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Purpose: Despite the widespread use of intraarterial thrombolytic therapy for peripheral arterial occlusive disease, a randomized study comparing its efficacy with that of operative intervention has never been performed. This study evaluates the potential of intraarterial urokinase infusion to provide clinical benefits in patients with acute peripheral arterial occlusion. Methods: Patients with limb-threatening ischemia of less than 7 days' duration were randomly assigned to intraarterial catheter-directed urokinase therapy or operative intervention. Anatomic lesions unmasked by thrombolysis were treated with balloon dilation or operation. The primary end points of the study were limb salvage and survival. Results: A total of 57 patients were randomized to the thrombolytic therapy group, and 57 patients were randomized to the operative therapy group. Thrombolytic therapy resulted in dissolution of the occluding thrombus in 40 (70%) patients. Although the cumulative limb salvage rate was similar in the two treatment groups (82% at 12 months), the cumulative survival rate was significantly improved in patients randomized to the thrombolysis group (84% vs 58% at 12 months, p = 0.01). The mortality differences seemed to be primarily attributable to an increased frequency of in-hospital cardiopulmonary complications in the operative treatment group (49% vs 16%, p = 0.001). The benefits of thrombolysis were achieved without significant differences in the duration of hospitalization (median 11 days) and with only modest increases in hospital cost in the thrombolytic treatment arm (median $15,672 vs $12,253, p = 0.02). Conclusions: Intraarterial thrombolytic therapy was associated with a reduction in the incidence of in-hospital cardiopulmonary complications and a corresponding increase in patient survival rates. These benefits were achieved without an appreciable increase in the duration of hospitalization and with only modest increases in hospital cost, suggesting that thrombolytic therapy may offer a safe and effective alternative to operation in the initial treatment of patients diagnosed with acute limb-threatening peripheral arterial occlusion. (J VASC SURG 1994;19:1021–30.)

Despite the advent of newer imaging modalities, conventional radiography and clinical examination remain the primary screening method in evaluation of the mediastinum following blunt thoracic trauma. Mediastinal witth (MW) is generally considered an important finding in assessing for aortic rupture. The degree of inspiration and patient positioning clearly affects MW, but is largely ignored in the literature. This study investigates the mediastinal widths of normal volunteers with differing degrees of inspiration and positioning, and compares them to radiographs of patients with known aortic ruptures. Mediastinal widths were obtained from chest radiographs of 16 patients with known aortic rupture, and from 50 volunteers using AP-inspiratory-supine, AP-expiratory-supine, and PA-inspiratory-upright technique. Upper 95% confidence limits were obtained for normals. A statistically significant difference in MW of normals was found between inspiratory-supine, expiratory-supine, and upright-inspiratory techniques. Compared to the same degree of inspiration in normals, 12 of 16 patients with aortic rupture had a MW above the upper 95% confidence limits. It is concluded that mediastinal width in normals is significantly affected by the degree of inspiration and positioning. When comparing mediastinal widths for normals and ruptures, there was a significant difference in MW for most degrees of inspiration. As depth of inspiration increased, differences between MW in controls and rupture patients increased. We conclude that patient positioning and degree of inspiration are important factors in assessing the mediastinum, and every effort should thus be made to obtain an upright-inspiratory film if clinically feasible prior to declaring a mediastinum as abnormal.

We report the case of a ruptured external carotid artery pseudoaneurysm successfully controlled by angiographic catheter occlusion which allowed subsequent surgical repair.

