Vascular Disorders of the Upper Extremity (third revised edition)

Vascular Disorders of the Upper Extremity (third revised edition)

Book Reviews SECTION EDITOR: William C. Krupski, MD Vascular Disorders of the Upper Extremity (third revised edition) Herbert I. Machleder (ed.). Arm...

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Book Reviews SECTION EDITOR: William C. Krupski, MD

Vascular Disorders of the Upper Extremity (third revised edition) Herbert I. Machleder (ed.). Armonk, NY: Futura Publishing, 1998. ISBN: 0-87993-409-3. Pages: 528. Price: $98.00. Vascular Disorders of the Upper Extremity by Herb Machleder, MD, is an excellent book that represents a work in progress. The first edition appeared in 1983. Since that time there have been tremendous changes in the practice of vascular surgery and in the understanding and treatment of vascular diseases. Unlike multi-edited textbooks, Dr. Machleder has made significant contributions to this book with 6 out of 17 chapters. The book is divided into four parts: Part I on diagnosis, angiography and new imaging techniques; Part II on cumulative trauma disorders, including thoracic outlet syndromes; Part III on arteriovenous malformation and small vessel disease; and Part IV on upper extremity manifestations and systemic vascular diseases. The textbook is easy to read and is well illustrated with numerous black-and-white illustrations. Dr. Machleder has made steady improvements by building upon a logical approach to the evaluation of patients with upper extremity diseases and providing an update in relevant new technology. Since vascular problems of the upper extremity are relatively uncommon, standard surgical textbooks provide only a superficial approach because of space limitations. Thus, the primary importance of this book is that it deals solely with vascular problems of the upper extremity. Many chapters have been extensively revised and new chapters have been added. The chapters receiving the greatest attention include those written by Dr. Machleder himself and that by the group from Portland dealing with Raynaud’s and small-vessel diseases. A particularly important addition to the book is the section on cumulative trauma disorders and thoracic outlet compressions. Dr. Machleder’s writing is excellent in this section and provides insight into the thoracic outlet syndrome based on more than 17 years of experience. While his viewpoint in this area is particularly authoritative, it is nonetheless a singular one and is not balanced by opposing views. Neurogenic thoracic outlet is a contentious and controversial area that must be objectively studied. His viewpoints and those of the other authors should be balanced with a broader range of perspectives and a more objective appraisal of outcomes. And while Dr. Machleder’s chapters have been extensively revised, other chapters have been only modestly improved with the addition

of a few newer references and very little change in the actual text. Within the scope of vascular surgery there is no comparable text. This is an authoritative book that deals exclusively with vascular disorders of the upper extremity. The book provides a single-source text for specific problems that is easy to ready and understand. In addition, the textbook provides a thoughtful and studied approach into perplexing problems associated with cumulative trauma disorders and thoracic outlet compression. Thus, this book serves as a ready reference for a variety of physicians including vascular and general surgeons, as well as general internists and vascular medicine specialists. The book is highly recommended and well priced. William F. Oppat, MD William H. Pearce, MD

Cardiac Anesthesia (fourth edition) Joel A. Kaplan, David L. Reich, Steven N. Konstadt (eds.). Philadelphia, PA: W.B. Saunders, 1998. ISBN: 0-7216-7509-3. Pages: 1430. Price: $279.00. The fourth edition of Cardiac Anesthesia is a landmark one. It brings changes in both editors and content. The previous three editions of this classic reference text were edited by Dr. Kaplan alone while he was Chairman of the Department of Anesthesiology at Mt. Sinai Medical Center in New York. The latest edition adds two of his longstanding associates, Drs. Reich and Konstadt, CoDirectors of the Cardiac Anesthesiology Division at Mt. Sinai. In addition, the book was completed and went to press while Dr. Kaplan was moving to his new position as the Vice President for Health Affairs and Dean of the School of Medicine at the University of Louisville in Kentucky. As a contributor to both the third and fourth editions, as well as a reader of the first two editions while a resident and junior faculty member, I am of the opinion that the current text is not only the culmination of the editorial skills of Dr. Kaplan (and his publishers at W.B. Saunders) but also the maturation of cardiac anesthesiology as a sophisticated, complex, and critically important subspecialty of anesthesiology and perhaps, to an even greater degree, cardiac surgery and cardiology. The contributors are clearly a who’s who of contemporary cardiac anesthesia, with a diversity of clinicians, basic scientists, and even department chairs from most, if not all, of the major cardiac surgical centers in the U.S. and Canada. The book is divided into eight major groupings: preoperative assessment, physiology and molecular biology, monitoring, anesthetic pharmacology, management of cardiopulmonary bypass, postoperative care, and practice management. The addition of chapters in molecular biology and practice management/outcomes/economics emphasizes the maturation and changing scope of cardiac anesthesiology in its scope of basic (especially in receptor physiology and endothelial physiology) and clinical research (especially in perioperative outcomes). The former covers receptor physiology and the very topical issue of systemic inflammation, particularly in relation to the ad653

