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JVIR
I Publication Information I for Authors
Tlae Journal of Vascular and Interventional Radiology is published under the supervision of the Society of Cardiovascular and Interventional Radiology (SCVIR) and in collaboration with the Radiological Society of North America, Inc (RSNA). No responsibility is accepted by the Editor, the SCVIR, or the RSNA for opinions expressed by contributors. Neither the Editor nor the SCVIR nor the RSNA guarantees, warrants, or endorses any product or service advertised in this publication or described in its contents. Neither do they guarantee any claims made by the manufacturer(s) of such product(s) or service(s). JVIR is devoted to the timely publication of clinical and laboratory studies in the field of vascular and interventional radiology. The Journal publishes selected peer-reviewed papers presented a t the annual meeting of the SCVIR, as well as original articles from members and nonmembers of the SCVIR. Certain selected original JVIR articles of appropriate scope and importance may be republished in Radiology a t the discretion of the Editors and with the permission of the author(s). Likewise, certain papers published in Radiology may be republished in JVIR. In addition to these original clinical and laboratory papers, regular features of the Journal include (1)Critical Issues in Vascular and Interventional Radiology-articles of critical importance to those practicing vascular and intementional radiology. They may be invited papers or statements that issue from SCVIR committees, such as practice guidelines. They may be authored by vascular and interventional radiologists or by others. (2) Partners in Patient Care-articles of importance in the general care of patients undergoing vascular and interventional procedures. In general, authors for this section will represent nonradiology clinical disciplines. These may include gastroenterology, cardiology,vascular or general surgery, infectious diseases, urology, and others. (3)Interventional Radiology Rounds-articles that describe a unique or innovative intementional approach to a difficult case or group of cases. The article will be followed by a discussion by experts in vascular and intementional radiology and other related fields. Other regular features include Letters to the Editor, Book Reviews, and Abstracts of Current Literature. The instructions below conform with the Uniform Requirements for Manuscripts Submitted to Biomedical Journals (JA.MA 1993; 269:2282-2286). Once accepted, manuscripts are also subject to copyediting to conform to the Journal's standards. Manuscripts accepted become the property of the Journal of Vascular and Interventional Radiology and may not be published in whole or in part without the express written permission of the author(s) and the Journal. Permission to reproduce material published in the Journal of Vascular and Interventional Radiology must also be obtained from the Editor. Manuscripts should be addressed to: Gary J. Becker, MD-Editor, JVIR JVIR Editorial Office Miami Vascular Institute 8900 N Kendall Drive Miami, Florida 33176 (305) 598-5939 FAX (305) 270-3688
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and fatal reactions may occur wthout warnlng. and the rlsk must be weighed agalnst the beneflt of the procedure. A fully equipped emergency cart. or equivalent supplies and equipment, and personnel competent in recognlzlng and treating a6verse reactions of all types should always be avadable. If a Serious reaction should occur, immediately dlscont~nue administration. Since severe delayed reactions have been mown to OCCJr, emergeno facl In an0 compelem personCONTRAINDICATIONS ne s h o ~ l obe avallaole lor at leas1 30 to 60 m nJtes after HEXABRIX is contraindicated for use ~nmyelographp Refer adm#n#stnhon(See ADVERSE REACT ONS I to PRECAUTIONS concerning hypersenslBvity. HysterosalPreparatory dehydratlon 1s dangerous and may contribute PlngOgraphy should not be performed dunng the menstrual to acute renal fallure in infants. young children, the elderly, period: in pregnant patients: in patients with known infection patients with pre-existing renal insufficlency, patlents w ~ t h In any portion of the genital tract: or in patients in whom multiple myeloma, patients with advanced vascular dlsease cervlcal conization or curettage has been performed within and d~abeticpatients 30 days Arthmgraphy should not be performed 11idection is Acute renal fallure has been reported in diabetlc patients Presentin or neartheiolnt. wlth dlabetlc nephropathy and in susceptible non-diabettc Patients (often elderiv with ore-exlstlna renal dlseasel followWARNINGS lOnlC lodlnated contrast media inhibitblood enann~latmnm ins the administrationof iodinated conirast agents. Therefore, vrtro, more than nontonic mntrast ~ e d $ ~ l o i ~ m ' d & s ~ l i careful considerationof the potential risks should be given before performing this radiographicprocedure in these patients. prudent to avoid prolonged contact of blood with syringes Wntainino ionlc wntrast m M a Severe reactions to contrast media often resemble allera~c responses Thls has prompted the use of several provocaGe serious, rarely fatal, th&nboembol~c events causlng Preteshng methods none of wh~chcan be relled on to pred~ct myocardial infarction and stroke have been reported during severe reacflons No conclus~verelat~onsh~o between ?evere angiograph~cprocedures w ~ t hboth lonlc and nonlonlc contrast media Therefore. metictllnos .~.. ... intravxnllar ..... . ~ d m i n-.i d n - reactlons and antigen-antlbodyreactions 0; other m a i f e i t i tlons of allergy has been established. The possib~lityof non lecnn 4 ~ ISe n e m a r y part rL any our nq ang.ograph c procm~resto m nnm ze mromboemw tc events h ~ m e r o ~ s an idiosyncratic reactlon in patlents who have previously received a contrast medlum wlthout 111effect should always factors nc uomp length of proced~recatneler ano syrmge be mnsidered. Prior to the lnjechon of any wntrast medium, matend Lnoeriy~ng0 sease slate and wncomtanl meolcasons may WntnnLte lo me oeveopment of mromwemoo c Me patient should be questioned to obtain a medlcal h~story with emphasis on allergy and hypersensrtlvlty A poslt~vehae m r s For tnese reasons, me! c r OJS ang oprapn c tecnnlaues are reammenam ,nclud ng core anenton to g~lde- tory of bronchial asthma or allergy (Including food). a famlly hlstorv of allerov ~a orevious m a i o n or hvoersansihv~hto w re an0 m e t e r man#pulanon.~ s of e man loo systems a m a wnirast age; may mpry igreatirma" J;li Ils; Or mreeway stopmc*s Ireq~entcatheter fllsn ng m nepahiston, rnay be more accJrate man ore-lesnnp m preolcl nq r n zeo sa ne so ut ons and m nnmnznng tne engtn of me potentla for aacton. almougn not necessar y me severme proceorre The Jse of past c syr noes n place of glass ZI nges nas wen reportea lo oecrease o n note m nale me Q or m e of react.on n Ine no v oLa case A posnue n stor) of Ins m e ooes no1 ammtrar y contrano cate me 1.9 of a Ihblihood of s vilro clotting. m t r a s t agent wwn a oagnosr c p r m o r r e s M l g n t essenSerious or fatal reactions have beenassoctated with the tlal. OLI does ca l lor caulion [See ADVERSE REACTIONS I administranonof Iodine mntalnlng radlopaque med~a.II IS of Prophylacl ctherapy InC JO ng coltlcostero ds and ant ulmost importanceto be wmpletely prepared to treat any wnnlstamlnes s h o ~ l obe cons dereo lor palnents hno prosent trast medlum reachon. As wlth any WntraSt medam. senous neurolog~csequelae. w In aslrong a erglr n story aprev O L S reart#Ontoa contrast me0 Jm 01 a posll.ue pre.lesl smce n tnese pai8enls lncludlng permanent paralysis, can occur following cerebral the nodence of reactlon s h o to three tomes thal of Ine genarteriography, Selective splnal arterlography and arterlogran ooses of wrt wstero~dssno. o oe era ~ o p ~ a t l oAaeqLate Phy of vessels Supplying the splnal cord. The lniectlon of a SIaltPd eany enough pnor to contrast m e d m n,mon lo OP m t r a s f rnedlwn should never be made foflow~ngme admineffect ve an0 snor o conllnLe tnroJgn the t me of InIecI on lsfratlon of Msapressors, slnce they strongly potentiate neuand lor 24 norrs after n ecr on Ant nnstam nes s h o ~d OP rologic effects. aam n srerea unn n 30 mtnrles of me wntiast med Lm n erIn patients with subarachnold hemorrhage. a rare assaclallon Recent reports nd.catetnat sJcn pre-trealmpnl does tlon between wntrast admlnlstratlon and cllnlcal deteriorano1 Prevenl SerlOJs .fe-threaten ng reacl ons or1 may tlon, lncludlng convulslons and death, has been reported. redJce bom Inenr ncdence an0 sever fl A Separale syrmge Theretore, adminlstratlon of mfravascular lodinated wntrast should w rsed tor mese mcrhons media In these panents should be undertaken wim cauhon Genera anesmesa may oe ao.cateo n tne performance of A deitnite rrskexrsfs rn the use oi~nfravascularcontrasf some proreaLres n seeneo pabents nowever a n gner nc apents in patients who are lorown lo have mull~plemyeloma. Oence of aoverse reart on8 nas oeen leporleo n tnese In such Instances anuria has developed, resulting in progrespatlents an0 rnay w annnLtaDle to me nab8 IW ol me panen! slve ureme, renal failure and eventually death. Although neito ~denntyLntowaro rymploms or lo me hypotens.ve enect ther the contrast agent nor dehydration has separately 01 anestnes a wnlcn can prolong the cnrrr allon tome an0 proved to be the cause of anuria In myeloma. ~t has been ncreasefne Orral on of COntaC of tne contrast agent speculated that the combmation of both may be a causative Anq ograpny snoJlo oe avoloed Hnenerer poss o.e n tactor The rlsk In myelomatous patients is not a