Early pulmonary involvement in systemic sclerosis assessed by technetium-99m-DTPA clearance rate.

UNLABELLED: Systemic sclerosis (SS) is frequently associated with interstitial lung disease, but clinical symptoms and radiologic abnormalities may occur late in the course of the disease. This study investigated early pulmonary involvement by assessing the clearance rate of inhaled 99mTc-diethylenetriaminepentaacetic acid (DTPA). METHODS: Sixteen patients with proved SS, no clinical pulmonary symptoms and normal chest radiogram were prospectively studied. The 99mTc-DTPA clearance rate was calculated as the time to half clearance (T1/2) and compared with values obtained in healthy nonsmokers. RESULTS: Six patients showed abnormally increased clearance (T1/2 < 53 min). Rapid clearance was not correlated to SS disease duration or to abnormal pulmonary function tests. Five of six patients with abnormally increased clearance underwent high-resolution CT, which in all five demonstrated pathologic findings that were suggestive of early interstitial disease. CONCLUSION: These findings indicate that in SS asymptomatic patients may frequently present with abnormal 99mTc-DTPA clearance; 99mTc-DTPA lung scintigraphy may allow early detection of subclinical pulmonary involvement in SS.

Prognostic value of captopril renal scintigraphy in renovascular hypertension.

This study evaluates the prognostic value of captopril renal scintigraphy in hypertensive patients undergoing renal artery revascularization. Preoperative studies of 51 patients were correlated with blood pressure results at 6- and 12-mo follow-up. Captopril-renal scintigraphy was carried out 1 hr after oral administration of 50 mg of captopril, using either 220 MBq of 99mTc-DTPA or 74 MBq of 99mTc-MAG3, followed by a baseline study in case of abnormal results. Evidence of amelioration or normalization in relation to captopril study was considered predictive of blood pressure control following treatment. Blood pressure response was favorable in 37 patients, but failed to show any improvement in 14. The scintigraphic test was positive in 33 patients (15 cured, 17 improved, 1 failed) and negative in 18 (3 cured, 2 improved, 13 failed). Sensitivity and specificity for renovascular hypertension was 86.5% and 93%, respectively. For blood pressure cure and improvement, the test had positive and negative predictive values of 97% and 72%, respectively. A positive preoperative captopril renal scintigraphic result is a strong predictor of hypertension curability by renal artery revascularization.

A rare case of type I aortic dissection.

Aortic dissection is the most common acute disease of the aorta. It can occur in different clinical ways depending on the particular anatomical segments involved. The sudden appearance of claudicatio in the lower limbs may be indicative.

In vivo ultrasonic parametric imaging of carotid atherosclerotic plaque by videodensitometric technique.

Extensive experimental and clinical data show that the ultrasonic image conveys information on the biochemical composition of the atherosclerotic plaque, ie, the relative content of lipids (hypoechoic), fibrous tissue (hyperechoic), and calcific deposits (very echogenic with shadowing). A more dishomogeneous echo structure of the plaque is also more often associated with clinically complicated carotid plaques. To date, however, the assessment of plaque density and homogeneity by transcutaneous B-mode imaging remains subjective and qualitative. The aim of this study was to assess whether plaque echodensity and homogeneity might be established on a more objective and quantitative basis by description of the spatial distribution of echo amplitude (referred to as tissue texture) applied to digitized images, obtained with commercially available B-mode transcutaneous imaging systems. A total of 47 B-mode images derived from echotomographic studies in 10 patients were digitized off line. For each region of interest, a set of first-order (mean gray level, standard deviation, skewness, kurtosis: mathematical descriptors of the shape of the frequency distribution of gray-level histogram) and of second-order (entropy, angular moment: mathematical descriptors of the spatial distribution of gray levels within the region of interest) textural parameters were evaluated. The visual, concordant reading by two independent, experienced observers assigned the plaques on the basis of qualitatively assessed echodensity to three groups: "soft" (n = 18), "fibrotic" (n = 20), "calcific" (n = 9). Regarding spatial gray-level distribution, 46 plaques would be separated into "homogenous" (n = 17) and "dishomogeneous" (n = 29). On digitized images, the normalized mean gray level was the most effective first-order textural parameter for distinguishing soft (24.2 +/- 12.4 arbitrary units in a zero to 255 scale) from fibrotic (64.5 +/- 16.4) and calcific plaques (125.3 +/- 24.5), P < 0.01 for all intergroup differences. "Homogeneous" plaques were separated from "heterogeneous" ones on the basis of entropy (5 +/- 1 vs 7.9 +/- 9.7; P < 0.01), whereas the values of angular second moment overlapped (1.542E-3 + 1.334E-3 vs 5.181E-4 +/- 2.5615E-4, P = ns). In conclusion, quantitative texture analysis of ultrasonic images derived from transcutaneous, high-resolution, commercially available B-scan systems is feasible in man and provides a quantitative operator-independent assessment of plaque echodensity and homogeneity.

