Percutaneous transluminal revascularization for renal artery stenosis: Veterans Affairs Puget Sound Health Care System experience.

PURPOSE: The safety and efficacy of percutaneous transluminal intervention for renal artery stenosis is improving. This study evaluates the immediate and long-term anatomic and functional outcomes of percutaneous transluminal angioplasty and stenting for atherosclerotic renal artery stenosis in a Veterans Affairs population. METHODS: We performed a retrospective analysis of records from patients who underwent renal artery angioplasty with or without stenting at the Veterans Affairs Puget Sound Health Care System between January 1990 and June 1999. Indications for intervention included hypertension (78%) and rising serum creatinine (78%). Seventy-six patients (74 men, average age of 67 years, range 42-83 years) underwent 88 attempted interventions. Seventy-two percent of contralateral kidneys had significant disease (47% had a >60% stenosis; 16% were nonfunctioning or absent). RESULTS: Of the 88 planned interventions, 86 were successfully performed with placement of 46 stents (52%). Technical success (defined by <30% residual stenosis) was achieved in 78 vessels (89%). The procedure-related complication rate was 5%. Patient mortality by life table analysis was 49% at 5 years. Assisted primary patency rate at 5 years was 100%. Primary and secondary restenosis rates were 37% +/- 8% and 31% +/- 8% at 5 years, respectively. Sixty-eight percent of patients treated for hypertension demonstrated clinical benefit (improved or cured hypertension). This clinical benefit was maintained in 52% of the patients at 5 years, as measured by life table analysis. Serum creatinine was lowered or maintained in 88% of the patients, but this clinical benefit was only maintained in 25% of patients at 5 years. CONCLUSIONS: Transluminal intervention for clinically symptomatic atherosclerotic renal artery stenosis is technically successful and safe. There are excellent assisted-patency and low restenosis rates. There is immediate clinical benefit for most patients, as evidenced by improved control of hypertension and preservation of renal function. However, within 5 years the benefit is not maintained for either hypertension (50%) or renal function (20%). Therefore, although technically successful, functional outcomes after endoluminal intervention are not maintained in the long term.

Successful treatment of early postoperative aortic graft infection by percutaneous catheter drainage.

Successful treatment by percutaneous catheter drainage of an acute aortic graft infection with an associated pancreatic fistula is reported. Percutaneous catheter drainage can be considered in selected patients when the risk of reoperation is deemed unacceptable or when other reasonable treatment options do not exist.

Color Doppler imaging of infrainguinal arterial occlusive disease.

Few reports in the literature validate the use of color Doppler imaging (CDI) for the evaluation of lower extremity arterial occlusive disease, particularly in the tibial and peroneal arteries. This prospective, blinded study compares CDI to arteriography to address the following questions: (1) how well does CDI visualize arterial segments, including those below the knee? and (2) can CDI alone accurately classify the degree of occlusive disease? Twenty-nine men undergoing arteriography before a lower extremity arterial reconstructive procedure were studied with a color ultrasound scanner from the level of the inguinal ligament to the ankle. Color images were examined for the presence or absence of triphasic flow, poststenotic turbulence, color bruits, and collateral vessels. Among 636 arterial segments adequately visualized by arteriography, > or = 90% were identified with color Doppler imaging, including the tibial and peroneal arteries. With color criteria only, specificity was > or = 92% for distinguishing < 50% from > = 50% lesions and > or = 93% for differentiating patent from occluded arteries. Sensitivity for detecting an occlusion was > or = 97% in the superficial femoral (SFA) and popliteal arteries and 83% in the tibial vessels. For identifying a > or = 50% stenosis, sensitivity was > or = 85% in the SFA and popliteal arteries but only 79% and 86% in the posterior and anterior tibial arteries, respectively. CDI reliably identifies vessel location from the level of the groin to the ankle. For the detection of occlusions, CDI is an accurate screening tool in the SFA and popliteal arteries but is less accurate in the tibial vessels.(ABSTRACT TRUNCATED AT 250 WORDS)

Preliminary report: penile vein occlusion therapy: selection criteria and methods used for the transcatheter treatment of impotence caused by venous-sinusoidal incompetence.

