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Purpose: To test whether newer bilayer barium sulfate-bismuth oxide composite (XPF) thyroid collars (TCs) provide superior radiation protection and comfort during fluoroscopy-guided interventions compared with standard 0.5-mm lead-equivalent TCs., Materials and Methods: Institutional review board approval and written informed consent were obtained for this HIPAA-compliant study, and 144 fluoroscopy-guided vascular interventions were included at one center between October 2011 and July 2012, with up to two operators randomly assigned to wear XPF (n = 135) or standard 0.5-mm lead-equivalent (n = 121) TCs. Radiation doses were measured by using dosimeters placed outside and underneath the TCs. Wearing comfort was assessed at the end of each procedure on a visual analog scale (0-100, with 100 indicating optimal comfort). Adjusted differences in comfort and radiation dose reductions were calculated by using a mixed logistic regression model and the common method of inverse variance weighting, respectively., Results: Patient (height, weight, and body mass index) and procedure (type and duration of intervention, operator, fluoroscopy time, dose-area product, and air kerma) data did not differ between the XPF and standard groups. Comfort was assessed in all 256 measurements. On average, the XPF TCs were 47.6% lighter than the standard TCs (mean weight ± standard deviation, 133 g ± 14 vs 254 g ± 44; P < .001) and had a significantly higher likelihood of a high level of comfort (visual analog scale >90; odds ratio, 7.6; 95% confidence interval: 3.0, 19.2; P < .001). Radiation dose reduction provided by the TCs was analyzed in 117 data sets (60 in the XPF group, 57 in the standard group). The mean radiation dose reductions (ie, radiation protection) provided by XPF and standard TCs were 90.7% and 72.4%, with an adjusted mean difference of 17.9% (95% confidence interval: 7.7%, 28.1%; P < .001) favoring XPF., Conclusion: XPF TCs are a lightweight alternative to standard 0.5-mm lead-equivalent TCs and provide superior radiation protection during fluoroscopy-guided interventions., (© RSNA, 2013.)

Purpose: To evaluate the safety and efficacy of an endoluminal prosthesis for treatment of peripheral arterial occlusive disease (PAOD)., Materials and Methods: A self-expanding endoprosthesis with an expanded polytetrafluoroethylene tube inside a nitinol support structure was implanted in 127 patients with symptomatic PAOD in the iliac (61 limbs) and femoral arteries (80 limbs). Clinical category status, ankle-brachial index, and color duplex flow imaging results were recorded before treatment, at discharge, and at 1, 3, 6, and 12 months after treatment. Aspirin was administered throughout the study, and heparin was administered during and for 2 days after the procedure., Results: Endoprosthesis deployment was technically successful in all patients. Complications occurred in 24 of 141 procedures and included three major complications. Early thrombosis (within 30 days) occurred in one iliac and three femoral arteries. Late restenosis or reocclusion was observed in five iliac and 14 femoral arteries within the 1st year. Primary patency rates in iliac arteries were 98% +/- 3% (standard error) and 91% +/- 4%, respectively, at 6 and 12 months after treatment. Primary patency rates in femoral arteries were 90% +/- 3% and 79% +/- 5%, respectively, at 6 and 12 months. Secondary patency rates were 95% and 93% for iliac and femoral arteries, respectively, at 12 months after treatment., Conclusion: The device used in this study can be implanted without additional risks to the patient and provided encouraging patency rates up to 1 year.

A transjugular intrahepatic portosystemic shunt (TIPS) can be created percutaneously with the Palmaz balloon-expandable stent. This article describes a transjugular-only approach with a 16-gauge needle. A functional and efficacious shunt can be achieved in most cases with stent diameters of 8-10 mm. Occasionally, a 12-mm-diameter shunt is necessary for effective variceal decompression. The procedure is considered successful when the portosystemic gradient is lowered to 12 mm Hg or less after stent placement. Hepatic vein stenosis in the shunt outflow can develop after the TIPs procedure. This complication has been treated successfully with additional stent placement. TIPS can undoubtedly be performed successfully and safely with a transjugular-only approach; however, the full impact of TIPS on the treatment of portal hypertension remains to be determined.

