Supra-aortic arterial stenoses: management with Palmaz balloon-expandable intraluminal stents.

PURPOSE: The authors report on the use of Palmaz balloon-expandable intraluminal metallic stents to supplement conventional balloon angioplasty and to primarily treat a variety of supra-aortic arterial atherosclerotic lesions manifested by claudication or embolic phenomena. PATIENTS AND METHODS: Results from a series of seven patients are reported. Five patients received stents following percutaneous balloon angioplasty (PTA): four patients received five stents for suboptimal initial result of PTA and one patient received one stent for early restenosis following successful PTA. Two patients received three stents primarily: one patient had one stent placed for a highly eccentric innominate lesion and the other patient had two stents placed for an ulcerated nonocclusive subclavian lesion causing blue digits. RESULTS: Treatment produced immediate angiographic or hemodynamic improvement in all seven patients. Clinical follow-up was obtained on all patients (mean, 10 months; range, 3-18 months). One patient had an episode of vertigo after PTA of a right subclavian lesion that resolved after thrombolytic therapy and stent placement. CONCLUSION: The placement of metallic stents in supra-aortic arteries represented an effective adjunct to PTA of atherosclerotic stenoses in these vessels. Primary stent placement may be an effective treatment for selected lesions.

Percutaneous transluminal angioplasty of the abdominal aorta.

PURPOSE: To determine the long-term results of percutaneous transluminal angioplasty (PTA) of focal infrarenal abdominal aortic stenoses. PATIENTS AND METHODS: Over a 10-year period, 15 focal infrarenal abdominal aortic stenoses were treated with PTA in 14 patients (13 women and one man; mean age, 53.2 years; range, 43-78 years). RESULTS: The initial technical success rate was 100%. Clinical patency, as defined by continued absence or improvement in symptoms after PTA, was achieved in 14 of the 15 angioplasty procedures (93%) with a mean duration of clinical follow-up of 4.3 years (range, 0.6-9.8 years) in the 14 patients. Long-term noninvasive follow-up demonstrated continued patency of the angioplasty site in 11 of 11 patients available for study. The mean ankle-arm index in these 11 patients was 0.95 (range, 0.9-1.0) at a mean follow-up of 4.8 years (range, 0.6-9.8 years). There was no significant morbidity or mortality associated with the angioplasty procedures. CONCLUSION: In view of the high degree of technical success and the excellent long-term patency, we believe that PTA should be considered a primary method of treatment in properly selected patients with focal abdominal aortic stenoses.

Disseminated histoplasmosis diagnosed by percutaneous needle biopsy of a retroperitoneal lymph node. A case report.

A case of disseminated histoplasmosis diagnosed by percutaneous needle biopsy cytology is reported. The patient presented with fever and pancytopenia. Computed tomography (CT) revealed retroperitoneal lymphadenopathy. Cytology smears prepared from a CT-guided screw needle biopsy of one of the lymph nodes showed numerous histiocytes with intracytoplasmic yeast forms consistent with Histoplasma capsulatum. Fungal cultures prepared from additional needle biopsy material confirmed the diagnosis. This case illustrates the utility of needle biopsy in the evaluation of radiographically detected retroperitoneal lymphadenopathy and in the rapid diagnosis of infectious disease in certain clinical settings.

Percutaneous placement of a hepatic vein stent in the treatment of Budd-Chiari syndrome.

The authors describe the first reported use, to their knowledge, of an intravascular stent to relieve hepatic vein stenosis causing the Budd-Chiari syndrome. A patient with severe stenosis of the left hepatic vein is described. Multiple balloon angioplasty procedures were performed over a period of several months and provided only transient relief of symptoms. As an alternative to surgical management, an intravascular stent was placed, with complete resolution of symptoms. Intravascular stent placement may play an important role in treatment of the Budd-Chiari syndrome.

Blue toe syndrome: treatment with percutaneous atherectomy.

"Blue toe syndrome" refers to digital ischemia of the foot in the presence of palpable or Doppler audible pedal pulses. This clinical syndrome is caused by microembolization to small vessels from a proximal source. The use of percutaneous transluminal atherectomy is described in the treatment of embologenic superficial femoral artery lesions in seven patients. All seven had prompt healing of the ischemic toes, and none required surgical revascularization or amputation. One patient developed a recurrent stenosis at the atherectomy site and had a second episode of digital ischemia, which was treated by means of atherectomy with a larger device. Histologic study of atherectomy specimens suggests that emboli arise from adherent fibrinoplatelet aggregates or thrombus and less often from cholesterol-rich atheromatous plaque. Although either percutaneous transluminal angioplasty or atherectomy can be used to treat the underlying stenosis, percutaneous atherectomy offers the advantage of nonsurgical removal of embologenic material and provides material for histologic study. Percutaneous atherectomy is an effective method of treating embologenic superficial femoral stenoses in patients with ipsilateral blue toe syndrome.