[Use of a minor fibrinolytic drug (mesoglycan) in phlebitis]. / Sull'utilizzo di un farmaco fibrinolitico minore (Mesoglicano) nelle flebopatie.

33 subjects (28 women and 5 men), aged 22-72 and suffering from various types and degrees of venous pathology (varicose syndromes, post-phlebitic syndromes, recent thrombophlebitis) were subjected to clinical study. All patients were treated with Mesoglycan, a fibrinolysis stimulating drug, in oral doses of 2 12 mg capsules 3 times a day for 30 days. The study was intended to show the effectiveness of such treatment, and consisted of a clinical and instrumental assessment of the subjective and objective symptoms associated with venous conditions. The results obtained were analysed statistically and confirmed the therapeutic effectiveness of Mesoglycan for this type of pathology, particularly for thrombophlebitis where treatment produced early and lasting results. In conclusion, both the experimental findings and the clinical results obtained, confirm the view that Mesoglycan is a drug of choice for the prevention and treatment of venous pathologies.

[Ultrasonographic diagnosis of venous thrombosis: color Doppler and power Doppler]. / Diagnostica ultrasonica della trombosi venosa: il color-Doppler ed il power Doppler.

Eco color-Doppler (ECD) and Power Doppler (PD) currently allow an accurate and early diagnosis of deep venous thrombosis (DVT). "Ecocontrasts" boost sensitivity. The simple test of ultrasound probe compression shows excellent sensitivity in the proximal venous segments, comparable to a full ECD: the latter is preferable for distal segments. Ultrasound probe compression is not sufficient as the sole test when studying suspected leg DVT, but may form an integral part of a complete ECD study. The accuracy of ECD used in segments that are difficult to evaluate (iliac axes, inferior vena cava) has improved considerably thanks to PD. At these levels, it is certainly not possible to use ultrasound probe compression alone. The same is true for the diagnosis of recidivation, where a complete ECD is required to evaluate thrombotic overlap indicating true rethrombosis of partial or fully recanalised blood vessels. Phlebography no longer represents the gold standard for diagnosis compared to ultrasound techniques. Its use is limited to discriminating between genuinely doubtful and discordant cases of DVT and the search for occult embolic sources in patients with severe pulmonary embolism. The usefulness of an extensive study of venous vessels is gaining increasing confirmation, using the full potential of eco-Duplex methods in the systematic search for thrombotic lesions. The possibility of obtaining as much information as possible during the first complete scan reduces the costs of the procedure and is more accurate for the diagnosis of suspected DVT recidivation.

Management of patients with carotid stenosis.

