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Percutaneous transluminal angioplasty was performed on 45 patients with vascular stenoses after vein bypass surgery. In 25 cases, the angioplasty catheter was introduced by direct puncture of the vein graft. The procedure was successful and reoperation was avoided in all but one of these cases. There were no complications. The experience has shown that in selected postoperative patients, direct puncture of the graft is safe and greatly facilitates performance of the angioplasty.

The technique of transluminal dilatation of arterial stenoses has been greatly facilitated with the recent development of the vinyl balloon catheter by Gruntzig. Since these catheters became available to us in early 1978, we have utilized them to attempt dilatation of 62 arteries, including iliac, femoral and renal vessels. Immediate success was achieved in 57 of these vessels. There were five early complications (two distal embolizations and three prompt occlusions) and three late complications (two restenoses and one occlusion at ten days). The occlusions were all treated promptly surgically with good results and the stenoses redilated. Noninvasive pressure measurements were obtained on all patients whose iliac or femoral arteries were dilated both before and after the procedure, with objective improvement demonstrated by this method. The procedure itself is well tolerated by patients. It involves only minimal discomfort and risk and a markedly shortened hospital stay. The procedure can be easily accomplished by physicians who are thoroughly familiar with routine femoral catheterization techniques and it is believed that this technique will have a definite place in the future therapy of many cases of arterial stenosis.

Most benign strictures of the esophagus can be successfully dilated with conventional bougienage techniques. Occasionally strictures are so severe, lengthy, or irregular that these techniques fail, and surgery is required. We describe 2 patients with such severe esophageal strictures that conventional techniques were initially unsuccessful. However, esophageal dilatation of both strictures was successful using the Grüntzig balloon catheter. A torqueable guide wire was initially directed through the stricture under fluoroscopic control. The balloon catheter was then passed over the guide wire and inflated sequentially to a maximum diameter of 9 mm. Subsequent dilatations using conventional techniques were successful. The technique of negotiating severe, irregular esophageal strictures with a torqueable guide wire followed by Grüntzig balloon catheter dilatation may be valuable in the management of severe esophageal strictures.

In two patients, the value of percutaneous transhepatic decompression in the management of benign biliary strictures is illustrated. The procedure can help provide relief of jaundice, control of infection and improvement of nutritional status. Results of previous experience indicate that these factors play a major role in determining the over-all success rate in the surgical management of these patients.

Percutaneous thin needle aspiration biopsy was done on 34 patients for better staging of malignant disease by study of opacified lymph nodes, on 12 patients to eliminate the possibility of a malignant etiology of ureteral obstruction and on 7 patients with potentially metastatic soft tissue or visceral lesions. Ideally, a positive biopsy should change subsequent patient management and may eliminate the need for an exploratory operation. A significant number of falsely negative results occur and, for this reason, a negative biopsy should not affect subsequent patient management.

A residual distal common bile duct stone was successfully advanced into the duodenum after percutaneous transhepatic catheterization of the biliary tract. Nonsurgical retrieval of retained biliary duct stones through surgically created T-tube tracts has been shown to be a practical procedure with high reported success rates. Reoperation has been necessary in cases where no drainage tube was introduced at surgery or when stones have formed after the fistula closed. Transhepatic catheterization techniques may provide a way to manipulate residual biliary tract stones when no other access is available.

Four of 83 patients undergoing percutaneous transhepatic cholangiography were demonstrated to have hepatic abscesses communicating with the biliary tract. The abscesses resulted from obstruction of the common bile duct. The etiologies of the obstructions were chronic pancreatitis, recurrent cholangiocarcinoma. Radiographic demonstration of suppurative cholangitis is associated with a very poor prognosis.

Selective arterial infusions of vasopressin have often been successful in controlling arterial bleeding. When bleeding occurs in an area with a dual blood supply through a vascular arcade, situations may arise which can compromise angiographic management. These include: (1) artifacts caused by pressure injections of contrast material inaccurately depicting the usual distribution of blood flow in the arcade; (2) catheter-induced vasospasm altering the flow dynamics through the arcade; (3) vasopressin-induced constriction of the proximal portion of an arcade changing the origin of blood flow to the distal arcade; and (4) proximal occlusion of one limb of an arcade permitting continuation of bleeding through collateral channels. When angiographic techniques fail to control bleeding because of these circumstances, hemostasis may be achieved by treating both limbs of the vascular arcade.

The recently developed Grüntzig balloon dilatation catheter has facilitated the performance of transluminal angioplasty. The authors used this catheter in 35 arteries supplying the lower extremities in 27 patients. Immediate relief of symptoms (claudication and rest pain) occurred in 30 vessels (86%) in 23 patients. The procedure was well tolerated by all patients. Over 90% of initially successful dilatations were patent at 3 to 10 months.

A simple method for replacing biliary drainage or nephrostomy catheters that have fallen out is described. The original catheter tract is used.

Percutaneous transhepatic catheterization of the biliary tree was performed in 23 patients. In 21 the catheter was advanced past an obstructing lesion into the distal common bile duct and duodenum to establish antegrade biliary drainage. The catheter was left permanently in place as a form of endoprosthesis in 5 patients.

