Abstracts of Current Literature

I VASCULAR

Elimination of a Cirsoid Aneurysm ofthe Scalp by Direct Percutaneous Em­bolization with Thrombogenic Coils:Case Report. Carl B. Heilman, Eddie S.Kwan, Richard P. Klucznik, et al. J Neu­rosurg 1990; 73:296-300. (C.B.H., Depart­ment of Neurosurgery, Box 178, TuftsUniversity, New England Medical Center,750 Washington St, Boston, MA 02111)

• Cirsoid aneurysms of the scalp are noto­riously difficult lesions to manage. The au­thors report a patient in whom a large trau­matic cirsoid aneurysm of the scalp waseliminated using a combined neurosurgicaland interventional neuroradiological ap­proach. Transarterial embolization was uti­lized to reduce arterial blood supply to thefistula. Thrombogenic Gianturco spring coilswere then introduced via direct percutane­ous puncture of the aneurysm. The aneu­rysm thrombosed and the multiple tortuousscalp vessels disappeared. One month afterembolization, a small area of skin necrosisover the aneurysm necessitated surgical exci­sion of the lesion. The thrombosed aneurysmwas easily resected with minimal blood loss.Percutaneous embolization with thrombo­genic coils in this case was a safe and effec­tive ablative technique.AUTHORS'ABSTRACT

Hickman Catheter-induced ThoracicVein Thrombosis: Frequency andLong-term Sequelae in Patients Re­ceiving High-Dose Chemotherapy andMarrow Transplantation. William D.Haire, Robert P. Lieberman, James Ed­ney, et al. Cancer 1990; 66:900-908.(W.D.H., Departments of Internal Medi­cine, Radiology, and Surgery, Universityof Nebraska Medical Center, Omaha, NE68198-3330)

• One hundred sixty-eight bone marrowtransplant recipients and 49 patients who re­ceived high-dose chemotherapy were evalu­ated for symptomatic thrombosis after Hick­man catheter placement. The timing ofthrombotic complications was different be­tween these two groups, with the transplantgroup having a significantly lower thrombus­free survival by 28 days after catheter place­ment. By 100 days after placement thethrombus-free survival rates of the twogroups were similar. The platelet count attime of catheter placement was significantlylower in the nontransplant group, and thethrombus-free survival was longer in pa-

tients whose catheter was placed when theirplatelet count was less than 150,000, suggest­ing that thrombocytopenia delays thrombot­ic complications. Placement of two Hickmancatheters resulted in a 12.9% thrombosis rate(21 of 162 patients) and was significantlymore likely to be associated with thrombosisthan placement of one catheter. Long-termfollow-up evaluation of patients treatedwithout successful fibrinolytic therapyshowed no residual symptoms of venous ob­struction. In those patients presenting withconcomitant catheter obstruction resultingfrom thrombosis, low-dose fibrinolytic thera­py was successful in restoring catheter func­tion 70% of the time. Placement of twoHickman catheters is associated with an in­ordinate incidence of thrombosis. Thrombo­cytopenia at the time of catheter placementmay delay this complication. Thromboticcatheter obstruction can be treated success­fully with low-dose fibrinolytic therapy.Even without fibrinolytic therapy, catheter­induced subclavian vein thrombosis rarelycauses long-term disability.AUTHORS' ABSTRACT

Ultrasound Guidance Improves theSuccess Rate of Internal Jugular VeinCannulation: A Prospective Random­ized Trial. Douglas L. Mallory, WilliamT. McGee, Thomas H. Shawker, et al.Chest 1990; 98:157-160. (From the De­partments of Critical Care Medicine andUltrasonography, Clinical Center, Nation­al Institutes of Health, Bethesda, Md; theDepartment of Critical Care Medicine, St.John's Mercy Medical Center and St.Louis University, St. Louis; and the Cen­ter for Health Service Education and Re­search, St. Louis University School ofMedicine, St. Louis)

• Study Objective: To compare conven­tional versus ultrasound (US)-guided inter­nal jugular vein cannulation techniques. De­sign: Patients were randomly assigned to re­ceive either conventional or two-dimensionalUS-guided internal jugular vein cannulation.Patients who could not be cannulated withfive or fewer passes by either technique, werecrossed over to the other technique. Setting:Clinical research unit in a tertiary care cen­ter. Patients: All conscious patients who re­quired urgent or urgent-elective internal jug­ular vein cannulation during the study peri­od. Interventions: The two-dimensional UStransducer imaged all cannulation attempts.For patients randomized to US guidance, theoperator viewed two-dimensional US imagesand received verbal guidance from the US

technician. For patients randomized to theconventional arm, two-dimensional US im­ages were recorded without visual or verbalfeedback. Measurements and Main Results:Two-dimensional US was significantly betterthan conventional guidance in reducing thenumber of failed site cannulations from sixof 17 (35%) to 0 of 12 (P < .05). Two-dimen­sional US also reduced the mean number ofpasses required to cannulate the vein from3.12 to 1.75 (P < .05) and was also successfulin six of six patients (100%) who failed can­nulation by conventional means (P < .05).Conclusions: Intensivists can increase suc­cessful internal jugular vein cannulation us­ing US guidance. Two-dimensional USshould be considered for patients difficult tocannulate or those at high risk of cannula­tion complications.AUTHORS' ABSTRACT

Intraoperative Intra-arterial Uroki­nase Infusion as an Adjunct to FogartyCatheter Embolectomy in Acute Arte­rial Occlusion. Rolando Garcia, R. MarkSaroyan, Jon Senkowsky, et al. Surg Gyn­ecol Obstet 1990; 171:201-205. (From theDepartment of Surgery, Tulane Universi­ty School of Medicine, New Orleans)

• Sixteen patients (seven men and ninewomen; mean age, 66 years) with acute arte­rial ischemia were treated with operativethromboembolectomy by Fogarty catheter­ization and urokinase. Seven patients werediabetic, 10 were hypertensive, and six hadundergone prior vascular surgical treatment.The operative arteriograms confirmed vascu­lar occlusive phenomenon. The ankle-to-bra­chial ratio was a mean of 0.02. Perioperative­ly, patients had anticoagulation systemicallywith heparin. All patients underwent trans­femoral embolectomy using a Fogarty cathe­ter. An initial retrieval of clots was accom­plished. After documentation of residual clotwith arteriography, instillation of urokinase(50,000 units) and clamping of vessel for 15minutes was performed. Subsequent passageof the Fogarty catheter and repeat urokinaseinfusion resulted in further retrieval of clots,and improvement was noted with repeat in­traoperative arteriography. All interventionsresulted in clinical restoration of perfusion tothe affected limb. Two patients underwentamputation of a lower extremity (one trans­metatarsally and one below the knee) duringthe 30-day postoperative period. Improve­ment in distal runoff was demonstrated withintraoperative arteriography, and increasesin the ankle-to-brachial ratio from 0.1 to 1.04(mean, 0.54) were noted. No complications

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May 1991

from bleeding occurred. One patient diedpostoperatively because of myocardial in­farction. Salvage of the limb may increasewith combined embolectomy and thrombo­lytic therapy.AUTHORS' ABSTRACT

Acute Critical Ischaemia of the Limb:A Prospective Evaluation. J. J. Earn­shaw, B. R. Hopkinson, G. S. Makin. EurJ Vasc Surg 1990; 4:365-368. (J.J.E., Vas­cular Studies Unit, Bristol Royal Infirma­ry, Bristol BS2 8HW)

• A total of 119 patients with acute periph­eral arterial ischaemia were studied prospec­tively to validate the definition of acute criti­cal ischaemia suggested by the working partyof the International Vascular Symposium.The majority of the patients had primarytreatment using thrombolytic therapy. Over­all limb salvage after 30 days was achieved in56% of the patients, 19% required amputa­tions and 25% died. Comparisons of the out­come in patients with or without a distalneurosensory deficit (limb salvage 30% VB

72%, P = .0001) and those with absent or au­dible Doppler ankle blood flow (limb salvage37% vs 78%, P = .0001) confirmed that theseverity of the initial ischaemia was a signifi­cant indicator of prognosis. The def'mition ofacute critical ischaemia as assessed by objec­tive measurement of Doppler pressures hasbeen validated and can be used to divide pa­tients into groups with critical and subcriti­cal ischaemia with different prognoses.AUTHORS'ABSTRACT

Analysis of 1,084 Consecutive LowerExtremities Involved with Acute Ve­nous Thrombosis Diagnosed by DuplexScanning. Thomas M. Kerr, John J.Cranley, J. Robert Johnson, et al. Surgery1990; 108:520-527. (T.M.K., John J. Cran­ley Vascular Laboratory, Good SamaritanHospital, Cincinnati, OH 45220-2489)

• A retrospective analysis of 8,658 consec­utive lower extremity venous duplex scansobtained between the years 1982 to 1988 re­vealed 953 patients with involvement of1,084 extremities with acute deep or superfi­cial thrombi. Records of patients with acutethrombi were then evaluated for the inci­dence, location, and patterns of distribution.There were 485 women (50.9%) and 468 men(49.1%), with a mean age of 62.9 years:l:: 16.7and 58.8 years :l:: 15.2, respectively. Therewere 371 right-sided thrombi (180 womenand 191 men), 451 left-sided thrombi (235women and 216 men), and 131 (70 women

and 61 men) patients with thrombi in bothlower extremities. Women were found to beuniformly older, and the left leg was found tobe involved more frequently (P < .05). Theoverall distribution of the 3,169 veins in­volved with acute thrombi in decreasing or­der were: popliteal, 16.1%; superficial femo­ral, 15.0%; posterior tibial, 13.4%; commonfemoral, 13.2%; greater saphenous, 9.9%; so­leal, 9.1%; peroneal, 7.2%; deep femoral,6.6%; lesser saphenous, 5.7%; anterior tibial,2.0%; varicosities, 1.6%; and perforating,0.3%. A different rank order was found inanalysis of single thrombus patterns as fol­lows: greater saphenous, 27.5%; soleal, 20.1%;lesser saphenous, 13.4%; varicosities, 8.8%;popliteal, 8.1%; posterior tibial, 9.1%; com­mon femoral, 3.5%; superficial femoral, 4.9%;peroneal, 2.8%; deep femoral, 1.0%; anteriortibial, 0.3%; and perforating, 0.3%. In pa­tients with multiple and bilateral thrombithere was a large number of unique patternsof thrombosis. Locations, patterns, and fre­quency of acute venous thrombi vary withage, sex, and leg involved. Patterns and sta­tistical analyses of pertinent observationswere performed.AUTHORS'ABSTRACT

Angioscopy for Intraoperative Man­agement of Thromboembolectomy. Ja­cob Segalowitz, Warren S. Grundfest,Richard L. Treiman, et al. Arch Surg1990; 125:1357-1362. (J.S., Department ofSurgery, Cedars-Sinai Medical Center,Suite 8215, 8700 Beverly Blvd, Los Ange­les, CA 90048)

• The authors' experience with angioscopysuggests that direct visualization of the arte­rial lumen during thromboembolectomy pro­cedures would provide a more reliable meth­od of assessing luminal morphologic charac­teristics than angiography alone. Thirty-twografts were inspected (seven aortobifemoral,18 infrainguinal bypass, and seven dialysisaccess fistula grafts) in 32 patients. Thirty­one patients had thrombotic events, and onepatient had an acute embolus. Angioscopyfollowing standard catheter thrombectomyrevealed significant amounts of retainedthrombus or neointima in all thrombecto­mies. Angioscopic information from 18 pa­tients with an infrainguinal bypass graft ledto graft revision in six cases and placementof a new graft in 10 cases. One graft limb wasreplaced in seven aortobifemoral grafts, andmultiple repeated thrombectomies were em­ployed to extract debris in the remaining sixcases. Repeated graft thrombectomy wasalso beneficial in dialysis access fistulas. An-

gioscopy allowed the surgeon to omit thecompletion angiogram and led to an im­proved technical result. The authors con­clude that angioscopy is useful duringthromboembolectomy procedures.AUTHORS'ABSTRACT

Is Arterial Proximity a Valid Indica­tion for Arteriography in PenetratingExtremity Trauma? A ProspectiveAnalysis. Fred A. Weaver, Albert E. Yel­lin, Madeline Bauer, et al. Arch Surg1990; 125:1256-1260. (F.A.W., Depart­ment of Surgery, LAC/USC Medical Cen­ter, 1200 N State St, Rm 9442, Los Ange­les, CA 90033)

• Three hundred seventy-three patientswith a penetrating extremity injury werestudied to assess the yield of arteriography.Patients underwent arteriography if any ofthe following was present: bruit, history ofhemorrhage or hypotension, fracture, hema­toma, decreased capillary ref'ill, major soft­tissue injury, or nerve or pulse deficit. In theabsence ofthese findings, arteriography wasperformed if the injury was in "proximity" toa major neurovascular bundle. In 216 pa­tients, arteriography was performed when anabnormal finding was noted. Sixty-five inju­ries were identified, 19 requiring interven­tion. Proximity was the indication for arteri­ography in 157 patients. Seventeen injurieswere identified, of which one required repair.In penetrating extremity trauma, the needfor arteriography is based on clinical find­ings. The use of arteriography to screen foran arterial injury when proximity alone isthe indication rarely identifies a significantinjury and should be abandoned.AUTHORS' ABSTRACT

Greenfield Filter as Primary Therapyfor Deep Venous Thrombosis and/orPulmonary Embolism in Patients withCancer. Jon R. Cohen, Noel Tenenbaum,Marc Citron. Surgery 1991; 109:12-15.(J.R.C., Department of Surgery, Long Is­land Jewish Medical Center, New HydePark, NY 11042)

