Soft-tissue venous malformations in adult patients: imaging and therapeutic issues.

Venous malformations are the most common vascular malformations. However, confusion with respect to terminology and imaging guidelines continues to result in improper diagnosis and treatment. An appropriate classification scheme for vascular anomalies is important to avoid the use of false generic terms. Adequate imaging in association with clinical findings is crucial to establishing the correct diagnosis. Doppler ultrasonography should be the initial imaging modality and demonstrates absence of flow or low-velocity venous flow. Computed tomography and magnetic resonance (MR) imaging are used primarily for pretreatment evaluation of lesion extension. These lesions are usually hypointense on T1-weighted MR images and markedly hyperintense on T2-weighted images with variable gadolinium enhancement. Direct phlebography helps confirm the diagnosis and exclude other soft-tissue tumors. Three distinct phlebographic patterns (cavitary, spongy, dysmorphic) have been identified. In most cases, conservative treatment is recommended. Sclerotherapy with or without surgery is useful in cases of functional impairment or significant aesthetic prejudice, even if recurrences are frequent. Direct phlebography is performed when a more detailed assessment of the vascular pattern is needed or as part of sclerotherapy. Use of the appropriate imaging technique is critical in establishing the diagnosis, evaluating extension, and planning appropriate treatment.

Detection of renal artery stenosis: prospective comparison of captopril-enhanced Doppler sonography, captopril-enhanced scintigraphy, and MR angiography.

OBJECTIVE: The objective of our study was to compare the value of captopril-enhanced Doppler sonography, captopril-enhanced renal scintigraphy, and gadolinium-enhanced MR angiography for detecting renal artery stenosis. SUBJECTS AND METHODS: Forty-one patients with suspected renovascular hypertension were prospectively examined with captopril-enhanced Doppler sonography, captopril-enhanced renal scintigraphy, gadolinium-enhanced MR angiography, and catheter angiography. The sensitivity and specificity of each technique for detecting renal artery stenosis measuring 50% or greater and 70% or greater were compared using the McNemar test. Positive and negative predictive values were estimated for populations with 5% and 30% prevalence of renal artery stenosis. Kappa values for interobserver agreement were assessed for both gadolinium-enhanced MR angiography and catheter angiography. RESULTS: For detecting renal artery stenosis measuring 50% or greater, the sensitivity of gadolinium-enhanced MR angiography (96.6%) was greater than that of captopril-enhanced Doppler sonography (69%, p = 0.005) and captopril-enhanced renal scintigraphy (41.4%, p = 0.001). No significant difference in specificity was observed among modalities. For renal artery stenosis measuring 50% or greater, positive and negative predictive values were respectively 62% and 86% for captopril-enhanced Doppler sonography, 49% and 76% for captopril-enhanced renal scintigraphy, and 53% and 98% for gadolinium-enhanced MR angiography. Interobserver agreement was high for both gadolinium-enhanced MR angiography (kappa = 0.829) and catheter angiography (kappa = 0.729). CONCLUSION: Gadolinium-enhanced MR angiography is the most accurate noninvasive modality for detecting renal artery stenosis greater than or equal to 50%. The use of captopril-enhanced Doppler sonography in combination with gadolinium-enhanced MR angiography for identifying renal artery stenosis needs to be evaluated with a cost-effectiveness analysis.

Preoperative embolization in the management of a mediastinal paraganglioma.

Parangliomas are rare and highly vascular tumors of neuroendocrine cell origin which are treated by complete surgical resection. Preoperative embolization to reduce perioperative bleeding complications, although described in paragangliomas of the neck and carotid body, has never before been described in the case of a mediastinal paraganglioma. The following is a presentation of such a case of mediastinal paraganglioma, in which embolization was used successfully before surgical resection.

Infrarenal aortic stenosis: value of stent placement after percutaneous transluminal angioplasty failure.

