Therapeutic renal arterial occlusion for elimination of proteinuria: 'medical nephrectomy'

A patient with severe nephrotic syndrome who was too debilitated to undergo surgical nephrectomies, underwent therapeutic bilateral renal artery occlusion by the selective injection of isobutyl 2-cyanoacrylate into the renal arteries. The therapy resulted in dramatic cessation of urine flow and elimination of proteinuria.

The natural history of coronary artery stenosis. A longitudinal angiographic assessment

Comparison of sequential large film coronary angiograms was performed for 58 patients with coronary artery disease, and no coronary surgery, to determine the relationship between the location, type, and degree of stenoses and their tendency to progress. Of 230 stenoses, 76 (33%) showed progression and 154 (67%) remained stable on the follow-up studies. Progression occurred in 38 (66%) patients. A statistically significant higher tendency to progress was found with tubular stenosis with ulcerating plaques (100%) and stenoses with collateral circulation (58%). A significant linear trend for progression was also found with the increasing number of risk factors of coronary disease. The above-average progression tendency of stenoses of the right coronary artery, tubular irregular stenoses, and Grade 2 stenoses, was not statistically significant.

Diagnostic effectiveness of infusion hepatic angiography. A comparison with the conventional technique

The diagnostic effectiveness of infusion hepatic angiography was evaluated in 72 patients with various liver diseases, who also had conventional hepatic angiography. In a comparison of the two techniques, the infusion study was found diagnostically essential in 4 patients (6%), and afforded improved diagnosis in 52 others (72%). In 13 patients (18%), it gave equivalent information; and in 3 patients (4%), less information than the conventional technique. Infusion hepatic angiography is a useful complementary technique in anatomical liver diagnosis, especially in its ability to improve upon the diagnostic accuracy of the capillary phase of hepatic angiography.

Ventriculography and coronary arteriography in the acutely III patient. Complications, extent of coronary arterial disease, and abnormalities of left ventricular function

Of 99 patients who underwent "emergency" diagnostic studies, 82 had "unstable angina" (group A), 15 had recent myocardial infarction (group B), and two had intractable congestive heart failure due to acute mitral regurgitation (group C). Two cardiac and two local complications occurred either during the procedure or during the following 48 hours. There were no deaths or myocardial infarctions. Ten (12 percent) patients of group A had "normal" coronary arteries and normal left ventricular function; 13, 26 and 33 patients had one, two, and three coronary arteries involved, respectively. Those with three-vessel disease had a significantly higher left ventricular end-diastolic pressure (LVEDP) and lower ejection fraction (EF) than those with one- and two-vessel disease. Those with previous myocardial infarction had a significantly higher incidence of reduced EF and of wall motion abnormalities than those without a previous myocardial infarction. All patients in group B had significant coronary arterial disease, and 80 percent (12) had abnormal left ventricular function. Their mean LVEDP and EF were significantly higher and lower, respectively, than those found in group A. In conclusion, acutely ill patients were studied with low risk. Most patients had three- or two-vessel disease. Abnormal left ventricular function was related to three-vessel disease and to recent and old myocardial infarction.

Left main coronary artery spasm. A potential cause for angiographic misdiagnosis of severe coronary artery disease

Two patients had catheter-induced spasm of the left main coronary artery during diagnostic coronary arteriography. One patient had no coronary artery disease, and the other had minimal disease of the right coronary artery. Spasm was relieved by nitrates; however, in one patient several doses were needed over 35 minutes. Catheter-induced spasm must be considered in the diagnosis of left main coronary artery disease, particularly on a patient with isolated left main coronary artery disease.

