Intra-arterial prostaglandin e(1) infusion in patients with rest pain: short-term results.

PURPOSE: To present our results after short-term (1 month) intra-arterial infusion therapy of PGE1-alprostadil via a port system implanted in the ipsilateral external iliac artery (EIA) in patients with severe rest pain. METHODS: Ten patients with severe rest pain were included. All patients showed extensive peripheral vascular disease below the knee. The tip of the catheter was introduced via a retrograde puncture in the ipsilateral external iliac artery (EIA). The patients received intraarterial infusion of PGE1, 20 mgr alprostadil daily, via the port catheter for 1 month. RESULTS: Clinical success was evaluated according to subjective grading of pain (group A significant decrease, group B moderate decrease and group C no response). A significant decrease of rest pain was observed in 8 (group A, 80%) patients, a moderate decrease in 2 (Group B, 20%), whereas no patients demonstrated any significant response. Both patients of group B had Buergers' disease and continue to smoke during therapy. No peripheral thrombosis or clinical deterioration was noticed. CONCLUSION: Intraarterial infusion of PGE1 alprostadil on a daily basis, using a port catheter into the ipsilateral EIA, in selected patients with severe rest pain, seems to be very effective, without any serious complications.

Transcatheter arterial embolization as therapy of renal angiomyolipomas: the evolution in 15 years of experience.

OBJECTIVE: This study aims at presenting the evolution of the embolization technique in treating renal angiomyolipomas (AMLs) either diagnosed in patients with acute bleeding or discovered accidentally. METHODS: Ten patients with renal AMLs have been through thirteen selective transcatheter arterial embolizations for 15 years. Two patients had tuberous sclerosis complex (TSC) with bilateral tumors and were embolized twice. Four embolic materials were employed: PVA particles, Gianturco coils, microspheres and microcoils. Catheterization was achieved by means of 5F Cobra 2 catheters and coaxial microcatheter systems. RESULTS: On an emergency basis, embolization was a first-line treatment. In one case, surgery was necessary; in two patients, a second embolization was performed. When treatment was preventive, a single embolization proved to be sufficient, as well. There was no significant deterioration of the serum creatinine levels in the post-embolization period. CONCLUSION: Selective arterial embolization is a rather safe and effective technique to treat AMLs both urgently and preventively. Different embolic materials can be employed. Microspheres and microcatheters stand for new promising materials.

Acute iliac artery rupture: endovascular treatment.

The authors present 7 patients who suffered iliac artery rupture over a 2 year period. In 5 patients, the rupture was iatrogenic: 4 cases were secondary to balloon angioplasty for iliac artery stenosis and 1 occurred during coronary angioplasty. In the last 2 patients, the rupture was secondary to iliac artery mycotic aneurysm. Direct placement of a stent-graft was performed in all cases, which was dilated until extravasation was controlled. Placement of the stent-graft was successful in all the cases, without any complications. The techniques used, results, and mid-term follow-up are presented. In conclusion, endovascular placement of a stent-graft is a quick, minimally invasive, efficient, and safe method for emergency treatment of acute iliac artery rupture, with satisfactory short- and mid-term results.

Endovascular treatment of renal arteriovenous malformations.

We report a case of renal arteriovenous malformation treated with superselective endovascular embolization using a light mixture of n-butyl-2-cyanoacrylate and Lipiodol. Diagnostic imaging modalities and treatment methods are discussed. In conclusion, successful superselective embolization should be the standard of care.

Effects of superselective embolization for renal vascular injuries on renal parenchyma and function.

AIM: Our objective was to evaluate the outcome of superselective embolization used for treatment of renal vascular injuries on renal parenchyma and renal function. MATERIALS AND METHODS: Between January 1999 and December 2001, 6 consecutive patients (five males, one female, mean age 45 years) underwent embolization to treat bleeding from renal vascular injuries, resulting from iatrogenic interventions (4) and blunt abdominal trauma (2). Five patients had increased serum creatinine. Angiography depicted a pseudoaneurysm (PA) in three, PA with arteriovenous fistula (AVF) in one, and active extravasation in two patients. Superselective catheterization was achieved using a 5-F catheter in three, and coaxial microcatheter in the remaining three cases. All lesions were successfully embolized with 0.035" or 0.018" coils. RESULTS: Bleeding was ceased in all patients and did not recur. Mean post-embolization parenchymal ischemic area was 11.7% (range: 0-30%). Imaging follow-up (mean: 12 months, range: 5-23) showed that mean parenchymal infarcted area was 6% (range: 0-15%). Serum creatinine level was normal in all patients one week after the procedure and at the latest follow-up. CONCLUSION: Superselective embolization resulted in permanent cessation of bleeding. Serious parenchymal infarction was prevented and serum creatinine level returned to the pre-bleeding values. Embolization should be considered as the treatment of choice in this patient population.