Translunate, palmar perilunate fracture-subluxation of the wrist.

Three cases of palmar perilunate subluxation associated with a fracture of the palmar pole of the lunate are described. Wrist hyperflexion with a longitudinal loading force transmitted through the capitate probably accounts for this injury.

Primary bladder carcinoma: evaluation with MR imaging.

Magnetic resonance (MR) imaging was performed in 23 patients (25 tumors) with proved bladder neoplasms. MR studies were retrospectively evaluated and compared with computed tomographic (CT) and pathologic findings. Bladder neoplasms, having a signal intensity intermediate between those of urine and perivesical fat, were best seen on T1-weighted and proton-density images. MR imaging was as accurate as technically well-performed CT studies in detecting extravesical tumor extension. MR could additionally be used to assess the integrity of the bladder wall. On T2-weighted images the normal bladder wall appeared as a thin, linear, low-intensity structure. The disruption of this low-intensity line was indicative of deep muscle invasion, whereas preservation of this low intensity line implied a more localized lesion. Although chemical shift artifacts might cause apparent disruption of the bladder wall, knowledge of this artifact coupled with additional imaging along different planes helps avoid misinterpretation of this artifact as deep muscle invasion.

MR imaging of the scrotum with a high-resolution surface coil.

Magnetic resonance (MR) imaging of the scrotum with a high-resolution surface coil was performed in ten healthy volunteers and 20 patients with scrotal abnormalities demonstrated by high-resolution real-time ultrasound (US). Four patients had an abnormal testis (two tumors, one cyst, one testicular atrophy), and 16 patients had extratesticular abnormalities (four hydroceles, five epididymal cysts, one hernia, and six cases of epididymitis). The normal structures of the scrotum were depicted clearly on MR images. In all cases, the tunica albuginea was easily differentiated from the testis and epididymis. MR imaging enabled one to distinguish intratesticular from extratesticular lesions and to determine whether a lesion was solid or cystic. Complicated and simple fluid collections could also be differentiated. In general, MR imaging and US scanning provided similar information. A potential advantage of MR imaging is in the evaluation of patients with painful scrotal lesions that may limit US evaluation.

Acute renal rejection versus acute tubular necrosis in a canine model: MR evaluation.

Findings of magnetic resonance (MR) imaging in acute renal rejection and acute tubular necrosis (ATN) were studied in dogs. On T1-weighted images, corticomedullary differentiation was absent in kidneys undergoing acute rejection. The loss of corticomedullary differentiation in these kidneys was secondary to a decrease in the relative signal intensity of the cortex, indicating prolongation of the T1 relaxation time of the cortex. In contrast, corticomedullary differentiation was preserved on T1-weighted images of autotransplanted kidneys and kidneys with ATN. MR imaging findings correlated with changes in water content in these three groups of kidneys. Kidneys undergoing acute rejection showed a marked increase in water content compared with kidneys in the other two groups. No change in fat content was found in any group.

Oblique magnetic resonance imaging of the cardiovascular system.

This exhibit demonstrates that cardiac anatomy can be imaged by MRI in oblique planes that are equivalent to views obtained radiographically or at angiocardiography. These MR images may be obtained either by simple patient positioning or by electronic rotation of the imaging axis. The advantages of this technique include its simplicity and its ability to show detailed anatomy noninvasively. Major cardiac structures including chambers, walls, vessels and bronchi are optimally demonstrated in long axis or cross section. This permits estimation of chamber volume, wall thickness, vessel position and variations from normal. Smaller structures are also well visualized. These include the pericardium, papillary muscles, azygos vein and some cross sectional anatomy of the coronary arteries and veins. The valvular structures can be shown during diastole or systole. The ability of MRI to show these cardiac structures due to the intrinsic contrast differences in signal intensity between muscle, fat, flowing blood and lung suggest an important future for MR cardiac imaging in a broad group of congenital and acquired diseases of the heart, pericardium and great vessels.

Urography with a low osmolality contrast agent. Comparison of Hexabrix with Conray 325.

