[Possibilities and limits of interventional therapy in chronic peripheral arterial occlusive disease]

In the therapy of the chronic peripheral vascular occlusion, angioplasty is rarely used to treat the infra-renal aortic stenosis, whereas the stenosis and the short occlusion of the iliac artery is a classical indication. Primarily, stenoses and occlusions of the iliac artery should be treated with balloon angioplasty exclusively. Only secondarily, when the result of angioplasty was insufficient, e.g. remaining stenosis or dissection, stent implantation is appropriate. Angioplasty is most frequently applied in the obliteration of the femoro-popliteal artery. It can be stated that early- and long-term results are the better, the shorter the occlusion is. Stent implantation in the femoro-popliteal artery should be avoided because of poor results. Only with the intention of limb salvage, when there is no opportunity for surgical treatment, a stent implantation should be considered. In case of recurrent stenoses after stent implantation, angioplasty can be reapplied with great success. The indication for any vascular intervention should be a decision of both, the interventional radiologist and the vascular surgeon, because both kinds of treatment are palliative and not causal. It is the task of the angiologist to do clinical diagnostics and the after-treatment. Quality monitoring is indispensable. It consists of documentation of pre-angioplasty diagnostics and should be able to prove the correct indication for the intervention. The result of the intervention should also be documented by angiography and functional tests. Regular control of the patient after the intervention is necessary for the early recognition of recurrent stenoses.

[Coarctation of the abdominal aorta]

HISTORY AND FINDINGS

When a 27-year-old woman went to her general practitioner with symptoms of acute gastroenteritis he noted a paraumbilical murmur on auscultation. There were no symptoms of intermittent claudication or abdominal angina. All peripheral pulses were easily palpable and bilaterally equal, and there were no vascular murmurs. Physical examination and blood pressure (140/70 mm Hg bilaterally) were normal.

INVESTIGATIONS

Biochemical tests gave no indication of inflammatory disease. Oscillography showed a brief decrease in amplitude after muscular exertion, predominantly of the thigh. Posterior tibial systolic pressure was 20 mm Hg lower than radial pressure on the right, 25 mm Hg on the left. Colour Doppler sonography demonstrated elongated and looping coarctation of the abdominal aorta.

TREATMENT AND COURSE

As the patient had no symptoms only regular follow-up was indicated. There have been no symptoms for 27 months and no progression of the coarctation.

CONCLUSION

In young patients with the described symptoms abdominal coarctation should be included in the differential diagnosis.

[Percutaneous transluminal angioplasty of the deep femoral artery. Retrospective evaluation of early technical and clinical results in 196 cases of catheterization]

AIM

Stenosis of the deep femoral artery with simultaneous occlusion of the superficial femoral artery usually is considered to be a classical indication for vascular surgery. Angioplastic therapy of this vessel is rarely reported. Retrospective analysis of the technical and clinical results following catheter treatment of the deep femoral artery was performed to demonstrate the possibilities of this less invasive method.

MATERIAL AND METHOD

196 angioplasties in 174 patients were performed. 77 patients (39%) suffered from stage II disease according to Fontaine classification (grade I category 2/3 [Rutherford]), 36 (18%) from stage III (grade II category 4) and 75 (38%) from stage IV (grade III category 5).

RESULTS

Catheter treatment was successfully performed in 77% (151/196) of the cases. Clinical improvement was seen following 61% (96/196) of the treatments. The complication rate was 3.4% (7/196: thrombosis of the CFA, ascending occlusion of the SFA, occlusion/spasm of the arteria circumflexa femoris lateralis, pulmonary embolism).

CONCLUSION

Catheter treatment is a minimal invasive, cost-effective alternative to surgical reconstruction of the deep femoral artery.

Accuracy of duplex scanning in the prediction of pressure gradients across peripheral artery stenoses

The present study investigates the validity and accuracy of the modified Bernoulli equation in the Doppler-derived evaluation of pressure drops across peripheral artery stenoses. Conventional duplex-derived (x) and catheter-measured (y) mean and peak pressure gradients across iliac artery stenoses were determined in 35 iliac arteries of 28 patients. The correlations between both methods were r = 0.84 (n = 35; SEE = 4; y = 0.89x + 2) for the mean and r = 0.86 (n = 27; SEE = 10; y = 0.76x + 11) for the peak pressure gradients. In a second study, color-coded duplex-derived (x) and catheter-measured (y) pressure gradients across iliac artery stenoses were determined in 28 further patients. The correlations were 0.86 (n = 28; SEE = 5; y = 0.98x + 0.5) for the mean and r = 0.83 (n = 18; SEE = 15; y = 0.83x + 4) for the peak pressure gradients. These data show that the modified Bernoulli equation can be applied to predict pressure gradients across iliac artery stenoses in patients with peripheral artery diseases.

