Single barbed stainless steel coils for venous occlusion: a simple but useful modification.

Embolization of coils into the lungs has been reported following their use for the obliteration of large arteriovenous fistulas. So far, except for a recent report, they have not been used on the venous side of the circulation. Experimental studies at our institution demonstrated that the placement of coils on the venous side can result in embolization to the lungs, even when oversized coils are introduced. A simple, easy to perform modification of the standard stainless steel coils (Gianturco-Wallace-Chuang spring embolus and coilons) makes these devices safe embolic agents for used on the venous side of the circulation, as for example in the obliteration of spermatic veins.

Intraparenchymal embolization for obliteration of an intramedullary AVM of the spinal cord. Technical note.

A new technique is presented in which expandable compressed Ivalon sponge emboli were used to obliterate an intramedullary arteriovenous malformation of the spinal cord by intraparenchymal embolization. A case is described in which this method was used.

The three types of criss-cross heart: a simple rotational anomaly.

Criss-cross heart is an angiographically confusing malformation where apparent crossing but not mixing of contrast medium is seen at atrioventricular level. The malformation can be understood by a clockwise or counter-clockwise ventricular rotation. In the normal heart or one with complete transposition ventricular rotation is clockwise. With corrected transposition rotation occurs in a counter-clockwise fashion. One case of criss-cross heart with associated corrected transposition and two criss-cross hearts occurring with complete transposition are reported.

Nonsurgical removal of intravascular foreign bodies.

With increasing use of indwelling venous catheters, embolization of intravascular catheter fragments has become a well-known complication. Because of the high risk and serious complications, embolized fragments should be retrieved whenever possible. Four cases of successful nonsurgical percutaneous catheter retrieval (two adults and two children) are described using a wire loop and a hook-shaped catheter technique. The method described allow a safe and rapid retrieval and should always precede surgical exploration.

Redistribution of renal blood flow caused by contrast media.

Rerouting of blood from the renal cortex to the renal medulla (Trueta shunting), observed in 5 cases, may occur in normal kidneys during renal angiography. The temporary nature of this artifact may be proved by performing an abdominal aortogram with the catheter tip inserted farther away from the renal arteries. The exact mechanism of this phenomenon is unknown; it may also occur with various renovascular disorders.

Polyvinyl alcohol (Ivalon)--a new embolic material.

Successful nonsurgical treatment of gastrointestinal bleeding and arteriovenous malformations by embolization techniques has been previously documented. 1) Compressed Ivalon sponge was found to be a suitable embolic material in animals and in four patients. 2) The material has been extensively used in surgery, and its biocompatibility has been proved. 3) Expansion of the compressed sponge to its original size after embolization makes this material extremely effective. Recanalization did not occur in animals and humans. 4) For the occlusion of larger arteries, Ivalon can be wrapped around the guidewire. Ivalon sponge absorbs blood and serum, unwraps itself allowing withdrawal of the guidewire. 5) Embolization procedures are not without risk since reflux of embolic material may occur. Therefore, these procedures have to be carried out under fluoroscopic control.

Coronary atherosclerosis in subjects with mitral stenosis.

The coronary arteries were examined in 60 specimens from patients with mitral stenosis. In three, localized obstruction was nonatherosclerotic in nature (in one, arterial dysplasia; in two, embolic). In 18 of the remaining 57 cases (31.5%), significantly obstructive atherosclerosis in one or more segments of the coronary arterial system was found. This represented 46% of the males and 27% of the females. The incidence of involvement of three or more arteries by significantly obstructive atherosclerosis was 39%, while in a cited series of subjects with angina pectoris three or more vessels were involved in 79% of the cases. It may be concluded that, on the average, the distribution of lesions in patients with mitral stenosis and significant coronary atherosclerosis is less wide than in subjects with clinical coronary disease.

Dissecting aneurysm of aorta complicating aortic valvular stenosis.

Six cases of classical dissecting aneurysm of the aorta complicating aortic valvular disease in which aortic stenosis was dominant are described. In three of the cases the aortic complication occurred after the natural aortic valve had been replaced by a prosthetic valve. The longest postoperative period was four months. The factor common to all reported cases in our series was cystic medial necrosis of the aorta. The authors agree with the concept of McKusick and associates that aortic dissecting aneurysm complicating aortic valvular disease is an association other than chance and is related to cystic medial necrosis of the aorta. The latter, in turn, is a consequence of the altered hemodynamics of aortic valvular disease, particularly stenosis.

Dual stiffness Malecot (Stamey) catheter.

A new catheter with a soft plastic shaft and a stiff mushroom has been developed for drainage of various fluid-filled cavities. It can be introduced with a flexible guidewire system. Its dual stiffness provides greater comfort for and acceptance by the patient.

Syphilitic aneurysms of the innominate artery.

Syphilitic aortitis can cause formation of fusiform or saccular aneurysms of the ascending aorta or transverse arch. The authors report 3 cases in which a saccular aneurysm developed at the origin of the innominate artery and was seen as a mediastinal mass on the chest radiograph.

