Frederick S. Keller

Percutaneous angiographic embolization: A procedure of increasing usefulness: Review of a decade of experience***

During the past decade percutaneous therapeutic vascular occlusion was performed on 152 occasions in 124 patients. The primary indication for vasoocclusive therapy was acute or recurrent bleeding. Upper gastrointestinal bleeding from arterial sources was controlled in 92 percent of patients and acute variceal bleeding in 83 percent. Renal embolization was performed for palliation of severe pain and hematuria from unresectable renal primary or secondary malignancies, to decrease blood loss and facilitate surgery in operable renal tumors, and for ablation of renal function to control chronic protein loss or severe hypertension. Our encouraging experience convinces us that transcatheter embolization is a useful, safe and effective procedure in selected patients. It seems certain that the technique of therapeutic embolization will be improved, its indications extended and its application become commonplace whenever angiographic skills and facilities exist.

Bleeding from esophageal varices exacerbated by splenic arterial-venous fistula: Complete transcatheter obliterative therapy

A cirrhotic patient who had previously undergone both mesocaval shunting and transthoracic esophageal and gastric devascularization with splenectomy (Sugiura procedure) presented with recurring intractable variceal hemorrhage. Diagnostic visceral angiography demonstrated a large splenic arterial-venous fistula and gastroesophageal varices. Transarterial occlusion of the fistula and transhepatic obliteration of the varices successfully done at one sitting prevented further bleeding. Follow-up angiography nine months later revealed persistent occlusion of the previous fistula and no evidence of esophageal varices.

Pancreatic arteriography, transhepatic pancreatic venography, and pancreatic venous sampling in diagnosis of pancreatic cancer.

Arteriography with visualization of small intrapancreatic arteries is a sensitive method in the diagnosis of pancreatic carcinoma. It can detect small intrapancreatic tumors and differentiate neoplasms from other pancreatic lesions. It also aids in staging pancreatic cancer and determining resectability. Transhepatic pancreatic venography is less sensitive than arteriography but it also can be useful in evaluating tumor operability. Pancreatic venous sampling is an important method for localizing hormone‐secreting islet cell tumors.

Value of angiography in the management of abdominal aortic aneurysm

The value of angiography in the management of abdominal aortic aneurysms (AAA) was assessed in 100 consecutive patients with AAA. Angiographic information influenced management decisions and/or surgery performance in 75: In 23 patients at high risk for surgery because of associated medical problems, it helped in deferring surgery; in 52 patients it resulted in a change of operation from a standard aneurysm resection with conventional grafting to a more conservative procedure (three patients), more extensive grafting (45 patients) and/or the addition of other vascular reconstructions (32 patients). Angiography is considered an integral step in the routine preoperative workup of AAA and is particularly valuable for the determination of important anatomic details about the aneurysm (upper and lower extensions, relation to the renal arteries), the detection of associated vascular disease (of renal, visceral, pelvic and peripheral arteries), and the demonstration of aberrant renal arteries and collateral visceral circulation. Catheter techniques are considered most suitable and safe for examination of AAA.

Value of angiography in diagnosis and therapy of acute upper gastrointestinal hemorrhage.

Since the early 1970s our angiography group has had the opportunity to perform diagnostic angiography on more than 450 patients with acute gastrointestinal bleeding and has used various angiotherapeutic techniques on more than 200 of them. On the basis of our experience and that of others, we have developed an angiographic approach to the patient with acute upper gastrointestinal hemorrhage which should be presented here. Initially, in the early seventies, an aggressive approach was employed, and we tried to perform angiography on an emergency basis as the first procedure while the patient was still massively bleeding. This approach led to an unacceptably high proportion of negative studies, was costly, overloaded the angiographic laboratory with unnecessary examination, and most important of all, it could be dangerous to the patient. It did not take into account the fact that 40-80% of patients will stop bleeding with bedrest and medical therapy. As was often the case, bleeding had stopped by the time angiography was performed, either from hypotension or the initiation of supportive measures. The angiographic diagnosis of acute arterial bleeding is based on the visualization of direct extravasation of contrast material into the gastrointestinal lumen (Figure 1). If bleeding is from a large artery such as in the peptic ulcer, this is readily demonstrated by selective angiograms. However, if

Materials and methods for transcatheter vascular occlusion: Some personal, practical views

In his paper, Greenfield reviews in detail the materials, devices, methods, and appropriate uses of transcatheter therapeutic vascular occlusion. In another report, White and coworkers focus on a specific and promising approach to selective vascular occlusion, the detachable balloon. Over 150 publications in the 1979 scientific literature emphasize the importance and diversity of methods now available for transcatheter vascular occlusion. The following comments reflect our personal views, based on a decade of experience in this field.

Secondary tumors of the kidney: a new diagnostic procedure.

AbstractThe transjugular approach to the liver for cholangiography and liver biopsy is described. The transjugular approach to biopsy renal lesions is a new technique. In the case presented a specific histological diagnosis was made, enabling further therapeutic decisions without an operation.