contraindlPalents mtn nomocystnrra oeca~seof Ine r sr of norcng cation to the procedure. however, partial dehydration in the thromboslsand embolism preparation of these patients for the examination is not recommended since this may predispose to precipitation of PRECAUTIONS FOR myeloma protein In the repal tubules. No form of therapy. including dialysis. has been successful in reversing the SPECIFIC PROCEDURES effect. Myeloma, wh~choccurs most commonly in persons Pediatric Angmcdrdrography It is advisable to montor for over 40, should be wnsldered before insb'tuting intravascular ECG and vital signs changes throughout the procedure. administrationof contrast agents. When large lndivldual doses are administered. Suffic~ent Admrnislrabon 01 radiopaque mafenah to p a m t s known time shouldbe allowed for any observed changes to return to or suspected lo have pheochromocyfoma should be peror near baseline prior to making the next injection. formed with exireme caution. If, in the opinion of the physiCauhon should be used when maklng nght heart Injections cian, the posslble b e n m of such procedures outweigh the In patlents wlth pulmonary hypertension or incipient heart fallure, since this may lead to increased right slde pressures mnsldered risks, the procedures may be performed, however, the amount of radiopaque medium injected should be wlth subsequent bradycardia and systemic hypotension. kept to an absolute minimum. The blood pressure should be Panentswith pulmonary diseasepresentaddihonal nsks. assessed throughout the procedure, and measures for treatCaution is advlsed In cyanotic infants since apnea. bradycardia. other arrhythm~asand a tendency to acldosls ment of a hypeflensivecrisis should be available. are more likely to occur Since intravascular administration of contrast medla may promote sickling in individuals who are homozygous for Since infants are more likely to respond wth convulsions Sickle cell disease, fluid restriction IS not advlsed. than are adults. the amount of total dosage is of part~cular In pabents wlth advanced renal disease. lodlnated wnlrast mportance Repealed n.ect ons are nazaroors In ~nlanls wghlng less man 7 kg part c ~ a r i ywnen me% nfanls nave media should be used wkh caution and only when the need pre-ex,mnp mmprom.sw rtgnl heart f ~ n on n or oblterarea for the examination dictates, slnce excretion of the medium may be impaired. Patlents with combined renal and hepatlc disease, those with Severe hypertension or wngesbve heart %lect,/e Corondry Arlenograpny *In or u,rnoot IPH "enhllure and recent renal transplant recipmts present an addirr,cumgrapnf DLrlng I ~ dam Pn stratron 01 arge doses of ..-. . .. rlWABRlX wntnLoJs monnor ng of vlal s gns s oesrao e Renal fallure has been reported In patients with llver dyrCam on IS advoseo n Ine adm n stranon of arge no Lmes to luncbon who were given an orai cholecystograph~cagent folpanents wth ncpent nean f a ~ l ~ m r e ~ s ofe me poss~blm, lowed by an intravascular iodinated radiopaque agent and of aggraval ng the pre-ex sllnp cono8tfion rlypolens.on s n o ~ l doe correcteo prompt y s nce Imay r e s ~Itn sertobs also in patients with occult renal disease, notably diabetics and hypertensives. In these classes of patients there should arrhythmias. be no fluid restriction and every attempt made to maintaln Special care regarding dosage should be observed In normal hydration prior to wntrast med~uminjection, since patients with right ventricular fallure, pulmonary hyperdehydratlon is the slngle most important factor ~nfluencing tension, or stenotlc pulmonary vascular beds because of hemodynamic changes which may occur after Inlection mto further renal impairment. Caution should be exerclsed In performing contrast the nght heart outflow tract. medium studles In patlents with endotoxemla and/or those Peripheral Arferiography, Moderate decreases In blood pressure occur frequently w~thintra-arter~al(brachial) injecwith elevated body temperatures. Repom of thyroid storm occurring followlng the intravas- bOnS Th~schange IS usually translent and requlres no treatment: however, the blood pressure should be mon~toredfor cular use of iodlnated radiopaque agents In patients with approximatelyten mlnutesfollowing injechon. hyperthyrodism or with an autonomously functioning thyroid Extreme cautlon during injection of the contrast agent IS nodule, suggest that thls additional r ~ s kbe evaluated before necessary to avoid extravasation and fluoroscopy la recomuse of this drug, Iodine-containingwntrast agents may aker mended Thls 1s especially important m patlents with severe the results of thyrold funct~ontests which depend on lodlne estimation,e.g.. PBI, and may also affect results of radioactive arterial dlsease CerebralAngiogwhy: Cerebral anglography should be periodine uptake studles. Such tests, if indicated. should be performed with speclai caution in patlentswith advanced artenoformed prior to theadmln~strat~on of this preparation Sclerosis. severe hypertension, cardlac decompensat~on. PRECAUTIONS senil~ty,r m n t cerebralthrombos~sorembolsm, and migraine Dlagnostlc procedures which Involve the use of lodlnated intra-Arfer~alD ~ g ~ tSubtraclron al Angrography The rlsks lnfravascularcontrast agents should be carrled but under the assoclated with IA-DSA are those usuallv attendant wlth direchon of personnel sklled and experlend in the particucatheter procedures Follow~ngthe procedure gentle preslar procedure to be performed. All procedures utllizlng sure hemostasls IS requlred, followed by observat~onand contrast media carry a definite rcsk of producing adverse lmmoblllzatlon of the llmb for several hours to prevent reactions While most reactlonsare minor, life-threatening hemorrhage from the ste of artenal puncture Each mllllliter of HEXABRIX contains 393 mg of ioxaglate meglumine, 196 mg of loxaglate sodium and 0.10 mg edetate Cdlaum disodium as a stabilizer The solution wntains 3.48 mg (0.15 mEq) sodium in each milliliter and provides 32% (320 mUmL) organicallybound iodine
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Patlent motlon. lncludlng respration and swallowing, can result In m~sreg~stration leading to image degradation and non-diagnosticstudies intravenous Digital Sublraclion Angrography, The risks associated wim IV-DSA include those usually attendant with catheter proceduresand indude intramural injections, vessel dissection and tissue extravasatlon. The potentlal rlsk IS reduced when small test lnlectlons of contrast med~umare made under fluoroswpic observation to insure that the caneter tip is prow* positioned and, in the case of penpheral olacement that the vein is of adeouah. size Patent mot on I n c l ~ ong res0ni;oiind seal ow ng can resr t n m#sreglslral.on Pa0 np lo mape degradallon an0 non-oaonosh~ stud * -~ - - - PP ~Peripheral Venography: Speclal care is requlred when venography IS performed In patients wlfh Suspected thrombosis, phlebitis. severe ischemic disease, local Infection M a totally obslructedvenous system Extreme cautlon during injection of wntrast media IS necessary to avoid extravasatlon and fluoroscopy is recommended. Thls IS espdally Important In patients with severe arterial or venous dlsease. Excretory urography: Infants and small children should not have any fluid restrictions prior to excretory urography (See WARNINGS and PRECAUTIONS wncerning preparatory dehvdratlonI ionlrasr ~nhancemenllnBod! Compufea Tomograpnf Panent cooperal on s essentlai smce patent monon nc LOno resprat on can marrealy afIW mage qLany The ~ s ofe an ntrauasrr ar contrast m e d ~ r mcan obscLre tLmors n patents Jndergo np CT evd~aton of Ine aver resLmng m a fa SP negar ve ownos s Dynamc CT scann no e Uv p r m OJre of cno ce lor ma lpnant trmor ennancement Annrograpnf Slr+t asept c tecnn que s reqr reo to pre rent me (ntrooLcbon01 nlecnon nroroscup c wntrol snoL o ne Lseo to n s ~ r eproper nsoodct on of the need e mlo tne Synob a space an0 prevent extracaps~arnlecnon Asp ranon of excessive synovialfluid will reduce the pain on injection and prevent the dtlution of the contrast agent. It G Important mat unduepressurenot beexerted during theinjecton. Hvslerosalpingography' Caution should be exerclsed In PatlentS suspected of havlng cervical or tubal carcinoma to avotd possible spread of the lesion by the prwedure. Delayed onset of pain and fever (1-2 days) may be lndlcatiie of pelvic ~
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Cdroncgenes8s Mo1agenes.s lmmrmenf 01 Fennhry ho ong lerm an ma stJo#esnave been perlormed lo eva jate carcnopen c polenta However anmal studes srggest mat I n s Orlg s not mutagen c and ooes not affect l e r l ~ l ~ #n ty males or females. Pregnancy Category B: Reproductlon studies have been performed in rats and rabblts at doses up to two tlmes the maximum adult human dose and have revealed no evidence of impalred fertblhty or harm to the fetus due to HEXABRIX. There are, however, no adequate and well wntrolled stud~es in pregnant women. Because anlmal reproduction studies are not always predictiveof human response. this drug should be used dunng pregnancy only if clearly needed. Nunrng Mothers: loxaglate salts are excreted unchanged In human mtlk. Because of the wtential for adverse effects In nurslng Infants, bottle feedings should be substituted for breast feedings for 24 hours follow~ngthe administration of 0 1 sdrug. Pediatrlc Use: Safety and effectiveness In chlldren has been established in pedlatrlc angiocardiography and intravenous excretory urography Data have not been submitted to Support the safety and effectiveness of HEXABRIX in any other lndicabon. (Precautions for speciflc procedures receive comment under that procedure.)