Angiodysplasia of the right colon treated by embolization with ivalon (polyvinyl alcohol).

Angiodysplasia of the colon is being recognized with increasing frequency as a source of lower gastrointestinal bleeding in the elderly. In one patient with colonic angiodysplasia, superselective segmental embolization of the ileo-colic artery with Ivalon resulted in the cessation of bleeding without causing bowel infarction. However, because of the development of collateral branches to the angiodysplastic malformation, bleeding recurred. While colectomy remains the treatment of choice in younger patients, in high risk patients embolization with a permanent embolic material, such as Ivalon, is an attractive alternative.

Systemic-to-pulmonary collaterals in pathological states: a review.

Abnormal systemic-to-pulmonary-artery anastomoses can exist in many pathological conditions and result in a left-to-right shunt. Three such conditions are (a) congenital abnormalities, e.g., pulmonary vein atresia, (b) acquired states, e.g., chronic bronchiectasis, and (c) post-surgical states, e.g., a Mustard procedure for complete transposition. Regardless of the etiology, the anastomosis and resulting shunt produce increased oxygen saturation in the ipsilateral pulmonary artery. Four cases are presented, with emphasis on the angiographic and hemodynamic findings.

"Pseudo" intramural injection following percutaneous transluminal angioplasty.

An angiographic appearance of "pseudo" intramural injection is commonly produced following intraluminal balloon dilatation resulting from the dehiscence of the atheromatous intima that is an unavoidable consequence, and not a complication of angioplasty. These angioplasty-induced changes differ from true intramural dissections in that they are confined to the dilatation site and do not extend beyond this area.

Mechanical thrombectomy with the Amplatz device: human experience.

PURPOSE: The authors present their early experience of mechanical arterial and graft thrombectomy with the Amplatz thrombectomy device. PATIENTS AND METHODS: Preliminary data are presented for 14 patients treated with the Amplatz thrombectomy catheter. The procedure was carried out in 10 arterial polytetrafluorethylene grafts, in two native arteries, and in two patients with venous thrombosis. RESULTS: The thrombectomy catheter completely removed the clot in 11 patients and partially removed clot in three patients. Mean thrombectomy time was 2 minutes 45 seconds. Despite distal blood pressure cuff occlusion, two instances of insignificant distal embolization occurred. Mechanical clot dissolution has consistently produced hemolysis without adverse clinical effects. The underlying causative factors such as stenoses were treated by means of angioplasty, atherectomy, or surgical endarterectomy. CONCLUSION: Mechanical thrombectomy with this device is a new, effective technique and can rapidly remove the thrombus. From preliminary results, the device seems most promising in clearing out thrombi in occluded synthetic femoral-to-popliteal bypass grafts. The device could have wider application if it were steerable and if it could be introduced from the contralateral approach.

Nonsurgical closure of large arteriovenous fistulas.

We report a nonsurgical closure of large postnephrectomy arteriovenous fistulas in two patients. To out knowledge, this method has not previously been attempted because of the large size of the communication and the risk of pulmonary embolization. However, the development of new embolization techniques makes a nonsurgical approach feasible and safe.

Anatomic causes of pulmonary stenosis in complete transposition.

Among 166 specimens with classical complete transposition, pulmonary or subpulmonary stenosis was present in 22 cases. The bases for obstruction were pulmonary valvular stenosis (one case), membranous subpulmonary stenosis (nine cases), anomalous attachment of the mitral valve to the ventricular septum (five cases) and combinations of causes (seven cases). Conditions contributing to combinations of causes included the above, in addition to accessory mitral or pulmonary valvular tissue and herniation of a tricuspid valvular pouch through a related ventricular septal defect. In addition to the 166 cases mentioned, our collection contained six cases of atypical complete transposition characterized by a conus being present in the each ventricel. In three of these six, subpulmonary stenosis was present and caused by a narrow inlet to the left ventricular conus.

Kimray-Greenfield vena cava filter: percutaneous introduction.

A percutaneous technique is described for the introduction of Kimray-Greenfield filters into the vena cava through either the internal jugular or femoral approach.

Experience with the Amplatz retrievable vena cava filter.

The Amplatz retrievable inferior vena cava filter was designed to be used as either a permanent indwelling filter or a short-term, percutaneously removable filter. The authors placed 52 filters in 52 patients. No deaths occurred as a result of filter placement or usage. Follow-up in 42 (81%) patients included inferior vena cavography (n = 31), computed tomography (n = 4), duplex ultrasound (n = 4), and autopsy (n = 3). Inferior vena cava thrombosis was found in seven (17.5%) of the 40 previously nonobstructed venae cavae studied. Two patients with caval thrombosis required a second filter to prevent embolization of thrombus that had extended to the lung side of the first filter. No clinically evident pulmonary emboli after filter placement have been noted. Six filters were successfully retrieved or repositioned percutaneously. The relatively high rate of caval thrombosis with extension above the filter may be due to a higher trapping efficiency or to filter geometry. The role of this filter in the treatment of deep venous thrombosis and pulmonary emboli is unclear.