Angioscintigraphic assessment of arterial and portal liver blood flow: comparison with splanchnic angiography.

In order to validate an angioscintigraphic method for the evaluation of the components of hepatic blood flow, the results of angioscintigraphy were compared with splanchnic angiography in 25 cirrhotics. Two indices of hepatic portal perfusion and a splenohepatic arterial index were calculated. These were correlated with portal diameter and hepatic artery diameter, respectively. No correlation was found between grades of portal perfusion according Nordlinger's criteria and these indices. The method is very simple and could be applied to evaluate the changes of liver hemodynamics induced by drugs or shunt surgery.

[Pharmaco-radiodiagnosis of the digestive tract]. / La farmaco-radiodiagnostica dell'apparato digerente.

A brief account of the subject from the chronological standpoint is followed by a classification of the drugs most often used in radiological examination of the digestive tract into two groups according to their effects on individual viscera, namely excitomotor and hypotonising drugs. The indications and contraindications for each drug are explained, and the most common methods for the pharmacoradiological investigation of each organ are indicated. It is felt that this form of examination leads to an earlier radiological diagnosis and one more consonant with the real anatomical and pathological situation.

Cholangiographically-enhanced CT of the pancreas and biliary tree.

Cholangiographically-enhanced CT scans were performed on nine patients with biliary obstruction or suspected pancreatic masses. The opacification of the biliary tree was obtained by slow infusion of 25 ml of cholangiographic contrast medium diluted in 75 ml of saline and administered 45 mins before the CT examination. Two separate CT sequences were obtained, one with cholangiographic contrast alone, the other with associated parenchymal enhancement. The tolerability of the overall procedure was very good. The measurement of the HU values of the biliary ducts showed a marked increase in bile density. These structures could easily be appreciated within the liver and in the porta hepatis; the pancreatic head and its relationships with the main bile duct were evident. The densitometric measurement of the liver parenchyma before and after contrast enhancement did not show any variation with respect to the standard HU values. Cholangiographically-enhanced CT proved to be useful for the diagnosis of biliary obstruction; it may also be a promising diagnostic tool for the evaluation of pancreatic masses.

[Holter-detected myocardial ischemia. Impact for prognosis and decision making after acute myocardial infarction]. / Ischemia all'Holter. Impatto prognostico e decisionale nel post infarto.

BACKGROUND: Aim of the study was to evaluate the prognostic and decision making value of Holter detected myocardial ischemia after acute myocardial infarction in comparison with clinically detected postinfarction angina and exercise test. METHODS: To this aim the patients consecutively admitted to our coronary care unit with acute myocardial infarction during one year were retrospectively evaluated. One hundred and eighty-nine patients (age 70+/-11 years, 137 male and 51 female) had a 24 hour Holter monitoring. One-year follow up of these patients was obtained. RESULTS: Myocardial ischemia was detected by Holter monitoring in 21 patients (11%), 4 with and 17 without angina. Symptom limited exercise test was obtained before discharge in 116 patients (62%): 45% were positive, 42% non-diagnostic and 13 negative for myocardial ischemia. Post infarction angina was present in 15 patients (9%). Patients with Holter detected myocardial ischemia were older (73+/-10 vs 66+/-11 years, p<0.05) and had higher prevalence of both angina and positive exercise test (p<0.01). One-year follow up was obtained in 186 patients. Holter detected myocardial ischemia positive predictive value for death or reinfarction was 15%, negative predictive value was 90%, similar to the absence of angina (90%) and the absence of positive exercise test (93%). Angina and exercise test identified 62% of patients with Holter detected myocardial ischemia. Residual myocardial ischemia was exclusively observed by Holter monitoring in 4% of the population, particularly in 1 patients with and 7 without exercise test. CONCLUSIONS: The additive contribution of Holter detected myocardial ischemia in the prognosis and decision making of post infarction patients is rather scanty.

