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Purpose: To identify predictors of clinical outcome after percutaneous revascularization of the renal arteries., Materials and Methods: In 63 patients, the therapeutic response was retrospectively assessed after percutaneous revascularization of the renal arteries indicated for hypertension (41.3%), renal failure (4.8%), or both (53.9%). All patients underwent percutaneous transluminal renal angioplasty, complemented by stent insertion in 30 patients. The authors analyzed the role of clinical and imaging factors, including scintigraphy, Doppler sonography, and angiography for predicting clinical success., Results: In the hypertensive population, there were three cures (5.6%), 26 improvements (48.1%), and 25 failures (46.3%). Among patients with renal insufficiency, 12 were improved (37.5%), 11 were stabilized (34.4%), and nine deteriorated (28.1%). Predictors of favorable outcome for hypertension were shorter duration of hypertension, higher diastolic blood pressure, fibromuscular dysplasia, abnormal Doppler study, higher percentage of angiographic stenosis, and lower grade of aortic atheromatous disease. Predictors of favorable outcome for renal failure were nondiabetic status, abnormal Doppler study, and higher percentage of angiographic stenosis. Abnormal Doppler and scintigraphic examinations predicted successful treatment of hypertension in 60% and 53.8% of cases, respectively, and renal insufficiency in 85% and 60% of cases, respectively., Conclusion: Clinical and angiographic variables were the best predictors of therapeutic success for hypertension. Doppler sonography was useful in patients with renal failure.

Unlabelled: Preliminary studies with 99mTc-apcitide (99mTc-P280), a synthetic peptide that binds to glycoprotein IIb/IIIa receptors expressed on activated platelets, have shown promising results in the detection of acute deep vein thrombosis (ADVT). The purpose of this study was to compare the diagnostic value of early and delayed imaging with 99mTc-apcitide in patients with suspected ADVT, using contrast-enhanced venography as the gold standard., Methods: Thirty-nine patients (17 women, 22 men; mean age 59 y) with signs or symptoms suggestive of ADVT (within 10 d of onset) and scheduled for contrast-enhanced venography were prospectively studied. The patients were injected with approximately 740 MBq (20 mCi) 99mTc-apcitide within 36 h of contrast-enhanced venography. Both anterior and posterior planar images (8-10 min/view) of the lower extremities using a dual-head gamma camera were obtained at 10, 60 and 120 min after the injection of 99mTc-apcitide. The three sets of images initially were interpreted randomly and separately by three experienced observers unaware of the clinical history, the site of ADVT and results of contrast-enhanced venography. All images from the three sets for a given patient were then analyzed together during a second session. Conventional contrast-enhanced venography was performed on 31 patients before 99mTc-apcitide scintigraphy and in the remaining 8 patients after 99mTc-apcitide scintigraphy. 99mTc-apcitide findings were considered positive forADVT when a focus of increased uptake was found to correspond to the location of a deep vein. Disagreements were resolved by consensus., Results: Twenty-two patients had ADVT observed on contrast-enhanced venography, whereas 17 had normal findings. Six cases of ADVT were infrapopliteal. One patient did not complete the third set of images with 99mTc-apcitide. The sensitivity of 99mTc-apcitide in detecting ADVT was 63.6% (14/22), 68.2% (15/22), 76.2% (16/21) and 86.4% (19/22) for images obtained at 10, 60 and 120 min and for the three sets analyzed together, respectively. The specificity was 82.4% (14/17), 76.5% (13/17), 88.2% (15/17) and 88.2% (15/17) for images obtained at 10, 60 and 120 min and for the three sets of images together, respectively., Conclusion: Although the set of 99mTc-apcitide images obtained 120 min after injection showed good overall diagnostic accuracy, the combination of at least two sets of images provided the highest accuracy in detecting ADVT.

Purpose: To compare the diagnostic value of carbon dioxide to that of iodinated contrast material for digital subtraction angiography of the abdominal aorta and lower extremities., Materials and Methods: Thirty-five patients underwent comparative CO2 and iodinated contrast material arteriography of the abdominal aorta and lower extremities. For each contrast study, three independent observers evaluated the degree of opacification and percentage of stenosis of each vessel, the degree of certainty of their observations, and the overall quality of the study. Data of CO2 and iodinated studies were compared using analysis of variance for repeated measures. Interobserver and intertechnique agreements were estimated with Cohen's kappa and intraclass correlation coefficient., Results: Iodine-based vascular opacification was superior to that with CO2 in the central and distal arteries (P = .02). The degree of certainty and overall quality score were higher for iodine than for CO2-based contrast studies (P = .00001). The interobserver agreement for categorizing stenoses was higher for iodine as compared to CO2-based angiography. No significant difference was observed between the mean stenosis values obtained with CO2 and iodine-based angiography in any segment. Intraclass correlation coefficient demonstrated a high degree of convergence of the two techniques for assessing the percentage of stenosis., Conclusion: CO2 can be used as an alternative to iodinated contrast material for obtaining arteriograms of the abdominal aorta and lower extremities for investigating atherosclerotic disease.

