The coronary-subclavian-vertebral steal syndrome (CSVSS).

OBJECTIVE: Reverse flow in the internal thoracic artery (ITA) after coronary bypass surgery due to an occlusion or severe stenosis of the subclavian artery is a rare situation. Symptoms can be recurrent and intermittent angina pectoris in the case of a coronary-subclavian steal (CSSS) or-in addition with cerebral symptoms-in the case of a coronary-subclavian-vertebral steal syndrome (CSVSS). METHOD: We describe the cases of four patients with recurrent angina pectoris 5, 11, and 14 years as well as directly after coronary bypass surgery with LITA grafts to LAD. In two patients there was the additional aspect of vertebral steal symptoms with dizziness and intermittent drop attacks. RESULTS: A PTA of the subclavian occlusions in three cases was not feasible, so that three patients were operated on by extrathoracal approach and carotido-subclavian bypass (CSB) in two cases, and local thrombendarteriectomy of the subclavian and vertebral artery (TEA)+ -patchplasty in one case. Patient 4 was treated by PTA and stent placement into the subclavian artery. Antegrade flow in all four LITAs could be achieved resulting in immediate relief from angina pectoris and cerebral symptoms. Patients 1 and 3 showed no further symptoms with equal BP of the upper extremities and anterograde flow in the LITA grafts and vertebral artery at 10-month follow-up. Patient 2 unfortunately died from an unrelated cause (asthmatic state) 4 months after the operation despite an uneventful recovery. CONCLUSION: The occurrence of a CSSS or CSVSS after coronary bypass surgery with retrograde flow in the ITA graft (as described in our four patients) is a rare, but potentially hazardous, situation. If the subclavian occlusion is not amenable to endovascular strategies, the extrathoracal approach by CSB or local TEA and patchplasty provides an excellent means with good midterm and long-term results.

[Optimizing staff radiation protection in radiology by minimizing the effective dose]. / Optimierung des Strahlenschutzes für das Personal in der Radiologie auf Grundlage der effektiven Dosis.

PURPOSE: In the present study the optimization of radiation protection devices is achieved by minimizing the effective dose of the staff members since the stochastic radiation effects correlate to the effective dose. MATERIALS AND METHODS: Radiation exposure dosimetry was performed with TLD measurements using one Alderson Phantom in the patient position and a second phantom in the typical position of the personnel. Various types of protective clothing as well as fixed shields were considered in the calculations. RESULTS: It was shown that the doses of the unshielded organs (thyroid, parts of the active bone marrow) contribute significantly to the effective dose of the staff. Therefore, there is no linear relationship between the shielding factors for protective garments and the effective dose. An additional thyroid protection collar reduces the effective dose by a factor of 1.7 - 3.0. X-ray protective clothing with a 0.35 mm lead equivalent and an additional thyroid protection collar provides better protection against radiation than an apron with a 0.5 mm lead equivalent but no collar. CONCLUSION: The use of thyroid protection collars is an effective preventive measure against exceeding occupational organ dose limits, and a thyroid shield also considerably reduces the effective dose. Therefore, thyroid protection collars should be a required component of anti-X protection.

[Thoracic radiography in intensive care units. Comparison of an asymmetric film-screen-grid combination with an L-film]. / Thoraxaufnahmen auf der Intensivstation. Vergleich einer asymmetrischen Film-Folien-Raster-Kombination mit einem L-Film.

PURPOSE: Using an asymmetrical screen-film-grid combination with an ITC-VHC special grid (Kodak), the effect of the individual components was evaluated with regard to detail in the lungs and mediastinum as well as patient dose. MATERIALS AND METHODS: The system was compared with the Curix Ortho screen film system (Agfa L-film) using phantoms and 62 patients in an intensive care unit. The results were analysed by three independent observers. Dose measurements on phantoms were carried out with a WD 10 (Wellhoefer) dosimeter and with a thermoluminescence dosimeter for patients. RESULTS: Both phantom and patient images showed improved demonstration of mediastinal structures with similar details of lung structure. Details in the peripheral lungs are significantly better shown with the ITC-VHC system with the special grid than they are without the grid. However, there is an increase about three to four times in radiation dose when using the grid. CONCLUSION: Our trial shows that the use of the ITC-VHC grid system is to be recommended for routine clinical use because of the better demonstration of details, but one must be aware of the increased radiation dose to the patient.

