Aberrant right subclavian artery--esophageal fistula: a cause of overwhelming upper gastrointestinal hemorrhage

A patient had massive hematemesis due to a fistula between an unsuspected aberrant right subclavian artery and the esophagus, with the fistula caused by prolonged esophageal intubation. Lack of awareness of this complication delayed the correct diagnosis, which was eventually made at a second angiographic study. With knowledge of the fistula, this potentially fatal situation can be promptly diagnosed by endoscopy and emergency angiography. Transcatheter embolization is suggested as a potential alternative to surgery in the treatment of the aberrant right subclavian artery--esophageal fistula.

Iatrogenic intrahepatic arterial-portal fistula

We describe a case of an iatrogenic intrahepatic arterial-portal fistula that developed after percutaneous transhepatic variceal embolization. The fistula led to early recurrent bleeding after embolization and was successfully treated by selective catheter occlusion with the use of a coil spring. The occurrence and management of arterial-portal fistulae in interventional liver procedures and ethanol embolization of gastroesophageal varices are discussed.

Clinical outcome after percutaneous transhepatic obliteration of esophageal varices

A 4.5-yr experience with percutaneous transhepatic obliteration of gastroesophageal varices in 49 patients is reviewed with respect to technical success, control of active hemorrhage, rebleeding frequency, survival, and complications to better define clinical guidelines regarding its application. The procedure was successfully completed in 94% (46 of 49) of patients, and complete obliteration of all variceal feeder vessels was achieved in approximately one-half (52%). Variceal hemorrhage was controlled in three-quarters (76%) of actively bleeding patients, and recurrent hemorrhage occurred in 65% of patients at mean follow-up of 33 wk. Complete obliteration of all variceal feeder vessels was found not to be necessary from a technical standpoint, because the frequency of control of active hemorrhage and rebleeding were not significantly different in those patients having partial as compared with complete obliteration. In comparison with the reported outcome following standard medical therapy of bleeding varices, survival after variceal obliteration appears similar, but death from hemorrhage may be reduced. The interval to rebleeding is longer in patients having elective variceal obliteration after medical control of hemorrhage than in actively bleeding patients undergoing urgent obliteration of varices. The complication rate of obliteration was acceptable, but Child's class C patients with uncontrolled hemorrhage were a subgroup that experienced high mortality and derived little benefit from obliteration. Variceal obliteration is most appropriate in the bleeding but medically stabilized patient or the inoperable patient with recurrent bleeding. Active bleeding is most often controlled and recurrent bleeding may be prevented for several months, thus allowing consideration of elective shunt surgery.

Transluminal expandable nitinol coil stent grafting: preliminary report

A method is described for the percutaneous catheter placement of expandable nitinol coil stents for the nonoperative restoration and maintenance of patency in internal flow pathways, especially the lumina of blood vessels and biliary ducts.

Percutaneous vaso-occlusion for nonmalignant renal lesions

Transarterial renal embolization has been used in the management of renal cancer. We report on 9 patients who underwent selective and superselective renal arterial embolization for nonmalignant renal lesions. Embolization was done in 5 patients for hemorrhage owing to renal angiomas, renal artery, pseudoaneurysm, percutaneous renal biopsy and adult polycystic kidney disease, and in 2 patients with end stage renal disease because of massive proteinuria. Another chronic renal failure patient with severe hypertension was treated successfully with bilateral renal embolization. A postoperative renal arteriovenous fistula was treated successfully by catheter vaso-occlusion. Renal embolization may be a suitable alternative to surgery in poor operative risk patients and for technically difficult benign lesions. Renal infection is a contraindication to embolization.

Percutaneous embolization of bony pelvic neoplasms with tissue adhesive

Eight patients with tumors of the bony pelvis underwent embolization with isobutyl-2-cyanoacrylate (IBCA). Five patients had primary bone tumors, of which 2 were malignant and 3 were benign; 3 patients had metastases to the bony pelvis from the thyroid gland, kidney, and femur, respectively. Embolization was performed to minimize blood loss during resection of a giant-cell tumor in one patient and insertion of a hip prosthesis in another who had metastatic renal carcinoma. It was also done prior to scheduled surgery in one of the patients with aneurysmal bone cyst, but healing was sufficient to cancel the operation; in the other patient, embolization was the only therapy. Palliative embolization was performed in 4 patients with malignant tumors after other means failed to control pain or slow progression. IBCA appears to be an efficient means of occluding the vessels feeding selected primary bone tumors and metastases.

