Blue toe syndrome: treatment with intra-arterial stents and review of therapies.

PURPOSE: To determine if intra-arterial stent placement can adequately treat lesions producing microemboli to the lower extremities. MATERIALS AND METHODS: During a 6.5-year period, 15 patients presenting with blue toe syndrome had 16 presumed embolic lesions treated with intra-arterial stents. These patients were evaluated during routine clinical follow-up during a 6-month period. This evaluation included physical and noninvasive arterial examinations. When patients could not return for follow-up, hospital, clinical, vascular laboratory, and radiology records were reviewed to assemble the appropriate information. Outcomes included symptoms of recurrent emboli, amputation, and death. RESULTS: Treated embolic lesions included two aortic stenoses, three bilateral iliac artery stenoses, nine unilateral iliac artery stenoses (one patient received separate treatment of unilateral iliac lesions), and two superficial femoral artery stenoses. Patients were followed-up for a mean of 18 months. Eight of 15 patients (53%) were improved or stable without complications. There were eight negative outcomes experienced in seven patients. Three patients (20%) were deceased at follow-up. Four patients (27%) had undergone amputation; one transmetatarsal amputation and three below-the-knee amputations. Only one of these was related to progressive disease in the treated extremity (7%). One patient (7%) experienced recurrent embolic symptoms. Stents were patent in all patients. CONCLUSION: Patients with blue toe syndrome are at high risk of limb loss and mortality despite treatment. Intra-arterial stent placement provides an alternative to standard surgical treatment. Further studies are needed to define the optimum therapy.

Isolation of the left innominate artery in an elderly patient without congenital heart disease.

We report a rare anomaly consisting of a right aortic arch with an isolated left innominate artery in an elderly man without congenital heart disease.

Suprarenal vena caval filter placement: follow-up of four filter types in 22 patients.

PURPOSE: To determine if suprarenal placement of inferior vena cava (IVC) filters is associated with renal dysfunction or other complications. MATERIALS AND METHODS: Case files of all patients with suprarenal vena caval filter placement since 1985 were reviewed for clinical and biochemical evidence of renal dysfunction and renal vein thrombosis. The occurrence of associated complications, including IVC occlusion, filter fracture, device migration, and recurrence of pulmonary embolism was also recorded. RESULTS: Twenty-two (2.9%) of 764 IVC filters were implanted above the renal veins: titanium Greenfield filter modified hook (TGF-MH) (n = 16), LGM type I (n = 2), LGM type II (n = 2), and Bird's Nest (BN) type I (n = 2). Reasons for suprarenal filter placement included thrombus to the level of the renal veins (n = 9), failure or poor position of the infrarenal filter (n = 6), pregnancy or intent of pregnancy (n = 4), and the malpositioning of BN filters above the renal veins (n = 2). A single patient demonstrated evidence of transient renal dysfunction. Pulmonary embolus was found at autopsy in one patient. Abdominal radiographs were obtained at follow-up of 18 patients and demonstrated a 2 cm or more migration of the filter in five patients (27.7%). This rate of migration was significantly different from the 3% migration rate reported by the authors' institution in the follow-up of 320 infrarenal IVC filters. There was one filter fracture (5.5%.) and penetration of the IVC occurred in one patient (5.5%). CONCLUSION: Follow-up indicates suprarenal IVC filter placement is safe, and no evidence of permanent renal dysfunction after placement was found. Filter migration was the most frequent complication, but no clinical sequelae were noted with these patients.

Azotemia: gadopentetate dimeglumine as contrast agent at digital subtraction angiography.

In an azotemic patient with suspected renal artery stenosis, undiluted gadopentetate dimeglumine was administered in an aortic bolus to provide contrast at digital subtraction angiography of the aorta and renal arteries. The contrast material (5 mmol/mL) was power injected (rate, 15 mL/sec; total dose, 30 mL). Selective renal arteriography was also performed with 5 mL of undiluted gadopentetate dimeglumine hand injected into each renal artery (total dose, 40 mL). The patient tolerated the procedure without complication or worsening of renal function, and diagnostic angiographic images were obtained.