Elliot O. Lipchik

Anatomic and Hemodynamic Correlations in Carotid Artery Stenosis

Pressures were measured in the carotid arteries of 61 patients proximal and distal to atherosclerotic plaques which were carefully studied by angiography and anatomical dissection. (1) An atherosclerotic plaque causing a constriction of less than 47% luminal diameter leaving a lumen greater than 3.0 mm in diameter never caused pressure drops of greater than 10 mm Hg. Stenoses of greater than 63% luminal diameter leaving lumens less than 1.0 mm in diameter always caused pressure drops. (2) Atherosclerotic plaques producing defects which narrowed the lumen fell into a distinct pattern: (a) Type 1 lesions—This basic lesion filled the bulb of the internal carotid artery near its origin, causing a 1 to 2 cm smooth elliptical encroachment on the lumen. (b) Type 2 lesions—Short localized areas of thickening in addition to the basic lesion caused bar-like defects of the lumen at the origin of the internal carotid artery or near the distal end of the lesion. (c) Type 3 lesions—Multiple bar-like defects were sometimes seen. (d) Type 4 lesions—The areas of increased thickening of the lesion were sometimes quite narrow, producing diaphragm-like defeats on the lumen. Although theoretically these various types of stenoses should produce different hemodynamic changes, insufficient numbers of observations were made to corroborate these presumptions. (3) Angiograms in general mimicked the gross appearance of the plaques and predicted the actual degree of stenosis produced but did not identify many diaphragm defects, ulcerations, or small thrombi.

Echocardiographic Recognition of the Congenital Bicuspid Aortic Valve

Twenty-one patients (age four to 25 years) with bicuspid aortic valves proved by surgery and angiography (12) or angiography alone (9) were studied by echocardiography. Seventeen patients had aortic valve disease (11 stenosis, 6 incompetence) and four had coarctation of the aorta with normally functioning aortic valves. A comparison group of 16 patients (9 with aortic valve disease and 7 without aortic valve disease) who had proven tricuspid aortic valves was also studied. Echocardiograms in tricuspid aortic valve patients showed the closed position of the cusps near the middle of the aortic lumen. In contrast marked eccentricity of the aortic valve cusp echoes in diastole could be demonstrated in all with bicuspid aortic valves. The Eccentricity Index (½ aortic lumen diameter/minimum distance of the diastolic cusp echo from the nearest aortic margin) was low (range 1.0-1.25) with tricuspid aortic valves and high (range 1.5-5.6) with bicuspid aortic valves (P < 0.001). This index was not significantly affected following successful valvotomy. Bicuspid aortic valve cusps showed normal systolic motion pattern resulting in marked asymmetry of leaflet images. About half of patients with bicuspid aortic valves also showed multilayered echoes in diastole in the absence of fluoroscopic evidence of valvular calcification. Echocardiography appears to be specific in the recognition of the bicuspid aortic valve.

Echocardiographic features of subpulmonic obstruction in dextro-transposition of the great vessels.

Eleven patients with transposition of the great vessels (TGV) and subpulmonic (left ventricular outflow) obstruction documented by cardiac catheterization/ angiography were studied by echocardiography. Ten showed prolonged mitral-septal apposition in diastole indicative of a narrow left ventricular outflow tract. In addition, 5 patients showed systolic anterior movements (SAMs) of the anterior mitral leaflet resembling those observed in hypertrophic subaortic stenosis. The SAMs were large in 3 patients and may have accentuated the outflow obstruction. Additional evidence for this was provided by the tendency of the pulmonic valve towards closure with the onset of mitral SAMs. A comparison group of 21 patients with TGV and no outflow obstruction did not show these features. Echocardiography appears to be useful in the diagnosis of subpulmonic muscular obstruction in TGV. Demonstration of definite mitral SAMs in some patients suggests the presence of associated functional obstruction of the type seen in hypertrophic subaortic stenosis.

Obstruction of the Abdominal Aorta Above the Level of the Renal Arteries

Obstruction of the abdominal aorta is an almost commonplace diagnosis today. Most of the cases reported in the literature occur in the lower aorta, particularly at the bifurcation (3). There have been many examples of aortic occlusion at the level of the renal arteries, but in most instances these were secondary to a “Leriche“ type of atherosclerotic aortic occlusion (8), or they were due to syphilis (5) or coarctation (7, 9). The occlusion to be reported in this presentation was situated in the abdominal aorta above the renal arteries. A careful review of the literature failed to reveal a counterpart or a radiologic study of any other suprarenal atherosclerotic occlusive lesion. Baylin (2) and Ross and Mc-Kusick (12) described two cases which have certain resemblances to ours, but apparently no radiographs were obtained since the findings were discovered only during the autopsy examination. Case History J. C., a 45-year-old white male executive, was referred to Strong Memorial Hospital on Dec. 2, 1962, w...

