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BackgroundThe erosion of the early mortality advantage of elective endovascular aneurysm repair (EVAR) compared with open repair of abdominal aortic aneurysm remains without a satisfactory explanation.MethodsAn individual-patient data meta-analysis of four multicentre randomized trials of EVAR versus open repair was conducted to a prespecified analysis plan, reporting on mortality, aneurysm-related mortality and reintervention.ResultsThe analysis included 2783 patients, with 14 245 person-years of follow-up (median 5·5 years). Early (0-6 months after randomization) mortality was lower in the EVAR groups (46 of 1393 versus 73 of 1390 deaths; pooled hazard ratio 0·61, 95 per cent c.i. 0·42 to 0·89; P = 0·010), primarily because 30-day operative mortality was lower in the EVAR groups (16 deaths versus 40 for open repair; pooled odds ratio 0·40, 95 per cent c.i. 0·22 to 0·74). Later (within 3 years) the survival curves converged, remaining converged to 8 years. Beyond 3 years, aneurysm-related mortality was significantly higher in the EVAR groups (19 deaths versus 3 for open repair; pooled hazard ratio 5·16, 1·49 to 17·89; P = 0·010). Patients with moderate renal dysfunction or previous coronary artery disease had no early survival advantage under EVAR. Those with peripheral artery disease had lower mortality under open repair (39 deaths versus 62 for EVAR; P = 0·022) in the period from 6 months to 4 years after randomization.ConclusionThe early survival advantage in the EVAR group, and its subsequent erosion, were confirmed. Over 5 years, patients of marginal fitness had no early survival advantage from EVAR compared with open repair. Aneurysm-related mortality and patients with low ankle : brachial pressure index contributed to the erosion of the early survival advantage for the EVAR group. Trial registration numbers: EVAR-1, ISRCTN55703451; DREAM (Dutch Randomized Endovascular Aneurysm Management), NCT00421330; ACE (Anévrysme de l'aorte abdominale, Chirurgie versus Endoprothèse), NCT00224718; OVER (Open Versus Endovascular Repair Trial for Abdominal Aortic Aneurysms), NCT00094575.

Purpose: The purpose of this study was to evaluate the technical success, complications, long-term clinical outcome, and patency after primary infrarenal aortic stenting for aortic and aortoiliac stenosis. Between January 1999 and January 2006, 22 consecutive patients underwent endovascular treatment because of infrarenal aortic stenosis with and without common iliac stenosis (10 men; mean age 64 ± 14 years). Eleven (11 of 22) patients had an isolated aortic stenosis, whereas 11 of 22 had aortic stenosis that extended into the common iliac arteries (CIAs). Thirteen patients were Rutherford classification type 3, and 9 patients were type 4. Statistical analysis included paired Student t test and Kaplan-Meier life table analysis; p < 0.05 was considered significant. Technical and initial clinical success was achieved in all patients. There were three (14 %) procedure-related complications, which included two access-point pseudoaneurysms and one non-flow-limiting left external iliac dissection. Patients were followed-up for a mean period of 88 months (range 60-132). Mean preprocedure ankle brachial pressure indexes (ABPI) were 0.60 ± -0.15 (right) and 0.61 ± -0.16 (left). After the procedure they were 0.86 ± -0.07 (right) and 0.90 ± -0.09 (left). The increase in ABPI was significant (p < 0.05), and this continued throughout follow-up. Four (18 %) patients had recurrence of symptoms during follow-up. These occurred at 36, 48, 48, and 50 months after the original procedure. All four patients were successfully treated with repeat angioplasty procedures. There was a significant difference in primary patency between isolated aortic stenosis (100 %) and aortoiliac stenosis (60 %) (p = 0.031). Cumulative follow-up was 1920 months yielding a reintervention rate of 0.025/events/year. Conclusion: Primary stenting of infrarenal stenosis is safe and successful with a low reintervention rate. It should be considered as first-line treatment for patients with infrarenal aortic stenotic disease. [ABSTRACT FROM AUTHOR]

