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We present four patients in whom bedside placement of a central venous catheter was complicated by entrapment of a J-tip guidewire by a previously placed vena cava (VC) filter. Two Venatech filters were fragmented and displaced into the superior VC or brachiocephalic vein during attempted withdrawal of the entrapped wire. Two stainless-steel Greenfield filters remained in place and intact. Fluoroscopically guided extraction of both wires entrapped by Greenfield filters was successfully performed in the angiography suite. [ABSTRACT FROM AUTHOR]

A technique is described that allowed percutaneous retrieval of an endoscopically placed, obstructed biliary stent using loop snare capture of an angled hydrophilic wire which was wrapped around the stent initially. [ABSTRACT FROM AUTHOR]

Purpose: Evaluate retrospectively the long-term primary patency of directional atherectomy (DA) in the femoropopliteal arteries.Materials and Methods: DA was used alone in 59 patients (47%) or in combination with predilatation to allow passage of the device (43%) or after thrombolysis (10%) to treat 127 (93%) excentric atherosclerotic stenoses and nine (7%) occlusions of the femoropopliteal arteries. Forty-eight patients were followed by telephone interview, scheduled outpatient visits, color-flow Doppler evaluation, and angiography for 1-36 months (mean 16.9 months).Results: Technical success (reduction of the stenosis or occlusion to less than 30% luminal diameter) was achieved in 110 lesions (80.3%) during 48 procedures in 37 patients. Mean luminal diameter was increased 54% with a concomitant increase in mean ankle/brachial indices of 0.33. According to Kaplan-Meier survival curves, patency at 12 and 24 months was 88% and 75%, respectively. When patients who retained patency but developed restenosis were excluded, the probability of patency at 12, 24, and 36 months was 76%, 58%, and 32%, respectively. Major and minor complications occurred in 15 (21.4%) procedures each for a total complication rate of 42.8%.Conclusion: Based on our results, DA is an effective method for percutaneous treatment of atherosclerotic disease involving the femoropopliteal arteries. It has similar patency but a relatively high complication rate compared with PTA. [ABSTRACT FROM AUTHOR]

Transcatheter embolization has emerged as the treatment of choice for pelvic arteriovenous malformations (AVMs), because surgical resection may be difficult and is associated with a high recurrence rate. We report a patient with a large recurrent pelvic AVM in whom transcatheter embolization was not feasible. This patient underwent surgical resection of the AVM, which was accomplished with deep hypothermic circulatory arrest. Early postoperative angiography demonstrated a small amount of residual AVM, which was successfully embolized with microcoils. Follow-up magnetic resonance angiography at 2 months showed no residual AVM. In cases where surgical resection of an extensive AVM is required, deep hypothermic circulatory arrest offers the distinct advantages of performing the resection in a bloodless field and enabling adequate visualization of important adjacent structures.

Purpose: To determine how compliance with recommendations made by physicians during the 2000 Legs For Life National Screening for Peripheral Vascular Disease (PVD) and Leg Pain is affected through the use of (i) simple and concise patient information and recommendation cards and (ii) a "targeted" postscreening follow-up plan., Materials and Methods: Patients were initially screened for PVD by completion of the Legs For Life Risk Factor Assessment form and determination of bilateral ankle/brachial indexes (ABIs). Each patient then met with an interventional radiologist or vascular surgeon. Patients with normal ABIs (>1.0 bilaterally) or mildly abnormal ABIs (<1.0 but >0.90) were classified as having no risk and low risk, respectively. Patients with ABIs of 0.70-0.89 were classified as having moderate risk for PVD and patients with ABIs <0.69 were classified as having high risk for PVD. Physicians reviewed the Risk Factor Assessment form with each patient and made specific lifestyle improvement recommendations. For the year 2000 screening, patients classified at moderate and high risk for PVD received special instructions and a card containing clearly printed information on the purpose of the Legs For Life screening, their level of risk for PVD, specific recommendations for follow-up, and phone numbers to call to help arrange for that follow-up. Two weeks after the screening, a second copy of this card was mailed to each moderate- and high-risk assessed patient. Four months later, each of these patients was contacted by telephone to determine if they had pursued additional care or testing., Results: A total of 185 patients were screened, 42 (23%) of whom were determined to be at moderate or high risk for PVD. Four months after the screening, 39 (93%) of these patients were available for follow-up. Twenty (51%) patients had received no further medical advice or treatment. Nineteen (49%) patients had pursued further medical care which included physician consultation (n = 19; 100%), noninvasive Doppler evaluation (n = 10; 26%), diagnostic arteriography (n = 2; 5%), initiation of pharmacologic therapy for claudication (n = 1; 3%), percutaneous intervention (n = 1; 3%), or vascular surgery (n = 1; 3%). Seventeen of 39 patients (44%) reported that claudication-type leg pain was still a concern and/or lifestyle-limiting problem., Conclusion: Patients can be provided with problem-focused information and succinct physician recommendations at and soon after a screening for PVD, which can contribute to enhanced patient compliance. However, a host of personal, social, health, and physician-related issues still prevent a large percentage of patients from achieving relief of PVD-associated leg pain.

