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Celiac artery aneurysms (CAAs) are rare but potentially devastating lesions. Given the high rates of mortality on rupture at large sizes, they should be treated promptly with either surgical or endovascular interventions in appropriate-risk patients. Several options exist for treatment, including surgical repair and endovascular embolization with or without stent or stent graft placement. Because of their rarity, there are few reports of successfully treated CAA lesions. Herein, we describe successful endovascular treatment of one of the largest CAAs reported in the literature. Keywords: Visceral aneurysms, Embolization, Celiac artery aneurysm, Visceral angiography

Capillary malformation-arteriovenous malformation (CM-AVM) syndrome is classically a RASA1 mutation with small CMs and either central nervous system or musculoskeletal AVMs. However, CM-AVM2 has recently been discovered, and is characterized by an EPHB4 mutation to the EPHB4-RAS-ERK pathway. The skin findings favor those of hereditary hemorrhagic telangiectasia with Bier spots and telangiectasias, and the presence of central nervous system and musculoskeletal AVMs mirror classic CM-AVM. To our knowledge, this is the first report of a visceral AVM in CM-AVM2 in the literature. The patient presented with recurrent gastrointestinal bleeds, and after an extensive workup culminating in diagnostic visceral angiography, was found to have a CM-AVM2 with a jejunal AVM.

Objective: To determine, time to angiography for patients with positive gastrointestinal bleeding (GIB) on prior investigation (endoscopy [ES], nuclear medicine [NM] Tc99m red blood cells (RBC) scan, or computed tomography angiography), affects angiographic bleed identification. Materials and Methods: Visceral Angiograms performed from January 2012 to August 2017 were evaluated. Initial angiograms performed for GIB were included in the study. Exclusion criteria included recent abdominal surgery or procedure (30 days), empiric embolization (embolization without visualized active bleeding), and use of vasodilators, or subsequent angiogram. Timing and results of ES, NM Tc99m RBC scan, or computed tomography angiogram and catheter angiogram were recorded. In addition, age, gender, angiogram time, anti- platelet therapy, anti-coagulation therapy, bleed location, international normalized ratio, and units of packed RBCs received in the 24 h before catheter angiography were included in the study. Results: One hundred and seventy angiograms were included in the final analysis. Forty-three angiograms resulted in the identification of an active bleed (68.9 years, and 67.4% male). All of these patients were embolized successfully. One hundred and twenty-seven angiograms failed to identify an active bleed (70.4 years, and 49.6% male). No significance was found across the two groups with respect to time from prior positive investigation. Receiver operating characteristic analysis demonstrated that units of packed RBCs received in the preceding 24 h were correlated with positive bleed identification on catheter angiography. Conclusion: Time to angiography from prior positive investigation, including ES, NM Tc99m RBC scan, or computed tomography angiogram does not correlate with positive angiographic outcomes. Increasing units of packed RBCs administered in the 24 h before angiogram do correlate with positive angiographic findings.

The transjugular intrahepatic portosystemic shunt (TIPS) was developed experimentally in canines in the late 1960s. It was one of the early interventional radiologic techniques. Although there was some science, serendipity played a major role in the creation of TIPS. It was a natural process, and here is the story. I was a diagnostic radiologist in the Central Military Hospital in Prague, Czechoslovakia, for 16 years, beginning in 1951. I performed my first angiographic procedure, splenoportography, in 1954. After performing more than 1,000 procedures, writing many papers and one book, and creating a teaching movie on splenoportography, I became quite familiar with the portal circulation. After our hospital in Prague opened a new angiographic room in 1957, I started doing visceral angiography and gained additional knowledge about the liver, pancreas, and spleen. Although I performed clinical research and published many papers when I was in Prague, I had not been exposed to any basic animal research. This situation abruptly changed when I came to the United States in 1967 at the invitation of Charles Dotter. Coming to the University of Oregon Medical School for a 1-year research fellowship was a fortuitous move for me. Charles had an angiographic room for animal research, where I worked on some of his research ideas. But mainly, through his ingenuity and creativity, he became my persuasive teacher. He always emphasized that I should think about potential interventional treatment during diagnostic procedures. Also, he stressed that I should always consider improving existing or developing new interventional tools. After 1 year with Charles, I was ready to become an active interventionalist.