Transhepatic obliteration of gastroesophageal varices with absolute ethanol

Absolute ethanol was evaluated as a vaso-obliterative agent in 15 patients with bleeding of gastroesophageal varices. Initial control of hemorrhaging was obtained in 13 (87%). Two patients died from unrelated causes within 48 hours of the procedure. Variceal bleeding recurred in seven of the 11 remaining patients (64%) from one week to 13 months after embolization. Four patients did not rebleed; two of them died (4 weeks and 6 months after the procedure), and two are alive (14 and 16 months after the procedure). Significant disadvantages of ethanol for obliteration of gastroesophageal varices (marked prolongation of procedure time and lack of radio-opacity) probably contributed to the high incidence of portal vein thrombosis (3 patients [20%]).

Glucagonoma and its angiographic diagnosis

Four patients with metastatic glucagonoma are described. Angiography demonstrated a small avascular primary tumor of the tail of the pancreas in one patient and large hypervascular tumors of the pancreatic head in the other three. Liver metastases, were hypervascular in all four. Including our 4 with 21 cases from the literature, glucagonomas show a 92% incidence of increased tumor vascularity--thus increasing the likelihood of successful angiographic diagnosis. The awareness of clinically subtle or atypical glucagonomas and use of plasma glucagon determination are important factors leading to early diagnosis of these neoplasms. Since angiography can localize the tumor, assess its extent, and detect hepatic metastases, it is essential to the detailed evaluation of glucagonomas.

Pharmacoangiography in the diagnosis of recurrent massive lower gastrointestinal bleeding

The source of recurrent massive lower gastrointestinal bleeding can sometimes escape detection by conventional diagnostic measures. In such situations, bleeding can be directly provoked by pharmacoangiography using vasodilators, anticoagulants, and/or fibrinolytic agents. Heparin, streptokinase, and tolazoline, used separately or in combination, can augment, prolong, or reactivate transient, covert bleeding, thereby facilitating angiographic identification and localization of the lesion. Physiological, clinical, and angiographic factors are discussed. Although rarely needed, this useful and sometimes crucial diagnostic approach demands the combined skills and support of the radiologist, clinician, and surgeon.

Percutaneous interventional catheter therapy for lesions of the chest and lungs

Percutaneous, nonsurgical interventions using angiographic catheter techniques and radiologic guidance were used in the management of seven cases of various lesions of the chest and lungs. Successful catheter therapy included the embolization of a large, acquired, postinflammatory vascular malformation causing massive hemoptysis and a cavernous hemangioma of the chest wall. Sixteen pulmonary arteriovenous fistulas (one patient), an iatrogenic internal mammary artery-to-innominate vein fistula, and a persistent, postbiopsy bronchopleural fistula were successfully closed. Percutaneous drainage of a pyogenic lung abscess and the nonoperative retrieval of an intravascular foreign body that had embolized to the left pulmonary artery were also successfully achieved. Performed under local anesthesia with minimal morbidity, stress, and risk, interventional catheter therapy is remarkably cost-effective. Primary chest physicians are encouraged to consider this mode of therapy whenever applicable.

Percutaneous angiographic embolization: a procedure of increasing usefulness: review of a decade of experience

During the past decade percutaneous therapeutic vascular occlusion was performed on 152 occasions in 124 patients. The primary indication for vasoocclusive therapy was acute or recurrent bleeding. Upper gastrointestinal bleeding from arterial sources was controlled in 92 percent of patients and acute variceal bleeding in 83 percent. Renal embolization was performed for palliation of severe pain and hematuria from unresectable renal primary or secondary malignancies, to decrease blood loss and facilitate surgery in operable renal tumors, and for ablation of renal function to control chronic protein loss or severe hypertension. Our encouraging experience convinces us that transcatheter embolization is a useful, safe and effective procedure in selected patients. It seems certain that the technique of therapeutic embolization will be improved, its indications extended and its application become commonplace whenever angiographic skills and facilities exist.