Purpose: To prospectively evaluate the efficacy of a low-dose, 3-hour infusion of recombinant tissue plasminogen activator (rt-PA) for the treatment of hemodialysis catheter (HDC)-associated fibrin sheaths. This report expands the authors' experience with this technique over that previously reported., Materials and Methods: Fifty-five patients with end-stage renal disease (38 women, 17 men) undergoing catheter-directed hemodialysis treatment were evaluated for 124 episodes of HDC dysfunction. This patient group had a mean age of 57 years and an age range of 23-92 years. Radiographic contrast studies and/or clinical evaluation were consistent with the presence of a fibrin sheath on the arterial and/or venous port in all cases. Each patient underwent a thrombolytic infusion consisting of 2.5 mg rt-PA in 50 mL normal saline at 17 mL/h (3-hour infusion) per port. All infusions were performed in the interventional radiology recovery room on an outpatient basis. Patients were followed prospectively for technical success, complications, catheter patency, and long-term outcome., Results: The technical success rate, defined as return of effortless manual aspiration and infusion capability from both ports followed by at least one successful dialysis session, was 91%. No patient was excluded from rt-PA therapy because of contraindications, and the procedure-related complication rate was zero percent. A Kaplan-Meier survival analysis yielded primary patency rates at 30, 60, 90, and 120 days of 0.55, 0.36, 0.25, and 0.15 (SE <.10), respectively; secondary patency rates at 60, 120, 180, and 240 days were 0.70, 0.46, 0.30, and 0.27 (SE <.10), respectively (P < 001). At the end of the study period, all 52 surviving patients continued to undergo catheter-directed hemodialysis and 34 (65%) were using the same catheter present at the time of entrance into the study. Of the 18 patients (35%) requiring catheter exchange, 16 (89%) did for persistent malfunction after rt-PA therapy, one (5.5%) for infection, and one (5.5%) for a fractured hub., Conclusion: Thrombolytic therapy with use of a 2.5-mg rt-PA infusion through each port over a 3-hour period would appear to be a safe method for treating HDC-associated fibrin sheaths. Immediate return of catheter function is achieved in most patients, obviating more invasive techniques. Primary patency rates are relatively short, but catheters that fail can be retreated, resulting in secondary patency rates that are substantial and significantly improved.

Purpose: To identify rates of adverse events associated with the use of conscious sedation in interventional radiology., Methods: In a 5-month period, prospective data were collected on patients undergoing conscious sedation for interventional radiology procedures (n = 594). Adverse events were categorized as respiratory, sedative, or major adverse events. Respiratory adverse events were those that required oral airway placement, ambu bag, or jaw thrust. Sedation adverse events were unresponsiveness, oxygen saturation less than 90%, use of flumazenil/naloxone, or agitation. Major adverse events were hypotension, intubation, CPR, or cardiac arrest. The frequency of adverse events for the five most common radiology procedures were determined., Results: The five most common procedures (total n = 541) were biliary tube placement/exchange (n = 182), tunneled catheter placement (n = 135), diagnostic arteriography (n = 125), vascular interventions (n = 52), and other catheter insertions (n = 46). Rates for respiratory, sedation, and major adverse events were 4.7%, 4.2%, and 2.0%, respectively. The most frequent major adverse event was hypotension (2.0%). Biliary procedures had the highest rate of total adverse events (p < .05) and respiratory adverse events (p < .05)., Conclusion: The frequency of adverse events is low with the use of conscious sedation during interventional procedures. The highest rates occurred during biliary interventions.