Preoperative evaluation and exact description of origins and courses of hepatic vasculature is essential to avoid iatrogenic complications and to have effective results in surgical and radiologic procedures of hepatobiliary pancreatic region. Therefore, preoperative visceral angiography is critical. Digital substraction angiography is gold standart for the evaluation of vascular structures but its invasive nature limits its use. In recent years with the introduction of Multidetector CT (MDCT) Angiography, the use of conventional angiography has been reduced. We present a case of hepatic arterial variation in which Common Hepatic Artery (CHA) originates from not Celiac Trunk but from Superior Mesenteric Artery (SMA) which is established in preoperative MDCT Angiography of a patient scheduled for Whipple operation for cancer of pancreatic head.

The purpose of this study was to evaluate the usefulness of a tool that we developed to simulate performance of visceral angiography to train beginners in the field of splanchnic angiography. Seven residents and two fellows who were rotating within the Division of Interventional Radiology at our institution between June and August 2008 participated in the evaluation of this tool. They had no experience in performing visceral angiography as an operator. Time for selection of arterial branches arising from the celiac axis on the model was measured before and after training. After such training, the participants performed actual visceral angiography as an operator with instructors beside them. Success of the trainees in selecting visceral arterial branches was evaluated in these real-life cases. In the first test using the model, seven of nine trainees (77.8%) succeeded in selecting all required arteries, while the remaining two failed to select all required arteries. After training using the model, all trainees succeeded in selecting all required arteries just before the actual angiographic study. In the actual angiography, the catheter was successfully inserted from the femoral artery and advanced to the superior mesenteric, celiac, splenic, common hepatic, gastroduodenal, and right and left hepatic arteries by all trainees with only two exceptions. In conclusion, this tool is helpful for training beginners in visceral angiographic procedures.

The objective of our study was to review the final diagnosis and outcome in patients undergoing visceral angiography for gastrointestinal hemorrhage in whom a diagnosis of inflammatory bowel disease (IBD) had been suspected on the basis of angiographic findings.A retrospective review was performed of all visceral angiography referrals over a 10-year period. During that time, 522 visceral angiograms were obtained for the investigation of acute or chronic gastrointestinal bleeding. IBD was reported as a possible or probable diagnosis based on the angiographic findings in 43 patients (8.2%) (male-to-female ratio, 23:20; age range, 11-79 years; mean age, 48.6 years).Active IBD was confirmed in 25 (58%) of these 43 individuals (male-to-female ratio, 15:10; mean age, 46.5 years), representing 4.8% of all patients referred for the investigation of gastrointestinal bleeding. In 14 of these individuals, a diagnosis of IBD had not been suspected previously. A diagnosis other than IBD was found to be the cause of the angiographic findings in seven subjects. In the 32 patients in whom a cause for the angiographic findings was identified, IBD was the diagnosis in 25 (78%).In a group of patients referred for angiography to investigate acute or chronic gastrointestinal bleeding, IBD can be expected to be the cause in approximately 5%. Radiologists should be aware of the angiographic abnormalities seen in patients with IBD and be prepared to consider this diagnosis even if the results of other previous investigations have been reported as normal.