Anatomical vs "Functional" left ventricular aneurysm: angiographic differentiation and management implication

Accurate diagnosis of the type of the left ventricular aneurysm (LVA) is essential for selection of appropriate surgical therapy. To assess the efficacy of angiography including conventional and dynamic ventriculography and coronary angiography in determining the LVA nature, 41 consecutive patients with various types of LVA, proven by surgery or autopsy, were evaluated. In all 22 patients with a "true", anatomical LVA, the angiographic diagnosis was correct. Nineteen patients had a "functional" LVA. In 16 of them studied by all three methods, the determination of the underlying pathologic process in the regions of wall motion abnormalities was correct; it corresponded to the findings at surgery in 15 patients, at autopsy in 1 patient, and also to follow-up angiographic studies in 12 patients. False diagnoses of an anatomical LVA were made at the beginning of the series in 3 patients in whom dynamic ventriculography was not used. On the basis of reported experience and review of the literature, findings important for differential diagnosis of individual lesions are emphasized. It is concluded, that a comprehensive evaluation of conventional left ventriculography complemented when necessary by dynamic ventriculography, together with coronary angiography, enables an accurate diagnosis in most cases. It is suggested that the term LVA be used for an anatomical aneurysm only; in patients with "functional" LVA an attempt should be made to determine the nature of the underlying processes, in particular to differentiate reversible from irreversible wall motion abnormalities.

Angiography in diagnosis and therapy of diffuse hepatocellular disease

Angiography is of value in the diagnosis and interventional therapy of diffuse hepatocellular disease. Hepatic arteriography is the primary diagnostic method; hepatic venography, portal venography, transvenous liver biopsy and direct cholangiography are complementary. They allow the assessment of type and stage of diseases, their hemodynamic consequences and permit the differentiation of diffuse diseases from tumorous processi. Selective vasopressin infusion and transhepatic catheter obliteration of varices are interventional techniques used to control massive bleeding from gastroesophageal varices--one of the most serious complications of diffuse hepatocellular diseases.

Retrograde pancreatic venography: autopsy study

Changes of the venous system in various pancreatic diseases were evaluated by retrograde pancreatic venographic studies done on 110 autopsy specimens of the pancreas. Fifty-one normal specimens exhibited well filled, regularly arranged veins. Postmortem autolysis (ten specimens) caused penetration of contrast medium into the parenchyma. Acute pancreatitis (six specimens) was associated with hypervascularity and venous irregularity. Chronic pancreatitis was associated with unevenly distributed venous deformities. Pseudocysts caused avascular foci which displaced adjacent vessels. Seven pancreatic cancers produced irregular encasement and occlusion of pancreatic and peripancreatic veins with thrombosis of major portal trunks-changes differing substantially from those caused by other diseases. Periancreatic cancer invading the pancreas caused encasement of superficial and occasionally deep pancreatic vessels. Acute leukemic infiltration demonstrated extreme deformity with complete structural disorder of intrapancreatic branches. Retrograde pancreatic venography, if used clinically, would enable radiographic diagnosis of the most common diseases of the pancrease.

Bleeding from esophageal varices exacerbated by splenic arterial-venous fistula: complete transcatheter obliterative therapy

A cirrhotic patient who had previously undergone both mesocaval shunting and transthoracic esophageal and gastric devascularization with splenectomy (Sugiura procedure) presented with recurring intractable variceal hemorrhage. Diagnostic visceral angiography demonstrated a large splenic arterial-venous fistula and gastroesophageal varices. Transarterial occlusion of the fistula and transheptic obliteration of the varices successfully done at one sitting prevented further bleeding. Follow-up angiography nine months later revealed persistent occlusion of the previous fistula and no evidence of esophageal varices.