Rationale and Objectives. A two-center, prospective, double-blind study was conducted to compare the performance parameters (efficacy, safety, and injection-associated discomfort) of iohexol with those of the new, isosmolar contrast medium iodixanol in extremity phlebography. Methods. Ninety-nine patients from two centers, for whom venography was clinically indicated, were blindly randomized into two groups, iohexol at 300 mg I/ml (IOH-300) or iodixanol at 270 mg I/ml (IOD-270). Patient vital signs and reports of adverse events were recorded for a minimum of 1 hr and monitored until the outcome was known. Any discomfort associated with the injection was also recorded. Laboratory measures included urinalysis, creatinine levels in serum and blood urea nitrogen. Results. Both contrast media provided good or excellent visualization in nearly all patients (100% of patients in the IOD-270 group and 96% in the IOH-300 group). The incidence of adverse reactions was low in both groups (8.5% in the IOD-270 group and 10% in the IOH-300 group). Injection-associated discomfort lasting less than 4 min occurred in nine patients, four in the IOD-270 group and five in the IOH-300 group. Although clinically relevant changes in vital signs occurred in more than half the patients, most were judged to be anxiety related. Review of laboratory data revealed no evidence of toxicity for either agent. There was no statistically significant difference between the two agents with regard to any of these observed parameters. Conclusion. The data support the conclusion that both IOD-270 and IOH-300 are safe and effective agents when used for adult phlebography and are associated with little injection-site discomfort.

We examined the changes in luminal diameter and vasa vasorum after stent dilation of the aorta of nonatherosclerotic rabbits.Balloon-expandable stents were placed in the aortas of rabbits at the L3 level and were expanded. After 8 weeks, the rabbits were euthanized, perfused with barium sulfate particles, frozen, sectioned, and X-rayed.The luminal intrastent diameter (2.3 +/- 0.23 mm) was significantly different (p.05) from the expanded stent diameter but was not different from the luminal diameter above (2.3 +/- 0.53 mm) and below (1.9 +/- 0.18 mm) the stent. The number of vasa vasorum at the stent (46 +/- 7.2) was significantly increased compared with above (21 +/- 4.8, p.001) and below (14.4 +/- 4.6, p.001) the stent.After 8 weeks, luminal diameter was uniform. The increased vasa vasorum in the stented section suggested an increase in blood flow to the aortic wall, which may be important to the remodeling process.

We evaluated the changes in the down-stream Doppler waveforms caused by a proximal stenosis in the main renal artery of dogs.Renal parenchymal arterial waveforms downstream from mild (50%), moderate (50-75%), and severe (76-95%) stenoses were compared with nonstenotic baseline waveforms in five mongrel dogs. Waveform shapes were categorized as biphasic or monophasic. The percentage of biphasic and monophasic waveforms was determined for each stenosis. The acceleration index (AI) and the acceleration time (AT) were determined using traditional and modified calculations (AI' and AT'). Late systolic deceleration (DS), diastolic deceleration (DD), and the resistive index (RI) also were measured.AT, AI', and AT' demonstrated significant differences between the severe stenoses and nonstenotic baselines (p.05); however, there was no difference between the mild and moderate stenoses versus baselines. The percentage distribution of monophasic and biphasic waveforms was highly correlated with the degree of stenosis. Monophasic waveforms increased on average from 22.5% of baseline waveforms to 76.5% of waveforms in the severe stenoses. Biphasic waveforms decreased on average from 69.9% of baseline waveforms to 18.7% of waveforms in the severe stenoses.Quantitative evaluation of the downstream waveform parameters (AI, AT, AI', AT', DS, DD, and RD in the dog kidney is not sufficiently accurate, but calculation of the percentage of the monophasic and biphasic waveforms present may be useful to predict a hemodynamically significant renal artery stenosis (or = 50%).

The use of Thorotrast as a contrast medium is now of historical interest. Thorotrast-induced angiosarcoma, though rare, still generates considerable clinical interest because of the characteristic opacification of the liver, spleen, and lymph nodes, and the long latency period between exposure and the onset of the tumor. We present a case of hepatic angiosarcoma which developed 37 years after the administration of Thorotrast.

In 17 elderly patients, 19 angioplasties (17 nonostial, 2 ostial) were performed to treat acute decreases in renal function caused by high-grade renal artery stenosis in patients considered to be high-risk surgical candidates. Seventeen angioplasties (percutaneous transluminal renal angioplasty, PTRA) were technically successful and 7 patients showed improved renal function, as reflected by a fall in mean serum creatinine from 566 to 180 mumol/l (6.4 to 2.1 mg/dl). Four others had stabilization of function and 3 out of 4 with acute oliguria improved. Complications included femoral hematoma (4), minor peripheral embolism (3), renal artery thrombosis (1) renal artery dissection (1). One fatal complication was thrombosis of the aortic bifurcation due to catheterization. Four other patients died of cardiovascular causes unrelated to PTRA. Eleven patients experienced stabilization or improvement in renal function, but five out of six PTRA failures required maintenance hemodialysis and died in the hospital. Percutaneous transluminal angioplasty may offer the best change of favorable outcome in selected severely ill elderly patients with uremia, hypertension and renal artery stenosis.