Objective: The purpose of this study was to assess the value of the ratio between the internal carotid systolic velocity (ICSV) at the carotid bulb and the distal internal carotid systolic velocity (DICSV) for the detection of carotid artery stenosis., Subjects and Methods: Two hundred eleven patients were enrolled in a prospective study comparing several Doppler measurements with carotid angiography. The following spectral measurements were obtained with Doppler sonography: ICSV/DICSV ratio, ICSV, ICSV/common carotid systolic velocity (CCSV) ratio, and internal carotid (end) diastolic velocity (ICDV). Receiver operating characteristic curves were generated for two groups: the first group being 365 carotid arteries for which all Doppler measurements were successfully obtained and the second being a subgroup of 258 carotid arteries for which an ICSV of 100 cm/sec or greater was present., Results: In the group of 365 carotid arteries, the ICSV/DICSV ratio improved the detection of stenosis of 60% or greater as compared with the ICDV (p = .03). In 258 carotid arteries with an ICSV of 100 cm/sec or greater, the ICSV/DICSV ratio allowed for a better angiographic correlation for identifying stenoses of 60% or greater and 70% or greater as compared with ICSV (p = .006 and .023, respectively), ICSV/CCSV (p = .0013 and .003, respectively), and ICDV (p = .0015 and .020, respectively)., Conclusion: Using the ICSV/DICSV ratio for the Doppler detection of carotid artery stenosis is advantageous when the ICSV is 100 cm/sec or greater.

Purpose: To evaluate the safety and long-term clinical and hemodynamic results of percutaneous transluminal angioplasty (PTA) of the infrarenal aorta., Materials and Methods: During nearly 10 years, 102 patients with symptomatic infrarenal atherosclerotic aortic stenosis underwent PTA. Follow-up information was available in 92 patients (17 men, 75 women; mean age, 51.9 years). Stenosis involved the aortic bifurcation in 18 patients and only the infrarenal abdominal aorta in 74 patients. Technical success was defined as residual stenosis less than 50% or a pressure gradient less than 10 mm Hg after PTA. Clinical patency was defined as the absence or improvement of symptoms after PTA. Hemodynamic patency was defined as a normal Doppler waveform in the common femoral arteries, an ankle-brachial ratio greater than 0.95, or the absence of a thigh-brachial pressure gradient., Results: Technical success was achieved in 78 patients after PTA. After 10 years, primary clinical and hemodynamic patency rates were 72% and 46%, respectively. After a mean follow-up of 51 months, 15 of the 22 symptomatic recurrences were due to aortic restenosis; 11 of these were treated with repeated PTA with or without stent placement, and three eventually required aortic surgery. No morbidity was encountered., Conclusion: Infrarenal aortic PTA proved to be safe and provided durable, long-term clinical improvement. In this group of relatively young patients, the clinical patency rate of PTA was equivalent to that of aortic surgery but with less morbidity.

Objective: The goal of this study was to compare patients with aortic graft infection treated by primary percutaneous drainage with patients who initially underwent surgery., Materials and Methods: A retrospective review of 23 consecutive patients treated for aortic graft infection was performed. Eleven patients were initially treated with percutaneous drainage and 12 were treated with surgery. The morbidity, mortality, and postprocedural reintervention rates and clinical outcome were analyzed for each group., Results: The septic process resolved in nine (82%) of 11 patients treated with percutaneous drainage. Of these nine patients, four were treated with percutaneous drainage alone. Drainage was followed by removal of the infected prosthetic graft in the remaining five patients. In the surgical group, sepsis resolved in only four patients (33%) (p = .036). No periprocedural deaths occurred in the percutaneous drainage group, whereas six patients in the surgical group died in the perioperative period (p = .014)., Conclusion: Percutaneous drainage can be used as an initial form of treatment in the management of aortic graft infections. Surgery after percutaneous drainage appears to be safer than surgery alone.

