Percutaneous renal revascularization.
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Catheterization↗
Biomedical subjects
C J Tegtmeyer
Publications and source records attributed to C J Tegtmeyer.
Contemporary diagnostic approaches to acute pulmonary emboli.
Because of its availability and familiarity, the V/Q scan remains the most frequently used noninvasive screening study for the diagnosis of acute PE. Fast CT and MR imaging techniques probably will have more significant roles in the future in the diagnosis and management of PE, but limited availability and familiarity with these imaging modalities make it impractical to currently recommend them as primary screening tools for acute PE. Although the cost and time benefits appear to place fast CT ahead of MR imaging, more clinical experience and a greater understanding of the imaging nuances and pitfalls of interpretation for both fast CT and MR imaging are needed. Medicare reimbursements (both technical and professional fees) for a CT or MR scan are already competitive with a V/Q scan (Table 2), so that they may ultimately prove to be more cost-effective screening modalities for PE than a V/Q scan. Until the role for intraarterial DSA becomes further defined with clinical trials and outcome analyses, it cannot be recommended as a reference standard for the diagnosis of PE. Although conventional pulmonary angiography is associated with a 1% to 2% major nonfatal complication rate and a 0.1% to 0.5% mortality rate, chronic anticoagulation has reported major bleeding complication rates of 1.5% to 20% at 1 year, and inferior vena cava filters are associated with inferior vena cava thrombosis rates of 3% to 25%. Therefore, initiating or withholding therapy for the "presumed" presence or absence of PE based on a V/Q scan alone has the potential for generating excessive costs and morbidity in a large population of patients. Until the validity of fast CT and MR imaging have been proven, a pulmonary angiogram is required when there is any doubt about the diagnosis of PE. A negative pulmonary angiogram is often more useful in the management of a patient than an angiogram that demonstrates PE. By ruling out the presence of PE, an alternative and possibly more significant diagnosis will be pursued. Lastly, it is necessary for us to define more clearly the term clinically significant PE. This is important because fast CT, MR imaging and intraarterial DSA techniques can now reliably visualize third order pulmonary artery branches. Whether this degree of resolution allows for adequate detection of clinically significant PE will only be determined by extensive patient tracking and outcome analyses.
Acute Disease↗
Balloon angioplasty above the aortic arch: immediate and long-term results.
OBJECTIVE: Angioplasty above the level of the aortic arch is becoming more common, and the indications for it are increasing. We report our experience with this procedure, including life-table analysis of the long-term results. MATERIALS AND METHODS: We dilated 32 lesions in 29 patients. Early in our series, patients were referred primarily because of arm claudication or vertebrobasilar insufficiency. Subsequently, the indications were expanded to include inflow to left internal mammary-coronary artery bypass grafts, inflow to axillobifemoral bypass grafts, and inflow to dialysis fistulas in the upper extremity. A femoral artery approach was used in 18 patients and an axillary approach was used in 11. Clinical follow-up included evaluation of symptoms and bilateral measurements of peripheral pulses and blood pressure. Follow-up angiograms were obtained in nine patients. RESULTS: Eighteen of the lesions dilated were located in the left subclavian artery, eight were in the right subclavian artery, four were in the axillary or proximal brachial artery, and two were in the innominate artery. Interestingly, three of eight right subclavian arteries treated had an anomalous origin from the arch of the aorta. Initial technical success was 100%. All 29 patients had long-term follow-up of 4-88 months (mean, 36 months). In one patient, stenosis recurred 8 months after angioplasty. This patient subsequently had redilatation. Life-table analysis projected a 7.5-year cumulative primary patency rate of 96.6%. No cerebrovascular complications or embolic events occurred. CONCLUSION: Angioplasty of the great vessels is safe and effective, and the long-term results are favorable when compared with results after surgery. As a result, the indications for this procedure should be broadened.