ADVERSE REACTIONS Adverse reac[.ons ro n ectab e conlrasl mema tall Into WO categornes cnemolox c rearnoons and d oryeratr reactlons CnemOtox c reacl ons resL t from the phys ochem~cal Properl~esot tne contrasl me0 a. the oose an0 me speed of n1ect8on A hemooynam c o slrrbances an0 nlurles to organs or resse s pertdsed by the conlrast me0 Jrn are nctuoed In In s category Id osyncrattc reacllons nc ude a other reactnons Tney o c c ~more t IreaLenIty n panenrs 20 to 40 years o a d o r w crar c reactions may or nay not be depenoent on the Oose nectm, the sceeo ol n~echon,me mooe ot n,W.on an0 me raa.oglaph#c PrOCeOLre 0 Osyncrat creacllons are s ~ o o. * oeo nlo m nor. ~ntermedate an0 severe Tne mmor leactoons are self- mreo an0 of snort dLrat on the severe reactions are Ilfe-threatening and treatment is urgent and mandatow, NOTE: NOI all of the following adverse reactlons have been reported with HWABRIX. Because HEXABRIX is an iodinated intravascularwntrast agent, all of the side effecls and t o x ~ c ity associated wth agents of this dass are thmrebcally posslble, and this should be borne In m ~ n dwhen HWABRIX IS admlnlstered. Severe. Ilfe-threatenmg anaphylactrld reactlons, mostly of cardiovascular orlgln, have occurred followlng the adminirtration of HEXABRIX as well as other lodine-containing contrast aoents Most deaths occur durina iniectlon or 5 to 10 mlnutei later: the maln feature being cirdiic arrest wth cardlovascular disease as the maln aggravating factor Isolated reports of hypotenslve collapse and shock are found in the Ilterature. Based upon clinical literature, reported deaths from the admln~strationof wnventional lodlnated contrast agents range from 6.6 per 1 million (0 Wffipercent) to 1 in t0,WO patients(0.01 percent). Regardless of the contrast agent employed, the overall estimated incidence of serlous adverse reactlons IS h~gher
mtn coronary artenograpny Inan m omer proeeaLres Car 0 aC oecompensatlon ser8ous arrnythm8as or myocarola lschem a or nfarctlon may occur d~rnngcoronary arterwg raohvand - , eft wnh - n~ - Dnrrnhv ----, The most treqoenl adverse reanlons are nabsea vom8nnp lac a1 flusn an0 a tee Ing of oody warmm These are Ls.alh, of or et orrat on In aoub.e.bm nd clnn#caltrais rlEXABRIX plodrceo less o scomfort Jpon nlect on (paan an0 heat) when wmparw to vanon omer mnhast agents Other reac .. ....
---
Hvpersensmnrv ~acl$ns Derma man festanons of ~n . car a wltn or untnout PILIIJS erytnema and macJ opapJ ar rasn Dry moan Sweat ng Con Lncl va symploms Facla per pneral an0 anglonedrot c edema Symptoms related lo Ihe respiratory system Inc doe sneezlng nasal stufftness coughing, choking. dyspnea, chest tightness and wheezing. whlch may be initial manifestationsof more severe and infrequent reactlons Including asthmaticattack, laryngospasm and bronchospasm with or without edema, pulmonary edema. apnea and cyanosis. Rarely, mese allergs-type reactions can progress Into anaphylaxis w ~ t hloss of conscious. ness, wma, severe cardlovascular dimdxnces, and death Cadovascutar reactions- Generalized vasodilation, HushIng and venospasm. Occasionally thrombosis or. rarely, thrombophlebitis. Extremely rare cases of disseminated intravascular coagulatlon resulting in death have been reported. Severe cardlovascular responses lndude rare cases of hypotensive shock, coronary Insufficiency, cardiac anhythmk, fibrillation and arrest. These severe reactons are usually reversible with prompt and appropriate management: however,fatalities have occurred. Technique reactmnc Extravasation w ~ t hburnlng paln, hematomas, ecchymosis and tissue necrosis, vascular COnStrlCtlOn due to injection rate, thrombosis and thrombophleb~l~s. Ne~roiogrcalreacbons: Spasm, convulsions, aphasia. syncope, paresis, paralysis resulting from spinal w r d injury and pathology associated wlth the syndrome of transverse myelitis, visual field losses whlch are usually transient but may be permanent, m and death. Mher reacflons. Headache, lrernbhng, shaking, chills without fever, hyperthermla and lightheadedness. Temporary renal shutdown or m e r nephmpm. Pediatric ang~ocard~ography has been complicated by intramural lnjectlon wlth marked adverse effects on cardiac functlon. Durlng selective coronary arteriography with or wlthout left ventrlculography, patients may have clinically insignlfcant ECG changes The following adverse effects have occurred In wnjunction with the administration of lodinated intravascular contrast agents for this procedure, hypotenslon, shock, anginal pain. myocardial infarctlon. cardlac arrhythmias (bradycardia, ventricular tachycardia, ventricular fibrlllatlon) and card'ac arrest. Fatalities have been reported. COmpllcatlOns to the procedure include dissection of coronary arteries. dislodgement of atheromatous plaques. perforatlon. hemorrhage and thrombosis. Following peripheral arterlography, hemorrhage and thrombosis have occurred at the puncture sce of the percutaneous injection Brachlal plexus injury has been reported following axillaryartery injection. The malor causes of cerebral arterlographlc adverse reactlons appear to be repeated inject~onsof the contrast of doses higher than those reammaterial. adm~n~snahon mended, the presence of occlusive atherosclerotic vascular dlsease and the melhod and technique of injecbon. Adverse reactlons are normally mild and transient. A feellng of warmth in the face and neck is frequently experienced. Infrequently, a more severe burning discomfort is observed. Transient visual hallucinations have been reported. Serious neurolog~calreactions that have been assoclared w ~ t hcerebral anglography and not listed under Adverse React~ons Include stroke. amnesiaand respiratorvdiffrculties Vrsual field defects with anopsla and reversible neurological deficit lasting from 24 hours to 48 hours have been reported. Confusion, d~sorlentationwith halluc~natlon,and absence of vision sometimes lasting for one week have also been reponed Car0 ovascular react ons mat may ormr wrm some heqlency are bradywa,a an0 elmel an Increase or decrease In SySlem c blooo pressure The blood pressure change s rrans en1 an0 usua ly r e u ~res no rrearmenr Artnrograpny may InoJce a n t paln or 0 scomfort a h ch s usua y mnlo n o Irans~enlbm oaaslonally may w severe an0 persst for 2410 48 noLrs lo ow ng Ine proced~reEft~slonrepL r np asp ratlon may occur In pat ents wnth rnermatolo arthrrls Fever and pan cramptng an0 tenderness of tne aboomen nave been reportedfo lowlng hysterosa p ngography
OVERDOSAGE OYeroosageS rnay o c c ~ rThe aowrse eftens of overoosage are late-threatenmgand affect manly me prlmonary an0 card~ovasc~lar systems The symptomr may nc Jde cyanos.s. bradycardla, acidosis, pulmonary hernormage, wnvulsions, coma and cardlac arrest. Treatment of an overdose IS directed toward the support of all vital functions and prompt ~nStiMiOnof symptomatictherapy. loxwlate falls are diatyzabk The intravenous LO50 values of HEXABRIX (In grams of ~od~neiklogram body welght) were 11.2 g/kg In mlce, > 8 g/kg In rats. x . 4 glkg In rabblts and > 10 2 g/kg in dogs.
DOSAGE AND ADMINISTRATION Details on dosage are provlded in the package insert. CONSULTFUUPACKAGEiNSERTBEFOREUSE. Revised September 1993
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PUBLICATION INFORMATION FOR AUTHORS Continued
Original writings will be accepted only with the understanding that they are contributed solely to JVIR. Manuscripts should be typewritten and double- or preferably triple-spaced (all pages) on only one side of the paper with at least 3-cm margins. If the manuscript is produced using a dot matrix printer, appropriate steps should be taken to assure legibility (eg, printers could be set in the double-strike mode). Each manuscript component should begin on a new page in this order: Title page, Abstract, Text, Acknowledgments, References, Tables (each on a separate page), and Captions for illustrations. The title page and abstract page should not be numbered. Sequential numbering should begin with the Introduction. Four copies of the manuscript and four complete sets of mounted figures should be submitted. Because accepted manuscripts will not be returned, the author should retain a copy. Receipt of each manuscript is acknowledged; please allow 10-15 days from the time you mailed the manuscript for receipt of an acknowledgment. Because JVIR is now edited electronicallv. authors of accepted papers are required to submit the&revised manuscri~ts on com~uter diskettes in addition to hard copy. ~i&-densityk1/4-inch diskettes are preferred, but high-density 3l/z-inch diskettes may be submitted. Personal computer files in WordPerfect 4.2 or later are preferred, but other word processing programs-Microsoft Word for PC or Mac or WordPerfect for Macare acceptable. Use minimal formatting with all programs and indicate which program was used. Files prepared in any other word processing program should be saved unformatted in text only (ASCII), and the program used should be indicated. Label diskettes with name and manuscript number. The entire article should be submitted as a single text file, with the elements in the standard order: Title Page, Abstract, Text, Acknowledgments,References, Captions, Tables. Only the final version of the manuscript should be on the submitted disk. Leave text ragged right (nojustification). IMF'ORTANT: Do not use the table function of your word processor to create tables. Also, do not use the space bar in tables. Use tabs to separate columns and hard returns to separate rows. Do not use centering tabs or other codes for centering anywhere in manuscript. Insert only one space after punctuation marks. Do not use embedded endnotes to create reference lists or for figure and table citations. As always, double-space your manuscript (including references and tables).
