Primary sclerosing cholangitis in the presence of a lupus anticoagulant.

Lupus anticoagulant, an immunoglobulin that prolongs the partial thromboplastin time, has been associated with thrombotic events, including deep venous thrombosis, pulmonary emboli, and Budd-Chiari syndrome. In this report, primary sclerosing cholangitis was diagnosed in a man with a 10-year history of multiple thrombotic events related to a circulating lupus anticoagulant. Progressive jaundice and pruritus developed, and sclerosing cholangitis was confirmed by direct cholangiography. Sclerosing cholangitis is the second hepatobiliary disease reported in association with a lupus anticoagulant.

The radiologic significance of the left pulmonary ligament. Experience with 26 patients.

Pathologic processes confined to or by the left pulmonary ligament present a confusing radiographic appearance. Such processes may simulate pleural scarring, parenchymal scarring, or even left lower lobe collapse. Radiologic awareness of this structure is limited because in the normal state, it is not visualized on either posteroanterior or lateral chest x-ray films. The absence of secondary signs of left lower lobe collapse, together with a process which may extend above the level of the left hilum, is valuable in confirming that such a triangular density seen behind the left cardiac border is disease in or confined by the pulmonary ligament, rather than left lower lobe collapse.

Dose reduction in mammography.

Two mammographic imaging systems (Xerox and Kodak Min-R) were evaluated. Three hundred consecutive mammographic examinations were performed utilizing both imaging systems. Results of these studies indicated equivalency of image detail at identical source-to-image receptor distance (SID). Patient exposure as measured by the thermoluminescent dose meter for Kodak Min-R system was approximately 25% that of Xeromammography system. Due to reduced power requirement, it is possible to increase the SID when Min-R system is employed for imaging. Improved geometric arrangement provided superior diagnostic images in 5.5% of 200 comparison cases.

The ultrasonographic characterization of tendons.

Ultrasonography has not been utilized in the diagnosis of musculoskeletal disorders. However, the superficial location of tendons and ligaments lend themselves to evaluation by this modality. The ultrasonographic characteristics of the normal Achilles tendon are described in both the rabbit and man. The characteristic ultrasonographic findings after injury to the Achilles tendon are also determined. This imaging technique provides a sharp definition of the tendon and surrounding structures and easily demonstrates abnormalities. The superficially located quadriceps tendon is also well visualized by ultrasound and representative examples are shown. Ultrasound should be considered as another useful method for evaluation of these superficial musculoskeletal structures.

Correlation of foot arterial anatomy with early tibial bypass patency.

The detailed arterial anatomy of the foot in severe limb ischemia is not well known. This study was undertaken to define foot arterial anatomy and correlate these findings with the early results (6 months) of femoral-distal bypass. After completion of the bypass, operative arteriography was performed by direct injection of contrast media into the graft. A lateral view of the distal limb and foot was obtained. Foot vessel anatomy was classified into primary and secondary pedal arches, analogous to the superficial and deep volar arches of the hand. For peroneal bypass, special attention was paid to perforating branches and their communications with these two pedal arches. A total of 56 distal bypass operations was analyzed. Femoral--anterior tibial bypass was performed in 26 cases. When either a primary or a secondary pedal arch was intact, early graft patency (6 months) was achieved in 20 of 21 patients. When neither pathway was present, graft failure occurred in four of five cases. Similarly, of 10 femoral--posterior tibial grafts, seven remained patent with at least one pedal arch intact, whereas six of seven grafts failed when neither arch was patent. Bypass to the peroneal artery was successful in eight of nine limbs when a patent primary or secondary arch was reconstituted via either the anterior or posterior perforating branches. None of four peroneal grafts remained patent when both arches were occluded. As a whole, in 40 limbs with either a patent primary or secondary pedal arch, early graft success was achieved in 35 limbs (87.5%). In contrast, in 16 limbs with no patent arch, only two (12.5%) were successfully reconstructed (P less than 0.001). Analysis of the results of femoral-distal bypass based on a single plantar arch as the sole determining anatomic factor in graft patency is not adequate. The secondary pedal arch and communicating branches of the peroneal artery are also of surgical significance. Operative arteriography can define runoff in the foot, and this information has prognostic significance. It may allow rational judgment regarding reintervention in patients with failed grafts.

Surgical correction of chronic deep venous insufficiency by valvular transposition.

Twelve limbs in nine patients undergoing venous valve transposition in treatment of severe chronic deep venous insufficiency are the subject of this report. Hemodynamic measurements including venous pressure studies, photoplethysmography, directional venous Doppler assessment, and impedance plethysmography were done pre- and postoperatively in each case, as was ascending and descending venography. The surgical technique is described in detail and diagrams illustrate general features of the reconstruction. The results show that a functioning valve in the deep venous system of the lower extremity may reverse pre-operative pathophysiology. This preliminary view of the operation indicates that it may have great promise in the field of direct venous reconstruction.

Hemodynamic assessment of transluminal angioplasty for lower extremity ischemia.