[Color-coded duplex ultrasonography in the diagnosis of renal artery stenosis]

To diagnose possible renal artery stenosis in 120 patients (36 women, 84 men; mean age 57.3 [21-84] years) colour duplex sonography (CDS) of the renal arterial tree was performed before 53 intraarterial angiographies and 67 central venous digital subtraction angiographies. The criterion of stenosis was a maximal flow velocity of > 180 cm/s in the colour duplex sonogram and a diameter reduction of > 50% in the angiogram. CDS demonstrated the renal artery bed in 209 of 247 renal arteries (85%). 84 of the 209 had regional maximal velocities of > 180 cm/s. The sensitivity and specificity of CDS when comparing it with both angiographic methods (in 185 cases that could be evaluated, in 74 of them with abnormal results) were 91 and 88.2%, respectively. Comparing CDS results with those by intraarterial angiography alone (88 cases, with 51 abnormal findings), sensitivity and specificity were 92.1 and 91.8%, respectively. These results demonstrate that CDS can reliably demonstrate flow obstructions in the renal arterial tree and can thus be recommended for the diagnosis of renovascular hypertension.

[Determination of the length of the occlusion in extremity arteries--color duplex ultrasound versus angiography]

In the management of patients with peripheral arterial occlusive disease the length and location of an arterial occlusion has an impact on the choice of the method of arterial reconstruction, i.e. percutaneous transluminal angioplasty or vascular surgery. The aim of this study was to determine the accuracy of colour-coded Doppler sonography (CDS) compared to conventional contrast arteriography in detecting the length and localisation of an occlusion in peripheral arteries. 100 legs of 94 patients (27 women, 44 to 82 years of age [mean 60.9 years] and 67 men, 21 to 78 years of age [mean 61.3 years]) with clinically suspected artery occlusion were examined prospectively with CDS before angiography and angioplasty. The exact localisation was correctly diagnosed by CDS in 95% with a high correlation (r = 0.95) of occlusion length between both methods. The sensitivity in detecting occlusions was 98% (positive predictive value 98%). It is concluded that colour-coded Doppler sonography can diagnose the length and location of an occlusion in peripheral arteries accurately and therefore can be used as a noninvasive method to select patients for further therapy management.

Recanalization of chronic arterial occlusions: low-speed rotational angioplasty. 5 years experience in peripheral and coronary vessels

Chronic complete occlusions still represent the major technical limitation of percutaneous transluminal angioplasty, both in peripheral and coronary vessels. The clinical use of low-speed rotational angioplasty started in 1986 for the peripheral and in 1987 for the coronary arteries, and has already become part of the clinical routine in several centres. Up to now more than 350 patients with peripheral and 250 patients with coronary occlusions have been treated in Frankfurt; a multicentre questionnaire already contains information about 1,252 patients with peripheral vessel obstructions. In peripheral occlusions the acute success rate was more than 80% if low speed rotational angioplasty was used as the first attempt; after failure of conventional techniques still more than 60% of the vessels could be recanalized successfully. In addition to occlusions of the arteries of the lower limb, indications now may include the iliac artery and the subclavian artery. In each of the patients with chronic coronary occlusions an attempt with conventional techniques had failed before. Following a learning curve, which was also influenced by a better understanding of morphological preconditions, the acute success has now reached 70%. Both in patients with peripheral and those with coronary occlusions the technique turned out to be a safe procedure. Early angiographically documented long-term results in both indications are comparable with conventional balloon techniques. It is concluded that the use of low-speed rotational angioplasty (ROTACS) can improve the results of non-operative invasive treatment, both in peripheral and in coronary arteries.

Noninvasive assessment of pressure gradients across iliac artery stenoses: duplex and catheter correlative study

The present study investigates prospectively the validity and accuracy of the simplified Bernoulli equation in the duplex-derived determination of pressure gradients across iliac artery stenoses in patients with occlusive artery disease. In 28 patients (age range, 38 to 76 years; mean, 53 years) with short iliac artery stenoses, we obtained both duplex scan stenotic jet velocity and catheter pressure measurements. Mean and maximum pressure gradients were determined by both methods, as was the peak-to-peak catheter gradient. The correlation between the duplex-determined and nonsimultaneously measured catheter mean pressure gradients was r = 0.77 (standard error of the estimate [SEE] = 5 mm Hg), that between the duplex-derived and catheter-determined maximum pressure gradients was r = 0.80 (SEE = 10 mm Hg), and that between maximum duplex-determined and peak-to-peak catheter gradient was r = 0.76 (SEE = 12 mm Hg). The peak-to-peak catheter gradient was significantly lower than the maximum duplex-derived gradient (46 versus 53 mm Hg, P < 0.05). Duplex-determined mean pressure gradient decreased from 15 +/- 6 to 3 +/- 1 mm Hg after balloon angioplasty of the iliac stenoses. Duplex scan can be used to predict pressure gradients across short iliac artery stenoses, provided that errors caused by angle malcompensation are prevented.

