David M. Hovsepian

Lower Extremity Venous Thrombolysis with Adjunctive Mechanical Thrombectomy

PURPOSE To evaluate the use of adjunctive mechanical thrombectomy (MT) with pharmacologic catheter-directed lower extremity venous thrombolysis. MATERIALS AND METHODS Catheter-directed thrombolysis with adjunctive MT was used to treat 28 symptomatic limbs in 20 patients (22 procedures) with lower extremity deep vein thrombosis (DVT) between August 1997 and July 2001. Procedural success, major bleeding, thrombolytic infusion time, and total thrombolytic agent dose were recorded. RESULTS Procedural success was achieved in 23 of 28 limbs (82%). Fifteen patients (18 limbs) received iliac vein stents. Major bleeding was observed after three of 22 procedures (14%) and resulted in transfusion in two patients and endometrial ablation in the third patient. Mean per-limb infusion time was 16.8 hours +/- 12.8. Mean per-limb total doses were lower than those reported in published studies of DVT thrombolysis: 2.67 million U +/- 1.60 urokinase, 18.4 mg +/- 10.7 tissue plasminogen activator, and 13.8 U +/- 6.9 reteplase. Venographic analysis demonstrated minimal thrombus removal (26.0% +/- 24.1) when using MT alone, compared with substantial thrombus removal (62.0% +/- 24.9) when using MT after pharmacologic thrombolytic agents had been administered (P =.006). CONCLUSION The use of adjunctive MT to augment pharmacologic catheter-directed DVT thrombolysis provides comparable procedural success and may reduce the required thrombolytic dose and infusion duration.

Toward Best Practices in Radiology Reporting

The goals and current efforts of the Radiological Society of North America Radiology Reporting Committee are described. The committees charter provides an opportunity to improve the organization, content, readability, and usefulness of the radiology report and to advance the efficiency and effectiveness of the reporting process.

Elevated Plasma Levels of Matrix Metalloproteinase-9 in Patients with Abdominal Aortic Aneurysms: A Circulating Marker of Degenerative Aneurysm Disease

PURPOSE Matrix metalloproteinase-9 (MMP-9) is abundantly expressed in abdominal aortic aneurysms (AAAs), where it plays a pivotal role in connective tissue destruction. Elevated plasma concentrations of MMP-9 (MMP-9PL) also have been reported in patients with AAAs, but it is unclear if this can distinguish patients with AAAs from those with atherosclerotic occlusive disease (AOD). The purpose of this study was to further define the utility of elevated MMP-9PL levels in the diagnosis and evaluation of AAAs, and to examine if changes in MMP-9PL can be used as a functional biomarker of degenerative aneurysm disease. MATERIALS AND METHODS Peripheral venous blood was obtained from 25 patients with AAAs, 15 patients with AOD, and five normal control subjects. MMP-9PL levels were determined by an enzyme-linked immunosorbent assay. In four patients undergoing open AAA repair, MMP-9PL levels were directly compared with the amount of MMP-9 produced in aortic tissue. Six additional patients undergoing operative AAA repair were followed for 3-10 months to determine how treatment affected elevated MMP-9PL concentrations. RESULTS Mean (+/- SE) MMP-9PL was 36.1 +/- 7.7 ng/mL in normal control subjects, 54.7 +/- 10.5 ng/mL in patients with AOD, and 99.4 +/- 17.4 ng/mL in patients with AAAs (P < .05 versus normal control subjects and patients with AOD). Elevated MMP-9PL levels (> 87.8 ng/mL) were found in 12 of 25 (48%) patients with AAA but in only one of 15 (7%) patients with AOD (P < .05). MMP-9PL levels did not correlate significantly with either age, gender, or aneurysm diameter, although there was a trend toward the highest values in male patients with large AAAs. Production of MMP-9 in aneurysm tissues paralleled MMP-9PL levels, and elevated MMP-9PL levels decreased by 92.7% +/- 3.2% after surgical AAA repair. CONCLUSIONS Elevated MMP-9PL levels were observed in approximately one half of patients with AAAs and less than 10% of those with AOD (positive predictive value of 92.3%), but normal MMP-9PL levels had limited utility in excluding the presence of an aortic aneurysm (negative predictive value, 52%). MMP-9PL levels in patients with AAAs appeared to directly reflect the amount of MMP-9 produced within aneurysm tissue, and MMP-9PL levels decreased substantially after aneurysm repair. Measures of circulating MMP-9 may provide a biologically relevant marker of connective tissue metabolism in patients with AAAs.