Purpose: To determine compliance within a community with recommendations made by physicians during the 1999 Legs for Life National Screening for Peripheral Vascular Disease (PVD) and Leg Pain., Materials and Methods: Patients were initially screened for PVD by completion of the Legs for Life risk factor questionnaire and determination of bilateral ankle/brachial indexes (ABIs). Each patient subsequently met with an interventional radiologist or vascular surgeon. Patients with normal ABIs (>1.0 bilaterally) or mildly abnormal ABI(s) (<1.0 but >0.90) were classified at no and low risk for PVD, respectively; patients with ABI(s) of 0.70-0.89 were classified at moderate risk for PVD; and patients with ABI(s) <0.69 were classified at high risk for PVD. Risk factors for PVD were assessed by the consulting physician and discussed with all patients. Recommendations were made for additional evaluation and/or follow-up care, if necessary. Seven months after screening, patients who were assessed at moderate and high risk for PVD were contacted by telephone to determine if they had pursued additional care or testing., Results: A total of 205 patients were screened for PVD, 48 (23%) of whom were determined to be at moderate to high risk. Forty-four (92%) patients were available for follow-up. At 7 months after screening, 31 (70%) patients had received no further medical advice or treatment. Thirteen (30%) of these patients had completed a follow-up appointment, but only three with a physician specializing in peripheral vascular disease. None of the patients had clinical follow-up with an interventional radiologist. Five (11%) patients had undergone noninvasive Doppler evaluation and one (2%) had undergone diagnostic arteriography. No patient had undergone any form of percutaneous or surgical intervention., Conclusion: Patient compliance with physician recommendations after outpatient screening for PVD is low. The Legs for Life screening program could be considered successful in that it provides for patient education and the identification of moderate to high-risk patients. Physicians participating in this program may have to modify their approach to patient screening and follow-up if a concomitant goal is to deliver specialty care.

Purpose: To prospectively evaluate the efficacy of a low-dose, 3-hour recombinant tissue plasminogen activator (rt-PA) infusion for the treatment of hemodialysis catheter (HDC)-associated fibrin sheaths., Materials and Methods: Seventeen patients with end-stage renal disease (female, n = 11; male, n = 6), who were undergoing catheter-directed hemodialysis, were evaluated for 28 episodes of HDC dysfunction. This patient group ranged in age from 25 to 92 years (mean, 57 years). Radiographic contrast and/or clinical evaluation were consistent with the presence of a fibrin sheath on either the arterial and/or venous port in all cases. Patients subsequently underwent a thrombolytic infusion consisting of 2.5 mg rt-PA in 50 mL normal saline at a rate of 17 mL/h (3-hour infusion) per port. All infusions were performed in the interventional radiology recovery room, on an outpatient basis. Patients were followed-up prospectively for technical success, complications, catheter patency, and long-term outcome., Results: The immediate technical success rate, defined as return of manual aspiration and infusion capabilities to both ports, was 100%. No potential patients required exclusion from thrombolytic therapy secondary to contraindications, and no procedure-related complications occurred. The arithmetic mean and median catheter patency at the end of the study was 41 and 25 days, respectively (range, 1-116 days). A Kaplan-Meier survival analysis yielded a 30-, 60-, and 90-day probability of patency of 0.67, 0.61, and 0.51, respectively. At the end of the study period, all 17 patients remained on catheter-directed hemodialysis and 13 (76%) were utilizing the same catheter present at the time of entrance into the study., Conclusion: Thrombolytic therapy utilizing a 2.5-mg rt-PA infusion through each port during a 3-hour period would appear to be a safe, efficient method for treating HDC-associated fibrin sheaths. Three-month patency rates are comparable to those reported for other methods of restoring function to HDC catheters, including new catheter placement, catheter exchange over a guide wire, thrombolytic infusions with urokinase, and percutaneous fibrin sheath stripping.

Purpose: To evaluate the efficacy of percutaneous radiologic placement of peritoneal dialysis (PD) catheters., Material and Methods: Nineteen patients with end-stage renal disease were referred for percutaneous radiologic placement of a commercially available PD catheter. The patient group consisted of 11 men and eight women with a mean age of 58 years (range, 38-85 y). All procedures were performed on an outpatient basis with use of conscious sedation. Patients were followed up to determine technical success, complication rate, catheter survival (continuous patency without infection or mechanical dysfunction), and long-term outcome., Results: The technical success rate for catheter placement was 95% (18 of 19). Complications included one (5%) failed attempt at catheter placement and one (5%) case of postplacement peritonitis. Mean and median catheter survival durations were 320 and 289 days, respectively (range, 33-823 d). A Kaplan-Meier survival analysis yielded 6-, 12-, and 24-month probabilities of catheter survival of 0.89 +/- 0.15, 0.81 +/- 0.20, and 0.81 +/- 0.20, respectively. Long-term outcomes included: continued PD, n = 9 (47%); death, n = 6 (32%; all related to comorbid disease); successful renal transplant, n = 2 (10.5%); and continued or resumed hemodialysis, n = 2 (10.5%)., Conclusion: Percutaneous radiologic placement of PD catheters has a high technical success rate, low complication rate, and can be performed on an outpatient basis. Catheter survival is comparable to that achieved with surgical and percutaneous endoscopic methods of catheter placement.