A double-blind, parallel group comparison study of Hexabrix and Conray 325 for adult intravenous urography was performed. Sixty patients with a mean age of 54 years were included. Doses of contrast ranged from 0.5-1.1 ml/kg for both groups with a mean of 0.7 ml/kg. Hematology, urinary and biochemical laboratory tests were performed prior to the study in all patients and at 24 hours afterward in nearly half the group. Biochemical laboratory tests were done at 72 to 96 hours in approximately one third of the patients. Hexabrix proved satisfactory for standard urography at a chosen dose of 16 g of iodine (50 ml). There were no statistically significant differences in the diagnostic quality of the urogram in the two groups except for bladder filling. The decreased osmotic diuresis associated with Hexabrix necessitated delayed bladder filming for optimal evaluation. Excellent patient tolerance was achieved with less pain on injection with Hexabrix. There was one death in the Hexabrix group in a patient with multiple medical problems. Although the patient's medical problems appeared well controlled and did not meet specific rejection criteria, they almost certainly played a role in his death. Hexabrix may be useful for adult urography at a lower dose range, eg, 16 g iodine, than is typically used, which also may be cost effective (competitive) given the higher projected cost of the new low osmolar agents.

Magnetic resonance imaging of fibrosing mediastinitis.

Magnetic resonance imaging (MRI) was performed in seven patients with fibrosing mediastinitis. Comparison was made in each case to standard chest radiography and computed tomography (CT). Angiography was performed in three cases. Although MRI and CT were found to be equivalent in defining the extent of adenopathy, CT was superior at demonstrating calcifications, often important in making the diagnosis of fibrosing mediastinitis. MRI, however, offered complementary information, particularly in assessing vascular patency without the need for intravenous contrast media. On T2-weighted images, the adenopathy associated with fibrosing mediastinitis was noted to be of relatively low signal intensity, possibly indicating its benign nature.

Intravenous cholangiography in the CT era.

With the availability of computed tomography (CT), ultrasonography (US), percutaneous transhepatic cholangiography (PTC), and endoscopic retrograde cholangiopancreatography (ERCP), the use of intravenous cholangiography (IVC) has waned. A retrospective study of 69 intravenous cholangiograms performed from 1979 through 1982 assessed the utility of intravenous cholangiography, as well as its effect on patient management, at an institution where CT was highly developed. In no case after normal findings on CT and/or ultrasound examination did IVC make a positive pathologic diagnosis. After abnormal results on CT and/or US examinations, in no case did IVC add to the diagnosis. Finally, after technically suboptimal results of CT and/or US examinations, IVC made only 1 positive pathologic diagnosis. Overall, IVC correctly demonstrated only 5 of 9 cases of common duct stones or strictures. Of the 26 cases with anatomical correlation there were a total of 7 false-positive and -negative IVC examinations. In this series, IVC was rarely useful in the diagnosis of biliary tract disease. Given the high inaccuracy rate of IVC in this study, its use for the exclusion of biliary tract disease is discouraged.

Renal ablation using hot contrast medium: an experimental study. Work in progress.

Ablation of the kidney was attempted in 12 dogs by injecting 10-30 ml of heated (100 degrees C) contrast medium (Hypaque-60, diatrizoate meglumine) into the renal artery. Complete renal ablation without collateralization was demonstrated. Hot contrast medium is an effective embolic agent, and its use is associated with few of the drawbacks of presently used techniques.

Spermatic vein obliteration using hot contrast medium in dogs.

Obliteration of varicoceles in men with infertility has been shown to improve semen quality and increase fertility rates. Many current techniques involve complex procedures and specialized equipment and may be associated with adverse effects. Transcatheter thermal vessel occlusion was utilized for spermatic vein obliteration in dogs. Diatrizoate (76%) contrast medium at a temperature of 100 degrees C was injected into canine spermatic veins. Follow-up venography and histologic examination revealed thrombosis of the injected veins without damage to the surrounding tissues in all cases. Clinical and laboratory examination of the animals revealed no adverse systemic effects. It is concluded that transcatheter thermal venous occlusion is an effective technique for spermatic vein occlusion in a canine model.

Work in progress. Transcatheter thermal venous occlusion: a new technique.

Diatrizoate (76%) contrast agent heated to 100 degrees C was injected into the veins of dogs and one human volunteer for the nonsurgical occlusion of the vessels. Follow-up venograms and histologic examinations, at intervals varying from one day to four weeks later, revealed thrombosis of the injected veins in all animals. Thrombosis occurred one to five days after injection of contrast agent. The authors conclude that hot contrast medium is a safe and convenient agent for inducing thrombosis. It is much easier to use than mechanical devices, tissue glues, and plastics, which involve complex procedures and specialized equipment. In contrast to other sclerosing agents, hot contrast agent is rapidly converted into a nonsclerosing agent by cooling. The new technique allows a more controlled thermal injury to the vascular wall and is under fluoroscopic control.