PURPOSE: To evaluate the long-term clinical and hemodynamic effectiveness of aortic stent placement in cases of failure of intended infrarenal percutaneous transluminal aortic angioplasty (PTAA). MATERIALS AND METHODS: Fifty-three patients who underwent technically successful PTAA were compared with 24 patients who underwent aortic stent placement because of PTAA failure (19 patients) or ulcerated lesions (five patients) that otherwise would have been treated surgically because of the embolization hazard associated with PTAA alone. Clinical patency was defined as the absence or improvement of symptoms after the intervention. Hemodynamic patency was defined as a normal Doppler waveform in the common femoral arteries, an ankle-brachial index greater than 0.95, or the absence of a thigh-brachial pressure gradient. RESULTS: Three-year clinical and hemodynamic patency rates, respectively, were 85% and 79% for PTAA and 69% and 43% for aortic stent placement. No morbidity was encountered. With use of the Cox proportional hazards model, two significant risk factors were retained for restenosis: unchanged smoking habit (P =.04) and small dilatation diameter (P =.001). Aortic stent placement, performed in patients with a smaller aortic diameter (10.3 vs. 12.7 mm for PTAA), appeared to be a predictive factor for restenosis by using univariate analysis. By using the Cox proportional hazards model, however, the restenosis rates after PTAA and aortic stent placement were not significantly different. CONCLUSION: When aortic diameter is taken into consideration, there is no evidence that clinical outcome after secondary aortic stent placement would be poorer than technically successful PTAA.

Arterial embolotherapy for upper gastrointestinal hemorrhage: outcome assessment.

PURPOSE: To identify predictors of clinical outcome after arterial embolotherapy for upper gastrointestinal (UGI) hemorrhage. MATERIALS AND METHODS: Seventy-five consecutive patients (mean age, 62.5 y) underwent arterial embolization for acute UGI hemorrhage. Bleeding was detected at endoscopy and angiography in 22 patients, at endoscopy alone in 29 patients, and at angiography alone in 24 patients. As such, embolization was directed by angiography in 46 patients (61.3%) and by endoscopy (referred to as "blind" embolization) in 29 patients (38.7%). The embolic agents used were metallic coils, polyvinyl alcohol particles (size range, 355-710 microm), gelatin sponge, and tissue adhesive. Predictors of bleeding recurrence and mortality were analyzed with logistic regression and Cox models, respectively. RESULTS: The technical success rate of embolization was 98.7%. Primary clinical success was achieved in 57 patients (76%). Secondary clinical success occurred in five additional patients (82.5%) after repeat embolization. There were four (5.3%) complications: two cases of self-resolving duodenal ischemia, one hepatic infarct, and one inguinal hematoma. The periprocedural mortality rate was 34.6% (26 of 75), mostly related to underlying illness. Early recurrence of bleeding (within 30 days of embolization) was associated with coagulation disorders (international normalized ratio >1.5, partial thromboplastin time >45 seconds, or platelet count <80,000/microL; odds ratio, 19.46; P = .001) and with the use of coils as the only embolic agent (odds ratio, 7.73; P = .01). Cirrhosis and cancer shortened the overall survival of patients after embolic therapy. The mean patient follow-up time was 34.5 months. CONCLUSION: Arterial embolotherapy for UGI hemorrhage is safe, effective, and durable. Coagulopathy and the use of coils as the only embolic agent were associated with a higher risk of early bleeding recurrence.

Imaging of renovascular hypertension: respective values of renal scintigraphy, renal Doppler US, and MR angiography.

Renovascular hypertension affects 15%-30% of patients who have clinical criteria suggestive of renovascular disease. Noninvasive screening is crucial for patient selection prior to conventional angiography and renal revascularization. Renal scintigraphy has been reported to be sensitive for detection of renovascular hypertension, but some of its limitations (eg, in the setting of bilateral renal artery stenosis and renal failure) should be considered. Doppler ultrasonography (US) allows direct evaluation of the renal arteries as well as transrenal Doppler waveform analysis, but it remains operator dependent. Gadolinium-enhanced magnetic resonance (MR) angiography is becoming an excellent alternative to conventional angiography. The main limiting factors of this technique are inadequate visualization of segmental and accessory renal arteries as well as a tendency toward overestimation of stenoses. Given the high cost and low availability of MR angiography, scintigraphy and Doppler US should be considered the primary studies in screening for renovascular hypertension. MR angiography could be reserved for patients with inconclusive scintigraphic and Doppler US results, patients with high clinical suspicion of renovascular hypertension, and patients with a contraindication to conventional angiography.

