Nonoperative management of benign postoperative biliary strictures

Selected benign biliary strictures can be treated safely and successfully by percutaneous balloon dilatation. Primary biliary strictures appear to be less responsive to balloon dilatation alone and require stenting with large catheters (16-20 F) for several months to permit scarring around the catheter. A long period of healing around such a large-bore stent is crucial to the success of such treatment. The most important physiologic indicators for successful dilatation are a long period of stricture challenge with a catheter placed proximal to the dilated segment to allow bile to drain internally across the previously strictured segment, and a near anatomic result as demonstrated by cholangiogram.

Cerebral embolism--first manifestation of pulmonary arteriovenous malformation in patients with hereditary hemorrhagic telangiectasia

Four of five patients with asymptomatic small or moderate-size pulmonary arteriovenous malformation (PAVM) presented with a paradoxical embolus and stroke. In these patients chest radiographic findings were subtle and arterial hypoxemia provided the real clue to diagnosis. Computed tomography (CT) and cerebral arteriography confirmed embolic occlusion in four of five patients. Careful family screening including posteroanterior (PA) and lateral chest radiographs and arterial oxygen determinations in sitting or standing positions are recommended for early detection of asymptomatic patients with PAVM. Early therapeutic intervention (with balloon embolotherapy) is recommended to avoid paradoxical embolization.

Percutaneous transhepatic biliary drainage for bile leaks and fistulas

Percutaneous transhepatic cholangiography and biliary drainage were performed in 12 patients with major injuries to the bile ducts manifested by biliary leaks and fistulas. Eleven of the 12 patients had had inadvertent biliary trauma during surgery. In six patients, the biliary leaks sealed with percutaneous drainage. In other patients requiring definitive surgical procedures on the biliary tract, initial percutaneous drainage allowed these procedures to be delayed until the patients' clinical condition improved. Percutaneous biliary drainage is an important adjunct to the management of patients with traumatic extravasation of bile into the peritoneal cavity or biliary-cutaneous fistula.

Late false aneurysm following replacement of ascending aorta: the problem of the teflon graft in combination with a silk suture anastomosis

Two patients underwent resection and replacement of the ascending aorta using a low-porosity Teflon graft anastomosed with silk suture. In both patients false aneurysms developed that required operation 13 and 23 years postoperatively. The clinical courses of these patients, along with data from the literature, suggest that the combination of a low-porosity Teflon graft and a silk suture anastomosis presents a major potential hazard for the development of anastomotic false aneurysm.

Silicone biliary stents for percutaneous management of biliary obstruction

Silicone tubes in 2-F increments from 12 to 20 F were developed for long term external-internal drainage of benign and malignant biliary obstructions. Passed coaxially over Teflon catheters and a guidewire, the silicone stents were softer and had larger sideholes than conventional drainage tubes. Once the acute track had matured (two weeks or longer), a silicone stent, 2 F larger than the preceding one, could be placed at each succeeding tube change. We have placed these tubes in 50 patients, 24 of whom had initially placed percutaneous catheters and 26 of whom had surgically placed stents. These tubes remain patent at least as long as conventional catheters and all patients have reported increased comfort using these catheters compared with standard ones.

Inpatient admissions for interventional radiology: philosophy of patient management

As an alternative to performing interventional radiology on inpatients under the care of internists and surgeons, the authors have established a cardiovascular radiology admitting service for well-screened, elective patients. The patients are admitted under the care of a cardiovascular radiology fellow and a staff physician. From April 1982 to December 1983, 133 patients were admitted to the service. Patients are cared for in a surgical ward or in an intermediate unit, as determined by the clinical situation. Advantages of this approach include a broader patient referral base, improved rapport with clinical colleagues and patients, improved follow-up data, and rapid evaluation and treatment, resulting in short hospital stays. The major disadvantages involve the commitment of time and staff necessary to provide quality care. The concept of the interventional radiologist in the role of admitting physician has important implications in terms of negotiations for additional financial compensation, commensurate with the skill and time required for performing these procedures and caring for the patient.

Iliac artery occlusion: management with intrathrombus streptokinase infusion and angioplasty

Chronic and acute unilateral iliac artery occlusions were successfully treated in 7 of 8 patients using low-dose intrathrombus streptokinase infusions ranging from 6 to 43 hours in combination with percutaneous transluminal angioplasty. Angioplasty of an underlying stenosis was performed as soon as clot lysis was maximal and an underlying stenosis was demonstrated. Long-term follow-up to date has been excellent. This approach to unilateral iliac occlusion appears to be safer than previously reported angioplasty of iliac artery occlusion.

Renal artery angioplasty. Technical considerations and results

Renal angioplasty was attempted on 38 renal arteries in 34 patients and was technically successful in 84.2%. Twenty-four patients were followed for 1 to 36 months (mean 15.3 months). The hypertension was cured or improved in 18 (75%), unchanged in 2 and recurrent after an initial period of improvement in four. Six patients were not available for further evaluation as five had additional renovascular surgery and one was lost to followup. Four patients had major complications; loss of the kidney occurred in one patient (2.9%). Respiratory renal mobility, predilatation with tapered teflon catheters and the contralateral femoral approach were found to be important technical aids for successful renal artery angioplasty.