Adult↗
Thromboembolectomy with the transluminal extraction catheter (TEC) as an adjunct to thrombolysis.
Multiple surgical and percutaneous interventional radiologic techniques have been used to restore blood flow in an acutely ischemic extremity. The transluminal extraction catheter (TEC) system was used as a mechanical thromboembolectomy device to supplement pharmacologic thrombolysis in one patient. In this case, 40 hours of direct intraarterial infusion of urokinase into the occluded vascular segments of a threatened lower extremity resulted in incomplete thrombolysis. Therefore, a 7-F TEC system was advanced percutaneously through the occluded vessels with restoration of luminal patency in all vessels treated. No distal embolization occurred. The TEC system facilitated prompt recanalization of vessels occluded by acute thrombus superimposed on atherosclerotic disease.
Aged↗
Treatment of hemodialysis fistula pseudoaneurysms with detachable balloons: technique and preliminary results.
Pseudoaneurysm formation is commonly encountered during the life of a dialysis fistula. When these become excessively large or numerous, surgical revision of the graft has been the only treatment option. The authors have treated seven patients by using percutaneous placement of a detachable balloon to occlude a pseudoaneurysm of an upper extremity graft. In four cases the balloon was directed into the pseudoaneurysm from a femoral artery approach. In three cases a direct puncture was made into the pseudoaneurysm for placement of the balloon. The patients were followed up from 1 week to 7 months. Initial technical success was achieved in all seven cases with no complications. Thrombosis of two grafts occurred during the first week after the procedure: one because of herniation of the balloon out of the pseudoaneurysm and one for unknown reasons. One balloon was inadvertently punctured and deflated during subsequent dialysis. Treatment in the other four cases was successful, as evidenced by no further enlargement of the pseudoaneurysms. Direct puncture of the pseudoaneurysm simplifies the procedure and probably decreases the likelihood of balloon herniation because of the orientation of the balloon.
Aneurysm↗
Normal venous anatomy and collateral pathways in upper extremity venous thrombosis.
Collateral pathways are well known in superior vena cava occlusion but not in axillary or subclavian vein occlusion, even though these occlusions are becoming more common. In a series of 127 arm venograms obtained for suspected venous thrombosis, the authors found 32 instances of subclavian or axillary vein occlusion. The authors reviewed the cases for site of occlusion and definition of collateral pathways. In 15 cases, the occlusion was in the subclavian vein, with collateral flow established chiefly via veins in the neck. Ten cases of axillary vein occlusion with chest wall collateral pathways were identified. Seven cases could not be categorized. Knowledge of these pathways is useful for accurate interpretation of upper extremity venograms. A more thorough understanding of venous pathways in the upper body may aid in the treatment of patients with chronic disease and longterm indwelling central venous catheters.
Arm↗
Use of interventional radiology for hypertension due to renal artery stenosis in children.
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Angioplasty, Balloon↗
Real-time ultrasound for the detection of deep venous thrombosis.
PURPOSE: Accurate diagnosis of deep venous thrombosis (DVT) is a clinical problem in emergency practice. A prospective trial was conducted comparing real-time ultrasound with contrast venography in the diagnosis of proximal DVT. METHODS: Seventy patients whose clinical presentations mandated diagnostic evaluation for DVT had real-time ultrasound of the involved leg followed by contrast venography. Initial readings of ultrasound and venography were compared with each other and with final readings to assess reliability of interpretation. RESULTS: Final ultrasound readings agreed with final venogram readings in all patients. Negative initial ultrasound readings agreed with final venogram readings in 56 of 56 patients (negative predictive value, 100%; 95% confidence interval, 94 to 100). Eighteen patients had positive initial ultrasound readings compared with 14 who had positive final venogram readings (positive predictive value, 78%; 95% confidence interval, 55 to 91). CONCLUSION: Negative real-time ultrasonography reliably excludes proximal DVT. Positive ultrasound reliably diagnoses proximal DVT only in experienced hands.