Palmaz balloon-expandable stents were placed in 28 hypertensive patients with atherosclerosis involving the ostia of the renal arteries. Stents were placed to treat elastic recoil immediately after conventional angioplasty in 20 patients and restenosis after percutaneous transluminal angioplasty in eight patients. Technical success (greater than 30% residual stenosis) was achieved in 27 patients. Complications occurred in five patients. At follow-up (1-25 months), hypertension was cured in three patients and improved in 15 patients, with a cumulative cure or improvement of 64% at 6 months. Of 14 patients with a serum creatinine level of 1.5 mg/dL (132.6 mumol/L) or greater before the placement of stents, five demonstrated improved renal function, five showed stabilization of their condition, and four demonstrated deterioration. Follow-up angiography (2-18 months) was performed in 18 patients. Restenosis was present in seven patients and was accompanied by a relapse of hypertension in only three patients. Of the other four patients with restenosis, two had no initial improvement and two had an initial response without a relapse of hypertension. In this preliminary study, renal stents were beneficial in many patients with poor results from conventional angioplasty for ostial atheroma.

The cause of superior vena cava syndrome (SVCS) in two patients was identified by means of endovascular biopsy of the superior vena cava (SVC) performed with a percutaneous atherectomy catheter. In both cases, the extracted tissues were neoplastic, therefore obviating additional invasive procedures. After a specific diagnosis was established, external-beam radiation therapy was used to treat the SVCS. The atherectomy catheter was used in conjunction with other percutaneous techniques, including balloon angioplasty and endovascular stenting of the SVC.

The results of an ongoing five-year study of percutaneous transluminal angioplasty for the treatment of peripheral vascular disease are presented. A balloon catheter was used for iliac and superficial femoral and popliteal artery dilatation. Forty out of 43 procedures performed were considered to have initial success, with iliac angioplasty showing a greater success rate (96%) than superficial femoral angioplasty (90%). Complications requiring surgical intervention occurred in only 3 patients. Advantages of this technique include local anesthesia, early ambulation, reduced hospital stay, and reproducibility.

Urethral strictures that are impassable in retrograde fashion present a special problem to the urologist because they cannot be managed by standard dilatation techniques or direct-vision internal urethrotomy. Open urethroplasty is usually required. We describe a technique to catheterize the urethra in an antegrade fashion and dilate the strictures. Our study involved six patients with impassable urethral strictures that were successfully traversed and dilated. Percutaneous transvesical antegrade catheterization and balloon dilatation are beneficial for patients with bladder outlet obstruction.

The author reports a case of Gaucher's disease in which lymphangiography was performed to evaluate cervical lymphadenopathy, later shown to be Hodgkin's disease. The 24-hour lymphangiogram showed fragmentation of the normal nodal architecture and foamy-appearing lymph nodes in the aortic bifurcation. Microscopic study of these nodes revealed abnormalities characteristic of Gaucher's disease.

Transcatheter therapeutic arterial embolization was employed in 11 patients with gastrointestinal hemorrhage and 8 patients with bleeding from other sites. Hemorrhage was stopped successfully in all of the patients with gastrointestinal bleeding and 6 of the 7 patients with active bleeding from other sites. There were no significant complications or sequelae, although ischemia msy cause problems in such patients. Embolization is of considerable value when pharmacological therapy fails or is not appropriate due to the site of bleeding. In some cases it may represent the definitive treatment, as in pelvic trauma or renal hemorrhage; in others, embolization may serve to halt bleeding long enough to permit surgery. Therapeutic embolization should be considered whenever active extravasation of contrast material is demonstrated.

"Blue toe syndrome" refers to digital ischemia of the foot in the presence of palpable or Doppler audible pedal pulses. This clinical syndrome is caused by microembolization to small vessels from a proximal source. The use of percutaneous transluminal atherectomy is described in the treatment of embologenic superficial femoral artery lesions in seven patients. All seven had prompt healing of the ischemic toes, and none required surgical revascularization or amputation. One patient developed a recurrent stenosis at the atherectomy site and had a second episode of digital ischemia, which was treated by means of atherectomy with a larger device. Histologic study of atherectomy specimens suggests that emboli arise from adherent fibrinoplatelet aggregates or thrombus and less often from cholesterol-rich atheromatous plaque. Although either percutaneous transluminal angioplasty or atherectomy can be used to treat the underlying stenosis, percutaneous atherectomy offers the advantage of nonsurgical removal of embologenic material and provides material for histologic study. Percutaneous atherectomy is an effective method of treating embologenic superficial femoral stenoses in patients with ipsilateral blue toe syndrome.

