Transverse section imaging of soft tissue tumors and peripheral vascular disease.

The development of soft tissue tumors and peripheral vascular disease is accompanied by changes in physiologic parameters such as blood flow and metabolism. Positron tomography can provide regional values of parameters such as blood flow, blood volume, oxygen utilization, and glucose metabolism in normal and diseased tissue. Such information may be of value in determining appropriate therapy and in assessing the effects of therapy. Equilibrium imaging during continuous inhalation of C15O2 provides a means of measuring blood flow on a regional basis. Equilibrium C15O2 imaging has been applied on a preliminary basis in patients with soft tissue tumors. In general, tumor tissue exhibits markedly higher rate of blood flow than normal tissue. In some patients, necrotic areas exhibit a greatly diminished blood flow. In the case of peripheral vascular disease, equilibrium C15O2 imaging shows decreased blood flow in affected regions. A significant increase in blood flow is seen following transluminal dilation.

Intraoperative localization of small bowel bleeding sites with combined use of angiographic methods and methylene blue injection.

Superselective catheter placement with angiographic techniques and methylene blue injection at laparotomy through a prepositioned angiographic catheter have helped to localize small bowel bleeding lesions. The technique has been applied successfully in two patients with arteriovenous malformations and one patient with bleeding mucosal ulcerations of the small bowel.

Tender pulsatile abdominal mass. Abdominal aortic aneurysm or not?

Twenty-nine patients had symptomatic pulsatile abdominal masses. Initially six patients underwent emergency surgical exploration without prior arteriography. An abdominal aortic aneurysm was found in only one patient. In the next 23 patients, in whom arteriography was performed, no aneurysm was detected and emergency surgery could be avoided. In patients with symptomatic pulsatile abdominal masses, in the absence of hypovolemic shock the initial diagnostic study should be abdominal angiography. It is an accurate and safe procedure, and supplies the necessary preoperative information should abdominal aortic surgery become necessary. If, however, no aneurysm is found, valuable information is still obtained with regard to the underlying disease process.

Leiomyosarcoma of the inferior vena cava. Diagnosis and surgical management.

Leiomyosarcoma of vascular origin are rare tumors arising most frequently from the inferior vena cava (IVC). We report on three patients one of whom underwent definitive resection. These tumors most commonly involve the upper segment of the IVC, and appear with manifestations of the Budd-Chiari syndrome. Lesions at this level are not amenable to surgical therapy. Tumors of the middle and lower segments of the IVC usually cause right-sided pain. Diagnosis is difficult, but is best approached preoperatively by angiography and vena cavography. Optimal therapy of lesions at these levels is surgical resection. Resection of the IVC below the hepatic veins is possible with renal function preserved by collateral drainage of the left renal vein.

Pancreaticoduodenal artery aneurysm simulating carcinoma of the head of the pancreas.

Aneurysms of the pancreaticoduodenal arcades, although uncommon, may rupture and produce symptoms similar to those of pancreatic carcinoma. We describe one patient with a ruptured interior pancreaticoduodenal artery aneurysm and a large hematoma in the pancreatic head. He had a three-week history of painless jaundice. Angiography was essential in establishing the diagnosis and defining a vascular road map preoperatively. The surgical management involved resection of the aneurysm and vascular reconstruction.

Massive arterial hemorrhage in patients with pancreatitis. Complementary roles of surgery and transcatheter occlusive techniques.

Massive arterial hemorrhage from multiple sites caused by tissue injury and infection following severe pancreatitis occurred in 12 patients, who were treated with the combination of angiographic embolization techniques and surgery; five survived. Complete hemostasis was obtained in eight of 12 patients who underwent primary angiographic therapy. Bleeding was temporarily controlled in two patients, who then underwent directed surgical ligation of the bleeding vessel under more favorable conditions. In two patients, bleeding was not controlled. The use of permanent occluding materials, particularly bucrylate, resulted in the highest success rate. When the bleeding artery could not be individually catheterized for safe occlusion, balloon occlusion or vasopressin infusion stabilized the patient's condition, with a decrease in the rate of bleeding prior to subsequent surgical therapy. Inadequate control of further tissue necrosis and sepsis was the cause of death in five of the seven patients who died. The other two patients died of recurrent hemorrhage despite attempts at both arteriographic occlusion and surgical ligation.