Purpose: To compare nonstepping digital subtraction angiography (DSA) (ie, storage phosphor radiography adapted to a stationary imaging plate changer) with conventional screen-film angiography in the evaluation of the lower extremities., Materials and Methods: Fifty-one patients with peripheral vascular disease underwent both nonstepping DSA and screen-film angiography. The angiographic and radiologic techniques of both systems were kept identical for each patient. Three radiologists independently rated the overall quality of each angiogram. In their evaluations for each of 12 arterial segments on all 102 angiograms, they also rated the degree of opacification, the diameter reduction of the most severe stenosis, and their level of confidence., Results: Mean overall quality scores and levels of confidence were better for nonstepping DSA than for screen-film angiography (P < .001). Full opacification was reported in 95.6% and 89.2% of all 1,836 segments with nonstepping DSA and screen-film angiography, respectively (P < .0001). The difference between the mean stenosis grades obtained with screen-film angiography and nonstepping DSA was not statistically significant. Intertechnique agreements were good (kappa = 0.77, 0.81, and 0.81), whereas interobserver agreements were influenced by the observer's experience with the imaging techniques., Conclusion: Nonstepping DSA images of the lower extremity were of better diagnostic quality than were screen-film angiograms. The development of dedicated nonstepping DSA equipment is warranted.

Objective: The goal of this study was to assess the value of quantitative and qualitative analysis of the early systolic rise on Doppler waveforms obtained before and after administration of captopril in patients suspected of having renal artery stenosis., Subjects and Methods: Seventy-one hypertensive patients (135 kidneys) were studied with transrenal Doppler sonography. Ninety-six kidneys were studied again after administration of captopril. All patients also underwent renal angiography. All Doppler studies were independently reviewed by two observers. Specific criteria for Doppler waveform patterns that were applied in the detection of renal artery stenosis included acceleration, acceleration time of early systolic rise, differential velocity of systolic rise, and resistive index. These criteria were then correlated with angiography, and receiver operating characteristic curves were generated., Results: On the basis of waveform pattern recognition. Doppler sonograms obtained before administration of captopril had a sensitivity of 81% and a specificity of 98% for the detection of renal artery stenosis greater than or equal to 50%. Sensitivity of Doppler sonography obtained after administration of captopril was 100%, and specificity was 100%. For renal artery stenosis greater than or equal to 70%, sensitivity was 94% and specificity was 89% before administration of captopril. The area under the receiver operating characteristic curve for the acceleration criterion was significantly larger after administration of captopril (p = .009) for the detection of renal artery stenosis greater than or equal to 50%. After captopril administration, an acceleration threshold value of 440 cm/sec2 for early systolic rise was associated with a sensitivity of 100% and a specificity of 94% for the detection of renal artery stenosis greater than or equal to 50%., Conclusion: Doppler sonography of the renal arteries performed before administration of captopril appears to be an excellent screening tool in the detection of severe stenosis (> or = 70%). Administration of captopril improves the detection of renal artery stenosis greater than or equal to 50% with Doppler sonography when observers use both morphologic and quantitative criteria.

Purpose: To determine the analgesic efficacy and safety of interpleural block for percutaneous biliary drainage., Materials and Methods: In this double-blind study, 34 age- and sex-matched patients who were to undergo percutaneous biliary drainage because of malignant biliary obstruction were randomly assigned to the true-block group (30 mL 0.5% bupivacaine block) or placebo-block group; all had access to a patient-controlled analgesia (fentanyl) pump. Self medication, pain reports, blood pressure, heart rate, and oxygen saturation were monitored during and until 8 hours after drainage. The McGill Pain Questionnaire was administered 1 hour after biliary drainage., Results: Patients in the placebo group self administered statistically significantly more fentanyl than did patients in the true-block group (P = .008). Peak pain scores (10-point scale) and McGill Pain Questionnaire scores were statistically significantly higher for the placebo group patients (P = .017 and P = .001, respectively). There were no differences between groups in terms of blood pressure, heart rate, and oxygen saturation. Two patients had pneumothorax caused by the interpleural block., Conclusion: Interpleural block was effective in decreasing pain and opioid requirements during and after percutaneous biliary drainage and did not compromise the cardiopulmonary status of the patient. However, the rate of pneumothorax was higher than previously reported.