[A versatile phantom for hemodynamic measurements with ultrasound Doppler equipment]. / Ein vielseitiges Phantom für hämodynamische Messungen mit Ultraschall-Doppler-Geräten.

The test object described comprises a blood simulating liquid pumped through tubes embedded in tissue-mimicking material. The main components of the system can be realised in different ways. They are largely exchangeable with each other. Water, reticulated foam or silicone rubber is used as bulk background material, blood vessels are simulated using latex or silicone tubes or heat-shrink sleeving; in the artificial blood, sephadex particles or silicone emulsion were used as scatterers. The suspension of scattering particles is driven by a roller pump or a membrane dosage pump. The features of the components are described and the applications of the different phantoms discussed.

Controlled trial of high- versus low-dose aspirin treatment after percutaneous transluminal angioplasty in patients with peripheral vascular disease.

Percutaneous transluminal angioplasty of aortoiliac and femoropopliteal atherosclerotic lesions can provide long-lasting hemodynamic improvement. High-dose aspirin is commonly prescribed as reocclusion prophylaxis, but low doses would be preferable because of fewer adverse effects. We performed a double-blind, randomized, controlled clinical trial in patients with peripheral vascular disease with lesions appropriate for angioplasty. We compared the efficacy and side effects of two doses of aspirin (50 mg vs. 900 mg daily) during a period of 12 months after angioplasty. A total of 359 patients were evaluated: 175 were randomly assigned to treatment with 900 mg aspirin daily and 184 to 50 mg aspirin daily. Thirty-nine patients developed restenosis at the angioplasty site; the cumulative percentage of event-free survival after 1 year (patency rate) was 85% in 900 mg group and 84% in 50 mg group. An equivalence test showed the two groups equivalent with respect to restenosis rates (P = 0.0003 for an equivalence region of < 10% difference. Nine patients (5%) in the 900 mg group had serious gastrointestinal side effects (peptic ulcer, 8; erosive gastritis requiring transfusion, 1) compared to two ( peptic ulcer) in the 50 mg group (P = 0.03). The results of our study show that a dose of 50 mg aspirin a day is as effective as 900 mg for the prevention of restenoses after lower limb angioplasty, and that severe gastrointestinal side effects are less frequent.

[Dose-dependent side effects of acetylsalicylic acid therapy. Results of a prospective randomized clinical study in patients with peripheral arterial occlusive disease]. / Dosisabhängige Nebenwirkungen der Acetylsalicylsäuretherapie. Ergebnisse einer prospektiven, randomisierten klinischen Studie bei Patienten mit peripherer arterieller Verschlusskrankheit.

BACKGROUND AND METHODS: In 359 patients with peripheral arterial occlusive disease who had undergone percutaneous transluminal angioplasty (PTA), a randomized double-blind, controlled clinical study was done to investigate the tolerability of acetyl salicylic acid (ASA) given for reocclusion prophylaxis. A comparison was made between a conventional daily dose of 900 mg ASA and a dose of 50 mg ASA. RESULTS: Within an observation period of one year following PTA, 35 patients (20%) in the 900 mg group, and 32 patients (17%) in the 50 mg group left the trial because of side effects (p = NS). Under the higher dose, however, severe gastrointestinal side effects (ulcer, haemorrhagic gastritis requiring transfusion) were significantly more common (nine patients delta 5.1% vs two patients delta 1.1%, respectively; p = 0.03). Overall, 107 patients (30%) reported subjective side effects such as upper abdominal pain, a sensation of fullness or nausea during the course of the trial. 62 of these patients were from the 900 mg group (35%) as compared with 45 patients (24%) in the 50 mg group (p = 0.02). Self-scoring of epigastric pain on the basis of a visual analogue scale revealed a score of 1.3 (95% confidence interval 0.9 to 1.6) in the 900 mg group and 0.8 (95% confidence interval 0.6 to 1.0) in the 50 mg group. The subjective pain intensity showed a uniform time course for all three types of symptom, with a maximum after three months. CONCLUSION: Our results confirm the superior tolerability of the lower dose, in particular in elderly patients. For long-term treatment, the smallest possible effective dose should be chosen.

[The AMBER thoracic imaging system in routine diagnosis]. / Das AMBER-Thoraxaufnahmesystem in der Routinediagnostik.

