PTA versus surgery, but even in the absence of these, the reporting of indications and results needs to be standardized: severity of symptoms at presentation and the extent of conservative treatments employed before intervention; life-table methodology on an intent-to-treat basis with clear delineation of end points; stratification by important variables such as lesion length, runoff status, extent of preexisting tissue loss, presence of diabetes and ESRD, and ideally, functional outcome and quality-of-life measures. Finally, we should learn from our surgical colleagues that close surveillance and early reintervention will probably increase the effectiveness of our percutaneous treatment methods.

Venous invasion in renal vein leiomyosarcoma: case report and review of the literature.

Tumors arising from veins are rare, usually present with nonspecific clinical and imaging findings and almost universally show histology of leiomyosarcoma. This twentieth reported case of primary renal vein leiomyosarcoma demonstrates invasion of the renal vein with endoluminal propagation of tumor into the infrahepatic inferior vena cava (IVC), an unreported manifestation. The combination of CT, ultrasound, and angiographic studies allowed differentiation from renal cell carcinoma by suggesting a tumor arising from the renal vein.

Value of preoperative renal artery embolization in reducing blood transfusion requirements during nephrectomy for renal cell carcinoma.

PURPOSE: The authors evaluated the effectiveness of preoperative ethanol renal artery embolization in reducing transfusion requirements during nephrectomy for renal cell carcinoma. PATIENTS AND METHODS: Of 93 consecutive patients who underwent nephrectomy for renal cell carcinoma from 1980 to 1990, 24 patients underwent embolization within 24 hours of nephrectomy. Finding in this group were compared with those in 69 control patients who underwent surgery without preoperative embolization. RESULTS: Embolized tumors were larger than nonembolized ones (mean volume, 595 vs 257 mL) (P < .05). Patients with large hypervascular tumors (volume over 250 mL) who underwent complete embolization received significantly smaller mean blood transfusion volumes than control patients (250 vs 800 mL; P = .01). The transfusion volume associated with incomplete embolization was higher than that associated with no embolization. CONCLUSION: Complete alcohol embolization significantly reduces the volume of blood transfused during nephrectomy for large hypervascular renal cell carcinomas, and incomplete embolization is associated with larger transfusions. Preoperative embolization must be complete and should be performed more widely.

Comparison of duplex ultrasonography and ascending contrast venography in the diagnosis of venous thrombosis.

The application of duplex ultrasonography to the diagnosis of venous thrombosis requires validation by comparison of the duplex findings with the results of ascending contrast venography. In this study, 2534 veins were examined by both methods with contrast venography results serving as the standard for comparison. In this setting, duplex ultrasonography proved to be 100% sensitive and 99% specific for venous thrombosis. Duplex ultrasonography is as reliable as venography in the diagnosis of venous thrombosis and has no associated risks or known complication. In addition, duplex ultrasonography provides information regarding pathologic anatomy that is comparable to the detail provided by high-quality venography. The authors conclude that duplex ultrasonography should be the diagnostic method of choice for evaluating patients with suspected venous thrombosis.

Compression of vein graft by hematoma during fibrinolytic therapy simulating intrinsic venous stricture--a case report.

Narrowing of a vein graft at an area of perigraft extravasation was encountered during fibrinolytic therapy for graft thrombosis. With cessation of fibrinolytic therapy, extravasation ceased and the vein lumen widened. Extrinsic compression and/or spasm due to a hematoma should be included as causes of vein graft narrowing in patients undergoing fibrinolytic therapy.

Radiology in intestinal ischemia. Angiographic diagnosis and management.

Angiography is an essential component of the diagnosis and treatment of patients with acute and chronic intestinal ischemia. Aortography and selective angiography permit identification of the cause and precise anatomy of intestinal ischemic syndromes, and also help plan their potential correction. Direct intra-arterial infusion of pharmacologic agents into splanchnic vessels has now become part of the therapy of these conditions. This article reviews angiographic techniques and their applications in the management of intestinal ischemic syndromes.