Penile vein occlusion therapy is a fluoroscopic guided technique developed for treating venous-sinusoidal incompetence in patients with erectile dysfunction. We report our experience with 22 patients who have been followed for greater than 1 year. Catheterization of the veins draining the penis was technically possible in 20 of 22 patients (91%). Of these 20 patients 5 (25%) were cured and 9 (45%) had significantly improved erectile function. All 5 patients (100%) with venous-sinusoidal incompetence plus normal cavernous arterial flow, no glans or corpus spongiosal shunts, and bilateral complete coil occlusion of the crural and common crural veins were cured. No deterioration of function was noted at 1 and 2 years. Patient selection and bilateral occlusion of the penile veins are essential to achieve successful penile vein occlusion therapy.

Diagnosis of osteomyelitis in the presence of soft-tissue infection and radiologic evidence of osseous abnormalities: value of leukocyte scintigraphy.

To evaluate the usefulness of 111In-leukocyte scintigraphy for identifying osteomyelitis in the presence of soft-tissue infection, we prospectively studied 45 bone sites adjacent to soft-tissue infection in patients with abnormal findings on radiographs and 99mTc bone scans that were suggestive of osteomyelitis. 111In-leukocyte scans were analyzed in terms of the intensity of abnormal uptake and its location relative to bone. The diagnosis of osteomyelitis was established from results of percutaneous bone biopsy culture (n = 35), histologic examination of surgical specimens (n = 8), and clinical follow-up (n = 2). Osteomyelitis was present at 22 sites, including 16 of 18 sites with increased leukocyte uptake in bone, resulting in a sensitivity of 73%, specificity of 91%, and positive predictive value of 89% for this finding. Osteomyelitis was present at four of 17 sites with predominantly soft-tissue localization of leukocyte activity in the region of bone, none of seven sites with normal leukocyte scans, and two of three sites with diminished leukocyte uptake in bone. Although not helpful in distinguishing infectious from noninfectious bone abnormalities, 3- and especially 24-hr bone scans viewed in conjunction with leukocyte studies provided important correlation to aid in estimating the location of focal abnormal leukocyte uptake. The finding of soft-tissue infection with increased uptake of labeled leukocytes that extends to involve adjacent bone strongly suggests concurrent osteomyelitis. When the presence of abnormal leukocyte uptake in bone is uncertain, additional imaging and possibly biopsy may be required to establish or exclude the diagnosis of osteomyelitis.

Role of duplex scanning for the detection of atherosclerotic renal artery disease.

To assess the accuracy of renal artery duplex scanning for the purpose of diagnosing atherosclerotic renal artery stenosis, we compared the findings of renal arteriograms to the results of duplex scanning in 41 patients. Using an increase of renal artery peak systolic flow velocity of greater than 180 cm/sec, duplex scanning was able to discriminate normal from diseased renal arteries with a sensitivity of 95% and a specificity of 90%. Using the principle that blood flow velocity across a stenosis is roughly proportional to the degree of stenosis, it appeared that a ratio of the peak velocity in the renal artery to the aorta (RAR) of greater 3.5 predicted a greater than 60% diameter reduction of that renal artery, which is felt to be a significant stenosis. Forty-eight vessels were classified as having a greater than 60% diameter reduction by arteriography. Using the RAR of greater than 3.5, duplex scanning agreed in 44 renal arteries (sensitivity 92%). In the 26 renal arteries where arteriography showed a less than 60% diameter reduction, duplex scanning agreed in 16 vessels and correctly detected a focal narrowing in nine of the remaining ten vessels. Ten of 11 occluded renal arteries were correctly identified by duplex scanning. Duplex scanning determined the location of the renal artery lesion with an accuracy of 95% (kappa 0.74). Since duplex scanning can accurately demonstrate and locate focal renal artery stenosis, we believe it may become an accurate screening test for renovascular hypertension.(ABSTRACT TRUNCATED AT 250 WORDS)

The role of preoperative radionuclide ventriculography in defining outcome after revascularization of the extremity.