Complications of percutaneous transaxillary catheterization for arteriography and selective chemotherapy

This report enumerates and analyzes the complications of percutaneous transaxillary catheterization encountered in 200 consecutive patients undergoing diagnostic arteriography, and 20 consecutive patients who had catheter placement for selective chemotherapy. Diagnostic arteriography led to minor complications in eleven percent and major complications in two percent. Risk correlated with the type of procedure, number of catheter exchanges and particularly, the presence of arteriographic risk factors, such as hypertension, bleeding tendencies, and advanced atherosclerosis. Therapeutic catheter placements had a 15 percent incidence of minor and a 20 percent incidence of major complications. Here, also, complications were more likely in the presence of the arteriographic risk factors. Suggested means for decreasing the hazards of the transaxillary catheterization include: exclusion of high risk patients, use of a proper puncture site, careful catheter manipulation, the fewest possible catheter exchanges, correct manual hemostatis following catheter withdrawal, and close observation of the patient after the procedure. Early surgical intervention is indicated in the presence of a progressively developing neural defect.

Epinephrine renal venography

Experience with the use of epinephrine renal venography in 60 patients with various renal disease is reviewed. The technique offers an important supplement to selective arteriography. It is of particular value in the diagnosis of avascular infiltrative tumors of the renal parenchyma and pelvis. Further, it is of value in the detailed demonstration of renal vein thrombosis and in seeking the cause of unexplained gross hematuria. It can also aid in evaluating expansile avascular renal masses and renal parenchymal disease. The authors found only a relatively low value for epinephrine renal venography in the diagnosis of hypervascular renal tumors and the early detection of venous extension of hypernephromas.

Complications of indwelling chemotherapy catheters

Fifty consecutive chemotherapeutic infusions for cancer via precutaneously introduced arterial catheters were reviewed to determine the frequency of angiographic and clinical complications related to the indwelling catheter. Fibrin cloaking along the catheter was found in 20 patients studied by pull-out arteriography and was unassociated with clinical symptoms. Major thrombus formation occurred around the catheter tip in 28% of the infused vessels, all within the hepatic artery. Clinical symptoms developed in only three patients where thrombosis of the hepatic artery had propagated into the celiac axis. Systemic heparinization did not reduce the incidence of thrombus formation but did increase the incidence of mild gastrointestinal bleeding. Several factors may reduce the incidence of complications, such as puncture of a large artery, use of soft, pliable, and small diameter catheters, proper free position of the catheter in the infused vessel, regular angiographic checkups for catheters position, and early evidence of thrombus formation.

Transjugular approach to the liver, biliary system, and portal circulation

More than 5 years of clinical and animal experience with the use of a transjugular approach to the liver, biliary system, and portal circulation is reviewed. It has been of clinical value in connection with hepatic manometry and venography, liver biopsy, and cholangiography. Satisfactory hepatic manometry and venography were achieved by the transjugular approach in all 47 cases where attempted; diagnostic liver specimens were obtained in 71 of 83 patients (86%); and cholangiography was successful in 48 of 52 patients with enlarged intrahepatic ducts (92%). No complications occurred with these studies. In animals, transjugular catheterization was used as a means for portal, mesenteric, and pancreatic venography. These procedures are ready for diagnostic clinical use. Therapeutic techniques explored in animals include intravascular tamponade of gastric coronary vein and the nonsurgical creation of intrahepatic portacaval shunts, both of promise in the future management of massive gastrointestinal bleeding from varices.

Vasocilators in the canine mesenteric circulation. Evaluation of a potential aid in the diagnosis of gastrointestinal bleeding

Radiodiagnostic potential of intra-arterially injected vasodialting agents was investigated by their effect on total and segmenal resistances (VR) of mesenteric vasculature, blood flow in superior mesenteric artery and its bleeding branch; heart rate and ventricular and systemic blood pressure. Dipyridamole, isoxsuprine, protricular and systemic blood pressure. Dipyridamole, isoxsuprine, prochlorperazine, lidocaine, meglumine diatrizoate and carbon dioxide were poor dilators. Phentolamine produced hypotension; glucagon and serpasil an extremely long dilation. A large and short vasodilation was produced with tolazoline and nylidrin, but both agents increased VR of the postcapillary segment and caused transient hypotension and arrhythmias, nylidrin's side effects were smaller. Oxygen produced large and long vasodilation and minimal systemic effects. It is concluded that oxygen or possibly nylidrin are suitable agents should an intermittently bleeding mesenteric artery be dilated for diagnostic purposes prior to angiography.

