Ernest J. Ring

Potential mechanisms of angioplasty

There are at least five potential mechanisms for enlarging the arterial lumen using the technique of percutaneous transluminal angioplasty. Each of these mechanisms is reviewed along with evidence from clinical or experimental angioplasty supporting or refuting an actual role for that mechanism in mechanical dilation of diseased vessels. Although plaque compaction is not plausible, each of the other four responses—redistributive modeling of plaque, embolization of plaque components, plastic stretching of the arterial wall, and phagocytic removal of plaque during healing after angioplasty—has been confirmed in at least some circumstances. Since the lesions probably differ in their biomechanical properties, we conclude that it is unlikely that a single mechanism will explain all of the successful dilations.

Endoscopic sphincterotomy assisted by catheterization antegrade

Salky described a technique for gastrostomy-jejunostomy conversion which employs fluroscopy and a J -wire to thread the feeding tube into the proximal small intestine. With the use of the gastroscope, the feeding tube is simply and readily positioned in the duodenum. A similar endoscopic technique has been described by Bernton et a1. for placement of rectal tubes with the aid of the colonoscope. Introduction of the feeding tube through the gastrostomy avoids the discomfort and complications associated with tubes placed through the nose. In addition, the feeding tube can be easily maintained in position while the gastroscope is withdrawn through the pylorus. The introduction of the gastroscope and a feeding tube, beside one another and through the esophagus, frequently results in dislodgment of the feeding tube when the scope is withdrawn.

Current Status of Percutaneous Transluminal Angioplasty

With the development of a dilating balloon catheter that permits percutaneous treatment of many arterial stenoses and some occlusions, a definite advance in the therapy of peripheral vascular disease has been made. It is still too early to be certain what ultimate position this means of therapy will take in the overall treatment of vascular disease, as its use is still being extended and long-term results are not yet clearly known. When compared with surgical therapy, however, it has some striking advantages, although the durability of its effect appears to be less. Despite the fact that more time and experience are needed before its ultimate position is established, we believe that the evidence to date warrants inclusion of this form of therapy in the armamentarium of every major vascular center.

Thin needle biopsy in the diagnosis of ureteral obstruction with malignancy

Ureteral obstruction after treatment for abdominal cancers is a common situation in which the thin needle biopsy presents an attractive low morbidity alternative to laparotomy for the diagnosis of malignant disease. A negative biopsy is still nonconclusive, although helpful in determining the next step in the patients management. In our own series, biopsy in the region of ureteral obstruction revealed tumor rather than benign disease in four of five patients. No morbidity was encountered.

Long-Term Results of Transluminal Angioplasty of the Femoral Arteries

Percutaneous transluminal angioplasty (PTA) as a means of treating occlusive vascular disease of the lower extremities has become widespread. Within the last 3 years, reports of experience in centers across the United States and Europe have been published in both radiological and surgical literature [1–7]. Many of these reports have only dealt with short-term studies and small numbers of patients. Others fail to examine the variables that a vascular surgeon normally uses to evaluate surgical procedures. In this paper, we report the results of femoral artery PTA from the viewpoint of a vascular surgeon by examining those factors that are known to affect the outcome of surgical treatment of lower extremity occlusive arterial disease in order to provide a better way of comparing the results of angioplasty to those of surgery.

New Indications for Renal Infarction

Two patients with stage D transitional cell carcinoma of the kidney presented with recurrent massive hematuria. Both had prompt cessation of bleeding following renal infarction. Another patient had malignant hypercalcemia related to metastatic renal cell carcinoma and became normocalcemic after renal infarction. Angiographic renal infarction offers a rational alternative to conventional therapy in the management of these 2 problems.

Percutaneous Transluminal Angioplasty Treatment of Renal Transplant Artery Stenosis

Since June 1979, percutaneous transluminal angioplasty (PTA) has been the procedure of choice for renal transplant artery stenosis (RTAS) at the Hospital of the University of Pennsylvania. Of 241 renal allograft recipients, 17 (7%) when studied by arteriogram because of suspected RTAS proved to have significant stenosis (the mean reduction in luminal width for the group being 68%) and underwent PTA. RTAS was equally prevalent in cadaver and related kidney allografts and was no less common in HLA-identical related donor grafts, arguing against the importance of immune factors in etiology. RTAS was equally prevalent whether the anastomotic technique was end to end or end to side. However, when RTAS occurred after end to side anastomoses, it was usually postanastomotic. Fifteen of 17 of the attempts at dilation by PTA were successful by angiographic analysis. Thirteen of the 15 successfully dilated patients had long-term allograft survival and in all of these instances blood pressure (BP) was decreased after PTA. After a mean of 67 weeks, BP decreased from a systolic of 184 ± 24 mm Hg pre-PTA to 135 ± 15 mm Hg (P < 0.001) and from a diastolic of 115 ± 10 mm Hg pre-PTA to 87 ± 11 mm Hg (P < 0.001). The majority of patients continue to require antihypertensive drugs but in a less vigorous regimen than pre-PTA. Serum creatinine level fell following PTA from 1.9 ± 0.6 to 1.7 ± 0.5 mg/100 ml (P < 0.01). Repeat angiographic study was done in nine patients, an average of 61 weeks after PTA, and no recurrent RTAS was identified. Three minor complications of PTA occurred but none led to long-term sequelae. Thus, we believe PTA of RTAS is relatively safe, carrying less mortality and morbidity than operative treatment, and is capable of improving BP control and renal allograft function.