Seven patients with concomitant atherosclerotic iliac stenosis and femoral artery occlusive disease were treated with polyvinyl balloon catheter dilation of the iliac artery and subsequent distal operative arterial reconstruction. The iliac lesions were short, localized, common and external iliac stenoses and the femoral lesions were superficial femoral artery occlusions in six patients and a common femoral occlusion in another. All seven iliac stenoses were successfully dilated. Subsequent operative femoral artery reconstruction was successful in these patients, with restoration of popliteal or pedal pulses and relief of ischemic symptoms over a follow-up period of two to 14 months. One patient's femoral popliteal bypass graft thrombosed four months postoperatively.

With the advent of the angiographic balloon catheter, transluminal angioplasty has become a more effective procedure for the alleviation of symptoms of peripheral ischemia. In the past two and a half years we have performed this procedure on over 208 iliac and femoral arteries. One hundred twenty iliac arteries were dilated. Of these, 86% remained patent at one year and 83% at two years. Eighty-eight femoral arteries were dilated. Of these, 75% remained patent at one year and 67% at two years. These vessel survival rates are slightly less than those following surgery. However, the morbidity from transluminal angioplasty is very low and the mortality is essentially zero.

Coronary veins in seven of eight patients with bleeding esophageal varices were successfully catheterized and embolized with Gelfoam followed by multiple steel coils. Bleeding immediately ceased in all seven, but recurred within 1 month in six. One had not rebled on 3 month follow-up. Therefore, steel coils do not prevent recurrent bleeding any more effectively than other embolic materials used for this purpose.

The efficacy of percutaneous transhepatic biliary drainage for long-term (greater than 3 months) decompression of biliary obstruction was evaluated in 35 patients with benign (10) and malignant (25) obstructing lesions. The results indicate that such drainage is a safe and effective means for long-term decompression of the biliary tract in selected patients, especially patients who are poor operative risks and those with metastatic or nonresectable malignancy. In addition, the procedure provides access to the biliary tract for percutaneous dilatation of selected common duct or anastomotic strictures.

The acute effects of nicotine and ethanol were studied in low and high rates of intracranial self-stimulation (ICSS) of the medial prefrontal cortex (MPFC) in the rat. Nicotine tended to increase low ICSS rates but did not change or even reduced high ICSS rates. Independent of ICSS rate, ethanol tended to decrease ICSS, but only at high doses (1.0 g/kg). It is suggested that the effects of nicotine and ethanol on ICSS may be mediated by their effects on dopamine.

Since June 1979, percutaneous transluminal angioplasty (PTA) has been the procedure of choice for renal transplant artery stenosis (RTAS) at the Hospital of the University of Pennsylvania. Of 241 renal allograft recipients, 17 (7%) when studied by arteriogram because of suspected RTAS proved to have significant stenosis (the mean reduction in luminal width for the group being 68%) and underwent PTA. RTAS was equally prevalent in cadaver and related kidney allografts and was no less common in HLA-identical related donor grafts, arguing against the importance of immune factors in etiology. RTAS was equally prevalent whether the anastomotic technique was end to end or end to side. However, when RTAS occurred after end to side anastomoses, it was usually postanastomotic. Fifteen of 17 of the attempts at dilation by PTA were successful by angiographic analysis. Thirteen of the 15 successfully dilated patients had long-term allograft survival and in all of these instances blood pressure (BP) was decreased after PTA. After a mean of 67 weeks, BP decreased from a systolic of 184 +/- 24 mm Hg pre-PTA to 135 +/- 15 mm Hg (P less than 0.001) and from a diastolic of 115 +/- 10 mm Hg pre-PTA to 87 +/- 11 mm Hg (P less than 0.001). The majority of patients continue to require antihypertensive drugs but in a less vigorous regimen than pre-PTA. Serum creatinine level fell following PTA from 1.9 +/- 0.6 to 1.7 +/- 0.5 mg/100 ml (P less than 0.01). Repeat angiographic study was done in nine patients, an average of 61 weeks after PTA, and no recurrent RTAS was identified. Three minor complications of PTA occurred but none led to long-term sequelae. Thus, we believe PTA of RTAS is relatively safe, carrying less mortality and morbidity than operative treatment, and is capable of improving BP control and renal allograft function.

A patient with recurrent episodes of acute pancreatitis found to be caused by the presence of a choledochocele is presented. Transhepatic cinecholangiography revealed a choledochocele receiving the terminations of the common bile duct and pancreatic duct, which emptied via a pinpoint opening into the duodenum. With duodenal peristalsis, the contrast material filling the choledochocele could be seen refluxing into the pancreatic duct. A discussion of the possible etiologies of choledochoceles and a review of the existing literature is presented.

Ureteral obstruction after treatment for abdominal cancers is a common situation in which the thin needle biopsy presents an attractive low morbidity alternative to laparotomy for the diagnosis of malignant disease. A negative biopsy is still nonconclusive, although helpful in determining the next step in the patient's management. In our own series, biopsy in the region of ureteral obstruction revealed tumor rather than benign disease in four of five patients. No morbidity was encountered.