Response to dopamine hydrochloride in the hepatorenal syndrome

Functional renal failure accompanying advanced cirrhosis of the liver carries a grave prognosis. Seven patients with the hepatorenal syndrome and five patients with decompensated cirrhosis of the liver without renal failure were studied by the xenon Xe 133 washout technique. Mean renal blood flow and its cortical component were decreased in both groups compared to normal transplant donors, but to a significantly greater degree in hepatorenal syndrome. In hepatorenal patients, intra-arterial infusion of subpresor doses of dopamine hydrochloride improved the angiographic appearance of the renal cortical vasculatrue and the cortical blood flow rate. Urine flow rate and glomerular filtration rate did not consistently improve with 12- to 24-hour intravenous infusions, although two patients survived, temporally related to the study. These patients had shown signs of liver function recovery.

Objective and subjective analysis of left ventricular angiograms

In order to determine the reproducibility of analyses of left ventriculograms, 35 cineangiograms were evaluated by four observers, two using standard quantitative techniques to determine ventricular volumes and a newly devised quantitative system to evaluate wall motion and two others using only visual inspection of the angiograms. Objective analysis repeated by the same observer correlated well for end-diastolic and end-systolic volumes and ejection fraction (r = .98, .99, respectively) and only one of 105 (1%) wall segments were identified differently. Variability in assessments increased when comparisons were made with a second objective observer. Correlation coefficients for the three volumetric parameters were .93, .98, and .95 and there was disagreement in the assessment of 8% of wall segments. Wide variability was present between an objective and two subjective observers in analyses of end-diastolic volumes (r = .63, .64). Regional wall motion was assessed differently in 19% and 27% of segments, respectively. Though the correlation of objectively and subjectively determined ejection fractions was much better than the correlation for volume (r = .92, .84), it was not as good as the correlation between two objective observers. Occasional errors of clinical significance occurred. We conclude that subjective analysis has a significant error rate and that reproducibility and accuracy of analysis of left ventriculograms require objective analysis.

Comparison of heparin and streptokinase in the treatment of venous thrombosis

Heparin or streptokinase was administered in a prospective randomized fashion to 50 patients with phlebographically confirmed venous thrombosis of the extremities of 14 days or less duration. A total of 49 patients completed the investigative protocol with 26 receiving heparin and 23 receiving streptokinase. All patients were evaluated with sequential phlebograms. Complete thrombolysis with restoration of venous valve function occurred in one of 26 patients receiving heparin and in six of 23 patients receiving streptokinase. Fifty per cent of the patients treated with streptokinase with a total duration of symptoms of three days or less achieved complete lysis. The total incidence of therapeutic complications was similar in the two groups, but was more severe in the streptokinase treated patients.

Left main coronary artery disease. Risks of angiography, importance of coexisting disease of other coronary arteries and effects of revascularization

To elucidate the determinants of the poor prognosis of patients with left main coronary artery disease and to assess the efficacy of diagnostic and therapeutic interventions the angiographic features and clinical course of 58 patients with left main coronary artery disease studied between September 1967 and June 1974 were analyzed. Eighty-three coronary arteriograms were obtained in these 58 patients using the Judkins technique; there were no immediate complications although one patient died 3 days after study. Previously cited predictors of left main coronary artery, unstable or nonexertional angina and marked S-T segment depression with exercise were found in a minority of patients; thus, the presence of the disease could not reliably be predicted before arteriographic study. Coexisting disease was found in either two or three other coronary arteries in 46 of 58 patients; only 2 patients had isolated left main coronary artery disease. Because the criteria for operability have changed in recent years, current criteria without knowledge of the treatment actually given or its outcome. The condition of 10 of 58 patients was judged inoperable in retrospect because of severe coexisting distal coronary artery disease (8 patients) or ventricular dysfunction (2 patients). Of 19 patients whose condition was judged operable in retrospect but who were treated without surgery, 9 died, 8 within 18 months; 10 have survived 12 to 83 months. Another 27 patients with a condition judged operable in retrospect had received saphenous vein bypass grafts. In this group, there were four operative and three late deaths. The severity of angina decreased in survivors treated surgically but was unchanged in survivors treated without surgery. The improvement in survival rates of surgically treated patients was not statistically significant. The data indicate that coronary arteriography can be performed at low risk with the Judkins technique even though preangiographic prediction of left main coronary artery disease is unreliable. Coexisting disease in oter major coronary arteries is an important determinant of the poor prognosis of patients with left main coronary artery disease and precludes surgery in 13 percent. Isolated left main coronary artery disease is uncommon. Surgical therapy relieves symptoms more effectively than nonsurgical therapy.