Revascularization of the extremity was performed upon 110 patients after preoperative radionuclide ventriculography (RNVG). Mean ejection fraction (EF) was 50 +/- 13 per cent. Ventricular wall motion abnormalities were present in 46 per cent. Revascularization included inflow procedures, such as aortofemoral (n = 25) or extraanatomic bypass (axillofemoral or femorofemoral, n = 11); infrainguinal reconstruction, including femoropopliteal or distal bypass (n = 43), and other procedures to improve perfusion of the limb or correct complications after previous vascular reconstruction upon the extremity (n = 31). Perioperative (30 days) mortality rate was 0.9 per cent and 97.0 per cent of the patients were discharged alive from the hospital. Myocardial infarction (MI) occurred in 3.6 per cent, new ventricular arrhythmia in 1.8 per cent and congestive heart failure in 6.4 per cent of the patients during the perioperative period. During follow-up study (607 +/- 363 days), 7.3 per cent required major amputation, ipsilateral to reconstruction, 5.5 per cent required surgical or angiographic revision for hemodynamic failure of the reconstruction prior to thrombosis and 12.7 per cent thrombosed part or all of the reconstruction. Revascularization failure did not appear to be related to the level of cardiac function. Those with normal (greater than 50 per cent) EF had greater over-all survival by life table analysis than those with EF less than or equal to 50 per cent (p = 0.0006, Mantel-Cox test). Ventricular wall motion abnormalities were associated with reduced over-all survival (p = 0.008, Mantel-Cox test). The presence of angina or previous MI, singularly or in combination, did not have an adverse effect on over-all survival, whereas diabetes (p = 0.0058, Mantel-Cox test) and cigarette smoking (p = 0.0137, Breslow test) were associated with significantly diminished over-all survival. Preoperative RNVG can identify subgroups at a survival disadvantage after revascularization of the extremity in a population in which the presence of angina or previous MI does not predict survival.

Treatment of acute renal artery occlusion after percutaneous transluminal angioplasty.

Four patients with occlusive complications after percutaneous transluminal renal artery angioplasty (PTA) have been treated from July 1, 1984, to March 14, 1988. During this interval such renal artery angioplasties were performed in 44 patients. Two resulted in complete main renal artery occlusion, one angioplasty resulted in occlusion of a stenotic renal artery bypass graft, and one renal PTA resulted in segmental branch renal artery narrowing, which was thought to represent a dissection. The latter segmental renal artery narrowing was treated expectantly with good long-term results. One of the main renal artery occlusions was treated by radiologic means by reentry and repeat transluminal dilation. The other two acute complete occlusions, one of an autogenous artery and the other of an aortorenal bypass graft, were treated by aortorenal or ileorenal bypass grafting, respectively. The overall incidence of main renal artery occlusion (including the bypass graft occlusion) after PTA requiring operative intervention was 4.5% (2/44). Revascularization was accomplished after 6 and 8 hours of renal ischemia time for the two surgical procedures. Despite this, the bypass grafts done emergently remain patent, and the involved kidneys appear to be functional. The incidence of main renal artery occlusion after PTA is not as low as would be apparent from a review of the literature. It is proposed that main renal artery occlusion after PTA can be treated successfully by surgical and interventional radiologic techniques because of the presence of protective renal collateral circulation whose formation was stimulated by the renal artery lesion that prompted PTA.

Nonselective angiography after intracorporal papaverine injection: an alternative technique for evaluating penile arterial integrity.