Aim: To identify variables related to complications following tunnelled dialysis catheter (TDC) replacement and stratifying the risk to reduce morbidity in patients with end-stage renal disease. Materials and Methods: One hundred and forty TDCs (Split Cath, medCOMP) were replaced in 140 patients over a 5 year period. Multiple variables were retrospectively collected and analysed to stratify the risk and to predict patients who were more likely to suffer from complications. Multivariate regression analysis was used to identify variables predictive of complications. Results: There were six immediate complications, 42 early complications, and 37 late complications. Multivariate analysis revealed that variables significantly associated to complications were: female sex (p = 0.003; OR 2.9); previous TDC in the same anatomical position in the past (p = 0.014; OR 4.1); catheter exchange (p = 0.038; OR 3.8); haemoglobin <11 g/dl (p = 0.033; OR 3.6); albumin <30 g/l (p = 0.007; OR 4.4); prothrombin time >15 s (p = 0.002; OR 4.1); and C-reactive protein >50 mg/l (p = 0.007; OR 4.6). A high-risk score, which used the values from the multivariate analysis, predicted 100% of the immediate complications, 95% of the early complications, and 68% of the late complications. Conclusion: Patients can now be scored prior to TDC replacement. A patient with a high-risk score can be optimized to reduce the chance of complications. Further prospective studies to confirm that rotating the site of TDC reduces complications are warranted as this has implications for current guidelines. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the feasibility and safety of early and proactive involvement of interventional radiology (IR) in the management of placenta accreta spectrum (PAS) by performing the cesarean operation and prophylactic uterine artery embolization in the IR angiography suite as a combined procedure., Materials and Methods: This study evaluated the effectiveness and safety of prophylactic uterine artery embolization prior to placental separation in cases of antenatally proven or suspected abnormal placentation. Over a 5-year period, 16 consecutive patients with PAS underwent combined IR and obstetric intervention. In all cases, cesarean delivery was performed in the IR angiography suite. Vascular access was obtained prior to surgery with balloon placement into both internal iliac arteries. These balloons were inflated after delivery, followed by uterine artery embolization (14 of 16) if there was evidence of active postpartum bleeding or inability to deliver the placenta., Results: There was no fetal or maternal mortality and no significant IR or surgical adverse events. Mean blood loss was 1900 mL. Seven patients (44%) underwent hysterectomy., Conclusions: In patients with PAS, cesarean section in the angiography suite preceded by prophylactic balloon placement and followed by uterine artery embolization was feasible, safe, and effective in preventing massive blood loss, with a 56% uterine sparing rate., (Copyright © 2023 SIR. Published by Elsevier Inc. All rights reserved.)

The rapid imaging evaluation and diagnosis of rupture and impending rupture of an abdominal aortic aneurysm (AAA) is imperative. This article describes the imaging findings of rupture, impending rupture, and other abdominal aortic abnormalities. It is important not to overlook AAA as the consequences can be life threatening. All patients who had open or endovascular repair of AAA rupture over 6 years (2008-2012) were identified from our departmental database. The computed tomography (CT) images of 99 patients were reviewed for relevant findings. The mean age of the patients was 65 years and 85% were male., (Copyright © 2013 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Aortic penetrating atherosclerotic ulcer (PAU) is a relatively common incidental finding on thoracic computed tomography (CT) examinations. This is likely to relate to the steady increase in the number of CT examinations performed and also due, in part, to the increasing age of the general population. There is as yet no consensus on the management of incidental PAUs in asymptomatic patients. This article aims to review the literature and discuss the natural history, prognosis, and management of incidental PAU., (Copyright © 2012 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Acute aortic syndrome (AAS) is a constellation of potentially life-threatening acute aortic diseases. The spectrum includes penetrating atherosclerotic ulcer, intramural haematoma, dissection, and unstable thoracic aneurysm. AAS cannot be reliably diagnosed clinically and multidetector computed tomography (MDCT) has revolutionized the diagnosis and management of this group of conditions in the acute setting due to its availability, speed, and accuracy. The purpose of this review is to illustrate key MDCT findings of AAS. Imaging techniques, radiological findings, and common pitfalls are also discussed., (Copyright © 2013 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Objective: To assess the patterns of regression of renal angiomyolipoma (AML) post embolisation and report the outcomes related to the use of different embolic materials., Methods: A retrospective review of all patients who underwent embolisation for renal AML at our institution between January 2004 and April 2012., Results: 13 patients underwent 16 episodes of embolisation. Coils were used as the primary embolisation material in 10 episodes and microspheres in 6 episodes. The size reduction rate highly correlated on CT follow-up between the two groups, with 25.6% vs 22.7% reduction at 12 months, 27.5% vs 25.1% at 24 months, 35.0% vs 33.0% at 36 months and 35.0% vs 36.8% at 48 months. During follow-up, all tumours reduced in size with one patient requiring subsequent embolisation whose tumour reduced by only 6.5% after 1 year and subsequently exhibited regrowth after 4 years. Two patients presented with rebleeding and underwent repeat embolisation. Our overall retreatment rate (23%) is well within the literature range (up to 37%). None of the patients underwent surgery., Conclusion: The majority of AML shrinkage occurs within the first year following embolisation and appears to plateau after 3 years, which could have an impact on follow-up strategy. The percentage reduction at 1 year may reflect the long-term effect of embolisation with tumours demonstrating minor size reduction more likely to relapse at long-term follow-up. Embolisation of renal AML produces durable long-term results regardless of the choice of embolic agent., Advances in Knowledge: These findings provide information to guide CT follow-up of renal AML post embolisation.

