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Objectives open surgical intervention for aneurysms of the distal arch and descending thoracic aorta is associated with high morbidity and mortality. Stent grafts offer an attractive alternative treatment for these aneurysms. The aim of this study was to assess the morbidity and mortality of endovascular treatment for these aneurysms with stent grafts.Design, patients and methods a prospective observational study was performed of 37 consecutive patients treated from July 1997 to October 2000 (30 at Guy's and St. Thomas» and 7 at Sheffield). Indications included degenerative aneurysms (n=18), false aneurysm (5), acute dissection (4), aortic transection (4), aneurysm related to previous surgery for coarctation (3), chronic dissection (2) and traumatic dissection (1). Nineteen were performed as elective and 18 as non-elective procedures. Results three non-elective patients died in hospital (in-hospital and 30-day mortality 8%) and one suffered a stroke with spontaneous full recovery. No elective patient died. One patient with a persistent proximal endoleak required conversion to open repair at 6 weeks. Two patients with persistent flow into the sac at 24 h spontaneously thombosed at subsequent 3 month follow-up. Two further patients developed new distal endoleaks at 3 months and required distal extension cuffs. One patient died at 28 months of aortic rupture. Serial CT scans had shown prolapse of the stent graft into the aneurysm sac and the patient died just before planned endovascular repair. No patient suffered paraplegia or renal failure. Intensive care facilities were only required for patients who needed them preoperatively. Conclusions thoracic stent grafts can be performed with low morbidity and mortality. They offer a realistic alternative to open surgery. Long term follow up is required to assess their durability.

Objectives to compare the effects of crossing renal artery ostia with various stents. Methods the renal artery ostia of 24 large white pigs were covered with a Wallstent® (nine ostia), a Palmaz® stent (nine ostia) and a Memotherm® stent (13 ostia). After an interval of 6–15 weeks, aortography, renal pressure and blood samples were performed and the pigs then sacrificed for histological examination. Results histological examination revealed an organised collagen matrix with endothelial cells covering the struts in contact with the aorta. This occurred with all stents but was most organised with the Wallstent. This matrix did not involve the renal artery ostia crossed by Wallstents, but in one Palmaz stent and in 12/13 Memotherm stents, a disorganised acellular matrix caused partial ostial occlusion. There was no mean fall in renal artery pressure but traces were damped in 8/13 cases of partial occlusion. There was a rise in serum creatinine in two cases using the Palmaz stent. Conclusions covering renal arteries with the Wallstent appears to be safe in the short-term. Placement of stents with larger struts across renal arteries will require imaging methods, such as intravascular ultrasound (IVUS) to ensure that the ostia are not obstructed.

A 62-year-old man presented to our hospital with a pulsatile swelling on the right side of his neck. A gadolinium enhanced magnetic resonance arteriogram (MRA) confirmed that the swelling was a pseudoaneurysm at the site of the right carotid endarterectomy, performed 8 years earlier (Fig. 1). The patient originally presented in 1995 with right hemisphere transient ischaemic attacks. An arch arteriogram confirmed an 85% stenosis of the proximal right internal carotid artery. A standard carotid endarterectomy and Dacron patch repair was performed under antibiotic cover (augmentin and gentamycin) without neurological or wound complications. Ten months after discharge he developed inflammation and swelling on the right side of the neck. A duplex scan of the 2 cm mass revealed a fluid collection around the patch, but no evidence of an aneurysm. Aspiration confirmed pus and although no organisms were cultured, oral flucloxacillin was started for a presumed infection with staphylococcus