Applications and techniques of gastrointestinal intubation

Gastrointestinal intubation has found increasing applications over the past several years. Although usually an uncomplicated procedure, passage of an intestinal tube may be impeded by ineffective peristalsis, obstructing lesions or surgical alteration of the normal anatomy. A variety of techniques are described for passing tubes into the stomach, duodenum and small bowel. These techniques are an out-growth of those initially developed for manipulating tubes through the vascular, biliary and genitourinary systems. The characteristics of the various decompression and alimentation tubes as well as the dangers of gastrointestinal intubation are also discussed.

Abstracts Papers presented at the Eleventh Annual Session of the Society of Gastrointestinal Radiologists, October 1, 1981, Boca Raton, Florida

Papers Presented at the Eleventh Annual Session of the Society of Gastrointestinal Radiologists, October 1, 1981, Boca Raton, Florida ESOPHAGEAL NODULARITY A NORMAL VARIANT OF THE ESOPHAGEAL MUCOSA Seth N. Glick, M.D. Steven K. Teplick, M.D. Department of Diagnostic Radiology Hahnemann Medical College and Hospital 230 North Broad Street Philadelphia, PA. 19102 Small superficial round nodules (2-4 mm) are frequently observed on routine double contrast esophagrams. They may be focal or diffuse, and appear as fine granularity or sharply defined filling defects. Endoscopic~lly, they are seen as white excrescences on a normal mucosal background. However, they may not be appreciated, unless specifically sought, becaUse of inadequate lumenal distension. Biopsy reveals normal or slightly hyperplastic squamous epithelium and vacuolated epithelial cells containing abundant glycogen. This has been termed glycogenic acanthosis. Esophageal symptoms are usually absent or cannot be correlated with this morphology. We evaluated 300 consecutive esophagrams considered to demonstrate adequate mucosal detail. Nodularity was found in 30%. These were usually confirmed endoscopically when sought. In addition to true nodules, pseudo-nodules may be caused by several types of artifacts such as transverse esophageal folds. Several pathologicconditions may resemble the normal esophageal nodules, however, radiologic and clinical criteria can usually make the distinction. The Esophageal Survey in Upper Gastrointestinal Radiography Dean D. T. Maglinte, M.D., Katharine L. Krol, M.D., Lloyd D. Caudill, M.D., David L. Brown, M.D., and William Michael McCune, M.D. Gastrointestinal Radiology Section Methodist Hospital and Graduate Medical Center, 1604 North Capitol Ave., Indianapolis, IN 46206 When an upper gastrointestinal study is requested on a patient with non-specific abdominal complaints, there are no guidelines as to what should be the minimum esophageal survey. Of 200 patients referred for upper gastrointestinal series, 40 (20%) had radiographic evidence of esophageal disease. Reflux esophagitis, frequently considered difficult to diagnose radiographically, was demonstrated in 31 (16%). A non-invasive carcinoma, varices and a leiomyoma were found. It is suggested that a thorough evaluation of the esophagus consisting of double contrast, single contrast distention radiograph, fluoroscopic motility assessment and mucosal relief study be included in every upper gastrointestinal series. This minimum multiphasic routine evaluation offers the potential for improvement in diagnostic accuracy with little additional examination time. Barium Swallow After Total Laryngectomy Koehler RE, Balfe DM, Setzen M, Weyman P J, Baron RL, Ogura J Department of Radiology and Divls]on of Otolaryngology, Washington University School of Medicine, St. Louis, Mo Dysphagia is a frequent problem in patients who have undergone total laryngectomy and the barium swallow is often useful for evaluaHng the cause for the symptoms. The examination may be di f f icul t to interpret, however, because a variety of anatomic changes may be produced by radiation, infection, fistula, recurrent tumor or the operation itself. We analyzed radiographs and clinical information on 43 patients with total laryngectomy with followup periods ranging from g months to 17 years. Recurrent tumor was found in IS patients and was evident radiographically as a mass deviating the neopharynx in 14. Benign strictures in nine patients apeared either as a long symmetrical r~arrowing or as a very short, weblike narrowing. Fistulas were demonstrated in 12 patients and presaged the development of recurrent tumor in five. Cricopharyngeal muscular-dysfunctlon accounted for the dysphagia in five cases. An understanding of these patterns leads to more accurate interpretation of the postoperative barium swallow and the radiographic findings often indicate the correct diagnosis with a high degree of confidence. 0364-2356/82/0007-0087

Renal venography. New applications in pathologic conditions.

01.80 9 1982 Springer-Verlag New York Inc.