Eric C. Martin

Multicenter Trial of the Wallstent in the Iliac and Femoral Arteries

PURPOSE To report the results of the FDA phase II, multicenter trial of the Wallstent in the iliac and femoral arteries. PATIENTS AND METHODS Two hundred twenty-five patients entered the trial. Stents were placed in the iliac system in 140 patients and in the femoral system in 90 (five patients required both iliac and femoral stents). Clinical patency was measured over 2 years by means of life-table analysis with use of clinical and hemodynamic data and the Rutherford scale. Angiographic patency was measured at 6 months. RESULTS In the iliac system the primary clinical patency was 81% at 1 year and was 71% at 2 years. The secondary clinical patency was 91% and 86%, respectively. The 6-month angiographic patency was 93%. In the femoral system the primary clinical patency was 61% at 1 year and 49% at 2 years. The secondary patency was 84% and 72%, respectively. The 6-month angiographic patency was 80%. CONCLUSIONS The results are similar to those with the Palmaz stent in the iliac system and with angioplasty alone in the iliac and femoral systems.

Guidelines for Peripheral Percutaneous Transluminal Angioplasty of the Abdominal Aorta and Lower Extremity Vessels

A Statement for Health Professionals From a Special Writing Group of the Councils on Cardiovascular Radiology, Arteriosclerosis, Cardio-Thoracic and Vascular Surgery, Clinical Cardiology, and Epidemiology and Prevention, the American Heart Association

Percutaneous intraaortic balloon insertion

A new single chambered percutaneous intraaortic balloon has been constructed around a central guidewire. The balloon can be wrapped around the guidewire, enabling its insertion into the femoral artery through a 12F sheath inserted with the conventional Seldinger technique. Percutaneous intraaortic balloon insertion has been performed in 27 patients (mean age 58 years) for a variety of medical and surgical indications. Percutaneous balloons could not be advanced into the aorta in two patients (7.4 percent) with severe bilateral aortoiliac occlusive disease. In all 25 patients undergoing intraaortic balloon pumping satisfactory circulatory support was achieved, and 21 (84 percent) of the patients survived to be discharged from the hospital. The mean duration of intraaortic balloon pumping was 3.5 days. Percutaneous intraaortic balloon insertion requires less than 5 minutes and has been successfully performed in the cardiac catheterization laboratory, coronary care unit, operating room and recovery room. After direct balloon removal, external pressure was applied for 30 minutes. No patient experienced hematoma of the groin, aortic dissection, compromised distal pulses or late wound complications. Percutaneous balloon insertion permits the rapid institution of circulatory support and broadens the medical and surgical applications of intraaortic balloon pumping.

Total occlusions of the femoropopliteal artery: high technical success rate of conventional balloon angioplasty

Seventy patients 48-93 years of age underwent standard percutaneous transluminal angioplasty (PTA) for femoropopliteal artery occlusions 1-10 cm long. PTA was accomplished through an antegrade puncture of the common femoral artery. The angiographic criterion for technical success was restoration of the vessel lumen with no significant residual stenosis. The authors report technical success in 64 (91%) of their patients, an improvement over a technical success rate of 74% in their previous series of 46 other PTA patients with occlusions 1-20 cm long. In this series, no complications related to PTA necessitated emergency surgical intervention. Refinements in PTA can be attributed to changes in patient selection and medication, improvements in balloon catheters and guide wires, and greater proficiency on the part of angiographers. This update reflects currently achievable results with standard angioplasty techniques, and it is against such results that all new vascular recanalization techniques, including laser-assisted PTA, should be compared.

Spontaneous complete closure of a congenital coronary artery fistula

The first documentation is reported of spontaneous closure of a coronary artery to right ventricle fistula that was demonstrated initially in a 14 month old boy. Over a 4 year period after diagnosis, the characteristic continuous murmur gradually disappeared. When the patient was 5 1/2 years of age, selective coronary arteriography showed normal coronary vessels and circulation. Six other cases of coronary fistula observed during the past 10 years are also reviewed. This study supports the rationale for clinical follow-up rather than obligatory surgical intervention in asymptomatic patients with a small shunt who have no evidence of myocardial dysfunction.

