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Objective: Radiation exposure to interventionalists is increasing. The currently available standard radiation protection devices are heavy and do not protect the head of the operator. The aim of this study was to evaluate the effectiveness and comfort of caps and thyroid collars made of a disposable, light-weight, lead-free material (XPF) for occupational radiation protection in a clinical setting., Subjects and Methods: Up to two interventional operators were randomized to wear a XPF or standard 0.5-mm lead-equivalent thyroid collars in 60 consecutive endovascular procedures requiring fluoroscopy. Simultaneously a XPF cap was worn by all operators. Radiation doses were measured using dosimeters placed outside and underneath the caps and thyroid collars. Wearing comfort was assessed at the end of each procedure on a visual analog scale (0-100 [100 = optimal])., Results: Patient and procedure data did not differ between the XPF and standard protection groups. The cumulative radiation dose measured outside the cap was 15,700 μSv and outside the thyroid collars 21,240 μSv. Measured radiation attenuation provided by the XPF caps (n = 70), XPF thyroid collars (n = 40), and standard thyroid collars (n = 38) was 85.4% ± 25.6%, 79.7% ± 25.8% and 71.9% ± 34.2%, respectively (mean difference XPF vs standard thyroid collars, 7.8% [95% CI, -5.9% to 21.6%]; p = 0.258). The median XPF cap weight was 144 g (interquartile range, 128-170 g), and the XPF thyroid collars were 27% lighter than the standard thyroid collars (p < 0.0001). Operators rated the comfort of all devices as high (mean scores for XPF caps and XPF thyroid collars 83.4 ± 12.7 (SD) and 88.5 ± 14.6, respectively; mean scores for standard thyroid collars 89.6 ± 9.9) (p = 0.648)., Conclusion: Light-weight disposable caps and thyroid collars made of XPF were assessed as being comfortable to wear, and they provide radiation protection similar to that of standard 0.5-mm lead-equivalent thyroid collars.

Objective: There is growing evidence supporting the use of coronary CT angiography (CTA) to triage patients in the emergency department (ED) with acute chest pain and low risk of acute coronary syndrome (ACS). We hypothesized that coronary CTA can guide early management and safely discharge patients by introducing a dedicated patient management protocol., Subjects and Methods: We conducted a prospective cohort study in three EDs of a large health care system (> 1300 beds). Five hundred twenty-nine patients (mean age, 52.1 years; 56% women) with chest pain, negative cardiac enzyme results, normal or nondiagnostic ECG findings, and a thrombolysis in myocardial infarction (TIMI) risk score of 2 or less were admitted and underwent CTA. A new dedicated chest pain triage protocol (levels 1-5) was implemented. On the basis of CTA findings, patients were stratified into one of the following four groups: 0, low (negative CTA findings); 1, mild (1-49% stenosis); 2, moderate (50-69% stenosis); or 3, severe (≥ 70% stenosis) risk of ACS. Outcome measures included major adverse cardiac events (MACEs) during the first 30 days after CTA, downstream testing results, and length of stay (LOS). LOS was compared before and after implementation of our chest pain triage protocol., Results: Three hundred seventeen patients (59.9%) with negative CTA findings and 151 (28.5%) with mild stenosis were discharged from the ED with a very low downstream testing rate and a very low MACE rate (negative predictive value = 99.8%). Twenty-five patients (4.7%) had moderate stenosis (n = 17 undergoing further testing). Thirty-six patients (6.8%) had stenosis of 70% or greater by CTA (n = 34 positive by invasive angiography or SPECT-myocardial perfusion imaging). The sensitivity of CTA was 94%. The rate of MACEs in patients with stenosis of 70% or greater (8.3%) was significantly higher (p < 0.001) than in patients with negative CTA findings (0%) or those with mild stenosis (0.2%). A 51% decrease in LOS-from 28.8 to 14.0 hours--was noted after implementation of the dedicated chest pain protocol (p < 0.001)., Conclusion: Chest pain patients with negative or mild nonobstructive CTA findings can be safely discharged from the ED without further testing. Implementation of a dedicated chest pain triage protocol is critical for the success of a coronary CTA program.