Adult↗
Results and complications of angioplasty in fibromuscular disease.
Percutaneous transluminal angioplasty (PTA) was used to treat 66 patients with 85 renal artery stenoses due to fibromuscular dysplasia. The hypertension was refractory to medical management in 46 patients, and the initial success rate was 100%. Clinical follow-up has been obtained in all patients, who were followed for as long as 121 months. The recurrence rates were 8% of lesions and 10% of patients. Cumulative patency rate predicted for 10 years was 87.07%. The mean systolic pressure decreased by 52 mm Hg and the mean diastolic pressure decreased by 35 mm Hg in response to treatment. Twenty-six patients (39%) were cured, 39 (59%) were classified as improved, and one (2%) did not respond to PTA. Fourteen of the patients also had elevated blood urea nitrogen and creatinine levels. Renal function was improved in 86% of the patients and stabilized in 14% of the patients. Analysis of the long-term results suggests that PTA should be the initial treatment for choice of patients with fibromuscular dysplasia in the renal arteries.
Angioplasty, Balloon↗
Results and complications of angioplasty in aortoiliac disease.
Percutaneous transluminal angioplasty was used to treat 340 aortoiliac lesions in 200 patients who were followed for as long as 90 months (mean, 28.7 months; median, 23 months). The initial success rate was 94.7% for lesions and 93.0% for patients. The indications for percutaneous transluminal angioplasty included claudication in 117 patients (58.5%), rest pain or ischemic night pain in 47 (23.5%), limb salvage in 33 (16.5%), and aiding in wound healing in three (1.5%). In the series, 70% of the patients had two or more cardiovascular risk factors. Angioplasty was initially unsuccessful in 14 patients, and 10 patients were lost to follow-up. Follow-up was obtained in 176 patients. The long-term results were analyzed using the life table method to determine cumulative patency. Fourteen patients were considered failures because of recurrent disease or symptoms. The projected 7.5-year cumulative patency rate was 85%. When the response to redilatation was considered, the projected 7.5-year cumulative patency rate was 92%. The results indicate that percutaneous transluminal angioplasty can successfully correct aortoiliac lesions and provide a long-term benefit for as long as 7.5 years.
Angioplasty, Balloon↗
Inferior vena caval invasion by renal cell carcinoma: false positive diagnosis by venacavography.
We reviewed the records of 22 renal cell carcinoma patients who were referred to this hospital to determine inferior vena caval extension of tumor. Preoperative radiological studies from referring hospitals and this institution were compared to the operative findings. Four cases of false positive inferior vena caval involvement on preoperative venacavograms performed and interpreted elsewhere were identified. In 3 of these cases a repeat preoperative inferior venacavogram performed at this hospital made the correct diagnosis. In the remaining case an inferior venacavogram was not repeated but no tumor was found at operation. One patient who did not undergo an operation was believed to have vena caval involvement by computerized tomography but venacavography was negative. Reasons for the false positive studies included suboptimal technique and misinterpretation of normal flow defects. Our technique for venacavography is presented. The importance of satisfactory preoperative radiological studies is stressed.
Carcinoma, Renal Cell↗
In situ lithotripsy of ureteral calculi: review of 261 cases.
The authors report 261 cases of single ureteral calculi treated with in situ lithotripsy after retrograde manipulations had failed. Previous reports have indicated that extracorporeal lithotripsy of impacted ureteral calculi has not been highly successful. Two hundred five of the calculi were located in the proximal ureter, above the sacroiliac joint; 27 were in the presacral ureter, overlying the bony pelvis; and 29 were in the juxtavesicular ureter, below the inferior border of the sacroiliac joint. Retrograde ureteral catheters were in place during lithotripsy for 215 calculi. Two hundred fifty-four (97%) calculi were successfully treated with lithotripsy and, when necessary, with additional postlithotripsy radiologic and urologic interventions. Seven (3%) calculi were not successfully fragmented. Nephrostomy was performed in 13 (5%) patients. Retrograde ureteral catheters were not found to enhance calculus fragmentation. In situ lithotripsy of ureteral calculi has been shown to be feasible as an alternative to ureterolithotomy when retrograde manipulation has failed.
