Interventional radiology in palliative medicine.

Substantial developments in interventional radiology over the last two decades have resulted in the introduction of new methods of treatment for patients with advanced malignancy. These new minimally invasive techniques avoid the need for prolonged hospital inpatient care.

Superior vena caval obstruction managed by the Gianturco Z Stent.

Twenty patients with superior vena caval obstruction (SVCO) due to malignancy were managed using the Gianturco Z Stent. Three patients had adjunctive thrombolysis. The primary clinical success was 90% (18/20 patients). Thirteen patients were free of SVCO to death or follow-up without re-intervention (primary patency = 65%). Three patients had re-intervention for recurrent symptoms, two successfully (secondary long-term patency = 75%). Stenting of the SVC is a valuable, under-used technique for the symptomatic relief of superior vena caval obstruction.

Case report: pelvic pain syndrome--successful treatment of a case by ovarian vein embolization.

Pelvic pain syndrome, without an apparent organic cause, is a common gynaecological complaint. Investigations, including laparoscopy are frequently negative but ovarian venography has demonstrated that pelvic varices are a consistent finding in these patients. The aetiology of pelvic varices has been the subject of debate, but it has recently been suggested that the primary problem is venous reflux in dilated, incompetent ovarian veins. Surgical ligation of the ovarian veins has been used effectively in small series of patients with this condition. We report a patient with the clinical and radiological features of this syndrome in which treatment by bilateral ovarian venous embolization produced prolonged symptomatic relief.

Case report: the ultrasound and Doppler appearances of pelvic varices.

Dilatation of the veins of the broad ligament and ovarian plexi cause a very specific clinical entity called the pelvic congestion or pelvic pain syndrome. The ultrasound and Doppler appearances of this condition are unique and should be easily recognized. We describe these appearances in one patient and review the literature.

Malignant 'angiodysplasia'.

Four patients with chronic gastrointestinal blood loss of obscure aetiology were investigated by visceral angiography. All showed angiographic abnormalities in the caecum with characteristic features seen in angiodysplasia as well as other conditions such as inflammatory bowel disease, carcinoma. All four patients had a malignant cause for their angiographic appearance. This paper stresses the importance of reviewing previous examinations before accepting a diagnosis of angiodysplasia. The angiographic features of contrast pooling on the anti-mesenteric border of the caecum or ascending colon, a dilated intramural vein and early filling of a draining vein imply that serious pathology is present.

Noninvasive measurement of renal blood flow with technetium-99m-DTPA in the evaluation of patients with suspected renovascular hypertension.

If a hypertensive patient with renal artery stenosis (RAS) is to benefit from percutaneous transluminal renal angioplasty (PTRA) in terms of a sustained improvement in blood pressure control, one may postulate a demonstrable reduction in renal blood flow (RBF) to that kidney, reversible by PTRA. In a population of 32 hypertensive patients, RAS was present in 23 of 62 kidneys. Eleven of the 32 patients underwent renal revascularization, of whom 6 showed improvement in blood pressure control at 6 mo, i.e., had renovascular hypertension (RVH). There was no correlation between RBF and angiographic appearances of the renal artery. Furthermore, there was no significant difference between RBF in the stenosed kidneys of the patients with RVH compared with the stenosed kidneys of patients without RVH. Individual kidney RBF was 22% (s.d. 11) higher 1-3 wk after PTRA but the increase did not correlate with clinical outcome. Angiotensin converting enzyme (ACE) inhibition increased RBF by 25% (s.d. 25) of baseline flow before PTRA but the increase did not correlate with clinical outcome. Measurement of RBF is of limited value for the prediction of the long-term blood pressure response following PTRA.

Carotid artery stenosis--reassessment of the Doppler criteria.

Few previous studies of the accuracy of duplex Doppler in the assessment of carotid artery stenosis have looked at the accuracy in excluding disease in populations with a significant number of normal arteries. In addition, few studies have compared different criteria for stenosis. Duplex Doppler was used to evaluate the carotid arteries in 80 patients. Two well-described methods for analysing Doppler traces were used and the results were compared with those obtained from non-selective digital subtraction angiography. On the basis of these findings, the Doppler criteria used for carotid stenosis were redefined in terms of changes in peak velocity rather than Doppler frequency shift. Using these criteria, the sensitivity of Doppler in identifying carotid stenosis was 97% (98% sensitivity for greater than 50% stenosis) and specificity was increased from 84% to 93%.