[Reopening chronic arterial occlusions]

Chronic complete occlusions still represent the major technical limitation of percutaneous transluminal balloon angioplasty, both in peripheral and coronary vessels. The clinical use of low speed rotational angioplasty (ROTACS) started in 1986 for the peripheral and in 1987 for the coronary vessels, and has already become part of the clinical routine in several centers. Up to now, more than 300 patients with peripheral and more than 200 patients with coronary occlusions were treated in Frankfurt. In peripheral occlusions the acute success rate was more than 80% if used as the first attempt; after failure of conventional techniques still more than 60% of the vessels could be recanalized successfully. In addition to occlusions of the arteries of the lower limbs, the indication now includes the iliac artery and several other indications are under investigation. In each of the patients with chronic coronary occlusions an attempt with conventional techniques had failed before. Following a learning curve, which was also influenced by a better understanding of morphological preconditions, the acute success rate has now reached 70%. Both in patients with peripheral and those with coronary occlusions no deaths occurred. First angiographically documented long-term results in both indications are comparable to conventional balloon angioplasty. It is concluded that the use of low speed rotational angioplasty (ROTACS) can improve the results of nonoperative invasive treatment, both in peripheral and in coronary arteries.

[Varicosis of the great saphenous vein as a main symptom of iatrogenic arteriovenous fistula]

A 22-year-old man with movement-dependent knee-joint pain was operated on for patellar chondroplasia and meniscal dysplasia after two previous arthroscopic removal of free joint bodies had failed to bring relief. A few months after the operation the same leg had become swollen with signs of venous congestion, long saphenous vein varicosity and traumatic pretibial crural ulcer. The long saphenous vein was partially excised. 18 months after the arthrotomy there was clinical and colour-Doppler evidence of an arteriovenous fistula with false aneurysm in the region of the popliteal artery as cause of the venous congestion. The ulcer healed completely after ligation of the fistula and excision of the false aneurysm. --Arterio-venous fistula should be included in the differential diagnosis as a possible cause of postoperative swelling of a limb.

[The indications for rotation angioplasty of the a. femoralis superficialis and the a. poplitea. The treatment results in 75 complicated chronic arterial vascular occlusions]

75 patients with difficult occlusions in the superficial and popliteal arteries were treated by the "Rotacs" system. This technique is efficient in treating occlusions longer than 10 cm, with an initial success rate of 60.5%. In primary failed conventional angioplasties Rotacs-PTA was successfully employed in 56% as a second intervention. This is considered to be an advance in PTA technique. In stage II disease the PTA results are better than in diseases of the stages III and IV, which agrees with conventional catheter treatment. In the femoropopliteal overlapping segment the initial successful PTA of short, hard, mostly calcified occlusions was only 33%. The complication rate of Rotacs technique compares with that of the conventional methods.

[Duplex sonographic determination of blood pressure gradient in iliac artery stenoses. Comparison with invasive measurement]

The present study investigates the validity and accuracy of the simplified Bernoulli equation in the duplex-derived determination of pressure gradients across iliac artery stenoses. 28 patients presenting with iliac artery stenoses were examined by both duplex scanning and intraarterial catheter pressure measurement. The catheter-determined and duplex-derived mean pressure gradient was 16 +/- 7 and 14 +/- 7 mmHg, respectively. There was a fairly good correlation between the mean pressure gradients assessed nonsimultaneously by both methods (r = 0.77). The catheter-determined and duplex-derived maximum instantaneous pressure gradient was 53 +/- 16 and 52 +/- 21 mmHg, respectively. The correlation coefficient (r) for the maximum instantaneous pressure drop values determined by the two methods was r = 0.79. The results show that duplex ultrasound predicts mean and maximal-instantaneous pressure gradients with acceptable approximation in patients with iliac artery stenoses.