Percutaneous revascularization of the renal arteries: predictors of outcome.

PURPOSE: To identify predictors of clinical outcome after percutaneous revascularization of the renal arteries. MATERIALS AND METHODS: In 63 patients, the therapeutic response was retrospectively assessed after percutaneous revascularization of the renal arteries indicated for hypertension (41.3%), renal failure (4.8%), or both (53.9%). All patients underwent percutaneous transluminal renal angioplasty, complemented by stent insertion in 30 patients. The authors analyzed the role of clinical and imaging factors, including scintigraphy, Doppler sonography, and angiography for predicting clinical success. RESULTS: In the hypertensive population, there were three cures (5.6%), 26 improvements (48.1%), and 25 failures (46.3%). Among patients with renal insufficiency, 12 were improved (37.5%), 11 were stabilized (34.4%), and nine deteriorated (28.1%). Predictors of favorable outcome for hypertension were shorter duration of hypertension, higher diastolic blood pressure, fibromuscular dysplasia, abnormal Doppler study, higher percentage of angiographic stenosis, and lower grade of aortic atheromatous disease. Predictors of favorable outcome for renal failure were nondiabetic status, abnormal Doppler study, and higher percentage of angiographic stenosis. Abnormal Doppler and scintigraphic examinations predicted successful treatment of hypertension in 60% and 53.8% of cases, respectively, and renal insufficiency in 85% and 60% of cases, respectively. CONCLUSION: Clinical and angiographic variables were the best predictors of therapeutic success for hypertension. Doppler sonography was useful in patients with renal failure.

The Erasme study: a multicenter study on the safety and technical results of the Palmaz stent used for the treatment of atherosclerotic ostial renal artery stenosis.

PURPOSE: To assess, in a multicenter setting, safety, technical results, and restenosis rate of the Palmaz stent for treatment of atherosclerotic ostial renal artery stenosis. METHODS: Ten centers enrolled 106 patients (120 treated renal artery stenoses) in the study. Patient selection was based on unsuccessful percutaneous transluminal renal angioplasty (residual stenosis >/= 20%) performed for treatment of ostial stenosis >/= 50%, in patients with hypertension and/or impaired renal function. Safety was assessed by means of the complication rate, and technical results by the number of successful stent placements and occurrence of restenosis (>50%) at intraarterial angiographic follow-up. RESULTS: Stent placement was successful (n = 112) or partially successful (n = 5) in 117 (98%) arteries. Complications occurred in 19 procedures; seven were of serious clinical significance. Angiographic follow-up was performed in 89 of 117 (76%) cases, at a mean of 8 months (range 2. 5-18 months). Fifteen stents (16.9%) showed restenosis (at a mean of 8.5 months), of which 10 were successfully redilated. CONCLUSION: Renal artery stenting has a high technical success rate, a complication rate comparable to percutaneous transluminal renal angioplasty, and a low rate of restenosis at 8 months angiographic follow-up.

Digital subtraction angiography of the abdominal aorta and lower extremities: carbon dioxide versus iodinated contrast material.

