Primary stenting of the superior mesenteric artery for treatment of chronic mesenteric ischemia--a case report.

Percutaneous transluminal angioplasty (PTA) has been well described in the treatment of mesenteric artery stenoses but has met with limited success in ostial lesions. The authors describe a case of a 79-year-old woman diagnosed with chronic mesenteric ischemia associated with a 22-pound weight loss and postprandial pain. The celiac axis and inferior mesenteric artery were occluded. A high-grade, calcified stenosis was present in the proximal superior mesenteric artery. This was treated with primary stent placement using a Palmaz stent deployed from an axillary approach. A brief discussion of mesenteric ischemic and visceral artery PTA is included.

Clinical follow-up of patients after a negative digital subtraction pulmonary arteriogram in the evaluation of pulmonary embolism.

PURPOSE: This study was designed to examine the clinical course of patients following digital subtraction pulmonary arteriography (DSPA) interpreted as negative for pulmonary emboli (PE). MATERIALS AND METHODS: Sixty-three patients underwent DSPA interpreted as negative for PE over a 27-month period. Follow-up data were collected by means of medical and diagnostic radiology record review, interviews of referring physicians, and patient telephone interviews. RESULTS: Of 63 patients, two were excluded and seven were lost to follow-up, leaving a study population of 54 patients. Mean follow-up was 12.1 months (range, 0-28.5 months). Thirty-one reported no symptoms of PE. Of 13 patients reporting intermittent chest pain and/or dyspnea during their mean follow-up of 13.6 months, 10 had a history of cardiac, nonthrombotic pulmonary, or gastroesophageal reflux disease. There were no subsequent positive angiograms or ventilation/perfusion scans. Comorbid conditions in the 10 patients who died included cardiac events (n = 4), advanced cancer (n = 2), sepsis/pneumonia (n = 2), sarcoidosis (n = 1), and cerebrovascular accident (n = 1). No documented PE was identified. CONCLUSION: The technique of DSPA is sufficiently sensitive to exclude clinically significant PE. The advantages of image post-processing, in addition to the savings in cost, time, and contrast media, support its use in the angiographic diagnosis of PE.

Percutaneous retrieval of a surgical laparotomy sponge from the peritoneal cavity.

Percutaneous retrieval of an extravascular foreign body is an uncommon procedure. This report describes the successful retrieval of a 46 x 46-cm laparotomy sponge from the peritoneal cavity using a Nitinol Gooseneck Snare system. This technique can eliminate the need for exploratory surgery and may be particularly useful in poor operative candidates.

Double-blind study of a new nonionic contrast agent for digital subtraction arteriography.

RATIONALE AND OBJECTIVES: Since the development of the first low-osmolality contrast agent in 1969, a new group of ionic and nonionic compounds have emerged. These new agents have dramatically improved diagnostic imaging by exhibiting significant improvements in safety and technical efficacy over that of high-osmolality agents. This study was designed to compare the safety, tolerance, and technical efficacy of iopromide, a new low-osmolality, nonionic contrast agent, with that of both ioversol and iopamidol for digital subtraction angiography (DSA). METHODS: One hundred fifty patients with conditions requiring intraarterial digital subtraction angiography were randomly assigned to receive 150 mg I/mL iopromide or either 160 mg I/mL ioversol or 128 mg I/mL iopamidol. Cerebral, aortovisceral, and peripheral arteriography was performed. RESULTS: No significant difference was found in safety, tolerance, and technical efficacy between iopromide and ioversol. Iopamidol had significantly less technical efficacy than iopromide, but there were no significant differences in safety or tolerance between these two agents. CONCLUSIONS: All three contrast media (CM) are useful for cerebral DSA. Although these agents were diagnostically adequate for use during aortovisceral and peripheral DSA, none was able to optimally opacify vessels during these studies in the concentrations administered.

Percutaneous retrieval of foreign bodies: experience with the nitinol Goose Neck snare.

PURPOSE: The authors present their experience with the nitinol Goose Neck snare system in the retrieval of retained foreign bodies in 20 patients. PATIENTS AND METHODS: Foreign bodies were located in the vascular system in 13 patients, urinary tract in four, biliary system in one, gastrointestinal tract in one, and the peritoneal space in one. All retrievals were performed with use of standard angiographic/interventional techniques. RESULTS: Success was achieved in all cases without attendant complications. Foreign bodies removed included catheter and guide-wire fragments, an embolization coil, broken or occluded double pigtail catheters, a Wallstent, and a surgical laparotomy sponge. CONCLUSION: All procedures were performed quickly, safely, and without difficulty. Because of its excellent torque control, positive grasping capacity, excellent radiopacity, lack of traumatic effect, and availability in different sizes appropriate for use in a wide variety of difficult anatomic spaces, the authors recommend that this device be considered the first choice for all foreign body retrieval procedures.

Stent placement in a splenic vein stenosis after TIPS creation.

A hemodynamically significant splenic vein stenosis was found during placement of a transjugular intrahepatic portosystemic shunt in a patient with gastric variceal bleeding. A second stent was placed across the splenic vein stenosis, which was obstructing normal hepatopetal flow, causing venous hypertension in the splenic and short gastric veins. This produced a successful hemodynamic and angiographic result and, clinically, controlled the patient's bleeding.

Angioplasty, bypass surgery, and amputation for lower extremity peripheral arterial disease in Maryland: a closer look.