Most lesions that decrease renal blood flow originate within the renal artery; however; large, aortic, atherosclerotic plaques can overhang the renal ostium producing a functional renal artery stenosis. At the Hospital of the University of Pennsylvania, 45 consecutive percutaneous transluminal angioplasties were examined retrospectively and classified as to site of the obstructing lesions and clinical outcome. Stenoses within the renal artery responded very well to angioplasty, with 83% of patients showing either an excellent or good result. Conversely, when aortic plaques were responsible for inflow obstruction, 76% of patients responded poorly or not at all to balloon dilatation. It is proposed that this disparity of response reflects the anatomic differences in the orientation of elastic and collagen fibers of the muscularis and advential layers of the renal artery and the aorta.

The use of multihole catheters to achieve longterm antegrade biliary drainage in 43 patients with obstructive jaundice is described. Catheters were positioned with sideholes both above and below an obstruction and continued patency maintained. Better results were obtained using larger diameters and larger sideholes.

The authors describe the use of a new guide wire which reduces complications during catheter exchange and stenotic dilatation while performing transluminal angioplasty.

Renal venography may be an extremely useful adjunctive diagnostic procedure in selected cases of renal disease. The techniques utilized in renal phlebography are described, and the newer applications of this technique are discussed and illustrated.

Evaluation of the origin of the deep femoral artery is important in planning treatment of ischemic disease of the lower extremity. While arteriography in the ipsilateral anterior oblique projection will adequately demonstrate the femoral bifurcation in 91% of cases, the posterior oblique projection will be necessary in 9%. Selection of the most useful oblique projection can be done by studying the AP arteriogram.

Percutaneous balloon catheter dilation was used to treate 12 high-grade stenoses in ten autogenous vein bypass grafts since September 1978. Four lesions occurred in femoropopliteal grafts, seven in femorotibal grafts, seven in femorotibial grafts, and one in an axillofemoral graft. Balloon catheter dilation was successful and surgery avoided in 11 of the 12 lesions. Pedal pulses were restored in eight of the ten patients, and the pulse in a femorotibial bypass graft was improved in another. Postdilation arteriography demonstrated a substantial increase in luminal diameter, and ankle pressure indexes were improved in all successful cases. The tenth had an operative correction of the stenosis. There were no complications with the procedure. Percutaneous balloon catheter dilation appears to be an effective method of treating stenosis in autogenous vein grafts and a useful alternative to surgical revision.

Superior mesenteric arteriography was performed following infusions of vasopressin, epinephrine and saline into the superior mesenteric arteries of dogs, pigs, rabbits and monkeys and compared with the well-known effects in human beings. Species-specific effects were noted and compared with the known differences in various vascular beds in human beings. In non-primate animals, vasopressin appeared to act at a more distal site than in primates, but with a similar decrease in superior mesenteric arterial flow. The results in primates were similar to those in human beings.

The evaluation of solitary hepatic lesions detected on scintiscans is a common clinical problem. It is usually assumed that radionuclide rapid sequence flow studies and blood pool images are reliable and accurate methods of demonstrating the vascularity of hepatic lesions. Our recent experience with 3 patients with angiographically proven hepatic hemangiomas indicates that radionuclide techniques may fail to detect the vascularity of hemangiomas. We speculate that blood flow within a hepatic hemangioma may be sluggish and its vascularity may be appreciated only by arteriography. Therefore, we alert the clinician to assess the vascularity of solitary hepatic tumors by angiography before percutaneous liver biopsy and thereby avert the possibility of life-threatening exsanguination, as occurred in one of our patients.

The ileal loop method of supravesical urinary diversion may be complicated by strictures of the ureteroileal anastomosis, the ileocutaneous stoma, or the ileal loop itself. These strictures may produce hydronephrosis with a resultant deterioration of renal function. Decompression via percutaneous nephrostomy is frequently indicated, either as an antecedent to corrective surgery or as a permanent method of urinary drainage. A technique is described which extends the percutaneous nephrostomy to allow placement of drainage catheters from below. This obviates flank catheters and permits antegrade drainage of urine through the preexisting ileocutaneous stoma into the usual collecting appliance. The method has been applied successfully in three patients.

Percutaneous transhepatic catheterization of the biliary tree was performed in 41 patients with obstructive jaundice. In 39 patients, the catheter was successfully advanced past the obstructing lesion into the distal common duct and duodenum to establish internal biliary drainage. The remaining two patients had the obstructed biliary tract drained externally. Chronic internal catheter drainage was instituted in five patients with stricture and ten with malignant obstruction as a means of palliating symptomatic jaundice. Twenty-two patients had marked reduction in serum bilirubin levels and pruritus, eight patients had moderate decreases in serum bilirubin levels, and six patients did not improve despite adequate catheterization due to hepatic parenchymal disease. This procedure effectively decompresses the severely obstructed biliary tree prior to surgery and can also palliate patients with unresectable malignant biliary obstruction and stent high-risk, benign strictures.

T tubes were successfully reintroduced through previously created drainage tracts in 17 consecutive attempts. The new tubes can re-establish bile flow in a variety of circumstances in avoiding reoperation.