Follow-Up Studies↗
Experience with new retrieval forceps for foreign body removal in the vascular, urinary, and biliary systems.
A new type of foreign body retrieval forceps recently has become available. It consists of single- or multiple-tooth forceps mounted on a flexible stainless steel 0.038-inch shaft. The authors have successfully used this device in the vascular system (three cases), in the urinary tract (seven cases), and in the biliary system (two cases) without complications. Foreign bodies removed include a catheter fragment, angiographic guide wire, detachable balloon, stone retrieval basket, and various stents. All the procedures were performed quickly and without difficulty. For the authors, these forceps have become the first choice in many retrieval situations.
Adolescent↗
New balloon-through-balloon angioplasty technique for the treatment of segmental lesions.
A new balloon catheter on a wire that can be passed through standard 5- and 7-F angioplasty catheters recently became available. This capability allowed the authors to dilate segmental arterial lesions in which different balloon sizes were required without multiple catheter exchanges. Six patients were successfully treated with this technique, without complications.
Angiography↗
Vascular injury following foreign body perforation of the esophagus. Review of the literature and report of a case.
Esophageal perforation resulting from foreign body ingestion is a rare occurrence. Most of the complications associated with this event, such as retroesophageal abscess, mediastinitis, pericarditis, pneumothorax, and pneumomediastinum, are widely recognized. However, little attention has been directed to the possibility of vascular injury caused by the perforating object. Isolated case reports have described significant morbidity and mortality subsequent to major vascular trauma resulting from an esophageal foreign body, usually emphasizing the presence of a "signal" hemorrhage from the gastrointestinal tract as a key to diagnosis. This report describes a case of esophageal perforation caused by an ingested fishbone that resulted in significant aerodigestive hemorrhage, possibly as the result of an unusual isolated vascular injury. The literature on vascular trauma following foreign body perforation of the esophagus is reviewed, and suggestions for the diagnosis and treatment of these dreaded complications are made.
Adult↗
Insertion of subclavian hemodialysis catheters in difficult cases: value of fluoroscopy and angiographic techniques.
Double-lumen hemodialysis catheters designed to be placed via a subclavian vein approach have gained rapid acceptance over the past several years. Several studies have shown a significant rate of subclavian vein stenosis or occlusion after placement of these catheters. A large number of these patients require repeat placement of catheters with access often becoming increasingly difficult to obtain. Over the past 5 years, we have been asked to place 38 catheters in 34 patients that could not be placed at the bedside. Our procedure consists of obtaining a preliminary venogram to evaluate the reason for difficulty. The subclavian vein is then cannulated under direct fluoroscopic visualization while the peripheral venous line is injected with contrast material. Percutaneous angiographic techniques are then used to position the catheter. Satisfactory placement was obtained in all 38 cases. There were no complications, which is surprising considering the number of complications seen with the standard methods of insertion. This represents a new role for the interventional radiologist, one that can be important in minimizing the number of new dialysis sites in any one patient.
Angiography↗
Balloon occlusion of a pseudoaneurysm in a below-the-knee amputation stump.
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Aged↗
Guide wire angioplasty balloon catheter: preliminary report.
A new balloon catheter has been developed for angioplasty. The balloon is more flexible and its walls are thinner than those of conventional catheters. It folds down better yet withstands 8-10 atm of pressure. This advance has been married to new guide wire technology, producing a low-profile angioplasty balloon on a 0.038-inch guide wire. It compared favorably with a standard 7-F angioplasty catheter when tested at 4 atm in a rabbit and has been successfully used to dilate ten peripheral stenoses in four patients.
Angioplasty, Balloon↗