Transluminal angioplasty of the iliac and femoropopliteal arteries. Current status.

Transluminal angioplasty for the management of atherosclerosis obliterans has been performed in 160 patients for 100 iliac and 98 femoropopliteal lesions. The procedure was performed percutaneously except in eight patients in whom operative exposure was required. Angioplasty was technically successful in all 100 iliac artery lesions. There was hemodynamic and clinical improvement in 92 lesions. The procedure was technically successful in 84 of the 98 femoropopliteal artery lesions with hemodynamic improvement in 74 and clinical improvement in 78. There were ten complications directly related to the angioplasty and six related to the arteriographic procedure. Cumulative patency rates for the angioplasties were 92% and 75% at three years for iliac and femoropopliteal lesions, respectively. These promising results suggest that transluminal angioplasty has a definite role in the management of atherosclerosis obliterans of iliac and femoropopliteal arteries.

Interventional angiography of the renal fossa.

In this article, the authors present an overview of interventional procedures that aim at (1) opening of the renal artery with percutaneous transluminal renal angioplasty, intra-arterial thrombolysis, and/or transcatheter thromboembolectomy and (2) reducing or obstructing renal artery blood flow with transcatheter embolization.

Hepatic and splenic infarctions: complications of therapeutic transcatheter embolization.

Two cases are described in which therapeutic transcatheter Gelfoam embolization was complicated by fatal hepatic infarction in one patient and splenic infarction with abscess formation in another patient. These are unusual complications of this widely used therapeutic technique. The probable pathophysiology of these complications is discussed and suggestions for managing and avoiding them are made.

Mesenteric arterial infusions of vasopressin for hemorrhage from colonic diverticulosis.

Twenty-four patients with massive rectal hemorrhage and known or subsequently proved colonic diverticular disease had the bleeding site localized by mesenteric angiography and received intra-arterial infusion of vasopressin to arrest the bleeding. In twenty-two patients the bleeding was controlled with the vasopressin infusion whereas in the remaining two, hemorrhage did not stop and surgery was performed. Of the twenty-two patients in whom bleeding was arrested by vasopressin infusion, twelve received no further surgical therapy, five had elective prophylactic surgical resection after a period of hemostasis, and the remaining five underwent segmental resection for bleeding that recurred after cessation of the infusion. Of the twelve patients who were not operated on, three had rebleeding two, four, and twelve months after vasopressin infusion and two of these three patients required surgery. The remaining nine have had no recurrent bleeding for periods ranging from seven to thirty-four months. Of ten patients who had segmental resection after precise localization of the bleeding site and initial control with vasopressin, no one has had recurrent hemorrhage for periods ranging from two to eighteen months.

Gastrointestinal bleeding. An angiographic perspective.

Angiography has become an integral tool in the management of patients with gastrointestinal bleeding. It is used for localizing the site of bleeding and then for controlling the bleeding when more conservative methods of treatment are unsuccessful.

The vincula; with particular reference to their vessels and nerves.

The blood vessels and nerves of the vincula in the human hand were studied by anatomical dissection, serial histological section, and angiography. The segmental blood supply of the flexor tendon through the vincula was seen to come from constant branches of the digital vessels that pierce the fibrous sheath proximal to both the proximal and distal interphalangeal joints. These were traced with their accompanying nerves into the flexor tendons. Communication between the interosseous circulation and that of the tendons was demonstrated. The clinical implication of these findings and their application to tendon surgery are discussed.

Prophylaxis of deep-vein thrombosis after total hip replacement. Dextran and external pneumatic compression compared with 1.2 or 0.3 gram of aspirin daily.