[Stress imaging in coronary artery disease: state of the art]. / Stress imaging nella cardiopatia ischemica: stato dell'arte.

To date, several diagnostic tools allow an accurate non-invasive evaluation of coronary artery disease; this is due to the great progress in echocardiographic and nuclear imaging techniques in the last 10 years. The large availability of different stress imaging techniques allows to choose the most appropriate technique for each patient according to the clinical characteristics. This paper presents the state of the art of echocardiographic and nuclear stress imaging for the diagnosis of coronary artery disease and for the prognostic stratification of infarcted patients. Advantages and limits of the different techniques are described rather than putting in competition echo and nuclear cardiology as has often been done in the past. Cardiologists should select among the various techniques on the basis of clinical characteristics of single patients, center's experience and an objective evaluation of economical aspects.

[Hematoma of right ventricular outflow tract mimicking an infiltrating tumor as a consequence of acute aortic dissection]. / Dissecazione aortica acuta complicata da ematoma del tratto di efflusso ventricolare destro.

The aortic dissection may be associated with unusual complications such as fistula formation and vascular compression. We describe a case of a 71-year-old patient admitted to our Hospital because of acute chest pain; transthoracic and transesophageal echocardiography revealed the presence of a type A aortic dissection associated with a mass infiltrating the right ventricular outflow and proximal tract of the pulmonary artery. The ultrasonographic morphology and the surgical findings showed the presence of a hematoma which was consequent to acute aortic dissection and which mimicked a tumor infiltrating the right ventricular outflow.

[A case of an aneurysm of the main pulmonary artery and of its 2 branches]. / Un caso di aneurisma dell'arteria polmonare principale e dei due rami.

A case of a 76-year-old female with a large aneurysm of the main pulmonary artery and initial tract of its branches is reported. Literature is reviewed as to possible etiopathogenesis. Based on past medical history, clinical findings and investigative procedures, we hypothesize a possible congenital origin of the anomaly; its gradual aggravation might be due to the development of pulmonary hypertension.

[Efficiency of tetracaine in digital angiography of the blood vessels of the neck]. / Efficacia della tetracaina nell'angiografia digitale dei vasi del collo.

Deglutition artifacts often degrade diagnostic quality in digital subtraction angiography (DSA) of neck vessels. In order to reduce this drawback, the authors gave a local anesthetic (Tetracaine) to the patients undergoing DSA of aortic arch and carotid arteries. Hundred-twenty-three subjects divided into two groups were examined: Tetracaine was administered to one group (64 patients) and not to the other (59 cases). In the first group deglutition artifacts were not noted in 59/64 cases. Among those patients not treated with Tetracaine/deglutition artifacts were absent in 45/59 cases. This local anesthetic did not produce important toxic reactions. Therefore the authors believe that administration of local anesthetics can reduce deglutition artifacts in DSA of neck vessels.

[Radiologic aspects of non-Hodgkin lymphomas of the kidney]. / Les aspects radiologiques des lymphomes non-Hodgkiniens du rein.

The authors review a series of 992 patients presenting with non-Hodgkins lymphoma and treated by the Milan Cancer Institute between 1968 and 1977. Intravenous urography was performed in 237 cases but only revealed 9 patients (3.8%) with non-Hodgkin lymphoma. Comparison of this low percentage with the 35% shown by necropsy examinations (9 mths) highlights the difficulty of detecting this condition by urography. The authors therefore recommend completion of the diagnosis by other radiological techniques (CT scan, renalarteriography (3 cases) and non-invasive examinations (ultrasound scanning, or Ga67 scintigraphy).

[Intra-arterial digital angiography of the liver and portal system]. / L'angiografia digitale intra-arteriosa del fegato e del sistema portale.