PURPOSE: To compare the diagnostic value of carbon dioxide to that of iodinated contrast material for digital subtraction angiography of the abdominal aorta and lower extremities. MATERIALS AND METHODS: Thirty-five patients underwent comparative CO2 and iodinated contrast material arteriography of the abdominal aorta and lower extremities. For each contrast study, three independent observers evaluated the degree of opacification and percentage of stenosis of each vessel, the degree of certainty of their observations, and the overall quality of the study. Data of CO2 and iodinated studies were compared using analysis of variance for repeated measures. Interobserver and intertechnique agreements were estimated with Cohen's kappa and intraclass correlation coefficient. RESULTS: Iodine-based vascular opacification was superior to that with CO2 in the central and distal arteries (P = .02). The degree of certainty and overall quality score were higher for iodine than for CO2-based contrast studies (P = .00001). The interobserver agreement for categorizing stenoses was higher for iodine as compared to CO2-based angiography. No significant difference was observed between the mean stenosis values obtained with CO2 and iodine-based angiography in any segment. Intraclass correlation coefficient demonstrated a high degree of convergence of the two techniques for assessing the percentage of stenosis. CONCLUSION: CO2 can be used as an alternative to iodinated contrast material for obtaining arteriograms of the abdominal aorta and lower extremities for investigating atherosclerotic disease.

The value of internal carotid systolic velocity ratio for assessing carotid artery stenosis with Doppler sonography.

OBJECTIVE: The purpose of this study was to assess the value of the ratio between the internal carotid systolic velocity (ICSV) at the carotid bulb and the distal internal carotid systolic velocity (DICSV) for the detection of carotid artery stenosis. SUBJECTS AND METHODS: Two hundred eleven patients were enrolled in a prospective study comparing several Doppler measurements with carotid angiography. The following spectral measurements were obtained with Doppler sonography: ICSV/DICSV ratio, ICSV, ICSV/common carotid systolic velocity (CCSV) ratio, and internal carotid (end) diastolic velocity (ICDV). Receiver operating characteristic curves were generated for two groups: the first group being 365 carotid arteries for which all Doppler measurements were successfully obtained and the second being a subgroup of 258 carotid arteries for which an ICSV of 100 cm/sec or greater was present. RESULTS: In the group of 365 carotid arteries, the ICSV/DICSV ratio improved the detection of stenosis of 60% or greater as compared with the ICDV (p = .03). In 258 carotid arteries with an ICSV of 100 cm/sec or greater, the ICSV/DICSV ratio allowed for a better angiographic correlation for identifying stenoses of 60% or greater and 70% or greater as compared with ICSV (p = .006 and .023, respectively), ICSV/CCSV (p = .0013 and .003, respectively), and ICDV (p = .0015 and .020, respectively). CONCLUSION: Using the ICSV/DICSV ratio for the Doppler detection of carotid artery stenosis is advantageous when the ICSV is 100 cm/sec or greater.

Comparison of early and delayed scintigraphy with 99mTc-apcitide and correlation with contrast-enhanced venography in detection of acute deep vein thrombosis.

UNLABELLED: Preliminary studies with 99mTc-apcitide (99mTc-P280), a synthetic peptide that binds to glycoprotein IIb/IIIa receptors expressed on activated platelets, have shown promising results in the detection of acute deep vein thrombosis (ADVT). The purpose of this study was to compare the diagnostic value of early and delayed imaging with 99mTc-apcitide in patients with suspected ADVT, using contrast-enhanced venography as the gold standard. METHODS: Thirty-nine patients (17 women, 22 men; mean age 59 y) with signs or symptoms suggestive of ADVT (within 10 d of onset) and scheduled for contrast-enhanced venography were prospectively studied. The patients were injected with approximately 740 MBq (20 mCi) 99mTc-apcitide within 36 h of contrast-enhanced venography. Both anterior and posterior planar images (8-10 min/view) of the lower extremities using a dual-head gamma camera were obtained at 10, 60 and 120 min after the injection of 99mTc-apcitide. The three sets of images initially were interpreted randomly and separately by three experienced observers unaware of the clinical history, the site of ADVT and results of contrast-enhanced venography. All images from the three sets for a given patient were then analyzed together during a second session. Conventional contrast-enhanced venography was performed on 31 patients before 99mTc-apcitide scintigraphy and in the remaining 8 patients after 99mTc-apcitide scintigraphy. 99mTc-apcitide findings were considered positive forADVT when a focus of increased uptake was found to correspond to the location of a deep vein. Disagreements were resolved by consensus. RESULTS: Twenty-two patients had ADVT observed on contrast-enhanced venography, whereas 17 had normal findings. Six cases of ADVT were infrapopliteal. One patient did not complete the third set of images with 99mTc-apcitide. The sensitivity of 99mTc-apcitide in detecting ADVT was 63.6% (14/22), 68.2% (15/22), 76.2% (16/21) and 86.4% (19/22) for images obtained at 10, 60 and 120 min and for the three sets analyzed together, respectively. The specificity was 82.4% (14/17), 76.5% (13/17), 88.2% (15/17) and 88.2% (15/17) for images obtained at 10, 60 and 120 min and for the three sets of images together, respectively. CONCLUSION: Although the set of 99mTc-apcitide images obtained 120 min after injection showed good overall diagnostic accuracy, the combination of at least two sets of images provided the highest accuracy in detecting ADVT.