Diaphragm-Like Obstructions of the Human Arterial Tree

Thin, band-like arteriosclerotic lesions causing significant obstruction of the involved arteries have been described pathologically and angiographically. They may be easily overlooked during angiography, and could theoretically be found in all vessels prone to atherosclerosis.

Congenital corrected transposition of the great vessels without cardiac anomalies

Abstract The clinical, angiocardiographic, vectorcardiographic and phonocardiographic findings in a fifty-four year old man with uncomplicated corrected transposition of the great vessels are presented. A soft, grade 26 precordial systolic murmur was present, and the second heart sound at the base appeared single on auscultation but was normally and narrowly split on phonocardiogram. The P-R interval was prolonged and paroxysmal nodal tachycardia frequently occurred. The patient never manifested any evidence of heart failure and the inverted ventricles functioned well with their reversed pressure and volume loads. Sixteen well documented cases of uncomplicated corrected transposition have been reported in the American literature, and the available clinical data on seven of these cases are reviewed. The present patient is the only one in the older age group with complete antemortem documentation of all cardiovascular parameters.

Unusual Symptomatic Aortic Arch Anomalies

Anomalies of the aortic arch are not uncommon. Quite often they may be suspected from the standard four chest films, with barium in the esophagus, and definitively demonstrated by angiocardiography. Those anomalies forming vascular rings, e.g., the double aortic arch, have been well documented in the literature. The purpose of this report is to illustrate three anomalies of the aortic arch and its brachiocephalic branches: anomalous innominate artery, the cervical aortic arch, and congenital stenosis of one or more of the brachiocephalic vessels. The second and third of these have not been previously documented in the radiologic literature. Most vascular rings and malformations of the aortic arch can be related to either a persistence or abnormal regression of one or more of the six original paired primitive aortic arches. The caudal descent of the heart occurs as the first two arches regress and disappear. Edwards (1, 2), in his simplified classification, uses the basic embryologic pattern of two arches,...

Angiographic and Scintillographic Identification of Riedel's Lobe of the Liver

Riedels lobe (1) represents an anomaly of the right lobe of the liver which is usually easy to recognize and rarely of clinical significance. It may present as a localized tumor in the right upper quadrant of the abdomen, however, and, when associated with liver disease such as cirrhosis, may be mistaken for an extrahepatic or an intrahepatic lesion. Splenoportography and liver scans have been used to clearly define the anomaly and to resolve the differential diagnosis. Case Reports CASE I: M. B., a 33-year-old white woman with a three- to four-year history of alcoholism. Four months prior to admission, liver decompensation was manifested by ascites and hematemesis. A radioactive rose bengal scan was performed at another institution (Fig. 1), and the patient was referred to Strong Memorial Hospital, Rochester, N. Y., with a diagnosis of tumor of the right lobe of the liver. On admission the patient was pale and cachectic but not icteric. A fluid wave was present in the abdomen. The liver was hard, nonten...

Angiocardiographic evaluation of mitral valve stenosis. Use in selection of surgical approach.

Some divergence of opinion exists as to the merits of “closed” versus “open” commissurotomy for the correction of pure acquired mitral stenosis (9). Part of this controversy is probably due to the small but real percentage of early failures, as well as to the relatively frequent recurrence of mitral stenosis following the procedure (6). Such recurrences and failures may be due in part to the presence of one of the following pathologic features of the mitral valve: insufficient closure; heavy calcification; significant reduction in functioning valve tissue with scarring and fusion; extensive deformities of the valve secondary to abnormalities of the chordae tendineae. Also, thrombi in the left atrium, with their possible dislodgment at surgery, may present formidable technical problems for the surgeon. The assessment of the functional derangement of the mitral valve is best achieved by selective angiocardiography, in conjunction with and complementary to hemodynamic evaluations of cardiac function by simul...

Phlegmasia Cerulea Dolere

Phlegmasia cerulea dolens is a severe form of venous thrombosis presenting as an edematous, painful, purplish-blue lower extremity. Its rapid recognition as venous thrombosis rather than arterial insufficiency is important in avoiding gangrene and other life threatening complications. Three cases illustrating the presentation of this disorder are reported.