Background: The purpose of this study is to examine the feasibility of performing totally thoracoscopic internal mammary-to-coronary artery bypass grafting with the assistance of radiologically guided catheter intervention., Methods: Fourteen dogs were subjected to mobilization of the internal mammary artery and anastomosis of it to the left anterior descending coronary artery over an angiographic catheter inserted into the internal mammary artery under fluoroscopy. The anastomosis was completed over the catheter using sutures and the application of fibrin glue. Eight animals underwent the anastomosis after their sacrifice. The other 6 animals were put on closed chest cardiopulmonary bypass and had their anastomosis done after intraaortic balloon occlusion and cardioplegic arrest of the heart. All animals had an angiographic and pathologic examination at the completion of the anastomosis., Results: Anastomosis was completed in all dogs. Three anastomoses leaked and two were noted to be stenosed at completion of the anastomosis. One leak was sealed by application of fibrin glue. Both stenotic anastomoses were caused by suturing of the back wall when a short angiographic catheter could not be positioned across the anastomosis., Conclusions: Minimally invasive totally thoracoscopic mammary-to-coronary artery bypass grafting with catheter assistance is feasible. Technical improvement and appropriate instrumentation are required to minimize anastomotic failure.

Purpose: To evaluate the long-term results of peripheral biliary diversion by means of anastomoses of the left lobe of the liver to the stomach., Materials and Methods: Transhepatic perforation of the left lobe of the liver into the lesser curvature of the stomach was performed in 35 patients with a presumed diagnosis of malignant obstructive jaundice. Jaundice was found to be caused by a malignant stricture in 32 patients and a benign stricture in three. Perforation was performed under fluoroscopic, endoscopic, and laparoscopic guidance in 33 patients and without laparoscopy in the other two. The hepaticogastric anastomosis was secured with a gastrostomy tube; patency of the tract was maintained with placement of a metallic stent. Kaplan-Meier analysis was used to evaluate survival, anastomosis patency rate, and jaundice recurrence., Results: Technical success was achieved in all patients. Two (6%) patients had anastomotic obstruction. The actuarial survival rate was 91%, 80%, 59%, and 26% at 1, 3, 6, and 12 months. The mean patency was 234 days +/- 252. The jaundice-free rate among surviving patients was 100%, 96%, 93%, and 80% at 1, 3, 6, and 12 months. The reintervention rate was 14%. Late cholangitis occurred in seven (20%) patients., Conclusion: This peripheral diversion procedure appears to be safe and shows good long-term patency.

Objective: Renal artery stenting has recently been used to treat failures or complications of renal angioplasty. Although technical results and complication rates have been reported, clinical follow-up and long-term data are limited. The purpose of this study was to evaluate the midterm clinical efficacy and safety of Palmaz stents in rescuing renal artery angioplasty failures., Materials and Methods: Palmaz stents were placed in 35 renal arteries of 33 patients (14 men and 19 women; 37-77 years old; mean age, 62.6 years old) for immediate angioplasty failure (29 arteries) or for recurrent stenosis after previous angioplasty (six arteries). Indications for treatment were hypertension alone (16 patients) or hypertension associated with renal failure (17 patients). Blood pressure, medication, and serum creatinine level were followed after stenting., Results: No residual stenosis was found immediately after stenting. Mean clinical follow-up was 13.4 months (range, 1-34 months). Of the 33 patients, two (6%) were cured of their hypertension, 20 (61%) were improved, and 11 (33%) did not respond to renal artery stenting. Of the 17 patients whose serum creatinine level was greater than 132 mumol/dl (1.5 mg/dl), seven (41%) were improved by renal artery stenting, six (35%) were stabilized, and renal function deteriorated in four (24%). Of the 33 patients, seven developed complications including one renal artery thrombosis, four renal artery emboli, one cholesterol embolization to the lower limbs, and one femoral hematoma that required surgery., Conclusion: Midterm results of renal artery stenting with the Palmaz stent to treat immediate or late angioplasty failures reveal improvements in blood pressure and renal function similar to those of successful primary balloon angioplasty.

We report the case of a young woman with three left renal artery aneurysms, diagnosed immediately postpartum, associated with a de novo high blood pressure. To assess anatomical and functional characteristics of renal artery aneurysms, renal angiogram, MRI, intravenous pyelography, ultrasonography and radionuclide renography were performed. Two patent saccular renal artery aneurysms were demonstrated in the left kidney by renal angiogram. A larger, thrombosed aneurysm was also depicted on the left side on ultrasonography, MRI and renal angiogram. The larger aneurysm was responsible for renovascular disease of the middle third of the kidney, as demonstrated by captopril and baseline radionuclide renographic studies. It also impeded drainage of the lower pyelocalyceal group, without obstructing it, as shown by concomitant furosemide (Lasix) evaluations.

