Ruza Antonovic

Accuracy of lower extremity arterial duplex mapping

We performed lower extremity arterial duplex mapping from the aortic bifurcation to the ankle in 150 consecutive patients evaluated for aortic and lower extremity arterial reconstruction and compared lower extremity arterial duplex mapping in a blinded fashion to angiography. On the basis of history, physical examination, and four-cuff segmental Doppler pressures individual lower extremities were classified as normal, isolated aortoiliac disease, infrainguinal disease, and multilevel inflow and outflow disease. For vessels proximal to the tibial arteries, lower extremity arterial duplex mapping was analyzed for its ability to insonate individual arterial segments, detect a 50% or greater stenosis, and distinguish stenosis from occlusion. In the tibial arteries lower extremity arterial duplex mapping was evaluated for its ability to visualize tibial vessels and to predict interruption of tibial artery patency from origin to ankle. Lower extremity arterial duplex mapping visualized 99% of arterial segments proximal to the tibial vessels, with overall sensitivities for detecting a 50% or greater lesion ranging from 89% in the iliac vessels to 67% at the popliteal artery. Stenosis was successfully distinguished from occlusion in 98% of cases. In the tibial vessels lower extremity arterial duplex mapping was better at visualizing anterior tibial and posterior tibial artery segments (94% and 96%) than peroneal artery segments (83%), (p less than 0.001). Overall sensitivities for predicting interruption of tibial artery patency were 90% for the anterior tibial, 90% for the posterior tibial, and 82% for the peroneal. Clinical disease category did not influence in a major way the accuracy of lower extremity arterial duplex mapping in either above-knee or below-knee vessels.

Duplex ultrasound criteria for diagnosis of splanchnic artery stenosis or occlusion

Mesenteric artery duplex scanning appears promising for detection of splanchnic artery stenosis or occlusion or both in patients with symptoms suggestive of chronic intestinal ischemia. However, no specific duplex criteria have been developed for detection of mesenteric artery stenosis. We obtained mesenteric artery duplex scans and infradiaphragmatic lateral aortograms in 34 patients to determine duplex criteria for mesenteric stenosis. Seventy percent or greater angiographic stenosis was present in 10 superior mesenteric arteries and 16 celiac arteries. Duplex scans were reviewed to determine if celiac artery and superior mesenteric artery ratios of peak systolic velocities and end-diastolic velocities to peak aortic systolic velocity, as well as celiac artery and superior mesenteric artery peak systolic velocities and end-diastolic velocities alone, could predict a greater than or equal to 70% angiographic stenosis or occlusion or both. The results obtained by use of receiver operator curves indicated peak systolic velocity alone was an accurate predictor of splanchnic artery stenosis. Specifically, a peak systolic velocity greater than or equal to 275 cm/sec in the superior mesenteric artery and greater than or equal to 200 cm/sec in the celiac artery or no flow signal (superior mesenteric artery and celiac artery) predicted a 70% to 100% stenosis with sensitivity, specificity, and positive predictive values of 89%, 92%, and 80% for the superior mesenteric artery. Similar values for the celiac artery were 75%, 89%, and 85%, respectively. End-diastolic velocities or calculated velocity ratios conveyed no additional accuracy in predicting splanchnic artery stenosis.

Gianturco-Rösch expandable Z-stents in the treatment of superior vena cava syndrome.

Gianturco-Rösch expandable Z-stents were used in 22 patients with superior vena cava syndrome (SVCS). Stents were placed in all patients in the SVC and in 17 patients, also into the innominate veins. Stent placement resulted in complete relief of symptoms in all patients. Twenty-one patients had no SVCS recurrence from 1 to 16 months, to their death, or to the present time. SVCS recurred only in 1 patient 9 months after stent placement due to tumor ingrowth and secondary thrombosis. Based on ours and on other reported experiences, expandable metallic stents are effective devices for treatment of the SVCS which is difficult to manage by other means.

Transjugular approach to liver biopsy and transhepatic cholangiography.

Abstract The percutaneous transjugular approach to liver biopsy and cholangiography (of Hanafee and Weiner) eliminates the necessity for traversing the peritoneal cavity and puncturing the liver capsule. The liver parenchyma is entered through the wall of a hepatic vein by a needle inserted into a catheter introduced percutaneously via the internal jugular vein. This approach offers a safe means for liver biopsy and transhepatic cholangiography in the patient with a bleeding tendency, high-grade obstructive jaundice or ascites. Acute cholangitis is the principal contraindication of this approach. The transjugular approach was used in 61 patients. Both biopsy and cholangiography were done in 36 patients, liver biopsy alone in eight patients, and cholangiography alone in 17 patients. Diagnostic biopsy specimens were obtained in 39 patients (89 per cent). Cholangiography succeeded in 29 of 31 patients (93 per cent) with enlarged intrahepatic ducts. There were no major complications. (N Engl J Med 289:227–231...