The value of protamine following heparin-covered angiography: double-blind placebo-controlled study

Routine postprocedural administration of protamine sulfate has been advocated to offset the anticoagulant effect of prophylactic heparin given during transfemoral catheter angiography. The value of protamine is shown in a double-blind, randomized, placebo controlled series of 257 cases.

Retrograde pancreatic venography after reduction of the arterial visceral flow: an experimental study

To evaluate techniques for retrograde pancreatic venography similar to epinephrine renal venography, 35 dogs had transjugular portography before and after the infusion of various doses of vasopressin systemically or selectively into the superior mesenteric and celiac arteries, or after occlusion of the distal thoracic aorta. Increased filling of the peripheral portal branches resulted, but none of the techniques provided diagnostically useful enhanced pancreatic visualization.

Failure of antiplatelet and anticoagulant therapy to improve patency of grafts after coronary-artery bypass: a controlled, randomized study

Fifty patients who underwent aortocoronary saphenous-vein bypass-graft surgery were randomly assigned to one of three groups to determine the effects of antiplatelet or anticoagulant therapy on graft patency. Twenty-four patients served as controls; 13 patients received aspirin (325 mg three times a day) and dipyridamole (75 mg three times a day); and 13 patients received closely regulated warfarin therapy. Medications were begun on the third post-operative day. Six months after surgery, all patients underwent coronary angiography to assess graft patency. There were no statistically significant differences between groups in various clinical, hemodynamic and angios, 27 of 33 grafts (82 per cent) with aspirin and dipyridamole and 29 of 37 grafts (78 per cent) with warfarin (P less than 0.5), all patients had at least one patent graft. Postoperative treatment either with aspirin and dipyridamole or with warfarin failed to improve the patency of the grafts.

Fine-needle cholangiography (FNC) in the nonjaundiced patient

Fine-needle cholangiography (FNC) in the jaundiced patient is well established, but its role in the diagnostic work-up of nonjaundiced patients has not been emphasized. We present 44 consecutive nonjaundiced patients with a serum bilirubin level of 2.4 mg% of less who underwent FNC. The indications were recurrent RUQ pain (77%), painless cholestasis (16%), and relapsing pancreatitis (7%). In all but two patients, one or more inconclusive techniques [oral cholecystography, ultrasonography, intravenous cholangiography, or endoscopic retrograde cholangiography (ERC)] had been employed prior to FNC. Biliary tract opacification was successful in 35 of 44 (80%). In nine of 35 (26%) choledocholithiasis and/or cholelithiasis was present. In four (11%) a significant extrahepatic biliary stricture was noted. More than five needle insertions were often required for successful entry. No complications occurred. Indications for FNC should be extended to include nonjaundiced patients with RUQ pain or painless cholestasis in whom oral cholecystography, ultrasonography, and intravenous cholangiography have been of no diagnostic help. The relative ease and low cost of FNC make it preferable to ERC in these patients.

Angiography in the diagnosis and therapy of acute upper gastrointestinal bleeding

The value of angiography in the diagnosis and therapy of acute upper gastrointestinal bleeding is discussed. Based on experience with diagnostic angiography in over 350 acute gastrointestinal bleeders and therapeutic interventional angiography in more than 150 of them several principles are illuminated. Angiography should be used after emergency endoscopy and a trial of medical therapy. Selective vasoconstrictive therapy is highly effective in controlling bleeding from superficial mucosal lesions although less effective for bleeding from major arteries as is seen in peptic ulcers. Selective transcatheter occlusive therapy is a fast and effective method for controlling arterial bleeding in appropriates cases. For variceal bleeding low dose intravenous infusion of vasopressin is as effective in decreasing portal pressure and blood flow as is selective superior mesenteric infusion. Direct selective occlusion of gastroesophageal varices by the transhepatic approach is a new and exciting method of treatment for variceal bleeding.