Aortic atherosclerosis reduces compliance in the systemic circulation and increases peripheral resistance, afterload and left ventricular wall stress. In patients with heart failure, these changes can impair left ventricular systolic function and energy efficiency, which could reduce exercise capacity. Though the interaction and the impact of aortic atherosclerosis on left ventricular function have been investigated, its prognostic implications in patients with heart failure are unclear. We used cardiac magnetic resonance imaging and gadolinium-enhanced abdominal aortography to investigate the prevalence and prognostic impact of atherosclerotic disease of the abdominal aorta and its side branches in 355 patients with heart failure. Sclerotic abdominal aortic disease was defined as a luminal narrowing >50% of the aorta and its side branches or the presence of abdominal aortic aneurysm. Patients with disease of the aorta and its branches were older (P < 0.0001), had overall longer stay in hospital (P = 0.006) and had more admissions (P = 0.001) and worse prognosis (hazard ratio: 1.97, 95% confidence interval: 1.29-3.00, P = 0.002) than those without. In a multivariable model, increasing age and pulse pressure, diabetes mellitus and increasing left ventricular end-diastolic volume were associated with a worse prognosis, but sclerotic abdominal aortic disease was not independently related to outcome (hazard ratio: 1.06; 95% confidence interval: 0.64-1.74; P = 0.823). These data demonstrate that atherosclerosis of the abdominal aorta and its side branches is common and associated with increased morbidity in patients with chronic heart failure. How such disease should be managed remains uncertain, but its recognition and characterisation are the first steps in finding out.

Purpose: To assess the feasibility, complications, and long-term success of embolization of pulmonary arteriovenous malformations (PAVMs) with the AMPLATZER Vascular Plug and AMPLATZER Vascular Plug II., Materials and Methods: The study included 15 consecutive patients (19 embolization episodes) who had embolization of PAVMs between April 2004 and April 2009 with an AMPLATZER Vascular Plug or AMPLATZER Vascular Plug II. There were 4 men and 11 women, with a mean age of 56 years (range 24-74 years). A prospective database of all cases of PAVM embolization is kept in the department. Patient history, detailed procedural records, and clinical and radiological follow-up were reviewed., Results: Among the 19 PAVMs, an AMPLATZER Vascular Plug was deployed in 11, and an AMPLATZER Vascular Plug II was deployed in 8. The technical success of the procedure was 100% for PAVM occlusion; 30-day mortality in the group was zero. Successful radiologic follow-up with the AMPLATZER Vascular Plug was a mean of 28 months (range 0-60 months) and with the AMPLATZER Vascular Plug II was a mean of 18 months (range 12-36 months). There was one recanalization of an AMPLATZER Vascular Plug 36 months after embolization giving an annual event rate of 0.03 recanalizations per AMPLATZER Vascular Plug or AMPLATZER Vascular Plug II per year. There were no major complications. Clinically, there was one (1 of 18 cases [5%]) immediate complication of chest pain that resolved in 24 hours with simple analgesia. There were no early or late clinical complications., Conclusions: The treatment of PAVM with either an AMPLATZER Vascular Plug or an AMPLATZER Vascular Plug II is safe and effective and associated with a low reintervention rate. Further follow-up is ongoing to ensure continued occlusion of treated PAVMs., (Copyright © 2011 SIR. Published by Elsevier Inc. All rights reserved.)

A 70-year-old patient, who had previously undergone open surgical repair of an aneurysmal aberrant right subclavian artery (ARSA), presented with recurrent symptoms and reperfusion of the aneurysm at the site of proximal ligation. This was successfully treated by a staged endovascular procedure., (© Georg Thieme Verlag KG Stuttgart · New York.)