Purpose: To determine rates and duration of patency achievable in forearm loop, upper arm straight, and brachial-internal jugular (IJ) vein hemodialysis grafts utilizing a combined percutaneous endovascular and surgical maintenance approach., Materials and Methods: A retrospective analysis of 74 hemodialysis grafts (forearm loop, n = 22; upper arm straight, n = 34; and brachial-IJ vein, n = 18) in 50 patients with end-stage renal disease was conducted. Operative notes, interventional procedural reports, and hospital records were used to construct a history for each of these grafts from the time of surgical placement until the time the graft was abandoned for an alternative method of dialysis. All procedures performed to maintain and/or restore patency during the usable lifetime of the grafts were documented., Results: Survival analysis using the Kaplan-Meier method demonstrated the following probabilities of primary patency at 6, 12, and 16 months, respectively: forearm loop graft = .46, .26, and .26; upper arm straight graft = .39, .22, and .16; and brachial-IJ vein graft = .19, .06, and .06 (forearm loop vs upper arm straight grafts, P > .05; forearm loop and upper arm straight vs brachial-IJ grafts, P < .001, P < .001, respectively). The probabilities of secondary patency at 12, 24, and 48 months, respectively, were: forearm loop graft = .89, .30, and NA; upper arm straight graft = .52, .35, and .17; and brachial-IJ vein graft = .54, .42, and .21 (P < .05 for all three comparisons: forearm loop > brachial-IJ > upper arm straight). Six percutaneous and two surgical procedures were compared and no significant differences in utilization were determined among the three graft types (ANOVA, P range, .38-.88)., Conclusion: Kaplan-Meier analysis determined the probability of primary patency for forearm loop grafts to be similar to that for upper arm straight grafts, and both were significantly greater than for brachial-IJ vein grafts. The secondary patency rates for forearm loop grafts are greater than for upper arm and brachial-IJ vein grafts, while that for the brachial-IJ vein graft is greater than the upper arm straight graft. Utilization of interventional and surgical resources required to maintain patency do not significantly differ among the three types of upper extremity hemodialysis grafts.

Purpose: To evaluate the long-term predictive value of the biliary manometric perfusion test and clinical trial for determining patency after treatment of bile duct strictures., Materials and Methods: One hundred four patients with benign biliary disease were treated with surgical (n = 59) or percutaneous (n = 45) techniques followed by intubation with large-caliber silicone stents. Prior to removal of the biliary stents, patients underwent a biliary manometric perfusion test (n = 168) and/or a clinical trial (n = 105) to objectively and subjectively evaluate the treated site for potential long-term patency. The patients were followed up for 1-87 months, and clinical outcomes were determined. Kaplan-Meier survival curves were generated for three patient groups, including those who (i) passed either test, (ii) failed either test, and (iii) failed either test, were re-treated, and passed either test., Results: Final successful treatment outcomes were documented in 47 (92%) surgically and 31 (86%) percutaneously treated patients, respectively (P = .001). The Kaplan-Meier survival curves determined the probability of patency at 0, 2, 4, and 6 years after treatment to be 1.0, .96, .78, and .59, respectively, after passing a biliary manometric perfusion test; and 1.0, .91, .78, and .78, respectively, after passing a clinical trial (P > .10). The probability of patency at 4 years after treatment was .45 after failing a biliary manometric perfusion test, and at 6 months was zero after failing a clinical trial (P = .001 and .001, respectively, vs the same test in the passing group). Seventy-nine percent of patients who failed either test required an additional period of repeated stent placement or reoperation. After repeated treatment, the probability of patency at 0-4 years was .80 and .88, respectively, for the biliary manometric perfusion test and clinical trial (P > .05 and P > .10, respectively, vs same test in the group that passed)., Conclusion: Patients who initially pass either the biliary manometric perfusion test or clinical trial have a significantly increased probability of patency versus those who fail; however, patients who fail either test and who then receive definitive additional treatment have a similar probability of patency as those who initially pass. Although the log rank test demonstrated the Kaplan-Meier survival curves from the biliary manometric perfusion test and clinical trial not to be significantly different in any of the three groups (ie, passing, failing, re-treated), the biliary manometric perfusion test is recommended over the clinical trial because of its simplicity, immediate results, and predicted cost savings.