Intravascular heparin is used routinely during peripheral and visceral angioplasty, although usage and dose vary widely. The aims of this prospective study were to: (1) Determine the pattern of Heparin usage by Vascular/Interventional Radiologists in the UK. (2) Determine the optimum doses of Heparin for vascular intervention on the basis of its pharmacokinetic profile. A questionnaire was sent to Consultant Radiologists who were also members of the British Society of Interventional Radiology (BSIR), regarding their use of heparin during peripheral angioplasty. This included heparin doses in flushing solution, timing and amounts of heparin used as a bolus dose and monitoring of clotting times. Seventy-three percent returned completed forms. A wide variation in practice was shown. Apart from the variety of individual protocols in use, significant findings were that more than 75% of the respondents were giving heparin as a bolus only after the lesion had been crossed with a guide-wire. None of the respondents were monitoring clotting times, even in prolonged and complicated procedures. The pharmacokinetic profiles of two separate bolus doses of heparin in two groups of 30 and 25 patients each were then evaluated. Our results showed that a 3000 IU bolus of heparin maintained the plasma APTT in the therapeutic range (at least twice the normal value), for at least 30 min in the majority of patients. A 5000 IU bolus maintained the APTT in the therapeutic range for 45 min in the vast majority of patients. Apart from minor bruising at the compression site and slightly increased compression times in a small number of patients, no significant immediate complication was noted. We conclude that in the context of peripheral angioplasty, there is a wide variation in the use of heparin as an adjunct to the procedure. In the light of our own experience we recommend a 3000 IU intra-arterial bolus of unfractionated heparin to be given once arterial access has been achieved. This would cover short, uncomplicated procedures. The larger 5000 IU dose would be more appropriate for longer and more complicated procedures. We also recommend monitoring APTT values in prolonged procedures, with administration of further bolus doses of heparin if required.

Radiation injury to subclavian and axillary arteries is a rare and late complication of radiotherapy. Until recently it has been treated almost exclusively by carotid-brachial bypass surgery. We report three cases who presented with severe upper limb ischaemia following previous axillary radiotherapy for breast carcinoma. One patient with an axillary artery occlusion failed angioplasty and required bypass surgery. A further patient with an axillary artery occlusion was successfully managed by the percutaneous placement of an arterial stent. The third patient with an isolated axillary artery stenosis responded to balloon angioplasty. All three patients remained asymptomatic. Percutaneous angioplasty and stent placement, where necessary, are appropriate first choice treatment for delayed radiation stenosis and occulusion in upper limb ischaemia.

Twenty patients with superior vena caval obstruction (SVCO) due to malignancy were managed using the Gianturco Z Stent. Three patients had adjunctive thrombolysis. The primary clinical success was 90% (18/20 patients). Thirteen patients were free of SVCO to death or follow-up without re-intervention (primary patency = 65%). Three patients had re-intervention for recurrent symptoms, two successfully (secondary long-term patency = 75%). Stenting of the SVC is a valuable, under-used technique for the symptomatic relief of superior vena caval obstruction.

Initial experience with a new technique, using an inflatable compression device during ascending phlebography, is described. This method is compared with standard varicography in a small series of patients with recurrent varicose veins. In this pilot study, 13 patients had 17 limbs examined by the new method and 14 limbs by varicography. Below knee perforator incompetence was demonstrated directly in all limbs by ‘pneumatic phlebography’. Short-saphenous vein and mid-thigh perforator incompetence were also more frequently demonstrated. The two tests are comparable at showing recurrent or persistent connection at the groin (13 limbs, overall). With modifications of the pressure device, pneumatic phlebography may prove to be an important method of assessing recurrent varicose veins.

The imaging investigations in six patients with alveolar soft part sarcoma (ASPS) are reviewed. Five patients presented with a pelvic or lower limb mass and one with haemoptysis from pulmonary metastases. Magnetic resonance imaging (MRI), CT, Doppler US and angiography studies demonstrated the highly vascular nature of this rare tumour and the frequent occurrence of pulmonary and intracranial metastases. Previously unreported Doppler US and MR evidence of multiple enlarged vessels and high blood flow within primary and secondary ASPS tumours is emphasized. Imaging is of considerable importance both for pre-operative localization and long term surveillance of this slow growing but invariably disseminating tumour.

Untreated thoracic aortic coarctation leads to early death predominantly because of hypertension and its cardiovascular sequelae. Surgical treatment has been available for > 50 years and has improved hypertension and survival. More recently, endovascular techniques have offered a minimally invasive alternative to traditional open repair. Early and intermediate results suggest angioplasty and stenting have an important role in the management of aortic coarctation, particularly in adults and older children.