Use of duplex scanning in the diagnosis of arteria profunda femoris stenosis

To evaluate the accuracy of duplex scanning in diagnosing arteria profunda femoris stenoses in patients with concomitant superficial femoral artery occlusions, 123 femoral artery bifurcations were examined in 103 patients. Peak systolic and time-averaged maximal flow velocity parameters were measured in the arteria profunda femoris and compared with independently performed angiography. For detecting stenoses greater than 30% diameter reduction (50% by area) of the arteria profunda femoris, duplex scanning had a sensitivity of 91% and 96%, a specificity of 85% and 98%, a positive predictive value of 86% and 98%, and a negative predictive value of 91% and 96%, for a peak systolic velocity of 180 cm/sec and more, and for a time-averaged maximal velocity of 50 cm/sec and more in the arteria profunda femoris, respectively. The day-to-day variability for peak systolic and time-averaged maximal velocity parameters was low with correlation coefficients between velocity measurements on both days of 0.96 and 0.98 (n = 20), respectively. In 10 patients with arteria profunda femoris stenoses and superficial femoral artery occlusions, undergoing percutaneous transluminal angioplasty of arteria profunda femoris stenosis, the duplex scan revealed a reduction in stenotic peak systolic velocity from 330 +/- 84 to 163 +/- 50 cm/sec and a decrease in stenotic time-averaged maximal velocity from 156 +/- 47 to 54 +/- 17 cm/sec after the interventional procedure. These results show that peak systolic and time-averaged maximal velocities are accurate parameters to detect significant arteria profunda femoris stenosis in patients with superficial femoral artery occlusions.(ABSTRACT TRUNCATED AT 250 WORDS)

[Duplex ultrasound studies of the deep femoral artery]

In case of occlusion of the superficial femoral artery (SFA), the deep femoral artery (DFA) supplies the entire lower extremity. Not infrequently, the SFA occlusion is associated with stenosis of the origin of the DFA. The angiographic study of the origin of DFA is often unsatisfactory. The purpose of the present study was to develop objective criteria for the diagnosis of the DFA origin stenosis by duplex scanning. In 60 patients, we examined 75 femoral bifurcations by duplex scanning and compared them with the independently performed angiography. Group 1 (n = 20 DFA origins) consisted of 10 normal individuals. Group 2 (n = 30 DFA origins) consisted of 25 patients with angiographically proven SFA occlusion and normal DFA. Group 3 (n = 25 DFA origins) consisted of 25 patients with angiographically proven SFA occlusion and DFA orifice stenosis. We measured the maximal systolic and mean flow velocity in the orifice of the DFA at rest and during the maximal hyperemia following 3 min of ischemia of the lower leg. At rest, the maximal flow velocity in groups 1-3 was 60 +/- 15, 142 +/- 44, and 255 +/- 60 cm/s (p less than 0.01) and the mean flow velocity was 8 +/- 6, 32 +/- 9, and 96 +/- 42 cm/s (p less than 0.01). During hyperemia, the maximal and mean flow velocity for groups 1-3 was 59 +/- 15, 155 +/- 42, and 286 +/- 82 cm/s (p less than 0.01) and 8 +/- 5, 55 +/- 19, and 144 +/- 51 cm/s (p less than 0.01), respectively. An origin stenosis of the DFA is highly probable when at rest the mean and maximal velocity in the proximal DFA exceed 50 cm/s and 180 cm/s, respectively. These results show that duplex scanning is able to detect safely DFA origin stenosis. The increase in postischemic DFA flow velocity when SFA occlusion is present, helps to evaluate total flow resistance of the deep-outflow channels (run-off) thereby being useful in planning appropriate therapy.

Doppler ophthalmic blood pressure measurement in the hemodynamic evaluation of occlusive carotid artery disease

In 102 patients with angiographically proven occlusive carotid artery disease of 60-100% diameter reduction, Doppler ophthalmic artery pressure and blood flow direction were recorded by the recently developed ophthalmomanometry-Doppler technique. Among these 102 patients, 50 presented with complete carotid artery occlusions and 52 with carotid artery diameter stenoses of greater than or equal to 60%. Mean +/- SD Doppler ophthalmic artery pressure was 69 +/- 15 mm Hg ipsilateral to the occlusion and 86 +/- 18 mm Hg ipsilateral to a stenosis of the carotid artery (p less than 0.001). The mean +/- SD Doppler ophthalmic pressure index (ratio of the ophthalmic artery to systemic blood pressure) was lower ipsilateral to the occlusion (0.46 +/- 0.08) than ipsilateral to a carotid artery stenosis (0.54 +/- 0.08; p less than 0.001); in both, the index was clearly diminished compared with normal values (0.68 +/- 0.04; p less than 0.001). It is concluded that the intracranial hemodynamic consequences in the patients with occlusion are on average more profound than in the patients with stenosis. In carotid artery occlusions, the mean +/- SD ipsilateral ophthalmic pressure index was 0.46 +/- 0.06 for antegrade and 0.46 +/- 0.09 for retrograde ophthalmic artery blood flow. In carotid artery stenoses, the mean +/- SD ipsilateral ophthalmic pressure index was 0.55 +/- 0.07 for antegrade and 0.48 +/- 0.06 for retrograde ophthalmic artery blood flow (p less than 0.01). These results indicate that in carotid stenoses the collateral capacity of the ophthalmic artery is insufficient compared with intracranial collaterals, while in carotid occlusions the blood flow direction in the ophthalmic artery does not predict intracranial hemodynamic compensation.

