- Email: [email protected]
Abdominal, renal and lumbar aortography with 3 f catheters — A true outpatient examination
376
ABSTRACTS
This study investigates the results obtained by radiologists-in-training with little previous experience in PTA. These results are of significance to radiologists commencing an angioplasty service. Sixty-one consecutive PTAs done by senior registrars in 49 patients over a 2½ year period were reviewed retrospectively by scrutinizing radiographs, reports and clinical notes. Previous PTA experience ranged from 2 to 12 cases (mean 5). The results are summarized below,
Number
Technical success
Complications
Follow-up
18 Renal (11 patients)
15
3
23 Iliac (18 patients)
21
7
20 Femoropopliteal (20 patients)
12
6
0 Cured, 9 Improved 4 Cured, 10 Improved 0 Cured, 9 Improved
No patient deteriorated as a result of PTA. All complications were minor: none required surgical intervention or emergency treatment. The indications, vascular lesions and complications are discussed. These results are compared with those in other studies and it is concluded that PTA is safe and effective even in relatively inexperienced hands. Minor complications are common but of little significance. Major complications are rare. ABDOMINAL, RENAL AND LUMBAR AORTOGRAPHY WITH 3 F C A T H E T E R S - A TRUE OUTPATIENT EXAMINATION J. F. REIDY
Guy's Hospital, London The use of 5 F catheters for arteriography via the femoral approach is now routine and more recently 4 F catheters are at least partially replacing them. Though most feel that the risks of trans-femoral catheterization and in particular post-catheterization bleeding have been reduced, a 3 h recovery and observation period is usually recommended. In practice this means that patients still need day-case or short-stay admissions. Although smaller catheters have been available for some time, their use has been limited by low maximum flow rates as well as problems in inserting these catheters over the small guidewires necessary for their use. We have recently developed and evaluated a 3 F catheter set (William Cook Europe) that is easy to use even in the presence of groin scarring. Used with digital angiography it will allow sufficient flow for abdominal aortography and peripheral vascular disease studies. The set comprises a 20 G 1 piece needle, an 0.25" guide wire (Amplatz 025" 'J'), a 3 F 50 cm long straight Teflon catheter with 6 sideholes. The catheter will in vivo take a maximum flow rate o f 6 ml/s. The cross-sectional area of this catheter is just over half (55%) that of a 4 F catheter and only I/3 of a 5 F catheter. Our early experience suggests that a 30 rain rest and recovery period following catheterization with these catheters is adequate and that no post-catheterization haematoma or bleeding occurs following a 5 min compression period. This makes this technique comparable to intravenous digital angiography in terms of invasiveness and the time needed to be spent in hospital. BRONCHIAL ARTERIOGRAPHY AND EMBOLIZATION BY A S I M P L E CATHETER T E C H N I Q U E M. S. T. RUTTLEY
University Hospital of Wales, Cardiff Persistent life threatening haemoptysis should be treated by bronchial artery (BA) embolization (Jones and Davies, 1990). Infrequent need dictates that even the specialist vascular radiologist will be only an occasional bronchial arteriographer. A simple reliable percutaneous technique of BA catheterization is therefore required. Use of the Judkins left coronary catheter (JL4) was suggested by observing effortless BA selection during its aortic passage by tyro coronary arteriographers. Bronchial arteriography for haemoptysis was performed here in nine patients in the period 1983-1990, In six the bleeding was life threatening and BAs were embolized. In all cases selective arteriography was easily completed with a JL4 from the femoral artery. An additional catheter was required for embolization in only one patient where the JL4 could not be advanced sufficiently in one BA for safe Ivalon injection but allowed exchange to a straight catheter without sacrifice of selective position. Haemoptysis was stopped by embolization in five patients; the sixth continued to bleed and required lobectomy (for mycetoma). There were no complications of arteriography or embolization.