Endovascular management of massive bilateral superior intercostal artery aneurysms following late surgical repair of juxtaductal coarctation of the aorta is described in a 40-year-old male patient. Both aneurysms were successfully treated by coil embolisation without the need for further surgical intervention., (© Georg Thieme Verlag KG Stuttgart · New York.)

This case report describes repair of a type I endoleak at the distal landing zone of a thoracic aortic stent graft by endovascular placement of a thoracoabdominal fenestrated stent graft (Cook, Brisbane, Australia). The fenestrated stent graft was interposed between a previous abdominal aortic aneurysm (AAA) Gelsoft tube graft (Sulzer Vascutek Ltd, Inchinnan, United Kingdom) and two overlapping Zenith thoracic endografts (Cook Inc, Bloomington, Indiana). Placement was made more complex because the distal thoracic endograft had rotated into a horizontal position. At 3-year clinical and computed tomography (CT) follow-up, continued clinical and radiologic success was shown with no further intervention required., (Copyright © 2011 SIR. Published by Elsevier Inc. All rights reserved.)

Carotid stump syndrome is one of the recognised causes of recurrent ipsilateral cerebrovascular events after occlusion of the internal carotid artery. It is believed that microemboli arising from the stump of the occluded internal carotid artery or the ipsilateral external carotid artery can pass into the middle cerebral artery circulation as a result of patent external carotid-internal carotid anastomotic channels. Different pathophysiologic causes of this syndrome and endovascular options for treatment are discussed.

Aim: Therapeutic angiography with embolization is fast becoming the preferred treatment modality for major bleeding in the lower gastrointestinal (LGI) tract. The aim of this study was to determine the long term outcome and complications of percutaneous coil embolization (PCE) and its efficacy as definitive therapy in patients with major LGI bleeding., Methods: All patients presenting to our institution with a haemodynamically significant LGI tract bleed between 1995 and 2001 that were unresponsive to conservative measures were considered for emergency angiography and coil embolization where appropriate. The outcome of these individuals was determined by case note review and telephone interview., Results: There were 20 patients (11 females) with a mean follow-up period 72 months, mean age was 67 years. All underwent PCE following positive angiogram. The most common site of bleeding was the right colon (40%); haemostasis was successfully achieved in 16 (80%) patients. Five of the 20 patients died within 30 days of the intervention, three following PCE and two following surgery. None of the mortality following PCE was considered procedure related. On long term follow-up four patients required readmission to hospital for further LGI bleeds at 1, 2, 12 and 16 months respectively. Ischaemic complications occurred in 23%., Conclusion: Superselective embolization as the primary technique for the treatment of haemodynamically significant LGI bleeding is an effective, feasible and safe technique. Long term follow-up in our series up to 72 months has shown that it should be considered as both a primary and potentially definitive treatment for life threatening LGI bleeds., (© 2010 The Authors. Colorectal Disease © 2010 The Association of Coloproctology of Great Britain and Ireland.)

Purpose: To determine immediate and long-term outcomes following catheter-directed intraarterial thrombolysis of occluded native arteries and infrainguinal vein grafts by using low-dose tissue-type plasminogen activator (tPA) in patients with lower limb ischemia., Materials and Methods: One hundred eleven intraarterial thrombolysis procedures were performed in 96 patients during the 2-year study period. Patient records were available for retrospective review in 85 thrombolytic procedures performed in 74 (77%) of the 96 patients. Forty-one native vessels (four iliac, 24 superficial/common femoral, and 13 popliteal/below-knee vessels), six iliac stents, and 38 infrainguinal vein grafts were treated by using a low-dose (0.5 mg/h recombinant tPA) catheter-directed thrombolytic regimen. Procedural success was based on angiographic and clinical outcomes, and the need for further reconstructive surgery or amputation was documented., Results: Intraarterial thrombolysis was successful in 76%, was partially successful in 11%, and failed in 13%. Adjunctive angioplasty was performed in 33 of 55 patients (60%) with successful lysis, and immediate reconstructive surgery was required in five patients. There was one episode of puncture site bleeding and one gastrointestinal hemorrhage but no procedure-related deaths at 30 days. After a median follow-up of 6.5 years, 30 of the 55 patients (55%) who underwent successful thrombolysis required no further surgical intervention; however, further surgery was required in 45% of patients after a mean interval of 301 days (range, 2-1,344 days), including 10 (18%) amputations (six major and four minor)., Conclusions: Low-dose intraarterial thrombolysis is safe and effective, delaying and dramatically reducing the need for surgical intervention in lower limb ischemia due to native vessel or infrainguinal graft occlusion., (Copyright 2010 SIR. Published by Elsevier Inc. All rights reserved.)