Two patients who sustained liver trauma with intrahepatic and intraperitoneal hemorrhage are reported. Selective and subselective arteriography identified the hemorrhagic artery in each case. Transcatheter therapeutic embolization successfully stopped the hemorrhage acutely in one patient and produced almost complete cessation of hemorrhage in the other patient. No further blood replacement was required after the emoblization procedures. Liver function tests were abnormal prior to embolization and gradually improved afterward. Neither patient required surgery, and both were discharged from the hospital. Each patient has remained free of symptoms for 5 and 4 months, respectively. Arteriography offers accurate diagnostic information and therapeutic potential in patients who experience hemorrhage following trauma. In addition, therapeutic embolization may offer decreased morbidity and reduced hospital stay. Successful results of therapeutic embolization depend on awareness of its usefulness and upon rapid mobilization of angiographic and support personnel.

Percutaneous transluminal angioplasty has become an effective method of restoring blood flow and relieving symptoms of peripheral arterial disease in the lower limbs. It has the advantages of less pain, morbidity, and cost compared with surgery. Best results are in short stenotic lesions where the patency rate at 2 years in iliac, superficial femoral-popliteal arteries, and popliteal arteries is 85%-90%, 50%-75%, and 70%-80%, respectively. Complications of distal embolization, thrombosis, and perforation occur in 3%-5% of attempts and require immediate surgery. Some considerations for the selection of patients, approach, technique, and use of drugs to control arterial spasm and thrombosis are reviewed briefly.

Two cases of bilateral Wilms' tumor are presented with discussion of angiographic features. Emphasis is placed on selective angiography in addition to inferior vena cavography for complete evaluation. Because of the incidence of bilateral disease, and the highly vascular nature of the tumor, selective angiography of the contralateral side should be considered in the initial evaluation of unilateral Wilms'tumor. Evaluation of the interface between tumor and normal parenchyma is extremely important in bilateral disease, in anticipation of partial nephrectomy.

Diagnostic angiography combined with transcatheter therapeutic embolization is a simple and effective means of treating complex clinical situations associated with posttraumatic hemorrhage. Bleeding pseudoaneurysms, even when large, can be readily managed by this combined modality with resultant decrease in morbidity and hospital stay. Five patients with posttraumatic pseudoaneurysms are presented. All five were treated by transcatheter therapeutic embolization with Gelfoam. Of these five cases, three involved extremities, one involved the retroperitoneal space, and the last was of renal origin. Two of the five cases still required surgical intervention after initial successful therapeutic embolization, one for recurrent bleeding from collaterals and the other for evacuation of a massive pseudoaneurysm which was causing distraction of fracture fragments. The early use of angiography in suspected cases of posttraumatic hemorrhage, together with careful evaluation of potential collateral supply, is stressed. The use of transcatheter therapeutic embolization in the extremities as presented here is yet another example of the ever-broadening applicability of this technique.

Twelve patients with arterial occlusions demonstrated by angiography were treated using intraarterial "low dose" streptokinase delivered to the site of occlusion via a 5 French catheter. The catheter was embedded at the site of arterial occlusion if possible, but if not, was placed immediately proximal to the occlusion. Streptokinase was infused at 5,000 U/hr in a volume of about 50 ml using an arterial infusion pump. The technique was applied to vessels of the upper and lower extremities as well as the renal arteries. Of 12 patients infused, 11 had successful thrombolysis. No hemorrhagic complications were encountered. This technique is extremely promising as a method of treatment of thromboses of recent origin, especially in the poor operative candidate, and for angioplasty-related thromboses.

Two cases of bilateral subclavian steal syndrome are presented, demonstrating complete occlusion at the origin of both subclavian arteries with distal reconstitution via reversal of blood flow through the vertebrobasilar system. Since unsuspected subclavian artery obstruction may present significant angiographic hazard, careful physical examination including blood pressures in both upper extremities and auscultation of the neck is necessary in order to avoid undesirable complications.