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verse effects of cardiopulmonary bypass. The latter covers managed care, cost containment, quality of life, and outcomes reporting, all of which have direct clinical relevance (despite the anesthesiologist’s relative lack of visibility in several of these high-profile outcomes). Although partly mentioned in several chapters, a major omission is the lack of a chapter on fast tracking, a pathway that has fundamentally and radically changed the practice of cardiac anesthesia. There are now numerous clinical studies on all aspects of fast tracking and unfortunately this edition (in preparation just prior to most of these publications) clearly has fallen short in this area. Another area that is covered somewhat better, although it too lacks a separate chapter, is the rapidly growing area of minimally invasive surgery. A few newer and important concepts in myocardial and coronary physiology, most notably myocardial preconditioning, stunning, and hibernation, are also omitted from direct consideration. The chapter on preoperative assessment is anomalous since its focus is exclusively on the cardiac patient undergoing noncardiac surgery, while the rest of the text is primarily on cardiac surgery (although thoracic aortic and assorted nonischemic, nonvalvular diseases are covered). Minor omissions and idiosyncrasies aside, the text does an admirable job in a state-of-the-art manner, covering the tools and drugs that anesthesiologists use on a daily basis for a wide range of cardiac procedures. Transesophageal echocardiography, a nearly routine tool in the heart room and a primary focus of teaching and research activities, is given a very comprehensive chapter with thorough and authoritative treatment (including color plates). There is an expanded focus on monitoring of the central nervous system and adverse effects of cardiopulmonary bypass (CPB) on the brain, “the last frontier” of clinical emphasis that anesthesiologists are contributing significant expertise to. Coagulation abnormalities and transfusion medicine are also covered admirably. Of course, anesthetic effects on the myocardium and circulation are covered in depth by many of the pioneers in the field, who address in particular the use of volatile agents, opioids, and sedatives. Given the size (and weight) of the text and its focus on basic concepts and physiology, the text is meaty reading for the beginning resident. However, there are many hours of reading and reference here for senior residents (in both anesthesia and surgery) as well as fellows and faculty. I constantly refer to this text as a starting point for teaching and research activities. In this field it has no competition as the definitive text, but given its continuing evolution and constant improvement, it clearly doesn’t take that position for granted. It belongs in every medical library of institutions where cardiac surgery is performed (and in most where it may not be). With the revolution in the Internet and multimedia (posing challenges for any paper textbook), as well as the addition of two new, younger experts in this field as co-editors, it will be very interesting to see what happens in the next edition in the new millennium. Martin J. London, MD

Instructions for Surgery Patients Steven G. Economou, Tasia S. Economou. Philadelphia, PA: W.B. Saunders, 1998. ISBN: 0-72167188-8. Pages: 744. Price: $69.00.