TITLE PAGE This page should include: (1)the full title of the manuscript; (2)the first names, middle initials, last names, and degrees of all authors; (3) the name and street address (not P.O. box) of the institution from which the work originated; and (4) the complete name, address, zip code, telephone number, and Fax number of the corresponding author. In the event that a manuscript is identified on its title page or in its content as having emanated from a particular institution, it will be assumed that the requisite approval of that institution has been obtained by the authors. If the paper has been presented
at an SCVIR meeting or has been accepted for presentation at an SCVIR meeting, a statement to that effect including the year of presentation should be provided at the bottom of the title page. A blind title page (without the author names) should be included with each copy of the manuscript for use in the review process.
ABSTRACT Abstracts are required for all major papers. Technical notes, case reports and Interventional Radiology Rounds have no abstract. The abstract should be no longer than 1and one-half type written pages (approximately 150 words) and should be organized into four paragraphs.
PURPOSE: Outline the goal or objective of the manuscript including the specific hypothesis under examination. The purpose should also be reflected in the title of the manuscript. MATERIALS AND METHODS: Briefly and succinctly describe the experimental methods, including what was done and how the data were collected and analyzed. RESULTS: Findings should be presented here. What observations were made? Include as much specific data as possible including P values and other indicators of statistical significance. CONCLUSIONS: The conclusions should flow directly and logically from the information presented in the abstract. Emphasize here what you want the reader to retain as the major conclusion of your study. NOTE: Unstructured abstracts may be used for review articles, including Partners in Patient Care.
KEY WORDS Below the abstract, three to six key words derived from the RSNA Index to Imaging Literature should be listed. For case reports and technical notes (no abstract required) the key words should be on a separate page. The key words will assist the indexers who must classify the paper under specific subject headings.
TEXT The text of a clinical or laboratory manuscript contains a series of sections that follow the title page and abstract. The headings of these sections are Introduction, Methods, Results, and Discussion. Lengthy papers may require subheadings within some sections to clarify their content.
Introduction: This section should (1)adequately but not extensively (ie, using strictly pertinent references only) describe the background information, experience, and literature leading up to the present study, and (2) clearly state the purpose of the study. Methods: Selectionof animal or human subjects should be described clearly. Details of materials (including manufacturer's name and location [city and state] in parentheses) and methods should be presented in sufficient detail
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SILICONEW I N G ND REINFORCED EXTENSION For more information, contact your ldca 'ook Representative or call 1-800-457-45 '* "*, -, ,* -a, .,,> * ,:.*-; '?
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PUBLICATION INFORMATION FOR AUTHORS Continued to enable readers to reproduce the study. References should be made to established methods that have been published, with particular emphasis on those that are not well known. New or substantially modified methods should be described, supported with rationale, and critically evaluated for real and potential limitations. Numbers of observations and statistical significance of the methods should be reported where appropriate. Detailed statistical analyses and mathematical derivations may sometimes be suitably presented in one or more appendices. When methods are sufficiently complex to warrant partitioning into subheadings, the precise divisions should be carefully considered. In general, each division should be of ~ ~ c i eindependent n t importance that (1)separate observations or data points will be recorded for that subheading in the Results section, or (2) it requires separate treatment in the Discussion section of the manuscript. Manuscripts reporting research involving human subjects must include a statement in the Methods section indicating approval by the institutional review board and noting that informed consent was obtained from each patient. Manuscripts reporting research involving animals must include a statement in the Methods section that either the protocol was approved by the institutional animal care committee or that the animal care complied with the "Principles of Laboratory Animal Care" (formulated by the National Society for Medical Research) and the "Guide for the Care and Use of Laboratory Animals" (NIH Publication no. 80-23, revised 1985).
Results: All data and observations should be reported in logical sequence in the text, tables, and illustrations. Do not repeat in the text all the data in the tables and/or illustrations; summarize only important observations. Complex reports may require subheadings in the Results section. In general, these subsections parallel subsections of methods. Only data and observations relevant to the individual subsection should be included in each one. Repetition of results reported in other subsections should be avoided. Discussion: Emphasize the new and important aspects of the study and conclusions that follow from them. Do not repeat in detail the data given in the Results section. Include in the Discussion the implications of the findings and their limitations, and relate the observations to other relevant studies. Link the conclusions with the goals of the study, but avoid unqualified statements and conclusions not supported completely by the data. Avoid claiming priority and alluding to work that has not been completed. State new hypotheses when warranted, but clearly label them as such. Recommendations, when appropriate, may be included.
ACKNOWLEDGMENTS Acknowledgments should start on a new page following the end of the text. Authors are responsible for obtaining permission from persons acknowledged for reasons other than technical, secretarial, or financial support, because readers may infer an endorsement of the data and conclusions.
REFERENCES Number the references consecutively in the order in which they are first mentioned. The abbreviations used for periodicals cited in the references should follow the style of Index
Medicus. For journal articles, list surnames and initials of all authors when six or less, such as: 1. Graham DJ, Alexander JJ. The effects of thrombin on bovine aortic endothelial and smooth muscle cells. J Vasc Surg 1990; 11:307-313. When seven or more authors are listed, only the first three names need to be identified, followed by "et al," such as: 1. Patchell RA, Tibbs PA, Walsh JW, et al. Arandomized trial of surgery in the treatment of single metastases to the brain. N Engl J Med 1990; 322:494-500.
Abstracts, editorials, and letters to the editor should be noted as such. In the case of books, the authors of a chapter, title of the chapter, editor(s), title of the book, edition, city, publisher, year, and specific pages must be provided. 1. Brief DK, Brener BJ. Extraanatomic bypasses. In: Wilson SE, Veith FJ, Hobson RW, Williams RA, eds. Vascular surgery: principles and practice. New York: McGraw-Hill, 1987; 414-424.
Please be sure that all documentation is accurate.
TABLES Tables should be referred to in the text, numbered sequentially in Arabic numerals, and have a title. All abbreviations used in the table should be explained in a footnote. Tables should be presented in the style used in the Journal. No vertical lines or shading should be included. Avoid excessive use of horizontal lines within the table.
ILLUSTRATIONS Illustrations should be limited to those required to show the essential features described in the paper. Unretouched glossy prints no larger than 20 x 25 cm (8 x 10 in) are desirable. Prints to be combined into one cut, such as anteroposterior and lateral views, should be the same height to facilitate reproduction. A tissue or transparent overlay may be used to designate the significant points of the illustrations. Drawings and charts should be rendered professionally in India ink on white paper. All photographs and drawings must be numbered and the top indicated on the back. For protection against loss or damage, each figure should then be neatly attached to paper (one illustration per page) and the number and top should be reindicated on this page. For attachment, avoid using glue, staples, or corner mounts. Because it holds the illustration securely to the page without damage, we recommend Scotch Removable Magic Tape (3M, St Paul, MN). Please do not add letters or numbers to the face of the illustration to identify the figure (such as 1A or 1B).This will be done during the printing process. Arrows should not be placed on radiographs prior to photography for print production; they should be placed on the final print and should be removable. If arrows, letters, and numbers are added to prints, they must be of professional quality and must be removable.
PUBLICATION INFORMATION F( R AUTHORS Concluded Professional artist service is available to authors without charge. The desired additions may simply be indicated on tissue or a transparent overlay attached to the print. Illustrations become the property of SCVIR and will be stored for 2 years after publication. Illustrations will be returned only on receipt of a written request from the corresponding author. We suggest that authors make and retain a set of figures in addition to the four sets submitted to the Journal. Electronic publishing a t the RSNA Publications Department, coupled with new image scanning technology that improves halftone production, has created the opportunity for streamlining the publication process. At the same time, quality will be enhanced. As a result, authors will no longer routinely receive photoproofs of their images. As in the past, the Publications Department and the Editorial Office will be reponsible for image quality a t the proof stage and, most important, in the printed journal.
CAPTIONS FOR ILLUSTRATIONS A caption must be supplied for each illustration and should not duplicate text material. All figure captions should appear collectively on one or more pages separate from the text, and each caption should also appear below the corresponding illustration.
CASE REPORTS A N D TECHNICAL NOTES A case report is a short note describing an unusual problem or procedure of interest to interventional radiologists. A technical note is a short description of a new technique, a modification of a common technique, or a description of new equipment that pertains to interventional radiology. Case reports and technical notes are evaluated for publication in the Journal using different criteria than those used for major papers. Authors should indicate that they are writing a case report or technical note by using the format outlined below. Format: No abstract is provided. A brief introduction should explain the background and special interest of the case or technique. For case reports, no more than two cases should be described in detail. The discussion section should focus on why this particular case or technique is important. The relevance of the case or technique to interventional radiologists should be emphasized.
LETTERS T O THE EDITOR Letters to the Editor can be used to offer commentary on any material published in JVZR. Letters to the Editor may also be used to convey material of more general interest to vascular and interventional radiologists. Letters to the Editor require the same transfer of copyright agreement and financial interest disclosure as original manuscripts.
Format: Letters should be double- or triple-spaced on only one side of the paper with a t least 3-cm margins. The length should be limited to three pages including a maximum of four references. Only one figure can be submitted with a Letter to the Editor. Authorship should be limited to four individuals. Letters to the Editor are accepted a t the discretion of the editor.
BOOK REVIEWS Any person who would like to help in reviewing books forJVIR should contact: Arthur C. Waltman, MD Department of Radiology Massachusetts General Hospital 32 Fruit St Boston MA 02114
UNITS A N D ABBREVIATIONS Radiation measurements and laboratory values should be given in the International System of Units (SI)(resources:SI Units in Radiation Protection and Measurements, NCRP Report no. 82 [August 19851; "NowRead This: The SI Units Are Here,"JAMA 1986; 255:2329-2339).Blood pressure should still be reportedinmillimetersof mercwy.Abbreviationsmust be spelled out when &st used in the text, such as "superficial femoral artery (SFA)."Laboratory slang, clinical jargon, and uncommon abbreviations should be avoided. Discussion of previous literature and material presented must be restricted to the significant findings.