Purpose: To determine the sensitivity, specificity, and charges associated with single-specimen bile cytologic study in patients with obstructive jaundice., Materials and Methods: Eighty consecutive patients with presumed malignant biliary strictures underwent percutaneous biliary drainage (PBD). Cytologic evaluation was performed on a single bile specimen from each patient collected at the time of the PBD. Final diagnoses were obtained from either percutaneous (n = 14) or surgical (n = 66) histologic specimens (gold standard). Both data sets were then compared to determine the sensitivity and specificity of bile cytology. The charges associated with bile cytodiagnosis were compared to those for other biopsy procedures utilized in the same setting., Results: Eighty bile specimens were obtained with a mean of 14 mL (range, 3-65 mL) per patient with 79 (99%) specimens adequate for cytologic processing. Eleven (13%) specimens were acellular. The overall sensitivity was 15% and specificity was 100%; these values were not dependent on the volume of the bile specimen (P > .10) or type of malignancy (P = .10). For bile cytodiagnosis, the mean charge was $160 and the successful biopsy rate (true-positive plus true-negative results/total number procedures) was 27%., Conclusion: Single-specimen bile cytology has a low sensitivity; however, because of its convenience, simplicity, atraumatic nature, and low relative charge versus comparable procedures, it may be useful as an adjunct to PBD in patients with suspected malignant biliary disease.

Percutaneous biliary drainage is the most common aetiology of haemobilia. Bile duct fistulae can also arise from the hepatic or portal vein, most commonly as a result of trauma. Percutaneous methods for treating haemobilia from all these sources are discussed in detail.

Purpose: To evaluate patency rates after guide wire directed manipulation of malfunctioning continuous ambulatory peritoneal dialysis (CAPD) catheters., Materials and Methods: During a 58-month period, 23 patients underwent 34 outpatient guide wire directed manipulations of their CAPD catheter to improve function (n = 30) or reduce pain and improve function (n = 4) during dialysis. Catheter patency rates were subsequently determined by review of departmental, hospital, and dialysis center charts; procedural reports; and patient telephone interviews., Results: Among 12 patients who underwent a single guide wire directed manipulation, long-term (> 30 days) catheter patency was achieved in seven (58%). With use of the Kaplan-Meier survival method, the 3-, 6-, and 12-month probability of patency after a single guide wire manipulation was 0.61, 0.54, and 0.11, respectively. The mean duration of patency achieved in this group was 131 days (range, 2-421 days). In those patients (n = 8) who underwent multiple catheter manipulations (n = 19), 11 (58%) procedures resulted in long-term patency, with each patient (100%) achieving at least one such period. The Kaplan-Meier survival method determined the probability of patency in this group at 3, 6, and 12 months to be 0.75, 0.69, and 0.54, respectively. The mean secondary catheter patency was 235 days (range, 2-646 days). Overall, 75% of patients followed up achieved at least one period of long-term catheter patency during the time of this study. One (3%) episode of postprocedure peritonitis occurred., Conclusion: Guide wire directed CAPD catheter manipulation is a relatively simple outpatient procedure that restores long-term catheter function for most patients with minimal risk for a major complication. Patients with nonfunctioning CAPD catheters who do not have peritonitis or sepsis will most likely benefit from at least one attempt at radiologic manipulation of their catheter.

Despite evidence of an increased incidence of lead fracture, the infraclavicular subclavian approach remains the dominant approach for placement of pacemaker and implantable defibrillator leads. Although this complication can be prevented by lead placement in the cephalic vein or by recently described approaches for lead placement in the axillary vein, these approaches have not gained widespread acceptance. The purpose of this study was to evaluate the safety and efficacy of an alternative technique for lead placement that uses contrast-guided venipuncture of the axillary vein with a 5Fr micropuncture introducer set. A total of 50 patients underwent an attempt at placement of pacemaker or implantable defibrillator leads via the axillary vein using this new technique. Patients were randomized into 2 groups based on whether the initial attempt at axillary vein access was performed medial or lateral to the rib cage margin. Lead placement was successfully accomplished in 49 of the 50 patients using this technique. Initial success was achieved in each of 25 patients randomized to the medial approach compared with 18 of 24 patients randomized to the lateral approach to the axillary vein (75%). In each of the 6 patients in whom the initial technique failed, lead placement was subsequently achieved with the medial approach. In addition to a higher initial success rate, the medial approach was determined to be preferable as evidenced by a shorter lead placement time, a smaller number of contrast injections, and a reduced requirement for additional micropuncture guidewires. There were no major complications associated with either approach. Contrast-guided venipuncture of the axillary vein is a safe and effective approach to placement of endocardial leads.