Surgeons often rely on hand-drawn diagrams to sketch out a procedure and usually proclaim a list of verbal instructions to their patients regarding their operation. Unfortunately, all too often, the surgeon-patient encounters are too brief, at least from the patient’s perspective. This book is intended to help surgeons communicate better with their patients, comprising information about more than 340 separate surgical and diagnostic procedures. The format of the book is well thought out. It is a softcover book with 8.5 × 11 pages that may be easily torn out (to make photocopies). Furthermore, the entire book has three-hole perforations so that the pages can be placed in a patient’s chart or a three-ring binder. A CDROM is included with the book for computer users to search for topics and print the appropriate instructions already provided in the book. Each subject is one or two pages long. The style is clear and the language is simple, informal English, avoiding technical jargon. One of the nicest features is the inclusion of over 400 black-andwhite illustrations to supplement the text. The chapters (or topics) cover a wide variety of surgical and diagnostic procedures and are arranged alphabetically. There are over 40 topics related to vascular surgery patients. Aortofemoral bypass includes general information about the disease process and anatomy, common signs and symptoms, diagnostic and treatment options, preoperative preparation, and postoperative care. Specific instructions are included about home care and a handy reminder is placed at the end of the page with information about what should prompt a call to the surgeon. Most chapters follow this same outline and in general, instructions are fairly broad. Other areas covered range from commonly performed operations such as carotid endarterectomy and dialysis shunts to the infrequent cases such as temporal artery biopsy and thoracic outlet syndrome. Also included are frequently performed diagnostic tests, such as ultrasound, CT scan, and MRI. Instructions for Surgery Patients is a very useful book for the busy practitioner and it would be interesting to get the patients’ perspective on it. The book is inclusive rather than exclusive, bridging the line between several surgical specialties (general surgery, gynecology, otolaryngology, etc.). Highly specialized or complex procedures, such as liver transplantation, were intentionally excluded. The authors relied on 70 contributors or consultants; all but 5 are from or affiliated with Rush Medical College. The instructions are broad enough to constitute a reasonable framework for surgeons to discuss the details of surgical and diagnostic procedures with their patients.

M. Ashraf Mansour, MD

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Minimally Invasive Cardiac Surgery Robbin G. Cohen, Michael J. Mack, James D. Fonger, Rodney J. Landreneau (eds.). St. Louis, MO: Quality Medical Publishing, 1998. ISBN 0-942219-79-1. Pages: 300. Price: $245.00. Following the lead of other surgical disciplines, cardiac surgery has now entered the arena of minimally invasive surgery. During the last three years there has been an explosion in surgical techniques as well as an increase in technology available to perform cardiac surgical operations through smaller incisions. This rapidly changing field is difficult to follow and confusing to many cardiac surgeons. Minimally Invasive Cardiac Surgery provides the reader with an excellent summary of the various techniques and technology that have emerged in the last few years. The book is edited by four of the leaders in the field. The chapters are written by a broad spectrum of authors with varying degrees of experience in this area. The chapters therefore vary a great deal in the style of writing and suffer to some degree from repetition of material covered in other chapters throughout the text. The authors, however, do provide very specific technical instructions, which will be extremely helpful to the surgeon unfamiliar with these operative techniques. The authors liberally share their anecdotal experiences of what has worked and what has not worked in their respective hands. The text is beautifully illustrated with color line drawings juxtaposed with operative photographs, making it very easy to understand the operative approaches. The reader should be cautioned, however, that the arena of minimally invasive cardiac surgery continues to evolve rapidly. A variety of new techniques have surfaced over the last three years, many of which have held great promise. Following the accumulation of sufficient experience, however, some of those techniques have been discarded. The reader must therefore be aware that a number of the techniques described in this text may be outdated in the near future. One such example is the Heartport system for the performance of cardiac operations. Although some centers have acquired a fairly large experience using the Heartport system, most programs nationwide have either shied away from it or abandoned it once tried. Recent disclosure in national publications such as The Wall Street Journal will likely discourage physicians and patients alike from use of the Heartport system. Since the Heartport system is discussed in more than one chapter of this text, it serves as an example of how quickly things may change. Among surgical procedures, cardiac surgical operations have arguably been studied in the most detail. The results are both safe and predictable. The field will no doubt continue to evolve and will certainly include minimally invasive techniques. Minimally Invasive Cardiac Surgery would be a fine addition to any cardiac surgeon’s library. Its contents represent what’s new in cardiac surgery. How many of the techniques included in this text will ultimately be incorporated into the surgical armory

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of all cardiac surgeons, however, has yet to be determined. David A. Fullerton, MD