Thromboembolism is the most common direct cause of maternal mortality in the UK. Inferior vena cava (IVC) filter placement is indicated in conditions where recurrent thromboembolism occurs despite adequate anticoagulation or when anticoagulation is contraindicated. The safety of IVC filter use in pregnancy is uncertain, as there are limited data available. In this study, we have reviewed pregnancy outcome in women with IVC filter use. Twelve pregnancies in six women, delivered in our hospital in the past 11 years, were identified from obstetric and radiology databases to have an IVC filter in situ. In four pregnancies, an IVC filter was placed during pregnancy. In eight pregnancies, an IVC filter was already in situ before pregnancy and continued for the entire duration of pregnancy. There were no antenatal complications noted due to IVC filter placement and no recurrent thromboembolism noted in pregnancies with an IVC filter in situ before conception. The mode of delivery was based on obstetric reasons in all cases. The mean birthweight was 2982 g, and all babies were born in good condition with Apgar scores within normal range. In conclusion, this case series did not identify any problems associated with IVC filter placement or continuation in pregnancy.

The case of a 30-year-old woman with a post-traumatic pseudoaneurysm of the superior mesenteric artery and associated celiac axis occlusion is presented. The patient was successfully treated with celiac artery recanalization and placement of a covered stent within the superior mesenteric artery. Follow-up at 3, 6, and 12 months and 3 years demonstrated patency of the covered stent and continued exclusion of the aneurysm. Although the long-term success of this procedure is unknown this management option should be considered where facilities are available, to reduce the increased morbidity associated with open surgical procedure.

Chronic soft-tissue haematomas are infrequently reported in the literature. We present a case of a slowly expanding post-traumatic chronic soft-tissue haematoma located anterior to the knee and leg, occurring in a region previously unreported. Both clinically and radiologically, it was impossible to distinguish the haematoma from an aggressive soft-tissue neoplasm. We review the literature and discuss the diagnostic problems related to this uncommon presentation.

Anaplastic thyroid cancer is a condition with a dismal prognosis in most cases. We present a case of subclavian vein compression in a case of anaplastic thyroid carcinoma treated with subclavian venous stenting. Subclavian vein compression is a recognized complication in disseminated carcinomatosis particularly in carcinoma of the breast and bronchus. It has never been described in anaplastic thyroid carcinoma.

Purpose: To describe the ultrasonographic (US) appearance of fibroid calcification occurring after uterine artery embolization (UAE) and discuss its etiology and pathology., Materials and Methods: Twenty-seven of a total of 38 patients were followed up clinically and with duplex US for longer than 6 months after UAE for uterine fibroids. At US, changes in uterine size, fibroid vascularity, and morphology have been recorded. Pathologic studies were performed by one of the authors on resected specimens from a different cohort of patients, at intervals ranging from 4 months to 1 year after UAE., Results: Twenty patients reported complete resolution of symptoms. In 16 of these, a reduction in fibroid volume of 70%-85% was recorded and, at US, the development of a peripheral hyperechoic rim around an increasingly hypoechoic fibroid was noted. Computed tomography in two patients revealed it to be a rim of calcium. Histologic studies in a different cohort of patients who had undergone hysterectomy at variable intervals after UAE demonstrated early aggregation of polyvinyl alcohol (PVA) particles, an intermediate giant cell inflammatory reaction, and calcification in the periphery of the infarcted fibroid at 6-12 months., Conclusion: Calcification is the end stage of hyaline degeneration. However, its peripheral location is unlike that of natural fibroid involution and hyaline necrosis. Pathologic studies in resected human fibroids after embolization suggest that its development is the end result of aggregation of PVA particles in peripheral fibroid arteries.