Coronary bypass for stable angina: a prospective randomized study

To evaluate the effects of coronary-artery bypass, 100 patients with stable, disabling angina were randomized to medical (49) or surgical (51) therapy. There was no statistical difference in major cardiac events after three years (death in five medical vs. four surgical, infarction in eight vs. 10, and unstable angina requiring operation or reoperation in eight vs. three cases). Surgical patients with three-vessel disease had fewer major events (P less than 0.05) than the comparable medical group and less unstable angina requiring operation (P less than 0.02). All unstable angina was less frequent in the surgical group (15 vs. six, P less than 0.01). Functional classification improved more in surgical patients at six months (P less than 0.01) and at late followup examination (P less than 0.05). After six months, surgical patients achieved significantly higher exercise work loads (P less than 0.01), exercise heart rates (P less than 0.05), maximum paced heart rates (P less than 0.01) and myocardial lactate extraction (P less than 0.01). On the basis of this interim report of a relatively small group of patients, we conclude that bypass results in greater functional improvement and less unstable angina than medical therapy. The likelihood of death and myocardial infarction is unchanged by operation.

Value of angiography in the management of abdominal aortic aneurysm

The value of angiography in the management of abdominal aortic aneurysms (AAA) was assessed in 100 consecutive patients with AAA. Angiographic information influenced management decisons and/or surgery performance in 75: In 23 patients at high risk for surgery because of associated medical problems, it helped in deferring surgery; in 52 patients it resulted in a change of operation from a standard aneurysm resection with conventional grafting to a more conservative procedure (three patients), more extensive grafting (45 patients) and/or the addition of other vascular reconstructions (32 patients). Angiography is considered an integral step in the routine preoperative workup of AAA and is particularly valuable for the determination of important anatomic details about the aneurysm (upper and lower extensions, relation to the renal arteries), the detection of associated vascular disease (of renal, visceral, pelvic and peripheral arteries), and the demonstration of aberrant renal arteries and collateral visceral circulation. Catheter techniques are considered most suitable and safe for examination of AAA.

Fluoroscopic guidance in femoral artery puncture

Analysis of 100 femoral arteriograms demonstrated a consistent relationship between the course of the femoral artery and the femoral head. Fluoroscopic guidance can be of value in femoral puncture when the arterial pulse is diminished or obscured, for training purposes, and for analysis and correction of missed punctures.

"Vascular" benign liver cyst in children: report of two cases

Cyst wall vascularity not evident on abdominal aortography was demonstrated by selective magnification angiography in two children with complicated solitary, nonparasitic liver cysts. In one, its character and degree led to a false diagnosis of tumor. The observed mural vascularity probably reflected secondary changes of inflammation and necrosis in one case and prior surgery in the other case. Histologic findings in previously reported cases, however, indicate that, contrary to accepted angiographic beliefs, mural vascularity also occurs in many noncomplicated, simple liver cysts. Angiographers should be aware of this, and that the possibility exists of visualizing this mural vascularity by selective magnification angiography.

Contribution of angiography to the diagnosis, staging and assessment of radiation and chemotherapy of solid abdominal malignancies in children

Sequential angiographic studies were done in six children to stage and assess the results of radiation and/or chemotherapy of solid abdominal malignancies: one bilateral Wilms' tumor, two neuroblastomas, two hepatoblastomas and one hepatocarcinoma. Angiography was of value in demonstrating the tumor, its location, extent and vascular characteristics, as well as its regression and recurrence. Wilms' tumor and neuroblastoma responded and well to radiation and chemotherapy with substantial decrease in tumor size and regression or disappearance of tumor neovasculature. Resceted tumors revealed this to be due to tumor necrosis, hemorrhage and/or cystic degeneration. Hepatoblastoma and hepatocarcinoma did not respond as well to chemotherapy, with only mild decrease in size and neovasculature of the tumor.

Angiographic infarction of a large hypernephroma with a tissue adhesive for control of hematuria

A case of a large inoperable hypernephroma in a 69-year-old man is presented. Recurrent life-threatening hematuria was controlled successfully by transcatheter embolization and infarction of the tumor using a tissue adhesive called isobutyl 2-cyanoacrylate. The patient remained without hematuria for 18 months until death from extensive metastatic diseases. The advantages and disadvantages of tissue adhesive as an embolization material are discussed.