The Natural History of Coronary Artery Stenosis: A Longitudinal Angiographic Assessment

Comparison of sequential large film coronary angiograms was performed for 58 patients with coronary artery disease, and no coronary surgery, to determine the relationship between the location, type, and degree of stenoses and their tendency to progress. Of 230 stenoses, 76 (33%) showed progression and 154 (67%) remained stable on the follow-up studies. Progression occurred in 38 (66%) patients. A statistically significant higher tendency to progress was found with tubular stenosis with ulcerating plaques (100%) and stenoses with collateral circulation (58%). A significant linear trend for progression was also found with the increasing number of risk factors of coronary disease. The above-average progression tendency of stenoses of the right coronary artery, tubular irregular stenoses, and Grade 2 stenoses, was not statistically significant.

Evaluation of primary lung cancer with Indium 111 anti-carcinoembryonic antigen(Type ZCE-025) monoclonal antibody scintigraphy

A study was undertaken to test whether indium 111 111In)‐labeled anti‐carcinoembryonic antigen (CEA) (type ZCE 025) monoclonal intact antibody (MoAb) would concentrate in primary lung cancer enabling its detection and localization by scintigraphy. The scintigraphic results were correlated with chest radiograph, computed tomograph (CT), bronchoscopy, surgical resection, and tumor CEA analysis. Twenty adult male patients with clinical suspicion of primary lung cancer were studied. Each subject was infused with 4 to 5 mCi of111In anti‐CEA ZCE 025 MoAb, and planar and tomographic scintiphotos were obtained on days 3 and 6 or 7 postinfusion. The scintigraphy was true‐positive in 12 of 16 patients with primary lung cancer, eight of nine patients with squamous cell carcinoma, and four of seven with adenocarcinoma; it was true‐negative in three of four patients with benign lung disease with an over all accuracy of 75%. In seven patients with confirmed primary lung cancer, but with negative bronchoscopic findings, the scintigraphy was true‐positive in four. In 11 patients with definitely positive or suspicious malignancy by bronchoscopy the monoclonal scintigraphy was positive in eight. In true‐positive cases, the location and size of the lesion by 111In anti‐CEA ZCE 025 MoAb imaging correlated well with CT findings and also tumor mass at surgery. Only one of 12 tumors stained positive for CEA had serum CEA levels greater than 10 ng/ml, indicating nonleakage of the tumor antigen into general circulation in early lung cancer. It is concluded that 111In anti‐CEA ZCE 025 MoAb planar and tomographic imaging shows potential to serve as a noninvasive diagnostic test in the evaluation of primary lung cancer. The lung lesion is likely to be malignant if it concentrates 111In anti‐CEA ZCE 025 MoAb and benign if it does not. Further studies in large number of patients with suspected primary lung cancer are needed to define the ultimate role for MoAb scintigraphy.

An unusual complication of cardiac transplantation—Infected aortic pseudoaneurysm

Infections after cardiac transplantation are a frequent cause of early morbidity and mortality. An unusual site for such a complication is at the aortic anastomotic suture line. We report a case of an infected aortic pseudoaneurysm, seen as recurrent septicemia, during the first 6 months after cardiac transplantation.

Angiographic Appraisal of Distal Vessel Suitability for Aortocoronary Bypass Graft Surgery

The accuracy of preoperative coronary arteriography in determining distal vessel operability was evaluated in 166 patients studied arteriographically before and after bypass surgery. Appraisal accuracy correlated closely with the type of distal vessel filling, being highest (97%) in poststenotic vessels with antegrade filling; lower (76%) beyond occlusions with generous retrograde collateral flow; and least (65%) in postocclusion vessels filled by insufficient collaterals. Optimum data collection is favored by the use of high-definition serial roentgenography with extended filming in multiple projections; competent interpretation requires the integrated assessment of interdependent variables, including distal vessel morphology, filling patterns, branch disease, run-off capacity, and myocardial status.

Extralobar pulmonary sequestration presenting as a mediastinal malignancy.

Pulmonary sequestration is an uncommon congenital anomaly usually diagnosed in childhood. It frequently presents as a lower lobe mass with symptoms from vascular shunting, anatomic impingements, or associated anatomic defects. This case report describes an adult with asymptomatic extralobar sequestration involving the mediastinum and left upper lobe. The unusual location and radiographic appearance, suggestive of malignancy, led to prompt surgical exploration. We review the literature on this topic, focusing on anatomic variability and difficulties with preoperative diagnosis.

The Importance of Temperature in Angiography of the Hand

Angiograms of the hand of a normal volunteer taken at skin temperatures ranging from 22 to 33 degrees C revealed that visualization of the arteries was highly dependent on the temperature. Lower temperatures produced vasospasm beginning in the smaller vessels and proportionally involving medium-sized and major arteries. Moderate warming led to optimum filling and is recommended prior to angiography of the hand. Prior injection of contrast material caused no perceptible change in the filling or appearance of the arteries.