• In 1985, as a result of the high complica­tion rate associated with anticoagulants inpatients who have cancer and deep venousthrombosis (DVT) and/or pulmonary embo­lism (PE), the authors established a policy ofplacing Greenfield f'ilters (GFs) as primarytherapy instead of anticoagulation. Since1985 they have been asked to consult in thetreatment of 18 patients with cancer andwith DVT and/or PE, and they have placed a

GF in each of these patients. This represent­ed 34% of the filters (18 of 53 fIlters) placedduring that same period. Over the same 4­year period, 11 patients with cancer andDVT and/or PE underwent anticoagulationtherapy. The purpose of this study was tocompare the results of anticoagulation versusGF insertion in these two groups of patients.A significantly higher number of major com­plications (n = 4) occurred in the anticoagu­lation group (P < .05, Fisher's exact test)than in the GF group (n = 0). The four com­plications that occurred in the anticoagula­tion group included three bleeding episodes(tumor bleeding, gastrointestinal bleeding,and hip hematoma) and one PE, despite ade­quate anticoagulation. Two patients died asa direct result of these complications (PEand gastrointestinal bleeding). The threepatients with bleeding complications eachrequired a transfusion of more than 3 unitsof blood. All four of the patients with com­plications had metastatic disease (pancreaticcarcinoma, chronic lymphocytic leukemia,prostate carcinoma, and uterine carcinoma).Although this is a small, nonrandomized,nonprospective study, the data seem to indi­cate that GF placement is safer than antico­agulation for DVT or PE in patients withcancer and particularly in patients withmetastatic disease. The authors concludethat GF insertions may be a better primarytreatment than anticoagulation.AUTHORS' ABSTRACT

Complex Hemangiomas of Infants andChildren: Individualized Managementin 22 Cases. Thomas R. Weber, Robert H.Connors, Thomas F. Tracy, Jr, et al. ArchSurg 1990; 125:1017-1021. (T.R.W., De­partment of Pediatric Surgery, CardinalGlennon Children's Hospital, 1465 SGrand Blvd, St. Louis, MO 63104)

• Large hemangiomas in infants and chil­dren are rare but can be life-threatening ifthey involve vital structures or producethrombocytopenia or congestive heart fail­ure. During a 6-year period, 22 infants andchildren, aged newborn to 7 years, weretreated for complex, symptomatic hemangio­mas. The lesions were located in the liver inseven, face or parotid gland in five, neck infour, extremity in two, and mediastinum,chest wall-spinal cord, trachea, and retroper­itoneum in one patient each. The diagnosiswas suggested by physical examination in allpatients and was confirmed by radiologic ex­amination in most patients. The treatmentwas individualized, usually progressed fromless to more invasive, and included observa-

tion, prednisone therapy, arterial ligation,and resection. All children were eventuallycured, with minimal morbidity. Childrenwith life-threatening hemangiomas can besuccessfully managed with the use of a vari­ety of techniques.AUTHORS' ABSTRACT

A Comparative Study of Intraopera­tive Angioscopy and Completion Arte­riography Following Femorodistal By­pass. B. Timothy Baxter, Robert J. Rizzo,William R. Flinn, et al. Arch Surg 1990;125:997-1002. (W.R.F., Division of Vascu­lar Surgery, Northwestern UniversityMedical School, 251 E Chicago Ave, Chi­cago, IL 60611)

• A prospective comparison of the findingsat standard completion arteriography withthose seen using videoangioscopy was donefollowing 49 cases of "femorodistal" bypassgrafting in 47 patients. The two techniqueswere compared with respect to the detectionof technical defects, modification of the sur­gical procedures, early graft patency (72hours), and complications. Completion arte­riography was specific (95%) but only moder­ately sensitive (67%) compared with angios­copy for detection of technical problems. Af­ter angioscopy, significant alterations in thesurgical procedure were noted in five (10%)of the 49 cases. Early graft failure occurredin three (6.1%) cases but none was identifi­ably due to technical problems. Four pa­tients suffered postoperative myocardial in­farctions, two (4.2%) of which were fatal; nopatients had contrast-induced allergies or re­nal failure. Angioscopy was measurably moreaccurate for the detection of technical prob­lems than completion arteriography, but of­fered little information about distal arterialanatomy that may have an impact on graftpatency or the use of antithrombotic thera­py.AUTHORS' ABSTRACT

Reocclusion Prophylaxis with Dipyri­damole Combined with AcetylsalicylicAcid Following PTA. H. W. Heiss, H.Just, D. Middleton, et al. Angiology 1990;41:263-269. (H.W.H., Department ofln­ternal Medicine III, Medical Clinic, Uni­versity of Freiburg, Hugstetterstrasse 55,D-78oo Freiburg, Germany)

• After primary successful percutaneoustransluminal angioplasty (PTA), 199 pa­tients were randomized into one of threetreatment groups, namely, placebo or a com­bination of 75 mg of dipyridamole with ei-

Abstracts • 289

Volume 2 Number 2

ther 330 mg (high dose) or 100 mg (low dose)of acetylsalicylic acid (ASA) three times aday. The duration of treatment was 6months. Of the 199 patients admitted to thestudy, 156 completed the 6-month trial peri­od. Not all patients had a second angiogram,and in these cases clinical findings were usedin the evaluation. Evaluation of the com­bined angiographic and clinical resultsshowed improvement or no deterioration in37% of patients in the placebo group com­pared with 49% in the low-dose and 61% inthe high-dose ASA groups, respectively. Theonly statistically significant difference ob­served was between the placebo group andthe group treated with dipyridamole andhigh-dose ASA (P = .01). This difference re­mained statistically significant at P = .039 ifonly the angiographic findings were consid­ered for group comparison. It cannot, howev­er, be concluded from this study that 75 mgof dipyridamole in combination with 100 mgof ASA three times a day is more effective inpreventing reocclusion after PTA than incombination with 330 mg of ASA three timesa day.AUTHORS' ABSTRACT

Angiographic Criteria for Predictionof Early Graft Failure of SecondaryInfrainguinal Bypass Surgery. SadettinKaracagil, Bo Almgren, SWfan Bowald,et al. J Vase Surg 1990; 12:131-138. (S.K.,Department of Surgery, University Hospi­tal, S-75185, Uppsala, Sweden)

• Complete intraoperative postreconstruc­tion angiograms were obtained during 93reoperations after failed femoropopliteal andfemorodistal bypass grafts to evaluate thepredictive value of a new method of angio­graphic runoff assessment. Good runoff wasdefmed as patency of two or three lower legarteries to the foot, or one patent vessel con­tinuous with an intact anterior or posteriorfoot arch in femoropopliteal and proximalfemorodistal bypasses, and integrity of botharches in low femorodistal bypasses. All oth­er outflow patterns were considered poor.The cumulative I-year patency rate was 61%with a 79% limb salvage rate after reopera­tions performed in limbs with good runoff. Inreoperations with poor runoff, the patencyrate was only 5% with a 22% limb salvagerate. In reoperations with good runoff, an85% patency rate of vein grafts comparedwith 43% of prosthetic grafts clearly demon­strated the importance of graft material onearly outcome. The improved prediction ofearly outcome with this new method of an­giographic runoff evaluation might allow

290 • Journal of Vascular and Interventional Radiology

May 1991

more rational management of patients withfailed infrainguinal grafts.AUTHORS' ABSTRACT

Cerebrovascular Accident afterGreenfield Filter Placement for Para­doxical Embolism. Ronald Dalman, TedR. Kohler. J Vase Burg 1989; 9:452-454.(T.R.K., Veterans Administration Medi­cal Center, Surgery Service [112], 1660 SColumbian Way, Seattle, WA 98108)

• A 69-year-old man with paradoxical em­bolism suffered a cerebral embolism despitetreatment with anticoagulants and place­ment of a Greenfield filter. The open archi­tecture of the filter allows it to maintain ca­val patency better than other mechanical de­vices, but this design also permits passage ofemboli up to 3 mm in diameter. Althoughsuch small emboli do not produce symptomsin the pulmonary circuit, they can be devas­tating in the cerebral circulation. For thisreason, the Greenfield filter may be inade­quate treatment for paradoxical embolism.Ligation of the inferior vena cava is proposedas an alternative that provides better protec­tion against small emboli.AUTHORS'ABSTRACT

A Clinical Trial of Laser Thermal An­gioplasty in Patients with AdvancedPeripheral Vascular Disease. RodneyA. White, Geoffrey H. White, Mark C.Mehringer, et a1. Ann Surg 1990; 212:257­265. (R.A.W., Harbor-UCLA MedicalCenter, 1000 W Carson St, Torrance, CA90509)

• A 3-year prospective trial of laser ther­mal-assisted balloon angioplasty in 28 pa­tients included 27 who had advanced periph­eral vascular disease (severe tissue loss, gan­grene, infection, and rest pain), seven whowere failures of previous therapy (surgeryand thrombolysis), and four who were highrisk for operation (myocardial infarctionwithin 6 weeks and/or ejection fractions of~20%). Laser angioplasty was performed inthe operating room via a groin incision by asurgeon-radiologist team. In the 27 patientswith advanced peripheral vascular disease(ankle-brachial systolic pressure index 0.27± 0.2 in 10 nondiabetic patients and 0.46 ±0.1 in 17 diabetic patients), recanalization ofthe native vessel was successful in 16, andpatency was restored in two chronically oc­cluded polytetrafluorethylene (PTFE)grafts. In these 18 (67%) successfully recanal­ized patients, however, five amputationswere required within 1 month, and another

six were needed between 8 and 12 months.Early amputations were caused by a failureof wound healing, even through angioplastysites were patent. Late amputations werecaused by reocclusion of the treated site infive of six patients. In the remaining sevenpatients in whom laser angioplasty alone wassuccessful, five have healed limbs at 6-24months and two remain incompletely healedbut functional. The patency for successfulprocedures ranged from 48 hours to 25months (mean, 5.6 months ± 6.4 [± SD]),with cumulative patency by life-table analy­sis of 55.5% at 3 months, 38.8% at 6 months,and 11.1% at 12 months. There were no pro­cedure-related deaths. Complications includ­ed seven arterial wall perforations by the la­ser probe. The authors conclude that laserangioplasty has a limited role in advancedperipheral vascular disease but may providean interval patency, thus allowing postpone­ment of operation for high-risk patients untiltheir medical condition permits surgery, orto correct local tissue necrosis or infection inthe operative field before reconstruction, andto restore patency to thrombosed PTFEgrafts.AUTHORS' ABSTRACT

Clinical Spectrum of Symptomatic Ex­ternal Iliac Fibromuscular Dysplasia.Loie Sauer, Linda M. Reilly, Jerry Gold­stone, et al. J Vasc Surg 1990; 12:488-496.(L.S., Division of Vascular Surgery, Box0222, University of California, San Fran­cisco, CA 94143)

• External iliac fibromuscular dysplasia isa rare and usually asymptomatic disorder.The authors report eight symptomatic pa­tients seen over a 15-year period and reviewpathophysiologic mechanisms accounting forthe three following distinct lower extremityischemic sequelae: (u) Emboli-episodic fo­cal digital ischemia (blue toe) was seen inthree patients. Resection and primary anas­tomosis of focal iliac ulcerative fibromuscu­lar dysplasia (one patient) or resection andreplacement (two patients) removed the em­bolic source and relieved the symptoms.(b) Chronic ischemia-gradual onset offullleg claudication in four patients was treatedby operative graduated intraluminal dilationin three patients and prosthetic bypass inone. Arteriography subsequently showed aremodeled lumen in the three patients whounderwent dilation. (e) Dissection-acuteonset leg ischemia resulted from presumeddissection of the external iliac segment. After4 months of conservative management of an­tiplatelet agents and exercise, symptoms re-

solved completely, and arteriogram showedspontaneous restoration of a normal lumenin the dissected segment. The clinical pre­sentation of fibromuscular dysplasia maymimic other arterial processes such as ath­erosclerosis. Diagnosis is made only with ar­teriography with specific magnification viewsof the external iliac arteries and careful sur­veillance of the renal arteries. Appropriatetreatment should be tailored to the clinicalpresenting symptom. For microembolic dis­ease, resection and replacement are required.For chronic ischemia, intraluminal dilation isgenerally sufficient and durable and hasproved to be a simpler and acceptable alter­native to replacement or bypass. In acutedissection, surgical intervention may be de­ferred if the limb is viable to allow spontane­ous healing and remodeling. Persistentsymptoms may be the only indication for in­tervention in this ischemic manifestation ofexternal iliac fibromuscular dysplasia.AUTHORS' ABSTRACT

Initial Trial of Argon Ion Laser End­arterectomy for Peripheral VascularDisease. John Eugene, Richard A. Ott,Yvon Baribeau, et aI. Arch Burg 1990;125:1007-1011. (J.E., University of Cali­fornia Irvine Medical Center, 101 TheCity Dr, Orange, CA 92668)

• In the initial trial of open laser endarter­ectomy, 16 patients underwent 18 recon­structions for claudication (13 patients), restpain (three patients), and gangrene (two pa­tients). The mean (± SD) preoperative an­kle-arm index was 0.53 ± 0.18. The laser en­darterectomies were aortobi-iliac (one pa­tient), iliac (one patient), superficial femoral(seven patients), profunda femoral (sevenpatients), and popliteal-posterior tibial (twopatients). All operations included surgicalexposure, vascular control, administration ofheparin, and an arteriotomy. Atheromaswere dissected from arteries with argon ionlaser radiation (power, 1.0 W). End pointswere welded with laser light. Arteries wereclosed primarily. The laser endarterectomieswere 6-60 cm long and required 168-2,447.5J. All patients had symptomatic relief, with apostoperative ankle-arm index of 0.97 ±0.10. There were no arterial perforationsfrom laser radiation. Surgical complicationsincluded early thrombosis requiring throm­bectomy (three patients) and hematoma re­quiring evacuation (one patient). The laserendarterectomies have an 88% patency at 1year. Open endarterectomy can be per­formed with laser radiation. A larger clinicaltrial is necessary to define the indications for

laser endarterectomy in peripheral vasculardisease.AUTHORS'ABSTRACT

Traumatic Rupture of the Aorta: Criti­cal Decisions for Trauma Surgeons.Richard N. Townsend, Joseph J. Colella,Daniel L. Diamond. J Trauma 1990;30:1169-1174. (R.N.T., Suite 304, 420 ENorth Ave, Pittsburgh, PA 15212)