Rapid onset of hand ischemia of unknown etiology: clinical evaluation and follow-up of ten patients

Ten patients presenting with a history of the acute onset of hand ischemia have undergone detailed clinical, immunologic, and arteriographic evaluation. The disease is characterized by the acute onset of hand ischemia proceeding to fingertip ulceration, in the absence of recognized systemic disease. None of the patients had any evidence of large artery obstruction. Arteriography showed diffuse obstruction of the palmar and digital arteries. No evidence was found in any patient of any systemic disease process associated with small artery obstruction. These patients are suspected of having a previously unreported variant of hypersensitivity angiitis. Patients are left with permanent obstruction of the palmar and digital arteries. Follow-up suggests the disease in non-recurrent and is characterized by progessive clinical improvement associated with the development of collateral circulation. Conservative management of the condition is recommended.

Limitations of angiographic differential diagnosis in major hepatic processes

In 11 instances (6%) of 183 consecutive hepatic angiograms done for subsequently proven pathologic hepatic processes, either the diagnosis was incorrect (4 patients) or a satisfactory differential diagnosis was not established (7 patients), despite obvious angiographic abnormalities. Incorrect diagnoses were made in patients with suppurative hapatocarcinoma and liver cyst, macronodular regenerative cirrhosis, and multiple intrahepatic abscesses. Satisfactory differential diagnoses could not be established in patients with enlarged intrahepatic ducts, acute viral hepatitis, recurrent cirrhosis and acute liver necrosis. On analysis, means for minimizing diagnostic failure include the use of enhancement techniques such as infusion angiography and pharmacoangiography and an unbiased, detailed analysis of the angiographic findings. Changes secondary to the pathologic process and the coexistence of multiple processes, however, can occasionally prevent an accurate diagnosis.

Hand angiography and Raynaud's syndrome

Forty-eight patients with Raynaud's syndrome and seven volunteers without it were studied by magnification hand angiography which included studies of the effects of cold exposure before and after the selective intraarterial administration of reserpine. Most of the patients with Raynaud's syndrome, in addition to organic obstructive disease, exhibited both basal vasoconstriction and exaggerated, persisting cryogenic vasospasm of the hand arteries. Studies done two days after reserpine administration revealed decreases in both basal and cryogenic vasospasm in most patients and the degree of angiographic improvement correlated well with subsequently determined clinical responses to long-term vasodilator drug therapy. Hand angiography with examinations after cold exposure and its combination with the postreserpine pharmacodynamic studies is a useful technique in Raynaud's syndrome, both diagnostically and in predicting the outcome of longterm vasodilator therapy.

The importance of temperature in angiography of the hand

Angiograms of the hand of a normal volunteer taken at skin temperatures ranging from 22 to 33 degrees C revealed that visualization of the arteries was highly dependent on the temperature. Lower temperatures produced vasospasm beginning in the smaller vessels and proportionally involving medium-sized and major arteries. Moderate warming led to optimum filling and is recommended prior to angiography of the hand. Prior injection of contrast material caused no perceptible change in the filling or appearance of the arteries.

Cryodynamic hand angiography in the diagnosis and management of Raynaud's syndrome

Cryodynamic hand angiography (CHA) with angiograms done before, just after, and during rewarming following hand immersion in ice water was performed in 39 patients with Raynaud's syndrome and eight volunteers without it. The normal response to cold stimulus was angiographically evident as mild, transient digital arterial constriction. Most of the patients with Raynaud's syndrome, in addition to organic obstructive disease, exhibited basal vasoconstriction and exaggerated persisting cryogenic vasospasm of the hand arteries. Similar angiographic studies done in 32 cases two days after the selective intra-arterial administration of reserpine revealed no differences in normal subjects but substantially decreased vasospasm in patients with Raynaud's syndrome. CHA with postreserpine studies was found to be diagnostically useful in Raynaud's syndrome, revealing the degree of organic arterial disease and functional vasospasm. In addition, correlation of postreserpine studies with observed clinical responses to long-term vasodilator drug therapy indicated that CHA has a good chance to predict the probable outcome of such therapy in Raynaud's syndrome.

