Charles T. Dotter

Transluminal Treatment of Arteriosclerotic Obstruction: Description of a New Technic and a Preliminary Report of Its Application

The rationale and technic of a new procedure—transluminal recanalization of arterio-sclerotic obstructions—has been described.Of the 11 extremities treated, six have shown marked improvement (four amputations averted). It is reasonable to assume that with a perfected technic and patients with less advanced disease, the percentage of successful recanalizations would increase.Early treatment with this technic may well prevent otherwise serious disease, not just prevent amputation of extremities not suitable for definitive surgery. We are satisfied that percutaneous transluminal recanalization is the treatment of choice for many lesions of the femoral and popliteal arteries. We believe this method is ready for application to obstructions up to approximately 10 cm. by those skilled in the use of vascular catheters. No doubt the interest and ingenuity of others will lead to refinements of technic as well as further clarification of the role of this attack on arteriosclerotic obstructions.

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 re canalization 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 devel oped 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.

Streptokinase and Heparin in the Treatment of Pulmonary Embolism: A Randomized Comparison

Treatment with streptokinase followed by heparin was compared on a randomized basis with treatment with heparin alone in patients with acute pulmonary embolism. The diagnosis and results of treatment were established by pulmonary angiography. Fifteen patients received streptokinase and 16 received heparin alone. Complications included bleeding and pyrexia in both treatment groups and anaphylaxis in a patient receiving streptokinase. There were three deaths attributed to the disease its treatment. Patients in the strepto kinase group had significantly greater angiographic improvement (P = 0.0125) than those in the heparin group.

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.

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 transhepatic 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.

Bronchial Circulation in Severe Multiple Peripheral Pulmonary Artery Stenosis Case Report Illustrating the Origin of Continuous Murmur

In an infant with severe, multiple, peripheral pulmonary artery stenoses angiography clearly demonstrated enlarged tortuous bronchial arteries, especially in the right lung, where a major tortuosity corresponded closely to the point of maximal intensity of a loud continuous murmur. Increased bronchial circulation may be responsible for continuous murmurs in patients with severe multiple peripheral pulmonary artery stenosis.

Effect of Cardiac Catheterization and Angiocardiography on the Serum Glutamic Oxaloacetic Transaminase

The effect of cardiac catheterization and angiocardiography on the SGO-T was studied in 46 patients. Abnormal enzyme elevations occurred in a significant number of subjects. Such procedures constitute an addition to the known causes of SGO-T elevation.

Radiologic Technic for Qualitative and Quantitative Study of Blood Flow

This preliminary report deals with the direct radiographic study of discrete, relatively small spots of artificial radiopacity during their passage through the cardiovascular structures and offers a new and promising technic for studying the motion of blood. As used here, motion refers to movement of and within the blood stream. So defined, it is fundamental to the subject-matter of hemodynamics. Continuing studies are focused upon two major hemodynamic parameters: 1. The velocity, acceleration and deceleration of circulating blood. Through appropriate specialized radiographic technics, it is possible to measure the movement of blood as a function of time. Observations may be completed in 1 msec., repeated in rapid sequence and made simultaneously at many different points within the cardiovascular system. 2. Flow characteristics of circulating blood. The graphic study of flow patterns at multiple points within the blood stream can be carried out simultaneously with blood velocity observations. By analogy, in this technic the blood vessels and chambers of the heart serve as wind tunnels; the blood is the wind, the spots of opacity are smoke tracers and the myocardium is the source of power. The results of extensive experimental studies indicate that the above goals are achievable and warrant the considerable effort and costs involved. It is hoped that this preliminary report will encourage others to explore the possibilities of the method and thereby hasten its perfection.

Coronary Radiography and Endarterectomy Postmortem Study of Feasibility of Surgery

Postmortem angiography, kerosene perfusion, latex mass-injection radiographic studies and the conventional methods of anatomic pathology have been used in a study of coronary artery disease in 189 hearts, 88 of which had myocardial infarction associated with coronary arteriosclerosis. Analysis was directed to ascertain whether sclerotic lesions appeared to be amenable to surgical removal and whether such removal is likely to result in an increased flow of blood to the myocardium. Affirmative conclusions to these questions were reinforced by 42 postmortem coronary resections done in 31 cases. Fluidtight closures permitted follow-up perfusion studies in 25 successful resections done for the relief of coronary luminal narrowing, and in 16 of these significant increase in the perfusion rate resulted. Twelve of these 25 were endarterectomies, and increased perfusion rates were achieved in 10 of them. From the logical standpoint, direct relief such as appears mechanically feasible through surgical endarterectomy offers an attractive therapeutic approach to myocardial ischemia from coronary arteriosclerosis. The presence of multiple main-vessel lesions and of distalsmall-branch disease does not preclude significant improvement; these are not contraindications to such surgery.In view of the frequency and mortality of coronary arteriosclerosis and because of the inadequacies of other methods of therapy in use today, the clinical trial of a direct attack upon the occluding lesion appears to be warranted. Current clinical failures provide opportunities while external artificial circulation and other methods for left ventricular assistance or bypass pumping provide means for gaining surgical experience and offering at least a slim chance to patients whose lives would otherwise be lost. Radiographic studies of the coronary system will be essential to any surgical attack likely to succeed.

Materials and methods for transcatheter vascular occlusion: Some personal, practical views

In his paper, Greenfield reviews in detail the materials, devices, methods, and appropriate uses of transcatheter therapeutic vascular occlusion. In another report, White and coworkers focus on a specific and promising approach to selective vascular occlusion, the detachable balloon. Over 150 publications in the 1979 scientific literature emphasize the importance and diversity of methods now available for transcatheter vascular occlusion. The following comments reflect our personal views, based on a decade of experience in this field.