AIM A rapid assessment stroke clinic (RASC) was established to provide a rapid diagnostic service to individuals with suspected transient cerebral or ocular ischaemia or recovered non-hospitalized strokes. In this report we review imaging findings and clinical outcomes of patients proceeding to the carotid surgery programme. METHODS Between October 2000 and December 2002, 1339 people attended the RASC. The findings of head CT and carotid Doppler ultrasound of the 1320 patients who underwent brain and carotid imaging were reviewed, and the number subsequently proceeding to carotid angiography and intervention was reported. RESULTS CT head scans were normal in 57% of cases; 38% demonstrated ischaemia or infarction; and 3% yielded incidental or other significant findings not related to ischaemia. On screening with carotid Doppler ultrasound, 7.5% showed greater than 50% stenosis on the symptomatic side. A total of 83 patients (6.2%) proceeded to cerebral angiography and 65 (4.8%) underwent carotid endarterectomy or endovascular repair. CONCLUSION Rapid-access neurovascular clinics are efficient in selecting patients for carotid intervention, but this is at a cost and the number of potential strokes prevented is small. Alternative management pathways based on immediate medical treatment need to be evaluated.

We have used continuous ambulatory electrocardiography and concurrent monitoring of arterial oxygen saturation (SpO 2 ) and non-invasive arterial pressure in a pilot study of 29 unsedated patients undergoing percutaneous peripheral vascular angioplasty. Twelve patients (Group 1) received oxygen 41 min −1 by Hudson mask during the procedure, the remaining 17 patients (Group 2) breathing air. Fourteen patients in Group 2 had an SpO 2 of 94% or below during the procedure, compared with two patients in Group 1. Episodes of silent ischaemia were recorded during the procedure in one patient in Group 1 and five patients in Group 2. Adminsstration of oxygen significantly reduced the incidence and severity of hypoxaemia, and may be responsible for the reduction in silent ischaemia.

Background and Purpose— Carotid intervention by carotid endarterectomy (CEA) or endovascular treatment may cause hemodynamic change. The immediate and long-term effects on blood pressure after these procedures were assessed. Methods— Patients were randomized to CEA (n=49) or endovascular treatment (n=55) that comprised percutaneous transluminal angioplasty alone (n=31), balloon-expandable stent (n=13), or self-expandable stent (n=11). A baseline 24-hour ambulatory blood pressure recording was made before carotid intervention and repeated at 24 hours, 1 month, and 6 months after the procedure. Results— In the first 24 hours after the procedure, episodes of hypotension occurred in 75% of the CEA group and 76% of the endovascular group; hypertension occurred in 11% and 13%, respectively. There was a significant fall in blood pressure at 1 hour after the procedure in both groups (24 and 16 mm Hg fall in CEA and endovascular groups, respectively), but this was only sustained in the endovascular group. The pattern of blood pressure response in the first 24 hours was significantly different ( P Conclusions— Both CEA and endovascular treatment have an effect on blood pressure stability, particularly within the first 24 hours after the procedure.

We report a case of humero-spinal dysostosis which is only the fourth reported in the literature. The condition is characterized by distal bifurcation of humeri, elbow joint dislocation, spinal malformation, widened iliac bones and talipes equinovarus.

Purpose: to determine the 12 months success rate with a balloon expandable, flexible stainless steel stent in iliac artery obstructions. Materials and Methods: one-hundred and twenty-six consecutive patients with iliac obstructive disease and who demonstrated an unsatisfactory angioplasty result with a post-dilatation gradient of at least 10 mmHg, or a primary occluded lesion were included in the study. Follow-up was by Doppler sonography, ankle pressures with and without exercise and clinical parameters. Results: after stent placement, the mean percentage diameter stenosis decreased from 79 to 4%, with a mean intra-arterial pressure gradient of 3 mmHg. Primary stent patency was 94% at 6 months and 89% at 12 months. Primary clinical result at 6 months was 88% and at 12 months 81%. Primary assisted clinical result (after re-pta) at 6 and 12 months was 89 and 86%, respectively. The Ankle Brachial Index (ABI) after exercise at 1 month follow-up was reduced from 0.88 to 0.75, with minor deterioration at 6 months to 0.72, and at 12 months to 0.68. The 1, 6, and 12 months follow-up Piek Systolic Velocity (PSV) ratios across the stented lesions remained stable at a mean of 1.4, 1.6, and 1.6, respectively. However, respectively 44, 39 and 34% of the patients still experienced symptoms of claudication. Conclusions: the results presented here support the suggestion stenting to be an effective device in the treatment of iliac artery obstructive disease. This study also, confirms other study results concerning haemodynamic patency after iliac stenting on the indication of a 10 mmHg pressure gradient after pta and the discrepancy between good haemodynamic patency and clinical result.

