VASCULAR INTERVENTION Moderator: Andy Platts / Bob Wilkins
Free papers (8 mins presentation / 2 mins discussion)
Abstract 28
THE USE OF THE ANGIOSEAL HAEMOSTATIC PUNCTURE CLOSURE DEVICE IN HIGH RISK PATIENTS.
GJ O'Sullivan, N Sellars, A-M Belli, TM Buckenham. Department of Vascular Radiology, St George's Hospital, London UK.
PURPOSE: The increase in day case angiography and more complex interventional procedures has led to an increase in arterial access site complications. We report our experience with 68 patients with a self sealing device that obviates the necessity to perform manual compression after arterial puncture.
MATERIALS AND METHODS: The Angio-Seal Hemostatic Puncture Closure Device (Sherwood, Davis and Geck) is intended for use in closing the defect in the femoral arterial wall produced by percutaneous catheter access using 8F or smaller sheaths or catheters. It consists of 3 completely bio-resorbable components. A detailed description of the device and its deployment will be provided. We have used this device in 82 arteries in 68 patients all of whom were considered to be at high risk for development of a haematoma for reasons that will be discussed.
RESULTS: There was 1 major haematoma requiring operative removal. A portion of the device embolised in 2 other patients leading to a critically ischaemic limb which needed surgery. A further 6 patients developed small haematomas which settled on bed rest. 24 out of 30 patients who were potentially well enough to mobilise did so after an average of 2.3 hours. In 6 patients we failed to deploy the device-all early in our experience.
CONCLUSIONS:Once the initial learning curve has been overcome the Angio- Seal device is a simple and successful method of achieving arterial haemostasis following catheterisation which is associated with a low risk of complications.
Abstract 29
PERCUTANEOUS COIL EMBOLISATION IN THE MANAGEMENT OF IATROGENIC PSEUDOANEURYSMS
GJ O'Sullivan, N Sellars, A-M Belli, TM Buckenham. Department of Vascular Radiology, ST George's Hospital, London UK
PURPOSE: Ultrasound Guided Compression Repair (UGCR) is the first line therapy for Iatrogenic Pseudoaneurysms (IPA). If this fails or is contraindicated then other endovascular techniques including embolisation or endoluminal stent grafting are available. We report our 6 year experience with embolisation.
MATERIAL AND METHODS: From 1991-1997 we have performed percutaneous coil embolisation on a total of 24 patients. Of these, 17 were in the Superficial (10) or Common (7 ) Femoral Arteries; 2 were in the Superior/Inferior Gluteal Artery and 1 each occurred in the Superior Mesenteric, Radial, Peroneal and Subclavian Arteries. Their mean age was 61 years; there were 16 males and 8 females.
RESULTS: Overall we were successful in occluding the IPA in over 95 % of cases. Although there are a number of potential complications associated with this procedure, superficial skin necrosis over a radial artery pseudoaneurysm in which the coils continued to unwind is the only one we have encountered. The average cost for the entire procedure including follow-up was £1,500 versus surgery at £2,300.
CONCLUSION: If Iatrogenic pseudoaneurysms require treatment Ultrasound Guided Compression Repair is the accepted first line therapy. Percutaneous embolisation is reserved for those patients in whom this fails or is contraindicated, but is a safe and highly efficacious technique.
Abstract 30
IPSILATERAL PERIPHERAL ANGIOPLASTY AFTER FEMORAL ANGIOGRAPHY- A DIRECTION REVERSAL TECHNIQUE
PD Edwards, R Moxon. Department of Radiology, Addenbrokes Hospital, Cambridge
PURPOSE: To perform an antegrade angioplasty immediately after a diagnostic retrograde femoral angiogram, using the same arterial puncture site.
