Martin L. Goldman

The role of duplex scanning in the selection of patients for transluminal angioplasty

As part of our initial evaluation to determine whether patients with lower extremity ischemia are candidates for intervention, arterial duplex examinations are performed in the noninvasive vascular laboratory. Patients with isolated short stenoses on the duplex examination are referred for transluminal angioplasty. One hundred thirty-four arteriograms were performed for ischemic peripheral vascular disease in 122 patients between July 1987 and March 1990. One hundred ten (82%) of the arteriograms were preceded by a lower extremity arterial duplex evaluation. Fifty cases (45%) were scheduled for transluminal angioplasty based on the findings of the duplex examination. Transluminal angioplasty was performed in 47 of 50 cases (94%). No significant differences in age, sex, or diabetes were found between the patients who were referred for transluminal angioplasty and those who were not. These data demonstrate that duplex scanning of the lower extremities allows the detection of lesions that will be amenable to transluminal angioplasty. We think that duplex scanning should become the standard screening tool for detection of treatable lower extremity lesions.

Transcatheter Vascular Occlusion Therapy with Isobutyl 2-Cyanoacrylate (Bucrylate) for Control of Massive Upper-Gastrointestinal Bleeding

Transcatheter embolization with bucrylate, a tissue adhesive, was performed in 16 patients with massive upper-gastrointestinal bleeding. Control of arterial bleeding from the stomach was achieved in 6 of 8 patients, and from the duodenum in 3 of 4. Embolization of gastric veins resulted in temporary control of esophageal variceal bleeding in 3 of 4 patients. Histological study showed no evidence of bucrylate causing histotoxicity in 2 patients. Because bucrylate polymerizes rapidly, a localized vascular occlusion mimicking a surgical ligation is produced. Because collateral vessels are not occluded. localized tissue ischemia is unlikely. Tissue adhesives are, however, difficult to use.

The Transjugular Technique of Hepatic Venography and Biopsy, Cholangiography, and Obliteration of Esophageal Varices

The transjugular technique facilitates various diagnostic and therapeutic procedures in the liver. Even in patients with defective hemostasis, severe ascites, or marked obesity, liver biopsy or cholangiography can be performed with relative safety. It also provides an alternative route for entry into the portal system.

Epinephrine renal venography in severe inflammatory disease of the kidney.

In a comparative study of the diagnostic value of epinephrine renal venography (ERV) and angiography in eight patients with severe inflammatory disease of the kidneys, the spectrum of abnormalities exhibited by ERV was more striking than the angiographic findings. Complete disorganization of the renal venous architecture with linear streaking of contrast agent is a sign of renal inflammatory disease. ERV is a useful adjunctive diagnostic procedure in cases of a nonfunctioning kidney.

Treatment of acute renal artery occlusion after percutaneous transluminal angioplasty

Four patients with occlusive complications after percutaneous transluminal renal artery angioplasty (PTA) have been treated from July 1, 1984, to March 14, 1988. During this interval such renal artery angioplasties were performed in 44 patients. Two resulted in complete main renal artery occlusion, one angioplasty resulted in occlusion of a stenotic renal artery bypass graft, and one renal PTA resulted in segmental branch renal artery narrowing, which was thought to represent a dissection. The latter segmental renal artery narrowing was treated expectantly with good long-term results. One of the main renal artery occlusions was treated by radiologic means by reentry and repeat transluminal dilation. The other two acute complete occlusions, one of an autogenous artery and the other of an aortorenal bypass graft, were treated by aortorenal or ileorenal bypass grafting, respectively. The overall incidence of main renal artery occlusion (including the bypass graft occlusion) after PTA requiring operative intervention was 4.5% (2/44). Revascularization was accomplished after 6 and 8 hours of renal ischemia time for the two surgical procedures. Despite this, the bypass grafts done emergently remain patent, and the involved kidneys appear to be functional. The incidence of main renal artery occlusion after PTA is not as low as would be apparent from a review of the literature. It is proposed that main renal artery occlusion after PTA can be treated successfully by surgical and interventional radiologic techniques because of the presence of protective renal collateral circulation whose formation was stimulated by the renal artery lesion that prompted PTA.

Epidural venography in the diagnosis of lumbar spinal stenosis.

Epidural venography is valuable in diagnosing lumbar spinal stenosis. It shows anterior displacement of the posterior medial longitudinal intervertebral veins at the level of the lamina and the superior and inferior articular facets. This results in decreased distance between and sometimes overlapping of the posterior and anterior medial longitudinal intervertebral veins. Three cases of spinal stenosis diagnosed by epidural venography are presented.

Gallstone susceptibility to in vitro fragmentation by a 480-nm pulsed dye laser. Correlation with computed tomography characteristics

The object of this investigation was to determine gallstone susceptibility to laser lithotripsy and to discover whether this susceptibility is related to the computed tomography (CT) appearance of gallstones. Gallstones collected from surgery were scanned by CT and classified as homogeneously dense (greater than 90 Hounsfield units [HU]), homogeneously faint (30-60 HU), or rimmed. Sixty stones were subjected to laser energy at 20, 40, 60, 80, or 100 mJ. Fracture and fragmentation (all particles less than 2 mm) were assessed in relation to the energy level setting and number of laser pulses delivered. The authors found that a 480-nm, flashlamp-pumped pulsed dye laser can fragment completely all the types of human gallstones that were tested, although there is significant variability in gallstone susceptibility to laser lithotripsy. This susceptibility varies with CT appearance: dense stones require fewer pulses and lower energies for fracture and fragmentation, compared to faint or rimmed stones. The authors anticipate that CT characterization of gallstones may be a clinically useful screening tool before laser lithotripsy.