Safety and Efficacy of Percutaneous Fiducial Marker Implantation for Image-guided Radiation Therapy

PURPOSE To evaluate the safety and technical success rate of percutaneous fiducial marker implantation in preparation for image-guided radiation therapy. MATERIALS AND METHODS From January 2003 to January 2008, we retrospectively reviewed 139 percutaneous fiducial marker implantations in 132 patients. Of the 139 implantations, 44 were in the lung, 61 were in the pancreas, and 34 were in the liver. Procedure-related major and minor complications were documented. Technical success was defined as implantation enabling adequate treatment planning and computed tomographic simulation. RESULTS The major and minor complication rates were 5% and 17.3%, respectively. Pneumothorax after lung implantation was the most common complication. Pneumothoraces were seen in 20 of the 44 lung implantations (45%); a chest tube was required in only seven of the 44 lung transplantations (16%). Of the 139 implantations, 133 were successful; in six implantations (4.3%) the fiducial markers migrated and required additional procedures or alternate methods of implantation. CONCLUSIONS Percutaneous implantation of fiducial marker is a safe and effective procedure with risks that are similar to those of conventional percutaneous organ biopsy.

Endoluminal graft repair for abdominal aortic aneurysms in high-risk patients and octogenarians: is it better than open repair?

ObjectiveTo analyze the short-term and midterm results of open and endoluminal repair of abdominal aortic aneurysms (AAA) in a large single-center series and specifically in octogenarians. MethodsBetween January 1997 and October 2000, 470 consecutive patients underwent elective repair of AAA. Conventional open repair (COR) was performed in 210 patients and endoluminal graft (ELG) repair in 260 patients. Ninety of the patients were 80 years of age or older; of these, 38 underwent COR and 52 ELG repair. ResultsPatient characteristics and risk factors were similar for both the entire series and the subgroup of patients 80 years or older. The overall complication rate was reduced by 70% or more in the ELG versus the COR groups. The postoperative death rate was similar for the COR and ELG groups in the entire series and lower (but not significantly) in the ELG 80 years or older subgroup versus the COR group. The 36-month rates of freedom from endoleaks, surgical conversion, and secondary intervention were 81%, 98.2%, and 88%, respectively. ConclusionThe short-term and midterm results of AAA repair by COR or ELG are similar. The death rate associated with this new technique is low and comparable, whereas the complication rate associated with COR in all patients and those 80 years or older in particular is greater and more serious than ELG repair. Long-term results will establish the role of ELG repair of AAA, especially in elderly and high-risk patients.

Structure and assembly of haptoglobin polymers by electron microscopy

Haptoglobin (Hp) consists of light (L) and heavy (H) chains, the latter of which combine with hemoglobin alpha beta dimers to form a highly stable complex. Human haptoglobin assembles as HL units that occur in two allelic forms; HL1 , which is monovalent, and HL2 , which is divalent. As a result, three phenotypic forms exist in the human population: Hp1-1, the homozygous form in which the monovalent HL1 unit occurs as a dimer; Hp2-2, the homozygous form of the divalent HL2 unit, which gives a series of polymers; and the heterozygous Hp2-1 form, which gives a different series of polymers. We have investigated the structures and assembly properties of these two haptoglobin polymeric series in their complexes with hemoglobin using high-resolution scanning transmission electron microscopy. Polymers of complex are composed of ellipsoidal or bilobal head groups, which are the H alpha beta subunits connected by thin filament-like structures, which are the L chains. Polymers of size up to pentamers can be identified easily by counting the number of head groups in the molecule. Complex 2-1 and complex 2-2 trimers were studied extensively. The differences in detailed morphology show that while the 2-1 trimer is a linear polymer, the 2-2 trimer is a closed circular molecule. The micrograph images suggest that complex 2-2 tetramers and pentamers, and perhaps higher forms may also be cyclic. The structure of the L2 subunit of haptoglobin is shown to be composed of two domains, which may be similar in structure to the single domain of the monovalent L1 chain. The two L2 domains are connected by a hinge that has quite limited flexibility. Using these structural models, assembly characteristics and structural properties of the trimers and tetramers of complex 2-1 and complex 2-2 are described.

Structure of haptoglobin and the haptoglobin-hemoglobin complex by electron microscopy.

The human serum protein, haptoglobin, forms a stable, irreversible complex with hemoglobin. Haptoglobin is composed of two H chains, which are connected via two smaller L chains to give a protein of 85,000 Mr. In the complex, each H chain binds an alpha beta dimer of hemoglobin for a total molecular weight of 150,000. The scanning transmission electron microscope has been used to derive new information about the shape and structure of haptoglobin and hemoglobin, and about their relative orientation in the complex. The micrographs of negatively stained images show that haptoglobin has the shape of a barbell with two spherical head groups, which are the H chains. These are connected by a thin filament with a central knob, which corresponds to the L chains. The overall length of the molecule is about 124(+/- 8) A and the interhead distance is 87 (+/- 7) A. In the haptoglobin-hemoglobin complex, the head groups are ellipsoidal and under optimal staining conditions bilobal . Thus, the alpha beta dimers are binding to the H chains, but off the long axis of the barbell by 127 degrees in a trans configuration. This angle considerably restricts the region on the surface of the H chain structure that can contain the hemoglobin binding site. The interhead group distance for complex is 116.5(+/- 6.3) A or 30 A greater than for haptoglobin. The N terminus of the beta chain was located on the trans off-axis configured barbell structure of complex by using a hemoglobin that was crosslinked between the alpha beta dimers in the region of the beta N terminus. The distances and angles that are measured on the micrographs for the native and crosslinked complex molecules permit the directions of two of the alpha beta dimer ellipsoid axes to be assigned. Taken together, these data provide an approximate relative orientation for the binding of the alpha beta dimer to the H chain of haptoglobin.