Radiology in intestinal ischemia. Plain film, contrast, and other imaging studies.

Because plain films are usually normal or nonspecific in both colonic and acute mesenteric ischemia, they are not diagnostically helpful. The barium enema is the most useful radiographic examination in the diagnosis of colonic ischemia, and a double-contrast study will show abnormalities in almost all cases. Findings specific for colonic ischemia characteristically change with time. Thumbprinting is the most diagnostic finding; it is seen early in the course of the disease and usually resolves or is replaced within 1 or 2 weeks by an acute ulcerating colitis pattern. The latter may heal over months or go on to stricture formation or a persistent colitis. Nonspecific abnormalities can also be identified on CT and ultrasound, but the incidence of the findings with colonic ischemia is not known. Plain film findings occur late in the course of acute mesenteric ischemia and thus cannot be relied on for the diagnosis, although they may be useful in excluding other conditions. When acute mesenteric ischemia is suspected, angiography should be performed, but CT, ultrasound, and, perhaps, MR imaging may contribute to the diagnosis.

Radiocontrast-associated renal dysfunction: incidence and risk factors.

Contrast-induced nephropathy is a potentially serious untoward reaction to radiologic contrast media. The incidence of this nephropathy and the predisposing conditions are not well established, possibly because of methodologic differences between studies. We evaluated the incidence of contrast-induced nephropathy after femoral arteriography in 394 patients by using multiple definitions (different increases in serum creatinine or blood urea nitrogen levels at various times). When an increase in the level of serum creatinine of greater than 0.3 mg/dl and greater than 20% on day 1, 2, or 3 and on day 5, 6, or 7 was used to define the disorder, the incidence in our group of patients was 10% for nonazotemic patients vs 30% for azotemic patients (p less than .001); 2% for nondiabetic, nonazotemic patients vs 16% for diabetic, nonazotemic patients (p = .003); and 38% for patients who were both diabetic and azotemic vs 16% for diabetic, nonazotemic patients (p = .022). Baseline renal insufficiency and diabetes mellitus (especially when insulin dependent) were significant predisposing factors. The effects of dehydration and increased volume of contrast medium on the incidence of contrast-induced nephropathy were not clear; the age and sex of the patient were not important risk factors. The incidence of contrast-induced nephropathy depends on the definition used. Although contrast-induced nephropathy may develop in any patient, diabetes, renal insufficiency, and, possibly, dehydration and dose of contrast medium are risk factors.

Incidental paranasal sinus abnormalities on MRI of the brain.

T2-weighted magnetic resonance imaging (MRI) presents paranasal sinus pathology with remarkable clarity. However, it has yet to be demonstrated that all MRI findings represent true pathology and not minor or incidental findings of no consequence. In an effort to resolve this question, we have analysed retrospectively 263 consecutive T2-weighted MRI examinations of the head performed for indications not associated with possible sinus pathology. We examined these studies for abnormally increased signal in the paranasal sinuses and the sites of involvement. Mucoperiosteal thickening, mucus retention cysts, air-fluid levels or total sinus opacification were recorded. Of the 263 studies examined, 65 (24.7%) demonstrated abnormalities in the paranasal sinuses. We conclude that because of its great sensitivity MRI will often detect abnormalities in the paranasal sinuses which are unrelated to the patients' presenting problems.

Translumbar arch aortography: a retrospective controlled study of usefulness, technique, and safety.

Subclavian and axillary artery stenoses may lead to axillofemoral bypass graft failure. These arteries were assessed preoperatively with arch aortography performed after conventional high translumbar peripheral aortography by exchanging the initial 16-gauge sheath for a 5-F pigtail catheter. Thirty-two diagnostic translumbar runoff and arch (TLR-arch) aortograms were obtained in 30 patients with advanced lower extremity ischemia. In six patients (20%), the results of the arch study influenced the choice of an inflow site. These patients were compared with 70 control subjects who underwent conventional translumbar aortography without arch studies. In the TLR-arch group, two major complications occurred in one patient, while in the control group 11 major complications occurred in 10 patients. One retroperitoneal hematoma occurred in the TLR-arch group; two occurred in the control group. The mean change in hematocrit for the TLR-arch group was -3.81% (-0.0381), and for the control group it was -4.17% (-0.0417). This difference was not statistically significant. Arch aortography is a valuable adjunct to the translumbar aortofemoral study. It can be simply performed without increasing the morbidity of the peripheral study.

