David J. Delany

The role of noninvasive tests versus pulmonary angiography in the diagnosis of pulmonary embolism

We studied 243 patients in whom 248 pulmonary angiograms were performed because of suspected pulmonary embolism. Ventilation and perfusion lung scanning in 140 of them revealed 38 to be in low and high probability groups. Of 19 patients with subsegmental and nonsegmental perfusion defects that were matched with ventilation defects, none had pulmonary embolism. Conversely, angiography was positive in 17 of 19 patients with multiple segmental or lobar perfusion defects in areas of normal ventilation. Doppler flow examinations of the veins of the legs showed normal flow in 61 of 79 (77 percent) patients with pulmonary emboli and, therefore, were insensitive indicators of embolism. There was no mortality from angiography, and serious complications occurred in 2 percent of the patients. Anticoagulation in 83 patients was associated with bleeding in 25, two of whom died. The data indicate that ventilation-perfusion lung scanning can be used to separate many of the patients suspected of having pulmonary embolism who need anticoagulant treatment from those who do not. However, there is a considerable number of patients with nonspecific abnormalities on lung scan. For this group of patients with nonspecific abnormalities, the risk of complications from empiric treatment with anticoagulant drugs is probably greater than the risk of complications from pulmonary angiography. Further, our data show that patients with negative angiography have a very low risk of subsequent pulmonary embolism. In this group of patients, therefore, pulmonary embolism should be demonstrated by angiography before long-term anticoagulant therapy is prescribed.

Small bore catheter drainage and sclerotherapy for malignant pleural effusions

Thexs accumulation of large amounts of fluid in the pleural space is a common sequela of disseminated carcinomatosis. Traditional management has included therapeutic thoracentesis or the placement of a large bore chest tube for drainage with the subsequent installation of a sclerosing agent in an attempt to achieve pleural symphysis. An evaluation of all patients treated in this manner during a 4‐year period was undertaken to assess the degree of success obtained with a large bore standard chest tube versus a small pigtail catheter. A study group consisting of 20 patients with a total of 24 pleural effusions was treated with drainage and sclerotherapy. In this group, eight of 13 effusions were adequately treated with pigtail catheter drainage and sclerotherapy, compared with four of 11 effusions adequately treated with standard chest tube drainage and sclerotherapy. Although the numbers are small, it appears that pigtail catheter drainage and sclerosis is at least as successful as the more traditional drainage with the standard chest tube.

The Role of Transbronchial Lung Biopsy in Diffuse Pulmonary Disease

Forty consecutive patients underwent flexible fiberoptic transbronchial lung biopsy for diagnosis of diffuse nodular or infiltrative lung disease. Biplane fluoroscopic examination with image intensification greatly facilitated accurate placement of the biopsy forceps near the pleura; Specimens of lung parenchyma were obtained for culture and histological study in every case. A pathological diagnosis was correctly established in 34 of 40 patients. Transbronchial biopsy was helpful in the clinical management of an additional 4 patients. Biopsy results were not accurate in 2 patients. No significant morbidity was associated with the procedure. Fiberoptic transbronchial lung biopsy is a safe and useful adjunct to the diagnosis of parenchymal lung disease.

Tricuspid Atresia: Corrective Operation without a Bioprosthetic Valve

A case of successful correction of type IB tricuspid atresia is described in which the patients own normal pulmonary valve was used in its natural location. Morphological features of tricuspid atresia suggest that use of the in situ pulmonary valve is possible in most patients with normally related great arteries. Elimination of the requirement for valved conduits and bioprosthetic valves may eventually permit corrective operation in the very young child.

Quantitative digital fluorography. Computer vs. human estimation of vascular stenoses.

Digital subtracted images of iodinated rods, incorporating accurately measured areas of eccentric stenosis were obtained. The average subjective estimations of fractional area reduction (211 readings each) by three experienced angiographers were compared with values obtained using an interactive computer algorithm using the densitometric data. Results were analyzed to identify major influences on accuracy, including iodine concentration, vessel width, absolute severity of the stenosis, and vessel orientation. While no single factor appeared to seriously affect human accuracy, computer readings were significantly influenced by the tilt of the vessel in relation to the x-ray beam. Various potential sources of error including beam hardening, stenosis geometry, and scattering are discussed and appropriate algorithm corrections suggested. The importance of the availability of a reliable and accurate method to quantify vascular stenosis and volume of stenotic material is stressed.

CT demonstration of central pulmonary venous and arterial occlusive diseases

Computed tomography was used to evaluate three patients with complicated pulmonary vascular patterns. The physiologic and anatomic changes seen on chest radiography were well defined by CT and in each case CT suggested the correct diagnosis.

Hepatic angiography in hereditary hemorrhagic telangiectasia.

Three patients presenting with gastrointestinal bleeding and characteristic radiologic findings of hereditary hemorrhagic telangiectasia are described. Emphasis is placed not only on the angiodysplasia evident from abdominal angiography, but also on the demonstration by the chest radiograph of a chronic mild hyperdynamic state.

Intravenous digital subtraction angiography of orbital and ocular circulation

In serial experiments on cats, intravenous digital subtraction angiography (DSA) was utilized to observe orbital and ocular circulation. Images of the orbital arterial system as well as normal ocular vasculature were obtained, utilizing dosage of contrast material acceptable for human study. Images obtained after intraarterial DSA had no advantage over those obtained with intravenous DSA. After retrobulbar injection of 3 ml of saline, intravenous DSA demonstrated straightening of the external ophthalmic arteries showing the potential of this method for identifying orbital vascular pathology.