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A new small intestinal biopsy technique was developed and evaluated: it involves the rapid replacement of a simple duodenal tube using a controllable spring guide and fluoroscopy. A suction biopsy catheter was then passed coaxially through the tube as often as needed for sampling, after which other diagnostic studies were done with the same intubation. In clinical trials totaling 31 biopsies in 15 adult patients, the method proved safe and effective. Currently, the time required to intubate the ligament of Treitz and obtain two biopsies is usually less than 15 minutes.

Randomly assigned streptokinase or heparin therapy was studied in 50 patients with deep vein thrombosis of less than 2 weeks' duration. Venography was performed prior to therapy, after 3 days, and after 10 days. Two radiologists who were unaware of the patient's therapy compiled a single average lytic score for each patient at each time interval. Lysis of venous thrombi was significantly greater with streptokinase than with heparin after 3 days, but not after 10 days of treatment. Lytic scores achieved with streptokinase were significantly better than those achieved with heparin therapy (P less than .01) in male patients who were symptomatic for 3 days or less. In females, regardless of the duration of symptoms, thrombolytic results obtained with streptokinase were not significantly different than results obtained with heparin.

Of 402 United States owners of side-viewing duodenoscopes surveyed, 222 (55%) responded, reporting 10,435 endoscopic retrograde cholangiopancreatograms. Procedure failed occurred in 30%, complications in 3%, and death in 0.2%. Complications included pancreatitis, cholangitis, pancreatic sepsis, instrumental injury to the gastrointestinal tract, and drug reactions. Pancreatitis was associated with injection into the pancreatic duct, sepsis with injection into an obstructed duct or pseudocyst, and injury with abnormal gastroduodenal anatomy. Experienced workers had a 15% incidence of complications, whereas inexperience gave 4 times the failures (62%) and twice the complications (7%). The causes of complications and their prevention are discussed.

Experimental catheter obstruction of the left gastric (coronary) vein was explored in 10 dogs. Using a transjugular approach, the liver was punctured and the portal vein catheterized. Coaxially introduced catheters were then used to catheterize selectively and produce an intravascular obstruction (tamponade) of the gastric coronary vein. Ballon catheters were used for a temporary occlusion. Injection of a tissue adhesive, isobutyl 2-cyanoacrylate, was used for a definitive obliteration. The achieved results show the anatomical feasibility of this approach and give good perspective for development of a clinical method for percutaneous intravascular tamponade of the bleeding gastroesophageal varices in cirrhotics.

This report enumerates and analyzes the complications of percutaneous transaxillary catheterization encountered in 200 consecutive patients undergoing diagnostic arteriography, and 20 consecutive patients who had catheter placement for selective chemotherapy. Diagnostic arteriography led to minor complications in eleven percent and major complications in two percent. Risk correlated with the type of procedure, number of catheter exchanges and particularly, the presence of arteriographic risk factors, such as hypertension, bleeding tendencies, and advanced atherosclerosis. Therapeutic catheter placements had a 15 percent incidence of minor and a 20 percent incidence of major complications. Here, also, complications were more likely in the presence of the arteriographic risk factors. Suggested means for decreasing the hazards of the transaxillary catheterization include: exclusion of high risk patients, use of a proper puncture site, careful catheter manipulation, the fewest possible catheter exchanges, correct manual hemostatis following catheter withdrawal, and close observation of the patient after the procedure. Early surgical intervention is indicated in the presence of a progressively developing neural defect.

A percutaneous transhepatic cholangiogram tract was used to visualize a large stone in the common duct; following the tract's dilation, the stone was crushed and partially removed. Fragments were flushed and also passed spontaneously into the duodenum. The approach described offers a feasible alternative to surgery.

A patient with severe nephrotic syndrome who was too debilitated to undergo surgical nephrectomies, underwent therapeutic bilateral renal artery occlusion by the selective injection of isobutyl 2-cyanoacrylate into the renal arteries. The therapy resulted in dramatic cessation of urine flow and elimination of proteinuria.

Fifty consecutive chemotherapeutic infusions for cancer via precutaneously introduced arterial catheters were reviewed to determine the frequency of angiographic and clinical complications related to the indwelling catheter. Fibrin cloaking along the catheter was found in 20 patients studied by pull-out arteriography and was unassociated with clinical symptoms. Major thrombus formation occurred around the catheter tip in 28% of the infused vessels, all within the hepatic artery. Clinical symptoms developed in only three patients where thrombosis of the hepatic artery had propagated into the celiac axis. Systemic heparinization did not reduce the incidence of thrombus formation but did increase the incidence of mild gastrointestinal bleeding. Several factors may reduce the incidence of complications, such as puncture of a large artery, use of soft, pliable, and small diameter catheters, proper free position of the catheter in the infused vessel, regular angiographic checkups for catheters position, and early evidence of thrombus formation.

Two cases of angiographically demonstrated chemodectomas of uncommon locations and behavior are reported: one located retroperitoneally and one with multi-centric sites including both carotid bodies and the upper mediastinum, with late distant bone metastases. Based on this experience and that reported by others, the angiographic appearance of chemodectomas is described and the value of angiography in the diagnosis and therapy of chemodectomas is discussed.