RIGHTS A N D PERMISSIONS Written permission must be granted by the publisher and author to-reproduce any previoisly published figures, and any such material must be clearly noted and its source given in the manuscript. A letter of perkission must accompany photographs of patients or health care personnel if they could possibly be recognized; otherwise, the eyes must be blocked out to prevent identification.
AUTHOR Authors must be certain that no manuscript on the same or similar material has been or will be submitted to another journal by themselves or others a t their institution before their work appears in JVIR. The submission by authors of similar material to advertising media must be indicated a t the time JVIR receives the manuscript.
I Publication Information I for Authors
Tlae Journal of Vascular and Interventional Radiology is published under the supervision of the Society of Cardiovascular and Interventional Radiology (SCVIR) and in collaboration with the Radiological Society of North America, Inc (RSNA). No responsibility is accepted by the Editor, the SCVIR, or the RSNA for opinions expressed by contributors. Neither the Editor nor the SCVIR nor the RSNA guarantees, warrants, or endorses any product or service advertised in this publication or described in its contents. Neither do they guarantee any claims made by the manufacturer(s) of such product(s) or service(s). JVIR is devoted to the timely publication of clinical and laboratory studies in the field of vascular and interventional radiology. The Journal publishes selected peer-reviewed papers presented a t the annual meeting of the SCVIR, as well as original articles from members and nonmembers of the SCVIR. Certain selected original JVIR articles of appropriate scope and importance may be republished in Radiology a t the discretion of the Editors and with the permission of the author(s). Likewise, certain papers published in Radiology may be republished in JVIR. In addition to these original clinical and laboratory papers, regular features of the Journal include (1)Critical Issues in Vascular and Interventional Radiology-articles of critical importance to those practicing vascular and intementional radiology. They may be invited papers or statements that issue from SCVIR committees, such as practice guidelines. They may be authored by vascular and interventional radiologists or by others. (2) Partners in Patient Care-articles of importance in the general care of patients undergoing vascular and interventional procedures. In general, authors for this section will represent nonradiology clinical disciplines. These may include gastroenterology, cardiology,vascular or general surgery, infectious diseases, urology, and others. (3)Interventional Radiology Rounds-articles that describe a unique or innovative intementional approach to a difficult case or group of cases. The article will be followed by a discussion by experts in vascular and intementional radiology and other related fields. Other regular features include Letters to the Editor, Book Reviews, and Abstracts of Current Literature. The instructions below conform with the Uniform Requirements for Manuscripts Submitted to Biomedical Journals (JA.MA 1993; 269:2282-2286). Once accepted, manuscripts are also subject to copyediting to conform to the Journal's standards. Manuscripts accepted become the property of the Journal of Vascular and Interventional Radiology and may not be published in whole or in part without the express written permission of the author(s) and the Journal. Permission to reproduce material published in the Journal of Vascular and Interventional Radiology must also be obtained from the Editor. Manuscripts should be addressed to: Gary J. Becker, MD-Editor, JVIR JVIR Editorial Office Miami Vascular Institute 8900 N Kendall Drive Miami, Florida 33176 (305) 598-5939 FAX (305) 270-3688
PUBLICATIONS STAFF Robert S. Bolan, PhD, SCVIR Executive Director and Business Manager Delmar J. Stauffer, RSNA Executive Director and Business Manager Cathy D. Mendelsohn, Managing Editor Thomas A. Shimala, Director of Advertising Roberta E. Arnold, Director of Publications Carol A. Douglas, Graphics and Production Manager Wayne K. Larsen, Production Estella Ramirez, Editorial Assistant Ann Blair, Operations Manager Stacey Jones, Schedule Coordinator
COPYRIGHT A N D EXCLUSIVE SUBMISSION The copyright agreement must accompany the initial submission of all manuscri~tsfor regular articles, case reports, editorials, commentaries, criticil issues papers, letters, and technical notes. All authors of any single composition must sign this agreement. In the case of officers or employees of the U.S. government, the SCVIR recognizes that works prepared as part of their official government duties are in the public domain, but they must still sign the copyright agreement.
FINANCIAL INTEREST Advances in the field of vascular and interventional radiology are intimately related to advances in imaging and catheter technology. It is both natural and common for investigators to initiate, stimulate, support, direct, analyze, create, modify, improve on, and implement these advances. It is also natural for such leading individuals to write original scientific manuscripts describing their work. Yet when authors of scientific papers have financial relationships with sponsoring companies or organizations about whose products or services they are reporting, a real or perceived conflict of interest may arise. Editors must be advised of such relationships, so that they may make a careful assessment of each situation. Therefore, all authors of original papers submitted to JVIR must complete the financial interest portion of the copyright agreement, then sign in the appropriate blank. Any author who, by completing the financial interest section of the JVIR copyright agreement, indicates that he1 she has a financial interest in a company or organization whose products or services are described in the manuscript, must submit a brief accompanying statement describing that relationship. This should be in the form of a short paragraph signed by the author. Only after careful consideration of this information can the Editor make an informed decision about the existence of a real or perceived conflict of interest. When, for a given author, the Editor determines that a situation of real or perceived conflict may exist, the author will be so identified with a footnote by hisher name on the first page of the published paper. --Continued
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and fatal reactions may occur wthout warnlng. and the rlsk must be weighed agalnst the beneflt of the procedure. A fully equipped emergency cart. or equivalent supplies and equipment, and personnel competent in recognlzlng and treating a6verse reactions of all types should always be avadable. If a Serious reaction should occur, immediately dlscont~nue administration. Since severe delayed reactions have been mown to OCCJr, emergeno facl In an0 compelem personCONTRAINDICATIONS ne s h o ~ l obe avallaole lor at leas1 30 to 60 m nJtes after HEXABRIX is contraindicated for use ~nmyelographp Refer adm#n#stnhon(See ADVERSE REACT ONS I to PRECAUTIONS concerning hypersenslBvity. HysterosalPreparatory dehydratlon 1s dangerous and may contribute PlngOgraphy should not be performed dunng the menstrual to acute renal fallure in infants. young children, the elderly, period: in pregnant patients: in patients with known infection patients with pre-existing renal insufficlency, patlents w ~ t h In any portion of the genital tract: or in patients in whom multiple myeloma, patients with advanced vascular dlsease cervlcal conization or curettage has been performed within and d~abeticpatients 30 days Arthmgraphy should not be performed 11idection is Acute renal fallure has been reported in diabetlc patients Presentin or neartheiolnt. wlth dlabetlc nephropathy and in susceptible non-diabettc Patients (often elderiv with ore-exlstlna renal dlseasel followWARNINGS lOnlC lodlnated contrast media inhibitblood enann~latmnm ins the administrationof iodinated conirast agents. Therefore, vrtro, more than nontonic mntrast ~ e d $ ~ l o i ~ m ' d & s ~ l i careful considerationof the potential risks should be given before performing this radiographicprocedure in these patients. prudent to avoid prolonged contact of blood with syringes Wntainino ionlc wntrast m M a Severe reactions to contrast media often resemble allera~c responses Thls has prompted the use of several provocaGe serious, rarely fatal, th&nboembol~c events causlng Preteshng methods none of wh~chcan be relled on to pred~ct myocardial infarction and stroke have been reported during severe reacflons No conclus~verelat~onsh~o between ?evere angiograph~cprocedures w ~ t hboth lonlc and nonlonlc contrast media Therefore. metictllnos .~.. ... intravxnllar ..... . ~ d m i n-.i d n - reactlons and antigen-antlbodyreactions 0; other m a i f e i t i tlons of allergy has been established. The possib~lityof non lecnn 4 ~ ISe n e m a r y part rL any our nq ang.ograph c procm~resto m nnm ze mromboemw tc events h ~ m e r o ~ s an idiosyncratic reactlon in patlents who have previously received a contrast medlum wlthout 111effect should always factors nc uomp length of proced~recatneler ano syrmge be mnsidered. Prior to the lnjechon of any wntrast medium, matend Lnoeriy~ng0 sease slate and wncomtanl meolcasons may WntnnLte lo me oeveopment of mromwemoo c Me patient should be questioned to obtain a medlcal h~story with emphasis on allergy and hypersensrtlvlty A poslt~vehae m r s For tnese reasons, me! c r OJS ang oprapn c tecnnlaues are reammenam ,nclud ng core anenton to g~lde- tory of bronchial asthma or allergy (Including food). a famlly hlstorv of allerov ~a orevious m a i o n or hvoersansihv~hto w re an0 m e t e r man#pulanon.