Diabetic patients are four times more likely to develop peripheral vascular disease than the general population. This disease is likely to be more aggressive, with five times more patients developing critical limb ischaemia. Early diagnosis and treatment allows up to 80% of these patients to have some form of surgical or endovascular re-vascularisation. The primary imaging modalities to be used should be duplex ultrasound followed by angiography. Magnetic resonance angiography, however, holds out promise for the future as being a good method of non-invasive imaging. Endovascular (interventional radiological) procedures have a major role to play in treatment of vascular stenoses and occlusions. Thrombolytic agents can be used to dissolve thrombus within occluded vessels and so restore patency. Percutaneous transluminal angioplasty is of value in dilating the stenotic lesions within the vessels and so restoring normal blood flow. Endovascular stents may be inserted to ensure longer term patency. There is indirect evidence to suggest that the outcomes of endovascular procedures in the diabetic patient are less good than those in the general population, but nevertheless such procedures may save the diabetic patient from primary amputation and allow healing of ischaemic ulcers., (Copyright 2000 John Wiley & Sons, Ltd.)

Purpose: To assess long-term outcomes following percutaneous transluminal angioplasty (PTA) of congenital aortic coarctation in adults., Methods: Seventeen patients underwent PTA for symptomatic adult coarctation of the aorta. Sixteen patients, with a mean age of 28 years (range 15-60 years), were reviewed at a mean interval after angioplasty of 7.3 years (range 1.5-11 years). Assessment included magnetic resonance imaging (MRI), Doppler echocardiography, and clinical examination. Current clinical measurements were compared with pre- and immediate post-angioplasty measurements., Results: At follow-up 16 patients were alive and well. The patient not included in follow-up had undergone surgical repair and excision of the coarctation segment following PTA. Mean brachial systolic blood pressure for the group decreased from 174 mmHg before angioplasty to 130 mmHg at follow-up (p = 0.0001). The mean gradient had fallen significantly from 50.9 to 17.8 at follow-up (p = 0.001). The average number of antihypertensive drugs required per patient decreased from 0.56 to 0.31 (p = 0.234). No significant residual stenoses or restenoses were seen at MRI. Small but clinically insignificant residual pressure gradients were recorded in all patients using Doppler echocardiography. Complications included one transient ischemic attack at 5 days, one external iliac dissection requiring stent insertion, and a further patient who developed a false aneurysm close to the coarctation site at 12 months which subsequently required surgical excision., Conclusion: PTA of adult coarctation is safe and effective in the long term. Although primary stenting has recently been advocated in the treatment of this condition, our results suggest that PTA remains the treatment of choice.

A stent-graft was used to palliate superior vena caval obstruction in a 50-year-old patient with histologically proven ingrowth of malignant thymoma through three previously inserted non-covered stents. The stent-graft is still patent 12 months later. This is the first report of such a procedure where histological evidence of tumour ingrowth is available and long-term patency is verified.

Purpose: To assess selected balloon-expandable and self-expanding stents for radial force, flexibility, radio-opacity, and trackability, and to relate these physical characteristics to potential indications for placement., Methods: Force-strain curves were plotted for each stent and the force required to produce 50% luminal narrowing was recorded. The ability of the stent to show elastic recoil following deformation was also noted. Flexibility was measured by bending the stents against a force transducer and recording the force required per degree of flexion. Radio-opacity was measured by comparing each stent against a standard aluminum step wedge. Trackability was measured by testing the ability of the stent on its delivery system to track over angles of 90 degrees and 60 degrees., Results: The balloon-expandable stents showed greater radial strength and radio-opacity but, apart from the AVE Iliac Bridge stent, showed poorer flexibility and trackability. The self-expanding stents showed less radial force but were able to re-expand following deformity. They were generally more flexible and had better trackability but lower radio-opacity., Conclusion: There is no stent which exhibits all the ideal properties required and therefore the interventionist will need to keep a range of stents available if all lesions are to be addressed.

Aim: This study is a long-term clinical follow-up of the Bird's Nest Filter which addresses issues such as caval patency, filter integrity, morbidity and mortality., Materials and Methods: 78 consecutive patients with Bird's Nest Filters inserted between 1989 and 1994 were recalled for clinical assessment and imaging follow-up. Pre- and post-filter medical histories were obtained from the patients and their medical records. They were examined for clinical signs of inferior vena cava occlusion. Imaging follow-up was by plain abdominal radiography, colour duplex ultrasound and computed tomography., Results: 52 patients were alive and well at 4-6 years. Thirty-day mortality was 5.1%. Three-year mortality was 19.2%. Recurrent pulmonary embolus occurred in 1.3%. IVC occlusion was demonstrated in 4.7%. No evidence of filter migration was seen. Wire prolapse occurred in 70% on abdominal X-ray and asymptomatic performation of the caval wall in 85.3% on CT. Morbidity and mortality were the same whether the patient was anticoagulated or not., Conclusion: The Bird's Nest Filter is safe and effective in both the short and long term.