Forty patients with impotence were evaluated by means of nonselective angiography after intracorporal papaverine injection. The penile arterial network was visualized in 39 patients (97%). The technique was technically simple, and there were no complications. The most common sites of arterial disease were the arteries at the base of the penis (58%) and the internal pudendal artery (31%). In patients with advanced atherosclerotic disease, formation of collaterals within the penile arterial network appears to be important in maintaining flow to the cavernosal arteries. Asymmetry of arterial disease was frequently encountered (54%), indicating the importance of bilateral visualization of the arteries supplying the cavernosal arteries. Penile arteries were not visualized adequately in any of the patients studied nonselectively without intracorporal papaverine.

CT of sacral injury.

Eighty-eight patients with 188 sacral fractures were examined with computed tomography (CT) and conventional radiography. Four main patterns of sacral injury were defined: sacroiliac diastasis (39%), sacral and/or iliac lip fractures (25%), vertical shear fractures (25%), and comminuted fractures (5%). Initial interpretation of plain radiographs failed to define 29% of the sacroiliac joint diastases, 57% of the lip fractures, 34% of the vertical shear fractures, and 25% of the comminuted fractures. The extent of injury was better delineated with CT, and a more certain diagnosis of sacral injury was possible with CT than with radiography. Because of the higher detection rate and improved imaging of fracture configuration, CT should be performed in all patients with sacral injury.

Nail-gun injuries. Accident, homicide, or suicide?

It may be difficult to distinguish industrial accidents from suicide attempts or even assaults or homicide. Nail guns are relatively new industrial tools that can produce severe or fatal injuries. The configuration of the nail on patients' radiographs after such injuries can be helpful in determining the cause of injury. Steel nails that are bent are due to a ricochet and thus indicate accidental injury. Straight-nail injuries to the co-workers of nail-gun users are most likely due to over-penetration of the substance being nailed or accidental mid-air firing; however, intentional injury cannot be ruled out. Extremity injuries caused by straight steel nails in nail gun users are the result of carelessness or poor technique, but suicide should be considered when straight nails cause wounds to the chest, head, or abdomen.

Indications for angiography in extremity trauma.

The angiograms of 119 extremities of patients with gunshot wounds (65), lacerating injuries (17), and blunt trauma (29) were retrospectively evaluated and correlated with clinical history. Indications for angiography were decreased or absent pulse or blood pressure, cold limb, bruit or murmur, uncontrolled bleeding or increasing hematoma, neurologic deficit, and proximity of the injury to vascular structures. Angiographic findings were compared with preprocedure clinical assessment. Angiograms performed only because of proximity of the wound/injury to major vessels showed no major arterial injuries. However, angiograms performed for one or more of the other indications demonstrated significant vascular abnormalities in 44% of gunshot wounds, 80% of knife injuries, and 67% of blunt trauma. Of the indications for arteriography, pulse abnormalities or cold limbs were most often associated with significant angiographic findings, positive studies occurring in 74% of cases. Despite the differences in mechanism of injury, physical examination is sensitive and effective in predicting which patients will have negative angiographic studies after each of the three forms of trauma.

CT of acetabular fractures: postoperative appearances.

Thirty-one postoperative pelvic computed tomographic (CT) scans in 29 patients studied between 1 day and 7 years after open reduction and internal fixation of acetabular fractures were reviewed. CT was most useful in the immediate postoperative period for detecting residual intraarticular fragments, localizing metallic fixation devices, and assessing the adequacy of reduction. CT scans obtained in the late postoperative period were useful primarily for determining the position and extent of ectopic bone before surgical removal.

Observer variability in evaluating extracranial carotid artery stenosis.

