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Is angiography necessary when an internal carotid artery occlusion is discovered on colour carotid doppler ultrasound?
ABSTRACTS not easy to obtain. There is, however, a relationship between myocardial concentration and hepatic concentration of amiodarone and its metabolites. Since amiodarone contains iodine and is concentrated in the liver, the increased hepatic attenuation from single slice computed tomography was compared with serum levels and the electrocardiographic QTc in 12 patients before and during amiodarone therapy. Hepatic attenuation increased by a mean value of 18.25 H U over a 12 m o n t h study period. This increase correlated well with increased QTc (r = 0.83) and the serum amiodarone levels ( r - 0 . 8 9 ) , but less well with serum desethyl amiodarone levels (r = 0.43). An iodine-containing p h a n t o m was used to construct a curve of attenuation against iodine concentration in mol/1. An indirect measurement ofamiodarone concentration in g/1 wet weight of liver could therefore be determined. Single slice CT is useful in monitoring patients on amiodarone where the electrocardiogram is unhelpful. It is also useful in assessing compliance and may be useful in the diagnosis of possible side effects of the drug.
IS A N G I O G R A P H Y NECESSARY W H E N AN I N T E R N A L C A R O T I D A R T E R Y O C C L U S I O N IS D I S C O V E R E D ON COLOUR CAROTID DOPPLER ULTRASOUND? P. S. S I D H U , H. R. J A G E R and K. T. K H A W
Diagnostic Radiology Department, Harnmersmith Hospital, London It is important to distinguish between a high grade stenosis and a complete occlusion of an internal carotid artery (ICA) as surgery is indicated for the former but is unnecessary in the latter. Angiography is frequently performed to exclude a 'missed' severe stenosis, when Doppler ultrasound suggests ICA occlusion. The study assesses the accuracy of colour Doppler in diagnosing a complete occlusion compared with angiography. F r o m a retrospective review of a series of 725 consecutive Doppler examinations, 37 total occlusions were found (19 right and 18 left). Fourteen patients were referrals from outside the hospital, 23 went on to have assessment with digital subtraction arch angiography. The results o f the angiograms were reviewed independently and matched with the ultrasound results. In all 23 patients complete occlusion of the ICA reported on Doppler ultrasound was confirmed by angiography. None of these patients had a high grade stenosis and no patient went on to have any surgical intervention on that side. We conclude that with the advent of colour, total occlusions of the ICA can be accurately diagnosed with carotid Doppler ultrasound and further examination with angiography to exclude a severe stenosis is unnecessary.
I N V E S T I G A T I O N AND P R O G N O S I S OF C O N G E N I T A L P U L M O N A R Y ATRESIA W I T H I N T A C T V E N T R I C U L A R SEPTUM R. P A R R Y , W. DHIMIS, J. W I S H E A R T and P. W I L D E
Departnwnts of Radiology and Cardiac Surgery, Bristol Royal Infirmary, Bristol Prior to 1982 there were disappointing surgical results in the management of pulmonary atresia with intact ventricular septum (PA + IVS) (73% mortality). A local review at that time emphasized the importance of cardiac catheterization in providing morphological information about the right ventricle (RV) and tricuspid valve (TV). This led to a change in policy and a three stage surgical strategy was instituted. Since 1982 the mortality rate has fallen to 40%. In an attempt to reduce this further, cardiac catheters of the 20 patients presenting since 1982 were reviewed to determine adverse prognostic features and rationalize the timing and nature of investigational procedures. The RV morphology was assessed for development of the inlet, trabecular and outflow portions and the diameters of the TV and pulmonary arteries were measured. The presence and number of fistulae from the RV to the right coronary arteries (CA) were noted and graded as minor or major fistulae (major if contrast shunt enabled identification of the CA). O f the eight deaths in this group five had major RV to C A fistulae. O f 12 sut'vivors only one had a major fistula. These findings emphasize the adverse prognostic influence of major CA fistulae. The study also confirmed the recent change to diagnostic echocardiography rather than catheterization before initial surgical intervention.