~ s of e man loo systems a m a wnirast age; may mpry igreatirma" J;li Ils; Or mreeway stopmc*s Ireq~entcatheter fllsn ng m nepahiston, rnay be more accJrate man ore-lesnnp m preolcl nq r n zeo sa ne so ut ons and m nnmnznng tne engtn of me potentla for aacton. almougn not necessar y me severme proceorre The Jse of past c syr noes n place of glass ZI nges nas wen reportea lo oecrease o n note m nale me Q or m e of react.on n Ine no v oLa case A posnue n stor) of Ins m e ooes no1 ammtrar y contrano cate me 1.9 of a Ihblihood of s vilro clotting. m t r a s t agent wwn a oagnosr c p r m o r r e s M l g n t essenSerious or fatal reactions have beenassoctated with the tlal. OLI does ca l lor caulion [See ADVERSE REACTIONS I administranonof Iodine mntalnlng radlopaque med~a.II IS of Prophylacl ctherapy InC JO ng coltlcostero ds and ant ulmost importanceto be wmpletely prepared to treat any wnnlstamlnes s h o ~ l obe cons dereo lor palnents hno prosent trast medlum reachon. As wlth any WntraSt medam. senous neurolog~csequelae. w In aslrong a erglr n story aprev O L S reart#Ontoa contrast me0 Jm 01 a posll.ue pre.lesl smce n tnese pai8enls lncludlng permanent paralysis, can occur following cerebral the nodence of reactlon s h o to three tomes thal of Ine genarteriography, Selective splnal arterlography and arterlogran ooses of wrt wstero~dssno. o oe era ~ o p ~ a t l oAaeqLate Phy of vessels Supplying the splnal cord. The lniectlon of a SIaltPd eany enough pnor to contrast m e d m n,mon lo OP m t r a s f rnedlwn should never be made foflow~ngme admineffect ve an0 snor o conllnLe tnroJgn the t me of InIecI on lsfratlon of Msapressors, slnce they strongly potentiate neuand lor 24 norrs after n ecr on Ant nnstam nes s h o ~d OP rologic effects. aam n srerea unn n 30 mtnrles of me wntiast med Lm n erIn patients with subarachnold hemorrhage. a rare assaclallon Recent reports nd.catetnat sJcn pre-trealmpnl does tlon between wntrast admlnlstratlon and cllnlcal deteriorano1 Prevenl SerlOJs .fe-threaten ng reacl ons or1 may tlon, lncludlng convulslons and death, has been reported. redJce bom Inenr ncdence an0 sever fl A Separale syrmge Theretore, adminlstratlon of mfravascular lodinated wntrast should w rsed tor mese mcrhons media In these panents should be undertaken wim cauhon Genera anesmesa may oe ao.cateo n tne performance of A deitnite rrskexrsfs rn the use oi~nfravascularcontrasf some proreaLres n seeneo pabents nowever a n gner nc apents in patients who are lorown lo have mull~plemyeloma. Oence of aoverse reart on8 nas oeen leporleo n tnese In such Instances anuria has developed, resulting in progrespatlents an0 rnay w annnLtaDle to me nab8 IW ol me panen! slve ureme, renal failure and eventually death. Although neito ~denntyLntowaro rymploms or lo me hypotens.ve enect ther the contrast agent nor dehydration has separately 01 anestnes a wnlcn can prolong the cnrrr allon tome an0 proved to be the cause of anuria In myeloma. ~t has been ncreasefne Orral on of COntaC of tne contrast agent speculated that the combmation of both may be a causative Anq ograpny snoJlo oe avoloed Hnenerer poss o.e n tactor The rlsk In myelomatous patients is not a contraindlPalents mtn nomocystnrra oeca~seof Ine r sr of norcng cation to the procedure. however, partial dehydration in the thromboslsand embolism preparation of these patients for the examination is not recommended since this may predispose to precipitation of PRECAUTIONS FOR myeloma protein In the repal tubules. No form of therapy. including dialysis. has been successful in reversing the SPECIFIC PROCEDURES effect. Myeloma, wh~choccurs most commonly in persons Pediatric Angmcdrdrography It is advisable to montor for over 40, should be wnsldered before insb'tuting intravascular ECG and vital signs changes throughout the procedure. administrationof contrast agents. When large lndivldual doses are administered. Suffic~ent Admrnislrabon 01 radiopaque mafenah to p a m t s known time shouldbe allowed for any observed changes to return to or suspected lo have pheochromocyfoma should be peror near baseline prior to making the next injection. formed with exireme caution. If, in the opinion of the physiCauhon should be used when maklng nght heart Injections cian, the posslble b e n m of such procedures outweigh the In patlents wlth pulmonary hypertension or incipient heart fallure, since this may lead to increased right slde pressures mnsldered risks, the procedures may be performed, however, the amount of radiopaque medium injected should be wlth subsequent bradycardia and systemic hypotension. kept to an absolute minimum. The blood pressure should be Panentswith pulmonary diseasepresentaddihonal nsks. assessed throughout the procedure, and measures for treatCaution is advlsed In cyanotic infants since apnea. bradycardia. other arrhythm~asand a tendency to acldosls ment of a hypeflensivecrisis should be available. are more likely to occur Since intravascular administration of contrast medla may promote sickling in individuals who are homozygous for Since infants are more likely to respond wth convulsions Sickle cell disease, fluid restriction IS not advlsed. than are adults. the amount of total dosage is of part~cular In pabents wlth advanced renal disease. lodlnated wnlrast mportance Repealed n.ect ons are nazaroors In ~nlanls wghlng less man 7 kg part c ~ a r i ywnen me% nfanls nave media should be used wkh caution and only when the need pre-ex,mnp mmprom.sw rtgnl heart f ~ n on n or oblterarea for the examination dictates, slnce excretion of the medium may be impaired. Patlents with combined renal and hepatlc disease, those with Severe hypertension or wngesbve heart %lect,/e Corondry Arlenograpny *In or u,rnoot IPH "enhllure and recent renal transplant recipmts present an addirr,cumgrapnf DLrlng I ~ dam Pn stratron 01 arge doses of ..-. . .. rlWABRlX wntnLoJs monnor ng of vlal s gns s oesrao e Renal fallure has been reported In patients with llver dyrCam on IS advoseo n Ine adm n stranon of arge no Lmes to luncbon who were given an orai cholecystograph~cagent folpanents wth ncpent nean f a ~ l ~ m r e ~ s ofe me poss~blm, lowed by an intravascular iodinated radiopaque agent and of aggraval ng the pre-ex sllnp cono8tfion rlypolens.on s n o ~ l doe correcteo prompt y s nce Imay r e s ~Itn sertobs also in patients with occult renal disease, notably diabetics and hypertensives. In these classes of patients there should arrhythmias. be no fluid restriction and every attempt made to maintaln Special care regarding dosage should be observed In normal hydration prior to wntrast med~uminjection, since patients with right ventricular fallure, pulmonary hyperdehydratlon is the slngle most important factor ~nfluencing tension, or stenotlc pulmonary vascular beds because of hemodynamic changes which may occur after Inlection mto further renal impairment. Caution should be exerclsed In performing contrast the nght heart outflow tract. medium studles In patlents with endotoxemla and/or those Peripheral Arferiography, Moderate decreases In blood pressure occur frequently w~thintra-arter~al(brachial) injecwith elevated body temperatures. Repom of thyroid storm occurring followlng the intravas- bOnS Th~schange IS usually translent and requlres no treatment: however, the blood pressure should be mon~toredfor cular use of iodlnated radiopaque agents In patients with approximatelyten mlnutesfollowing injechon. hyperthyrodism or with an autonomously functioning thyroid Extreme cautlon during injection of the contrast agent IS nodule, suggest that thls additional r ~ s kbe evaluated before necessary to avoid extravasation and fluoroscopy la recomuse of this drug, Iodine-containingwntrast agents may aker mended Thls 1s especially important m patlents with severe the results of thyrold funct~ontests which depend on lodlne estimation,e.g.. PBI, and may also affect results of radioactive arterial dlsease CerebralAngiogwhy: Cerebral anglography should be periodine uptake studles. Such tests, if indicated. should be performed with speclai caution in patlentswith advanced artenoformed prior to theadmln~strat~on of this preparation Sclerosis. severe hypertension, cardlac decompensat~on. PRECAUTIONS senil~ty,r m n t cerebralthrombos~sorembolsm, and migraine Dlagnostlc procedures which Involve the use of lodlnated intra-Arfer~alD ~ g ~ tSubtraclron al Angrography The rlsks lnfravascularcontrast agents should be carrled but under the assoclated with IA-DSA are those usuallv attendant wlth direchon of personnel sklled and experlend in the particucatheter procedures Follow~ngthe procedure gentle preslar procedure to be performed. All procedures utllizlng sure hemostasls IS requlred, followed by observat~onand contrast media carry a definite rcsk of producing adverse lmmoblllzatlon of the llmb for several hours to prevent reactions While most reactlonsare minor, life-threatening hemorrhage from the ste of artenal puncture Each mllllliter of HEXABRIX contains 393 mg of ioxaglate meglumine, 196 mg of loxaglate sodium and 0.10 mg edetate Cdlaum disodium as a stabilizer The solution wntains 3.48 mg (0.15 mEq) sodium in each milliliter and provides 32% (320 mUmL) organicallybound iodine
i
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S;;hi
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Patlent motlon. lncludlng respration and swallowing, can result In m~sreg~stration leading to image degradation and non-diagnosticstudies intravenous Digital Sublraclion Angrography, The risks associated wim IV-DSA include those usually attendant with catheter proceduresand indude intramural injections, vessel dissection and tissue extravasatlon. The potentlal rlsk IS reduced when small test lnlectlons of contrast med~umare made under fluoroswpic observation to insure that the caneter tip is prow* positioned and, in the case of penpheral olacement that the vein is of adeouah. size Patent mot on I n c l ~ ong res0ni;oiind seal ow ng can resr t n m#sreglslral.on Pa0 np lo mape degradallon an0 non-oaonosh~ stud * -~ - - - PP ~Peripheral Venography: Speclal care is requlred when venography IS performed In patients wlfh Suspected thrombosis, phlebitis. severe ischemic disease, local Infection M a totally obslructedvenous system Extreme cautlon during injection of wntrast media IS necessary to avoid extravasatlon and fluoroscopy is recommended. Thls IS espdally Important In patients with severe arterial or venous dlsease. Excretory urography: Infants and small children should not have any fluid restrictions prior to excretory urography (See WARNINGS and PRECAUTIONS wncerning preparatory dehvdratlonI ionlrasr ~nhancemenllnBod! Compufea Tomograpnf Panent cooperal on s essentlai smce patent monon nc LOno resprat on can marrealy afIW mage qLany The ~ s ofe an ntrauasrr ar contrast m e d ~ r mcan obscLre tLmors n patents Jndergo np CT evd~aton of Ine aver resLmng m a fa SP negar ve ownos s Dynamc CT scann no e Uv p r m OJre of cno ce lor ma lpnant trmor ennancement Annrograpnf Slr+t asept c tecnn que s reqr reo to pre rent me (ntrooLcbon01 nlecnon nroroscup c wntrol snoL o ne Lseo to n s ~ r eproper nsoodct on of the need e mlo tne Synob a space an0 prevent extracaps~arnlecnon Asp ranon of excessive synovialfluid will reduce the pain on injection and prevent the dtlution of the contrast agent. It G Important mat unduepressurenot beexerted during theinjecton. Hvslerosalpingography' Caution should be exerclsed In PatlentS suspected of havlng cervical or tubal carcinoma to avotd possible spread of the lesion by the prwedure. Delayed onset of pain and fever (1-2 days) may be lndlcatiie of pelvic ~
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Cdroncgenes8s Mo1agenes.s lmmrmenf 01 Fennhry ho ong lerm an ma stJo#esnave been perlormed lo eva jate carcnopen c polenta However anmal studes srggest mat I n s Orlg s not mutagen c and ooes not affect l e r l ~ l ~ #n ty males or females. Pregnancy Category B: Reproductlon studies have been performed in rats and rabblts at doses up to two tlmes the maximum adult human dose and have revealed no evidence of impalred fertblhty or harm to the fetus due to HEXABRIX. There are, however, no adequate and well wntrolled stud~es in pregnant women. Because anlmal reproduction studies are not always predictiveof human response. this drug should be used dunng pregnancy only if clearly needed. Nunrng Mothers: loxaglate salts are excreted unchanged In human mtlk. Because of the wtential for adverse effects In nurslng Infants, bottle feedings should be substituted for breast feedings for 24 hours follow~ngthe administration of 0 1 sdrug. Pediatrlc Use: Safety and effectiveness In chlldren has been established in pedlatrlc angiocardiography and intravenous excretory urography Data have not been submitted to Support the safety and effectiveness of HEXABRIX in any other lndicabon. (Precautions for speciflc procedures receive comment under that procedure.)