Carotid atherosclerosis is one of the main risk factors for ischemic stroke. The annual risk of ipsilateral stroke for asymptomatic, albeit severe stenoses is as low as 1 to 2%, but increases to 13% in patients with recent ischemic symptoms. However the risk decreases after the first 2-3 years from the symptomatic episode, dropping to 3%. Echo-color Doppler ultrasonography is the screening method of choice, being highly accurate, noninvasive and low-cost. Carotid angiography still represents the gold standard, however, less invasive techniques as RM angiography and Angio-CT are becoming increasingly common. Based on NASCET, ECST and ACAS results, carotid endarterectomy (CE) is strongly recommended for severe symptomatic stenoses, while for the moderate symptomatic and the severe asymptomatic ones the benefit in terms of stroke risk reduction is modest and surgery should be restricted to selected cases in surgical centers of high experience. For severe asymptomatic stenoses NNT is too high to recommend indiscriminate surgery; we are waiting for the results of ACSRS trial, designed to identify a subset of patients at risk of ipsilateral stroke greater than 4%/y, that may be considered for CE, while patients at low risk will be spared from unnecessary operation. Apart from surgery, in all patients with carotid atherosclerosis correction of cardiovascular risk factors is mandatory. Antiplatelet therapy (ASA alone or with dypiridamole, ticlopidine) is effective in secondary prophylaxis of athero-thrombotic stroke; its use in asymptomatic carotid stenoses can be recommended, even if more because of a plausible rationale than of clinical trial-based evidences.

[Duplex and Doppler color echocardiography for the study of renovascular hypertension. Comparison with arteriography]. / Eco-duplex e color-Doppler nello studio dell'ipertensione reno-vascolare. Confronto con l'arteriografia.

Doppler US was employed to examine 46 patients with suspected renovascular hypertension (RVI) to detect stenosis/occlusion of the renal artery. In 25 cases duplex-Doppler technique was used, in 19 color-Doppler US, and 2 patients were examined with both methods. Doppler US was always performed before angiography which was considered as the reference gold standard. Using duplex-Doppler US, the diagnosis of renal artery stenosis was based on qualitative (spectral analysis of the waveform and absence of flow signal in cases of renal artery occlusion), and semiquantitative parameters (resistive index). Diagnostic accuracy of duplex US--which was compared with that of angiography--was 83%, its sensitivity was 91.6%, and specificity was 85%. With color-Doppler, two additional quantitative parameters were used (peak systolic frequency shift at the stenosis and stenosis index). In this group of patients sensitivity was 70%, specificity was 100%, and accuracy 85%. The good diagnostic yield of the method is counter-balanced by some limitations--e.g., operator dependence and long examination time (30-40 minutes, especially with duplex US). In the authors' opinion, Doppler technique can be used in the diagnosis of RVI, even though further study is necessary to exactly define diagnostic parameters, and to verify reproducibility and both inter- and intra-observer repeatibility. Technological progress may in the future reduce both difficulty and time of the examination.

[Color-Doppler and angioplasty in renovascular hypertension]. / Color-Doppler e angioplastica nell'ipertensione renovascolare.

Renovascular hypertension is defined as a kind of hypertension secondary to altered renal perfusion with the activation of the renin-angiotensin system. Since a large number of these patients benefits from treatment--be it medical, surgical or angioplastic--a non-invasive low-cost method allowing accurate screening was looked for. Color-Doppler was employed by many authors to evaluate renovascular hypertension, for both the early diagnosis of the condition and the evaluation of treatment results in renal artery stenoses. However, the authors agree that color-Doppler cannot play a major role in the screening of renovascular hypertension due to the various qualitative and quantitative variables not being adequately codified, to the lack of a single color-Doppler method and to the difficult comparison of the results from the different units. Nevertheless, improved results are promised by technological evolution, together with the possibility to codify color-Doppler variables more easily repeatable. B-mode units with 3.5 and 5 MHz probes were employed in the thinnest subjects. In 5-25% of cases accessory renal arteries were observed. After identifying the vessel to be studied with several spatial scans, the smallest possible sample volume (usually 3-5 mm) was positioned. The normal flowmetric range was 0.07-0.1 s: it must not exceed 0.16 s, with persistence of high diastolic flow. Some authors' criteria were followed to define either stenosis or renal artery obstruction; moreover, pulsatile flow index was considered, together with the resistive index, pulsatility index and stenosis index.