One hundred twenty eight cervical carotid arteriograms were twice viewed by three readers for the evaluation of atherosclerotic disease at the carotid bifurcation. Stenoses were estimated using calipers to the nearest 5% and lesions were qualitatively characterized as smooth, irregular, or ulcerated. The intraobserver correlation coefficient between estimates of percent stenosis was .94 overall and .98 for the internal carotid artery. The average intraobserver variability in estimating percent stenosis was 5.23% for all vessels and 6.04% with a standard deviation of 8.09% for the internal carotid artery. The intraobserver percent agreement at a fixed stenosis is defined as the percent of the time one reader on two readings would read at least the fixed percent stenosis among cases that might be read as having the fixed percent stenosis. The intraobserver percent agreement rate for the internal carotid artery was 95.9% at greater than 0% stenosis, 90.4% for 50% or greater stenosis, and 96.8% for 100% stenosis (total occlusion). The interobserver correlation coefficient between readers was .92 overall and .97 for the internal carotid artery. The absolute difference in percent stenosis between readers was 7.21% for all vessels and 8.64% for the internal carotid artery with a standard deviation of 9.5%. The interobserver agreement rate for the internal carotid artery at greater than 0% stenosis was 93.0%, 85.4% for 50% or greater stenosis and 96.8% at 100% stenosis. The addition of oblique views had no statistical effect on estimates of percent stenosis but increased the frequency with which irregularity and ulceration were diagnosed in the internal carotid artery.

CT of acetabular fractures: analysis of fracture patterns.

Thirty-one consecutive patients who sustained acetabular fracture or posterior femoral head dislocations were examined by computed tomography (CT). By analysis of closely spaced, thin CT images, it was possible to characterize the three-dimensional nature of these injuries. Traditional classification into anterior column, posterior column, and complex two-column fractures was facilitated. CT was especially useful in evaluation of the two-column fractures in which unique information concerning the configuration of the fracture, integrity of the acetabular dome and quadrilateral surface, and identification of the stable fragment was obtained. Surprisingly constant fracture patterns were identified. CT was also useful in determination of presence or absence of loose bodies in the joint and in evaluation of the femoral head and sacroiliac joint in all types of fracture.

CT of acetabular fractures: comparison with conventional radiography.

Computed tomography (CT) and plain radiography of the pelvis were compared in 26 adult patients in whom acetabular fractures or posterior femoral head dislocations were demonstrated or suspected on initial radiographs. The detection of abnormalities of the sacrum, sacroiliac joint, iliac wing, acetabular roof, joint space, anterior pelvic column, posterior pelvic column, posterior acetabular lip, pubic rami, and quadrilateral surface of the ilium by the two methods was compared. The ability of the two techniques to establish the stable fragment was also examined. Three independent readings of each examination for each pelvic region were tabulated, and sensitivity and specificity values were calculated. There was no significant difference between plain radiography and computed tomography in detection of fractures of the iliac wing, anterior pelvic column, posterior pelvic column, and the pubic rami, with high sensitivity and specificity for both examinations. CT was more sensitive than plain radiography in detecting fractures involving the sacrum, quadrilateral surface, acetabular roof, and posterior acetabular lip. In addition, abnormalities of the hip joint space, principally loose bone fragments, were detected more often by CT. Sensitivity of both examinations for abnormalities of the sacroiliac joint was relatively poor, but examinations were highly specific. Determination of the stable fracture fragment(s) was readily accomplished by CT scanning in all 26 patients; in five patients incorrect determinations were made with conventional radiographs alone.

Ultrasonic duplex scanning for disease of the carotid artery.

The duplex ultrasonic scanner combines real-time B-mode imaging with a single-gate, variable-range pulsed Doppler. The detection and categorization of the severity of carotid artery atherosclerosis is achieved by performing spectral analysis of the pulsed Doppler velocity signal obtained from vessels of interest. Using this technique, 750 patients with suspected extracranial carotid artery disease were evaluated between January 1978 and January 1980. One hundred thirty-five of these 750 patients (18%) underwent cerebral arteriography performed with biplanar views of the carotid bifurcation. The degree of stenosis was measured independently in these patients and was available for comparison with the results of duplex scanning and spectral analysis. Duplex scanning correctly detected the presence of disease in 252 of 259 carotid arteries studied (97%). The extent of involvement varied from plaques that produced less than 10% diameter reduction to those that resulted in a total occlusion. The technique was less accurate with lesions that produced less than 10% diameter reduction.