Indications in Vascular and Endovascular Surgery R.M. Greenhalgh (ed.). Philadelphia, PA: W.B. Saunders, 1998. ISBN: 0-7020-2445-7. Pages: 475. Price: $125.00. This 475-page book, with chapters written by 106 authors, is a unique contribution that follows the first publication, which was done similarly 10 years ago under the title Indications in Vascular Surgery. This edition includes opinions regarding endovascular techniques as they have emerged for treatment of many vascular disease processes. The 37 chapters vary widely in detail, new information, and personal experience of the primary author. All of them are easy to read, have many fine photographs and drawings, and have rather complete sets of references that are nicely updated. Each chapter has an editorial comment at the end which can applaud the effort, ask additional questions of the author, or disagree with information contained in the chapter. These editorials vary in content as well. The first chapter is an excellent summary of the clinical use of the vascular laboratory. The next two chapters deal with the political nature of endovascular grafts and their regulation and future topics which are very timely. A plea is made to perform these procedures in trials only so that investigators might continue to gather data. The section on carotid disease contains six chapters. The highlight for me was the chapter “Should the type of carotid plaque determine the carotid procedure: conventional or endovascular?”, written by Biasi and Mingazzini. They demonstrate carotid plaque by using drawings, duplex scan images, and computer-generated pictures and show its varying morphology. This will certainly be important if carotid plaques are to be angioplastied or stented. The next section on renal artery stenosis is primarily a summary of the latest literature. The section Aortic Questions and Indications (11 chapters) discusses indications and experiences from utilizing many types of aortic stent grafts. The diagrams are very educational and the data up to date. The next section, Intermittent Claudication, is quite controversial and entertaining to read. Some new technologies—endoscopic femoropopliteal vein bypass, intravascular ultrasound, and superficial femoral artery stents—are presented in different chapters. In the following section, Distal Reconstruction Questions and Indications is complete yet reflects opinions of the primary authors with not much data comparison to alternative methods. The last section, Venous Questions and Indications, discusses three topics: “Do we know if duplex should be used for varicose vein surgery?”, “What are the indications for endoscopic perforator surgery?”, and “When and how should we unblock deep veins?”. All three chapters are nicely written, are complete with sum-

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maries of others’ data, and are complimented with excellent drawings and radiographs. This book is quite a potpourri of vascular indications, with opinions from many practitioners. It is reading for the learned vascular surgeon and not the novice, as many chapters present only one side of the story. It can serve as a recent reference text because of the complete references given by many of the authors. For this reader, it was fun to read the book and to formulate my own biases for or against those in print. I think other vascular surgeons will have a similar experience reading this book. Julie Ann Freischlag, MD

The Vulnerable Atherosclerotic Plaque: Understanding, Identification, and Modification (American Heart Association Monograph Series) Valentin Fuster (ed.). Armonk, NY: Futura Publishing, 1998. ISBN: 0-87993-406-9. Pages: 448. Price: $115.00. A new paradigm has taken hold in cardiovascular medicine. It was not long ago that the focus of cardiologists was on the hemodynamically significant lesion. Our diagnostic studies were directed toward identifying flowlimiting stenoses, and our therapies were targeted at relieving these obstructions. This strategy has served us fairly well in relieving the symptoms of coronary artery disease. However, this strategy has largely failed us in predicting who is at risk, and from which lesion. More importantly, there is little evidence that therapies directed toward relieving stenoses confer longevity upon our patients. The new paradigm is to focus on the nature, not the size, of the lesion. Accumulating evidence indicates that it is the so-called vulnerable plaque that is responsible for most myocardial infarctions and cardiovascular deaths. The vulnerable plaque is lipid-rich, with a thin, fibrous cap and a large necrotic core filled with lipid, cell debris, and thrombogenic agents such as tissue factor.1,2 Under the hemodynamic stresses of shear and tensile stress, these lesions rupture, releasing the thrombogenic constituents of the necrotic core, which induce thrombosis and sudden occlusion of the vessel. Typically, plaque rupture is preceded by an inflammation and undermining of the fibrous cap. Macrophages can be seen infiltrating into, and degrading, the fibrous cap.3,4 T cells collaborate in the sabotage by releasing cytokines, such as interferon gamma, which activate macrophage expression of collagenase.5 Alterations in endothelial biology overlying the lesions may contribute to this inflammatory process.6-9 The normal endothelium produces a panoply of paracrine factors (such as endothelium-derived nitric oxide) that cause vasodilation and inhibit platelet and leukocyte adherence. However, in the metabolic milieu of atherosclerosis, the vasoprotective mechanisms of the endothelium are attenuated, and the endothelium begins to express