Frequency and significance of coronary arterial dominance in isolated aortic stenosis

Myocardial infarction during aortic valve replacement has previously been reported to result from obstruction of a branch of the left main coronary artery by the perfusion cannula. Patients with a dominant left coronary arterial system may be at greater risk. To assess the frequency and significance of a dominant left coronary arterial system the coronary angiograms of 75 consecutive patients more than 34 years of age with isolated aortic stenosis were studied and compared with those of a control group of 150 patients. Among the patients with aortic stenosis, 19 (25 percent) had left dominance, 9 (12 percent) a balanced circulation and 47 (63 percent) a dominant right coronary arterial system. Among control patients, 14 (9 percent) had left dominance 18 (12 percent) a balanced system and 118 (79 percent) right dominance. The increased prevalence of left dominance in patients with aortic stenosis was significant (P less than 0.005). Among patients with aortic stenosis, the left main coronary artery was shorter (P less than 0.01) in those with left dominance (6.2 +/- 1.3 mm [mean +/- standard error]) than in those with right dominance (9.9 +/- 0.7). Sixty-nine patients with aortic stenosis underwent aortic valve replacement. Perioperative myocardial infarction occurred in 4 of 15 (26.7 percent) of those with left dominance and in 4 of 54 (7.4 percent) of those with right dominance or a balanced circulation (P less than 0.05). Perioperative myocardial infarction occurred in all three patients with left dominance and obstructive coronary artery disease. The increased prevalence of a dominant left coronary arterial system in aortic stenosis suggests that this may be part of a developmental complex. Patients with left dominance have a shorter left main coronary artery than patients with right dominance. They also have an increased risk of perioperative myocardial infarction if there is associated obstructive coronary artery disease. Preoperative information about the coronary arterial anatomy and extent of coronary artery disease may be helpful in planning the use of coronary perfusion and other myocardial preservation techniques during surgery in order to reduce the incidence of myocardial infarction.

The clinical significance of Raynaud's syndrome

This study was performed to determine the frequency of occurrence of associated autoimmune disease in a group of patients presenting with Raynaud's symptoms. A consecutive group of 100 patients presenting with Raynaud's syndrome underwent detailed prospective clinical and immunologic evaluation. Magnificantion hand arteriography was performed in certain patients. Based on current diagnostic criteria, the following autoimmune diseases were diagnosed or were suspected strongly: Raynaud's syndrome with scleroderma or CRST--28 patients; Raynaud's syndrome with lupus erythematosus--ten patients; Raynaud's syndrome with miscellaneous autoimmune disease--43 patients: Raynaud's syndrome without diagnosable autoimmune disease--19 patients. Fourteen of the 19 patients in the latter group had isolated serologic abnormalities. Arteriography showed combined organic arterial obstruction and vasospasm of the palmar and digital arteries in all patients. Patients with severe Raynaud's symptoms had more extensive arterial obstruction than did patients with mild or moderate Raynaud's symptoms. These results suggest that all patients with Raynaud's syndrome should be regarded as at high risk for having an associated autoimmune disease.

Infusion hepatic angiography in diagnosis of liver metastases

Infusion hepatic angiography was used, together with conventional angiography, for diagnosis in 68 patients with liver metastases. The combination of both techniques led to a diagnostic accuracy of 97%. Metastases were missed in only two patients, both of whom had underlying liver or biliary disease. In a comparison of the two techniques, the infusion study was found diagnostically essential in five patients (7%) and afforded improved diagnosis in 49 others (72%). In 10 patients (15%), it gave equivalent information; and in four patients (6%) less information than the conventional technique. Infusion hepatic angiography is a useful complementary technique in antatomic liver diagnosis, especially in its ability to improve upon the diagnostic accuracy of the capillary phase of hepatic angiography.