Low-speed rotational angioplasty in chronic peripheral artery occlusions: experience in 83 patients. Work in progress

Between December 1986 and October 1988, 83 patients with chronic peripheral artery occlusions were treated with a new technique. In 56 patients, the superficial femoral artery was completely occluded; in 21 patients, the popliteal artery; and in six patients, the iliac artery. The length of occlusion ranged from 5 to 35 cm (mean, 12.5 cm). The duration, estimated by history, was 5-48 months (mean, 16.5 months). In seven patients, durations of 6-36 months were documented angiographically. A flexible, blunt, motor-driven rotating catheter was introduced through an 8-F sheath, and rotational angioplasty was performed at low speed (up to 200 rpm). In 49 of 60 (82%) patients in whom this new technique was used as the primary intervention, the occlusions were successfully reopened. In 23 patients in whom conventional methods had failed more than 4 weeks earlier, the success rate for rotational angioplasty was 67% (12 of 18 patients); when the time interval was less than 4 weeks, only one of five patients was treated successfully. In none of the 83 patients did a perforation occur. This new technique can reopen chronic artery occlusions with a high degree of success and without the danger of vessel-wall perforation, even after failure of conventional techniques.

[Rotation angioplasty--clinical experiences in 83 patients with chronic arterial vascular occlusion]

Chronic, total vascular occlusion represents the limit for use of balloon dilatation. Occlusions of the superficial femoral artery and popliteal artery of more than 10 cm in length have a low recanalization rate of 50 to 60% with conventional angioplasty. In iliac artery occlusions, in addition to a high rate of complications, the recanalization rate is only about 30 to 40%. Starting in 1984, we developed a slowly rotating (100 to 200 r.p.m.), electrically-driven, flexible catheter with a blunt tip, inside lumen and outer diameter of 2.2 mm for the purpose of recanalization (Figure 1). The theoretical basis was that such a catheter would seek the soft occluding thrombus as the path of least resistance. Since 1986, the procedure has been carried out in 56 patients with occlusion of the superficial femoral artery, 21 with occlusion of the popliteal artery and six with occlusion of the iliac artery. The duration of occlusion ranged between five and 48 months and the length of the occlusions between 5 and 35 cm (mean 12.5 cm); the patients were in Fontaine stage II and IV, the ankle arm-index ranged between 0 and 0.86 (mean 0,51). After antegrade or retrograde puncture of the common femoral artery and intra-arterial injection of 5,000 units of heparin, the rotation catheter was advanced through an 8F sheath through the occlusion by means of slow rotation (Figure 2). After contrast medium injection to document the intraluminal position of the catheter and the catheter exchange over a 0.35'' wire, the channel created was dilated.(ABSTRACT TRUNCATED AT 250 WORDS)

Results of low speed rotational angioplasty for chronic peripheral occlusions

After experimental investigation using postmortem human arteries, 19 patients with chronic peripheral artery occlusions were treated with a new angioplasty technique between December 1986 and October 1987. In 17 patients the superficial femoral artery and in 2 patients the popliteal artery were completely occluded. The length of the occlusions ranged between 5 and 25 cm (mean 11). The duration--estimated according to patients' history--was 5 to 48 months (mean 17). In 5 patients, durations of up to 30 months had been documented by angiography. A flexible, blunt, motor-driven rotating catheter was introduced through an 8 or 9Fr sheath and rotational angioplasty was performed at low speeds (up to 200 rpm). In 11 of 14 patients in whom this new technique was used as the primary intervention, the occlusions could be successfully reopened. In 2 patients after failure of conventional techniques the rotating catheter could not bypass the preexisting dissections in the same intervention. In 2 of 3 further patients after failure of conventional techniques the occlusions could be successfully reopened in a second intervention after several weeks. In none of the 19 patients did a perforation occur. It is concluded that with the new technique chronic peripheral artery occlusions can be reopened with a high success rate and without the danger of arterial wall perforation. The method can also be used in patients in whom conventional techniques have failed.