343
C O L O U R F L O W D O P P L E R IN T H E F O L L O W - U P OF F E M O R O - P O P L I T E A L BYPASS G R A F T S - IS IT NECESSARY? E. M. P A R T R I D G E , G. J. M U R P H Y , A. M. N I C O L S O N and J. N. J O H N S O N
Department of Radiology and Vascular Surgery, Halton General Hospital NHS Trust, Runcorn Failure of femoro-popliteal vascular grafts is a problem in vascular surgery. The routine outpatient assessment of these patients is based on their clinical symptoms and the ankle-brachial index (ABI). A prospective 2 year follow-up of all femoro-popliteal grafts using colour flow Doppler was undertaken. The aim of this study was to see if any grafts had significant stenoses not revealed by the simple outpatient tests. Thirty-six femoro-popliteal grafts were scanned in 29 patients. Twenty interventional radiological procedures were performed on 15 grafts (16 percutaneous transluminal angioplasties, three combined thrombolysis and angioplasty and one angioplasty with stent insertion). Thirty per cent of the stenoses were detected by colour Doppler examination before the patient had symptoms or a reduction in the ABI. In our series there were two false positives and three false negatives. Forty per cent of the stenoses detected had their initial presentation more than a year from the date of operation. Conclusions: (I) Despite some false positives and false negatives, colour flow Doppler supplies information which alters clinical management in a significant number of cases; (2) long-term follow-up of femoro-popliteal graft is worthwhile.
R E C A N A L I Z A T I O N O F C R U R A L ARTERY O C C L U S I O N S FOR CRITICAL LIMB ISCHAEMIA K. D. M c B R I D E , M. J. S W A R B R I C K , D. C. C U M B E R L A N D and P. A. G A I N E S
Departments o]"Radiology, Royal Hallamshire and Northern General Hospitals', SheffieM The success of lower limb angioplasty depends upon distal run-off. In critical limb ischaemia, infrapopliteal angioplasty of trifurcation stenoses is occasionally necessary. However, recanalization of complete tibial artery occlusions for limb salvage is infrequently performed. This paper describes the joint Sheffield experience in treating these occlusions. During four years from 1988, 13 patients have had infrapopliteal angioplasty of crural artery occlusions. All presented with severe, critical limb ischaemia (Fontaine III and IV). There were 11 men and overall average age was 72 years (range 50-86). Nine were diabetic. Nine patients had combined proximal and tibial procedures, while four had tibial angioplasty alone. Previous thrombolysis, hot-tip laser assistance and ultrasound ablation were each used in one case. One procedure failed and required distal bypass surgery. On follow-up, nine patients significantly improved with resolution of rest pain in seven, ulcer healing in five and healing of local amputations in three. Three patients (all diabetics) required below-knee amputation. Two patients died of other causes. Angioplasty ofinfrapopliteal occlusive disease is justifiable for critical limb ischaemia with an encouraging limb salvage rate of 70% (9/13) in our series. The short-term outcome is best in non-diabetics.
