Melvin P. Judkins

Transluminal Treatment of Arteriosclerotic Obstruction: Description of a New Technic and a Preliminary Report of Its Application

The rationale and technic of a new procedure—transluminal recanalization of arterio-sclerotic obstructions—has been described.Of the 11 extremities treated, six have shown marked improvement (four amputations averted). It is reasonable to assume that with a perfected technic and patients with less advanced disease, the percentage of successful recanalizations would increase.Early treatment with this technic may well prevent otherwise serious disease, not just prevent amputation of extremities not suitable for definitive surgery. We are satisfied that percutaneous transluminal recanalization is the treatment of choice for many lesions of the femoral and popliteal arteries. We believe this method is ready for application to obstructions up to approximately 10 cm. by those skilled in the use of vascular catheters. No doubt the interest and ingenuity of others will lead to refinements of technic as well as further clarification of the role of this attack on arteriosclerotic obstructions.

Selective Coronary Arteriography

Until recently, there has been a reluctance to subject the coronary patient to the “added risk” of coronary arteriography. The recognition that coronary arteriography is no more hazardous than selective cardioangiography, that coronary visualization can depict precisely the presence and extent of disease, and that something can be done about coronary artery occlusive disease has extended the indications and increased the demand for detailed coronary delineation. Numerous technics for coronary visualization have been proposed (2, 4, 5, 8–11). In general, the various forms of the aortic root flush have been favored in Europe, while more selective technics have gained acceptance in the American centers. The new technic reported here facilitates consistent, rapid selective catheterization of both coronaries with a minimum of catheter manipulation; takes advantage of the ease, rapidity of performance, and low complication rate of percutaneous femoral catheterization; facilitates both direct serial and cine fil...

Systolic and Diastolic Abnormalities of the Left Ventricle in Coronary Artery Disease Studies in Patients with Little or No Enlargement of Ventricular Volume

Left ventricular volume and circumference were calculated from cineangiocardiograms at 60 frames/sec in 15 patients with arteriographically proven coronary artery disease (CAD) and five control subjects. The patients with CAD had no mitral regurgitation and had an average end-diastolic volume equivalent to that reported by others in normal subjects and to that of the control group. The average end-diastolic pressure was higher in CAD and was often abnormal, despite lack of increase in enddiastolic volume. The ejection was lower in the CAD group as was the extent of circumferential fiber shortening. Maximal and mean rates of fiber shortening correlated positively with ejection fraction and were low in some individuals with CAD.We conclude that our patients without significant increase in left ventricular enddiastolic volume had abnormalities of diastolic compliance and contractile performance.

Complications of Selective Percutaneous Transfemoral Coronary Arteriography and their Prevention A Review of 445 Consecutive Examinations

Complications encountered during a typical 12-month period of routine work with the Judkins percutaneous transfemoral method of selective coronary arteriography are reviewed. In 445 examinations, 20 complications (16 local and four cardiac) occurred. Local complications included nine delayed hemorrhages, five thromboses of femoral arteries, and two peripheral emboli. Cardiac complications included one ventricular fibrillation, one significant bradyarrhythmia, and two myocardial infarctions. Causes of individual complications are analyzed and means for their prevention discussed. Guidelines of the procedure are proposed to minimize the complications of selective coronary arteriography. Emphasis is placed on patient evaluation, preparation for the procedure, and meticulous examination technique.

Clinically suspect ischemic heart disease not corroborated by demonstrable coronary artery disease. Physiologic investigations and clinical course.

Abstract In 11 patients with angina pectoris and abnormal stress electrocardiograms, no narrowing or obstruction of coronary vessels was visible by selective cut film and coronary cinearteriography. One patient showed chemical evidence of myocardial hypoxia despite normal arteriograms. Similar evidence of impaired myocardial oxygen supply was absent in the remaining 10 patients. We found no abnormality in hemoglobin O 2 affinity which might jeopardize myocardial O 2 supply. The clinical course of these patients, including that during a 1 to 2 year followup period, has not been complicated by myocardial infarction or cardiac failure. In 5 symptoms have decreased.

Effects of Coronary Arteriography on Myocardial Blood Flow

Myocardial blood flow responses to selective coronary arteriography were studied in 22 patients. Left coronary flow was estimated by the radioactive inert-gas (133xenon) washout technic using precordial detection. Duplicate control studies were obtained before radiocontrast injection and test studies were performed at 1 min and 3, 5, or 7 min after angiography. Eleven patients received a single 7-ml injection of methylglucamine diatrizoate and 11 were given a series of injections (average total 40 ml), with the test blood flow studies after the final injection.Myocardial flow increased in every patient 1 min after contrast injection (average control flow 66.3 ml/min/100 g; test flow 78.8, +18.9%, P < 0.001). Blood flow increased further in seven of 10 studied at 3 min (average 95.7 ml/min/100 g, +35.7%, P < 0.001) and remained elevated at 5 and 7 min. Systemic pressure was unchanged from the control level, so coronary vascular resistance decreased in proportion to the increase in flow. Blood flow responses in patients with coronary artery disease were no different from normal subjects. Sham injections of normal saline produced no increase in coronary flow.Selective coronary arteriography results in a prompt increase in myocardial blood flow which persists for several minutes. The probable mechanism is coronary vasodilatation produced by the markedly hypertonic contrast material, an effect demonstrated previously in other vascular beds.