[Venous diseases of the lower extremities--methods and results of phlebography of the lower extremity--the superficial and deep systems]

The vena saphena magna is the most important arterial vascular substitute in today's vascular surgery. That is why modern varicose vein surgery is performed very carefully and cautiously with an aim to preserve the vessels as much as possible. This can be done only if the radiologist visualises both the healthy and the diseased superficial and deep venous systems as completely and a easily appreciable as possible when diagnosing varicosis. It is not enough to merely produce contrast images of the deep venous system when attempting to clarify varicosis via phlebography. The conditions obtaining at the points where the great saphenous vein and the small saphenous vein open into the femoral and popliteal veins, respectively, must be clearly visible. The maximum possible number of insufficient venae perforantes must be shown and the side branches of the great saphenous vein that have undergone varicose changes, must be visualised. It goes without saying that the deep venous system must be shown in a manner that it can be safely assessed. An extended thrombosis of the deep veins of the leg and pelvis does not present any diagnostic pitfalls when assessing the phlebogram. On the other hand, a beginning deep leg thrombosis is easily overlooked. Phlebographically it is quite difficult to clarify a relapsing thrombosis. This requires detailed knowledge of the patterns of signs in deep leg vein thrombosis.

Femoro-popliteal artery thrombolysis with intra-arterial infusion of recombinant tissue-type plasminogen activator--report of a pilot trial

Recombinant tissue-type plasminogen activator (rt-PA) was infused at a rate of 10 mg/h into 50 thrombosed femoral and popliteal arteries. Patency was restored in 43 but a secondary angioplasty led to 2 reocclusions and in 3 patients early rethrombosis occurred. A favourable clinical result was thus obtained in 38 patients (76%). Thirteen bleeding complications occurred in 10 patients, mainly haematomas at puncture sites. One patient required blood transfusion for gastro-intestinal bleeding from a previously unknown ulcer. The angiographic recanalisation rate in 16 patients who received a slower infusion of rt-PA (5 or 3 mg/h) was 94% and the clinical success rate in this series was 81%. However, the incidence of bleeding complications was not decreased by the slower infusion rate. The data obtained confirm the feasibility of rt-PA thrombolysis in peripheral arterial thrombosis and warrant a comparative study with streptokinase.

[Rotation angioplasty--initial clinical results of peripheral vascular occlusions]

After experimental investigations in postmortem human arteries, 19 patients with chronic peripheral artery occlusions were treated with a new technique between December 1986 and October 1987. In 17 patients the superficial femoral artery, and in two patients the popliteal artery, was completely occluded. The length of occlusions were between 5 and 25 cm (mean 10.9 cm); the duration (estimated according to patient's history) was 5-48 months (mean 17.2 months). In five patients, durations of up to 30 months had been documented by angiography. A flexible, blunt, motor-driven rotating catheter was introduced over an 8 or 9 F sheet and rotational angioplasty was performed at low speed, up to 200 rpm. In 11/14 patients in whom this new technique was used as the first attempt, the occlusions could be successfully reopened. In two patients after failure of the conventional technique the rotating catheter could not bypass the preexisting dissections in the same intervention. In 2/3 further patients after failure of the conventional technique the occlusions could be successfully reopened in a second intervention after several weeks. In none of our 19 patients did a perforation occur. It is concluded that by using the new technique, chronic peripheral artery occlusions can be reopened with a high success rate and without the danger of vessel wall perforation. The method can also be applied in patients in whom conventional techniques have failed.

Treatment of neurofibromatosis associated renal artery stenosis with hypertension by percutaneous transluminal angioplasty

A 12 year old girl with severe arterial hypertension was found to have neurofibromatosis associated bilateral stenoses of the main renal arteries and elevated plasma renin activity in the right main renal vein. Antihypertensive treatment was unable to normalize blood pressure. PTA of the right renal artery from a left axillary approach resulted in normalization of blood pressure and peripheral plasma renin activity. PTA seems to be an effective and safe method for treatment even of complicated forms of renal artery stenosis.

Catheter-lysis: indications and primary results

Catheter-lysis--local low-dose fibrinolytic therapy--extends the indication to catheter-treatment. Occlusions longer than 10 cm younger than 3 months may be treated by this method. This treatment is primarily indicated for Fontaine stage III/IV occlusions. The complication of acute embolism or acute reocclusion during routine angioplasty can be treated satisfactorily by catheter-lysis. The primary result of low-dose fibrinolysis depends on the clinical stage, peripheral outflow, age and length of the occlusion.