Objective: The authors provide the results of follow-up evaluation after combined surgical and radiologic management of 89 patients with major bile duct injuries during laparoscopic cholecystectomy., Summary Background Data: The incidence and mechanism of injury of major bile duct injuries during laparoscopic cholecystectomy has been clearly defined. Furthermore, a number of series have described the management of these injuries by surgical, endoscopic, and radiologic techniques with excellent short-term results. Long-term follow-up data, however, are lacking in the management of these injuries., Methods: Data were collected prospectively on 89 patients treated at a single institution with major bile duct injuries after laparoscopic cholecystectomy managed between July 1, 1990, and July 1, 1996. Patients referred with injuries underwent early percutaneous transhepatic cholangiography and biliary drainage. Based on the cholangiographic appearance and clinical situation, patients were managed by either percutaneous balloon dilatation or surgical reconstruction with a Roux-en-Y hepaticojejunostomy with transanastomotic stenting. Follow-up was obtained by personal interview during October 1996., Results: Two patients died without an attempt at definitive therapy. Both deaths were caused by sepsis and multisystem organ failure present at the time of transfer to the authors' institution. The remaining 87 patients were managed initially by either balloon dilatation (N = 28) or surgical reconstruction (N = 59). Ten patients have not completed treatment and still have biliary stents in place. Evaluation of 25 patients completing treatment after balloon dilatation (mean follow-up, 27.8 months) showed a success rate of 64%. Evaluation of 52 patients completing treatment after surgical reconstruction (mean follow-up, 33.4 months) showed a success rate of 92%. All failures were managed successfully by either surgical reconstruction or balloon dilatation., Conclusions: Major bile duct injuries can be managed successfully by combined surgical and radiologic techniques. This series provides, for the first time, significant follow-up on a large number of patients with overall success rates of 64% after balloon dilatation and 92% after surgical reconstruction. The combination of surgery and balloon dilatation resulted in a successful outcome in 100% of patients treated.

Purpose: To evaluate the feasibility of direct intravascular determination of renal artery (RA) blood flow with a Doppler probetipped guide wire., Materials and Methods: Potential renal donors (n = 10) with normal RAs (n = 23) underwent evaluation of RA blood flow velocity with use of a 0.018-inch, 12-MHz Doppler guide wire. The RA average peak velocity (APV) was obtained with the flow wire. RA diameter was obtained from the filmed images with magnification corrected to a known standard or by a computerized quantification program. These data were used to determine the vessel's cross-sectional area (CSA)., Results: The right and left RA APV, CSA, and blood flow differed insignificantly within the group and averaged 9.7 and 9.0 cm/sec (P = .43), 0.417 and 0.357 cm2 (P = .22), and 382 and 370 mL/min (P = .43), respectively. However, in individuals, the RA CSA and total volumetric blood flow varied by a mean of 29% (range, 4%-56%) and 50% (range, 19%-128%), respectively., Conclusion: This study demonstrates that direct intravascular determination of RA blood flow with a Doppler-tipped wire is both feasible and relatively uncomplicated. Results indicate that blood flow can vary significantly, both in kidneys within the same individual and from person to person. The Doppler wire may facilitate measurements of RA blood flow during endoluminal interventions and help determine an optimal endpoint for these procedures.

Objective: This study was designed to evaluate the total costs associated with repair of laparoscopic cholecystectomy (LC)-related bile duct injuries., Summary Background Data: The popularity of LC with both patients and surgeons is such that this procedure now exceeds open cholecystectomy by a ratio of approximately 4 to 10:1. However, costs associated with LC-related injuries, particularly regarding treatment patterns, have up to now not been explored fully., Methods: The complete hospital and interventional radiology (IR) billing records for 49 patients who have completed treatment for laparoscopic cholecystectomy-related bile duct injuries were divided into 8 categories. These records were totaled for comparison of costs between patient groups that experienced different injuries and treatment patterns., Results: Patients with LC-related bile duct injuries were billed a mean of $51,411 for all care related to repair of their bile duct injury. Patients incurred an average of 32 days of inpatient hospitalization and 10 outpatient care days. Postoperative treatment included long-term chronic biliary intubation averaging 378 days. Two patients (4%) died as a result of their LC-related complications. Patients with bile duct injuries that were recognized immediately at the time of the initial surgery ultimately experienced a total cost for their repair and hospitalization of 43% to 83% less than for patients in whom recognition of the injury was delayed (p < 0.019 to 0.070). In addition, the total hospitalization and outpatient care days was reduced by as much as 76% with early recognition of an iatrogenic injury., Conclusions: Repair of cholecystectomy-related bile duct injuries can run 4.5 to 26.0 times the cost of the uncomplicated procedure and carries a significant mortality rate. Intraoperative recognition of such an injury with immediate conversion to an open procedure for definitive repair can result in significant cost savings and relates directly to a decreased morbidity, mortality, length of hospitalization, and number of outpatient care days.

