Ethel J. Finck

Clinical applications of carbon dioxide/digital subtraction arteriography ☆

During an 18-month period 33 patients in whom there were contraindications to the use of iodinated contrast arteriography underwent 40 carbon dioxide/digital subtraction arteriograms for lower extremity ischemia (19), severe hypertension and renal insufficiency (12), or arterial aneurysm (2). Contraindications to iodinated contrast agents included renal insufficiency, congestive heart failure, and contrast hypersensitivity. Sixteen aortic, 15 iliac-femoral-popliteal-tibial, five aorta-iliac-femoral and four aorta-iliac-femoral-popliteal-tibial carbon dioxide/digital subtraction arteriography studies were performed. In 11 studies, imaging of selected arterial segments required the addition of 10 to 60 ml of dilute nonionic contrast. Guided by carbon dioxide/digital subtraction arteriography studies four femoral-tibial bypasses, three aneurysmorrhaphies, two aortorenal bypasses, one aortofemoral bypass and one femoral-femoral bypass were successfully performed in 11 patients. In addition, carbon dioxide/digital subtraction arteriography directed angioplasties of the common iliac (4), superficial femoral (6), popliteal (3), or tibioperoneal trunk (1) were performed in 10 patients. Complications of carbon dioxide/digital subtraction arteriography included transient deterioration in renal function in three patients in whom 20 ml of nonionic contrast was used, a nonfatal myocardial infarction after a popliteal percutaneous transluminal angioplasty in one patient, and transient tachypnea and tachycardia during a carbon dioxide/digital subtraction arteriography study in one patient. Diagnostic arteriograms are obtainable using carbon dioxide as the contrast agent. Carbon dioxide/digital subtraction arteriography permits patients with symptomatic arterial disease at high risk for contrast related complications to safely undergo arteriography and subsequent arterial reconstruction or endovascular intervention.

Trends in the management of traumatic vertebral artery injuries

From 1975 to 1988, 25 patients with a vertebral artery (VA) injury were treated. Admission neurologic status was intact in 14 patients (56 percent). Eight patients had deficits due to direct nerve or spinal cord injury, two patients had symptoms referable to vertebrobasilar ischemia, and one patient had a contralateral deficit due to an associated carotid artery injury. Twenty-two of 25 patients (88 percent) underwent diagnostic arteriography. Twelve patients (48 percent) with 9 occlusive and 3 minimal injuries were observed. Seven patients (28 percent), three with exsanguinating hemorrhage, were treated by operative exploration and VA ligation. Six patients (24 percent), two with a VA pseudoaneurysm and four with an arteriovenous fistula, were managed by percutaneous transcatheter embolization. The neurologic status was unchanged or improved in 22 patients (88 percent) at discharge. Two patients developed Horners syndrome after VA ligation. Transient posterior circulation ischemia occurred in a single patient after percutaneous transcatheter embolization. There was no mortality. The majority of VA injuries are best managed by nonoperative methods. Untoward neurologic sequelae are rare. Operative intervention and VA ligation should be reserved for patients with active hemorrhage or large pseudoaneurysms and arteriovenous fistulas which cannot be embolized.

Microcatheter Embolization of Non-neurologic Traumatic Vascular Lesions

PURPOSE The authors report their experience over a 28-month period with embolization of 23 non-neurologic traumatic vascular lesions in 21 patients with use of a coaxial microcatheter coil delivery system. PATIENTS AND METHODS The injuries included pseudoaneurysms (n = 17), arteriovenous fistulas (n = 3), and sites of extravasation (n = 3) and were caused by gunshot, shotgun, and stab wounds, as well as motor vehicle accidents and iatrogenic trauma. All microcatheter embolizations except one were performed with 2.2-F Tracker-18 catheters inserted coaxially through 5.0-5.5-F guiding catheters. In one case, a coaxial 3-F Teflon catheter was used. In all cases platinum microcoils (almost all non-fibril) and/or straight platinum embolization wires (with fibrils) were used. RESULTS Twenty-one (91%) of 23 vascular lesions were successfully occluded with use of the microcatheter system. The two cases in which microcatheter embolization failed were successfully managed by using larger catheters and steel coils. Two patients with hepatic vascular lesions (one site of extravasation and a pseudoaneurysm) and one patient with a lower extremity arteriovenous fistula required two procedures each for successful treatment. Procedures were life-saving in at least two patients. Two lesions recurred during follow-up ranging from 3 days to 17 months. Both of these recurrences were successfully treated with transcatheter embolization, in one case with use of microcatheters. CONCLUSION Microcatheter embolization with platinum coils and wires is an effective means for treating traumatic vascular lesions. A coaxial microcatheter system allows for easier, more rapid coil/wire delivery to smaller, spasm-prone arteries in such cases.