OBJECTIVE This study was designed to define the diagnostic advantage of computed tomography during arterial portography combined with computed tomography-assisted hepatic arteriography ( CTAP + CTHA) for preoperative detection of liver metastases secondary to pancreatic cancer compared with that of multidetector computed tomography (MDCT). METHODS From January 2002 to February 2003, we retrospectively studied 19 consecutive patients with pancreatic cancer. MDCT was performed on all patients prior to preoperative visceral angiography. Fourteen patients underwent CTAP + CTHA at the time of preoperative angiography. RESULTS Liver metastases were identified in 3 patients by means of MDCT. Of 14 patients who underwent CTAP + CTHA, 8 patients (57.1%) were diagnosed as having liver metastases, which could not be detected by MDCT. These tumors missed by MDCT ranged from 5 to 15 mm in size. On CTAP + CTHA, a single nodule in the liver was detected in 2 patients, 2 nodules in 2 patients, 3 lesions in 1 patient, and > or =4 lesions in 3 patients. The sensitivity and specificity of CTAP + CTHA versus MDCT were 75.0% versus 23.1% and 66.7% versus 100%, respectively. CONCLUSIONS In conclusion, the combination of CTAP and CTHA is useful to confirm liver metastases before operation for resectable pancreatic cancer because it has higher sensitivity to detect of liver metastases compared with MDCT.

Hemorrhagic complications are usually manifestations of the progress of severe pancreatitis. In major arterial hemorrhage resulting from pancreatic inflammatory disease, visceral angiography is valuable in localizing the site of bleeding, and hemostasis can be achieved by transcatheter arterial embolization. Successful transcatheter embolization of bleeding in the anterior superior pancreaticoduodenal artery using ethylene-vinyl alcohol copolymer (Onyx) was performed in a 38-year-old woman with acute biliary necrotic-hemorrhagic pancreatitis.

Vascular Causes of Acute Abdomen: Is There a Progress? The therapy of vascular causes of acute abdominal complications includes the treatment of ruptured aneurysms of the aortoiliac and visceral vessels as well as the management of acute visceral ischemia. Especially the treatment of acute mesenteric ischemia is a therapeutic challenge. The mortality rate has remainded extraordinarily high despite diagnostic and therapeutic efforts and progress in intensive care medicine. Additionally to the initial hypoxemia of the bowel a more severe tissue damage is induced via the reperfusion injury , with increase of the vital risk. Besides the detection of occlusive vascular lesions of different etiology, which have to be treated immediately, ‘nonocclusive mesenteric ischemia’ can be identified. Visceral angiography is the diagnostic tool of choice, giving basic information on concomitant lesions, for a rational vascular surgical intervention, and additionally, on the opportunity to administer vasoactive drugs. Despite increasing expertise in complex arterial reconstructions, concomitant treatment modalities and tremendous progress in research regarding chemical processes of reperfusion injury, ‘early diagnosis and immediate treatment’ remain the most important criteria for the survival of the mostly elderly patients. The most important progress today is represented by an increasing number of publications focussing on mesenteric ischemia, underlining the fact that best results can be obtained only when an aggressive diagnosis and consecutive treatment within the close borders of the ‘diagnostic and therapeutic window’ can be performed immediately.

Hypertension (HT) represents a major public health problem affecting many individuals worldwide. It is well known to be an important risk factor for the development of cerebrovascular and cardiovascular diseases. Classifying hypertension as 'primary' or 'secondary' depends on the underlying mechanism. In 5 to 10% of hypertensive patients, HT develops 'secondary' to a separate mechanism that has been encountered with increasing frequency in the tertiary refferral centers. The frequent causes of secondary hypertension include renal parenchymal disease, renal artery stenosis, primary hyperaldosteronism, phaeochromocytoma and Cushing's syndrome. Polyarteritis nodosa (PAN) can involve any organ and in varying degrees. Here we present a young hypertensive patient diagnosed as PAN with the angiographic findings of multiple microaneurysms involving celiac, renal and superior mesenteric arteries and associated with a rarely seen neurological entity-PRES syndrome.