Purpose: To assess the feasibility and efficacy of directional atherectomy in the treatment of iliac stent stenosis or occlusion and to evaluate the histologic composition of excised atherectomy specimens., Methods: Directional atherectomy of six occluded and 10 severely stenosed iliac stents was undertaken in 12 patients at a mean interval of 28 months (range 3-69 months) after stent insertion for occlusive aortoiliac disease. In cases of stent occlusion, atherectomy was preceded by low-dose thrombolysis. In all patients stent clearance with return of femoral pulses was achieved within 24 hr and there were no significant complications. All excised specimens were sent for histologic examination., Results: Eleven patients (92%) remain symptom free with unlimited walking distance at a mean follow-up interval of 11.5 months (range 3-31 months) after treatment. Histologic examination revealed typical myointimal hyperplasia at three excision sites, intimal fibrosis at three sites, atheroma at four sites and organized thrombus at six sites., Conclusion: Atherectomy offers an effective treatment in iliac stent occlusion and restenosis with no significant adverse effects. Debulking of these lesions seems to offer a more logical approach than simple balloon angioplasty. Clinical and duplex follow-up confirms satisfactory outcome within the first year but longer-term results are not yet known. The histologic data obtained demonstrate that stent restenosis and occlusion are likely to be multifactorial, and challenge the assumption that myointimal hyperplasia is the sole cause of iliac stent occlusion.

Background: The management of major colonic bleeding is problematic. A proportion of patients require emergency surgery which is associated with high morbidity and mortality. Percutaneous embolotherapy, previously considered a high risk procedure in the colon, may provide an alternative treatment in this group of patients., Aims: To assess the safety and efficacy of embolotherapy in the treatment of life threatening colonic haemorrhage., Patients and Methods: Thirty eight patients with fresh haemorrhage per rectum were referred for surgery because of failed conservative treatment. All underwent angiography; in 14 a bleeding site or vascular abnormality was detected. A coaxial catheter was directed to the most distal bleeding artery and this was embolised with platinum coils., Results: Detection of a bleeding site correlated with haemodynamic stability at the time of angiography (r = 1 for a systolic blood pressure less than 100 mm Hg). Bleeding sites or vascular abnormalities were detected and embolised in 14 patients (37%). In 12/14 there was immediate and sustained haemodynamic improvement; two continued to bleed and required emergency hemicolectomy (14%). Three developed ischaemic complications (21.4%); these were managed conservatively and required no intervention. The 30 day mortality was 7.1% in the embolotherapy group and 10.5% in the overall group of 38 patients., Conclusion: Colonic embolotherapy for life threatening haemorrhage is an effective, relatively safe procedure with a low incidence of major complications. Its use depends on the identification of a focal bleeding point or vascular abnormality, which in turn depends on the haemodynamic stability of the patient at the time of angiography.

Purpose: The results of treating malignant superior vena cava obstruction by means of percutaneous self-expanding stent insertion or by means of radiation therapy were compared., Patients and Methods: Seventy-six patients with malignant superior vena cava obstruction who were treated by stent insertion were studied prospectively and 25 patients who were treated by radiation therapy were studied retrospectively. A superior vena cava obstruction score was devised to measure treatment effectiveness. Speed of symptom relief and complications were recorded. End points in the study were recurrent obstruction or death. Asymptomatic survival times were compared by log rank and Mann Whitney tests of significance, as well as Kaplan-Meier analysis. A subgroup of 26 patients who were treated by stent placement only were compared with the radiation therapy group and analyzed separately., Results: There were seven complications in the overall stent group, one in the stent-only group, and 25 in the radiation therapy group. Stent insertion provided faster relief of symptoms and significantly greater improvement in the superior vena cava obstruction score than radiation therapy (P < .001, Mann-Whitney U test). A Kaplan-Meier analysis of asymptomatic survival demonstrated that significantly fewer patients in the overall and stent-only groups developed recurrent symptoms (P = .0005 and .001, respectively, log rank test)., Conclusion: This study suggests that percutaneous stent insertion in malignant superior vena cava obstruction fulfills the requirements of a palliative procedure significantly better than radiation therapy and that it should be the procedure of first choice.