Definitive treatment of selected vascular injuries and post-traumatic arteriovenous fistulas by arteriographic embolization.

Arteriographic embolization of carefully selected post-traumatic arteriovenous fistulas or bleeding vessels is a useful, safe alternative to direct surgical treatment, particularly in cases in which the involved vessel is not a critical artery and may be obliterated safely without fear of distal ischemia. The embolization procedure is readily accomplished at the time of diagnostic arteriography. It is ideally suited to treat lesions that are not readily accessible for surgical correction or in patients in whom surgery is thought to be too hazardous. The ease, efficacy and excellent long-term results achieved with arteriographic embolization and the lack of complications related to the procedure suggest that it should be used more frequently in treating carefully selected surgically accessible lesions.

Intraarterial Administration of Lidocaine for Analgesia in Hepatic Chemoembolization

Hepatic chemoembolization (HCE) routinely results in severe pain requiring massive doses of intravenously administered narcotics. This study examines the efficacy and safety of lidocaine administered intraarterially for analgesia in HCE. In 45 HCE procedures, lidocaine was injected into hepatic arterial branches just prior to and during chemoembolization. Adjunctive analgesic doses given during the procedure and the need for a morphine sulfate drip infusion for postprocedural pain control were recorded and compared with those in 20 procedures performed previously without lidocaine. In procedures with lidocaine, an average of 0.13 mg of morphine sulfate and 1.3 mg of midazolam were required. This is significantly lower than the 11.7 mg of morphine sulfate and 3.7 mg of midazolam used during procedures without lidocaine. A postprocedural morphine drip infusion was required for control of severe pain in 16 of 20 (80%) procedures performed without lidocaine compared with nine of 45 (20%) of those performed with lidocaine. Peripheral blood levels of lidocaine were well below the toxic level, and no complications referable to lidocaine toxicity occurred. Marked reductions in the amount of narcotic analgesia in HCE procedures may be safely achieved with the administration of intraarterial lidocaine.

Fatal hemorrhage from an arterio-portal-peritoneal fistula after percutaneous liver biopsy

Exsanguinating hemorrhage complicated a percutaneous needle biopsy in a 64-yr-old woman with a probable collagen vascular disease. Angiography performed before Gelfoam embolization demonstrated a hepatic arterio-portal venous-peritoneal fistula, a lesion not previously described, to be a cause of the hemorrhage. Although surgery remains the treatment of choice, the role of selective hepatic arteriography and Gelfoam embolization in patients with serious hemorrhage who are poor surgical risks needs evaluation.

Renal artery laceration secondary to percutaneous nephrostomy catheter placement

Renal artery hemorrhage secondary to placement of percutaneous nephrostomy catheters can lead to major operations and even nephrectomy. We recently treated a woman who suffered a renal artery laceration during percutaneous nephrostomy catheter placement using interventional radiographic techniques. The perforation site was identified using angiography and treated using selective embolization. The patient was able to avoid a surgical procedure with its inherent risks.

Successful retrieval of disconnected shunt tubing from the right heart and superior vena cava

SummaryA distal limb of a ventriculojugular shunt became disconnected in a child treated for hydrocephalus and chest films showed the tubing had migrated into the right heart and superior vena cava. — The tubing was retrieved under fluoroscopic control by a snare technique (a doubled-over guide wire introduced through a red Kifa catheter via the femoral vein).RésuméDans le cadre des progrès en médecine on a observé que des cathéters assortis, sondes et guides (utilisés à des fins diagnostiques ou thérapeutiques) se sont perdus dans le système vasculaire et se sont logés dans les grandes veines et dans le coeur droit. Parmi ces instruments, il y a des cathéters à perfusion intra-veineuse, des cathéters à pression veineuse centrale, à pace-maker, des guides angiographiques et des valves ventriculo-auriculaires. Comme la valve ventriculo-auriculaire représente un corps étranger intra-vasculaire dangereux, les neuroradiologists et neurochirurgiens devraient être familiarisés avec les méthodes de retrait de ces valves en cas de besoin.ZusammenfassungBei einem Kind mit einem Hydrocephalus löste sich das distale Glied des ventricuol-jugularen Shunts und gelangte in das rechte Herz und in die V. cava superior. Dieses abgelöste Glied konnte unter Röntgen-Kontrolle mit einer besonderen Technik wieder entfernt werden.