Quality Improvement Guidelines for Uterine Artery Embolization for Symptomatic Leiomyomata

Uterine artery embolization (UAE) is assuming an important role in the treatment of women with symptomatic uterine leiomyomata worldwide. The following guidelines, which have been jointly published with the Society of Interventional Radiology in the Journal of Vascular and Interventional Radiology, are intended to ensure the safe practice of UAE by identifying the elements of appropriate patient selection, anticipated outcomes, and recognition of possible complications and their timely address.

Imaging Guidance with C-arm CT: Prospective Evaluation of Its Impact on Patient Radiation Exposure during Transhepatic Arterial Chemoembolization

PURPOSE To prospectively evaluate the impact of C-arm CT on radiation exposure to hepatocellular carcinoma (HCC) patients treated by chemoembolization. MATERIALS AND METHODS Patients with HCC (N = 87) underwent digital subtraction angiography (DSA; control group) or combined C-arm CT/DSA (test group) for chemoembolization. Dose-area product (DAP) and cumulative dose (CD) were measured for guidance and treatment verification. Contrast agent volume and C-arm CT utility were also measured. RESULTS The marginal DAP increase in the test group was offset by a substantial (50%) decrease in CD from DSA. Use of C-arm CT allowed reduction of DAP and CD from DSA imaging (P = .007 and P = .017). Experienced operators were more efficient in substituting C-arm CT for DSA, resulting in a negligible increase (7.5%) in total DAP for guidance, compared with an increase of 34% for all operators (P = .03). For treatment verification, DAP from C-arm CT exceeded that from DSA, approaching that of conventional CT. The test group used less contrast medium (P = .001), and C-arm CT provided critical or supplemental information in 20% and 17% of patients, respectively. CONCLUSIONS Routine use of C-arm CT can increase stochastic risk (DAP) but decrease deterministic risk (CD) from DSA. However, the increase in DAP is operator-dependent, thus, with experience, it can be reduced to under 10%. C-arm CT provides information not provided by DSA in 33% of patients, while decreasing the use of iodinated contrast medium. As with all radiation-emitting modalities, C-arm CT should be used judiciously.

Development of new hepaticoenteric collateral pathways after hepatic arterial skeletonization in preparation for yttrium-90 radioembolization.

PURPOSE Development of new hepaticoenteric anastomotic vessels may occur after endovascular skeletonization of the hepatic artery. Left untreated, they can serve as pathways for nontarget radioembolization. The authors reviewed the incidence, anatomy, management, and significance of collateral vessel formation in patients undergoing radioembolization. MATERIALS AND METHODS One hundred thirty-eight treatments performed on 122 patients were reviewed. Each patient underwent a preparatory digital subtraction angiogram (DSA) and embolization of all hepaticoenteric vessels in preparation for yttrium-90 ((90)Y) administration. Successful skeletonization was verified by C-arm computed tomography (CACT) and technetium-99m macroaggregated albumin ((99m)TcMAA) scintigraphy. During the subsequent treatment session, DSA and CACT were repeated before administration of (90)Y, and the detection of extrahepatic perfusion prompted additional embolization. RESULTS Forty-two patients (34.4%) undergoing 43 treatments (31.2%) required adjunctive embolization of hepaticoenteric vessels immediately before (90)Y administration. Previous scintigraphy findings showed extrahepatic perfusion in only three cases (7.1%). Vessels were identified by DSA in 54.1%, by CACT in 4.9%, or required both in 41.0%. The time interval between angiograms did not correlate with risk of requiring reembolization (P = .297). A total of 19.7% of vessels were new collateral vessels not visible during the initial angiography. Despite reembolization, three patients (7.1%) had gastric or duodenal ulceration, compared with 1.3% who never had visible collateral vessels, all of whom underwent whole-liver treatment with resin microspheres (P = .038). CONCLUSIONS Development of collateral hepaticoenteric anastomoses occurs after endovascular skeletonization of the hepatic artery. Identified vessels may be managed by adjunctive embolization, but patients appear to remain at increased risk for gastrointestinal complications.