Acquired ileal diverticulum is an uncommon condition and diagnosis is often difficult when bleeding occurs from this source. Here we describe two cases of ileal diverticulum with massive bleeding. Both patients presented with anal bleeding, but upper and lower gastrointestinal endoscopy did not reveal the source. Selective visceral angiography finally detected bleeding lesions in the terminal ileum. Surgical resection was performed in both patients, confirming that the bleeding arose from diverticula less than 1 cm in size. In patients with obscure gastrointestinal bleeding, an ileal diverticulum should be considered, and selective visceral angiography should be performed for precise diagnosis.

There are few randomized, prospective trials evaluating the optimal diagnostic and therapeutic strategies in the management of lower gastrointestinal bleeding. However, recent data suggest that urgent colonoscopy represents a safe and effective initial diagnostic approach. The role of tagged erythrocyte scintigraphy is yet to be defined, but it may be of utility as a screening test for visceral angiography. Colonoscopy and angiography both offer substantial therapeutic options but remain of unproved benefit from a treatment standpoint; surgery continues to play an important role in the management of lower gastrointestinal bleeding. Obscure gastrointestinal bleeding, which often presents as lower gastrointestinal bleeding, continues to be one of the most challenging diagnostic and therapeutic problems in gastroenterology. Occult gastrointestinal bleeding, often arising from the lower gastrointestinal tract, usually mandates gastrointestinal evaluation.

Rationale and Objectives. We investigated whether iodixanol offers improved safety or tolerance compared with ioxaglate and evaluated whether iodixanol-enhanced radiographs are diagnostically comparable or superior to those produced with ioxaglate. Iodixanol is a new isosmotic hexa-iodinated nonionic contrast agent being evaluated for intravascular use. Methods. Fifty-four adult patients undergoing renal or visceral angiography, aortography, or both were enrolled in a prospective, randomized, double-blind, two-center study in which iodixanol and ioxaglate were compared. Subjects were monitored for adverse events, injection-associated discomfort, and changes in laboratory parameters and vital signs. Efficacy was measured by the overall quality of angiographic enhancement. Results. No serious adverse events occurred during this trial. Mild-to-moderate adverse events were more common in patients receiving ioxaglate ( p = .041). Injection-associated pain was reported by three patients receiving ioxaglate and none receiving iodixanol ( p = .093). Clinical laboratory and vital-sign data showed no differences between groups, and there was no difference in the overall quality of angiographic visualization ( p = .711). Conclusion. Iodixanol resulted in improved safety and patient tolerability while providing images of equivalent diagnostic efficacy compared with ioxaglate.

Although renal artery aneurysms (RAA) are infrequent they are encountered often enough that the vascular surgeon needs to be acquainted with the diagnosis and surgical treatment, especially in urgent situations and when there are unexpected intraoperative findings. Autopsy studies reveal an incidence of renal artery aneurysms of 0.01 to 0.09% which is probably an underestimate because small or intrarenal aneurysms may not be seen at autopsy. With the introduction of visceral angiography the incidence has been revised upwards to 0.73 – 0.97%. The most catastrophic complication of RAA is rupture (RRAA) which occurs in less than 3% of cases. Several types of treatment can be used for affected patients which usually involve nephrectomy, in situ or ex vivo repair. Nephrectomy is only an option of the contralateral renal function is normal. We present a very rare case of a large ruptured renal artery aneurysm which was not recognized preoperatively, repaired with successful kidney salvage.

Over a 14-year period 34 patients were referred for surgical treatment of insulinoma. The diagnosis was confirmed by demonstrating hypoglycaemia with inappropriate hyperinsulinaemia during prolonged fasting. Selective visceral angiography localized 30 solitary benign insulinomas and two carcinomas. In two patients with islet cell hyperplasia, angiography demonstrated a single lesion only. Ultrasonography had a sensitivity of 15 per cent and computed tomography a sensitivity of 24 per cent in the localization of tumours. All patients but one were treated by operation. Eighteen tumours were enucleated and 13 (including both patients with islet cell hyperplasia) were treated by distal pancreatectomy. Two patients underwent negative primary exploration; both had single adenomas removed at reexploration. There were no operative deaths but nine patients (predominantly those undergoing pancreatic resection) had complications. Thirty-one patients were symptom-free following operation at a mean follow-up of 16 months.