• The diagnosis and initial stabilization ofpatients with traumatic rupture of the aorta(TRA) is performed by trauma surgeons.The resuscitations of 54 TRA patients at aLevel I trauma center are reviewed. Al­though the survival of patients who under­went attempted repair was good (75%), 21(78%) of 27 deaths occurred during phases oftreatment controlled by a trauma surgeon.The techniques and sequencing of resuscita­tion can affect outcome. Pneumatic anti­shock garments (PASGs) were not beneficialin the prehospital setting for patients withTRA. In fact, PASGs were on and inflated inall patients who presented in cardiac arrest.Awake, unanesthetized intubation caused fa­tal aortic rupture in three patients. Pharma­cologic control of blood pressure during intu­bation is necessary. The amount of fluid,blood transfusion, and changes in bloodpressure secondary to therapy did not statis­tically affect outcome. The average timefrom arrival in the emergency room (ER) toacquisition of an angiogram was 64.7 min­utes. The average time from arrival in ER tooperating room was 159.7 minutes. Sevencases of TRA had delayed diagnosis usuallydue to a misinterpreted chest radiograph(five of seven cases). Delay in diagnosis didnot directly contribute to any deaths. Associ­ated abdominal injuries are a common causeof preventable deaths. Fourteen patientswith combined abdominal injuries and TRAwere identified. Four of six deaths occurredwith potentially reparable injuries. Operativeand diagnostic sequences must be adjustedto allow rapid control of all potentially fatalinjuries.AUTHORS'ABSTRACT

Surgical Treatment of Renal ArteryStenosis after Failed PercutaneousTransluminal Angioplasty. Arturo G.Martinez, Andrew C. Novick, Joseph M.Hayes. J Uro11990; 144:1094-1096.(A.C.N., Cleveland Clinic Foundation, 1Clinic Center Dr, Cleveland, OH 44106)

• From 1980 to 1989, 53 patients with re­novascular hypertension underwent surgical

treatment after initial unsuccessful manage­ment with percutaneous transluminal angio­plasty (PTA). Renal artery stenosis was dueto fibrous dysplasia in 17 patients and ath­erosclerosis in 36. The reasons for failure ofPTA were inability to dilate the stenotic le­sion (32 patients), acute renal arterial occlu­sion (two patients) or dissection (eight pa­tients) from attempted PTA, and the devel­opment of recurrent renal artery stenosisafter initially successful PTA (11 patients).Three patients underwent nephrectomy dueto the finding of a nonviable kidney at opera­tion. Successful surgical revascularizationwas achieved in 50 patients. There was nosignificant fibrosis or inflammation aroundthe previously dilated renal artery. PTA ne­cessitated performance of a more complicat­ed revascularization operation in only onepatient. If the kidney is viable at operationin patients treated by PTA, renovascular re­construction is not more technically difficultthan when done primarily and the same ex­cellent results can be achieved.AUTHORS' ABSTRACT

Intrapleural Tetracycline for the Pre­vention of Recurrent SpontaneousPneumothorax: Results of a Depart­ment of Veterans Mfairs CooperativeStudy. Richard W. Light, Vincent S.O'Hara, Thomas E. Moritz, et al. JAMA1990; 264:2224-2230. (R.W.L., VeteransAffairs Medical Center/151, 5901 E 7th St,Long Beach, CA 90822)

• This prospective, multicenter, random­ized, "unblinded," controlled clinical trialwas designed to determine if the intrapleuralinstillation of 1,500 mg of tetracycline hydro­chloride would be effective in diminishingthe ipsilateral rate of recurrence for sponta­neous pneumothorax. During the 4-year en­rollment period, 113 patients were assignedto the tetracycline group; 116 patients wereassigned to the control group. During the 5­year study period, the recurrence rate in thetetracycline group (25%) was significantlyless than that in the control group (41%). Useof tetracycline seemed to reduce the recur­rence rates for patients with either primaryor secondary spontaneous pneumothoraxand for patients with either an initial or a re­current pneumothorax. The authors con­clude that the intrapleural administration oftetracycline in patients with spontaneouspneumothorax significantly reduces the rateof ipsilateral recurrence but is associatedwith intense chest pain. Intrapleural tetracy­cline therapy is indicated for patients with aspontaneous pneumothorax who are hospi-

Abstracts. 291

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talized and are treated with tube thoracos­tomy.AUTHORS' ABSTRACT

Intravascular Ultrasound Imaging: InVitro Validation and Pathologic Cor­relation. Rick A. Nishimura, William D.Edwards, Carole A. Warnes, et al. JAmCall Cardial1990; 16:145-154. (RAN.,Mayo Clinic, 200 First St SW, Rochester,MN 55905)

• Intravascular ultrasound (US) imaging isa new method in which high-resolution im­ages of the arterial wall are obtained with useof a catheter placed within an artery. An invitro Plexiglas well model was used to vali­date measurements of the luminal area, andan excellent correlation was obtained. Onehundred thirty segments of fresh peripheralarteries underwent US imaging, and thefindings were compared with the correspond­ing histopathologic sections. Luminal areasdetermined with US imaging correlated wellwith those calculated from microscopic stud­ies (r = .98). Three patterns were identifiedon the US images: (a) distinct interface be­tween media and adventitia, (b) indistinctinterface between media and adventitia butdifferent echogenicity layers, and (c) diffusehomogeneous appearance. The types of pat­terns depended on the relative compositionof the media and adventitia. Calcification ofintimal plaque obscured underlying struc­tures. Atherosclerotic plaque was readily vi­sualized but could not always be differentiat­ed from the underlying media.AUTHORS'ABSTRACT

The Diagnosis and Management ofAortic Dissection. E. Stanley Crawford.JAMA 1990; 264:2537-2541. (E.S.C., De­partment of Surgery, Baylor College ofMedicine and Methodist Hospital, 6535Fannin St, MS B-405, Houston, TX77030)

• Aortic dissection is a severe disease.Most untreated patients with types I and II(proximal) dissection and over half of thosewith type III (distal) dissection die within 1year. Most of the deaths occur within 2weeks and are caused by rupture, aortic in­sufficiency, and branch vessel obstruction.Aortic dissection is suspected in patientswith anterior chest and back pain that pro­gresses downward. Diagnosis is confirmed bycomputed tomography, aortography, orechocardiography. Appropriate medicaltreatment and corrective surgery, includingtotal aortic replacement, performed in the

292 • Journal of Vascular and Interventional Radiology

May 1991

acute and chronic stages, are now successfulin over 90% of the cases; long-term results oftreatment are steadily improving and are ex­pected to exceed 50% at 10 years. The keys toa successful outcome are being aware of thesymptoms of dissection, early diagnosis, andprompt application of appropriate treat­ment; diligent follow-up includes controllingblood pressure, decreasing the velocity of leftventricular contraction, monitoring the sizeof the residual aorta, and taking appropriateaction if redissection, aneurysmal formation,or rupture occurs.AUTHORS'ABSTRACT

Iliofemoral Arterial Complications ofBalloon Angioplasty for Systemic Ob­structions in Infants and Children. Pa­tricia E. Burrows, Lee N. Benson, WilliamG. Williams, et al. Circulation 1990;82:1697-1704. (P.E.B., Department of Ra­diology, Hospital for Sick Children, 555University Ave, Toronto, Ontario, CanadaM5G lX8)

• The medical and radiologic records of 64consecutive infants and children who under­went transfemoral balloon dilation of theaorta or aortic valve were reviewed to deter­mine the incidence, nature, and posttreat­ment outcome of acute iliofemoral complica­tions. Balloon dilation angioplasty or balloonvalvotomy was performed with 8-F and 9-Fcatheters without an arterial sheath. Pa­tients ranged in age from 5 days to 15.4 years(mean, 6.4 years). Of 64 patients, 29 (45.3%)had an acute iliofemoral complication, in­cluding thrombosis (n = 18), complete dis­ruption (n = 5), incomplete disruption (n =3), and arterial tear (n = 3). The arterial pa­thology was confirmed in 23 of 29 patients byone or a combination of surgical explorationand repair (n = 18), angiography (n = 6),and magnetic resonance imaging (n = 3). Ofeight patients, three with arterial disruptionhad acute hypotension requiring transfusionand immediate surgery; the other five hadabsent pedal pulses after the procedure. Ofthese five, three developed bleeding duringthrombolytic therapy andunderwent surgi­cal exploration, and two were diagnosed byangiography after ineffective thrombolytictherapy. Angiography in three patients withiliac artery avulsion showed tapered occlu­sion in two and an aneurysm in one. In pa­tients with iliofemoral thrombosis, angiogra­phy showed occlusion from the puncture siteto the origin of the external iliac artery.Eleven patients (17% of the entire group and38% of the group with acute iliofemoral com­plications) had reduced or absent pedal

pulses at the time of discharge. A significantcorrelation was found between increased in­cidence of iliofemoral thrombosis and dis­ruption (as well as abnormal pedal pulses athospital discharge) and low patient weight.AUTHORS' ABSTRACT

A Flexible Sutureless IntraluminalGraft That Becomes Rigid after Place­ment in the Aorta. Masaru Matsumae,Mehmet C. Oz, Gerald M. Lemole. JThorac Cardiovasc Surg 1990; 100:787­792. (G.M.L., Ste 205, Medical Arts Pavil­ion, 4745 Stanton-Ogletown Rd, Newark,DE 19713-2070)

• A new sutureless intraluminal graft hasbeen developed with a ring made of a coiled,overlapping, stainless steel spring withratchets in one overlapping end. This graft isflexible during insertion but becomes rigidafter proper intraaortic placement as thespool is dilated and the ratchets lock into po­sition. The new graft was implanted in 10dogs and was evaluated histologically andangiographically at various intervals. No ringdislodgment, aortic rupture, stenosis, or an­eurysmal dilation was observed. The flexiblecomponent of this graft allows it to be intro­duced and secured in place easily and pro­vides a technical advantage compared withthe clinically used rigid intraluminal graft.AUTHORS'ABSTRACT

Rupture of Thoracic Aorta Caused byBlunt Trauma: A IS-year Experience.R A. Cowley, S. Z. Turney, J. R Hankins,et al. J Thorac Cardiovasc Surg 1990;100:652-661. (S.Z.T., MIEMSS, 22 SGreene St, Baltimore, MD 21201-1595)

• During the 15 years from 1971 through1985, 114 patients with rupture of the tho­racic aorta caused by blunt trauma were ad­mitted to the Shock Trauma Center of theMaryland Institute for Emergency MedicalServices Systems. Mean age was 31.3 years(range, 15-80 years). Ninety were male and24 were female, a 3.75:1 ratio. Of the 114 pa­tients, 89 (78.1%) survived initial resuscita­tion in the admitting area. Twenty-five ofthe 89 initial survivors (28.1%) died during orafter surgical repair. Paraplegia occurred in11 of the 78 operating room survivors(14.1%). Further analysis was done of the 83patients admitted in the 10-year period from1976 through 1985. Mean Injury SeverityScore, excluding aortic injury, was 18.2.Twenty-five of the 83 (30.1%) patients diedduring resuscitation in the admitting area oroperating room. Seven others died during

surgical repair and 12 died after surgery,leaving 39 survivors (39 of 83 [47%] total ad­missions and 39 of 58 [67.2%] survivors ofre­suscitation). Paraplegia/paresis developedafter surgery in six of 34 (17.6%) cases in­volving shunt and four of 17 (23.5%) caseswithout shunt. Other major complicationsoccurred in 21 of the operating room survi­vors. Statistically significant risk of death ormajor complication was associated with fe­male sex, higher Injury Severity Score, loweradmission blood pressure, larger hemothoraxon admission, less qualified surgeon, majoroperation before aortic repair, use of shunt,and tranfer directly from scene of injury.There was no advantage in this series to us­ing or not using a shunt in preventing para­plegia. Mortality rates are realistic for ahighly developed trauma system. Bettertechniques are needed to manage exsangui­nation and prevent paraplegia.AUTHORS' ABSTRACT

Restenosis after Balloon Angioplasty:A Practical Proliferative Model inPorcine Coronary Arteries. Robert S.Schwartz, Joseph G. Murphy, William D.Edwards, et al. Circulation 1990; 82:2190­2200. (RS.S., Division of CardiovascularDiseases, W-16B, Mayo Clinic, Rochester,MN 55905)

• A model of proliferative human resteno­sis was developed in domestic pigs by usingdeep injury to the coronary arterial media.Metal wire coils were delivered percutane­ously to the coronary arteries of 11 pigs withan oversized, high-pressure (14-atm) balloonand were left in place for times ranging from28 to 70 days. During placement, the balloonexpanded the coils and delivered them se­curely within the arterial lumen. Light mi­croscopic examination of the vessels con­firmed fracture of the internal elastic laminaby the coil. An extensive proliferative re­sponse occurred in 10 of the 11 pigs and wasassociated with a luminal area narrowing ofat least 50% in all but one pig. The histo­pathologic features of the proliferative re­sponse were identical to those observed inhuman cases of restenosis after angioplasty.Immunohistochemical studies confirmed theprominence of smooth muscle cells in theproliferative tissue. A similar response wasobtained in two of five porcine coronary ar­teries in which balloon inflation only wasperformed, without coil implant. This modelis practical and inexpensive and closely mi­mics the proliferative portion of human re­stenosis both grossly and microscopically.Thus, it may be useful for understanding hu-

man restenosis and for testing therapiesaimed at preventing restenosis after balloonangioplasty or other coronary interventionalprocedures.AUTHORS'ABSTRACT