Similarity of arterial and intravenous vasopressin on portal and systemic hemodynamics

The effects of superior mesenteric arterial and intravenous infusions of vasopressin and low and high dose intravenous infusions of vasopressin on splanchnic and systemic hemodynamics were compared in 20 anesthetized dogs. The following parameters were evaluated: flow in the superior mesenteric artery and portal vein, portal and systemic blood pressure, and cardiac output. In the comparison of selective arterial and intravenous infusions, no statistically significant difference was found between the degree of changes in portal flow, portal and systemic blood pressure, and cardiac output. Only the superior mesenteric artery flow showed a greater decrease with the selective arterial injection. In a comparison of intravenous high dose (corresponding to that used clinically) and low dose (one-fifth) infusions of vasopressin, a relatively high splanchnic and low systemic effectiveness of the low dose was found. It resulted in only a 15 to 20% smaller effect on flow in the superior mesenteric artery and portal vein and portal pressure; however, about 40% lesser systemic effect on arterial blood pressure and cardiac output than the high dose. The results of this experimental work warrant exploration in clinical practice, preferably by a controlled study. If clinical success in controlling hemorrhage confirms these hemodynamic results, an intravenous. low dose infusion of vasopressin would appear to be the method of choice in the vasoconstrictive therapy of gastrointestinal bleeding from varices.

Gallbladder and liver infarction occurring as a complication of acute bacterial endocarditis

A case of acute bacterial endocarditis is presented in which gallbladder infarction and areas of hepatic infarction were documented. Selective angiography showed findings consistent with emboli to the gallbladder and hepatic circulations.

Vasopressin and hepatic artery. Effect of selective celiac infusion of vasopressin on the hepatic artery flow

Electromagnetic flow measurement study was performed in 20 anesthetized dogs to evaluate the effect of selective celiac infusion of vasopressin on the hepatic arterial vasculature. Teh hepatic arterial flow showed a biphasic response with an initial decrease followed by a substantial increase in spite of a continued infusion. The left gastric, splenic, and superior mesentric arteries showed a monophasic response with persistent decrease of flow during the whole infusion. The biphasic response of the hepatic arterial flow is thought to be due to autoregulatory dilative action of the liver to a decrease of the portal flow. The results and previous clinical experience suggest that the selective infusions of vasopressin into arteries supplying the liver can be used for short-term vasoconstrictive therapy of acute gastrointestinal bleeding in patients without liver damage. Further experience is necessary to evaluate the safety of prolonged hepatic infusions in patients with liver damage.

Radiologic approach to the pancreas. A decade of progress

Radiologic diagnosis of the pancreas has undergone great progress in recent years and several valuable techniques are now available for examining the pancreas. Employed singly or in various combinations, as indicated by the individual patient's clinical and laboratory findings, they make possible an accurate diagnosis of pancreatic disease.

Experimental catheter obstruction of the gastric coronary vein. Possible technique for percutaneous intravascular tamponade of the gastroesophageal varices

Experimental catheter obstruction of the left gastric (coronary) vein was explored in 10 dogs. Using a transjugular approach, the liver was punctured and the portal vein catheterized. Coaxially introduced catheters were then used to catheterize selectively and produce an intravascular obstruction (tamponade) of the gastric coronary vein. Ballon catheters were used for a temporary occlusion. Injection of a tissue adhesive, isobutyl 2-cyanoacrylate, was used for a definitive obliteration. The achieved results show the anatomical feasibility of this approach and give good perspective for development of a clinical method for percutaneous intravascular tamponade of the bleeding gastroesophageal varices in cirrhotics.