The efficacy of three prophylactic regimens against deep venous thrombosis was assessed in 135 patients who were more than thirty-nine years old and had a total hip replacement. The three regimens were 1.2 grams of aspirin daily, 0.3 gram of aspirin daily, and external pneumatic compression of the calf and thigh combined with low-molecular-weight dextran that was given for three days, beginning during the operation. In all patients, detection of fresh thrombi was by the fibrinogen-uptake test, cuff-impedance plethysmography, and venography. New venous thromboses developed in twenty-nine of forty-eight patients receiving 1.2 grams of aspirin and in twenty-six of forty-three receiving 0.3 gram of aspirin, indicating that the lower dose of aspirin had no advantage. Thromboembolic disease developed in only nine of forty-four patients who were on the regimen of external compression and dextran. This combination was significantly better than aspirin in both men and women. Dextran appeared to be associated with excessive bleeding when given in doses of more than 500 milliliters during the operation, but not when given in less than that amount.

High and low-dose aspirin prophylaxis against venous thromboembolic disease in total hip replacement.

Aspirin has been demonstrated to be an effective prophylactic agent against postoperative venous thromboembolic disease, but the optimum dosage is unknown. We compared the efficacy of daily doses of 3.6 grams of aspirin (high dose) with that of 1.2 grams (low dose) in 182 patients. All patients were more than forty years old and all underwent a total hip replacement. This randomized, prospective, double-blind study was done using only objective dta for diagnosis. Twenty-three (44 per cent) of fifty-two women who were treated with the low dose had thrombi, compared with eighteen (34 per cent) of fifty-three women who were given the high dose. Thrombi developed in thirteen (32 per cent) and in eighteen (49 per cent) of thirty-seven men who were given the high dose. There were no statistically significant differences among the four groups, nor was there a significant difference among the subgroups that were determined according to prior history of venous thromboembolic disease. Therefore, the higher dose of aspirin was neither more nor less effective than the lower dose. Our data continue to support the use of 1.2 grams in men.

Detection of pulmonary emboli after total hip replacement using serial C15O2 pulmonary scans.

15-O-labeled carbon dioxide (C15O2) was used for the detection of preoperative and postoperative pulmonary emboli in seventy-three patients, more than forty years old, who had undergone a total hip replacement. When the C15O2 scan was suggestive of pulmonary embolism, it was followed by conventional perfusion and ventilation (V/Q) scans. If these also suggested the presence of embolism, pulmonary angiography was done. Three different prophylactic agents against venous thromboembolic disease had been used in the seventy-three patients. Seventeen (23 per cent) of the seventy-three patients had a positive C15O2 pulmonary scan followed by a positive ventilation-perfusion scan and a positive pulmonary angiogram that showed pulmonary emboli. Fourteen (83 per cent) of these patients with proved pulmonary emboli were asymptomatic. Fifteen additional patients also had a positive C15O2 scan. However, twelve of them had either negative ventilation-perfusion scans or chest radiographs that demonstrated atelectasis, and did not have a pulmonary angiogram. Three patients with a positive C15O2 scan had a negative pulmonary angiogram. Two of them had a ventilation-perfusion scan that was interpreted as showing probable pulmonary emboli, and the remaining patient did not have a ventilation-perfusion scan. Forty-six per cent of the patients with positive C15O2 scans did not have pulmonary emboli. This sensitive and readily repeatable test provides an excellent means of detection of silent emboli, an improved method of evaluating the efficacy of prophylactic agents, and the opportunity to correlate the site, size, and onset of deep-vein thrombosis with pulmonary emboli in vivo.(ABSTRACT TRUNCATED AT 250 WORDS)

Transcatheter embolization for the control of wound hemorrhage following hip surgery.

Angiography was done on sixteen patients with excessive bleeding from the wound following major hip surgery. In ten patients the bleeding site was so identified and the vessel was embolized with autologous clot or surgical gelatin. In six patients no site of bleeding could be seen. There was one angiographic complication: distal embolization to the popliteal artery. We concluded that angiography often may be helpful in localizing the site of excessive postoperative bleeding from a wound, and transcatheter embolization of the bleeding vessel then can be effective in controlling such bleeding.

Angiographic management of gastrointestinal bleeding with vasopressin.