adhesion molecules and chemokines that initiate the inflammatory process.10-12 These pathobiological mechanisms, and their consequences, are revealed in The Vulnerable Atherosclerotic Plaque: Understanding, Identification, and Modification, which has been edited by one of the pioneers in this emerging field of cardiovascular investigation. Dr. Valentin Fuster has assembled an impressive array of contributors, many of whom have made seminal contributions to this field. The book is in the monograph series of the American Heart Association (AHA) and has grown directly out of the work of the Vascular Lesions Committee of the American Heart Association. For the most part, the contributors elegantly present current concepts in the pathobiology of atherosclerosis. Included in this opus are thoughtful discussions of the determinants of plaque progression and instability; the role of the endothelium in vascular reactivity and remodeling; as well as the influence of hemodynamic and humoral forces on plaque biology. Furthermore, this treatise provides the latest information on new technologies to image plaque, including quantitative coronary angiography, intravascular ultrasonography, angioscopy, ultrafast computerized tomography, and magnetic resonance imaging. The promise of newer techniques is also discussed, including radioisotopic imaging, computerized tomography, and optical coherence tomography. A number of questions are thoughtfully raised and discussed. What causes plaque instability and thrombogenicity? What causes plaques to calcify, and does this process stabilize plaques? What is the role of inflammation, or infectious agents? Which of the current imaging techniques are most promising, in terms of differentiating the stable lesion (consisting largely of extracellular matrix) from the vulnerable plaque (with its necrotic core and thin fibrous cap). What is the role of vascular smooth muscle cell apoptosis, macrophage infiltration, and metalloproteinase activation? Although the book in general should be required reading for any student of this field, there is unevenness, with some disappointing chapters. In the chapter on aortic atherosclerosis, an outdated article on a questionable association between the use of coumadin and atheroembolism is uncritically cited. Later in the chapter, the author recommends surgery for highly mobile aortic thrombi, which seems odd, given the morbidity of aortic surgery and the fact that 70% of mobile aortic thrombi resolve spontaneously (as another contributor notes later in the book). More bad advice comes in the chapter on computerized tomography to detect coronary calcification. The author has such enthusiasm for the technique that he speculates that one may not need to treat asymptomatic hypercholesterolemic individuals with antilipid agents if their calcium score is low. This is a surprising statement given that many of the other contributors provide evidence that early atheromatous lesions may be at least as dangerous as highly calcified lesions. Moreover, there is abundant evidence from primary prevention trials that aggressive lipid modification reduces cardiovascular mortality and morbidity. By contrast, there is not a scintilla of

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evidence that patients with cardiovascular risk factors and low calcium scores will not benefit from lipid lowering. However, these are minor flaws in a gem of a book that should be read by any clinician or scientist with an interest in this area. The Committee on Vascular Lesions of the American Heart Association has been influencing scientific investigations since 1960. Initially, the work of the committee was to develop standardized methods to quantitate atherosclerotic lesions and to extract quantitative pathological information from large-scale studies (such as the Pathobiological Determinants of Atherosclerosis in Youth, which is now in its tenth year of highly innovative work). More recently, the multidisciplinary membership of the committee has focused on the clinical implications of vascular pathology, particularly in relation to the vulnerability of atherosclerotic lesions, as well as the methods to identify and stabilize these lesions. The recent work of the committee has resulted in this scholarly but highly readable treatise, which should be perused by any scientist or clinician who has an interest in this emerging field. John P. Cooke, MD, PhD

REFERENCES 1. Davies MJ, Richardson PD, Woolf N, et al. Risk of thrombosis in human atherosclerotic plaques: role of extracellular lipid, macrophage, and smooth muscle cell content. Br Heart J 1993;69:377-381. 2. Moreno PR, Bernardi VH, Lopez-Cuellar J, et al. Macrophages, smooth muscle cells, and tissue factor in unstable angina. Implications for cell-mediated thrombogenicity in acute coronary syndromes. Circulation 1996;94:3090-3097. 3. van der Wal AC, Becker AE, van der Loos CM, Das PK. Site of intimal rupture or erosion of thrombosed coronary atherosclerotic plaques is characterized by an inflammatory process irrespective of the dominant plaque morphology. Circulation 1994;89:36-44. 4. Lendon CL, Davies MJ, Born GV, Richardson PD. Atherosclerotic plaque caps are locally weakened when macrophages density is increased. Atherosclerosis 1991;87:87-90. 5. Mach F, Schonbeck U, Bonnefoy JY, Pober JS, Libby P. Activation of monocyte/macrophage functions related to acute atheroma complication by ligation of CD40: induction of collagenase, stromelysin, and tissue factor. Circulation 1997; 96:396-399. 6. Moncada S, Higgs EA. Molecular mechanisms and therapeutic strategies related to nitric oxide. FASEB J 1995;9:13191330. 7. Stamler JS, Mendelsohn ME, Amarante P, et al. Nacetylcysteine potentiates platelet inhibition by endothelium-derived relaxing factor. Circ Res 1989;65:789-795. 8. Kubes P, Suzuki M, et al. Nitric oxide: an endogenous modulator of leukocyte adhesion. Proc Natl Acad Sci USA 1991;88:4651-4685. 9. Tsao PS, Wang BY, Buitrago R, et al. Nitric oxide regulates monocyte chemotactic protein-1. Circulation 1997;96:934940. 10. Cybulsky MI, Gimbrone MA Jr. Endothelial expression of a mononuclear leukocyte adhesion molecule during atherogenesis. Science 1991;251:788-791.