Safety and Efficacy of ThrombolyticTherapy for Superior Vena Cava Syn­drome. Bruce H. Gray, Jeffrey W. Olin,Robert A. Graor, et al. Chest 1991; 99:54­59. (J.W.O., Cleveland Clinic, Cleveland,OH 44195)

• The experience at the Cleveland Clinicfrom 1982 to 1990 using thrombolytic thera­py for superior vena cava syndrome was ret­rospectively reviewed. Sixteen patients, 11 ofwhom had indwelling central venous cathe­ters, were treated with either urokinase (n =11) or streptokinase (n = 5). Either uroki­nase (4,400-V/kg bolus followed by 4,400 VIkg!h) or streptokinase (250,000-V bolus fol­lowed by 100,000 V!h) was used, and veno­grams were obtained before and after. Over­all, 56% of patients had complete clot lysisand relief of symptoms. Thrombolytic thera­py was effective in eight (73%) of 11 patientsreceiving urokinase and one (20%) of five pa­tients receiving streptokinase. Of those witha central venous catheter, eight (73%) of 11patients were successfully lysed, whereasonly one (20%) of five patients was success­fully lysed if no catheter was present. Ifthrombolytic therapy was performed within5 days of symptom onset, seven (88%) ofeight patients were successfully treated, ifthrombolytic therapy was performed morethan 5 days after symptom onset, two (25%)of eight patients were successfully treated.Symptoms were relieved and the catheterwas preserved in patients in whom thrombo­lytic therapy was effective. Factors predict­ing success were as follows: (a) the use ofurokinase compared with streptokinase;(b) the presence of a central venous catheter;and (c) a duration of symptoms of 5 days orless.AUTHORS' ABSTRACT

Nonoperative Observation of Clinical­ly Occult Arterial Injuries: A Prospec­tive Evaluation. Eric R. Frykberg, JohnM. Crump, James W. Dennis, et al. Sur­gery 1991; 109:85-96. (E.R.F., Departmentof Surgery, University Medical Center,655 W 8th St, Jacksonville, FL 32209)

• Forty-seven patients with 50 clinicallyoccult injuries of major arteries were studiedprospectively to determine the natural histo­ry of these lesions and the safety of nonoper-

ative management. Penetrating trauma wasthe predominant mechanism, and lower ex­tremity arteries were most commonly in­volved. The morphology of these arterial in­juries included 22 cases of intimal flaps, 21cases of segmental arterial narrowing, sixpseudoaneurysms, and one acute arteriove­nous fistula. There was one death as a resultof unrelated causes and another three inju­ries operated on immediately after arterio­graphic diagnosis. The remaining 46 injurieswere followed up nonoperatively by serial ar­teriography (39 injuries) or clinical examina­tion (seven injuries) during a mean intervalof 3.1 months (range, 3 days to 27 months).Complete resolution was documented for 29injuries (63%), whereas three improved, nineremained unchanged, and five worsened dur­ing the period of follow-up. All worsenedcases involved small or occult pseudoaneu­rysms that subsequently enlarged and thenunderwent immediate surgical repair with­out subsequent morbidity. Because 89% ofthe followed injuries never required surgery,nonoperative observation appears to be asafe and effective management option forclinically occult arterial injuries.AUTHORS' ABSTRACT

Percutaneous Coronary Excimer La­ser-assisted Balloon Angioplasty: Ini­tial Clinical and Quantitative Angio­graphic Results in 50 Patients. TimothyA. Sanborn, Sabino R. Torre, Samin K.Sharma, et al. JAm Coll Cardiol1991;17:94-99. (TAS., Division of Cardiology,Box 1030, Mount Sinai Medical Center,One Gustave L. Levy PI, New York, NY10039)

• The initial clinical experience and quan­titative angiographic results of percutaneouscoronary excimer laser-assisted balloon an­gioplasty are described for 55 lesions in 50patients. With use of xenon chloride (308­nm) excimer laser generator and 1.5-1.75­mm catheters, excimer laser angioplasty wasattempted at 135-ns pulse width, 25-40 Hzrepetition rate, 2-5-second laser deliverytime, and 30-S0-mJ/mm2 energy fluence. La­ser success (>20% reduction in absolute per­cent diameter stenosis) was achieved in 41(75%) of 55 lesions, with 100% subsequentballoon angioplasty success «50% residualstenosis). By quantitative digital calipertechnique, the percent diameter stenosis(mean ± SE) was reduced from 81% ± 1% to50% ± 3% after excimer laser angioplasty(P < .001) and to 20% ± 1% after balloon an­gioplasty (P < .001); minimal luminal diame­ter increased from 0.56 ± 0.04 to 1.46 mm ±

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0.08 (P < .001) and 2.03 mm ± 0.07 (P <.001), respectively. By videodensitometrictechniques, the percent area stenosis de­creased from 86% ± 2% to 54% ± 3% after ex­cimer angioplasty (P < .001) and to 26% ±3% after balloon angioplasty (P < .001).There were no perforations, need for emer­gency bypass surgery, or deaths. The overallincidence of abrupt closure (3.6%), dissection(1.8%), embolization (1.8%), filling defect(6%), myocardial infarction (5.5%), sidebranch occlusion (3.6%) or spasm (3.6%) wasinfrequent and more related to subsequentballoon angioplasty than to the laser proce­dure. In the early follow-up period (range, 1­10 months; mean, 7 months), 36 (72%) of the50 patients remained asymptomatic; symp­toms recurred in 14 patients (28%): in rela­tion to abrupt closure in the first 24 hours intwo patients (3.6%), late closure in the firstweek in two patients (3.6%), and restenosisin 10 patients (20%). Thus, percutaneouscoronary excimer laser angioplasty appearsto be a feasible and safe procedure in select­ed patients. At present, the procedure is un­dergoing significant development, includingmodification of the delivery catheters andoperating techniques. The impact of thistechnology on the angioplasty restenosis rateawaits further follow-up analysis.AUTHORS' ABSTRACT

Coronary Morphology after Percuta­neous Directional Coronary Atherec­tomy in Humans: Autopsy Analysis ofThree Patients. Kirk N. Garratt, WilliamD. Edwards, Ronald E. Vlietstra, et al. JAm Coll Cardiol1990; 16:1432-1436.(K.N.G., Mayo Clinic, 200 First St SW,Rochester, MN 55905)

• The morphologic basis of angiographical­ly successful percutaneous directional ather­ectomy and subsequent restenosis in humancoronary arteries is unknown. The clinicaland pathologic features of three patients whodied after coronary atherectomy are de­scribed. Tissue fragments obtained with ath­erectomy demonstrated atheromatous andfibroproliferative intima, media, and adven­titia. At autopsy, treated vascular segments(from the left anterior descending artery intwo patients and a vein graft in one patient)demonstrated discrete defects in the vascu­lar wall. Defects extending into atheroma,media, or adventitia corresponded with thepresence of these tissues in the atherectomyspecimens. Tissues were otherwise not dis­rupted in the manner associated with bal­loon angioplasty. Acute mural thrombus de­position was evident in the resection zone in

294 • Journal of Vascular and Interventional Radiology

May 1991

one patient. Late findings included fibropro­liferative intimal tissue extending from theresected areas into the vascular lumen. Inone patient intimal hyperplasia was suffi­cient to narrow the vascular lumen by 82%and was implicated in subsequent myocardi­al ischemia and infarction. The study indi­cates that (a) the vascular injury associatedwith atherectomy is distinct from that asso­ciated with balloon angioplasty, (b) acutemural thrombus deposition may occur evenwith resection limited to the intima, and(c) intimal hyperplasia may develop in re­gions treated with atherectomy and may beassociated with late myocardial ischemia andinfarction.AUTHORS' ABSTRACT

Lower Extremity Percutaneous Trans­luminal Angioplasty: MultifactorialAnalysis of Morbidity and Mortality.Jonathan E. Hasson, Charles W. Acher,Myron Wojtowycz, et al. Surgery 1990;108:748-754. (J.E.H., Department of Sur­gery, Section of Vascular Surgery, Univer­sity of Wisconsin Hospital and Clinics,600 Highland Ave, Madison, WI 53792)

• The authors analyzed the outcome of 202percutaneous transluminal angioplasty(PTA) procedures performed between 1983and 1989 to quantitate procedural risks anddefine factors associated with suboptimal re­sults or immediate clinical failure. Premor­bid factors studied included age, sex, treat­ment of single verus multiple lesions, steno­ses versus occlusions, premorbid status ofthe limb (claudication vs limb threat), andmost distal level of PTA. Adverse outcomesincluded complications (hematoma, acuteocclusion or thrombosis of PTA site, distalembolization, failure to dilate or cross, arte­rial dissection, rupture, and significant sys­temic derangement), major amputations (be­low knee and above knee), and deaths. Therewere 66 complications (32.7%), 22 amputa­tions (10.9%), and 12 deaths (5.9%) in this se­ries. Logistic regression analysis revealedthat the major predictive variable for the oc­currence of a complication (P = .002), andthe only predictive variable for the outcomesof amputation and death (P = .0001 and P =.0139, respectively), was the premorbid clini­cal status of the limb. Lower extremity PTAis not an intrinsically benign procedure andis associated with a significant risk of com­plication, amputation, and procedure-associ­ated death. These adverse outcomes clusterin patients with limb threat. Therefore itmay be reasonable to restrict the use of PTAto patients with claudication and strictly se-

lected cases of limb threat.AUTHORS'ABSTRACT

I CARDIAC

Angiographic Follow-up after Place­ment of a Self-expanding CoronaryArtery Stent. Patrick W. Serruys, Brad­ley H. Strauss, Kevin J. Beatt, et al. NEngl J Med 1991; 324:13-17. (P.W.S.,Catheterization Laboratory, ErasmusUniversity, PO Box 1738, 3000 DR Rotter­dam, The Netherlands)

• Background. The placement of stents incoronary arteries after coronary angioplastyhas been investigated as a way of treatingabrupt coronary artery occlusion related tothe angioplasty and of reducing the late inti­mal hyperplasia responsible for gradual re­stenosis of the dilated lesion. Methods. FromMarch 1986 to January 1988, the authors im­planted 117 self-expanding, stainless steelendovascular stents (Wallstent) in the nativecoronary arteries (94 stents) or saphenousvein bypass grafts (23 stents) of 105 patients.Angiograms were obtained immediately be­fore and after placement of the stent and atfollow-up at least 1 month later (unlesssymptoms required angiography sooner).The mortality after 1 year was 7.6% (eightpatients). Follow-up angiograms (after amean [± SDj of 5.7 months ± 4.4) were ob­tained in 95 patients with 105 stents andwere analyzed quantitatively by a computer­assisted system of cardiovascular angio­graphic analysis. The 10 patients withoutfollow-up angiograms included four whodied. Results. Complete occlusion occurredin 27 stents in 25 patients (24%); 21 occlu­sions were documented within the first 14days after implantation. Overall, immediate­ly after placement of the stent, there was asignificant increase in the minimal luminaldiameter and a significant decrease in thepercentage of the diameter with stenosis(changing from a mean [±SDj of 1.88 ± 0.43to 2.48 mm ± 0.51 and from 37% ± 12% to21% ± 10%, respectively; P < .0001). Later,however, there was a significant decrease inthe minimal luminal diameter and a signifi­cant increase in the stenosis of the segmentwith the stent (1.68 mm ± 1.78 and 48% ±34% at follow-up). Significant restenosis, asindicated by a reduction of 0.72 mm in theminimal luminal diameter or by an increasein the percentage of stenosis to 50% or moreoccurred in 32% and 14% of patent stents, re­spectively. Conclusions. Early occlusion re­mains an important limitation of this coro-

nary artery stent. Even when the early ef­fects are beneficial, there are frequently lateocclusions or restenosis. The place of thisform of treatment for coronary artery diseaseremains to be determined.AUTHORS'ABSTRACT

A Comparison between Heparin andLow-Dose Aspirin as Adjunctive Ther­apy with Tissue Plasminogen Activa­tor for Acute Myocardial Infarction.Judith Hsia, William P. Hamilton, NealKleiman, et al. N Engl J Med 1990;323:1433-1437. (J.H., George WashingtonUniversity, 2150 Pennsylvania Ave, NW,Washington, DC 20037)

• Background. The authors report the re­sults of the Heparin-Aspirin ReperfusionTrial, a collaborative study comparing earlyintravenous heparin with oral aspirin as ad­junctive treatment when recombinant tissueplasminogen activator (rt-PA) is used forcoronary thrombolysis during acute myocar­dial infarction. Methods. Two hundred fivepatients were randomly assigned to receiveeither immediate and then continuous intra­venous heparin (starting with a 5,000-Ubolus; n = 106) or immediate and then dailyoral aspirin (80 mg; n = 99) together with rt­PA (100 mg intravenously over a 6-hour peri­od) initiated within 6 hours of the onset ofsymptoms. The authors evaluated the paten­cy of the infarct-related artery by angiogra­phy 7-24 hours after beginning rt-PA infu­sion, the frequency of reocclusion of the ar­tery by repeat angiography on day 7, andischemic or hemorrhagic complications dur­ing the hospital stay. Results. At the time ofthe first angiogram, 82% of the infarct-relat­ed arteries in the patients assigned to hepa­rin were patent, as compared with only 52%in the aspirin group (P < .0001). Of the ini­tially patent vessels, 88% remained patentafter 7 days in the heparin group, as com­pared with 95% in the aspirin group (P notsignificant). The numbers of hemorrhagicevents (18 in the heparin group and 15 in theaspirin group) and recurrent ischemic events(eight in the heparin group and two in theaspirin group) were similar in the twogroups. Conclusions. Coronary patency ratesassociated with rt-PA are higher with earlyconcomitant systemic heparin treatmentthan with concomitant low-dose oral aspirin.This observation has important implicationsfor clinical practice and should be consideredin the design and interpretation of clinicaltrials involving coronary thrombolytictherapy.AUTHORS'ABSTRACT