Purpose: To compare the efficacy and safety of streptokinase (SK) and urokinase (UK) in the treatment of local thrombolysis., Patients and Methods: Over a 24-month period, 40 patients with 45 lower limb arterial occlusions of less than 45 days duration underwent intraarterial fibrinolysis. Twenty occlusions were treated with recombinant UK and tissue culture-derived UK, and 25 occlusions were treated with SK. The study was retrospective, but the two groups were very homogeneous in terms of vascular surgical history, medical risk factors, and occlusion characteristics., Results: Complete lysis (95% or more) was achieved in 84% of SK infusions and 89% of UK infusions. Endoluminal and surgical interventions as well as clinical outcomes of SK and UK treatment were comparable. However, infusion time was significantly longer for SK treatment: 28.5 hours versus 19.1 hours for UK treatment (P = .035). Complication rates were not statistically significantly different. Average length of stay in the intensive care unit was identical (2.2 days) for both groups, and the difference in hospital stay was not statistically significant (7.7 days for SK vs 8.7 days for UK)., Conclusion: At the concentrations and doses used, the efficacy and safety of SK and UK were comparable, despite longer SK infusion time.

Surgical treatment of an occluded or stenotic portacaval shunt carries a high risk of mortality, but the rate of restenosis after transluminal angioplasty is also high. The authors report high-grade stricture of a portacaval H-graft shunt in a 51-year-old man, who presented with hematemesis and melena. The patient was treated with concomitant balloon angioplasty and placement of a metallic stent through a percutaneous venous approach. The procedure was tolerated well by the patient, and stenosis had not recurred at follow-up 1 year later.

The authors describe a case in which infection developed in a patient after placement of a metallic endoprosthesis in the iliac artery. The patient died of respiratory failure secondary to sepsis. Imaging studies did not reveal an abscess, aneurysm, or stent occlusion. Stent cultures and hemocultures grew Staphylococcus aureus. As with any foreign body, infectious complications may occur after insertion of metallic stents and should be recognized as soon as possible to initiate appropriate therapy.

Purpose: To report a technique of peripheral biliary decompression by means of anastomosis of a bile duct in segment II of the liver to the lesser curvature of the stomach., Materials and Methods: Seven patients with unresectable biliary neoplasm were treated. After transhepatic catheterization of a segment II bile duct, the left lobe of the liver and the lesser curvature of the stomach were perforated under fluoroscopic and laparoscopic guidance. Anastomosis between the biliary tree and the stomach was maintained with a gastrostomy tube placed across the tract. After 2 weeks, the tube was removed and patency of the tract was preserved with a metallic stent., Results: Three patients died, at 3, 6, and 9 months, respectively, without reocclusion; the other four were alive at 5 months without jaundice. One patient had an episode of cholangitis, which was resolved with antibiotic therapy., Conclusion: This method yields a good patency rate with few problems. Further investigation is required to evaluate long-term patency and the necessity of laparoscopic guidance.

A 71-year-old woman had edema and venous dilatation of her upper right limb that caused painful functional disability following a shoulder injury. Arteriograms demonstrated an arteriovenous fistula between the subclavian artery and vein associated with thrombosis of the vein at the same level. The arteriovenous fistula was found to have multiple arteriovenous communications. Because of associated distal venous thrombosis, venous drainage was retrograde through the brachial vein. The inflow arteries of the fistula were embolized and then the subclavian vein thrombosis was recanalized, dilated, and an endoluminal stent inserted. Clinical signs completely resolved.

Mesenteric panniculitis also known as lipodystrophy is an inflammatory condition of adipose tissue. A case of a 55 year old, female who presented a weight loss and a tender palpable mass located in the left flank is reported. CT patterns were not specific but might suggest the diagnosis: fatty mass, with a higher density than subcutaneous fat, located in the root of the mesentery and surrounding mesenteric vessels without distoting them. Intestinal loops were only pulled in periphery. This signs are not always present and even in this typical pattern mesenteric panniculitis could not be differentiated from liposarcoma. Thus an histological proof was needed. The evolution was good, with resolution of the abdominal pain. The knowledge of this rare Radioclinical syndrome should prevent any aggressive therapy.

The authors report about four cases of urinoma detected during the neonatal period in three boys and one girl with congenital uropathy. It appeared as an infravesical obstruction in three cases (2 posterior urethral valves, one anterior urethral diverticulum) and as an obstruction of the pyeloureteral junction in the last case. The examination was prompted by the detection of a mass in the side during the clinical examination. The diagnosis is based on ultrasound, which evidences the liquid and extrarenal character of the urinoma and often allows demonstrating the underlying uropathy. The kidney may be difficult to localize if the urinoma is very large. IVP or radionuclide scanning may contribute to the diagnosis as they allow assessing the functional value of the kidney. The urinoma protects the kidney from the consequences of uropathy by allowing a relative decompression of the pyelocaliceal structures.