Transcatheter intraportal infusion of chemotherapy in a patient with metastatic liver disease resulted in erosion of the tip of the catheter into the biliary system within six months of its placement. This unusual complication adds to the disadvantages of direct portal administration of chemotherapeutic agents in the treatment of hepatic tumors.

Fistulas between the coronary artery and the left heart chambers are exceptionally rare, especially those emptying into the left ventricle. We know of 33 cases of coronary artery-left ventricular fistulas reported in the literature, 7 of which had multiple communications. The findings in 6 additional patients with multiple coronary artery-left ventricular fistulas are reported. Three of the 6 patients had fistulas communicating to the left ventricle from all three major coronary arteries. It is important to recognize this anomaly as it may be the source of angina in patients without angiographic evidence of major atherosclerotic coronary artery disease.

Non-Operative intrahepatic shunts between the left branch of the portal vein and hepatic vein were produced in 14 dogs with periportal cirrhosis and portal hypertension. Dilatation of the intrahepatic fistula was achieved with a Gruntzig catheter with a balloon diameter of 12 m. The catheter was introduced into the left branch of the portal vein passing through the right jugular vein, vena cava and hepatic vein by means of a co-axial system, using a stiff Teflon catheter with an external diameter of 6 mm. Repeated maximal inflation of the balloon, which was placed across the portal vein and inferior vena cava, produced an intra-hepatic portocaval shunt in all dogs. This resulted in immediate abolition of previously stable portal hypertension. The only significant complication was shunt occlusion within a week. In such cases the shunt was reopened by the same technique. The procedure had to be repeated at weekly intervals up to five times before a permanent intrahepatic shunt was established.

The value of performing arterial portography during reactive hyperemia was investigated in four dogs with presinusoidal cirrhosis, stable portal hypertension in excess of 20 cm of water, and extensive porto-systemic venous collaterals, and compared to tolazoline (1 mg/kg) and control studies. With SMA balloon occlusion the maximum decrease in portal flow and pressure occurred between 1 and 2 minutes. During reactive hyperemia following immediately the release of a 2-minute SMA occlusion, portal flow and pressure increased from pre-occlusion values (mean +/- 1 SE, n:4) of 15 +/- 2 ml per min per kg and 25 +/- 1 cm H2O to 32 +/- 5 ml per kg and 40 +/- 2 cm H2O. With reactive hyperemia both significant higher peak iodine concentrations in the portal blood and significant improvement in visualization of the portal system and porto-systemic venous collaterals occurred when compared to tolazoline or control angiograms. With reactive hyperemia both peak blood iodine concentrations and maximum opacification of the portal vein occur 2 to 3 and 4 to 6 seconds earlier than with tolazoline or in controls, respectively. Compared to controls, tolazoline increased peak iodine concentrations in portal vein significantly and improved visualization of the portal system and collaterals in 7 of 12 examinations. Judged from the experience in peripheral arteriography, performance of angiography during reactive hyperemia appears to be a very safe procedure. However, the use of balloon catheters carries additional risks particularly when not properly used.

Nonsurgical intrahepatic shunts between the left portal vein and left hepatic vein were created in seven dogs with portal hypertension by means of a Grüntzig angioplasty catheter with a balloon diameter of 12 mm. This catheter was introduced coaxially through a stiff 18-French Teflon catheter (diameter, 6 mm) using transjugular approach. The procedure had to be repeated in weekly intervals up to five times (range, one to five times; average, 2.4 times) until an intrahepatic shunt remained permanently open. Animals with open intrahepatic shunts were followed for one month to one year. Immediately after production of an intrahepatic shunt, the portal pressure fell from 23.7 +/- 3.5 cm of water to 10.6 +/- 1.4 cm of water, and remained in that range during the follow-up period. Portal blood flow increased at the same time from 9.1 +/- 2.9 mL/min/kg to 15.1 +/- 3.5 mL/min/kg. One week after successful shunt production, a second, more gentle rise of portal flow began. It lasted several weeks and was accompanied angiographically by a corresponding increase in shunt diameter. At necropsy, a smooth transition between the intima of the portal and hepatic vein and the shunt was found. Histologically, the endothelialized shunt consisted of granulation tissue with collagen deposition at one month and of fibrous connective tissue three months and later.