The results of percutaneous transluminal angioplasty (PTA) for 56 ischemic lower extremities in 51 patients were analyzed. Indications for balloon catheter dilatation were intermittent claudication in 46 limbs (82.1%), rest pain in five (8.9%), and ischemic ulceration in five (8.9%). Balloon dialation was technically successful in 16 of 17 iliac segment lesions (94.1%) with symptomatic improvement in each instance. Nine of the 16 limbs were hemodynamically improved with a significant increase (less than 0.15) in ankle systolic pressure index. Four additional limbs had improvement in the thigh index. The remaining three limbs were hemodynamically unimproved. During average follow-up of 7.1 months, the 13 initially improved limbs remained hemodynamically improved. Thirty-one of 42 femoropopliteal dilatations (73.8%) were technically successful, with uniform symptomatic improvement. Of these 31 limbs, 26 had a significant initial increase in ankle index, one had improvement in distal thigh index only, and the remaining four limbs were hemodynamically unimproved. During mean follow-up of 8.4 months in the 27 limbs that initially were improved after femoropopliteal dilation, the pressure index returned to the pre-PTA level in 12 instances (44.4%). These results indicate that PTA is useful in selected short-segment iliac lesions. Balloon dilation of femoropopliteal lesions was less successful and its application requires further evaluation. This study demonstrates the need for close monitoring of the objective hemodynamic response, as well as symptomatic and angiographic results, in establishing the proper role of PTA in the treatment of lower extremity ischemia.

Percutaneous transluminal angioplasty: an angiographer's viewpoint.

We outline the present role of angioplasty in the management of peripheral vascular disease and its application to other portions of the arterial and venous systems; we summarize several large series, including our own, which encompass more than 4,000 cases; and we discuss the pathophysiology of balloon dilation techniques and the criteria for patient selection. With appropriate patient selection, initial (90%) and long-term (85%) patency results are now comparable with surgical techniques when the iliac arteries are involved. Treatment of femoropopliteal disease is slightly less successful but is indicated in appropriate patients. We present the role of angioplasty in conjunction with grafting procedures and in the management of renal vascular hypertension, and we review the potential complications (2% to 3%), adjunctive medical management, and areas for further investigation.

Thoracic aortic imaging without angiography.

Imaging of the thoracic aorta without recourse to angiography has great theoretic appeal. We have used computerized tomography (CT) in the initial evaluation of 297 patients with suspected mediastinal disease. Nineteen of this group had important findings related to the thoracic aorta: aortic dissection (six), descending thoracic aortic aneurysm (nine), suspected aortic trauma (three), and suspected false aneurysm at a coarctation repair (one). In all cases, the aorta and related pathology were readily demonstrated by CT, aided by the intravenous infusion of contrast material. In 13 of 15 cases, aortic dissection and aortic aneurysm could be accurately diagnosed. In two instances of ascending aortic dissection, it was not possible to distinguish the false lumen from mural thrombus in an atherosclerotic aneurysm.

Bilateral renal artery thrombotic occlusion: a unique complication following removal of a transthoracic intraaortic balloon.

An intraaortic balloon pump (IABP) was inserted through the ascending aorta during a coronary artery bypass operation. Five days later, after removal of the IABP and ligation of the end-to-side Dacron graft, the patient became acutely anuric. Abdominal aortography demonstrated a large "trapeze-shaped" thrombus which occluded both renal arteries. Following thrombectomy the patient recovered, with eventual return of renal function to the preoperative state.

Angiographic features of benign renal adenoma.

Five cases of beign renal adenoma were studied angiographically. The findings are presented along with a review of the literature. There were 4 males and 1 female ranging in age from forty-two to sixty-three years. Each presented with a mass on excretory urography, and 1 contained calcification. The largest two lesions showed circumferentially distributed vascular supply. Two lesions showed a faint homogenous blush on the nephrogram phase of the angiogram, and the firth lesion, which arose in the wall of a cyst, was angiographically silent.

Computed tomography of the larynx.

The normal computed tomographic anatomy of the larynx and surrounding structures is illustrated and discussed. An attempt is made to distinguish various types of tissues in cross-sectional display. The advantages of computed tomography over other modalities used for imaging the laryngeal region include the capacity to depict structural relationships in cross-section, to better define cartilaginous involvement by adjacent neoplasms, and to identify vascular components with contrast enhancement. The clinical application of computed tomography with respect to radiation therapy treatment planning of laryngeal tumors in an important feature of this imaging technique.

Computed tomography in the detection of retroperitoneal hemorrhage after translumbar aortography.

Direct imaging of retroperitoneal hemorrhage following translumbar aortography was performed using computed tomography. Seven patients were scanned over the area of aortic entry immediately after undergoing angiographic examination. In five cases, there was definite evidence of periaortic hematoma, most commonly seen as a discrete soft tissue density with absorption coefficients between +20 and +35 EMI units. Other signs of retroperitoneal bleeding were less consistently present (e.g., loss of aortic contour, aortic displacement, and thickening of diaphragmatic crura). The clinical implications of detecting significant hemorrhage following translumbar aortography are also discussed.

Periportal sinusoidal dilatation associated with pregnancy.

Periportal sinusoidal dilatation is an hepatic vascular lesion previously reported solely as a complication of oral contraceptive therapy. We report a case occurring during pregnancy and describe the angiographic appearance and pathologic findings. Peliosis hepatis is the main consideration in the differential diagnosis--the features distinguishing of these hepatic lesions are presented.