After installation of an Amber lung x-ray imaging system the range of application of this technique was registered for two months. Additionally the image quality for structures of the lung parenchyma and mediastinum were proved and dose measurements were performed. 50.6% (772) patients from a total of 1525 could be x-rayed by the Amber imaging system. Related to all people able to stand 73.6% from 1049 patients were examined with the Amber system. Most of the imaging figures of merit specified by the German national physician board were accomplished, besides the fact that 1/3 of the p.a. radiographs were cut off at the side because of the small size of the film. The excellent image of pleuro-mediastinal structures was proofed quantitatively by counting the pleuro-mediastinal lines and comparing the results with standard radiographs. Measuring the exposure at entrance point we obtained nearly the same values for the Amber system using a screen-film combination with a speed of 400 and conventional radiographs (40-120 mu Gy; 21 pat.).

[The determination of the surface and organ doses in the AMBER system. Advanced Multiple Beam Equalization Radiography]. / Bestimmung von Oberflächen- und Organdosen am AMBER-System.

Surface and organ doses were determined by means of thermoluminescence dosimetry with the Alderson-Rando phantom and the patient, for the AMBER thoracic imaging system, sensitivity class 400, and the conventional grid screen stand, sensitivity class 200. The dose on entering the body, which varied according to object-dependent modulation of x-ray intensity, was 140 microGy for the mediastinum and 96 microGy for the lung in p.a. AMBER takes, and hence was comparable with the entrance dose of 132 microGy with the conventional grid screen stand. In lateral takes the entrance doses were lower with the AMBER system (302 microGy) than with conventional takes (593 microGy). Exposure of the gonads at the AMBER system for p.a. thoracic takes was lower than at the screen grid stand in females (4-6 microGy). More unfavourable values were measured for the gonad exposure in males (2-0.8 micrograms).

[The findings of color Doppler sonography in breast tumors]. / Befunde der Farb-Doppler-Sonographie bei Tumoren der Brustdrüse.

UNLABELLED: 72 histologically confirmed tumours of the breast--37 carcinomas and 35 benign tumours--for which mammograms were also available were examined by colour Doppler sonography. Vascularisation of benign processes showed at most 2 vessels (with the exception of 3 sarcoma phylloides and one proliferative mastopathy). Vascularisation clearly in excess of benign processes was observed in only 15 of the 37 carcinomas. In 33 of the carcinomas there was no doubt concerning the diagnosis preoperatively, in the remaining 4 the high vascularity was taken as an indication for surgery. CONCLUSION: In rare cases colour Doppler sonography can provide additional information in the presence of 'vascular' tumours. It is not possible to differentiate between poorly vascularised carcinomas and benign tumours.

[Color-coded Doppler sonographic studies of the morphology and hemodynamics of the pelvic and leg arteries in normal subjects]. / Farbcodierte doppler-sonographische Untersuchungen zur Morphologie und Hämodynamik der Arterien des Beckens und der Beine bei gesunden Probanden.

An attempt has been made to demonstrate the morphology and haemodynamics of the arteries in the pelvis and lower limbs by means of angiodynography in 20 normal individuals. Problem areas for morphological evaluation are the pelvic vessels, the vessels in the distal adductor canal and the fibular artery in the calf. Haemodynamic studies are successful if the morphology can be adequately shown, but for flow measurements this is true only in the thigh. The results of quantitative haemodynamic analyses are detailed in tabular form (systolic flow -, late systolic reverse and diastolic flow velocity; deceleration; pulsation index; flow values).

[Results of percutaneous transluminal irradiation of biliary tract carcinoma with 192Iridium]. / Ergebnisse der perkutan transluminalen Bestrahlung von Gallenwegskarzinomen mit 192Iridium.

In 22 patients with bile duct carcinoma's intratumoral irradiation was performed through a percutaneous biliary drainage. 17 of them had been found to be inoperable at laparotomy, 5 others had recurrent carcinoma at the site of a biliodigestive anastomosis. The applied dose ranged from 60 to 80 Gy at 6 mm distance of the centre of the Iridium source. In 12/22 patients a clear reduction in the degree of tumor stenosis could be established. Regarding the survival of the patients (8.6 months) results were relatively poor, due to extensive metastases. Patients with a documented dilatation of tumor stenosis showed a low significant longer survival period (12.3 months) than those without detectable response (4.2 months).

[Phantom measurements of blood flow using color-coded Doppler sonography (Quantum Angiodynograph): accuracy and sources of error]. / Phantommessung des Blutflusses mit der farbkodierten Doppler-Sonographie (Quantum Angiodynograph): Genauigkeit und Fehlerquellen.