Complications of lower-extremity outpatient arteriography via low brachial artery.

We retrospectively evaluated low brachial artery puncture for arteriography and its complications as an alternative approach route for bilateral lower extremity run-off. Using the Seldinger technique and catheterization with a sheathless 4-F multiple side-hole pigtail catheter, we performed 2250 low brachial artery punctures in outpatients. The right brachial artery (RBA) was successfully punctured in 2039 patients; the left brachial artery (LBA) in 200. The transfemoral approach was used in 11 patients when catheterizing either of brachial arteries failed. Ten major or moderate complications (2 pseudoaneurysms, 2 thrombosis, 1 dissection and 5 hematomas) were encountered. Surgical intervention was necessary in three cases. There were no transient ischemic attacks. Twenty-one patients suffered temporary loss of radial pulse which returned spontaneously in less than 1 hour. One patient demonstrated prolonged loss of pulse which required heparin. Low brachial artery puncture and catheterization at the antecubital fossa is a very safe and cost-effective alternative to the femoral artery approach for lower extremity intra-arterial arteriography in the hands of experienced operators. The success rate in catheterizing one of the brachial arteries was 99.52% with a low significant complications rate of 0.44%. The transbrachial approach should be used as a standard method for lower extremity IA-DSA in an outpatient setting.

Stent therapy for malignant superior vena cava syndrome: should be first line therapy or simple adjunct to radiotherapy.

UNLABELLED: The goal of this paper is to present our experience with superior vena cava (SVC) stenting, as first line procedure for immediate relief, in patients with malignancy, and its potential influence in the subsequent radiotherapy (XRT). Over a 1-year period, 18 patients with SVC syndrome due to severe stenosis secondary to mediastinal malignancy were referred for stent insertion. A SVC score was used to measure treatment effectiveness. Stent insertion had been successful in 18/18 patients (technical success 100%). All patients experienced symptomatic relief within few hours of the procedure. There were no major complications. In all patients we were able to start radiotherapy (XRT) the next day, after stenting according to our new institutional protocol. All patients were able to comply with the XRT program, perfectly well. CONCLUSIONS: SVC stenting provides immediate significant relief of the very annoying SVC syndrome symptoms, thus facilitating excellent compliance of all the patients to the subsequently XRT protocols. We strongly recommend SVC stenting as first line procedure, in patients with SVC syndrome due to malignancy prior to radiotherapy.

Abdominal aortic aneurysm and renal artery stenosis: renal function and blood pressure before and after endovascular treatment.

We describe three patients with abdominal aortic aneurysm (AAA) and renal artery stenosis (RAS). These patients were treated by placement of an aortic endograft and angioplasty or stenting of the renal artery. After the procedure renal function improved or remained stable in two patients and deteriorated slightly in one. Blood pressure was reduced in one hypertensive patient and remained normal in the other two normotensive patients. In conclusion, simultaneous treatment of AAA and RAS with aortic endograft placement and renal artery angioplasty with or without stent, is a safe and effective technique for selected high-risk patients.

Hepatic primary and secondary malignancies: comparison of helical CT and helical CT during arterial portography.

BACKGROUND/AIMS: To compare the sensitivity of helical CT to that of helical CT arterial portography in the detection of hepatic primary or secondary malignancies, in 20 patients who subsequently underwent surgery to confirm findings. METHODOLOGY: Twenty patients with suspected primary hepatic or secondary malignancies who all underwent helical CT and helical CT arterial portography preoperatively were prospectively evaluated. All the images were reviewed by two radiologists. The results were subsequently correlated with surgical and pathological findings. The sensitivity and the positive predictive values for lesion detection were determined for each modality. RESULTS: There were 39 pathologically confirmed hepatic malignant lesions. The overall sensitivity and positive predictive value of helical CT arterial portography were 87.1% and 82.5%, respectively, while of helical CT were 84.6% and 94.2%, respectively. CONCLUSIONS: Helical CT arterial portography and helical CT of the liver were approximately equivalent for lesion detection in patients who were evaluated preoperatively for resection of liver malignancies. The lower cost and non-invasive nature of helical CT suggest that it should be the preferred modality.

Doppler US of superior mesenteric artery in the assessment of ulcerative colitis. A prospective study.