Deep vein thrombosis treated with streptokinase or heparin. Follow-up of a randomized study

Twenty-seven patients with deep vein thrombosis whose primary therapy was randomized between streptokinase and heparin were reevaluated clinically and by ascending venography after a mean period of 7 months. Normal venograms were found in 6 (40%) of the streptokinase-treated patients and in 1 patient (8%) who had heparin therapy. Segmental valve preservation was found in 1 patient from each group. All patients with complete or partial valve preservation became asymptomatic. Vein recanalization without preservation of valves occurred in 18 patients: 8 (54%) of those on streptokinase, and 10 (83%) of those on heparin. At the time of follow-up, 11 of these 18 patients, including 8 who had had prior thrombosis, reported peripheral edema; the postphlebitic syndrome developed in 1. Factors favoring a good outcome of acute venous thrombosis were (1) no prior thrombotic disease, (2) localized thrombosis, and (3) prompt streptokinase therapy.

Intra-arterial sympathetic blockade in the treatment of clinical frostbite

Regional medical sympathectomy achieved by the intra-arterial injection of reserpine appeared to be of benefit in the treatment of five patients with acute or chronic frostbite injuries. Clinical improvement was associated with a significant increase in arteriographically determined regional perfusion.

Current angiographic approach to diagnosis and therapy of acute gastrointestinal bleeding

The author's current angiographic approach to the diagnosis and therapy of acute gastrointestinal (GI) bleeding is summarized and discussed. It is based on the authors' experience with diagnostic studies in more than 300 acute GI bleeders and the use of various angiotherapeutic techniques in 138 of them as well as the experience of others. A "moderately aggressive angiographic approach" is advocated for the diagnosis of acute GI bleeding in most patients with angiography used as needed after emergency endoscopy and preliminary medical therapy. Vasoconstrictive angiotherapy with selective intraarterial use of vasopressin is partially giving way to low dose, intravenous infusion of vasopressin and, where possible, to direct vascular occlusion. Selective transcatheter embolic occlusion of bleeding vessels is in indicated cases an accepted method for controlling arterial bleeding. Medical gelatin (Gelfoam) is the current authors' embolization material of choice. Selective variceal occlusion offers promising means for management of bleeding from gastroesophageal varices. Its possible combination with transcatheter intrahepatic portosystemic shunting might also provide non-surgical relief of portal hypertension.

Healing of deep venous thrombosis: venographic findings in a randomized study comparing streptokinase and heparin

Sequential ascending venographic studies were used to assess the healing of deep venous thrombosis in 50 patients randomly assigned to streptokinase or heparin therapy. Various degrees of thrombolysis and/or recanalization were demonstrated by venograms performed on the fourth and tenth days of treatment. Late follow-up studies (mean, 7 months after treatment) showed three basic patterns of resolution: (1) return to normal, (2) complete recanalization, and (3) incomplete recanalization and/or collateralization. Loss of valves or their function was associated with recanalization. The character, speed, and outcome of healing reflected the nature and extent of thrombosis, prior thrombotic disease in the extremity, and the type and timing of treatment. Streptokinase was highly effective and preferable to heparin in patients with deep vein thrombosis when therapy was begun within 4 days of onset of symptoms. In later stages of acute or recurrent deep vein thrombosis, the effectiveness of both drugs was significantly reduced.

Deep vein thrombosis treated with streptokinase or heparin. A randomized study

Randomly assigned streptokinase or heparin therapy was studied in 50 patients with deep vein thrombosis of less than 2 weeks' duration. Venography was performed prior to therapy, after 3 days, and after 10 days. Two radiologists who were unaware of the patient's therapy compiled a single average lytic score for each patient at each time interval. Lysis of venous thrombi was significantly greater with streptokinase than with heparin after 3 days, but not after 10 days of treatment. Lytic scores achieved with streptokinase were significantly better than those achieved with heparin therapy (P less than .01) in male patients who were symptomatic for 3 days or less. In females, regardless of the duration of symptoms, thrombolytic results obtained with streptokinase were not significantly different than results obtained with heparin.

Arteriovenous fistula complicating renal transplantation

A case of arteriovenous fistula of the major transplant vessels contributing to posttransplant hypertension hypertension and severe microangiopathic hemolytic anemia is reported. Improvement in blood pressure and correction of anemia followed ligation of the fistula. This case reinforces the need for diagnostic evaluation of all patients with sustained post-transplant hypertension.

Angiography in the diagnosis and therapy of bleeding from gastroesophageal varices

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