Tophaceous gout of the spine rarely causes spinal cord compression. Only eight cases have been reported previously. We report a further case presenting with progressive quadriparesis caused by gouty tophi at C1, treated successfully by decompressive laminectomy and internal fixation. This case and the previously reported cases are reviewed.

Ischaemic problems occur in about 8% of coronary angioplasties and are the major cause of morbidity and mortality associated with the procedure. Although the ischaemic event is usually due to acute vessel closure due to vessel dissection, it is noteworthy that 80-90% of radiographically visible dissections cause no problem. We have reviewed 200 consecutive coronary angioplasties in order to find predictive factors for those patients likely to suffer dissection followed by ischaemic complications. Thirty-four (17%) of the patients undergoing coronary angioplasty had radiographically visible dissections, of whom 12 (35%) suffered ischaemic complications. There were 16 (8%) major ischaemic complications following angioplasty. In four of these cases no obvious dissection was visible within the vessel. Eight out of a subgroup of 16 patients who had sequential stenoses along one vessel dilated at angioplasty had a dissection. Six of these eight patients suffered a major ischaemic complication following the dissection. Thus in this group of patients, sequential stenosis not only conferred a high probability of dissection during angioplasty but additionally carried an increased risk of ischaemic complications following the dissection. Awareness of this may affect case selection and may indicate the need for early re-examination of the vessel should problems occur following angioplasty.

A comparison between praecordial and transoesophageal cross-sectional echocardiography was undertaken in the follow-up of 14 patients who had previously undergone surgical excision of atrial myxoma. The mean interval between surgery and follow-up was 39 months. Evidence of recurrent tumour was seen in two patients by transoesophageal echocardiography but went undetected in one of these using the praecordial approach. Clear visualisation of the atria and interatrial septum was possible in all remaining cases using transoesophageal echocardiography and this allowed confident exclusion of tumour recurrence. Using praecordial echocardiography, technically inadequate studies meant that this was not possible in 4 patients. The significant late recurrence rate of excised atrial myxomas, emphasises the need for serial, postoperative echocardiographic studies. Praecordial echocardiography may be unreliable in the detection of recurrent atrial myxoma in its early stages and for this reason transoesophageal echocardiographic follow-up is justified in high risk patients.

When patients present with suspected prosthetic valve dysfunction, investigation is usually instituted to delineate the site and cause thereof. Precordial cross-sectional echocardiography is often helpful in this respect, but in the patient with acute pulmonary edema, imaging may be impaired because of discomfort and respiratory distress. The information obtained may also be suboptimal as a result of concomitant obesity, chest wall deformity, and pulmonary disease. In addition, further difficulties may relate to the acoustic shadowing produced by the metallic portion of the valve and its sewing ring, especially with valves in the mitral position. In such patients, cardiac catheterization may cause further decompensation and is associated with a recognized increase in morbidity and mortality. Angiography does not accurately site regurgitant jets in relation to the prosthetic valve concerned and will not detect the presence of vegetations. Transesophageal echocardiography circumvents many of these imaging difficulties and we evaluated its use in five patients with prosthetic heart valves who presented acutely ill, in severe pulmonary edema and suspected prosthetic heart valve failure. In each case, the diagnosis of valve dysfunction was established, and precise information regarding the site and cause of the failure was obtained. No complications or deterioration in patient condition resulted from the procedure and the findings were confirmed at surgery performed within 24 hours in all five patients. Transesophageal echocardiography should be included in the assessment of acute prosthetic heart valve failure.

The relationship between the velocity waveforms due to the early and late phases of ventricular filling recorded by pulsed Doppler changes with abnormalities of left ventricular diastolic function and it has previously been suggested that quantitative assessment of these changes may provide a clinically useful estimate of left ventricular end-diastolic pressure. Pulsed Doppler ultrasound was used to record transmitral blood flow velocities simultaneously and on the same recorder as left ventricular pressure measurements in 30 patients undergoing cardiac catheterisation for the investigation of ischaemic heart disease. Contrary to previous reports we found no relationship between transmitral flow and left ventricular end-diastolic pressure. Caution is required in the conclusions drawn from transmitral flow velocity patterns whose relationship to left ventricular end-diastolic pressure remains uncertain.