Tailored approach for evaluation of peripheral vascular disease: intravenous digital subtraction angiography

A tailored approach for evaluating patients with peripheral vascular disease has been developed using intravenous digital subtraction angiography (IV DSA). This approach includes a history, physical examination, and correlation with Doppler pressure measurements to predict the location of the dominant lesion. In 60 patients, two views of the aortoiliac segment plus three or four views of the femoral and runoff circulation in the most symptomatic leg were obtained. Of the 60 patients, 36% had percutaneous transluminal angioplasty as a primary form of therapy, 32% were treated surgically, and 32% were followed clinically. Only 10% of these patients required further evaluation by conventional angiography. By omitting inpatient arteriography, considerable financial savings and increased patient comfort result.

Intraarterial digital subtraction angiography in diagnostic arteriography

Intraarterial digital subtraction angiography (DSA) was performed in 133 diagnostic arteriographic procedures during a 10-month period. The increased contrast resolution of DSA permitted the use of a dilute (15%) contrast material. A significant reduction in contrast material dose compared with conventional film-screen arteriography and intravenous DSA was thus achieved. This was especially advantageous in patients with diminished renal function. The dilute contrast material also resulted in less patient discomfort. Subtracted images were available immediately on cathode ray tube display, resulting in faster procedures, and a considerable saving in film cost compared with conventional arteriography. It is concluded that intraarterial DSA is a useful technique that may replace conventional film-screen arteriography in many applications.

Percutaneous transluminal balloon valvuloplasty for pulmonary valve stenosis

Transluminal balloon valvuloplasty was used to treat congenital pulmonary valve stenosis in 20 patients. Follow-up cardiac catheterization was performed in 11 patients at intervals of from 2 to 12 months after the procedure. Peak systolic pressure gradient across the pulmonic valve decreased from 68 +/- 27 to 23 +/- 5 mm Hg (p less than .001) after valvuloplasty. There were no complications. Follow-up catheterization demonstrated persistent relief of right ventricular hypertension in the patients with typical pulmonary valve stenosis.

Digital subtraction angiography in interventional radiology

Intraarterial digital subtraction angiography (DSA) was used an an adjunct to interventional vascular procedures (embolotherapy and transluminal angioplasty) in 56 patients. The advantages of intraarterial DSA include improved contrast resolution, instantaneous subtraction capability, and immediate image availability. A considerable reduction in contrast dose and concentration, procedure time, and patient discomfort can be expected when interventional vascular procedures are performed with the assistance of intraarterial DSA.

Embolotherapy in vascular disease

Embolotherapy for nonneoplastic vascular diseases including hemorrhage and congenital vascular malformations is reviewed. Application of short, intermediate, and long-acting embolic materials to these conditions is presented along with potential complications associated with their misuse. Successful application of embolotherapy results from a thorough understanding of the disease process being treated, the distinctive features of the circulation to be embolized, and the embolic material used for the occlusion.

Balloon embolization to occlude a Blalock-Taussig shunt

Balloon embolization was used to successfully occlude a large residual Blalock-Taussig shunt. The use of an "upstream" nondetachable balloon catheter to reduce flow and turbulence during final positioning of the detachable balloon may have made the technique safer and more precise.

Percutaneous transluminal angioplasty of aortic graft stenoses

Postoperative aortic graft anastomotic stenoses at nine sites in eight patients were successfully treated with percutaneous transluminal angioplasty. There was a decrease in peak systolic pressure gradient in all eight patients, and in seven of the eight patients symptoms of claudication disappeared immediately after angioplasty. Four of the eight patients remained asymptomatic at follow-up. Ankle/arm indices were obtained before and after angioplasty in five patients, with postangioplasty improvement in all five.

Treatment of restenosis of coarctation by percutaneous transluminal angioplasty

Percutaneous transluminal angioplasty (PTA) was used successfully to treat coarctation restenosis in seven patients. The patients were 10 months to 17 years old at the time of the angioplasty, and the initial coarctation repair had been performed 10 months to 16 1/2 years previously. PTA reduced the systolic pressure gradient across the coarctation from a mean of 58 mm Hg before the procedure to a mean of 13 mm Hg immediately after PTA. Follow-up has been from 1 to 14 months and indicates that the decrease in the systolic pressure gradient is persistent.

Intraarterial digital subtraction angiography: a comparative view

Intraarterial digital subtraction angiography (IA DSA) was performed in 122 patients undergoing a variety of diagnostic and interventional angiographic procedures. Owing to the increased contrast resolution of DSA, diluted contrast material in concentrations of from 12-19% could be employed, thereby significantly reducing contrast material doses compared to doses used with conventional film-screen angiography or intravenous DSA. Patient discomfort was convincingly reduced due to the injection of dilute contrast material. Subtracted digital images could be viewed immediately on a cathode ray tube (CRT) resulting in faster procedures with less catheter time. Savings in film costs relative to conventional angiography were also achieved.

Carotid-cavernous fistula. Intravascular treatment with a self-sealing detachable balloon

Five traumatic carotid-cavernous fistulas were treated using a new self-sealing, detachable, silicone-rubber balloon, as part of a balloon-catheter system, and a modified technique for positioning the balloon. The fistulas were occluded successfully in four patients; in a fifth patient, a small fistula persisted. In each instance, the internal carotid artery flow was preserved. The flexible balloon-catheter system can be guided via the blood flow and still not require a coaxial catheter for detachment. Moreover, the flexibility of the balloon and catheter resulted in easy positioning through a tortuous internal carotid artery.