PURPOSE To describe the utility, safety, and efficacy of endovascular intervention for treating bleeding events after robotic pancreaticobiliary surgery. MATERIALS AND METHODS In this retrospective study, six patients (male/female, 3/3; mean age, 64 years) with histories of robotic pancreaticobiliary resection were referred for endovascular management of delayed postoperative intra-abdominal hemorrhage. Visceral angiography was performed, and the sites of suspected arterial hemorrhage were interrogated with selective microcatheter arteriography. The visualized bleeding sources were treated using catheter-directed embolotherapy with metallic coils, bare metal or covered stent insertion, or a combination of the two. The measured outcomes included the technical success of the angiographic occlusion, procedure safety, and procedure efficacy. RESULTS Pseudoaneurysms resulted in bleeding in six cases (100%). The endovascular interventions included coil embolization in three cases (50%), covered stent exclusion in two cases (33%), and bare metal stent-assisted coil embolization in one case (17%). The technical success was 100%, with complete cessation of bleeding in all cases. No immediate or delayed procedure-related complications were encountered in any of the patients. The efficacy of the endovascular therapy was 100% in this series, with no recurrent hemorrhage during the mean clinical follow-up period of 262 days (range, 67-446 days). CONCLUSION Endovascular therapy provides a minimally invasive, safe, and effective method for managing hemorrhagic events after complicated pancreaticobiliary surgery.

RATIONALE AND OBJECTIVES: To compare the safety of ionic and nonionic contrast agents in visceral angiography. METHODS: Beginning in 1989, a prospective, open trial was begun, and 1,890 patients who have undergone contrast injection were enrolled. Patients considered to be high risk were graded according to Palmer and received nonionic contrast media, while all other patients received ionic contrast media. RESULTS: Because of the small number of visceral angiography procedures performed (38), no definitive conclusions could be drawn as to the differences between ionic and nonionic agents regarding grade-2 and grade-3 adverse events. However, a difference in grade-1 events was apparent in favor of nonionic agents. CONCLUSIONS: More than 10 years ago, the Department of Radiology staff at Aker Hospital began using iohexol, first in infants, then in children, pregnant women, patients undergoing leg phlebography, and patients with serious, previously documented reactions from contrast media. Currently, the department staff administers nonionic agents exclusively for coronary angiography and other cardiac procedures in approximately 300 patients per year. Today, use of nonionic contrast media is the standard for almost all procedures requiring intra-arterial or intravenous application.

Despite visceral angiography and radiolabeled gastrointestinal scintigraphy, the localization of gastrointestinal bleeding can still be a challenge. Even preoperative localization with visceral angiography is no guarantee of successful intraoperative localization or subsequent pathological confirmation. We report a case of obscure gastrointestinal bleeding of small bowel origin, which was localized intraoperatively by fluorescein injected via a superselectively placed catheter.

Intraoperative enteroscopy was performed in 12 patients (median age 68 years) with obscure gastrointestinal bleeding probably of small bowel origin, six of whom were men. All the patients were evaluated by routine haematological, coagulation and biochemical profiles, upper and lower gastrointestinal endoscopies, visceral angiography and/or isotope scanning. All the patients were anaemic. Visceral angiography was useful on three of the 12 occasions on which it was used and isotope scanning was valuable on eight of the 11 occasions it was used. Nine patients had undergone previous laparotomy. Enteroscopy was performed successfully in all cases, with fresh blood and discrete vascular lesions being the chief findings (10 of 12 cases). Segmental resections (n = 8) and local resections (n = 2) were performed in ten patients, with two patients having more than one laparotomy for rebleeding. Five patients developed postoperative complications and there was an operative death and one late death. Three of the ten surviving patients experienced further rebleeding. Intraoperative enteroscopy is now an essential adjunct to laparotomy for gastrointestinal bleeding which has been localized to the small bowel before operation.