BACKGROUND/AIMS: The purpose of this study was to correlate blood flow velocity in the superior mesenteric artery and activity of ulcerative colitis. METHODOLOGY: Doppler spectral analysis of superior mesenteric artery blood flow velocities were obtained in a blind study from 28 patients after fasting (A1: 13 patients with pancolitis, A2: 5 patients with subtotal colitis, B: 10 patients with left-sided colitis) and 50 healthy volunteers (control group). Disease activity was determined with clinical and endoscopic findings. RESULTS: A significant increase in superior mesenteric artery blood flow measurements was observed in the active pancolitis group A1 [Vsyst = 3.64 +/- 0.18 m/sec and Vdiast = 0.94 +/- 0.09 m/sec as compared with healthy volunteers (Vsyst = 1.14 +/- 0.07 m/sec, Vdiast = 0.38 +/- 0.04 m/sec) P < 0.01. A minor increase in superior mesenteric artery blood flow velocity was observed in patients with subtotal colitis, group A2 (Vsyst = 2.06 +/- 0.14 m/sec, Vdiast = 0.45 +/- 0.05 m/sec) as compared with healthy volunteers P < 0.01. In group B with left sided colitis superior mesenteric artery velocity changes were not statistically significant (P > 0.05). CONCLUSIONS: Doppler US velocity measurement of superior mesenteric artery may be used as an adjunct in the assessment of ulcerative colitis extension and activity.

Renal artery stenting for renal insufficiency in solitary kidney in 26 patients.

OBJECTIVE: to present our experience with stent placement in renal arteries in solitary kidneys for treating renal insufficiency. DESIGN: retrospective analysis. MATERIALS: in 26 patients with solitary kidney (17 men, 9 women, mean age: 63 years), presented with renal insufficiency (se-creat >0.144 mmol/l), stent was placed in a stenosed renal artery. We analysed the clinical outcome, based on the level of creatinine at 3 months following the procedure. Clinical benefit was considered when there was a decrease compared to the baseline creatinine by >20% or a stabilisation of the creatinine value (+/-20% of the baseline). RESULTS: in 16 of the 26 patients (62%), clinical benefit was achieved. However, 38% of the study population, renal function continued to deteriorate. Baseline creatinine value was the single best predictor for clinical benefit achievement (odds ratio: 13; 95% confidence intervals: 1.6-107, p=0.01). CONCLUSION: renal stenting results in improvement or stabilisation of renal function in the majority of the patients with solitary kidneys and renal artery stenosis, presenting with renal insufficiency. Because best outcome was observed mainly in those patients with not progressed renal insufficiency, intervention should be focused on that group.

Transplant renal artery stenosis: hypertension and graft function before and after angioplasty.

We present a case, who after 15 years of renal transplantation developed severe deterioration of her hypertension without alteration in renal function. Colour Doppler sonography revealed a 90% stenosis near the anastomosis of the graft artery to iliac artery, which was successfully and uneventfully corrected by percutaneous balloon angioplasty. Following the procedure the blood pressure control dramatically improved and her antihypertensive regimen returned and remained at baseline for the subsequent year of observation. Renal function remained normal and stable before and after angioplasty.

Imaging and localization of pancreatic insulinomas.

For pancreatic insulinomas, the treatment of choice is surgical excision, which when successful is curative. Intraoperative palpation combined with ultrasonography theoretically depict almost all tumors, however the accuracy of palpation is improved by the preoperative localization. All recent advances in imaging have improved the likelihood for curative surgical resection. Our purpose is to demonstrate the characteristics of all modalities, which may be used in the preoperative localization algorithm.

Comparison of CT, MRI and CT during arterial portography in the detection of malignant hepatic lesions.

BACKGROUND/AIMS: A prospective study was performed to compare the sensitivities of computed tomography, magnetic resonance imaging and CTAP (CT during arterial portography) in the detection of focal malignant hepatic lesions. METHODOLOGY: Twenty-eight (28) patients with primary and secondary hepatic malignant tumors were evaluated. All of these patients underwent hepatic resection and a lesion-to-lesion imaging-pathological analysis was performed. RESULTS: The overall sensitivities were 53% for CT, 66% for MRI sequences and 88% for CTAP. For lesions smaller than 1 cm the sensitivities were 6% for CT, 17% for MRI and 72% for CTAP. The combination of CTAP and MRI yielded an overall detection rate of 93%. The difference between the sensitivity of CTAP and that of the other two imaging techniques was statistically significant (P < 0.04) according to the McNemar test. CTAP demonstrated four false-positive lesions, two of which were correctly characterized by MRI and one by CT. In 6 patients (21.4%) the surgical plan was modified after CTAP. CONCLUSIONS: We conclude that, CTAP has the highest sensitivity and should be part of the preoperative examination. In some instances, the addition of MR imaging must be considered a helpful adjuvant. Both techniques should be considered complementary in the preoperative diagnostic algorithm.