MATERIALS AND METHODS: 71 patients undergoing diagnostic retrograde femoral angiograms that were shown to have ipsilateral, peripheral arterial lesions amenable to angioplasty were studied. A common femoral puncture was made on the symptomatic side, with the Seldinger needle at right angles to the artery. Following a conventional retrograde angiogram, a 5Fr Sidewinder catheter was inserted over the exchange guide wire. The catheter shape was reformed in the distal aorta. The catheter was pulled towards the puncture site, with the tip in the direction of the superficial femoral artery (SFA). A floppy tip guide wire was passed well into the SFA. The catheter was withdrawn so the apex of the hairpin bend was level with the puncture site, and could be advanced into the SFA.
RESULTS: Reversal of the catheter was successful in 64 patients (90%). 52 (72%) had a successful angioplasty, 4 (6%) were treated with thrombolysis and 3 (4%) needed several procedures. There were no significant complications, or difficulty with haemostasis.
CONCLUSION: This is a safe technique that allows diagnosis and therapy in a single procedure without the need to perform a second arterial puncture.
Abstract 31
MECHANICAL AND CHEMICAL THROMBOLYSIS IN PULMONARY EMBOLISM - THREE TECHNIQUES.
J.R. Ferrando, G.J. Robinson, P.J. Cook* and D.E. Stableforth*, Departments of Radiology and Respiratory Medicine*, Birmingham Heartlends Hospital, Birmingham B9 5SS
The treatment of acute massive pulmonary embolism (PE) is a difficult clinical problem with a 10% mortality rate in the first hour following the onset of symptoms. Of the remaining patients only one third are correctly diagnosed initially and mortality in this group is 8%. Delay in diagnosis increases mortality to 30%.
Since October 1995 our department has offered a percutaneous thrombolysis service for patients referred via the Department of Respiratory Medicine with acute massive PE. During this time no patients have undergone surgical embolectomy for PE. Three different mechanical devices have been employed: the Amplatz thrombectomy catheter; the Grollman pulmonary artery catheter and the Hydrolyser. Thrombolytic agents have been infused locally in most cases. The techniques will be discussed along with our indications for their use.
To date 13 patients have been treated and none have been rejected for treatment. Eleven patients have shown clinical and radiological improvement. One patient died of a further massive PE during lysis and one patient suffered significant post procedure hypoxia thought to be related to multiple, small, distal emboli.
Two published series on percutaneous catheter embolectomy give mortality rates of 27% and 28% (26 and 18 patients respectively), whilst mortality figures for surgical embolectomy under cardiopulmonary bypass are 25-40%. Against this background we believe that combined mechanical and chemical thrombolysis should be more widely investigated to establish its role in the management of acute massive PE.
Abstract 32
PULMONARY ARTERY ANEURYSMAL DISEASE IN PATIENTS WITH LIFE-THREATENING HAEMOPTYSIS.
JE Jackson, A Mitchell*, Departments of Medical Imaging, Hammersmith Hospital and Charing Cross Hospital*, London
PURPOSE: Pulmonary artery pseudoaneurysms are an uncommon cause of life- threatening haemoptysis in patients who are referred for bronchial artery embolization and are reported as occurring in approximately 5% of such individuals.
MATERIALS AND METHODS: The records of five patients who presented over a five year period with severe haemoptysis who were demonstrated as having pulmonary artery pseudoaneurysms at angiography were reviewed.
RESULTS: Three patients had a history of chronic pulmonary tuberculosis one of whom had undergone a previous thoracoplasty; one patient suffered from silicosis and progressive massive fibrosis; the fifth patient had a history of a previous subdiaphragmatic abscess complicated by chronic lower lobe pulmonary sepsis and bronchiectasis. All but one of the aneurysms were visualized on selective bronchial or non-bronchial systemic arteriograms. None were visible on main pulmonary artery angiography due to reversal of flow in the affected pulmonary artery branches. Selective catheterization of the aneurysm or adjacent pulmonary artery branch was performed in all individuals and these were occluded with metallic coils or N-butyl-2-cyanoacrylate. Immediate cessation of haemorrhage was achieved.