11. Marui N, Offerman MK, Swerlick R, et al. Vascular cell adhesion molecule-1 (VCAM-1) gene transcription and expression are regulated through an antioxidant-sensitive mechanisms in human vascular endothelial cells. J Clin Invest 1993;92:1866-1872. 12. Ross R. Cellular and molecular studies of atherosclerosis. Atherosclerosis 1997;131(Suppl):S3-S4.

Vascular and Interventional Radiology Karim Valji. Philadelphia, PA: W.B. Saunders, 1999. ISBN: 0-7216-7003-2. Pages: 509. Price: $140.00. This book meets the objectives of the authors, which is stated in the preface: the book is written primarily for trainees in diagnostic radiology and vascular and interventional radiology. In addition, it is a good overview for the general radiologist, vascular surgeon, or interventional cardiologist who requires a comprehensive review of the current practice of vascular and interventional radiology. The first section is a general review of the principles of vascular and interventional radiology, including a discussion of patient evaluation and care, standard angiographic and interventional techniques, and pathogenesis of vascular diseases. The section on patient evaluation and care gives a concise overview of the potential complications associated with angiography. Topics include treatment of vasovagal reactions, iodinated contrast reactions, prophylaxis in patients with a history of contrast reactions, contrast induced nephropathy, as well as an overview of conscious sedation and treatment of adverse reactions to sedatives. The chapter on standard angiographic techniques includes an excellent description of arterial and venous access techniques, contrast agents, and frequently used pharmacological adjuncts. There is a solid overview of the pathogenesis of vascular diseases, with particularly informative discussions of the vasculitides. The second section of the text concerns the subject of vascular diagnosis and intervention and includes chapters on the thoracic and abdominal aorta, pelvic and lower extremity arteries, upper extremity arteries, and renal, mesenteric, hepatic, splenic, and portal vascular systems. These chapters are the most comprehensive of the textbook, and are well organized with each chapter discussing angiographic techniques, embryology, and normal and variant anatomy. Discussions of the pathology of the affected regions are limited to the major disorders with concise discussions of the etiologies, clinical features, imaging findings, and the medical, endovascular, and surgical treatment options. Also, when pertinent, there is a discussion of the potential complications and outcomes of percutaneous interventions. The second section of the text also includes chapters on endocrine, exocrine, and reproductive systems; pulmonary and bronchial arteries; lower extremity veins; inferior vena cava; upper extremity veins; and superior

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vena cava. The discussions of the interior and superior vena cava are particularly noteworthy and complete. The second section of the textbook concludes with chapters on vascular access, foreign body retrieval, hemodialysis access, and the lymphatic system. The final section of the book discusses nonvascular diagnoses and intervention. The percutaneous biopsy section includes a nice overview of sampling techniques, image guidance, specimen handling, patient preparation, and postbiopsy care with a discussion of specific applications as they apply to the thorax and intraabdominal organs. This section contains particularly well-written discussions of the biliary system with sections on patient selection, techniques, results and complications of percu-

Annals of Vascular Surgery

taneous cholangiography, and biliary drainage procedures. Topics include the treatment of malignant and benign biliary strictures, biliary stone management, and treatment of biliary leaks. The final chapter is a review of percutaneous management of urologic and genital system abnormalities. In summary, the text achieves its stated objectives and should be a welcome addition to the libraries of general radiologists, diagnostic and interventional radiology trainees, and surgical specialists who desire a succinct but comprehensive overview of vascular and interventional radiology. Stephen P. Johnson, MD