Simple techniques for percutaneous intravenous biopsy were used in 3 patients to obtain histopathologic diagnoses of thrombosis of the inferior vena cava and tumors invading renal veins. Techniques, risks and diagnostic sensitivity of percutaneous intravenous-biopsy are discussed.

Isobutyl 2-cyanoacrylate (IBC) delivered selectively in small doses produced immediate occlusion of the injected arteries in dogs without significant undesired sequelae. In one patient, pelvic hemorrhage was promptly stopped by a similar technique. In another patient, who was on chronic renal dialysis and judged too ill for nephrectomy, IBC occluded both renal arteries and terminated a life-threatening renal protein loss.

Two cases of bleeding from gastroesophageal varices treated by variceal obliteration illustrate multiple routes of variceal supply, and alert embolizing angiographers to the presence of spontaneous portosystemic shunts which should be kept open. In one case, variceal obliteration required embolization of the left gastric vein and a transhepatic collateral originating from the left hepatic portal branch and contributing substantially to variceal filling. A second patient with a relatively large spontaneous splenorenal shunt had recurrent variceal bleeding two months after a successful embolization of the coronary vein and a short gastric vein. A repeat study revealed the recurrent varices were supplied by enlarged right gastric and gastroepiploic veins. Superior mesenteric venography was necessary for their visualization.

Experience with the use of epinephrine renal venography in 60 patients with various renal disease is reviewed. The technique offers an important supplement to selective arteriography. It is of particular value in the diagnosis of avascular infiltrative tumors of the renal parenchyma and pelvis. Further, it is of value in the detailed demonstration of renal vein thrombosis and in seeking the cause of unexplained gross hematuria. It can also aid in evaluating expansile avascular renal masses and renal parenchymal disease. The authors found only a relatively low value for epinephrine renal venography in the diagnosis of hypervascular renal tumors and the early detection of venous extension of hypernephromas.

Analysis of 100 femoral arteriograms demonstrated a consistent relationship between the course of the femoral artery and the femoral head. Fluoroscopic guidance can be of value in femoral puncture when the arterial pulse is diminished or obscured, for training purposes, and for analysis and correction of missed punctures.

Interventional angiography with the use of indwelling arterial catheters, anticoagulants, vasodilators and fibrinolytic agents, complements conventional angiography in the diagnosis of acute lower gastrointestinal bleeding. These interventional techniques prolong, augment or reactive bleeding and, by enabling better timing of examinations, they increase the diagnostic efficacy of angiography. In the reported series of 63 patients with acute lower gastrointestinal hemorrhage, interventions increased the diagnostic yield of angiography for demonstration of extravasation from 32% to 65% and decreased the percentage of negative angiograms from 27% to 16%. Indications, techniques and risks of interventional angiography in the diagnosis of acute lower gastrointestinal bleeding are discussed.

Comparison of sequential large film coronary angiograms was performed for 58 patients with coronary artery disease, and no coronary surgery, to determine the relationship between the location, type, and degree of stenoses and their tendency to progress. Of 230 stenoses, 76 (33%) showed progression and 154 (67%) remained stable on the follow-up studies. Progression occurred in 38 (66%) patients. A statistically significant higher tendency to progress was found with tubular stenosis with ulcerating plaques (100%) and stenoses with collateral circulation (58%). A significant linear trend for progression was also found with the increasing number of risk factors of coronary disease. The above-average progression tendency of stenoses of the right coronary artery, tubular irregular stenoses, and Grade 2 stenoses, was not statistically significant.

Twenty-seven patients with deep vein thrombosis whose primary therapy was randomized between streptokinase and heparin were reevaluated clinically and by ascending venography after a mean period of 7 months. Normal venograms were found in 6 (40%) of the streptokinase-treated patients and in 1 patient (8%) who had heparin therapy. Segmental valve preservation was found in 1 patient from each group. All patients with complete or partial valve preservation became asymptomatic. Vein recanalization without preservation of valves occurred in 18 patients: 8 (54%) of those on streptokinase, and 10 (83%) of those on heparin. At the time of follow-up, 11 of these 18 patients, including 8 who had had prior thrombosis, reported peripheral edema; the postphlebitic syndrome developed in 1. Factors favoring a good outcome of acute venous thrombosis were (1) no prior thrombotic disease, (2) localized thrombosis, and (3) prompt streptokinase therapy.

The author's current angiographic approach to the diagnosis and therapy of acute gastrointestinal (GI) bleeding is summarized and discussed. It is based on the authors' experience with diagnostic studies in more than 300 acute GI bleeders and the use of various angiotherapeutic techniques in 138 of them as well as the experience of others. A "moderately aggressive angiographic approach" is advocated for the diagnosis of acute GI bleeding in most patients with angiography used as needed after emergency endoscopy and preliminary medical therapy. Vasoconstrictive angiotherapy with selective intraarterial use of vasopressin is partially giving way to low dose, intravenous infusion of vasopressin and, where possible, to direct vascular occlusion. Selective transcatheter embolic occlusion of bleeding vessels is in indicated cases an accepted method for controlling arterial bleeding. Medical gelatin (Gelfoam) is the current authors' embolization material of choice. Selective variceal occlusion offers promising means for management of bleeding from gastroesophageal varices. Its possible combination with transcatheter intrahepatic portosystemic shunting might also provide non-surgical relief of portal hypertension.