Digital subtraction versus film-screen angiography for detecting acute pulmonary emboli: evaluation in a porcine model.

PURPOSE: To compare the diagnostic performance of digital subtraction angiography (DSA) to that of film-screen angiography (FSA) for detecting acute pulmonary embolism (PE) in a porcine model. MATERIALS AND METHODS: DSA and FSA were performed in 13 pigs before and after central venous administration of autologous emboli. Results were compared to findings at necropsy with use of ex vivo pulmonary angiography to guide pathologic sectioning. The sensitivity and predictive value of a positive case for detecting each embolus were computed for each pulmonary artery branch order and compared with use of 95% confidence intervals. Interobserver variability among three readers for individual PE detection was calculated. RESULTS: Pathologic examination of the lungs revealed 100 total PEs (location by vessel order: 1st = 1, 2nd = 0, 3rd = 15, 4th = 32, > 5th = 52). On average, FSA review identified 72 (72%) emboli and DSA review, 65 (65%). There was no significant difference in sensitivity or predictive value of a positive case between DSA and FSA for detecting emboli (P > .05). There was similar agreement among readers for individual PE detection with DSA (mean, 84%) and FSA (mean, 80%). CONCLUSION: The diagnostic performance of DSA is equivalent to that of FSA for detecting emboli in porcine PA branches. Interobserver agreement for individual PE detection is similar for both imaging techniques.

Encephalopathy after transjugular intrahepatic portosystemic shunting: analysis of incidence and potential risk factors.

OBJECTIVE: Our purpose was to estimate the incidence of encephalopathy after transjugular intrahepatic portosystemic shunting (TIPS) related primarily to the diversion of portal vein blood flow and to identify periprocedural factors to predict patients at risk. MATERIALS AND METHODS: All patients who underwent TIPS with at least 1 month of clinical observation after the procedure were monitored for clinically evident encephalopathy. Other variables that could individually induce encephalopathy were retrospectively analyzed for interrelationships with spontaneous or worsened encephalopathy. RESULTS: Of the 150 patients, 68 (45%) suffered from encephalopathy after TIPS, but in only 33 (22%) was it new or worse than baseline measurements obtained before TIPS; in 18 of these 33 patients, an underlying medical cause was implicated. Fifteen (10%) of the 150 patients developed mental dysfunction, usually mild and well controlled, thought to be related only to TIPS and not to any underlying morbidity. Low portal vein pressures after TIPS were found to be interrelated with new or worsened spontaneous encephalopathy (p = .04). Like-wise, advanced age (> 59 years old) weakly corresponded to the development of encephalopathy after TIPS. CONCLUSION: TIPS causes an acceptably low rate of encephalopathy that is usually mild. No specific variables exist for predicting the development or progression of encephalopathy after TIPS.

Percutaneous ethanol sclerotherapy of postoperative lymphoceles.

OBJECTIVE: The purpose of this study was to describe our experience with ethanol sclerotherapy of postoperative lymphoceles. MATERIALS AND METHODS: We conducted a retrospective review of 32 patients who in a 6-year period underwent percutaneous ethanol sclerotherapy for the management of postoperative lymphoceles. Twenty-three patients had undergone staging lymphadenectomy for malignant tumors, eight patients had undergone renal transplantation, and one patient had undergone vascular surgery. Of the 32 patients in the study group, eight (25%) had undergone previous aspiration or drainage, and three patients (9%) had undergone surgical lymphocelectomy. Patients were treated by percutaneous drainage under fluoroscopic, sonographic, or CT guidance. Sclerotherapy was done with absolute ethanol. Follow-up was conducted by review of clinical charts and imaging studies and by contacting the patient when necessary. RESULTS: Technical success was achieved in 30 patients (94%), with resolution of lymphocele shown by clinical and imaging findings. Treatment was unsuccessful in two patients (6%), and two patients (6%) had recurrences. Three patients (9%) subsequently underwent surgical treatment of the lymphoceles. Of these three patients, one had a lymphocele recur after surgery, which was then successfully treated with sclerotherapy. The average duration of catheter placement was 19 days. Complications, all minor, included catheter-related infections treated with antibiotics in three patients (9%) and catheter dislodgment that required repeated drainage procedures in two patients (6%). Clinical follow-up averaged 25 months. CONCLUSION: Percutaneous ethanol sclerotherapy is a safe and effective treatment for postoperative lymphoceles. The technical success rate is high, the recurrence rate is low, and the complication rate is acceptable. Percutaneous sclerotherapy of lymphoceles is a less invasive alternative to surgical treatment.

Anatomic distribution of pulmonary emboli at pulmonary angiography: implications for cross-sectional imaging.