Preoperative evaluation of a patient with adrenal carcinoma and hepatic metastases was performed by arteriography, computed tomography (CT) and computed tomographic arteriography (CTA). Early and complete demonstration of tumor involvement by these imaging modalities allowed an accurate assessment of tumor extension and subsequent aggressive surgical removal of the primary as well as the metastasis in the liver.

Twenty angiographic procedures involving the superior mesenteric artery (SMA) were performed with balloon occlusion catheters in dogs with chronic liver cirrhosis and portal hypertension. The following complications were found: (a) rapid balloon inflation during angiography due to a leak between the two catheter lumens (two cases); (b) failure to deflate a balloon located in the SMA (two cases); (c) balloon detachment intravascularly and during catheter insertion (one case each); and (d) rupture of the SMA (one case). Balloon detachment occurred only with re-used catheters. The safety of angiographic occlusion balloon catheters for general use is questioned. Under no circumstances should catheters be re-used.

A case of mesenchymal hamartoma of the liver in a 30-year-old female is reported. Ultra-sonography, computed tomography, and hepatic angiography demonstrated the presence of a large, mixed cystic and solid mass within the liver, suggesting the diagnosis of a mesenchymal hamartoma. At surgery, the tumor proved to be unresectable.

Periportal fibrosis and portal hypertension were induced by periodic retrograde biliary injections of sesame oil for two to three months in 12 cholecystectomized dogs equipped with Thomas cannulas. Stable portal hypertension between 18 and 24 cm of water occurred in four of 12 dogs (baseline: 10.4 +/- 0.5 cm of water); the remaining eight dogs required continuous biliary oil injections to maintain the portal pressure in that range. Portosystemic venous collaterals were first seen three weeks after the initial biliary oil injection and were extensively developed after two months. Hepatopetal portal blood flow decreased 61 +/- 5% during the first six months, with the greatest decrease of 32 +/- 4% occurring in the first month. Hepatic arterial flow did not change in the first month and then began to rise slowly to peak at nine months at 170 +/- 32% of its baseline value. The greatest increase in hepatic arterial flow was found between the sixth and ninth month when the portal flow no longer changed significantly. Hepatic fibrosis originating from the portal triads and around extravasated oil droplets appeared to progress slowly during the entire observation period. Animals with advanced hepatic fibrosis remained in satisfactory general health with liver enzymes usually remaining in the high normal to low pathologic range, allowing extensive follow-up examinations at regular intervals.

Renal artery stenosis in a solitary kidney may result in severe hypertension and renal failure [1 , 2]. Critical arterial narrowing and final thrombotic occlusion is not an uncommon exacerbating factor leading to anuria [3]. Kidney function has been restored by surgical revascularization [4]; however, this therapeutic method carries both a high mortality and failure rate in this group of patients [5]. Application of the GrUntzig technique [6] of percutaneous transluminal angioplasty to stenotic renal arteries has been reported by several investigators as a nonsurgical method for correction of hypertension and deteriorating renal function [7-9]. We report the reversal of anuria by percutaneous transluminal recanalization of a recently occluded renal artery in a patient with a single functioning kidney.

Intrahepatic shunts between the left portal and hepatic veins were performed in 50 dogs (20 acute, 30 chronic experiments) using the transjugular approach with Dotter's coaxial catheter system. All shunts were occluded within two days; significant complications arose only after a shunt stayed in the animal a prolonged period. The intrahepatic tract wall was completely organized and fibrosed after three weeks.