Multivessel Coronary Angioplastyfrom 1980 to 1989: Procedural Resultsand Long-term Outcome. James H.O'Keefe, Jr, Barry D. Rutherford, DavidR. McConahay, et a1. J Am Call Cardiol1990; 16:1097-1102. (G. O. Hartzler, Car­diovascular Consultants, 4320 WornallRd, Medical Plaza 11-20, Kansas City, MO64111)

• From June 1980 to January 1989, 3,186patients had coronary angioplasty of two(2,399 patients) or three (787 patients) of thethree major epicardial coronary systems. Amean of 3.6 lesions (range, 2-14 lesions) weredilated per patient, with a 96% success rate.Acute complications were seen in 94 patients(2.9%) and included Qwave infarction in 47(1.4%), urgent coronary artery bypass sur­gery in 33 (1%), and death in 31 (1%). Multi­variate correlates of in-hospital death in­cluded impaired left ventricular function,age 70 years or older, and female gender.Complete long-term follow-up data wereavailable for the first 700 patients, and thefollow-up period averaged 54 months ± 15 induration. Actuarial 1- and 5-year survivalrates were 97% and 88%, respectively, andwere not different in patients with two- orthree-vessel disease. By Cox regression anal­ysis, age 70 years or older, left ventricularejection fraction of 40% or less, and prior cor­onary artery bypass surgery were associatedwith an increased mortality rate during thefollow-up period. Repeat revascularizationprocedures were required in 322 patients(46%). Restenosis resulted in either repeatangioplasty or bypass surgery in 227 patients(32%). Repeat coronary angioplasty was per­formed for isolated restenosis in 126 patients(18%), for restenosis and disease progressionat new sites in 85 patients (12%), and for newdisease progression alone in 54 patients (8%).Coronary bypass surgery was required in 110patients (16%) during the follow-up period.The actuarial4-year repeat revascularizationrate for patients with complete and incom­plete revascularization was 24% and 33%, re­spectively (P = .03). At follow-up study, 412of 700 patients were free of angina and 19%had class II angina. Thus, multivessel coro­nary angioplasty was safe and effective andresulted in excellent long-term symptom re­lief and survival. Although repeat coronaryangioplasty for restenosis or new disease, orboth, was performed in 38% of patients, only16% of patients required bypass surgery.AUTHORS'ABSTRACT

I GASTROINTESTINAL

Selective Arterial Stimulation of Se­cretin in Localization of Gastrinomas.Francis E. Rosato, Joseph Bonn, MarcellShapiro, et al. Surg Gynecol Obstet 1990;171:196-200. (F.E.R., Jefferson MedicalCollege, 1025 Walnut St, Rm 605, Phila­delphia, PA 19107)

• In two patients with malignant gastrin­oma and the Zollinger-Ellison syndrome, theauthors were able to use selective arterialstimulation with secretin as a technique tolocalize the lesions accurately, allowing re­section. The technique of selected arterial se­cretin stimulation is one of measuring varia­tions in gastrin levels in both the hepaticvein and a peripheral artery at specifiedtimes after injection of secretin into a specif­ic artery. When the criteria for localizationhave been met, one can plot the presence ofthe gastrinoma within the blood supply ofthe injected artery and, using angiograms,thus accurately localize the lesion. Thismethod promises to be a valuable additionaltumor-localizing procedure, particularlywhen gastrinomas are extrapancreatic.AUTHORS' ABSTRACT

Comprehensive Management of AcuteNecrotizing Pancreatitis and Pancre­atic Abscess. Russell Stanten, Charles F.Frey. Arch Surg 1990; 125:1269-1275.(C.F.F., Department of Surgery, Universi­ty of California, Davis Medical Center,4301 X St, Rm 2310, Sacramento, CA95817)

• Achieving reduced mortality rates in pa­tients with necrotizing pancreatitis and pan­creatic abscess is possible by employing acomprehensive management plan. Compo­nents of the plan include (a) rapid evalua­tion and assessment of the degree of physio­logic and anatomic derangement, the latterby the prompt use of vascular-enhancedcomputed tomography (CT); (b) adequatefluid resuscitation determined by early insti­tution of advanced hemodynamic monitor­ing; (c) attempts to identify and documentseptic foci via CT-guided percutaneous aspi­ration; and (d) aggressive surgical debride­ment. Close adherence to these policies al­lowed the authors to keep mortality in thisseriously ill group of patients to 14%. Mostdeaths occurred in patients who were re­ferred to this service late in the course oftheir disease. The Acute Physiology andChronic Health Enquiry (APACHE) II se­verity of illness index applied at the time of

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admission proved an accurate predictor ofmortality. A score of 25 or greater was highlypredictive of death, and a lesser score, of sur­vival.AUTHORS' ABSTRACT

Failure of Percutaneous Drainage inChildren with Traumatic PancreaticPseudocysts. Frederick J. Rescorla, Da­vid Cory, Dennis W. Vane, et al. J PediatrSurg 1990; 25:1038-1042. (J. L. Grosfeld,Surgeon-in-Chief, J. W. Riley Hospital forChildren, Indianapolis, IN 46202-5200.

• Recent reports have documented thesuccessful use of percutaneous drainage (PD)in the management of traumatic pancreaticpseudocysts in children. This study presentsfour cases of pancreatic pseudocyst in whichpercutaneous catheter drainage was per­formed. In one instance, no operative thera­py was required. However, in the other threecases PD failed to resolve the problem anddistal pancreatectomy with splenic salvagewas performed when contrast studies (endo­scopic retrograde cholangiopancreatographyor catheter injection) demonstrated disrup­tion of the main pancreatic duct. This reportsuggests that children with pancreatic pseu­docysts unresponsive to PD require promptinvestigation of ductal anatomy to rule outtransection or other major injury.AUTHORS' ABSTRACT

Massive Splenomegaly: Superior Re­sults with a Combined Endovascularand Operative Approach. Jonathan R.Hiatt, Antoinette S. Gomes, Herbert I.Machleder. Arch Surg 1990; 125:1363­1367. (J.R.H., Department of Surgery, Rm8215, Cedars-Sinai Medical Center, 8700Beverly Blvd, Los Angeles, CA 90048)

• Splenectomy for massive splenomegaly(drained splenic weight, >1,000 g) has an un­commonly high morbidity and mortality be­cause of technical challenges and problemsof hemostasis. In a group of 10 patients withmassive splenomegaly due to myeloprolifera­tive disorders (average splenic weight, 4,193g), the authors developed a management al­gorithm based on preoperative angiographicembolization of the splenic artery. Averageoperating time was 1.7 hours (range, 1-2.5hours). Average blood loss was 528 mL; six ofthe 10 patients had blood loss less than 250mL. There were four minor complicationsand one major complication (gastric ulcer re­quiring reoperation). There were no deathsin the perioperative period, and no patientsrequired reoperation for hemorrhage.AUTHORS' ABSTRACT

296 • Journal of Vascular and Interventional Radiology

May 1991

Targeting Cancer ChemotherapeuticAgents by Use of Lipiodo1 ContrastMedium. Toshimitsu Konno. Cancer1990; 66:1897-1903. (T.K., First Depart­ment of Surgery, Kumamoto UniversityMedical School, Honjo 1-1-1, KumamotoCity, Japan)

• Arterially administered Lipiodol Ultra­fluid contrast medium selectively remainedin various malignant solid tumors because ofthe difference in time required for the re­moval of Lipiodol contrast medium fromnormal capillaries and tumor neovasculature.Although blood flow was maintained in thetumor, even immediately after injection Li­piodol contrast medium remained in the neo­vasculature of the tumor. To target anti-call­cer agents to tumors by using Lipiodol con­trast medium as a carrier, the characteristicsof the agents were examined. Anti-canceragents had to be soluble in Lipiodol, be sta­ble in it, and separate gradually from it sothat the anti-cancer agents would selectivelyremain in the tumor. These conditions werefound to be necessary on the basis of themeasurement of radioactivity in VX2 tumorsimplanted in the liver of 16 rabbits that re­ceived arterial injections of 14C-Iabeled dox­orubicin. Antitumor activities and side ef­fects of arterial injections of two types ofanti-cancer agents were compared in 76 rab­bits with VX2 tumors. Oily anti-canceragents that had characteristics essential fortargeting were compared with simple mix­tures of anti-cancer agents with Lipiodolcontrast medium that did not have these es­sential characteristics. Groups of rabbitsthat received oily anti-cancer agents re­sponded significantly better than groupsthat received simple mixtures, and side ef­fects were observed more frequently in thegroups that received the simple mixtures.These results suggest that targeting of theanti-cancer agent to the tumor is importantfor treatment of solid malignant tumors.AUTHOR'S ABSTRACT

Balloon Catheter Dilatation for Hy­pertrophic Pyloric Stenosis. A. H.Hayashi, J. M. Giacomantonio, H. Y. C.Lau, et al. J Pediatr Surg 1990; 25:1119­1121. (D. A. Gillis, IWK Children's Hospi­tal, Department of Surgery, 5850 Univer­sity Ave, Halifax, Nova Scotia, B3J 3G9,Canada)

• Balloon dilating catheters (BDCs) haveprovided a nonoperative means of managingobstructive lesions within the gastrointesti­nal tract. Its potential utility in infants withhypertrophic pyloric stenosis (HPS) was

studied. Six patients with HPS underwentballoon catheter dilatation of the pylorus un­der the direct observation of the surgeon.The pylorus was exposed using a standardright upper quadrant incision. The BDC waspassed transorally into the stomach and ma­nipulated into the pyloric canal by the sur­geon. The balloon was inflated with saline toa maximum pressure of 50 psi for 2 minutes.Four patients were dilated with a 10-mm di­ameter balloon catheter, and in two patients,a 15-mm balloon was used. Success was de­fined as the complete and longitudinal dis­ruption of the seromuscular ring without vio­lation of mucosal integrity. Using this criteri­on, none had successful pyloric dilatation.No disruption occurred in three patients,partial disruption in two. These patientssubsequently underwent a Ramstedt pyloro­myotomy. Complete disruption was observedin one; however, a breach of the mucosa wasevident. This was repaired without incident.All seromuscular breaks occurred at thepoint of vascular entry along the lesser curve,presumably the weakest point of the ring.Pyloric dilatation using a BDC does not reli­ably disrupt the muscular ring. This prelimi­nary report recognizes that major refme­ments must occur before this method willsupplant the time-honored surgical pyloro­myotomy for HPS.AUTHORS' ABSTRACT

Percutaneous Endoscopic Gastrostomyand Early Mortality. Wendell K. Clark­ston, Owen J. Smith, James M. Walden.South Med J 1990; 83:1433-1436.(W.K.C., Division of Gastroenterology, St.Louis University Medical Center, 3635Vista at Grand Blvd, PO Box 15250, St.Louis, MO 63110-0250)

• To assess morbidity, mortality, and ben­efit associated with percutaneous endoscopicgastrostomy (PEG), the authors retrospec­tively studied 42 patients who had had PEG.Mortality was exceptionally high during thefirst 60 days after PEG (43%) and then stabi­lized. In nearly half of the cases (20 of 42 pa­tients) the PEG tube was removed duringthe first 60 days because of either death orimprovement. Patients with malignancy hada significantly higher morbidity and 60-daymortality than the neurologically impaired.The authors conclude that patients shouldbe carefully selected for PEG because earlymortality is high; a 60-day trial of soft naso­gastric feedings should be considered beforePEG and could reduce by nearly half thenumber of patients failing to receive long­term benefit; and patients with malignancy

have significantly greater morbidity andmortality after PEG and may not receive thesame advantage from the procedure.AUTHORS' ABSTRACT

Expandable Biliary Metal Stents forMalignancies: Endoscopic Insertionand Diathermic Cleaning for TumorIngrowth. Michel Cremer, Jacques De­vier, Beatriz Sugai, et al. Gastrointest En­dosc 1990; 36:451-457. (M.C., HopitalErasme, Hepato-gastroenterologie, Routede Lennik 808, Bruxelles, 1070, Belgium)

• Seventeen patients with malignant bili­ary strictures have been treated by endo­scopic insertion of self-expandable metallicprostheses. Two patients received two pros­theses inserted simultaneously in both theleft and right hepatic ducts for Klatskin tu­mor type III. Immediate results were satis­factory despite an operative mortality of18%, and neither early nor late clogging wasobserved even in patients who presented pre­viously with sludge above plastic stents thatwere removed. However, among five patientsfollowed for more than 4 months, two pre­sented with obstruction due to tumor in­growth into the stent through the metallicmesh. Accordingly, initial enthusiasm con­cerning long-term patency of these stentshas decreased. However, the authors de­scribe a technique of "diathermic cleaning"of tumor ingrowth, which can easily restorethe stent patency. The advantages of thesewire mesh 30-F stents are their easier inser­tion, better immediate drainage, and absenceof dislocation or perforation.AUTHORS' ABSTRACT

I HEPATOBILIARY

Prognostic Factors in Liver Metasta­ses after Transcatheter Arterial Em­bolization or Arterial Infusion. Y. Ya­mashita, M. Takahashi, Y. Koga, et al.Acta Radiol1990; 31:269-274. (Y.Y., De­partment of Radiology, Kumamoto Uni­versity School of Medicine, 1-1-1 Kuma­moto 860, Japan)