Selective arteriography and infusions of vasopressin have become valuable tools for localization and therapy of acute gastrointestinal hemorrhage. Gastric mucosal hemorrhage can be treated successfully in about 84% of cases. Gastric ulcers can be treated successfully in about 65-70%. Acute colonorectal bleeding is controlled in about 90% of patients.

Preoperative magnification angiography of donor and recipient sites for clinical free transfer of flaps or digits.

Based on the 14 free flap transfers we present with full survival, we recommend peroperative magnification angiography of both the recipient and donor sites. In our hands, this type of preoperative assessment seems to increase the margin of safety.

Preoperative imaging of the carotid bifurcation. Current trends.

BACKGROUND: There is disagreement about the most appropriate imaging examination necessary for the preoperative assessment of the carotid bifurcation. Our objective was to find out the preferences of clinicians on this issue in one large hospital. And to determine whether and how these preferences have changed over time. STUDY DESIGN: Observational, retrospective study. SETTING: Large metropolitan and university affiliated hospital. Numbers of patients per year who underwent carotid endarterectomy during 1990-1998. Numbers of patients per year who had conventional catheter carotid angiography during the same period. Assessment of the nature of preoperative carotid imaging in a sample of 400 patients (100 each in 1990, 1993, 1996 and 1998). Analysis of the types of imaging examinations by year and determination of underlying trends. MEASURES: Number of carotid angiograms expressed as a percentage of carotid endarterectomies performed each year. Types of preoperative imaging examinations of the carotids and changes over time. RESULTS: The number of preoperative conventional catheter angiograms decreased over time. In 1990 angiography was performed in 86% of carotid endarterectomies. In 1998 the proportion decreased to 16% (p<0.05). Conversely, the proportion of endarterectomies carried out based solely on ultrasonography increased from 6% in 1990 to 56% in 1998 (p<0.05). The proportion of endarterectomies performed based on the combined findings of ultrasound and magnetic resonance angiography increased from 3% in 1990 to 56% in 1996 and to 26% in 1998. Computed tomoangiography has not become popular. The observed reduction in the number of preoperative conventional carotid angiograms was independent of the presence/absence of symptoms, the level of serum creatinine, the subspecialty of the surgeon (vascular surgery vs neurosurgery) and the individual surgeon involved. CONCLUSIONS: In one large university affiliated hospital the trend in the preoperative imaging of the carotid arteries is moving away from conventional catheter angiography. There is increasing application of ultrasound combined with magnetic resonance angiography and a more pronounced trend towards the performance of carotid endarterectomy based only on ultrasonography.

The Friday afternoon pulmonary angiogram: temporal relationship between onset of symptoms and requests for angiography.

BACKGROUND: To determine if pulmonary embolism symptoms and pulmonary angiography have a proclivity for a particular day of the week, month or season (Part I) and to assess the length of time elapsing between the appearance of symptoms and requests for pulmonary angiography (Part II). DESIGN: Prospective (in part) collection of data and retrospective review of clinical records. SETTING: Large metropolitan, university affiliated hospital. METHODS: Part I: 2,969 consecutive pulmonary angiograms performed over 17 years, were collected according to the day of the week, month and season of their performance. Relevant rates were calculated. Part II: A study of the time interval between the onset of pulmonary embolism symptoms and requests for and performance of angiography was conducted in 128 patients. Results. Part 1. In the course of 17 years, more pulmonary angiograms were performed on Fridays (mean 37.2, SE 1.8), than on any other day of the week (p <.001). No proclivity for a particular month or season was observed. Part II. The mean time elapsed between the onset of symptoms and requests for angiography was 24 hours (range 0.2-162, SE 4.3) for inpatients, and 45 hours (range 3-358, SE 7.8) for outpatients. The angiogram was completed urgently, within two hours of the onset of symptoms, only in 2.4%. CONCLUSIONS: Pulmonary angiography has a proclivity for Fridays. Pulmonary embolism symptoms and consequent angiograms do not favour a specific day, month or season. In most cases the time elapsing between the onset of symptoms and requests for angiography is too long to be consistent with urgency. The frequent Friday pulmonary angiogram reflects a tendency to "mop up" unfinished business prior to the week's end.