From its very inception, gastrointestinal radiology was at the forefront of radiology, combining physiologic and anatomic information. From evaluation of esophageal motility to the first depiction of gastric ulcers and carcinomas of the alimentary tube, gastrointestinal radiology became indispensable to physicians and surgeons. Improvements in fluoroscopic and radiographic equipment, the tilting table, the image intensifier with the television train, the introduction of selective visceral angiography with safer contrast media and, more recently, digital subtraction angiography, digital ultrasound (US), color Doppler US, computed tomography, and magnetic resonance (MR) imaging--all of these advances have made imaging diagnosis more precise and specific. A new modality--localized tissue MR spectroscopy--should offer an insight into metabolism and suggest optimal modes of treatment and follow-up. The gastrointestinal radiologist of the future will have to be multimodality trained. A new generation of alimentary tract interventional radiologists will further the trend toward less invasive surgical therapy. No end of advances is in sight.

Glucagon is often used in radiology to decrease bowel motility for enhanced imaging, including visceral digital subtraction angiography. We present a case in which branch hepatic artery vasospasm followed the intravenous administration of glucagon during visceral angiography.

Pancreaticoduodenectomy with en bloc SMPV resection may be safely performed, with rates of morbidity and mortality that are similar to those of standard pancreaticoduodenectomy. Thin-cut dynamic contrast-enhanced CT is the staging modality of choice, with selective supplementation by visceral angiography. In carefully selected patients, resection of the SMPV confluence may provide for a negative retroperitoneal margin, thus allowing patients traditionally deemed unresectable on the basis of venous involvement a median survival equivalent to those in whom standard pancreaticoduodenectomy is performed. Vascular resection for localized pancreatic cancer represents an aggressive approach to local tumor control, and is ideally combined with other aggressive local-regional therapies, including preoperative or postoperative chemoradiation and (where available) intraoperative radiotherapy. Pancreaticoduodenectomy with vascular resection also requires a high degree of institutional expertise, and is optimally under taken in high-volume centers combining accurate preoperative imaging, high-volume surgical experience, and specialized postoperative care.

This article reports a patient with acute intra-abdominal hemorrhage secondary to a rare vascular disease, segmental arterial mediolysis The patient was a 56-year-old female who presented with severe acute abdominal pain. An abdominal and pelvic computed tomogram demonstrated suggestion of an intra-abdominal hemorrhage. Visceral angiography illustrated aneurysms in the branches of the inferior mesenteric artery. The patient underwent a left hemicolectomy with resection of the diseased artery. The angiographic and histologic findings were consistent with a diagnosis of segmental arterial mediolysis involving only the inferior mesenteric artery. This is the first known reported case of intra-abdominal hemorrhage related to segmental arterial mediolysis requiring emergent hemicolectomy.

The ongoing clinical development of iotrolan 280 mgl/ml for intravascular indications in the United States includes computed tomography, excretory urography, cerebral arteriography, aortography/visceral angiography, and peripheral arteriography. The safety, efficacy and patient tolerance of iotrolan has been assessed in two phase I and ten phase II and III multicenter, randomized, double-blind trials involving over 500 patients and volunteers. Each indication has been studied in two double-blind trials. It is anticipated that once these trials are complete, the data will permit a New Drug Application to be submitted to the US Food and Drug Administration.

Diagnostic X-ray angiography is an established and accurate method to document the presence, nature, and location of vascular disease. Its main strength lies in the evaluation of stenotic changes of the vessel lumen, whereas its role in assessing pathology of the vascular wall is more limited. X-ray angiography has some major advantages over other modalities: it has superior spatial resolution and provides useful additional information on flow direction, velocity, and volume. By means of selective catheterization, one can accurately measure intra-arterial pressure gradients across stenoses and, ultimately, perform endovascular procedures. In 1991 and 1993, the Society of Cardiovascular and Interventional Radiology published quality standards for X-ray angiography in noncoronary vessels [1, 2], which broadly underlie the philosophy put forward in this chapter.