PURPOSE: To determine how often emboli detected angiographically in peripheral pulmonary arterial branches would be missed with cross-sectional imaging. MATERIALS AND METHODS: Seventy-nine of 88 consecutive pulmonary angiograms interpreted as positive for pulmonary emboli were reviewed retrospectively to detect pulmonary emboli. Three angiograms interpreted as negative when reviewed retrospectively were excluded. Findings of 76 angiograms in 76 patients (32 men, 44 women; aged 19-85 years) were correlated with the results of scintigraphy (n = 72) and Doppler ultrasound (n = 60), clinical presentation (n = 76), and follow-up with chart review (n = 72). RESULTS: Two hundred five emboli were identified. Nineteen patients had solitary emboli. Sixty emboli were in the upper lobes. The largest arterial branch with pulmonary embolism was lobar in 14 patients, segmental in 38, subsegmental in 20, and smaller in three. CONCLUSION: If cross-sectional imaging can depict emboli in only segmental and larger arterial branches, then emboli in 23 of 76 patients (30%) would have been missed with cross-sectional imaging.

Safety of pulmonary angiography in the 1990s.

PURPOSE: To examine the safety of pulmonary angiography with low-osmolar contrast material and modern angiographic techniques and to analyze periprocedural complications with respect to potential predictors. PATIENTS AND METHODS: A retrospective review was conducted of data from 547 consecutive patients who underwent pulmonary angiography. Minor and major complications were analyzed by using several clinical parameters. RESULTS: There were five major (0.9%) and 26 minor complications (4.8%). Eleven of the 26 minor complications were contrast-induced nephrotoxicity. There were no periprocedural deaths. Patients with complications had an increased incidence of coexistent pulmonary morbidities and were of a poorer physical status according to the American Society of Anesthesiology criteria. Moderate to severe pulmonary hypertension was correlated with major complications. Age, volume of contrast material used, and presence of pulmonary embolism were not correlated with complications. CONCLUSION: Pulmonary angiography is a safe procedure with an acceptable complication rate. These findings should be considered in the selection of an imaging method for the diagnosis of pulmonary embolism.

Right coronary artery occlusion secondary to blunt trauma.

The heart lies in a vulnerable position when the chest is subjected to direct blunt trauma. Acute occlusion of a coronary artery from blunt chest trauma is rare, with occlusion of the right coronary artery at its origin recorded only twice in the English literature. A young male unrestrained driver sustained an acute deceleration injury with significant chest trauma when he crashed, crushing the steering wheel against his chest. Creatine phosphokinase isoenzymes were initially 2% of the total and 8% 12 h later. There were marked electrocardiographic changes, and an echocardiogram revealed abnormal left ventricular systolic function with an akinetic inferior-posterior wall and right ventricular enlargement. A wide mediastinum and mechanism of injury led to the performance of aortography which failed to disclose a right coronary vessel. Subsequently coronary angiography confirmed acute occlusion of the proximal right coronary artery. Because of other associated injuries, nonoperative medical management was successfully utilized.

Massive hemorrhage in the lower gastrointestinal tract in adults: diagnostic imaging and intervention.

Massive hemorrhage in the lower gastrointestinal tract, defined as bleeding distal to the ligament of Treitz at a rate in excess of 30 ml/hr, is most common in persons more than 50 years old. Most episodes stop spontaneously, although intervention to control the bleeding is needed eventually in 10-25% of patients. This review analyzes the use of scintigraphy, angiography, and interventional techniques in the diagnosis and treatment of these patients.

Iliac artery aneurysms. Radiographic evaluation.

We present seventeen cases of iliac artery aneurysm employing a variety of different imaging modalities (ultrasound, computed tomography, arteriography, magnetic resonance imaging). The utility of each of these techniques in the patient with iliac artery aneurysm is described.

Hypoplastic superficial femoral artery associated with bilateral persistent sciatic arteries: a diagnostic pitfall.

A patient with unsuspected bilateral persistent sciatic arteries (PSAs) underwent angiography following a gunshot wound to the right thigh. A hypoplastic superficial femoral artery associated with this rare vascular anomaly was misdiagnosed as being traumatically occluded. Pitfalls in the diagnosis of PSA as well as the embryology, clinical features, and complications are discussed.

Splenopneumopexy: evaluation with splenoportography.

Splenopneumopexy is a procedure designed to create a portopulmonary shunt in patients with esophageal variceal bleeding who are not candidates for conventional portosystemic shunts. Splenoportography was performed in three patients who underwent this surgical procedure. Portopulmonary shunts were identified in two of three patients. No complications resulted from splenoportography. Splenoportography is the procedure of choice to identify portopulmonary shunts in splenopneumopexy patients who have undergone splenic artery embolization.