Purpose: To compare the results obtained with three different techniques for percutaneous transhepatic intraductal biopsy., Materials and Methods: Eighty-eight patients with obstructive jaundice underwent placement of percutaneous biliary drainage catheters for biliary decompression. As part of the initial procedure or at a subsequent date, intraductal biliary biopsy (n = 109) was performed with use of one or more of three techniques including cytologic brush (n = 53), clamshell forceps under choledochoscopic guidance (n = 31), and clamshell forceps under fluoroscopic guidance (n = 25)., Results: Forty-eight patients (55%) had a final diagnosis of malignant disease, and 40 (45%) had a diagnosis of benign disease. One hundred six (97%) biopsy procedures yielded technically adequate specimens. No complications directly related to the biopsy procedures occurred. Overall sensitivity and specificity for each biopsy technique were 26% and 96% for the cytologic brush technique, 30% and 88% for the clamshell forceps under fluoroscopic guidance technique, and 44% and 100% for the clamshell forceps under choledochoscopic guidance technique, respectively. The sensitivities of the biopsy techniques for pancreatic carcinoma and cholangiocarcinoma, respectively, were 47% and 0% for brush; 75% and 0% for fluoroscopic clamshell; and 100% and 27% for choledochoscopic clamshell., Conclusion: The choledochoscope-directed biopsy technique had the greatest sensitivity and specificity of the three techniques evaluated, but this difference was not statistically significant versus the brush or fluoroscopic clamshell technique (P > .10). The sensitivity of all three techniques for pancreatic carcinoma was significantly greater than that for cholangiocarcinoma. Multiple biopsies did not increase the overall sensitivity of intraductal biliary biopsy as a diagnostic technique. All three techniques proved to be safe and easy to perform.

The authors describe an unusual case of radial artery pseudoaneurysm in a patient with a Brescia-Cimino fistula. Evaluation of a pulsatile mass on the patient's forearm which occurred after hemodialysis led to a nondiagnostic fistulogram. Color flow ultrasound was helpful in identifying the nature of the abnormality, which was subsequently confirmed arteriographically. This case illustrates that fistulography is not 100% sensitive and should be supplemented with other imaging modalities when the clinical and fistulographic findings are discordant.

Objective: Preoperative staging of pancreatic tumors is frequently accomplished through a combined effort of CT and arteriography. For tumor detection and delineation of disease extent CT is utilized routinely, with CT arterial portography (CTAP) being the single most accurate study for the detection liver metastases. Arteriography has remained the "gold" standard for assessing vascular involvement. The purpose of this study was to determine whether CTAP could become the single study of choice for assessing resectability in patients with pancreatic and periampullary tumors with particular emphasis on its accuracy in determining vascular involvement., Materials and Methods: Radiologic studies and medical records were reviewed in 20 patients who had received both CTAP and arteriographic examinations for preoperative assessment of pancreatic and periampullary tumors. These findings were correlated with results from either surgery (12 cases) or percutaneous biopsy and follow-up (8 cases) in 12 nonresectable and 8 resectable tumors., Results: Arteriography and CTAP correctly concurred in 75% of cases (15 of 20); CTAP correctly demonstrated vascular involvement not appreciated on arteriography in 15% (3 of 20) with an overall sensitivity and specificity of 90 and 100%, respectively. Arteriography was superior to CTAP in one patient (5%) with an overall sensitivity and specificity of 70 and 90%, respectively, for predicting vascular involvement by tumor., Conclusion: Our experience suggests that CTAP is more accurate than arteriography for demonstrating tumor involvement of major peripancreatic vessels. Because CTAP, additionally, has a high sensitivity for detecting liver metastases, no further studies may be necessary to determine operability of these patients.