Repeated percutaneous transluminal catheter-treatment. Primary results

An advantage of angioplasty lies in the repeatability of this method in the same vascular section, if reobliteration or restenosis occur. In 154 patients second PTA was performed in 159 extremities, in 26 third and in 4 fourth PTA. The best results of repeated PTA were observed in stenoses, as well in the iliac region as in the femoro-popliteal section. Because a reocclusion has unfavorable chances for a renewed PTA it is advisable to watch the patients. As soon as the patient suffers of more claudication, a new angiography is to be performed. The results of repeated PTA in state IV are worse than in state II, third PTA had only pour chances. Therefore a repeated PTA more than twice especially in obliterations is hardly justifiable.

Seldom indications for angioplasty

Rare applications and localisations of angioplasty are presented. The technique, the primary results and the complications of angioplasty of the visceral arteries, the branches of the aortic arch, the aorta and the venous bypass graft are discussed. The angioplasty is also a good therapeutic principle in the treatment of obstructive arterial vascular disease in these arterial areas.

Results of percutaneous transluminal angioplasty

Percutaneous transluminal angioplasty (Dotter technique) was used in 2,942 cases of iliofemoral atheromatous disease. Results varied with the characteristics of the obstructing lesion (length and location) and the clinical stage of ischemia (claudication, rest pain, gangrene). Based on the foregoing, angioplasty is done either as the preferred primary treatment or for the relief of clinically advanced disease in patients unsuitable for high risk surgery. Success is favored by the use of aggregation inhibitors and single-use Teflon or balloon catheters; complications are few.

[Cinedensitometric flow measurements before and after angioplasty in the femoropopliteal region]

In 31 patients with obstructions of the superficial femoral artery in occlusive vascular disease the flow in the popliteal artery was cinedensitometrically measured before and after angioplasty with the balloon catheter. Under resting conditions the flow was improved to the 2.63 fold value by recanalization of the 18 occlusions. By dilatation of the 13 stenoses the flow nearly could be doubled (f = 1.82). The idea is that a high flow is able to counteract to a reocclusion immediately after angioplasty. Therefore a vasodilatator should be applied in order to diminish the peripheral resistance and increase the flow in the treated region.

Semiquantitative assessment of lower limb atherosclerosis from routine angiographic images

In the present report a score system is introduced with the aim of analysing routine angiographic images. The system consists of a vectorial score, which codes the pattern of occlusions, stenoses and plaques, and of an additive score describing the severity of the lesions visualised. The technique is suitable for computerised data analysis.

[Computer-assisted tomography, B-scan sonography and cerebral angiography in obliterations of the carotid artery (author's transl)]

The real-time-B-scan is a new and essential method for diagnosing carotid stenoses. Whereas computer-assisted tomography shows only a minor sensitivity for detection of obliterations of cervical arteries, B-scan sonography has high sensitivity and specificity. B-scans should be increasingly performed both after uncertain clinical and computer tomographic findings prior to angiography of extracranial cerebral vessels. A more stringent indication for angiography and thus avoidance of investigational and irradiation risk can be achieved. Wide use of B-scan sonography may, through early recognition of carotid obliterations, lead to prevention of cerebral insults as patients can undergo vascular surgery at an early stage.

Hemodilution (HD) in patients with ischemic skin ulcers

In 25 patients with arterial occlusive disease in the clinical stage IV according to Fontaine a hemodilution down to an average hematocrit value of 0.31 +/- 0.02 was performed. Eighteen patients had peripheral ulcers of the lower limbs and 3 patients had ulcers of the upper ones. Four patients had tissular lesions both at the level of the feet and toes and hand and fingers. The average age of the patients was 43. Hemodilution was achieved by repeated withdrawals of approx. 500 ml blood, followed by reinfusion of the autologous plasma associated with infusion of substitutive solutions of low-molecular weight dextran to avoid hypovolemia. In all patients with peripheral ulcers of the upper limbs, with no exception, a good to a very good clinical effect was obtained ranging from extended to complete healing. The healing tendency of lesions in the feet and toe region was on the whole less marked and depended basically on the total number of vascular impediments found in one patient. The rheological and hemodynamic mechanism of the therapeutic effect of hemodilution, the preliminary criteria for indicating this therapy and its observed complications are discussed.

[A comparison of radiation exposure of angiographers using an above-table or below-table image intensifier (author's transl)]

Phantom measurements in the vicinity of an angiographic installation with the image intensifier below the table and subsequently with the intensifier above the table have shown that the former arrangement produces three times as much radiation to the head, gonads and leg during screening than when the intensifier is above the table. This has been confirmed in clinical practice during angioplastic procedures in other units. There is also a factor of 2.6 in favour of the above table intensifier applied to the lens of the eye of the investigator Radiation to the hand of the investigator is at least half with the above table arrangement.