Angiographic Diagnosis of Hepatic Rupture

Advance in the surgical ability to treat hepatic rupture has surpassed the diagnostic effectiveness of exploratory laparotomy. This frustrating situation has been aptly expressed by Solheim: “The damage to the liver parenchyma may be diffuse and vary widely in extent. A superficial defect in closed liver injuries may be merely an outward sign of general intrahepatic damage of unknown and varying extent, and it is this which threatens the patients life. Consequently laparotomy affords little prospect of assessing the prognosis, however well the visible liver damage seems to have been sutured” (11). Hepatic trauma is attended by high morbidity and mortality rates, despite the fact that its incidence is highest in the vigorous young male. One-third of those incurring hepatic injuries do not survive long enough to receive treatment. The immediately fatal injuries are characteristically multiple and are commonly accompanied by laceration of the heart and aorta (75 per cent). Another third succumb from the inj...

Lumen-Following Safety J-Guide for Catheterization of Tortuous Vessels

Atherosclerotic tortuosity and intimal reconfiguration add to the difficulty and risk of arterial catheterization regardless of how it is performed. The use of small J -shaped catheters as temporary, path-finding substitutes for conventional guides has earned wide acceptance (1). Although effective in principle, this technic requires procedural catheter changes which are time-consuming, inconvenient, and sometimes sanguinary. J-Guide A conventional movable core guide spring is heated and preshaped into a J configuration 6 mm across. This guide is then used in place of a J -catheter. A similar simultaneous development has been reported by others (3). In use, the J-guide is subjected to relatively hazardous stresses produced by repeated manipulation and sharp angulation of an already weakened heat-deformed tip. The chance of breakage is increased: indeed, such a tip was lost in a patient with severe arteriosclerotic peripheral vascular disease. Safety J-Guide2 After development of the safety guide (2), the ...

PERCUTANEOUS TRANSLUMINAL TREATMENT OF ARTERIOSCLEROTIC OBSTRUCTION.

DRUGS, DIET, regulated exercise, and other essentially supportive measures notwithstanding, there is no direct medical treatment for the primary lesion causing atheromatous obstruction. Despite impressive surgical progress, the practical fact remains that most victims of atherosclerosis are not helped by current surgical technic. Vital statistics give grim evidence of the inadequacy of current treatment: 500,000 coronary deaths occur in the United States each year. Though everyone stopped smoking, exercised regularly, ate wisely, and visited their doctors frequently, 50,000,000 Americans would not be able to forestall a disease already within their arteries. If means for prevention were discovered tomorrow, arteriosclerosis would long continue to outrank all other causes of disability and death. It follows that for professional, public health, and personal reasons, atherosclerosis is our most urgent unsolved medical problem. The purpose of this report is to describe a new approach to the treatment of arte...

Stress Electrocardiography in the Evaluation of Surgical Revascularization of the Heart

Electrocardiography was carried out during hypoxemia and graded exercise tests before and at intervals between 2 and 20 months after attempts to revascularize the heart by internal mammary artery implantation in 44 patients with angiographically documented coronary disease and angina pectoris. Eleven patients had single vessel disease; the right coronary was involved in seven of these patients. Thirteen patients had single vessel implants, employing the left internal mammary artery in 11 patients and a saphenous vein graft from the aorta in two. Thirty-one patients had double internal mammary artery implantation accompanied by gastroepiploic arterial implantation in four.Fifty per cent of the patients were symptomatically improved after surgery, the best results occurring in two patients with isolated anterior descending coronary disease. Of the 34 patients having postoperative coronary and mammary arteriography, 15% showed improvement which could be ascribed to mammary revascularization; 24% had limited myocardial revascularization and no symptomatic improvement; 29% had patent implants without development of collateral vessels, and the implanted vessels were occluded in 32%. Eleven of the 34 (32%) had fair or good symptomatic improvement in the absence of revascularization.The results of postoperative stress electrocardiography correlated closely with the findings on postoperative coronary and mammary angiography. The stress tests were persistently positive after operation in 83% of the patients having angiographically confirmed implant occlusion or nonrevascularization. The stress ECG response was reversed, becoming negative postoperatively, in five cases of angiographically proved significant revascularization. Thus, stress electrocardiography provided objective evidence of improvement in a small number of patients with limited coronary disease who developed good collateral circulation and correlated with the lack of revascularization in the majority even in those subjectively improved.