Twenty-seven patients were evaluated by intra-arterial digital subtraction angiography: 20 for portal hypertension--6 also after a porto-systemic shunt--, 4 for evaluation of a hepatic mass and 3 for pancreatic or biliary tumours. Intra-arterial DSA has always shown vascular abnormalities. The advantage of intra-arterial DSA are reduction of the required amount of contrast medium and, consequent, reduction of the frequency of contrast medium reactions. Its disadvantages are limited field size of image intensifier and reduced spatial resolution as compared with conventional angiography. However diagnosis had never been affected by this limitation.

[Abnormalities of the hepatic artery++ in relation to portal hypertension surgery. Study with angiography and echography]. / Le anomalie dell'arteria epatica in relazione alla chirurgia dell'ipertensione portale. Studio con angiografia e ecografia.

This study was aimed at investigating the occurrence of hepatic artery variants, at comparing the diagnostic value of duplex Doppler US with that of angiography, and at correlating the results with the technical problems in portal hypertension surgery. All patients were studied with angiography, conventional and duplex Doppler US. In 162 patients with portal hypertension, 38 hepatic artery variants (23.4%) were observed and classified according to Michaels. The commonest variant recognized by angiography was right hepatic artery arising from superior mesenteric artery (type III according to Michaels). US demonstrated hepatic artery variants in 9/162 patients (5.5%). At surgery, variants were found in 3/162 subjects (1.8%) and caused surgical problems in 2 of them (1.2%) - i.e., right hepatic artery arising from superior mesenteric artery. Arteriography is still the best examination to depict hepatic artery variants, while duplex Doppler US demonstrates only a few types. Moreover, the number of variants detected by imaging techniques (23.4%) differs greatly from that observed at surgery (1.8%). Finally, hepatic artery variants are not correlated with surgical problems, nor can the latter be foreseen by imaging methods. US is useful but not essential to detect hepatic artery variants which are subsequently confirmed by angiography.

[Arterial CT in the diagnosis of hepatocellular carcinoma: initial experience with 12 patients]. / L'arterio-TC nella diagnosi del carcinoma epatocellulare: iniziale esperienza in 12 pazienti.

Intra-arterial CT of the liver is a valuable method to evaluate hepatocellular carcinoma (HCC). It consists of an infusion of contrast medium into the hepatic artery during CT scanning. Twelve patients with suspected resectable HCCs were evaluated with CT arteriography before surgery. The results of CT arteriography were compared with those of US, of CT with intravenous contrast medium and of angiography; on the rule, all exams had been performed some days earlier. The diagnosis of HCC was confirmed by US-guided fine-needle biopsy. CT arteriography demonstrated liver lesions in 11 patients. The lesions were hyperdense in 3/11 patients (27.3%) and hypodense and surrounded by a hyperdense ring in 8/11 patients (72.7%). In 4 of 11 patients (36.4%) CT arteriography identified additional tumor nodules and thus surgery was excluded. In the latter cases, on the basis of CT arteriographic findings, US, CT with i.v. contrast medium and angiography were repeated but failed to demonstrate the additional nodules, either because they were too small or because of cirrhotic changes in liver parenchyma. Therefore, CT arteriography is recommended in the evaluation of selected patients, especially when detailed information on liver parenchyma is needed--e.g., before surgery. In these patients CT arteriography can be performed together with preoperative angiography.

[Echocardiographic gating in non-cardiac digital angiography]. / Il gating-EC-grafico nell'angiografia digitale non cardiaca.

This paper reports the results of the ECG-gating in non-cardiac digital subtraction angiography (DSA). One hundred and fifteen patients underwent DSA (126 examinations); ECG-gating was applied in 66/126 examinations: images recorded at 70% of R wave were subtracted. Artifacts produced by vascular movements were evaluated in all patients: only 40 examinations, carried out without ECG-gating, showed vascular artifacts. The major advantage of the ECG-gated DSA is the more efficient subtraction because of the better images superimposition: therefore, ECG-gating can be clinically helpful. On the contrary, it could be a problem in arrhythmic or bradycardic patients. ECG-gating is helpful in DSA imaging of the thoracic and abdominal aorta and of the cervical and renal arteries. In the examinations of peripheral vessels of the limbs it is not so efficient as in the trunk or in the neck.