PTA is an established method of revascularization in a variety of medical conditions. It is performed for specific morphologic and clinical indications. PTA is the procedure of choice in Fontaine stage IIB through IV lower extremity ischemia due to iliac and/or femoropopliteal stenosis or short occlusion. Its role is less certain in infrapopliteal disease, although current studies have begun to establish long-term effectiveness. PTA is the procedure of choice for renal revascularization in renovascular hypertension due to fibromuscular disease or non-ostial atherosclerosis, selected cases of renal artery stenosis associated with renal insufficiency, and transplant renal artery stenosis. It is also useful in treating the renovascular component of complex hypertension and may be indicated in severe renal artery stenosis (75%-99%), even in the absence of clinically demonstrable RVHTN. PTA has limited applications in the venous system and only short-term success in the treatment of stenoses in dialysis access fistulas. PTA often serves as an important adjunct to surgical revascularization by providing improved inflow or outflow. PTA is the procedure of choice when anatomically feasible in subclavian steal syndrome. The role of PTA in carotid artery disease, particularly atheromatous disease of the internal carotid artery, is uncertain. The same may be said of PTA for vertebral artery stenosis, although the overwhelming majority of vertebral artery stenoses are morphologically suitable for PTA. PTA and surgery are both effective in the treatment of abdominal angina. There are more data available to verify the long-term patency of thromboendarterectomy and bypass grafts than PTA for mesenteric ischemia. However, since the technical success for PTA is high and since coronary co-morbidity is the most common cause of perioperative mortality in surgical series, PTA should be seriously considered as the procedure of first choice. Serious complications of PTA occur in approximately 5% of cases. Two to three percent of PTA patients have complications requiring surgery or causing a prolongation or alteration of hospital course. The morbidity, mortality, and cost associated with PTA are low. The discomfort is minor, and postprocedural recovery rapid. The major limitations of PTA include its unsuitability for some lesions (long-segment occlusions and stenoses, orifice lesions, eccentric lesions) and postangioplasty restenosis. These problems are being addressed by ongoing laboratory and clinical research. In the near future, it is likely that endoluminal transmural sonography of the vessel wall will help guide our interventions.

In a retrospective analysis, the efficacy of lysis, the degree of systemic thrombolytic effect, and the rate of complications during local thrombolytic therapy with either streptokinase (SK) or urokinase (UK) were compared in 47 patients. There were 24 infusions of each agent; one patient in the UK group received two infusions. The overall efficacy of lysis was better in the UK-treated group (80% vs. 63%). The UK group had a lower frequency of systemic thrombolytic effect and of bleeding complications. SK antibody titers were measured in all patients who received infusions. Patients with high titers who were treated with SK responded poorly (20% lysis); patients with low titers responded at a rate equal to that of UK-treated patients. Three patients with high titers of SK antibodies did not respond to SK, but subsequent successful lysis did occur with UK. In conclusion, UK is believed to be preferable to SK for local thrombolytic therapy due to increased efficacy of lysis and decreased rate of systemic fibrinolytic effect and bleeding complications.

Four patients with typical renovascular hypertension due to atherosclerotic stenosis (3 patients) and near occlusion (one patient) were treated with percutaneous transluminal angioplasty (PTA). Two patients had malignant hypertension by clinical standards. All had significant reduction in blood pressure following angioplasty, resulting in either a normotensive state, or management with significantly less antihypertensive medication. Patency and normal renin levels were achieved within two months in 2 patients. Clinical follow-up documented continued reduction in blood pressure. Advantages of the procedure include local anesthesia, relatively little discomfort, repeatability, and the fact that surgery is not precluded if angioplasty is unsuccessful.

Development of an interventional radiology practice or section depends first on the commitment and ability of the interventionalist but is also contingent on an appropriate environment. Moreover, the interventionalist must attempt to change long-standing concepts and referral patterns with aggressive dissemination of information. He or she must be an advocate of the procedures offered, as well as their benefits to the patient and the health care system. One must actively include outpatient visits and admissions as part of services offered. Allies in this effort include primary care physicians, internists, hospital administration, and third-party payers. In addition, organized radiology can now offer some assistance through the Society of Cardiovascular and Interventional Radiology and the American College of Radiology. All of these factors will contribute significantly to the success of interventional radiology in both teaching and community hospital settings.