ACCELERATED P E R I P H E R A L ARTERIAL T H R O M B O L Y S I S USING T H E P U L S E - S P R A Y M E T H O D S. W H I T A K E R * , S. Y U S U F , R. G R E G S O N * , J. ASTIL, P. W E N H A M , B. H O P K I N S O N and G. M A K I N
Departments of *Radiology and Vascular Surgery, University Hospital NHS Trust, Nottingham Introduction: Standard infusion thrombolysis is effective in the treatment of limb ischaemia o f recent onset but its use is limited to patients whose affected limb can withstand continued ischaemia for the duration of infusion, often 24 h or more. We report our experience of accelerated peripheral arterial thrombolysis using a new Pulse-Spray catheter system (E-Z-EM Ltd). Design: Prospective evaluation. Subjects andMethod: 24 consecutive patients with recent onset of limb ischaemia. Their ages ranged from 35 to 89 years (median 74.5) and the duration of their history from t to 60 days (median 6 days). The length of occlusion on arteriography varied from 4 to 55 cm (median 23 cm). I 1/ 24 patients had critical ischaemia with sensory and/or motor deficit. Recombinant tissue plasminogen activator (Boehringer) was used in all cases in a concentration of 0.33 mg/ml, given in boluses of 0.2 ml every
IS A N G I O G R A P H Y NECESSARY W H E N AN I N T E R N A L C A R O T I D A R T E R Y O C C L U S I O N IS D I S C O V E R E D ON COLOUR CAROTID DOPPLER ULTRASOUND? P. S. S I D H U , H. R. J A G E R and K. T. K H A W
Diagnostic Radiology Department, Harnmersmith Hospital, London It is important to distinguish between a high grade stenosis and a complete occlusion of an internal carotid artery (ICA) as surgery is indicated for the former but is unnecessary in the latter. Angiography is frequently performed to exclude a 'missed' severe stenosis, when Doppler ultrasound suggests ICA occlusion. The study assesses the accuracy of colour Doppler in diagnosing a complete occlusion compared with angiography. F r o m a retrospective review of a series of 725 consecutive Doppler examinations, 37 total occlusions were found (19 right and 18 left). Fourteen patients were referrals from outside the hospital, 23 went on to have assessment with digital subtraction arch angiography. The results o f the angiograms were reviewed independently and matched with the ultrasound results. In all 23 patients complete occlusion of the ICA reported on Doppler ultrasound was confirmed by angiography. None of these patients had a high grade stenosis and no patient went on to have any surgical intervention on that side. We conclude that with the advent of colour, total occlusions of the ICA can be accurately diagnosed with carotid Doppler ultrasound and further examination with angiography to exclude a severe stenosis is unnecessary.
I N V E S T I G A T I O N AND P R O G N O S I S OF C O N G E N I T A L P U L M O N A R Y ATRESIA W I T H I N T A C T V E N T R I C U L A R SEPTUM R. P A R R Y , W. DHIMIS, J. W I S H E A R T and P. W I L D E
Departnwnts of Radiology and Cardiac Surgery, Bristol Royal Infirmary, Bristol Prior to 1982 there were disappointing surgical results in the management of pulmonary atresia with intact ventricular septum (PA + IVS) (73% mortality). A local review at that time emphasized the importance of cardiac catheterization in providing morphological information about the right ventricle (RV) and tricuspid valve (TV). This led to a change in policy and a three stage surgical strategy was instituted. Since 1982 the mortality rate has fallen to 40%. In an attempt to reduce this further, cardiac catheters of the 20 patients presenting since 1982 were reviewed to determine adverse prognostic features and rationalize the timing and nature of investigational procedures. The RV morphology was assessed for development of the inlet, trabecular and outflow portions and the diameters of the TV and pulmonary arteries were measured. The presence and number of fistulae from the RV to the right coronary arteries (CA) were noted and graded as minor or major fistulae (major if contrast shunt enabled identification of the CA). O f the eight deaths in this group five had major RV to C A fistulae. O f 12 sut'vivors only one had a major fistula. These findings emphasize the adverse prognostic influence of major CA fistulae. The study also confirmed the recent change to diagnostic echocardiography rather than catheterization before initial surgical intervention.