• From January 1986 to December 1988,85 patients (55 men and 30 women; meanage, 59 years) with metastatic liver tumorswere treated with transcatheter arterial em­bolization (TAE) or hepatic artery infusion(HAl). Sixty-eight patients with successfulcatheterization were treated with TAE usingiodized oil (Lipiodol) mixed with anticanceragent (ACA). In 12 of 68 patients with hyper-

vascular tumors, gelatin sponge was added.Patients with unsuccessful catheterizationwere treated with hepatic artery infusion ofACA. Forty-three patients received oral che­motherapy following TAE or HAL Overall,the 6-month and 1- and 2-year survival rateswere 69.5%, 31.8%, and 4.1%, respectively(mean, 233 days). A univariate analysis ofprognostic factors showed that number ofmetastases, stage, treatment times, and oralchemotherapy were all significant factors(P < .05). Ascites, jaundice, percentage ofhepatic replacement, and treatment protocolalso had some influence (P < .1). Sex, age,primary site, elevation of tumor markers,other metastatic lesions, portal vein involve­ment, and difference in anticancer agent hadno prognostic significance. A multivariateanalysis using Cox's proportional hazardmodel revealed that the number of treat­ments had the most important prognosticsignificance, followed by oral chemotherapy,stage, and percentage of hepatic replace­ment.AUTHORS'ABSTRACT

A Prospective, Randomized Evaluationof the Treatment of Colorectal CancerMetastatic to the Liver. Lawrence D.Wagman, M. Margaret Kemeny, LucilleLeong, et a1. J Clin Oncoll990; 8:1885­1893. (L.D.W., City of Hope NationalMedical Center, 1500 E. Duarte Rd,Duarte, CA 91010)

• Over a 4-year period (1982-1986), 91 pa­tients with solitary or multiple metastasesfrom colorectal cancer were stratified, basedon findings at laparotomy, to one of threegroups and then prospectively randomized toone of two treatment arms within eachgroup. Group A patients had solitary resect­able metastases, group B patients had multi­ple resectable metastases, and group C pa­tients had multiple unresectable metastases.Patients were randomized to one of twotreatment arms within a group: group A­arm AI: resection only, arm A2: resectionand continuous hepatic artery infusion(CHAI) offluorodeoxyuridine; group B­arm Bl: resection and CHAI, arm B2: CHAIonly; group C-arm Cl: CHAI, arm C2: sys­temic fluorouracil followed by CHAI. Medi­an time to failure (TTF) was 31.8,11.1, and8.8 months for group A, B, and C, respective­ly. Arm A2 had an improved TTF when com­pared with arm Al (P = .03). Median surviv­al correlated with extent of disease and was37.3,22.4, and 13.8 months for groups A, B,and C, respectively. Survival was notchanged by treatment variation (arms) with-

in each group. Two- and 5-year cumulativesurvivals for groups A, B, and C were 72.7%and 45.4%; 45.8% and 16.7%; and 31.7% and3.2%, respectively. In patients with multiplemetastases (groups B and C), those patientswhose original tumor was a Dukes' B had asignificantly improved TTF and survivalover those patients whose tumor was aDukes' C (P ::S .02).AUTHORS' ABSTRACT

Carcinoma of the Main Hepatic DuctJunction: Indications, Operative Mor­bidity and Mortality, and Long-termSurvival. Toshiharu Tsuzuki, MasakazuUeda, Shigeru Kuramochi, et al. Surgery1990; 108:495-501. (T.T., Department ofSurgery, Keio University School of Medi­cine, 35 Shinanomachi, Shinjuku-ku, To­kyo 160, Japan)

• The authors review their 16 years experi­ence doing extensive hepatic resection forthe treatment of cholangiocarcinoma of themain hepatic duct junction. During that timeperiod, 25 of 50 patients evaluated for cura­tive surgery underwent resection (resectabil­ity rate, 50%). Preoperative managementincluded visceral angiography to identifyvascular invasion and percutaneous transhe­patic biliary diversion (PTBD) of all ob­structed ducts. Operative mortality was 4%(one patient died of sepsis). The 5-year sur­vival rate (Kaplan-Meier method) was 19%.Four patients lived longer than 5 years. Theinitial and long-term results reported by thisgroup have not been duplicated consistentlyat other centers. The authors stress the im­portance of preoperative PTBD as a majorcontributor to their low perioperative mor­tality rate, indicating that, in their experi­ence, lowering serum bilirubin levels im­proves hepatocellular function and increasespatient tolerance of major hepatic resection.Drainage of all obstructed segmental ducts isnecessary to minimize the risk of pre- andpostoperative cholangitis and sepsis.AUTHORS' ABSTRACT

Isolated Gastric Varices: Splenic VeinObstruction or Portal Hypertension.Marc S. Levine, Kim Kieu, Stephen E.Rubesin, et al. Gastrointest Radioll990;15:188-192. (M.S.L., Department of Radi­ology, Hospital of the University of Penn­sylvania, 3400 Spruce St, Philadelphia,PA 19104)

• The presence of isolated gastric variceswithout esophageal varices is thought to behighly suggestive of splenic vein obstruction.

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Volume 2 Number 2

A review of radiologic files at the authors'hospital revealed 14 patients with isolatedgastric varices on barium studies performedduring the past 10 years. Eight of the 14 pa­tients had adequate clinical and/or radiolog­ic follow-up to suggest the pathophysiologyof the varices. Seven had evidence of portalhypertension, and the remaining patient hadevidence of splenic vein obstruction. Six pa­tients had signs of upper gastrointestinal(GI) bleeding. Double-contrast upper GI ex­aminations revealed thickened, tortuous fun­dal folds in six patients and a lobulated fun­dal mass in two. Thus, most patients withisolated gastric varices have portal hyperten­sion rather than splenic vein obstruction asthe underlying cause.AUTHORS' ABSTRACT

Liver Abscess Complicating Intratu­moral Ethanol Injection Therapy forHCC. Hidehiko Isobe, Tohru Fukai, Hir­oaki Iwamoto, et al. Am J Gastroenterol1990; 85:1646-1648. (H.I., Third Depart­ment of Internal Medicine, Faculty ofMedicine, Kyushu University, 3-1-1 Mai­dashi, Fukuoka 812, Japan)

• The authors report a patient who devel­oped multiple liver abscesses and sepsiscaused by lactobacilli after the percutaneousintratumoral injection of ethanol for hepato­cellular carcinoma. They diagnosed the liverabscess at an early stage because of the find­ing of gas at ultrasound and computed to­mography. Blood cultures grew gram-posi­tive rods, which were of the Lactobacillusspecies. The patient responded to the admin­istration of antibiotics, and his hepatic tu­mors have not recurred in the 7 months sincetreatment. This is the first report of liver ab­scess following percutaneous ethanol injec­tion therapy.AUTHORS' ABSTRACT

Cholangitis Associated with Cholecys­titis in Patients with Acquired Immu­nodeficiency Syndrome. Carlo Iannuzzi,Jacques Belghiti, Serge Erlinger, et a1.Arch Surg 1990; 125:1211-1213. (J.B., Hi>­pital Beaujon, 92118 Clichy cedex,France)

• Four patients with acquired immunode­ficiency syndrome developed severe abdomi­nal pain and fever due to acute acalculouscholecystitis. In all patients, preoperativelaboratory data showed elevation of alkalinephosphatase and 'Y-glutamyltransferase lev­els. Endoscopic or intraoperative cholangiog­raphy showed signs of intrahepatic and ex-

298 • Journal of Vascular and Interventional Radiology

May 1991

trahepatic cholangitis. Cholecystectomy wasperformed and prompt relief of symptomswas achieved in all patients; no postoperativecomplication was observed. One patient didnot develop any recurrence during an 18­month period of follow-up; two patients died2 and 3 months after the operation. One pa­tient developed recurrent abdominal painand cholestasis 4 months after the operation,with dilatation of the common bile duct andpapillary stenosis due to progression of chol­angitis. These observations suggest thatcholangitis is frequently associated with cho­lecystitis in patients with the acquired im­munodeficiency syndrome. Its pathogenesisis not known.AUTHORS' ABSTRACT

A 21-Year Experience with MajorHemorrhage after Percutaneous LiverBiopsy. Douglas B. McGill, Jorge Rakela,Alan R. Zinsmeister, et al. Gastroenterol­ogy 1990; 99:1396-1400. (D.B.M., MayoClinic, Rochester, MN 55905)

• Nine thousand two hundred twelve liverbiopsies were performed according to a de­fined protocol, and data were prospectivelyrecorded to identify risk factors for majorbleeding. There were 10 fatal and 22 nonfatalhemorrhages (0.11% and 0.24%, respectively).By comparison with a control group that didnot hemorrhage, malignancy, age, sex, andthe number of passes were the only predict­able risk factors. The risk of fatal hemor­rhage in patients with malignancy is estimat­ed to be 0.4%; for nonfatal hemorrhage,0.57%. In patients undergoing liver biopsyfor nonmalignant disease, the risks are 0.04%and 0.16%, respectively.AUTHORS' ABSTRACT

Repeated Dearterialization of HepaticTumors with an Implantable Occluder.Bo G. Persson, Bengt Jeppsson, HenrikEkberg, et al. Cancer 1990; 66:1139-1146.(B.G.P., Department of Surgery, LundUniversity, S-22185 Lund, Sweden)

• A new implantable device for repeatedhepatic dearterialization was evaluated in 13patients with tumors of the liver. Eleven pa­tients had colorectal secondaries and also re­ceived cyclic intraperitoneal infusion of 5­fluorouracil. Two patients had primary he­patocellular cancer (HCC). Four patientshad a variant arterial supply. The hepatic ar­tery was occluded repeatedly for 1 hour twicedaily for 1-17 months (mean, 8.5 months). Acomplete transient occlusion was obtained inall but three patients, in whom minor collat-

erals were missed at the initial operation.Collaterals developed in two patients duringtherapy. Leakage from the balloon occurredin two patients after 5 and 12 months. Twopatients developed thrombosis of the hepaticartery during therapy due to the cuff beingplaced too tightly around the vessel. A com­plete remission was demonstrated in one pa­tient with HCC, a partial response in threepatients (one HCC and two metastatic), sta­ble disease in two patients, and progressionin five patients. Median survival for colorec­tal lesions was 15 months (range, 2-23months) from start of the occlusions. Four ofnine patients developed calcifications oftheir lesions during therapy. One patientwith HCC was alive and free of disease 18months after the start of the occlusions.Both patients with HCC had an obstructedportal vein which may have contributed tothe favorable outcome. The occluder wasuniformly accepted by the patients who wereable to do their occlusions at home.AUTHORS'ABSTRACT

Diagnostic Value of Brush Cytology inthe Diagnosis of Bile Duct Carcinoma:A Study in 65 Patients with Bile DuctStrictures. Mordechai Rabinovitz, AlbertB. Zajko, Tarek Hassanein, et al. Hepatol­ogy 1990; 12:747-752. (M.R., 1000 J ScaifeHall, University of Pittsburgh School ofMedicine, Pittsburgh, P A 15261)

• Malignant strictures of the extrahepaticbile ducts are difficult to distinguish frombenign strictures, particularly in patientswith primary sclerosing cholangitis. Becauseattempts at diagnosing small cancers withfine-needle aspiration biopsy are not possi­ble in the absence of an associated mass le­sion and because the sensitivity of exfoliativebiliary cytology is controversial, brush cytol­ogy has been used as a potential means of es­tablishing a specific diagnosis of bile ductcarcinoma. Herein the authors report theirexperience with this technique when per­formed on 65 patients over a 5-year period.Each had at least one brushing. Thirty-sevenwere found to have bile duct carcinoma and28 were found to have benign strictures. Ofthese 37, the first brushing was positive formalignancy in 15 (40%), whereas four (11%)had cells suspected but not diagnostic of ma­lignancy. Thirteen patients with bile ductcarcinoma whose initial brushings were nega­tive for malignancy had second brushings. Ofthese, five (38%) had malignant cells, where­as three (24%) yielded Iluspicious cells. Threeof the eight whose first two brushings werenegative for malignancy were found to have

malignant cells on the third brushing. Incontrast, of the 28 patients with benign stric­tures, malignant cells were never found.However, in two patients, suspicious cellswere reported with the first but not the sec­ond brushing. A single negative or suspiciouscytological finding decreased the probabilityof bile duct carcinoma to 43%. Two and threesequential negative tests reduced the proba­bility to 32% lU).d 0%, respectively. When sus­picious cytological findings were excludedfrom the negative results, the probability ofhaving bile duct carcinoma was further re­duced to 41%, 20%, and 0%, respectively. Onthe basis of these results, it is concluded that(a) a single cytological brushing of a bile ductstricture has a low yield, (b) the sensitivity ofthe test increases with repeated attempts,(c) the probability of having bile duct carci­noma after three sequential negative cyto­logical brushings is very low «6%), and(d) these data provide evidence for the use­fulness of percutaneo\ls transhepatic cholan­giographyand bile duct cytological findingsin establishing a diagnosis of bile duct cancer.AUTHORS'ABSTRACT

The Effect of Ursodiol on the Efficacyand Safety of Extracorporeal Shock­Wave Lithotripsy of Gallstones: TheDornier National Biliary LithotripsyStudy. Leslie J. Schoenfield, GeorgeBerci, Richard L. Carnovale, et al. N EnglJ Med 1990; 323:1239-1245. (L.J.S., Divi­sion of Gastroenterology, Cedars-SinaiMedical Center, 8700 Beverly Blvd, Suite7511, Los Angeles, CA 90048)