Infrarenal aortic stenosis: long-term clinical and hemodynamic results of percutaneous transluminal angioplasty.

PURPOSE: To evaluate the safety and long-term clinical and hemodynamic results of percutaneous transluminal angioplasty (PTA) of the infrarenal aorta. MATERIALS AND METHODS: During nearly 10 years, 102 patients with symptomatic infrarenal atherosclerotic aortic stenosis underwent PTA. Follow-up information was available in 92 patients (17 men, 75 women; mean age, 51.9 years). Stenosis involved the aortic bifurcation in 18 patients and only the infrarenal abdominal aorta in 74 patients. Technical success was defined as residual stenosis less than 50% or a pressure gradient less than 10 mm Hg after PTA. Clinical patency was defined as the absence or improvement of symptoms after PTA. Hemodynamic patency was defined as a normal Doppler waveform in the common femoral arteries, an ankle-brachial ratio greater than 0.95, or the absence of a thigh-brachial pressure gradient. RESULTS: Technical success was achieved in 78 patients after PTA. After 10 years, primary clinical and hemodynamic patency rates were 72% and 46%, respectively. After a mean follow-up of 51 months, 15 of the 22 symptomatic recurrences were due to aortic restenosis; 11 of these were treated with repeated PTA with or without stent placement, and three eventually required aortic surgery. No morbidity was encountered. CONCLUSION: Infrarenal aortic PTA proved to be safe and provided durable, long-term clinical improvement. In this group of relatively young patients, the clinical patency rate of PTA was equivalent to that of aortic surgery but with less morbidity.

Aortic graft infection: the value of percutaneous drainage.

OBJECTIVE: The goal of this study was to compare patients with aortic graft infection treated by primary percutaneous drainage with patients who initially underwent surgery. MATERIALS AND METHODS: A retrospective review of 23 consecutive patients treated for aortic graft infection was performed. Eleven patients were initially treated with percutaneous drainage and 12 were treated with surgery. The morbidity, mortality, and postprocedural reintervention rates and clinical outcome were analyzed for each group. RESULTS: The septic process resolved in nine (82%) of 11 patients treated with percutaneous drainage. Of these nine patients, four were treated with percutaneous drainage alone. Drainage was followed by removal of the infected prosthetic graft in the remaining five patients. In the surgical group, sepsis resolved in only four patients (33%) (p = .036). No periprocedural deaths occurred in the percutaneous drainage group, whereas six patients in the surgical group died in the perioperative period (p = .014). CONCLUSION: Percutaneous drainage can be used as an initial form of treatment in the management of aortic graft infections. Surgery after percutaneous drainage appears to be safer than surgery alone.

Lower extremity: nonstepping digital angiography with photostimulable imaging plates versus conventional angiography.