It is concluded that the JL4 is a suitable catheter for bronchial arteriography and embolization. Jones, D K & Davies, RJ (1990). Massive haemoptysis. British Medical Journal, 300, 889-890. RADIOCONTRASTIINDUCED CHANGES TO BLOOD RHEOLOGY AND THEIR I M P O R T A N C E IN ANGIOGRAPIty N. H. STRICKLAND, P. DAWSON and M. W. R A M P L I N G
Hammersmith Hospital and St Mary's Hospital Medical School, London Factors which alter blood rheology will have important consequences in the clinical setting of angiography. Since blood viscosity is one of the key determinants of the rheological properties of blood, we have studied the differential effects of various concentrations of five different radiocon. trast media on the viscosity characteristics o f erythrocyte-plasrna suspensions. Measurements were made over a range o f applied shear rates in order to simulate normal laminar blood flow. Our results showed that, at both high and low shear rates, the rate of change of viscosity with contrast concentration differs markedly between the various types of contrast media. The conventional ionic monomers caused most disturbance to blood viscosity. Surprisingly, the monoionic dimer Hexabrix was least disturbing to the viscometric characteristics of blood, and the newer non-ionic monomers were intermediate in their effects. We suggest that gross effects on blood theology will be caused by radiocontrast agents during a number of in rive angiographic situations, in particular: early after contrast bolus injection into large vessels, in the microcirculation after selective injections; and during angioplasty procedures. THE P R O B L E M S OF ASSESSING PRE-OPERATIVE CRITICAL ISCHAEMIA: A COMBINED RADIOLOGICAL AND PHYSIOLOGICAL A P P R O A C H A. F. WATKINSON, M. G. WYATT, M. H O R R O C K S and G. G. H A R T N E L L
Bristol Royal Infirmary, Bristol In patients with critical ischaemia the pedal arch patency is a vital factor for successful outcome of femoro-popliteal or distal (FPD) bypass surgery• This patency may be underestimated with standard preoperative arteriographic techniques. This study aimed to compare the accuracy of pre-operative intraarterial digital subtraction angiography (IADSA) with pulse generated run-off (PGR) in the demonstration of pedal arch patency prior to FPD bypass• Comparison was also made with post-operative IADSA. In 42 patients undergoing FPD bypass for critical ischaemia PGR was compared with both pre- and post-operative IADSA. The number of calf vessels in continuity with the pedal arch was scored as 2, 1 or 0 (maximum 2 vessels) and the pedal arch as complete (2), incomplete (1) or occluded (0). There was no correlation between pre-operative IADSA and PGR.,There was good correlation between pre-operative PGR and post-operative IADSA for calf vessel continuity at the ankle (rs = 0.71, P<0.001 [Spearman rank correlation]) and for pedal arch patency (rs = 0.79, P < 0.001 [Spearman rank correlation]). This study emphasizes the limitations of pre-operative arteriography in demonstrating the pedal arch distal to femoral artery occlusion and confirms that P G R can show the integrity of feeding calf vessels and the patency of the pedal arch. This information enables surgery to be planned in situations when it would have been contra-indicated using the results of angiography alone.
D O P P L E R ULTRASOUND F O L L O W U P OF PATIENTS AFTER AORTIC ANGIOPLASTY D. J. WRIGHT, D. K I N G and J. REIDY
Guy's Hospital, London There is a limited experience of aortic angioplasty with even lesS objective evaluation of results. We have followed up aortic angioplasty cases with Doppler ultrasound, using tracking of the arterial system wlt~ a probe to assess local arterial gradients, as well as the ankle/brachial index (ABI). This combined approach is more sensitive for assessing stenotic disease than the ABI alone. We report on 13 patients (mean age 53 years, range 39-67 years, M :g, 6:7) who have undergone distal aorticangioplasty. Six patients ha~ dxsease confined to• the aorta , four p atle • " nts had aorto-iliac disease and
ABSTRACTS
This study investigates the results obtained by radiologists-in-training with little previous experience in PTA. These results are of significance to radiologists commencing an angioplasty service. Sixty-one consecutive PTAs done by senior registrars in 49 patients over a 2½ year period were reviewed retrospectively by scrutinizing radiographs, reports and clinical notes. Previous PTA experience ranged from 2 to 12 cases (mean 5). The results are summarized below,
Number
Technical success
Complications
Follow-up
18 Renal (11 patients)
15
3
23 Iliac (18 patients)
21
7
20 Femoropopliteal (20 patients)
12
6
0 Cured, 9 Improved 4 Cured, 10 Improved 0 Cured, 9 Improved
No patient deteriorated as a result of PTA. All complications were minor: none required surgical intervention or emergency treatment. The indications, vascular lesions and complications are discussed. These results are compared with those in other studies and it is concluded that PTA is safe and effective even in relatively inexperienced hands. Minor complications are common but of little significance. Major complications are rare. ABDOMINAL, RENAL AND LUMBAR AORTOGRAPHY WITH 3 F C A T H E T E R S - A TRUE OUTPATIENT EXAMINATION J. F. REIDY
Guy's Hospital, London The use of 5 F catheters for arteriography via the femoral approach is now routine and more recently 4 F catheters are at least partially replacing them. Though most feel that the risks of trans-femoral catheterization and in particular post-catheterization bleeding have been reduced, a 3 h recovery and observation period is usually recommended. In practice this means that patients still need day-case or short-stay admissions. Although smaller catheters have been available for some time, their use has been limited by low maximum flow rates as well as problems in inserting these catheters over the small guidewires necessary for their use. We have recently developed and evaluated a 3 F catheter set (William Cook Europe) that is easy to use even in the presence of groin scarring. Used with digital angiography it will allow sufficient flow for abdominal aortography and peripheral vascular disease studies. The set comprises a 20 G 1 piece needle, an 0.25" guide wire (Amplatz 025" 'J'), a 3 F 50 cm long straight Teflon catheter with 6 sideholes. The catheter will in vivo take a maximum flow rate o f 6 ml/s. The cross-sectional area of this catheter is just over half (55%) that of a 4 F catheter and only I/3 of a 5 F catheter. Our early experience suggests that a 30 rain rest and recovery period following catheterization with these catheters is adequate and that no post-catheterization haematoma or bleeding occurs following a 5 min compression period. This makes this technique comparable to intravenous digital angiography in terms of invasiveness and the time needed to be spent in hospital. BRONCHIAL ARTERIOGRAPHY AND EMBOLIZATION BY A S I M P L E CATHETER T E C H N I Q U E M. S. T. RUTTLEY
University Hospital of Wales, Cardiff Persistent life threatening haemoptysis should be treated by bronchial artery (BA) embolization (Jones and Davies, 1990). Infrequent need dictates that even the specialist vascular radiologist will be only an occasional bronchial arteriographer. A simple reliable percutaneous technique of BA catheterization is therefore required. Use of the Judkins left coronary catheter (JL4) was suggested by observing effortless BA selection during its aortic passage by tyro coronary arteriographers. Bronchial arteriography for haemoptysis was performed here in nine patients in the period 1983-1990, In six the bleeding was life threatening and BAs were embolized. In all cases selective arteriography was easily completed with a JL4 from the femoral artery. An additional catheter was required for embolization in only one patient where the JL4 could not be advanced sufficiently in one BA for safe Ivalon injection but allowed exchange to a straight catheter without sacrifice of selective position. Haemoptysis was stopped by embolization in five patients; the sixth continued to bleed and required lobectomy (for mycetoma). There were no complications of arteriography or embolization.