343
C O L O U R F L O W D O P P L E R IN T H E F O L L O W - U P OF F E M O R O - P O P L I T E A L BYPASS G R A F T S - IS IT NECESSARY? E. M. P A R T R I D G E , G. J. M U R P H Y , A. M. N I C O L S O N and J. N. J O H N S O N
Department of Radiology and Vascular Surgery, Halton General Hospital NHS Trust, Runcorn Failure of femoro-popliteal vascular grafts is a problem in vascular surgery. The routine outpatient assessment of these patients is based on their clinical symptoms and the ankle-brachial index (ABI). A prospective 2 year follow-up of all femoro-popliteal grafts using colour flow Doppler was undertaken. The aim of this study was to see if any grafts had significant stenoses not revealed by the simple outpatient tests. Thirty-six femoro-popliteal grafts were scanned in 29 patients. Twenty interventional radiological procedures were performed on 15 grafts (16 percutaneous transluminal angioplasties, three combined thrombolysis and angioplasty and one angioplasty with stent insertion). Thirty per cent of the stenoses were detected by colour Doppler examination before the patient had symptoms or a reduction in the ABI. In our series there were two false positives and three false negatives. Forty per cent of the stenoses detected had their initial presentation more than a year from the date of operation. Conclusions: (I) Despite some false positives and false negatives, colour flow Doppler supplies information which alters clinical management in a significant number of cases; (2) long-term follow-up of femoro-popliteal graft is worthwhile.
R E C A N A L I Z A T I O N O F C R U R A L ARTERY O C C L U S I O N S FOR CRITICAL LIMB ISCHAEMIA K. D. M c B R I D E , M. J. S W A R B R I C K , D. C. C U M B E R L A N D and P. A. G A I N E S
Departments o]"Radiology, Royal Hallamshire and Northern General Hospitals', SheffieM The success of lower limb angioplasty depends upon distal run-off. In critical limb ischaemia, infrapopliteal angioplasty of trifurcation stenoses is occasionally necessary. However, recanalization of complete tibial artery occlusions for limb salvage is infrequently performed. This paper describes the joint Sheffield experience in treating these occlusions. During four years from 1988, 13 patients have had infrapopliteal angioplasty of crural artery occlusions. All presented with severe, critical limb ischaemia (Fontaine III and IV). There were 11 men and overall average age was 72 years (range 50-86). Nine were diabetic. Nine patients had combined proximal and tibial procedures, while four had tibial angioplasty alone. Previous thrombolysis, hot-tip laser assistance and ultrasound ablation were each used in one case. One procedure failed and required distal bypass surgery. On follow-up, nine patients significantly improved with resolution of rest pain in seven, ulcer healing in five and healing of local amputations in three. Three patients (all diabetics) required below-knee amputation. Two patients died of other causes. Angioplasty ofinfrapopliteal occlusive disease is justifiable for critical limb ischaemia with an encouraging limb salvage rate of 70% (9/13) in our series. The short-term outcome is best in non-diabetics.
ACCELERATED P E R I P H E R A L ARTERIAL T H R O M B O L Y S I S USING T H E P U L S E - S P R A Y M E T H O D S. W H I T A K E R * , S. Y U S U F , R. G R E G S O N * , J. ASTIL, P. W E N H A M , B. H O P K I N S O N and G. M A K I N
Departments of *Radiology and Vascular Surgery, University Hospital NHS Trust, Nottingham Introduction: Standard infusion thrombolysis is effective in the treatment of limb ischaemia o f recent onset but its use is limited to patients whose affected limb can withstand continued ischaemia for the duration of infusion, often 24 h or more. We report our experience of accelerated peripheral arterial thrombolysis using a new Pulse-Spray catheter system (E-Z-EM Ltd). Design: Prospective evaluation. Subjects andMethod: 24 consecutive patients with recent onset of limb ischaemia. Their ages ranged from 35 to 89 years (median 74.5) and the duration of their history from t to 60 days (median 6 days). The length of occlusion on arteriography varied from 4 to 55 cm (median 23 cm). I 1/ 24 patients had critical ischaemia with sensory and/or motor deficit. Recombinant tissue plasminogen activator (Boehringer) was used in all cases in a concentration of 0.33 mg/ml, given in boluses of 0.2 ml every