PURPOSE: To compare nonstepping digital subtraction angiography (DSA) (ie, storage phosphor radiography adapted to a stationary imaging plate changer) with conventional screen-film angiography in the evaluation of the lower extremities. MATERIALS AND METHODS: Fifty-one patients with peripheral vascular disease underwent both nonstepping DSA and screen-film angiography. The angiographic and radiologic techniques of both systems were kept identical for each patient. Three radiologists independently rated the overall quality of each angiogram. In their evaluations for each of 12 arterial segments on all 102 angiograms, they also rated the degree of opacification, the diameter reduction of the most severe stenosis, and their level of confidence. RESULTS: Mean overall quality scores and levels of confidence were better for nonstepping DSA than for screen-film angiography (P < .001). Full opacification was reported in 95.6% and 89.2% of all 1,836 segments with nonstepping DSA and screen-film angiography, respectively (P < .0001). The difference between the mean stenosis grades obtained with screen-film angiography and nonstepping DSA was not statistically significant. Intertechnique agreements were good (kappa = 0.77, 0.81, and 0.81), whereas interobserver agreements were influenced by the observer's experience with the imaging techniques. CONCLUSION: Nonstepping DSA images of the lower extremity were of better diagnostic quality than were screen-film angiograms. The development of dedicated nonstepping DSA equipment is warranted.

Detection of renal artery stenosis with Doppler sonography before and after administration of captopril: value of early systolic rise.

OBJECTIVE: The goal of this study was to assess the value of quantitative and qualitative analysis of the early systolic rise on Doppler waveforms obtained before and after administration of captopril in patients suspected of having renal artery stenosis. SUBJECTS AND METHODS: Seventy-one hypertensive patients (135 kidneys) were studied with transrenal Doppler sonography. Ninety-six kidneys were studied again after administration of captopril. All patients also underwent renal angiography. All Doppler studies were independently reviewed by two observers. Specific criteria for Doppler waveform patterns that were applied in the detection of renal artery stenosis included acceleration, acceleration time of early systolic rise, differential velocity of systolic rise, and resistive index. These criteria were then correlated with angiography, and receiver operating characteristic curves were generated. RESULTS: On the basis of waveform pattern recognition. Doppler sonograms obtained before administration of captopril had a sensitivity of 81% and a specificity of 98% for the detection of renal artery stenosis greater than or equal to 50%. Sensitivity of Doppler sonography obtained after administration of captopril was 100%, and specificity was 100%. For renal artery stenosis greater than or equal to 70%, sensitivity was 94% and specificity was 89% before administration of captopril. The area under the receiver operating characteristic curve for the acceleration criterion was significantly larger after administration of captopril (p = .009) for the detection of renal artery stenosis greater than or equal to 50%. After captopril administration, an acceleration threshold value of 440 cm/sec2 for early systolic rise was associated with a sensitivity of 100% and a specificity of 94% for the detection of renal artery stenosis greater than or equal to 50%. CONCLUSION: Doppler sonography of the renal arteries performed before administration of captopril appears to be an excellent screening tool in the detection of severe stenosis (> or = 70%). Administration of captopril improves the detection of renal artery stenosis greater than or equal to 50% with Doppler sonography when observers use both morphologic and quantitative criteria.

Percutaneous biliary drainage: clinical trial of analgesia with interpleural block.

PURPOSE: To determine the analgesic efficacy and safety of interpleural block for percutaneous biliary drainage. MATERIALS AND METHODS: In this double-blind study, 34 age- and sex-matched patients who were to undergo percutaneous biliary drainage because of malignant biliary obstruction were randomly assigned to the true-block group (30 mL 0.5% bupivacaine block) or placebo-block group; all had access to a patient-controlled analgesia (fentanyl) pump. Self medication, pain reports, blood pressure, heart rate, and oxygen saturation were monitored during and until 8 hours after drainage. The McGill Pain Questionnaire was administered 1 hour after biliary drainage. RESULTS: Patients in the placebo group self administered statistically significantly more fentanyl than did patients in the true-block group (P = .008). Peak pain scores (10-point scale) and McGill Pain Questionnaire scores were statistically significantly higher for the placebo group patients (P = .017 and P = .001, respectively). There were no differences between groups in terms of blood pressure, heart rate, and oxygen saturation. Two patients had pneumothorax caused by the interpleural block. CONCLUSION: Interpleural block was effective in decreasing pain and opioid requirements during and after percutaneous biliary drainage and did not compromise the cardiopulmonary status of the patient. However, the rate of pneumothorax was higher than previously reported.