Hepatic neurofibromatosis, malignant schwannoma, and angiosarcoma in von Recklinghausen's disease

Liver involvement by neurofibromatosis is rare. This report describes a young man with von Recklinghausens disease and hepatic neurofibromas who developed a large right hepatic lobe malignancy and died of massive intratumor hemorrhage. Postmortem examination showed the tumor to be composed of both malignant schwannoma and angiosarcoma and to have arisen from contiguous neurofibromas in portal tracts. Widespread pulmonary metastases consisted of the angiosarcomatous elements alone. The expression of malignant schwannoma and angiosarcoma phenotypes in this tumor may be related to a common histogenesis from cells of the neural crest.

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.

Percutaneous Drainage in the Management of Hepatic Abscesses

Once a hepatic abscess has been defined radiologically, percutaneous drainage is the treatment method of first choice. Surgery is reserved for failure of percutaneous therapy. Percutaneous drainage for hepatic abscess has been safe, uncomplicated, and successful in seven patients treated by the authors between 1978 and 1980.

Optimal resources for the examination and endovascular treatment of the peripheral and visceral vascular systems. AHA Intercouncil Report on Peripheral and Visceral Angiographic and Interventional Laboratories.

In 1969 the Intersociety Commission for Heart Disease Resources was established through a contract with the American Heart Association under Public Law 89-239. Its responsibility was to produce guidelines defining optimal medical resources and care for the prevention and treatment of cardiovascular disease, including guidelines for radiologic facilities (1). This resource guideline was revised in 1976 (2) and again in 1983 (3). The Intersociety Commission was disbanded shortly thereafter, but a joint ad hoc task force of the American Heart Association and the American College of Cardiology continued this work with “Guidelines for Cardiac Catheterization and Cardiac Catheterization Laboratories” (4), published in 1991. The task force concluded that “. . . while noncardiac diagnostic and therapeutic procedures are growing in number . . . guidelines for these services are beyond the scope of this document.” These documents have charted the evolution of cardiac catheterization from a procedure performed in a few highly specialized laboratories for cardiovascular research to one performed in a number of interventional cardiac laboratories. The documents also have provided useful optimal resource guidelines. In the 1983 report similar standards for angiographic facilities were implied but never specifically stated, with the emphasis always on the heart. Nevertheless, the report mentioned angiographic facilities and considerable involvement by radiologists. Just as cardiac catheterization has evolved, so too have peripheral and visceral angiography. Diagnostic angiography proliferated in the 1960s and the 1970s, and interventional radiology emerged in the 1980s. Nevertheless, optimal resource standards have never been promulgated except in an abbreviated form (5). In 1989 the Council Affairs Committee of the AHA approved the formation of a committee on peripheral vascular disease under the auspices of the Council on Cardiovascular Radiology. In 1992 an ad hoc task force was created, with members from the Councils on Cardiovascular Radiology, Cardio-Thoracic and Vascular Surgery, Clinical Cardiology, and Kidney in Cardiovascular Disease, to develop guidelines for peripheral and visceral angiographic and interventional laboratories. Task force members are Eric C. Martin, MD, chair; William J. Casarella, MD (Council on Cardiovascular Radiology); Barry T. Katzen, MD (Council on Cardiovascular Radiology); Gerald M. Dorros, MD (Council on Clinical Cardiology); Gary S. Roubin, MD (Council on Clinical Cardiology); James A. DeWeese, MD (Council on Cardio-Thoracic and Vascular Surgery); and John H. Laragh, MD (Council on Kidney in Cardiovascular Disease). The task force is grateful for the contributions of the following consultants: John F. Cardella, MD; Joel E. Gray, PhD; Victoria M. Marx, MD; Edward L. Nickoloff, ScD; Michael J. Pentecost, MD; and David C. Levin, MD.

Transcatheter Sclerosis of the Gallbladder in Rabbits: A Preliminary Study

Catheter sclerosis of 56 rabbit gallbladders was attempted at laparotomy. The proximal cystic duct was occluded with a hemoclip and transcatheter administration of six different sclerosing agents and a saline control was performed. Eight animals were used for each agent, three being sacrificed after two weeks and the remainder after six weeks. Hot contrast and sotradecol were comparable with saline in their lack of effect on gallbladder mucosa. Alcohol alone, tetracycline, methylcyanoacrylate and alcohol plus trifluoroacetic acid were successful at two weeks in denuding the gallbladder epithelium and promoting fibrosis of the gallbladder wall. After six weeks, evidence of mucosal regeneration was present with all agents, and the epithelium appeared to have grown back from the occluded cystic duct. Late regeneration has not been previously reported and its significance when considering the application of the technique to the human gallbladder is discussed.