[Postoperative intravenous digital angiography of the carotid]. / L'angiografia digitale endovenosa della carotide operata.

Intravenous digital angiography was performed in 55 patients previously submitted to carotid endarterectomy. The angiographic examination was performed in asymptomatic subjects in 43/55 cases, as a routine procedure. In 12/55 cases (22%) the examination was performed following an ischemic recurrency. In 27 patients (49%), digital angiography was repeated before and after surgery, giving the opportunity of a serial evaluation of the vascular pattern. The angiographic findings in the site of operation was normal in 49/55 patients; in 6 patients (12%) steno-occlusive recurrencies were observed. In 21/55 cases (38%) carotid stenosis on the opposite side was demonstrated, owing to the pan-angiographic effect of intravenous contrast administration: among these cases, 18 appeared angiographically normal at the operation site. The clinico-angiographical correlation resulted fairly good (41/55-75%), taking into account the fraction of patients with contralateral carotid stenosis and neurological symptoms. Intravenous digital angiography is proposed as a first-choice diagnostic procedure for the follow-up after carotid surgery.

[Comparison of portal CT, arterial CT and CT with intravenous contrast media in the diagnosis of hepatocarcinoma]. / Confronto tra porto-TC, arterio-TC e TC con mezzo di contrasto per via endovenosa nella diagnosi dell'epatocarcinoma.

Sixty-nine patients underwent CT for hepatocellular carcinoma (HCC). All subjects were examined with CT before and after bolus injection of contrast medium: 42 HCCs were detected. 13/42 patients underwent also CT arteriography (contrast medium in the hepatic artery) and 29/42 were submitted to CT during arterial portography (contrast medium in the superior mesenteric artery). The results of the three techniques were compared with each other and with surgical and pathologic findings. CT during arterial portography detected other lesions in 5/29 patients while it confirmed CT diagnosis in the extant 24 cases; CT arteriography recognized other lesions in 2/13 subjects while in the extant 11/13 it confirmed CT diagnosis. Both CT arteriography and CT during arterial portography affected treatment protocol in 16.2% of cases. The results had surgical confirmation in all patients but 3 in whom intraoperative US showed some nodules undetected earlier. All the lesions were hypodense on CT during arterial portography. On CT arteriography, they were hyperdense in 4/13 cases and hypodense with an irregular hyperdense halo in 9/13 cases. To conclude, CT during arterial portography and CT arteriography are better diagnostic tools than CT: nevertheless, they are invasive techniques and should be employed in selected cases only.

[The hemodynamic significance of the angiographic changes after portasystemic shunting interventions for portal hypertension]. / Significato emodinamico delle modificazioni angiografiche dopo interventi derivativi porto-sistemici per ipertensione portale.

Seventy-two patients (52 males and 20 females, mean age: 50.6 years) were studied. They had undergone distal splenorenal shunts according to Warren and its modifications for portal hypertension. All patients were examined with digital and/or conventional angiography preoperatively and 15 days postoperatively. Preoperative and postoperative angiography was employed to evaluate the changes in vessel diameters including the hepatic, splenic and superior mesenteric arteries, the splenic, superior mesenteric and portal veins; the length of the main axis of the spleen was also measured. Furthermore, the degree of hepatic portal venous perfusion was evaluated according to the degree of portomesenteric-gastrosplenic disconnection. After surgery, the length of the main axis of the spleen is reduced and the hepatic artery diameter is increased, which are both signs of preserved hepatic flow and of reduced hypertension in the splanchnic venous system. The postoperative degrees of portal perfusion were correlated with the degrees of disconnection. In conclusion, the role is emphasized of early angiographic examinations after distal portosystemic shunts according to Warren to evaluate postoperative hemodynamic changes.