Purpose: To evaluate the biliary manometric-perfusion test (BMPT) and clinical trial as predictors of long-term success after percutaneous and surgical treatment of biliary tract strictures., Patients and Methods: After percutaneous intervention or surgical repair of extrahepatic bile duct strictures, 43 patients underwent long-term biliary intubation (mean, 13 months) with 61 internal-external stents. Before removal of the stents, all 43 patients underwent a BMPT (n = 65) and 24 underwent a 2-3-week clinical trial (n = 27) with stents positioned above the treated region. Patients were followed up 1-46 months (mean, 16 months) after stent removal, with clinical outcome determined by means of physical examination, biochemical evaluation, chart review, and telephone interview., Results: With logistic regression analysis, the BMPT and clinical trial were shown to have equal predictive value in determining treatment success or failure. Eighty-four percent of the clinical outcomes were correctly predicted with BMPT, versus 88% for the clinical trial. Kaplan-Meier survival curve analysis demonstrated the probability of remaining stricture free at 1 year after passing a BMPT and after passing a clinical trial to be 90% and 86% (P = .55), respectively., Conclusion: BMPT and clinical trial have similar capabilities in the prediction of long-term patency after treatment of benign biliary tract strictures, but the BMPT is less costly and time consuming for the patient.

Purpose: The authors summarize their 11-year experience with percutaneous varicocele occlusion at the Johns Hopkins Hospital., Patients and Methods: Data were obtained from the patients' medical records and from a mailed questionnaire. Most of the data analysis is based on the 182 patients who responded to the questionnaire., Results: Most of the occlusions were performed for infertility. The mean length of time couples had been attempting to conceive was approximately 44 months. Occlusion was technically successful in 95.7% of cases. Patients were followed up for a mean period of 59 months. Success is difficult to define because many patients and/or their wives received additional infertility treatment. Fifty-seven percent of all couples and 60% of a subgroup of couples who received no other treatment eventually conceived., Conclusion: Percutaneous occlusion is a well-established treatment for varicoceles. Pregnancy rates and recurrence rates are comparable to those following surgical varicocelectomy. It is unlikely that resultant pregnancies occur from random chance alone.

Purpose: The authors evaluated the technical success and immediate and long-term results of percutaneous varicocele embolotherapy in the adolescent population., Patients and Methods: Fifty-nine adolescent patients were referred for outpatient spermatic venography and possible varicocele embolotherapy. Embolization was attempted with use of detachable balloons, coils, "sandwiched" dextrose, or a combination of these techniques. Data regarding follow-up were obtained through telephone interviews or mailed questionnaires., Results: The technical success rate for spermatic vein occlusion was 90%. Follow-up, obtained in 79% of the patients, ranged from 6 months to 8.75 years (mean, 4 years). Thirty-nine of 42 patients (93%) reported disappearance (n = 31) or only a slight, asymptomatic residual varicocele (n = 8). Three patients reported a recurrence of their varicocele. Complications occurred in three of 59 cases (5%), none had any long-term sequelae. In six cases, embolization was not feasible because of multiple collateral vessels or venous spasm., Conclusions: Given the convenience of performing the procedure on an outpatient basis, the rapid recovery time, and long-term success and complication rates comparable to those with surgical ligation, we believe spermatic venography and percutaneous embolization is the treatment modality of choice for adolescent varicocele.

Purpose: This study was undertaken to determine the efficacy of celiac plexus block (CPB) as a method of providing analgesia for percutaneous biliary drainage (PBD)., Patients and Methods: Thirty-two patients scheduled to undergo PBD were prospectively assigned randomly into placebo (30 mL of normal saline) and treatment (30 mL of 0.25% bupivacaine) CPB groups. Each patient received .03 mg/kg of midazolam for premedication before PBD and had access to a patient-controlled analgesia pump during the procedure. The pump was set to deliver 0.2 mg of midazolam and 25 micrograms of fentanyl per dose with a 3-minute lockout time. Vital signs, including heart rate and blood pressure, were continuously monitored during the procedure and recorded for comparison with baseline values. Patients completed a 10-point visual analogue pain scale following completion of their procedure., Results: Patients in the placebo and treatment groups self-administered a mean of 2.0 and 1.85 mg of midazolam, respectively (P = .40), and a mean of 247 and 231 micrograms of fentanyl, respectively (P = .40). On a 10-point pain scale, the mean postprocedure versus preprocedure elevation in pain was 2.1 points in the placebo group versus 1.6 points in the treatment group (P = .60). Overall, the degree of satisfaction with the analgesia was equal in both groups., Conclusion: This study indicates that CPB is not an effective means of providing additional visceral pain relief over and above that which can be accomplished with self-administered intravenous medication for patients who undergo PBD.

Noninvasive imaging studies, particularly computed tomography (CT), are the first step in evaluation of patients with suspected hepatic trauma. Iatrogenic injury, accounting for up to one-third of cases, may commonly result in hepatic artery pseudoaneurysm formation. We present a case in which a giant hepatic artery pseudoaneurysm was misinterpreted as an intrahepatic hematoma on sequential CT scans due to the failure to employ dynamic contrast-enhanced scan techniques.