It is concluded that the JL4 is a suitable catheter for bronchial arteriography and embolization. Jones, D K & Davies, RJ (1990). Massive haemoptysis. British Medical Journal, 300, 889-890. RADIOCONTRASTIINDUCED CHANGES TO BLOOD RHEOLOGY AND THEIR I M P O R T A N C E IN ANGIOGRAPIty N. H. STRICKLAND, P. DAWSON and M. W. R A M P L I N G
Hammersmith Hospital and St Mary's Hospital Medical School, London Factors which alter blood rheology will have important consequences in the clinical setting of angiography. Since blood viscosity is one of the key determinants of the rheological properties of blood, we have studied the differential effects of various concentrations of five different radiocon. trast media on the viscosity characteristics o f erythrocyte-plasrna suspensions. Measurements were made over a range o f applied shear rates in order to simulate normal laminar blood flow. Our results showed that, at both high and low shear rates, the rate of change of viscosity with contrast concentration differs markedly between the various types of contrast media. The conventional ionic monomers caused most disturbance to blood viscosity. Surprisingly, the monoionic dimer Hexabrix was least disturbing to the viscometric characteristics of blood, and the newer non-ionic monomers were intermediate in their effects. We suggest that gross effects on blood theology will be caused by radiocontrast agents during a number of in rive angiographic situations, in particular: early after contrast bolus injection into large vessels, in the microcirculation after selective injections; and during angioplasty procedures. THE P R O B L E M S OF ASSESSING PRE-OPERATIVE CRITICAL ISCHAEMIA: A COMBINED RADIOLOGICAL AND PHYSIOLOGICAL A P P R O A C H A. F. WATKINSON, M. G. WYATT, M. H O R R O C K S and G. G. H A R T N E L L
Bristol Royal Infirmary, Bristol In patients with critical ischaemia the pedal arch patency is a vital factor for successful outcome of femoro-popliteal or distal (FPD) bypass surgery• This patency may be underestimated with standard preoperative arteriographic techniques. This study aimed to compare the accuracy of pre-operative intraarterial digital subtraction angiography (IADSA) with pulse generated run-off (PGR) in the demonstration of pedal arch patency prior to FPD bypass• Comparison was also made with post-operative IADSA. In 42 patients undergoing FPD bypass for critical ischaemia PGR was compared with both pre- and post-operative IADSA. The number of calf vessels in continuity with the pedal arch was scored as 2, 1 or 0 (maximum 2 vessels) and the pedal arch as complete (2), incomplete (1) or occluded (0). There was no correlation between pre-operative IADSA and PGR.,There was good correlation between pre-operative PGR and post-operative IADSA for calf vessel continuity at the ankle (rs = 0.71, P<0.001 [Spearman rank correlation]) and for pedal arch patency (rs = 0.79, P < 0.001 [Spearman rank correlation]). This study emphasizes the limitations of pre-operative arteriography in demonstrating the pedal arch distal to femoral artery occlusion and confirms that P G R can show the integrity of feeding calf vessels and the patency of the pedal arch. This information enables surgery to be planned in situations when it would have been contra-indicated using the results of angiography alone.
D O P P L E R ULTRASOUND F O L L O W U P OF PATIENTS AFTER AORTIC ANGIOPLASTY D. J. WRIGHT, D. K I N G and J. REIDY
Guy's Hospital, London There is a limited experience of aortic angioplasty with even lesS objective evaluation of results. We have followed up aortic angioplasty cases with Doppler ultrasound, using tracking of the arterial system wlt~ a probe to assess local arterial gradients, as well as the ankle/brachial index (ABI). This combined approach is more sensitive for assessing stenotic disease than the ABI alone. We report on 13 patients (mean age 53 years, range 39-67 years, M :g, 6:7) who have undergone distal aorticangioplasty. Six patients ha~ dxsease confined to• the aorta , four p atle • " nts had aorto-iliac disease and