CONCLUSION: Pulmonary artery pseudoaneurysms should always be considered in patients with chronic lung disease and massive haemoptysis especially in those who represent with further bleeding shortly after a technically successful bronchial artery embolization.
Abstract 33
Colonic Embolisation for Lower GI Haemorrhage.
RC Beese, *AG Heriot, *D Kumar T Buckenham, A Belli. Radiology Dept. St.George's Hospital
PURPOSE: Interventional embolisation is a recognized therapy for proximal gastrointestinal bleeding but its application to bowel distal to the ligament of Treitz has been limited because of concern over ischaemic complications due to lack of adequate collateral circulation.
MATERIALS AND METHODS: 8 patients (2 male, 6 female) with a median age of 69 years (range 31-78 years) were admitted; 6 as emergencies with acute gastrointestinal haemorrhage; 1 with chronic gastrointestinal haemorrhage due to rectal cancer recurrence which had failed to improve with radiotherapy; and 1 with a superior mesenteric artery pseudoaneurysm following a laparotomy for ischaemic bowel. All 8 patients were ASA grade 3 and over. Selective mesenteric angiography was performed in all cases, preceded by oesophagogastric duodenoscopy and colonoscopy in the acute cases in which they failed to identify the source of bleeding. Following detection by angiography of the bleeding site/aneurysm, which lay distal to the ligament of Treitz in all 8 cases (2 jejunal, 5 colonic, 1 rectal), therapeutic embolisation was undertaken. Embolisations were performed using polyvinyl alcohol particles or steel coil with selective arterial catherterisation.
RESULTS: The bleeding was successfully controlled in all cases, and there were no acute complications. Although large bowel ischeamia did occur in one patient and small bowel infarction in another patient within one week of the procedure. Embolisation of the pseudoaneurysm required a repeat procedure due to the aneurysm reopening proximally after 10 days. At follow- up (median 7 months; range 2-15 months), there have been no further complications or further episodes of bleeding.
CONCLUSION: Mesenteric embolisation is an acceptable therapeutic radiological intervention for lower gastrointestinal bleeding in selected patients and can be performed without ischaemic complications, although there should be a high index of awareness and early surgical intervention if ischaemia is clinically suspected.
GYNAECOLOGICAL INTERVENTION Moderator: Graham Houston / Mike Dean
Free papers (8 mins presentation / 2 mins discussion)
Abstract 34
FALLOPIAN TUBE RECANALISATION OF MID TUBAL OCCLUSIONS; TECHNICAL SUCCESS AND EARLY OUTCOME IN POST STERILISATION REVERSAL INFERTILITY.
G Houston, J Anderson, J Mills, A Harrold. Departments of Radiology and Assisted Conception Unit. Ninewells Hospital and Medical School, Dundee DD1 9SY
PURPOSE: To assess the technical success and early outcome of fluoroscopic fallopian tube recanalisation (FTR) in mid tubal occlusion following post sterilisation reversal surgery.
MATERIALS AND METHODS: From July 1995 to January 1998, patients with greater than 12 months secondary infertility underwent hysterosalpingography (HSG) with a view to fallopian tubal recanalisation or in vitro fertilisation. FTR was performed in proximal or mid tubal occlusion. Technical success, defined as complete tubal patency, and total, intrauterine and ectopic pregnancy rates were determined.
RESULTS: 26 patients presenting with secondary infertility following salpingoplasty for sterilisation reversal underwent hysterosalpingography. 8 of 26 patients, found to have mid tubal occlusion at the site of salpingoplasty had attempted FTR in 16 tubes (2 patients previous salpingectomy for ectopic). Technical success was achieved in 8 of 16 (50%) tubes, with at least one patent tube in 5 of 8 (60%) patients. At follow-up (mean 18 months, range 12 - 28 months), there was 1 pregnancy in those successfully recanalised (20%). There were no ectopic pregnancies.
CONCLUSION: FTR in mid tubal occlusion post sterilisation reversal surgery is technically feasible. In this small group there was a lower technical success, lower pregnancy rate and ectopic pregnancy rate than in unselected proximal tubal occlusion.