• Background. In the treatment of gall­stones with extracorporeal shock-wave litho­tripsy, the bile acid ursodiol is administeredto dissolve the gallstone fragments. Thisstudy was designed to determine the value ofadministering this agent. Methods. At 10centers, 600 symptomatic patients with threeor fewer radiolucent gallstones 5-30 mm indiameter, as visualized by oral cholecystog­raphy, were randomly assigned to receive ur­sodiol or placebo for 6 months, starting 1week before lithotripsy. Results. The stoneswere fragmented in 97% of all patients, andthe fragments were less than or equal to 5mm in diameter in 46.8%. On the basis of anintention-to-treat analysis of a11600 pa­tients, 21% receiving ursodiol and 9% receiv­ing placebo (P < .0001) had gallbladders thatwere free of stones after 6 months. Amongthose with completely radiolucent solitarystones less than 20 mm in diameter, 35% ofthe patients receiving ursodiol and 18% ofthose receiving placebo (P < .001) were free

of stones after 6 months. Biliary pain, usual­ly mild, occurred in 73% of all patients but inonly 13% of those who were free of stones af­ter 3 and 6 months (P < .01). There were fewadverse events. Only diarrhea occurred witha significantly different frequency in the twogroups: 32.6% were affected in the ursodiolgroup, as compared with 24.7% in the place­bo group (P < .04). Severe biliary pain oc­curred in 1.5% of all patients, acute cholecys­titis in 1.0%, and acute pancreatitis in 1.5%;endoscopic sphincterotomy was performed in0.5%, and cholecystectomy in 2.5%. Conclu­sions. Extracorporeal shock-wave lithotripsywith ursodiol was more effective than litho­tripsy alone for the treatment of symptomat­ic gallstones, and equally safe. Treatmentwas more effective for solitary than multiplestones, radiolucent than slightly calcifiedstones, and smaller than larger stones.AUTHORS'ABSTRACT

Piezoelectric Lithotripsy: Stone Disin­tegration and Follow-up Results in Pa­tients with Symptomatic GallbladderStones. Christian Ell, Willibald Kerzel, H.Thomas Schneider, et al. Gastroenterol­ogy 1990; 99:1439-1444. (C.E., Depart­ment of Medicine I, University of Erlang­en-Nuremberg, Krankenhausstrasse 12,D-8520 Erlangen, Germany)

• One hundred symptomatic patients withradiolucent gallbladder stones were treatedwith a new piezoelectric lithotripter and oralchemolitholytic agents. Stone disintegrationwas achieved in 99 of these patients (99%)with a mean (±SD) maximum fragment sizeof 5.1 mm ± 4.1. Significant differences werefound when the mean (±SD) fragment sizesof single stones less than or equal to 20 mm(4.2 mm ± 2.5) were compared with those ofsingle stones greater than 20 mm (5.8 mm ±3.4; P < .05) and multiple stones (6.2 mm ±3.8; P < .05), respectively. None of the pa­tients required anesthetics, analgesics, orsedatives before or during the treatment.The stone-free rates for all patients followedup for up to 4-12 months (mean ± SD, 10.7months ± 2.9) were 18% (1 month), 25% (2months), 38% (4 months), 52% (8 months),and 67% (12 months). Partly significant dif­ferences were obtained in stone-free rates forsingle stones (~20 mm) compared with larg­er stones (>20 mm) and multiple stones (P <.05), respectively. Serious adverse reactions(ie, cholestasis and pancreatitis) were ob­served in only three patients (3%). Theseconditions were induced by fragment impac­tion in the common bile duct. In two of thesepatients, endoscopic retrograde cholangio-

pancreatography with endoscopic sphincter­otomy was required. It is concluded that pi­ezoelectrically generated shock waves aresuitable for the effective and safe disintegra­tion of gallbladder stones in humans. Theanesthesia-free and analgesia-free shockwave application opens up the possibility toperform biliary lithotripsy as an outpatientprocedure. The stone-free rate achieved incombination with oral bile acids is mostpromising for single stones (~20 mm).AUTHORS' ABSTRACT

Diagnosis and Percutaneous Treat­ment of Pyogenic Hepatic Abscesses. P.Hochbergs, L. Forsberg, E. Hederstrom, eta1. Acta Radiologica 1990; 31:351-353.(P.H., Department of Diagnostic Radiolo­gy, University Hospital, S-221 85 Lund,Sweden)

• Twelve patients with intrahepatic ab­scesses were examined with computed to­mographyand ultrasonography (US) be­tween 1979 and 1988. The median size of thelesions was 7 em (range, 1-12 em). In eightpatients, they were located only in the rightliver lobe, and in three patients, in both liverlobes. At US the echogenicity of the abscess­es varied from hypo- to hyperechoic, which isconsistent with tumours. The final diagnosisof abscess was achieved at fine needle punc­ture and aspiration for bacterial culture.Nine patients were treated with percutane­ous drainage, three of them with two cathe­ters, and all received systemic antibiotictreatment. All patients survived the treat­ment.AUTHORS'ABSTRACT

Ascending Cholangitis: Surgery versusEndoscopic or Percutaneous Drainage.H. S. Himal, T. Lindsay. Surgery 1990;108:629-634. (H.S.H., Toronto WesternMedical Bldg, 25 Leonard Ave, No. 404A,Toronto, Ontario, Canada M5T 2R2)

• A retrospective review of 61 patientswith calculous cholangitis was carried out.There were 31 men and 30 women, and theirmean age was 75.8 years. All patients had ab­dominal pain, 87% had chills and fever, 65%had clinical jaundice, 26% were in shock, and54% had positive blood cultures. Because in­travenous hydration and antibiotics did nothelp, 33 patients underwent surgery, 25 pa­tients underwent endoscopic papillotomy(EP), and three patients underwent percuta­neous transhepatic drainage of the commonbile duct (PTD). Morbidity in the surgerygroup included two wound infections, one

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Volume 2 Number 2

respiratory failure, and one renal failure.Morbidity in the EP-PTD group was onecase of arterial bleeding requiring surgeryand one of pancreatitis treated conservative­ly. Two patients (6%) died in the surgerygroup, one of sepsis and the other of cardio­respiratory arrest. In the EP·PTD groupnine patients (32%) died of sepsis and multi­system organ failure. These patients wereconsidered too ill to undergo surgery, andthus repeat EP-PTD was carried out. Chol­angitis persisted, and retained common bileduct stones with sepsis was the cause ofdeath. Thus when initial EP or PTD is un­successful, surgical exploration of the com­mon bile duct should be carried out to con­trol sepsis.AUTHORS' ABSTRACT

Early Results of Combined Electrohy­draulic Shock-Wave Lithotripsy andOral Litholytic Therapy of Gallblad­der Stones at the University of Iowa.James W. Maher, Robert W. Summers,Thomas R. Dean, et al. Surgery 1990;108:648-654. (J.W.M., Section of Gastro­intestinal Surgery, University of IowaHospitals and Clinics, Iowa City, IA52242)

• One hundred thirty-three patients wereentered into a randomized, double-blind,placebo-controlled trial of extracorporealshock-wave lithotripsy for symptomatic gall­stones versus extracorporeal shock-wavelithotripsy plus adjuvant litholytic therapywith ursodeoxycholic acid (UDCA). Sixmonths after lithotripsy, patients receivingplacebo were crossed over to UDCA therapywithout unblinding the study. One hundredsixteen patients have complete 6 months offollow-up. Five patients were dropped fromthe study. Nine percent have required chole­cystectomy (11 patients with biliary colicand one with acute cholecysHJ;is). Ninety-onepatients had a solitary stone (64 patients hadstones ~ 20 mm and 27 patients had stones> 20 mm in diameter), and 25 patients hadtwo to three stones. Fifty percent were re­treated. Cumulative stone-free rates at 6, 12,and 18 months were 26%, 39%, and 41%, re­spectively. At 6 months there was a signifi­cant advantage for patients treated withUDCA versus placebo (36% vs 17% werestone free) that had disappeared by 12months (placebo-treated patients had re­ceived 6 months of UDCA). Patients withsolitary stones equal to or less than 20 mm indiameter treated with UDCA had stone-freerates at 6, 12, and 18 months of 58%, 58%,and 62%, respectively, versus 27%, 56%, and

300 • Journal of Vascular and Interventional Radiology

May 1991

50%. The difference was significant only atthe 6-month follow-up. Stone-free rates forpatients with large solitary stones and multi­ple stones were very low. Extracorporealshock-wave lithotripsy is both safe and effec­tive therapy for treatment of symptomaticgallstones in patients with a solitary stoneequal to or less than 20 mm in diameter.UDCA markedly improves the efficiency ofthe procedure and results in a stone-freegallbladder sooner.AUTHORS'ABSTRACT

I GENITOURINARY

Penile Vein Ligation for Corporeal In­competence: An Evaluation of Short­term and Long-term Results. BarryRossman, Maria Mieza, Arnold Melman. JUro11990; 144:679-682. (From the De­partment of Urology, Montefiore MedicalCenter/Albert Einstein College of Medi­cine, Bronx and Department of Radiology,Beth Israel Hospital, New York)

• Dynamic cavernosometry and caverno­sography can be used to identify patientswith corporeal venous incompetence as acause of erectile dysfunction. The authors re­viewed a series of 16 patients with venousleakage who underwent surgical correction ofthe specific abnormality identified on caver­nosography. Short-term and long-term re­sults were obtained, and while at least tem­porary improvement was noted in 89.5% ofthe patients, the long-term results tended toshow a reversion to the preoperative statusin the majority.AUTHORS' ABSTRACT

Endopyelotomy: Long-term Follow-upof 143 Patients. Markus Kuenkel, KnutKorth. J Endourol1990; 4:109-116. (K.K.,Department of Urology, Loretto Hospital,Freiburg, Germany)

• Between 1982 and September 1989, 180patients with primary or secondary pyeloure­teral junction obstruction underwent endo­pyelotomy. Of these, 143 have been followedup for as long as 43 months (mean, 12.4months; SD, 7.3 months). Clinical findings,isotope nephrography, and intravenous urog­raphy (lVU) were considered in preoperativeand postoperative evaluation. Depending onthe preoperative extent of hydronephrosis atIVU, we found good and very good results in85% of the cases. Results were more favor­able in primary stenoses. The outcome wasdependent on stenting time. Shorter stenoses

turned out better than long ones, and olderpatients seemed to have more favorable re­sults. Renal calculi had a negative effect onthe success rate. Fourteen recurrences wereobserved; these patients underwent another,successful, percutaneous trial. In no case wasopen surgical intervention necessary. Theauthors conclude that endopyelotomy is asafe endourologic procedure with long-termsuccess rates comparable to the results ofopen plastic surgery.AUTHORS' ABSTRACT

Transcervical Balloon Tuboplasty: AMulticenter Study. Edmond Confino,Han Tur-Kaspa, Alan DeCherney, et al.JAMA 1990; 264:2079-2082. (N. Gleicher,Center for Human Reproduction, 750 NOrleans St, Chicago, IL 60610)

• Transcervical balloon tuboplasty repre­sents a noninvasive technique to treat proxi­mal tubal occlusion. In a multicenter study,77 women with confirmed bilateral proximaltubal occlusion underwent the procedure. In71 patients (92%), at least one proximally ob­structed fallopian tube was recanalized. Con­comitant distal bilateral tubal occlusionswere diagnosed after successful proximaltubal balloon recanalizations in 13 patients(17%). In the remaining 64 patients, 22 clini­cal pregnancies (34%) have been confirmedduring a median follow-up period of 12months. Among those, 17 (77%) resulted innormal deliveries and five (23%) resulted in afirst-trimester miscarriage. One patient wasdiagnosed with an ectopic pregnancy. Among25 patients who had not conceived within 6months of the procedure, 17 (68%) demon­strated continuing tubal patency on repeatedhysterosalpingogram. The authors concludethat transcervical balloon tuboplasty is asafe outpatient technique that may representan alternative to in vitro fertilization or mi­crosurgical reanastomosis of fallopian tubes.AUTHORS'ABSTRACT

I HEAD AND NECK

Does Carotid Restenosis Predict an In­creased Risk of Late Symptoms,Stroke, or Death? Eugene F. Bernstein,Schlomo Torem, Ralph B. Dilley. AnnSurg 1990; 212:629-636. (E.F.B., ScrippsClinic and Research Foundation, 10666 NTorrey Pines Rd, La Jolla, CA 92037)

• The identification of carotid restenosisas an unexpected late complication of carotidendarterectomy has prompted concerns re-

garding its importance as a source of newcerebral symptoms, stroke, and death. To in­vestigate these concerns, the authors ana­lyzed a consecutive series of 507 patients un­dergoing 566 carotid endarterectomies, eachdocumented as technically satisfactory.Postoperative duplex Doppler examinationdata at 3 days, 1, 3, 6, 12 months, and annu­ally thereafter in 484 arteries (85.5%) permit­ted classification of these arteries accordingto the most severe degree of postoperativestenosis: normal (n = 306); 1%-19% (n = 89);20%-50% (n = 40); and more than 50% (n =49, including eight occluded). The incidenceof more than 50% restenosis was 14.5% in fe­male patients and 7.7% in male patients (P =.003). Life table analyses to 10 years revealeda significantly greater life expectancy amongthose with restenosis (P = .05). Stroke wasalso less likely in patients with restenosis, al­though this difference did not reach statisti­cal significance. When survival and strokewere both endpoints, the likelihood of pa­tients with more than 50% restenosis remain­ing alive and stroke free was also greaterthan the less than 20% stenotic group (P =.03). Thus patients with carotid restenosiswere less likely than patients with normalpostoperative scans to have late symptoms,stroke, or early death.AUTHORS'ABSTRACT

Carotid-Subclavian Bypass: A Decadeof Experience. Bruce A. Perler, G. Mel­ville Williams. J Vase Surg 1990; 12:716­723. (B.A.P., Department of Surgery, TheJohns Hopkins Hospital, 600 N Wolfe St,Baltimore, MD 21205)