Therapeutic tactics and late results in predominant truncal congenital malformation.

BACKGROUND: Congenital vascular malformations are rare vascular lesions of unknown etiology, non-degenerative or of inflammatory nature, which begin during embryological development; they are characterized by anomalies of the vascular system, apparently due to hemodynamic and metabolic disturbances. METHODS: Our diagnostic and therapeutic management in addition to the late results in 60, mainly truncal cases, out of 265 congenital vascular malformations, are analyzed in the present study. In a 20-year period 25,000 vascular examinations were carried out, among which 265 (1.06%) congenital vascular malformations (CVMs) were discovered, that is 77% (205/265) extra-truncal venous angiomata and 22.7% (60/265) truncal diffuse or localized types. The distribution of the above types was: 22 (36.6%) arteriovenous, 30 (50%) venous and 8 (13.4%) lymphatic. RESULTS: Surgery was carried out in 48.3% (29/60) of the truncal types of which 37.9% of the cases, on average, recurred 8 years later. Of the 22 arteriovenous malformations 20 patients were operated on (90%), of whom 35% (7/20) had a recurrence; of the 30 venous defects 30% (9/30) were operated on and 44.5% (4/9) of these had a recurrence. The recurrence rate rose to 50% (5/10) in cases of operative therapy of arteriovenous defects and to 20% (2/10) with combined surgical and non surgical methods. The recurrence incidence of venous defects with surgical treatment and sclerotherapy was 54.1% (6/11). CONCLUSIONS: Timely diagnosis, microsurgical techniques and highly specialized surgical and interventional experience are expected to improve these results significantly.

Preoperative localization of pancreatic insulinoma by selective intraarterial calcium injection and hepatic venous sampling.

Preoperative localization of insulinomas is desirable by most surgeons. Imaging with ultrasonography, computed tomography, magnetic resonance imaging, nuclear medicine and angiography may fail to demonstrate these small tumors in up to 10%, while a smaller percentage may be missed even after careful surgical exploration and intraoperative ultrasonography. Selective intraarterial injection of calcium with hepatic venous sampling has been reported to be a very accurate technique for preoperative localization of insulinomas. We report such a case where the clinical symptoms were highly suggestive but imaging algorithm failed to reveal any lesion and we review the literature.

Superselective microcoil embolization of a traumatic pseudoaneurysm of the cavernosal artery.

According to the literature, straddle injuries of the perineum may result in arteriosinusoidal fistula and secondary high-flow priapism. We report a case of a 23-year-old man who developed a traumatic pseudoaneurysm of the cavernosal artery, secondary to straddle injury, and presented with painless priapism. It was treated successfully with superselective microcoil embolization and the priapism resolved.

Embolization of a segmental renal artery pseudoaneurysm after partial nephrectomy in a solitary kidney.

Renal pseudoaneurysms are a well-documented complication following trauma or after percutaneous biopsy. When symptomatic, patients present with hematuria and deteriorating renal function. We present the case of a 62-year-old man who, due to development of a pseudoaneurysm, presented with gross hematuria 10 days after partial nephrectomy for a renal cell carcinoma in a single kidney. A segmental artery was embolized with stainless steel coils without significant loss of the limited renal vascularization.

Effect of balloon angioplasty and stenting following clips vs suture arterial stenosis: an experimental study.

BACKGROUND: Comparative evaluation of balloon angioplasty following intravascular stenting after experimental stenoses caused by arterial reconstruction with vascular clips and conventional sutures. MATERIALS AND METHODS: A total of 24 arteriotomies were carried out at the carotid and common iliac arteries of pigs following a 10 mm longitudinal arteriotomy and provocation of stenosis. Twelve of the arteries were reconstructed with vascular clips and 12 with conventional suture. Ultrasonography revealed stenosis fluctuating from 60-95% (PSV: 1.8-3.5 m/sec EDV: 1.3-1.47 m/sec PSV ratio > 3.5). After 8 weeks, following digital subtraction angiography, which revealed > 50% stenosis in all of the cases, balloon angioplasty followed by placement of intravascular stent was carried out. RESULTS: All the angioplasties remained angiographically and macroscopically patent two months after without thrombus formation. Rupture during dilatation occurred in one of the sutured cases. Histologically no degenerative changes, necrosis or remarkable intimal thickness were observed in either method. Focal inflammatory reaction was seen in 2 sutured and in 1 clipped cases while intimal ulceration was observed in 2 sutured cases. All cases with clips presented an intact endothelial surface. CONCLUSION: Early experimental results suggested that arterial stenosis provoked by clipped reconstruction could be managed successfully by balloon angioplasty followed by placement of intravascular stent.