ADVERSE REACTIONS Adverse reac[.ons ro n ectab e conlrasl mema tall Into WO categornes cnemolox c rearnoons and d oryeratr reactlons CnemOtox c reacl ons resL t from the phys ochem~cal Properl~esot tne contrasl me0 a. the oose an0 me speed of n1ect8on A hemooynam c o slrrbances an0 nlurles to organs or resse s pertdsed by the conlrast me0 Jrn are nctuoed In In s category Id osyncrattc reacllons nc ude a other reactnons Tney o c c ~more t IreaLenIty n panenrs 20 to 40 years o a d o r w crar c reactions may or nay not be depenoent on the Oose nectm, the sceeo ol n~echon,me mooe ot n,W.on an0 me raa.oglaph#c PrOCeOLre 0 Osyncrat creacllons are s ~ o o. * oeo nlo m nor. ~ntermedate an0 severe Tne mmor leactoons are self- mreo an0 of snort dLrat on the severe reactions are Ilfe-threatening and treatment is urgent and mandatow, NOTE: NOI all of the following adverse reactlons have been reported with HWABRIX. Because HEXABRIX is an iodinated intravascularwntrast agent, all of the side effecls and t o x ~ c ity associated wth agents of this dass are thmrebcally posslble, and this should be borne In m ~ n dwhen HWABRIX IS admlnlstered. Severe. Ilfe-threatenmg anaphylactrld reactlons, mostly of cardiovascular orlgln, have occurred followlng the adminirtration of HEXABRIX as well as other lodine-containing contrast aoents Most deaths occur durina iniectlon or 5 to 10 mlnutei later: the maln feature being cirdiic arrest wth cardlovascular disease as the maln aggravating factor Isolated reports of hypotenslve collapse and shock are found in the Ilterature. Based upon clinical literature, reported deaths from the admln~strationof wnventional lodlnated contrast agents range from 6.6 per 1 million (0 Wffipercent) to 1 in t0,WO patients(0.01 percent). Regardless of the contrast agent employed, the overall estimated incidence of serlous adverse reactlons IS h~gher
mtn coronary artenograpny Inan m omer proeeaLres Car 0 aC oecompensatlon ser8ous arrnythm8as or myocarola lschem a or nfarctlon may occur d~rnngcoronary arterwg raohvand - , eft wnh - n~ - Dnrrnhv ----, The most treqoenl adverse reanlons are nabsea vom8nnp lac a1 flusn an0 a tee Ing of oody warmm These are Ls.alh, of or et orrat on In aoub.e.bm nd clnn#caltrais rlEXABRIX plodrceo less o scomfort Jpon nlect on (paan an0 heat) when wmparw to vanon omer mnhast agents Other reac .. ....
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Hvpersensmnrv ~acl$ns Derma man festanons of ~n . car a wltn or untnout PILIIJS erytnema and macJ opapJ ar rasn Dry moan Sweat ng Con Lncl va symploms Facla per pneral an0 anglonedrot c edema Symptoms related lo Ihe respiratory system Inc doe sneezlng nasal stufftness coughing, choking. dyspnea, chest tightness and wheezing. whlch may be initial manifestationsof more severe and infrequent reactlons Including asthmaticattack, laryngospasm and bronchospasm with or without edema, pulmonary edema. apnea and cyanosis. Rarely, mese allergs-type reactions can progress Into anaphylaxis w ~ t hloss of conscious. ness, wma, severe cardlovascular dimdxnces, and death Cadovascutar reactions- Generalized vasodilation, HushIng and venospasm. Occasionally thrombosis or. rarely, thrombophlebitis. Extremely rare cases of disseminated intravascular coagulatlon resulting in death have been reported. Severe cardlovascular responses lndude rare cases of hypotensive shock, coronary Insufficiency, cardiac anhythmk, fibrillation and arrest. These severe reactons are usually reversible with prompt and appropriate management: however,fatalities have occurred. Technique reactmnc Extravasation w ~ t hburnlng paln, hematomas, ecchymosis and tissue necrosis, vascular COnStrlCtlOn due to injection rate, thrombosis and thrombophleb~l~s. Ne~roiogrcalreacbons: Spasm, convulsions, aphasia. syncope, paresis, paralysis resulting from spinal w r d injury and pathology associated wlth the syndrome of transverse myelitis, visual field losses whlch are usually transient but may be permanent, m and death. Mher reacflons. Headache, lrernbhng, shaking, chills without fever, hyperthermla and lightheadedness. Temporary renal shutdown or m e r nephmpm. Pediatric ang~ocard~ography has been complicated by intramural lnjectlon wlth marked adverse effects on cardiac functlon. Durlng selective coronary arteriography with or wlthout left ventrlculography, patients may have clinically insignlfcant ECG changes The following adverse effects have occurred In wnjunction with the administration of lodinated intravascular contrast agents for this procedure, hypotenslon, shock, anginal pain. myocardial infarctlon. cardlac arrhythmias (bradycardia, ventricular tachycardia, ventricular fibrlllatlon) and card'ac arrest. Fatalities have been reported. COmpllcatlOns to the procedure include dissection of coronary arteries. dislodgement of atheromatous plaques. perforatlon. hemorrhage and thrombosis. Following peripheral arterlography, hemorrhage and thrombosis have occurred at the puncture sce of the percutaneous injection Brachlal plexus injury has been reported following axillaryartery injection. The malor causes of cerebral arterlographlc adverse reactlons appear to be repeated inject~onsof the contrast of doses higher than those reammaterial. adm~n~snahon mended, the presence of occlusive atherosclerotic vascular dlsease and the melhod and technique of injecbon. Adverse reactlons are normally mild and transient. A feellng of warmth in the face and neck is frequently experienced. Infrequently, a more severe burning discomfort is observed. Transient visual hallucinations have been reported. Serious neurolog~calreactions that have been assoclared w ~ t hcerebral anglography and not listed under Adverse React~ons Include stroke. amnesiaand respiratorvdiffrculties Vrsual field defects with anopsla and reversible neurological deficit lasting from 24 hours to 48 hours have been reported. Confusion, d~sorlentationwith halluc~natlon,and absence of vision sometimes lasting for one week have also been reponed Car0 ovascular react ons mat may ormr wrm some heqlency are bradywa,a an0 elmel an Increase or decrease In SySlem c blooo pressure The blood pressure change s rrans en1 an0 usua ly r e u ~res no rrearmenr Artnrograpny may InoJce a n t paln or 0 scomfort a h ch s usua y mnlo n o Irans~enlbm oaaslonally may w severe an0 persst for 2410 48 noLrs lo ow ng Ine proced~reEft~slonrepL r np asp ratlon may occur In pat ents wnth rnermatolo arthrrls Fever and pan cramptng an0 tenderness of tne aboomen nave been reportedfo lowlng hysterosa p ngography
OVERDOSAGE OYeroosageS rnay o c c ~ rThe aowrse eftens of overoosage are late-threatenmgand affect manly me prlmonary an0 card~ovasc~lar systems The symptomr may nc Jde cyanos.s. bradycardla, acidosis, pulmonary hernormage, wnvulsions, coma and cardlac arrest. Treatment of an overdose IS directed toward the support of all vital functions and prompt ~nStiMiOnof symptomatictherapy. loxwlate falls are diatyzabk The intravenous LO50 values of HEXABRIX (In grams of ~od~neiklogram body welght) were 11.2 g/kg In mlce, > 8 g/kg In rats. x . 4 glkg In rabblts and > 10 2 g/kg in dogs.