Mesenteric arterial infusions of vasopressin for hemorrhage from colonic diverticulosis

Twenty-four patients with massive rectal hemorrhage and known or subsequently proved colonic diverticular disease had the bleeding site localized by mesenteric angiography and received intra-arterial infusion of vasopressin to arrest the bleeding. In twenty-two patients the bleeding was controlled with the vasopressin infusion whereas in the remaining two, hemorrhage did not stop and surgery was performed. Of the twenty-two patients in whom bleeding was arrested by vasopressin infusion, twelve received no further surgical therapy, five had elective prophylactic surgical resection after a period of hemostasis, and the remaining five underwent segmental resection for bleeding that recurred after cessation of the infusion. Of the twelve patients who were not operated on, three had rebleeding two, four, and twelve months after vasopressin infusion and two of these three patients required surgery. The remaining nine have had no recurrent bleeding for periods ranging from seven to thirty-four months. Of ten patients who had segmental resection after precise localization of the bleeding site and initial control with vasopressin, no one has had recurrent hemorrhage for periods ranging from two to eighteen months.

Radiologic diagnosis of pancreatic cancer

Modern radiology makes possible an accurate diagnosis of pancreatic cancer in about 95 percent of cases. Conventional upper gastrointestinal study, isotopic scanning, hypotonic duodenography, and ultrasonography are suitable as screening procedures. Special methods of high accuracy - pancreatic arteriography, endoscopic pancreatography, and transhepatic cholangiography are used as needed for definitive diagnosis.

The diagnosis and treatment of Raynaud's phenomenon

Twenty-five patients with Raynaud's phenomenon, including 20 with associated diseases and five with primary Raynaud's disease, were evaluated with sequential determinations of digital temperature recovery time after cold exposure and magnification hand arteriography before and after cold exposure and before and after intra-arterial reserpine. A variety of immunologic screening tests were performed, and the clinical response to oral guanethidine of phenoxybenzamine was determined. Temperature recovery time was prolonged in all but two patients with Raynaud's phenomenon before treatment. Arteriography revealed luminal obstruction of variable degree in all but two patients with Raynaud's phenomenon but not in those with Raynaud's disease. Radiographic vasospasm was noted in all patients. Patients with Raynaud's symptoms had a markedly greater vasospastic response to cold exposure than did three control patients without Raynaud's symptoms. Arteriography 48 hours after intra-arterial reserpine repeat revealed decreased vasospasm and a decreased vasospastic response to cold in most patients. A variety of serum protein and serologic aberrations were detected, with only eight patients being free of immunologic abnormalities, Nineteen patients were treated with guanethidine alone, three with guanethidine-phenoxybenzamine combination, and one with phenoxybenzamine alone. Good or excellent clinical results were noted in 19 of the 23 patients treated, with an average follow-up to date of 12 months.

Improvement in left ventricular wall motion following nitroglycerin

Coronary artery disease patients frequently have left ventricular wall motion abnormalities. Though nitroglycerin is commonly used in ischemic heart disease, its effects on wall motion abnormalities is unknown. In this study we have evaluated the effects of nitroglycerin on wall motion abnormalities and on ejection fraction in 25 patients. Sixteen had coronary artery disease (greater than 70% luminal narrowing). Six had no evidence of heart disease and three had congestive cardiomyopathies with normal coronary arteries. Left ventricular angiography was performed prior to and six minutes after administration of 0.4 mg of sublingual nitroglycerin. Twelve of the 16 coronary artery disease patients had wall motion abnormalities, and in seven of these, segmental wall motion improved after nitroglycerin. In five, all motion did not change. The initial heart rate, left ventricular systolic and end-diastolic pressure, and left ventricular end-diastolic volumes were not different for those whose wall motion improved versus those whose did not. The increase in the former and fall in the latter three hemodynamic parameters were significant (P less than 0.01) and similar for the two groups. In those whose wall motion abnormalities improved after nitroglycerin, ejection fraction (mean plus or minus se) increased significantly (P less than 0.05), from 0.47 plus or minus 0.025 to 0.62 plus or minus 0.046. In those without improvement, the ejection fraction went from 0.55 plus or minus 0.056 to 0.58 plus or minus 0.051 (NS). Three patients with congestive cardiomyopathy showed no improvement in ventricular wall motion or ejection fraction after nitroglycerin. Left ventricular wall motion abnormalities and ejection fraction improved in some coronary artery disease patients following nitroglycerin. The mechanism for this is unknown; however, ventriculography before and after nitroglycerin may be of potential usefulness for identifying areas of reversible wall motion abnormalities.