Portal blood iodine concentrations and the radiographic visualization of the portal vein were compared in five dogs (50 portograms). The portal blood iodine concentrations required for a certain degree of portal vein opacification varied considerably. However, an overall significant difference was found in the portal blood iodine concentrations of different degrees of portal vein visualization. An increase in the portal blood iodine concentrations from 0 to 30 mg per ml was associated with an overall improvement of the portal vein visualization. With a blood iodine concentration of 30 mg per ml, an excellent visualization of the portal system was always achieved that could no longer be improved by further increasing the portal blood iodine concentration up to 50 mg per ml. For a reliable diagnostic visualization of portal vein contributaries and branches, a blood iodine concentration of 30 mg per ml appears required; whereas for the visualization of the larger portal vein, 15 mg per ml appears sufficient.

One hundred patients with computed tomographic (CT) evidence of liver metastases (and confirmation by biopsy or progression of disease) had serum levels of alkaline phosphatase, serum glutamic oxaloacetic transaminase, and serum glutamic pyruvic transaminase measured within two weeks of scanning. All three enzymes were within the normal range in 33% of patients. Even with advanced involvement (defined as three or more metastatic lesions over 3 cm in diameter), 20% of patients had normal levels of all three liver enzymes. Although liver function tests (LFTs) (enzyme levels) are inexpensive and simple to perform, they failed to detect a significant number of patients with liver metastases.

Intrahepatic periportal fibrosis and portal hypertension were produced in the dog by repeated intraportal injection of a polyvinyl alcohol suspension over a two- to six-month period. Progressive hepatic fibrosis originating in the portal triads around occluded portal vein radicles occurred during the first year. Porto-systemic venous collaterals developed at the earliest three to four weeks after initial embolization. Angiographic changes included an increase in number and diameters of opacified hepatic arterial branches and a more dense arterial hepatogram than on the baseline studies, but these were only evident in advanced hepatic fibrosis. Decreases in portal and total hepatic blood flow of 53 +/- 15% and 17 +/- 7%, respectively, were observed after development of periportal fibrosis and stable portal hypertension, while the compensatory increase in hepatic arterial flow was a slowly evolving process resulting in an increase of 135 +/- 51% in the fibrotic stage. Animals with advanced hepatic fibrosis and portal hypertension remained in good general health, allowing extensive follow-up examinations at regular intervals over a prolonged period of time.

Four patients with a total of six mycotic aneurysms of the aorta were examined with computed tomography (CT) after intravenous contrast material enhancement, and with abdominal or thoracic aortography. In the three patients with mycotic aneurysms involving the abdominal aorta, CT scans showed a vascular paraaortic structure without calcified walls adjacent to a nondilated aorta, and a large non-contrast-enhanced retroperitoneal mass representing inflammatory tissue and blood from a contained aortic rupture. A CT scan of one aneurysm of the thoracic aorta demonstrated an enhanced saccular mass originating from the aorta without paraspinal component. In three of four patients, the CT findings were corroborated by aortographic evidence of an eccentric aneurysmal sac in an atypical location for atheromatous disease. In four patients with clinical manifestations suggesting mycotic aneurysm of the aorta, a combination of CT and angiographic imaging provided accurate diagnostic information for planning adequate and early surgical treatment.

Renal angiomyolipomas occur in two distinctive clinical patterns. One type includes those associated with tuberous sclerosis, in which the renal involvement is usually bilateral and multifocal. It can occur as early as childhood and has an equal gender distribution [1]. The second type occurs predominantly in women 40-70 years old. These patients do not suffer from tubenous sclerosis and the renal lesion is usually unilateral and unifocal [1]. Renal angiomyolipomas are composed of three main tissues: (1) abnormal thick-walled blood vessels with a tendency to hemorrhage, (2) smooth muscle, and (3) fat [1]. It is generally believed that all three tissue components arise from embryonal cells in the kidney [1]. Since there are no documented cases of distant metastases, the general behavior of this tumor is that of a benign lesion although it is occasionally locally invasive [1]. The first case of a renal cell carcinoma and an angiomyolipoma occurring as two separate masses within the same kidney was recently reported in a patient without stigmata of tuberous sclerosis [2]. We report a patient with tubenous sclerosis in whom a renal cell carcinoma is superimposed on a kidney completely involved with angiomyolipomatosis, and demonstrate the diagnostic difficulties of this condition.