Changing arteriosclerotic disease patterns and management strategies in lower-limb-threatening ischemia.

From January 1, 1974 to December 31, 1989, we treated 2829 patients with critical lower-extremity ischemia. In the last 5 years, 13% of patients had therapeutically significant stenoses or occlusions above and below the groin, while 35% had them at two or three levels below the inguinal ligament. Unobstructed arterial flow to the distal half of the thigh was present in 26% of patients, and 16% had unobstructed flow to the upper third of the leg with occlusions of all three leg arteries distal to this point and reconstitution of some patent named artery in the lower leg or foot. In the last 2 years, 99% of all patients with a threatened limb and without severe organic mental syndrome or midfoot gangrene were amenable to revascularization by percutaneous transluminal angioplasty (PTA), arterial bypass, or a combination of the two, although some distal arteries used for bypass insertion were heavily diseased or isolated segments without an intact plantar arch. Limb salvage was achieved and maintained in more than 90% of recent patient cohorts, with a mean procedural mortality rate of 3.3%. Recent strategies that contributed to these results include (1) distal origin short vein grafts from the below-knee popliteal or tibial arteries to an ankle or foot artery (291 cases); (2) combined PTA and bypass (245 cases); (3) more distal PTA of popliteal and tibial artery stenoses (233 cases); (4) use of in situ or ectopic reversed autogenous vein for infrapopliteal bypasses, even when vein diameter was 3 to 4 mm; (5) composite-sequential femoropopliteal-distal (PTFE/vein) bypasses; (6) reintervention when a procedure thrombosed (637 cases) or was threatened by a hemodynamically significant inflow, outflow, or graft lesion (failing graft, 252 cases); (7) frequent follow-up to detect threatening lesions before graft thrombosis occurred and to permit correction of lesions by PTA (58%) or simple reoperation; and (8) unusual approaches to all infrainguinal arteries to facilitate secondary operations, despite scarring and infection. Primary major amputation rates decreased from 41% to 5% and total amputation rates decreased from 49% to 14%. Aggressive policies to save threatened limbs thus are supported.

Unsuspected inflow disease in candidates for axillofemoral bypass operations: a prospective study.

Routine arteriography of the axillary, subclavian, and innominate arteries before axillofemoral bypass surgery has not been advocated because of the presumed rarity of stenosis of these inflow vessels. However, we have noted in this patient population with extensive atherosclerosis that inflow disease can cause axillofemoral graft failure despite normal preoperative clinical and noninvasive parameters. We prospectively determined the incidence of unsuspected inflow stenosis with arteriography in 40 consecutive candidates for primary (28) or secondary (12) axillofemoral bypass surgery. A new arteriographic technique with a single translumbar puncture was developed to safely and clearly visualize the potential inflow and outflow tracts. Ten of the 40 patients (25%) exhibited inflow stenosis greater than 50% of luminal diameter (unilateral in eight patients and bilateral in two patients). Seven were on the left side (five subclavian, two axillary) and five were on the right side (three subclavian, one axillary, one innominate). In eight of the 40 patients (20%) the stenotic inflow lesion was ipsilateral to the ischemic leg and therefore proximal to the preferred inflow site of an axillofemoral bypass. Upper extremity arterial pressure measurements suggested potential inflow artery stenosis in only three of the 12 (25%) instances. These findings show that equal arterial pressures in the upper extremities do not ensure adequate inflow for an axillofemoral graft. Routine arteriographic assessment of inflow intacts is recommended before axillofemoral bypass surgery.