To compare the differences in practice and outcome of all radiologically and surgically placed central venous catheters retrospectively over a 2-year period simultaneously, at a single institution.A total of 253 Hickman catheters were inserted in 209 patients; 120 were placed radiologically in 102 patients and 133 were placed surgically in 107 patients. The indication was chemotherapy in 76% of radiological and in 47% of surgical cases; the remainder were for total parenteral nutrition and venous access.There were 6 (4.5%) primary surgical failures and a further 17 (13%) surgical cases requiring multiple placement attempts. Pneumothorax occurred once (0.8%) surgically and four times (3.3%) radiologically. There were no radiological primary misplacements but there were five (3.7%) surgical ones. Catheter or central vein thrombosis occurred in four (3.3%) radiological and five (3.7%) surgical cases. The rate of infection per 1000 catheter-days was 1.9 in radiologically placed catheters and 4.0 in surgically placed ones (p0.001). Average catheter life-span was similar for the two placement methods (100 +/- 23 days).Radiological placement is consistently more reliable than surgical placement. There are fewer placement complications and fewer catheter infections overall.

Stroke is one of the most devastating of human illnesses and the most common life-threatening neurological disease [1]. Although stroke is more often disabling than lethal, it is still the third most common cause of death in the Western world after coronary heart disease and cancer [2,3]. According to a consensus statement on stroke, ‘Every five minutes someone in the United Kingdom has a stroke’ [4]. Stroke patients occupy around 10% of bed-days in the NHS and account for about 5% of health-care expenditure [5]. At 12 months after stroke onset, about 25% of patients will be dead and a further 30% will be reliant on the help of others for at least some of their activities of daily life [6]. The mortality from stroke has been declining worldwide over the last 30 years. In the UK the overall mortality from stroke fell about 20% between 1976 and 1986 but it is still double that in the USA

Duplex sonography combines the ability to real time image the carotid artery and accurately sample the vessel using pulsed Doppler. The flow information is presented graphically as velocity vs. time (Figure 8.1). It has become possible to color encode the velocity information and superimpose this upon the 2D gray-scale image — color flow Doppler. The color of each pixel displayed is the mean velocity and not peak velocity. It is standard practice that color flow Doppler is used quickly to locate and identify vessels and areas of turbulence; pulsed Doppler is then used to quantify flow accurately (Figure 8.2). ‘Power flow’ Doppler is a more recent development that analyzes the amplitude of the returning signal rather than frequency and direction. The signal is sensitive to flow, has a high signal to noise ratio and is less dependent upon the angle of insonation than pulsed or color flow Doppler. However, the image does not produce information on either peak velocity or direction of flow and is one of anatomy rather than function.

The first part of this chapter deals with the interventional indications for carotid artery disease based on the results of the recently published North American and European trials. The management of asymptomatic patients and those with acute stroke is also discussed.

To assess the use of percutaneous endovascular stent insertion in the management of superior vena cava (SVC) occlusion.Percutaneous endovascular stent insertion was attempted in 13 patients, age range 20-72 (mean 55.5) years, with symptomatic total occlusion of the SVC. Twelve patients had known malignant disease of the thorax. The other patient (age 20) had chronic SVC obstruction, the cause of which was unknown at the time of the procedure. There was initial angiographic assessment and removal of thrombus by thrombolysis (10 patients) and/or clot aspiration (3 patients). Following successful lysis or aspiration, single or multiple endovascular stents were inserted.The inability to cross the lesion with a guidewire prevented stent insertion in 2 patients (15.4%). There was primary success in the remaining 11 patients (84.6%), with associated symptomatic relief. Some recurrence of symptoms occurred in 5 of the 11 patients (45.5%) after a time interval ranging from 14 to 183 days. In all cases of symptomatic recurrence, patency was reestablished with further thrombolysis and/or further stent insertion. All successfully treated patients have since died. All 11 patients remained symptomatically free of SVC occlusion until death, with postprocedure survival ranging from 5 to 243 days.The percutaneous management of complete SVC occlusion with thrombolysis and/or clot aspiration followed by stent insertion is safe and effective, giving sustained symptomatic relief.