[Renal artery stenosis. Doppler color study before and after angioplasty]. / Stenosi delle arterie renali. Studio color-Doppler prima e dopo angioplastica.

Doppler flowmetry can be successfully employed to assess arterial patency after percutaneous transluminal angioplasty (PTA). The aim of this study was to assess color Doppler sensitivity in detecting renal artery stenosis prior to percutaneous angioplasty (PTRA) and vessel patency after it. Eleven patients (7 males and 4 females) affected with renal artery stenosis, unilateral in 9 cases and bilaterally in 2, underwent color-Doppler evaluation 1 day before and 7 days after PTRA. The operator was unaware of dilatation results. A total of 13 stenoses were treated. The qualitative and quantitative parameters we employed were: a) broadening of the spectrum, b) peak systolic frequency > 4000 Hz, c) stenosis index > 50%. Before PTRA, mean systolic peak at the stenosis was 7978 (range 4050-12500 Hz), while stenosis index was 71.9% (range 48-89%). After PTRA complete recovery was observed in 5 cases, no improvement in 1 and incomplete recovery in 7. Doppler results were in agreement with those of angiography in 6/13 while partial agreement only was seen in 7/13. Our results, although obtained in a small and highly selected group of patients, would seem to support the value of color-Doppler for the follow-up of patients after PTRA.

Evaluation by captopril renal scintigraphy and echo-Doppler flowmetry of hypertensive patients at high risk for renal artery stenosis.

Sixty-three hypertensive patients with probability of obstructive renal artery disease underwent both Captopril renal scintigraphy (CRS) and echo-Doppler flowmetry (EDF) before undergoing renal angiography. Angiography revealed renal artery stenosis (RAS) in 42 patients (unilaterally in 26 and bilaterally in 16). The sensitivity and specificity in the identification of RAS > or = 50% were 90% and 94%, respectively for Captopril renography, and 85% and 78% for echo-Doppler flowmetry. Captopril renography correctly identified stenoses greater than 50%, which is usually held to be the limit of hemodynamic significance. While the Doppler examination was more sensitive than Captopril renography (sensitivity 79% versus 64%) in the detection of all degrees of RAS, less information on the functional significance of RAS was provided. Both CRS and EDF could be usefully employed to assess kidney perfusion, but their appropriate clinical use must take into account inherent differences between the two techniques.

[Results of the use of the Strecker and Palmaz stents in the iliac artery region. Two years' experience]. / Risultati dell'impiego degli stent di Strecker e di Palmaz nel distretto arterioso iliaco. Esperienza di due anni.

Our personal experience is reported with the use of vascular endoprostheses (Strecker and Palmaz stents) in the non-surgical treatment of iliacofemoral steno-occlusive arteriopathy. Over a 15-month period, 56 PTAs were performed in 40 patients; 20 vascular endoprostheses were positioned--17 Strecker and 3 Palmaz stents--in 16 patients, to correct such PTA complications as dissections or to improve the results of a suboptimal PTA maneuver. Venous DSA follow-up was performed at 30 days, and serial color-Doppler US studies were performed every fourth month. Immediate and satisfying clinical results were observed in 15/16 patients (93.7%): only one case of acute thrombosis following the procedure was observed, which could not be treated with intraarterial fibrinolytic therapy and was therefore operated on. Overall long-term patency rate is 100%, mean follow-up is 13.8 months. Finally, the indications for the use of such devices in iliacofemoral arteriopathies are critically discussed, together with the criteria of choice of a type of stent over another one, the immediate and long-term results and the best follow-up protocols.