• From August 1979 to August 1989, carot­id-subclavian bypass or transposition proce­dures were performed on 18 women and 13men ranging in age from 19 to 75 years(mean, 58.2 years). Indications for surgeryincluded symptoms of vertebrobasilar insuf­ficiency in 16 (52%), upper extremity isch­emia in six (19%), both vertebrobasilar insuf­ficiency and extremity ischemia in four(13%), and stroke and/or hemispheric tran­sient ischemic attacks in four (13%) patients.One patient (3%) had angina pectoris causedby "coronary-subclavian steal." Formal by­pass grafts were performed in 28 cases (90%)by means of polytetrafluoroethylene (n =24), Dacron (n = 2), or saphenous vein (n =2), and carotid-subclavian transposition wasperformed in three cases (10%). Synchronousprocedures included carotid endarterectomy(n = 4), carotid-carotid bypass (n = 1), andaxillobrachial bypass (n = 1). There was nooperative mortality. Thirty-day primary pa-

tency was 97%. Follow-up has ranged from 1to 121 months (mean, 42 months). Threegrafts (polytetrafluoroethylene) have occlud­ed during follow-up yielding long-term pri­mary patency of 92% at 5 years and 83% at 8years. Relief of symptoms was initiallyachieved in 30 patients (97%). Recurrentsymptoms have developed in six patients(20%) from 2 to 55 months after surgery(mean, 26 months), including two with oc­cluded and four with patent grafts. Symp­tom-free survival is 89% at 1 year, 84% at 2years, and 71% at 7 years offollow-up. Sixpatients have died during follow-up yieldingoverall survival of 88% at 5 years, and 48% at10 years. Carotid-subclavian bypass and ca­rotid-subclavian transportation are safe, ef­fective, and have the necessary long-termdurability to justify their preferential use forsubclavian reconstruction in a patient popu­lation with excellent long-term survivability.AUTHORS'ABSTRACT

The Natural History of SymptomaticArteriovenous Malformations of theBrain: A 24-year Follow-up Assess­ment. Stephen L. Ondra, Henry Troupp,Eugene D. George, et al. J Neurosurg1990; 73:387-391. (S.L.O., Division ofNeurosurgery, Walter Reed Army MedicalCenter, Washington, DC, 20307-5001)

• The authors have updated a series of 166prospectively followed unoperated symptom­atic patients with arteriovenous malforma­tions (AVMs) of the brain. Follow-up datawere obtained for 160 (96%) of the originalpopulation, with a mean follow-up period of23.7 years. The rate of major rebleeding was4.0% per year, and the mortality rate was1.0% per year. At follow-up review, 23% ofthe series were dead from AVM hemorrhage.The combined rate of major morbidity andmortality was 2.7% per year. These annualrates remained essentially constant over theentire period of the study. There was no dif­ference in the incidence of rebleeding ordeath regardless of presentation with orwithout evidence of hemorrhage. The meaninterval between initial presentation andsubsequent hemorrhage was 7.7 years.AUTHORS'ABSTRACT

The Carotid Ghost: A Color DopplerUltrasound Duplication Artifact. Wil­liam D. Middleton, G. Leland Melson. JUltrasound Med 1990; 9:487-493.(W.D.M., Mallinckrodt Institute of Radi­ology, Washington University School ofMedicine, 510 S Kingshighway Blvd, St.Louis, MO 63110)

• Color Doppler ultrasound examinationsof the neck frequently demonstrate an arti­factual region of color assignment deep tothe common carotid artery that simulatesblood flow in deep cervical arteries. Based onanalysis of imaging performed on 10 normalvolunteers, it was shown that the pulsedDoppler waveform originating from the arti­fact was identical to that of the common ca­rotid artery. It was also shown that the arti­fact was always located deep to the commoncarotid artery regardless of location and po­sitioning of the transducer. In vitro modelingusing a flow phantom confirmed that the ap­pearance was artifactual in nature. Themechanism of production most likely is re­lated to a mirroring phenomenon at the deepwall of the common carotid artery.AUTHORS' ABSTRACT

Brain Microemboli during CardiacSurgery or Aortography. D. M. Moody,M. A. Bell, V. R. Challa, et a1. Ann Neurol1990; 28:477-486. (D.M.M., Departmentof Radiology, Bowman Gray School ofMedicine, Wake Forest University, Win­ston-Salem, NC 27103)

• The authors observed many focal dilata­tions or very small aneurysms in terminal ar­terioles and capillaries of four of five pa­tients and six dogs who had recently under­gone cardiopulmonary bypass. A smallernumber of sausagelike dilatations distendedmedium-sized arterioles. Two other patientshad a small number of the same microvascu­lar changes following proximal aortography.Thirty-four patients and six dogs not under­going cardiopulmonary bypass had none. (A35th patient who had not undergone cardio­pulmonary bypass or aortography showed asmall number of dilatations; mediastinal airwas a suggested source.) Some of the dilata­tions exhibited various forms of birefrin­gence. Because most of the dilatations ap­pear empty, the authors speculate that theyare the sites of gas bubbles or fat emboli thathave been removed by the solvents used inprocessing. These microvascular events, oc­curring only in conjunction with major arte­rial interventions, may be the anatomicalcorrelate of the neurological deficits or mod­erate to severe intellectual dysfunction seen

Abstracts. 301

Volume 2 Number 2

in at least 24% of patients after cardiac surgi­cal procedures assisted by cardiopulmonarybypass.AUTHORS'ABSTRACT

Pre-operative Micro-angioplasty ofRefractory Vasospasm Secondary toSubarachnoid Hemorrhage. J. E. Dion,G. R. Duckwiler, F. Vifiuela, et a1. Neuro­radiology 1990; 32:232-236. (J.E.D.,UCLA School of Medicine, Department ofRadiological Sciences, 10833 Le ConteAve, # BR-132, Los Angeles, CA 90024­1721)

• A patient with subarachnoid hemorrhagesecondary to a basilar artery aneurysm de­veloped severe bilateral middle and anteriorcerebral artery vasospasm with extensiveneurologic deficits. Microangioplasty of themiddle cerebral artery segments bilaterallyled to reversal of the neurologic deficits, al­lowing early operative treatment of the aneu­rysm in a previously inoperable patient.AUTHORS' ABSTRACT

I PEDIATRICS

Percutaneous Inferior Vena CavaPlacement of Tunneled Silastic Cathe­ters for Prolonged Vascular Access inInfants. Laura J. Robertson, Paul F. Ja­ques, Matthew A. Mauro, et al. J PediatrBurg 1990; 25:569-598. (L.J.R., Depart­ment of Radiology, University of NorthCarolina/NCMH, Chapel Hill, NC 27514)

• In infants and children requiring pro­longed and multiple central venous catheter­izations, conventional cannulation sites maybecome thrombosed or stenotic, making in­ability to gain vascular access a life-threaten­ing problem. The technique used by the au­thors for the percutaneous placement of infe­rior vena caval tunneled silastic catheters viathe translumbar and transhepatic approach­es is described. Three translumbar place­ments and one transhepatic placement inthree children without immediate complica­tions have been performed. The authors con­clude that percutaneous inferior vena cavalcannulation via the translumbar or transhe­patic routes offers a viable alternative inthese patients with difficult vascular access.AUTHORS'ABSTRACT

302 • Journal of Vascular and Interventional Radiology

May 1991

I TECHNOLOGY

Dependence of the XeCI Laser CutRate of Plaque on the Degree of Calci­fication, Laser Fluence, and OpticalPulse Duration. Rod S. Taylor, LyallA.J. Higginson, Kurt E. Leopold. LasersSurg Med 1990; 10:414-419. (R.S.T., Divi­sion of Physics, National Research Coun­cil of Canada, Ottawa, Canada KIA OR6)

• A XeCllaser with an optical pulse dura­tion of 35 nsec was used to determine the cutdepth per laser pulse of postmortem humanaorta as a function of laser fluence for fourmain categories of plaque development. Thedata indicate that the cut depth per pulseprogressively decreases as the degree of calci­fication increases even at very high (100 mJ/mm2) laser fluences. A comparison was madebetween the XeCllaser cut rate data ob­tained using the 35-nsec duration laserpulses to data obtained using 200-nsec dura­tion pulses for each of the four plaque types.As the degree of tissue calcification in­creased, higher XeCllaser fluences were re­quired for the long pulse case to achieve thesame cut depth per pulse as that observedusing the shorter pulse duration.AUTHORS'ABSTRACT

Early and Late Arterial Healing Re­sponse to Catheter-induced Laser,Thermal, and Mechanical Wall Dam­age in the Rabbit. Antonius Oomen, Lie­selotte van Erven, Walda V.A. Vanden­broucke, et al. Lasers Surg Med 1990;10:363-374. (C. Borst, Experimental Car­diology Laboratory, Heart Lung Institute,University Hospital Utrecht, Heidelberg­laan 100, 3584 CX Utrecht, The Nether­lands)

• Pulsed lasers are being promoted for la­ser angioplasty because of their capacity toablate obstructions without producing adja­cent thermal tissue injury. The implicit as­sumption that thermal injury to the artery isto be avoided was tested. Thermal lesionswere produced in the iliac arteries and aortaof normal rabbits by (a) electrical spark ero­sion, (b) the metal laser probe, and (c) con­tinuous-wave neodymium-yttrium aluminumgarnet (Nd-YAG) laser energy through thesapphire contact probe. High energy doseswere used to induce substantial damagewithout perforating the vessel wall. Thermallesions (n = 77) were compared with me-

chanicallesions (n = 22) induced by over­sized balloon dilation. Medial necrosis wasinduced by all four injury methods. Providedno extravascular contrast was observed afterthe injury, all damaged segments were pa­tent after 1-56 days. The progression of heal­ing with myointimal proliferation was re­markably similar for all injuries. At 56 days,the neointima measured up to 370 J'm. Inconclusion, provided no perforation withcontrast extravasation occurred, the normalrabbit artery recovered well from transmuralthermal injury. The wall healing response islargely nonspecific.AUTHORS' ABSTRACT

Thermal Laser Probe Angioplasty: In­fluence of Constant Tip Temperature,Plaque Composition, and Probe/VesselDiameter Ratio. G. Michael Vincent, Jo­lene Fox, Michael D. Johnson, et al. La­sers Surg Med 1990; 10:420-426. (G.M.V.,Department of Medicine, LDS Hospital,Eighth Ave and CSt, Salt Lake City, UT84143)

• Thermal laser angioplasty uses constantlaser power, producing widely variable tiptemperatures in vivo. Results have been sub­optimal. The authors studied the effect of50°-400°C tip temperatures on depth of ab­lation at 192 sites on plaqued and normal hu­man aorta in vitro, and the angiographic andhistologic response in vivo of 300°-400°C atprobe/vessel ratios of 0.5-1.0, in 40 normalcanine femoral artery segments. In vitro,there was a direct relationship between tiptemperature and depth of ablation (r = .71[all segments], r = .74 for fibrous plaque),but a poor correlation in fatty plaque (r =.35). In fibrous plaque, there was proportion­ately more ablation at tip temperaturesgreater than 300°C (mean depth, 0.62 mm)than at 150°-300°C (mean depth, 0.37 mm;P < .001). Ablation was similar in plaquedand normal aorta. In vivo, 300°C, 350°C, and400°C produced similar effects. At probe/vessel ratios less than 0.8, only disruption ofinternal elastic lamina was observed. At ra­tios greater than or equal to 0.8, spasm oc­curred in 39% (seven of 18), transmural dam­age in 28% (five of 18), and perforation inone of 18. Ablation is not selective for plaqueand is highly variable in fatty plaque. Tip tem­peratures above 300°C produce greater abla­tion than at lower temperatures. In clinical ap­plications, probe/vessel ratio less than or equalto 0.7 may be most appropriate, and it appearsthat thermal remodeling may contribute moreto outcome than plaque ablation.AUTHORS'ABSTRACT

I CONTRAST MATERIAL

Safety of Cardiac Angiography withConventional Ionic Contrast Agents.John W. Hirshfeld, Jr, William G. Kuss­maul, Peter M. DiBattiste, et al. Am JCardiol1990; 66:355-361. (J.W.H., Cardi­ac Catheterization Laboratory, Hospitalof the University of Pennsylvania, 3400Spruce St, Philadelphia, PA 19104)

• To characterize the frequency of adversereactions to conventional ionic contrastagents, data describing the frequency of suchreactions were gathered from 4,630 diagnos­tic cardiac angiographic procedures. The pa­tient population had a large prevalence of se­vere or unstable cardiac disease (56% hadNew York Heart Association class III, IV, orV; 12.6% had left ventricular end-diastolicpressure >25 mm Hg, and 34% had three­vessel or left main coronary artery disease).The overall minor adverse reaction rate was14.2%. Major adverse reactions (requiringtreatment) occurred in 61 (1.3%) procedures.All adverse reactions were managed success­fully, and there were no deaths. Adverse re­actions were more frequent in patients withhigher New York Heart Association classesand with elevated left ventricular end-dia­stolic pressure. The adverse reaction ratewas not increased in patients with more ex­tensive coronary artery disease, reduced leftventricular ejection fraction, or reduced car­diac index. The overall adverse reaction ratewas probably influenced by physician behav­ior. Smaller volumes of contrast agent wereadministered to patients with more severecardiac disease. Six percent of procedureswere abbreviated because of either an ad­verse reaction or concern that a reactionmight occur if the procedure were continued.As a result, the diagnostic data obtainedwere judged to be inadequate in 0.8% of pro­cedures. These data demonstrate that appro­priate operator caution within the highlymonitored environment of the cardiac cathe­terization laboratory allows cardiac angiogra­phy to be performed safely with convention­al ionic contrast agents in most patients.Nonionic contrast agents may offer an ad­vantage of providing greater safety and al­lowing a better study completion rate in pa­tients who are severely ill and hemodynami­cally precarious.AUTHORS' ABSTRACT