Instant selective arterial occlusion with isobutyl 2-cyanoacrylate

Isobutyl 2-cyanoacrylate (IBC) delivered selectively in small doses produced immediate occlusion of the injected arteries in dogs without significant undesired sequelae. In one patient, pelvic hemorrhage was promptly stopped by a similar technique. In another patient, who was on chronic renal dialysis and judged too ill for nephrectomy, IBC occluded both renal arteries and terminated a life-threatening renal protein loss.

Selective coronary arteriography by percutaneous left transaxillary approach using preshaped torquecontrol catheters

The percutaneous left transaxillary use of preshaped, torquecontrol coronary catheters is considered the technique of choice for selective coronary arteriography in patients with occlusive arterial ileofemoral disease and aortopelvic reconstructive surgery. It affords reliable, selective catheterization of the coronary arteries and their bimodal (cine and serial) examination. Percutaneous left transaxillary selective coronary angiography is a safe and useful technique when performed by experienced and skilled personnel in properly selected patients.

Coronary artery anatomy in left bundle branch block

It has previously been reported that the length of the left main coronary artery is short in patients with left bundle branch block (LBBB) and that an unexpectedly large number of LBBB patients had dominant left coronary arterial distribution. The present coronary arteriographic study of 13 patients with LBBB revealed a mean length of the left main coronary artery ( ± 1 sd ) of 10.9 ± 6.0 mm, a measurement which was not significantly different ( P > 0.5) from that of the left coronary arteries in 78 patients in a control group (10.0 ± 3 mm). The arterial distribution patterns showed a contribution of the right coronary artery to the posterior descending artery in 12 of the 13 patients with LBBB. Coronary artery anatomy does not appear related to the presence of LBBB.

Angiographic appraisal of distal vessel suitability for aortocoronary bypass graft surgery

The accuracy of preoperative coronary arteriography in determining distal vessel operability was evaluated in 166 patients studied arteriographically before and after bypass surgery. Appraisal accuracy correlated closely with the type of distal vessel filling, being highest (97%) in poststenotic vessels with antegrade filling; lower (76%) beyond occlusions with generous retrograde collateral flow; and least (65%) in postocclusion vessels filled by insufficient collaterals. Optimum data collection is favored by the use of high-definition serial roentgenography with extended filming in multiple projections; competent interpretation requires the integrated assessment of interdependent variables, including distal vessel morphology, filling patterns, branch disease, run-off capacity, and myocardial status.

Occlusion of coronary arteries after vein bypass

The coronary arteries of 100 patients were radiographically visualized by selective injection of contrast material. Findings in the three main arteries (left anterior descending, right, and circumflex arteries) were analyzed before and after aortocoronary-saphenous vein graft surgery. Proximal coronary artery stenosis progressed to complete occlusion in almost half the patients on whose stenotic arteries a graft had been placed. The incidence was higher than that observed in nongrafted arteries during the "natural" course of the disease. The frequency of occlusion in grafted coronary arteries was higher in severely stenotic than in moderately stenotic arteries. The fact that the occlusion occurred more often with a patent graft than with a closed graft suggests a hemodynamic component in its pathogenesis. The study indicates that in many patients the prognosis must remain linked to patency of the bypass graft.

Angiography in the diagnosis and management of extrapancreatic islet-cell tumors

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Experiences with angiography in diagnosis and treatment of acute gastrointestinal bleeding of various etiologies: preliminary report

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