The hemodynamic effects of prostaglandins PGA1, PGE1, PGE2, and PGF2 alpha on the splanchnic circulation were evaluated in five chronic dogs with portal hypertension, periportal fibrosis, and portosystemic venous shunting. The maximum effect was achieved with dosages of 2 micrograms/kg/min after bolus injection into the superior mesenteric artery. With this dosage a monophasic increase of portal blood flow and pressure was found with PGA1, PGE1, and PGE2, whereas PGF2 alpha caused a biphasic response: an initial decrease in portal blood flow and pressure was followed by an increase in these parameters. The average peak increase in portal blood flow and pressure was similar for PGE1 and PGF2 alpha, and significantly smaller for PGA1 and PGE2. Average peak iodine concentrations in the portal blood after superior mesenteric angiography were highest with PGF2 alpha, similar for PGE1 and tolazoline, and lowest in controls. The vasoconstrictor effect of PGF2 alpha is, overall, reduced and less reproducible when compared with vasopressin. This investigation suggests that both PGE1 and PGF2 alpha are effective for improved arterial portography, the latter agent appearing superior. On the other hand, PGF2 alpha cannot be recommended as a therapeutic agent for the treatment for gastrointestinal and particularly variceal bleeding.

A case of spontaneous dissection originating in the infrarenal abdominal aorta with retrograde extension into the thoracic aorta is reported along with the computed tomography and angiographic findings. Surgical repair resulted in the obliteration of the false lumen, healing of the thoracic hematoma, and clinical recovery. The principles for radiologic evaluation and therapeutic management are discussed.

Diatrizoate, iopamidol and ioxaglate were compared in five normal dogs and in five dogs with presinusoidal cirrhosis and portal hypertension for arterial portography. After selective injection of 40 ml of each contrast agent in iodine concentrations of 320 mg per ml into the superior mesenteric artery, portal vein blood samples were collected in 2-second intervals and the iodine concentrations determined using x-ray energy spectrometry. The highest iodine concentrations in the portal blood were found in both normal portal pressure and portal hypertension with ioxaglate, followed by iopamidol and diatrizoate in this order. Compared with diatrizoate, ioxaglate and iopamidol increased the peak portal blood iodine concentrations 45% and 22%, respectively. The use of ioxaglate in arterial portography should show the portal system at least as well as when a conventional contrast agent is used together with a vasodilator such as tolazoline.

Seventeen patients underwent 22 operations for pheochromocytoma over a 26 year period. The patients included 11 in three kindreds of familial pheochromocytoma and 6 with sporadic tumors. The diagnosis was usually suggested by the patient's history. Confirmation of the diagnosis frequently required repeated testing for urinary or plasma catecholamines. Arteriography was the most effective method of preoperative tumor localization. Two tumors were proven nonfunctional. Others secreted either norepinephrine or epinephrine and norepinephrine. The familial patients showed a high incidence of multiple, bilateral and extraadrenal lesions. In contrast to previous reports, the familial tumors were found more often in the right than in the left adrenal gland. HL-A genotyping analysis of the sporadic and familial patients failed to demonstrate any HL-A antigen association or interdependent segregation of tumor and HL-A antigens within kindreds.

A 44-year-old woman with hepatocellular carcinoma presented with intractable watery diarrhea and her condition was evaluated angiographically. Surgical ablation of the tumor resulted in complete resolution of the diarrhea. The tumor cells of the hepatocellular carcinoma were found to contain vasoactive intestinal polypeptide, gastrin, and prostaglandinlike immunoactivity. To our knowledge, this is the first report of such an association.

Massive bleeding in a patient with metastatic carcinoma of a solitary kidney may be controlled with transcatheter embolization. Selective occlusion may be done sparing renal parenchyma uninvolved by tumor and avoiding dialysis. We report a case of successful repeated selective embolizations with an excellent quality of life for 18 months.

A simple and safe technique for repeated percutaneous catheterization of the portal vein or one of its tributaries in chronic dogs is described.