DOSAGE AND ADMINISTRATION Details on dosage are provlded in the package insert. CONSULTFUUPACKAGEiNSERTBEFOREUSE. Revised September 1993
Malliickrodt Medical, Im. Mallinckrodt Radiology Division Post Oflice Box 5840 St. Louis, MO 63134
For orders, product information and medical assistance, call (800) 325-3688 01993 Mallinckrodt Medical, Inc.
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9/93
the optimum material for percutaneous drainage.
Large drain holes facilitate catheter patency and provide maximum drainage.
Thin wall construction provides a large inner lumen for maximum drainage.
"accordion" during insertion and permits easy guidewire passage for catheter exchange. GPTMGeneral-Purposecatheter NEPHRO-CATHTMNephrostomy catheter CHOLE-CATHTMBiliary catheter
TRU-FLOTMSump catheter
Questions? Please call us at 1-800-538-7374 or write to us at UreSil, L.P., 5418 W. Touhy Ave., Skokie, I1 60077 UreSil and Ureflex are registered trademarks of UreSil, L.P. CP, NEPHRO-CATH, CHOLE-CATH AND TRU-FLO are trademarks of UreSil, U.S. patent pending.
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PUBLICATION INFORMATION FOR AUTHORS Continued to enable readers to reproduce the study. References should be made to established methods that have been published, with particular emphasis on those that are not well known. New or substantially modified methods should be described, supported with rationale, and critically evaluated for real and potential limitations. Numbers of observations and statistical significance of the methods should be reported where appropriate. Detailed statistical analyses and mathematical derivations may sometimes be suitably presented in one or more appendices. When methods are sufficiently complex to warrant partitioning into subheadings, the precise divisions should be carefully considered. In general, each division should be of ~ ~ c i eindependent n t importance that (1)separate observations or data points will be recorded for that subheading in the Results section, or (2) it requires separate treatment in the Discussion section of the manuscript. Manuscripts reporting research involving human subjects must include a statement in the Methods section indicating approval by the institutional review board and noting that informed consent was obtained from each patient. Manuscripts reporting research involving animals must include a statement in the Methods section that either the protocol was approved by the institutional animal care committee or that the animal care complied with the "Principles of Laboratory Animal Care" (formulated by the National Society for Medical Research) and the "Guide for the Care and Use of Laboratory Animals" (NIH Publication no. 80-23, revised 1985).
Results: All data and observations should be reported in logical sequence in the text, tables, and illustrations. Do not repeat in the text all the data in the tables and/or illustrations; summarize only important observations. Complex reports may require subheadings in the Results section. In general, these subsections parallel subsections of methods. Only data and observations relevant to the individual subsection should be included in each one. Repetition of results reported in other subsections should be avoided. Discussion: Emphasize the new and important aspects of the study and conclusions that follow from them. Do not repeat in detail the data given in the Results section. Include in the Discussion the implications of the findings and their limitations, and relate the observations to other relevant studies. Link the conclusions with the goals of the study, but avoid unqualified statements and conclusions not supported completely by the data. Avoid claiming priority and alluding to work that has not been completed. State new hypotheses when warranted, but clearly label them as such. Recommendations, when appropriate, may be included.
ACKNOWLEDGMENTS Acknowledgments should start on a new page following the end of the text. Authors are responsible for obtaining permission from persons acknowledged for reasons other than technical, secretarial, or financial support, because readers may infer an endorsement of the data and conclusions.
REFERENCES Number the references consecutively in the order in which they are first mentioned. The abbreviations used for periodicals cited in the references should follow the style of Index
Medicus. For journal articles, list surnames and initials of all authors when six or less, such as: 1. Graham DJ, Alexander JJ. The effects of thrombin on bovine aortic endothelial and smooth muscle cells. J Vasc Surg 1990; 11:307-313. When seven or more authors are listed, only the first three names need to be identified, followed by "et al," such as: 1. Patchell RA, Tibbs PA, Walsh JW, et al. Arandomized trial of surgery in the treatment of single metastases to the brain. N Engl J Med 1990; 322:494-500.
Abstracts, editorials, and letters to the editor should be noted as such. In the case of books, the authors of a chapter, title of the chapter, editor(s), title of the book, edition, city, publisher, year, and specific pages must be provided. 1. Brief DK, Brener BJ. Extraanatomic bypasses. In: Wilson SE, Veith FJ, Hobson RW, Williams RA, eds. Vascular surgery: principles and practice. New York: McGraw-Hill, 1987; 414-424.
Please be sure that all documentation is accurate.
TABLES Tables should be referred to in the text, numbered sequentially in Arabic numerals, and have a title. All abbreviations used in the table should be explained in a footnote. Tables should be presented in the style used in the Journal. No vertical lines or shading should be included. Avoid excessive use of horizontal lines within the table.
ILLUSTRATIONS Illustrations should be limited to those required to show the essential features described in the paper. Unretouched glossy prints no larger than 20 x 25 cm (8 x 10 in) are desirable. Prints to be combined into one cut, such as anteroposterior and lateral views, should be the same height to facilitate reproduction. A tissue or transparent overlay may be used to designate the significant points of the illustrations. Drawings and charts should be rendered professionally in India ink on white paper. All photographs and drawings must be numbered and the top indicated on the back. For protection against loss or damage, each figure should then be neatly attached to paper (one illustration per page) and the number and top should be reindicated on this page. For attachment, avoid using glue, staples, or corner mounts. Because it holds the illustration securely to the page without damage, we recommend Scotch Removable Magic Tape (3M, St Paul, MN). Please do not add letters or numbers to the face of the illustration to identify the figure (such as 1A or 1B).This will be done during the printing process. Arrows should not be placed on radiographs prior to photography for print production; they should be placed on the final print and should be removable. If arrows, letters, and numbers are added to prints, they must be of professional quality and must be removable.
PUBLICATION INFORMATION F( R AUTHORS Concluded Professional artist service is available to authors without charge. The desired additions may simply be indicated on tissue or a transparent overlay attached to the print. Illustrations become the property of SCVIR and will be stored for 2 years after publication. Illustrations will be returned only on receipt of a written request from the corresponding author. We suggest that authors make and retain a set of figures in addition to the four sets submitted to the Journal. Electronic publishing a t the RSNA Publications Department, coupled with new image scanning technology that improves halftone production, has created the opportunity for streamlining the publication process. At the same time, quality will be enhanced. As a result, authors will no longer routinely receive photoproofs of their images. As in the past, the Publications Department and the Editorial Office will be reponsible for image quality a t the proof stage and, most important, in the printed journal.
CAPTIONS FOR ILLUSTRATIONS A caption must be supplied for each illustration and should not duplicate text material. All figure captions should appear collectively on one or more pages separate from the text, and each caption should also appear below the corresponding illustration.
CASE REPORTS A N D TECHNICAL NOTES A case report is a short note describing an unusual problem or procedure of interest to interventional radiologists. A technical note is a short description of a new technique, a modification of a common technique, or a description of new equipment that pertains to interventional radiology. Case reports and technical notes are evaluated for publication in the Journal using different criteria than those used for major papers. Authors should indicate that they are writing a case report or technical note by using the format outlined below. Format: No abstract is provided. A brief introduction should explain the background and special interest of the case or technique. For case reports, no more than two cases should be described in detail. The discussion section should focus on why this particular case or technique is important. The relevance of the case or technique to interventional radiologists should be emphasized.
LETTERS T O THE EDITOR Letters to the Editor can be used to offer commentary on any material published in JVZR. Letters to the Editor may also be used to convey material of more general interest to vascular and interventional radiologists. Letters to the Editor require the same transfer of copyright agreement and financial interest disclosure as original manuscripts.
Format: Letters should be double- or triple-spaced on only one side of the paper with a t least 3-cm margins. The length should be limited to three pages including a maximum of four references. Only one figure can be submitted with a Letter to the Editor. Authorship should be limited to four individuals. Letters to the Editor are accepted a t the discretion of the editor.
BOOK REVIEWS Any person who would like to help in reviewing books forJVIR should contact: Arthur C. Waltman, MD Department of Radiology Massachusetts General Hospital 32 Fruit St Boston MA 02114
UNITS A N D ABBREVIATIONS Radiation measurements and laboratory values should be given in the International System of Units (SI)(resources:SI Units in Radiation Protection and Measurements, NCRP Report no. 82 [August 19851; "NowRead This: The SI Units Are Here,"JAMA 1986; 255:2329-2339).Blood pressure should still be reportedinmillimetersof mercwy.Abbreviationsmust be spelled out when &st used in the text, such as "superficial femoral artery (SFA)."Laboratory slang, clinical jargon, and uncommon abbreviations should be avoided. Discussion of previous literature and material presented must be restricted to the significant findings.
RIGHTS A N D PERMISSIONS Written permission must be granted by the publisher and author to-reproduce any previoisly published figures, and any such material must be clearly noted and its source given in the manuscript. A letter of perkission must accompany photographs of patients or health care personnel if they could possibly be recognized; otherwise, the eyes must be blocked out to prevent identification.
AUTHOR Authors must be certain that no manuscript on the same or similar material has been or will be submitted to another journal by themselves or others a t their institution before their work appears in JVIR. The submission by authors of similar material to advertising media must be indicated a t the time JVIR receives the manuscript.