Tunis and colleagues attempted to assess the effect of peripheral angioplasty in a large population with descriptive epidemiologic methods. Their study suffered from a vague statement of purpose, inappropriate and inadequate outcome measures, undetermined differences in prevalence of peripheral vascular disease and prevalence of risk factors for bypass/amputation in 1989 versus 1979, no differentiation between levels of amputation or between primary and secondary amputation, lack of a unique ICD-9-CM code indicating angioplasty for peripheral vascular disease of the lower extremities, lack of unique patient identifiers, a mistaken perception of the adoption of angioplasty as "widespread" in Maryland, and the assumption of uniform coding accuracy throughout the period of study. We conclude that the study design of Tunis et al was inadequate to determine the beneficial effects of angioplasty or bypass surgery in the treatment of peripheral vascular disease. Moreover, the conclusion by Coffman (2) that "invasive procedures are indicated only for the severely ischemic limb" is completely unsupported by the study data. Physicians should not attempt to apply the results of the study by Tunis et al to individual case situations. It should be further appreciated that the study findings do not provide an adequate basis for policy-making decisions. It is clear that important clinical questions concerning the roles of angioplasty, bypass, and amputation should be answered with more definitive studies.

Femoropopliteal angioplasty. Factors influencing long-term success.

Prospective data was recorded on 217 percutaneous transluminal angioplasty (PTA) procedures performed in the superficial femoral and popliteal arteries over an 8-year period. After the initial procedure, patients were followed with serial noninvasive studies and, in 71 patients, repeat angiography. The mean follow-up period was 7 years (range, 2-11 years). Standard life-table survival analysis was used to assess the factors potentially affecting long-term outcome. Excluding an initial technical failure rate of 10%, overall patencies at 1, 3, and 5 years were 81%, 61%, and 58%, respectively. After the first year, the prognosis (i.e., failure rate) appears to be linear over the long term (i.e., up to 10 years). Factors negatively influencing long-term patency include the presence of diabetes mellitus, diffuse atherosclerotic cardiovascular disease, or threatened limb loss. Technical factors correlated with failure include lesion length, moderate eccentricity, and a poor post-PTA appearance.

Optimizing heparin utilization in angiographic flush solutions.

Various concentrations of heparin in angiographic flush solutions are employed during angiography. In an effort to determine whether differences in outcome are seen when either high or low concentrations of heparin in angiographic flush solutions are utilized, two groups of patients were evaluated. There was no difference in outcome and a small systemic effect from heparin was seen in both groups. Use of a low concentration of heparin is suggested for routine angiography.

Angioplasty-induced dissections in human iliac arteries: management with Palmaz balloon-expandable intraluminal stents.

Intravascular stent placement may be an effective treatment for percutaneous transluminal angioplasty (PTA)-induced dissection. Among the first 228 patients treated with Palmaz balloon-expandable intraluminal stents (BEISs) for iliac artery stenosis, stents were used to treat PTA-induced dissection in at least 12 iliac arteries in 11 patients. All 12 vessels were shown by angiography to be severely dissected. Stents were placed at the time of PTA in six vessels and as a separate procedure in the other six. An average of three stents per vessel were employed. All arteries showed marked improvement at angiography. Angiographic follow-up was obtained for eight vessels in seven patients at a mean follow-up time of 12.9 months. All had patent stent lumens with neointima formation, although one stented lumen had narrowed, and another clinical failure occurred despite a patent stented vessel and an ankle-arm index (AAI) of 1.35. With a mean clinical follow-up of 9.5 months, the mean AAI for the stented extremities in the nine remaining patients is 0.91 +/- 0.15. Palmaz BEISs are effective in the management of PTA-induced human iliac artery dissection.

Angiography in poor-risk patients with massive nonvariceal upper gastrointestinal bleeding.

The purpose of this retrospective study was to determine the diagnostic and therapeutic usefulness of gut angiography in patients with massive upper gastrointestinal bleeding from a nonvariceal source. All patients (n = 64) in this category who underwent a gut angiogram between 1980 and 1986 were studied. Pre-angiogram endoscopy was attempted in all patients and was nondiagnostic in 14 (22%). Contrast extravasation at angiography was seen in 25 of 64 patients (39%), and in over half of these patients endoscopy was nondiagnostic (n = 11) or wrong (n = 3). Attempts to control bleeding in this group by selective arterial embolization (n = 14) or intra-arterial vasopressin (n = 11) successfully averted operation in 13 of 25 patients (52%) and was associated with a 50% reduction in mortality (83% versus 38%). Selective embolization of vessels thought to be bleeding on clinical grounds without evidence of contrast extravasation (i.e., "blind" embolization) was not helpful in controlling hemorrhage. Urgent gut angiography in patients with massive upper gastrointestinal bleeding of arteriocapillary source is a useful diagnostic and therapeutic maneuver and warrants continued application in this group of poor-risk patients.

Obstructions of the hepatic duct confluence: internal drainage of bilateral lesions with a single catheter.

Strictures at the confluence of the right and left hepatic ducts are difficult to treat surgically, endoscopically, or percutaneously. Percutaneous decompression techniques previously described involved separate transhepatic catheterizations of the isolated right and left ducts. In the present study, modifications of existing self-retaining loop drainage catheters allowed bilateral internal biliary drainage of isolated right and left hepatic ductal systems with a single catheter in three patients. The technique can be used for primary palliation and for recurrent strictures after hepaticojejunostomy.