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

In recent years improved understanding of the clinical pathological correlation and the natural history of acute pancreatitis has resulted from information acquired through computed tomography (CT) with vascular enhancement, CT-guided aspiration for infection assessment, endoscopic retrograde cholan-giopancreatography, ultrasound, visceral angiography and operative findings. Stimulated by this flow of new information, a constantly evolving series of classification systems of acute pancreatitis have been produced.

Standard imaging studies in patients with chronic intestinal bleeding are often unrevealing because of the intermittent nature of the bleeding or the slow rate of extravasation. Visceral angiography and small-bowel endoscopy are mdicated when standard endoscopic and radiologic methods fail to identify the source. Recently, we encountered an unusual case of chronic, obscure intestinal hemorrhage that underscored the value of angiography even in patients with slow rates of blood loss.

Peroral small intestinal enteroscopy was performed in 35 consecutive patients with gastrointestinal bleeding of unknown origin by using a prototypic Sonde-type enteroscope. The median value for patient age was 69 years; duration of bleeding, 2 years (range, 2 months to 9 years); and transfusion requirements, 9 units. Bleeding was occult in 54% of these patients. Placement and passage of the enteroscope was performed by a gastrointestinal endoscopy assistant. Mean passage time was 4.3 hours. Complete passage was obtained in 14% of the patients, passage into the mid-distal ileum in 69%, and passage only into the jejunum in 17%. The diagnostic yield was 26%, with the majority of lesions encountered being mucosal vascular malformations. Small intestinal enteroscopy is a reasonable diagnostic procedure before embarking on visceral angiography and surgical exploration when standard endoscopic and radiologic methods fail to disclose a diagnosis.

Ninety patients with periampullary tumors, staged by CT scan and believed to be resectable, were staged further by visceral angiography. Most of these patients (78) had carcinoma of the head of the pancreas. Visceral angiography was normal in 62 patients. Major vessel encasement (17 patients) or occlusion (11 patients) was identified in 28 patients. There were no complications related to angiography. Among the 62 patients with normal angiograms, 48 underwent a pancreaticoduodenectomy, for a resectability rate of 77%. Among the 17 patients with vessel encasement, the resectability rate was 35%. For the 11 patients with vessel occlusion, the resectability rate was 0%. Combined with CT scan, visceral angiography is a useful adjunct in the staging of patients with periampullary tumors. Major vessel occlusion precludes resection, and major vessel encasement makes resection unlikely. If visceral angiography is normal, it is very likely that the tumor will be resectable.

"Spill-over" measurement is a simple method for estimating arterial blood flow during selective angiography. It depends on a direct comparison between a known contrast flow rate and the unknown blood flow in the aortic branch that is being examined. The criterion crucial to the measurement is the back-flow of contrast into the aorta. By means of model and animal experiments, it has been established why back-flow occurs and which factors favour or retard back-flow and thereby falsify the results. The results of "spill-over" measurements were compared with electro-magnetic measurements. A modification of the "spill-over" method is described, which makes it suitable for routine use in visceral angiography.

Upper gastrointestinal bleeding in patients with hepatic cirrhosis carries considerable mortality. Difficulties are encountered both in determining the source of bleeding and in controlling blood loss. The techniques of selective visceral angiography not only supply diagnostic information, but can be used to administer selective intra-arterial vasoconstrictor therapy to control blood loss. We report our experience with 28 patients in whom angiography was performed with particular reference to six patients treated with selective vasoconstrictor therapy. Although the precise role of the technique is not yet established, early experience is most promising. We believe it will play an important role in a difficult group of patients in the future and may well supplant present methods of controlling bleeding.