Nineteen malfunctioning or incorrectly positioned Hickman catheters from a series of 320 catheter placements were referred to the radiology department for salvage. Successful catheter ‘rescue’ was achieved on 14 occasions (73.6%). Eight catheters were repositioned, five were replaced and thrombolysis was successful in a patient with subclavian vein thrombosis. Catheter repositioning techniques are reviewed and a new technique for catheter replacement using the existing venous access and subcutaneous tunnel is described.

Acute lower limb ischemia secondary to Buerger's disease in a young patient responded to thrombolysis and subsequent popliteal and anterior artery angioplasty. The value of angioplasty in non-limb-threatening ischemia in Buerger's disease has not been established but this case illustrates a role for thrombolysis and angioplasty in acute ischemia.

Occlusion of the superior mesenteric artery by thromboembolism is an uncommon cause of acute intestinal ischemia but carries a high mortality. This report describes a case of mesenteric thromboembolism in an 80-year-old woman treated successfully by selective low-dose infusion of streptokinase over 17 hours. Only twelve previous cases have been reported in the world literature. Selective thrombolytic therapy appears effective in the treatment of mesenteric thromboembolism, particularly in elderly patients with a high operative risk.

Cholesterol embolisation is a little known complication of aortic surgery and radiological procedures with a mortality of 81%. Treatment has been poorly described and inadequate. We report a case in which we have followed an aggressive policy of treatment using modern vascular techniques not previously described in this condition.

Intravascular stents are recognized to be of value in maintaining patency in resistant stenoses, recanalized occlusions, and when initimal dissection has occurred during balloon angioplasty [1,2,3]. Apart from early thrombosis, complications are relatively infrequent. We report a case of perforation of an angioplasty balloon during iliac angioplasty by a Palmaz stent sited in the contralateral iliac artery.

Administration of alloxan (150 mg/kg body weight, i.p.) to male Wistar rats induced a reproducible and persistent diabetes mellitus as evidenced by elevated serum glucose and low serum insulin concentrations. Administration of either (-)epicatechin or (+)catechin (250 mg/kg, i.p. on each occasion) at 36, 24, 12 and 1 hour before and at 12 and 24 hours after alloxan administration did not prevent the induction of the diabetes. Similarly, treatment of animals with (-)epicatechin or (+)catechin (125 mg/kg i.p. twice daily) for 21 days commencing 24 hours after alloxan administration did not reverse the persisting elevated serum glucose and low serum insulin concentrations. Moreover, administration of these compounds did not relieve any of the symptoms of the alloxan-induced diabetes such as poor weight gain, polyuria or polydipsia. Thus, this study does not confirm previous reports of prophylactic and curative effects of (-)epicatechin against alloxan-induced diabetes in rats, in spite of the high dosages of the compounds used in these experiments.

Percutaneous high brachial aortography with a small diameter catheter (5 gauge) was used as an alternative to the translumbar approach in 45 patients in whom access via the femoral route was not considered possible. Only one serious complication occurred: the late development of a bleeding false aneurysm in a patient with renal failure and severe hypertension who was being treated with anticoagulants. The relevant limitations and complications of the translumbar and axillary approaches are discussed. We consider this technique to be a safe and simple alternative to translumbar aortography when femoral access is not possible.

Ultrasound was used to demonstrate the abnormal orientation of the mesenteric vessels in six cases of midgut malrotation. Five of these patients were known to have an abnormality of rotation before the ultrasound scan. In one patient malrotation was predicted from the ultrasound scan and confirmed by a barium study and at operation.

The mortality in von Hippel-Lindau disease (VHL) is due to the development of central nervous system or abdominal malignancies, particularly renal cell carcinomas. The abdominal manifestations of VHL discovered in the radiological screening of 22 members of an affected family are described. We discuss the problems of making the diagnosis and of detecting small renal and pancreatic tumours against a background of multiple cystic disease. A radiological screening and surveillance protocol using ultrasound and computed tomography is described.