A clinical trial of laser thermal angioplasty in patients with advanced peripheral vascular disease.

A 3-year prospective trial of laser thermal-assisted balloon angioplasty in 28 patients included 27 who had advanced peripheral vascular disease (severe tissue loss, gangrene, infection, and rest pain), 7 who were failures of previous therapy (surgery and thrombolysis), and 4 who were high risk for operation (myocardial infarction within 6 weeks and/or ejection fractions of less than or equal to 20%). Laser angioplasty was performed in the operating room via a groin incision by a surgeon-radiologist team. In the 27 patients with advanced peripheral vascular disease (ankle-brachial systolic pressure index [ABI] 0.27 +/- 0.2 in 10 nondiabetic, and 0.46 +/- 0.1 in 17 diabetic patients), recanalization of the native vessel was successful in 16, and patency was restored in 2 chronically occluded polytetrafluorethylene (PTFE) grafts. In these 18 (67%) successfully recanalized patients, however, five amputations were required within 1 month, and another six were needed between 8 and 12 months. Early amputations were caused by a failure of wound healing, even through angioplasty sites were patent. Late amputations were caused by reocclusion of the treated site in five of six patients. In the remaining seven patients in whom laser angioplasty alone was successful, five had healed limbs at 6 to 24 months and two remain incompletely healed but functional. The patency for successful procedures ranged from 48 hours to 25 months (5.6 +/- 6.4 mean months, +/- SD), with cumulative patency by life-table analysis of 55.5% at 3 months, 38.8% at 6 months, and 11.1% at 12 months. There were no procedure-related deaths. Complications included seven arterial wall perforations by the laser probe. We conclude that laser angioplasty has a limited role in advanced peripheral vascular disease but may provide an interval patency, thus allowing postponement of operation for high-risk patients until their medical conditions permits surgery, or to correct local tissue necrosis or infection in the operative field before reconstruction, and to restore patency to thrombosed PTFE grafts.

Cavernosography following clinical failure of penile vein ligation for erectile dysfunction.

In an attempt to determine what occurs to the venous circulation of the penis after ligation of the deep dorsal vein, 9 men with veno-occlusive dysfunction who underwent deep dorsal penile vein ligation and failed to achieve normal erectile function postoperatively consented to a postoperative cavernosogram. Preoperatively, the deep dorsal vein was visualized in all 9 patients, the cavernous vein in 2 and the corpus spongiosum in 1. Postoperatively, the deep dorsal vein was visualized in 1 patient, the cavernous vein in 1 and the corpus spongiosum in 8. These observations suggest that either the inability to identify a cavernous-spongiosal communication preoperatively or the induction of such a communication postoperatively may lead to a clinical failure in patients who undergo deep dorsal penile vein ligation.

Lesions involving the fourth ventricle evaluated by CT and MR: a comparative study.

A retrospective review of 21 patients with lesions involving the fourth ventricle was performed to determine the relative capability of computed tomography (CT) and MR for detection, characterization, localization, and diagnosis. Lesions involving the fourth ventricle included ependymoma (three), subependymoma (one), glioma (five), cysticercosis cyst (three), medulloblastoma (three), bleeding into the fourth ventricle (two), epidermoid cyst (two), "trapped" fourth ventricle (one), and lymphomatoid granuloma (one). Posterior fossa lesions that displaced but did not invade the fourth ventricle were excluded. Lesion detectability on CT was judged excellent in ten, good in 8, and fair or poor in 3. Detectability of lesions by MR was judged excellent in 16 and good in 5. There was complete agreement on lesion extension between CT and MR in 6 lesions, mild disagreement in 4, and moderate to significant disagreement in 11. Preoperatively, MR alone correctly diagnosed seven lesions, and CT alone correctly diagnosed three lesions. A review of the combined scans (after the correct diagnosis was given) showed both CT and MR were equal in the diagnosis of 14 lesions, MR better than CT in six, and CT better in one. There was complete agreement on both CT and MR with the surgical/pathologic findings in three lesions. Both studies proved disappointing in their ability to make the correct histologic diagnosis, probably because CT and MR characteristics may not always offer a definitive diagnosis and because of the wide spectrum of pathologic processes that may involve the fourth ventricle.

Brain white-matter lesions and psychosis.

In a prospective study of late-life onset psychosis, five of the first 27 patients studied had extensive white-matter lesions demonstrated by MRI and/or CT. None of 60 age-matched psychiatrically healthy controls demonstrated such lesions. All five patients had a mild dementia and a frontal behavioural syndrome. In addition, every patient performed poorly on neuropsychological tests of frontal function. Dysfunction of the frontal cortex associated with white-matter lesions appears to contribute to the clinical picture of some cases of late-life psychosis.

Prevalence of corporeal venous leakage in impotent men.

To provide insight into the prevalence of corporeal venous leakages as a factor in impotence, 44 consecutive impotent men who failed to achieve an erection after intracorporeal papaverine injection underwent dynamic infusion cavernosometry and cavernosography. If venous leakage is defined as either a failure to increase intracorporeal pressure greater than the systolic blood pressure or a rapid decrease in intracorporeal pressure after cessation of saline infusion during cavernosometry, 30 of the 44 men (68 per cent) fall into this category. If cavernosography (43 men) is used to define the presence of a venous leakage in these impotent patients 37 (86 per cent) fall into this category. These data support recent observations that there is a high incidence of venous leakage as defined by these criteria in men with organic impotence. The significance of these findings can be determined only once a similar study in age-matched potent men is performed.

Blunt traumatic dissection of the internal carotid artery treated by balloon occlusion.

An extensive traumatic intimal dissection of the internal carotid artery was successfully managed by permanent occlusion of the vessel with percutaneously-placed, inflatable balloons in a young patient who had suffered transient ischemic neurological attacks despite anticoagulation. This technique has not been previously reported for treatment of dissection. Review of 34 published reports of symptomatic intimal dissection associated with non-penetrating trauma to the head and neck revealed that most did not have a direct injury to the carotid region and that development of symptoms was often delayed. Only 50% of these patients had onset of neurological symptoms within six hours of the episode of trauma, while 33% remained asymptomatic for more than one week before complications occurred. In 15 patients who were treated surgically, only nine (60%) achieved full recovery. Operative repair was considered unduly hazardous in our patient because of extension of the spiral dissection to the base of the skull. Successful use of percutaneous balloon occlusion of the carotid in this patient suggests that this technique should be considered a worthy alternative for management of selected cases.

Percutaneous transluminal angioplasty for pediatric renovascular hypertension.

Five children had percutaneous transluminal angioplasty (PTA) for renal artery stenosis, involving the mid- or distal main renal artery or proximal branches in 4 and developing after saphenous vein patch angioplasty in 1. All 5 children became normotensive following the procedure, but one later became hypertensive due to recurrent renal artery stenosis. The authors recommend PTA for treatment of mid- to distal renal artery stenosis in children.