David H. Gordon

The role of percutaneous angioplasty in the management of chronic hemodialysis fistulas.

One hundred forty-one dilatations of stenotic lesions in dialysis access fistulas were performed. The initial success rate was 82%. The one-year patency rate was 45%, with a 2-year patency rate of 24%. Best results were obtained with a discrete stenosis at a graft-to-vein anastomosis. The procedure can be done on an outpatient basis and, although long-term results are poor, in appropriate patients multiple dilatations can be performed to keep a fistula functioning for many years.

Wandering spleen--the radiological and clinical spectrum.

Eight cases of wandering spleen demonstrate that this rare entity has a characteristic constellation of findings which, though nonspecific, are highly suggestive of the diagnosis. Angiography or isotopic imaging specific for the spleen confirms the diagnosis. Asymptomatic patients may be carefully observed, with the institution of splenectomy should signs of torsion develop.

Interventional radiology in the management of hepatic trauma.

Interventional radiology (catheter placement under radiologic guidance) is a safe and effective technique in the management of hemorrhage and infection after hepatic trauma. Twenty procedures in 17 patients were reviewed. All patients with hemorrhage, vascular lesions, and intra-abdominal fluid collections were successfully treated without mortality or substantial morbidity. These techniques are recommended in complicated liver trauma.

The Klippel-Trenaunay Syndrome: Clinical and Radiological Aspect1

Klippel-Trenaunay syndrome (KTS) is characterized by port-wine hemangiomas, deep venous system abnormalities, superficial varicosities, and bony and soft-tissue hypertrophy. When associated with an arteriovenous fistula, it has been termed Klippel-Trenaunay-Parkes-Weber syndrome. It is imperative that both the radiologist and surgeon be aware of this entity, as incomplete evaluation and inappropriate surgery may be devastating. Radiological workup includes phlebography, angiography, and conventional radiography of the involved extremities. Surgery should be performed only to relieve deep venous obstruction (if present) or to correct inequality in the lengths of legs. Removal of superficial varicosities is contraindicated because it will worsen existing symptoms. Five cases of KTS are presented and the literature reviewed.

Jugular venous ectasia in children. A report of 3 cases and review of the literature.

Three cases of jugular venous ectasia in children were diagnosed preoperatively by selective venography. These rare lesions appear to be congenital dilatations of the veins and should not properly be called aneurysms, as their histological structure is normal. A typical history and complex of physical findings are associated with this entity. It is important to include it in the differential diagnosis of neck masses in children.

Arteriovenous shunts involving the liver.

Arteriovenous shunting in the liver is a rare angiographic finding. Review of the literature shows that most cases are related to trauma or neoplasm. The authors discuss several entities which should also be included in the differential diagnosis, among them congenital arteriovenous malformations or hemangiomas of the liver and pancreas, cirrhosis with rearterialization of the liver, hepatic abscess, hypervascular liver metastases, and primary tumors with invasion of the portal and hepatic veins by arterial neovasculature.

Arteriography of Peripheral Hemangiomas

Arteriography has proved useful in evaluation of 17 patients with peripheral soft-tissue hemangiomas (15 benign, 2 malignant) by defining their extent, degree of vascularity, and source of vascular supply and allowing differentiation from arteriovenous malformations. In 11 cases (all benign), moderate fine-caliber hypervascularity with some degree of staining was seen. In 6 (4 benign, 2 malignant) there was marked hypervascularity with coarse, irregular vessels. The coarse or fine hypervascularity which characterizes most benign hemangiomas closely resembles that seen in malignant soft-tissue tumors and may preclude correct diagnosis by angiography alone. However, peripheral hemangiomas frequently exhibit distinctive clinical features which when combined with the arteriographic findings enable the radiologist to identify the lesion.

Increased 18F-FDG uptake is predictive of rupture in a novel rat abdominal aortic aneurysm rupture model.

OBJECTIVE To determine whether F-fluorodeoxyglucose (F-FDG) micro-positron emission tomography (micro-PET) can predict abdominal aortic aneurysm (AAA) rupture. BACKGROUND An infrarenal AAA model is needed to study inflammatory mechanisms that drive rupture. F-FDG PET can detect vascular inflammation in animal models and patients. METHODS After exposing Sprague-Dawley rats to intra-aortic porcine pancreatic elastase (PPE) (12 U/mL), AAA rupture was induced by daily, subcutaneous, β-aminopropionitrile (BAPN, 300 mg/kg, N = 24) administration. Negative control AAA animals (N = 15) underwent daily saline subcutaneous injection after PPE exposure. BAPN-exposed animals that did not rupture served as positive controls [nonruptured AAA (NRAAA) 14d, N = 9]. Rupture was witnessed using radiotelemetry. Maximum standard uptakes for F-FDG micro-PET studies were determined. Aortic wall PAI-1, uPA, and tPA concentrations were determined by western blot analyses. Interleukin (IL)-1β, IL-6, IL-10, and MIP-2 were determined by Bio-Plex bead array. Neutrophil and macrophage populations per high-power field were quantified. Matrix metalloproteinase (MMP) activities were determined by zymography. RESULTS When comparing ruptured AAA (RAAA) to NRAAA 14d animals, increased focal F-FDG uptakes were detected at subsequent sites of rupture (P = 0.03). PAI-1 expression was significantly less in RAAA tissue (P = 0.01), with comparable uPA and decreased tPA levels (P = 0.02). IL-1β (P = 0.04), IL-6 (P = 0.001), IL-10 (P = 0.04), and MIP-2 (P = 0.02) expression, neutrophil (P = 0.02) and macrophage presence (P = 0.002), and MMP9 (P < 0.0001) activity were increased in RAAA tissue. CONCLUSIONS With this AAA rupture model, increased prerupture F-FDG uptake on micro-PET imaging was associated with increased inflammation in the ruptured AAA wall. F-FDG PET imaging may be used to monitor inflammatory changes before AAA rupture.

Percutaneous coil embolization in the management of peripheral mycotic aneurysms

Traditional surgical treatment of a peripheral mycotic aneurysm has included emergency ligation and bypass. Occlusion of vessels just proximal and distal to a mycotic aneurysm can be safely accomplished via percutaneous embolization with coils. Surgery can be performed electively in a noninfected field. Coils can be placed near the site of vessel disruption minimizing loss of collateral flow.

Systemic venous blood return via the portal vein.

The patterns of collateral circulation which develop following obstruction of the inferior vena cava have been classically divided into three groups depending upon the level of obstruction, i.e., infrarenal, middle caval, and upper caval. The portal vein can play an active role at all three levels. Multiple potential routes to the portal vein are described and 6 cases are presented.