Immunological cross-reactivity between a glycoprotein isolated from Trichophyton mentagrophytes and human isoantigen A

A glycoprotein isolated from the cell wall of Trichophyton mentagrophytes was assessed for its cross-reaction with human blood group isoantigens. Rabbit antiglycoprotein antibodies agglutinated human erythrocytes of blood groups A1 and A2, and precipitated Blood Group Substance A in agarose gels. Erythrocytes of blood group B were only slightly agglutinated, and O(Rho+) and O(Rho-) erythrocytes were not. Additionally, the glycoprotein was shown to specifically inhibit isoagglutination of erythrocytes of group A. Partial identity between the glycoprotein and a crude extract of the fungus was demonstrated by immunodiffusion. Analyses revealed the glycoprotein to be composed of approximately 17% protein and 80% carbohydrate. The glycoprotein was found by indirect immunofluorescence to be located in the mycelial cell wall. The possibility that cross-reacting antigens may lead to a chronic, spreading infection is discussed.

[Fibronolytic treatment with activator: clinical results, angiographic findings and laboratory results (author's transl)]

Two-day treatment with activator (equimolar streptokinase-human plasminogen complex) was given to 26 patients. Indications were chronic arterial occlusion and stenosis of the lower-limb arteries (25 patients), and thrombosis of the subclavian veins. The onset of claudication had on average been 7.5 months previously, average walking distance 288 metres. Five occlusions of iliac arteries and three of femoral arteries were removed. In addition, stenosis of the aorta (one case), the iliac artery (ten cases) and femoral artery (one case) was partly removed. Occlusion of the axillary vein was also removed. Average duration of the successfully treated occlusions was 4.3 months. Those stenoses that responded to activator had the well-known morphological criteria for fibrinolysis. The walking distance of the patients increased from an average of 288 to 401 metres. Activator treatment was well tolerated. No serious, especially cerebral, complications occurred. The most striking laboratory finding was of circulating plasmin during the entire duration of the infusion.

[Angiographic examinations of the stomach following Billroth II resections with special reference to the gastro-jejunostomy (author's transl)]

The arterial blood supply of the anastomosis in 6 stomach resected dogs (Billroth II) is examined by common angiographic technique in vivo, microangiography, and microscopy. In all animals there are at the site of the gastrojejunostomy bizarre tortuous vessels which cross the anastomosis. These arteries have a diameter between 50 to 2000 mu. They are newly formed vessels which cannot be demonstrated by common coeliaco- and mesentericography in animal experiments or in patients.

[Modified in situ perfusion of the kidney using balloon catheters]

Experiences with the in situ hypotherme perfusion in the operative treatment of calculus in kidneys and calices are reported. A modified technique is presented using an inflatable Swan-Ganz-ballon catheter for simultaneous blocking of renal blood flow and perfusion.

[Changes of cutaneous blood flow after aortofemoral angiography (author's transl)]

Temperature versus time curves were registered during aortofemoral angiography in 48 patients. The cutaneous temperature was initially reduced in 46 of the patients. This phenomenon was interpreted as a temporary decrease of blood flow and can not be explained by hypertonicity of contrast media, but indicates additional pharmacodynamic effects. Reactive hyperemia depends on pathologic alterations of large and small vessels.

[Coronary-angiographic demonstration of the dilating effect of dipyridamole on coronary arteries and its inhibition by caffeine (author's transl)]

Selective coronary cineangiographies are performed repeatedly in 13 mongrel dogs. The contrast medium itself has no demonstrable dilating effect upon the vessels. After the first injection of 0.2 mg/kg of dipyridamole the left anterior coronary artery is significantly (p less than 0.001) dilated, which is in contrast to some results described in literature. Immediately after an injection of high doses of caffeine (10 mg/kg) the previously enlarged coronary diameter decreases significantly (p less than 0.001). During the action of caffeine subsequent infections of dipyridamole result in a very small, or no change in coronary diameter. The coronary-dilating effect of dipyridamole can be inhibited by high doses of caffeine (10 mg/kg).

[Partial thoracic renal ectopy (author's transl)]

Based on a case of his own the author surveys the literature of this rare condition. He discusses its clinical importance, the differential diagnosis from a lung shadow placed on the diaphragm and the distinction between congenital and posttraumatic displacement. An IVP will settle the diagnosis. Unless there are symptoms, operative correction is not needed.