Renal embolization for ablation of function in renal failure and hypertension.

The results of transcatheter renal artery embolization are presented in a small group of patients with end-stage renal disease. Five of the patients were suffering from severe drug-resistant hypertension, one from rejection of a renal transplant and one had heavy haematuria from a transplant kidney. All seven patients benefited from the procedure with no significant morbidity. The procedure of renal artery embolization and its potential complications are discussed. It is concluded that renal ablation by transcatheter embolization is not only effective, but also has a significantly lower morbidity and mortality than surgical nephrectomy in this group of patients with end-stage renal disease and associated problems.

Percutaneous transluminal angioplasty of the distal abdominal aorta.

Percutaneous Transluminal Angioplasty (PTA) has become widely practised and is a significant advance in the treatment of arterial disease. Its use in the treatment of atheromatous abdominal aortic stenoses in thirteen patients is described. Technical success was achieved in all with no complications. In a follow-up period from 7 to 70 months all patients have benefitted and 85% remain symptom free.

Angiodysplasia as a cause of iron deficiency anaemia.

Angiodysplasia, a condition of unknown aetiology, is thought to represent the commonest cause of obscure gastrointestinal bleeding, particularly in the elderly population. The lesions of angiodysplasia, which are small (less than 5 mm) and usually multiple, consist of microvascular abnormalities in the mucosa and submucosa of the bowel wall. They are most commonly found in the caecum and right side of the colon, but have been observed in the stomach, ileum and elsewhere in the colon. The diagnosis is made by either selective visceral angiography and/or colonoscopy, but the lesions cannot be detected on barium studies or with the naked eye at laparotomy. Localisation of the abnormalities by the histopathologist is greatly facilitated by special injection techniques demonstrating the blood vessels of resected colonic specimens prior to fixation and section. Treatment may be conservative (iron replacement) if the anaemia is not severe, by endoscopic fulguration or by colonic resection. Other common causes of gastrointestinal blood loss should always be excluded before the final diagnosis of angiodysplasia is accepted. Although the condition is well recognised as a significant cause of gastrointestinal blood loss a number of questions remain to be answered. The true incidence of angiodysplasia in the population is not known, the aetiology of the condition remains a mystery, although many theories abound.

Hemobilia. A disease in evolution.

Ten patients with hemobilia were treated over a six-year period. Six cases resulted from iatrogenic injury (percutaneous invasive procedures, four; surgical trauma, two); the others were caused by gallstone disease (two), liver trauma (one), and vasculitis (one). Five patients were treated successfully by selective arterial embolization. In the other five patients, embolization was not possible due to previous surgical and/or radiologic procedures, or it was contraindicated, and thus, surgical treatment was undertaken. One of these patients died. There were no long-term sequelae in the remaining nine patients followed up for 12 to 66 months. Selective hepatic arterial embolization is the treatment of choice for hemobilia. Inappropriate embolization or surgery frequently fails to control the bleeding and may also prevent later successful embolization.

Complications of embolization: analysis of 410 procedures.

Over a 10-year period, 284 patients underwent 410 embolization procedures because of liver, renal, or bone tumors; gastrointestinal bleeding; systemic or pulmonary arteriovenous malformations; and other miscellaneous lesions. A wide range of particulate and liquid embolic agents were used. The complications were analyzed with respect to the patient's underlying abnormality. Minor complications occurred after 16.3% of procedures, serious complications after 6.6%, and death after 2%. The postembolization syndrome (fever, elevated white blood cell count, and discomfort) was encountered after 42.7% of the procedures, and in 43.7%, no significant adverse reactions were documented. The major complications and deaths were encountered in patients with a serious underlying abnormality in whom no alternative form of treatment was available and who were extremely sick prior to the procedure. When considered in relationship to the natural progress of the disease and the lack of other treatment options, the overall complication rate seems acceptable.

Selective visceral angiography in obscure postoperative gastrointestinal bleeding.

Postoperative gastrointestinal bleeding may be difficult to diagnose and treat. Selective visceral angiography localised the bleeding site in seven out of ten episodes of obscure postoperative gastrointestinal haemorrhage, and in two cases radiological embolisation was used successfully to control the bleeding. Angiography, preferably during an episode of haemorrhage, is recommended whenever possible for patients with undiagnosed postoperative gastrointestinal bleeding.