Flow measurements were carried out on a phantom simulating tissue, using systematic variations of various parameters and of relevant geometric factors. The effect of imaging and flow parameters on the accuracy of the measurements is described and the conditions are defined which are necessary for obtaining a high degree of accuracy. Large errors are introduced by measurements carried out with large Doppler angles or if the delimiters used for automatic vessel measurements have not been set up accurately.

[Results of percutaneous transluminal embolization therapy in severe hemorrhages in the pelvis]. / Ergebnisse der perkutanen transkatheteralen Embolotherapie bei schweren Blutungen im Becken.

Percutaneous transluminal embolisation technique (PTE) is used to an increasing extent in preference to surgical operations for treatment of severe haemorrhages of surgical, gynaecological, and urological tumours of the pelvic region which are difficult to control. Based on a study of 35 patients (19 female and 16 male) with an average of 71 (32-87) years the indication of embolisation, the technique, the choice of material for embolisation, the rate of success, and the complications of this therapeutic method are discussed. In 34 of the 35 patients bleeding stopped after embolisation therapy. Only in one patient major side effects were seen. Our own experience has shown that an exact pretherapeutic angiogram of the pelvic vessels with selective or subselective catheterisation of tumour feeders is necessary for an effective embolisation.

[Digital subtraction angiography and iodine 123 amphetamine scintigraphy (IMP-SPECT) in the diagnosis of acute and chronic inner-ear hearing loss]. / Die digitale Subtraktionsangiographie (DSA) und die Jod-123-Amphetamin-Szintigraphie (IMP-SPECT) in der Diagnostik von akuten und chronischen Innenohrschwerhörigkeiten.

Vascular lesions may play a role in the genesis of acute and chronic hearing loss. After exclusion of other causes the vascular status of 33 patients was examined using digital subtraction angiography (DSA) for the supra-aortic vessels, and the N-isopropyl-(I-123)p-iodoamphetamine (IMP-SPECT) technique to investigate cerebral blood flow. Not a single case of stenosis affecting the hemodynamics, of a vascular anomaly or of a cerebrovascular perfusion disorder was found.

[Percutaneous transluminal irradiation of biliary tract cancer using iridium]. / Perkutan transluminale Bestrahlung von Gallenwegskarzinomen mit Iridium.

In ten patients with biliary carcinomas, percutaneous biliary drainage was instituted and intracavitary irradiation performed, using 192iridium with a dose of 40 to 80 Gy. Eight of these patients had been found to be inoperable at laparotomy and two had had a recurrence. In half the patients there was a reduction in the degree of stenosis due to the tumour, but in only one patient was it possible to remove the draining catheter. Survival time in eight patients was between one and eight months, average 5 months. Two patients survived for eleven and twelve months respectively. The relatively poor results are due to extensive metastases. On the other hand, there can be no doubt about the effectiveness of this treatment on locally confined tumours, in view of the reduction in the obstruction caused by the tumour.

[I.v. DSA in the diagnosis and follow-up of thoracic aortic dissection]. / I.v. DSA zur Diagnostik und Verlaufskontrolle der thorakalen Aortendissektion.

Intravenous DSA was performed in 53 patients with suspected dissection of the thoracic aorta and in 13 patients following surgery for aortic dissection. In 36 patients, the suspected diagnosis could be excluded definitely and, in 14 cases out of 17, a dissection was correctly diagnosed. All 11 type B dissections were correctly diagnosed. Of six type A dissections, only three were adequately demonstrated by IV DSA. In type B dissections, IV DSA is reliable, but in type A dissection with massive aortic insufficiency or pericardial tamponade the findings are not reliable. In all 13 patients who had surgery for dissection, IV DSA proved suitable for showing the anastomosis and progress of the disease.

[A new mathematical method for the radiological determination of total lung capacity]. / Ein neues Rechenverfahren zur radiologischen Ermittlung der totalen Lungenkapazität (TLC).

Various radiological methods for estimating lung volume depend on anatomical correlation with the volume of the thorax. It is not possible to derive general factors for correcting these methods and the accuracy and reliability can be improved only by introducing individual corrections. It must also be remembered that radiometric calculations of gas volume and lung capacity depend on the assumption that there is a fixed relationship between these. This, however, is untrue for a whole series of patho-physiological circumstances. Because of these problems, we describe our own radiometric method.