Abstract 35
BILATERAL UTERINE ARTERY EMBOLISATION FOR MYOMATA.
W J Walker. Royal Surrey County Hospital, Guildford GU2 5XX.
110 patients have undergone successful bilateral uterine artery embolisation for fibroids since 1996. The patients were followed up at 6 weeks, 3 months, 6 months, 12 months and so on with ultrasound scans, MRI scans where funding was available, questionnaires and blood tests at every attendance. The procedure involved bilateral catheterisation of the uterine arteries with instillation of PVA particles followed by Platinum coils. The most common diameter of particle used was 355-500 microns. Following the procedure pain was controlled with a PCA pump. Of 57 patients followed up for a period of 3 months or greater the average shrinkage in fibroid size was 64%. So far all patients with completed questionnaires have been satisfied with the procedure and symptoms of menorrhagia and compression syndrome resolved. Average time to feeling completely normal was 2.2 weeks. Two infective complications have occurred leading to hysterectomy. Five patients developed ovarian failure and became menopausal. On of these patients was 54 and the other 55. In the other three patients the ovarian failure was transitory and normal hormone profiles have been recorded by 6-9 months in all three who resumed menses. One patient developed an extremely heavy period requiring blood transfusion. One patient passed an apple size fibroid vaginally.
CONCLUSION: Bilateral uterine artery embolisation is not without complications (serious complication rate leading to hysterectomy 2%) but in terms of short and medium term follow up appears to offer an effective alternative to hysterectomy.
Updated results will be presented.
Abstract 36
INITIAL EXPERIENCE OF SETTING UP A UTERINE EMBOLIZATION SERVICE IN A DGH
EPH Torrie, RS Robertson, E Holt *and M Gibson. Departments of Radiology and *Obstetrics and Gynaecology, Royal Berkshire Hospital, London Road, Reading, Berks, RG1 5AN
PURPOSE; To report our initial experience of setting up a uterine embolization service in a DGH and results of the first 29 cases. Modifications made to the standard technique and patients' experiences of the procedure will be presented.
MATERIALS AND METHODS: A uterine embolization service was established in response to clinical demand. Patients were counseled before the procedure, kept diaries during and after the procedure and had uterine MRI before and 3 months after the procedure. 29 Patients (mean age 42, 35-57) with uterine fibroids underwent embolization.10/29 had menorrhagia, 10/29 had pelvic pain and 6/29 had both. The first 15 cases were performed with unilateral femoral artery puncture (although 3 needed bilateral puncture) and the next 14 were intentionally performed with bilateral femoral artery puncture. The screening times for these two groups were compared.
RESULTS: All patients had successful bilateral uterine artery embolization. One patient required 2 attempts to achieve embolization. The mean screening time for the unilateral femoral approach was 40 minutes (17 to 116) compared to 15 minutes (7 to 58) for the bilateral approach. Analysis of the patients' diaries showed that the procedure was tolerated well.
CONCLUSION: It is possible to set up a successful uterine embolization service in a DGH although there are considerable resources are needed. Intentional bilateral femoral artery puncture significantly reduces screening time.
Abstract 37
TRANSVAGINAL ULTRASOUND (TVUS) GUIDED ASPIRATION OF SELECTED OVARIAN CYSTS: RESULTS AND COMPLICATIONS.
JC Varghese, P. Byrne, B. Gaughan, MJ Lee. Academic Department of Radiology, Beaumont Hospital & Royal College of Surgeons in Ireland, Dublin.
PURPOSE: To evaluate the technique of transvaginal ultrasound guided aspiration of selected ovarian cysts.
MATERIALS & METHODS: Over a period of 2 years, 26 patients (Mean age: 43yrs., Range 23-84yrs) underwent TVUS guided aspiration of 27 ovarian cysts (RT/LT: 17/10, mean size, 6cm; range 3-10 cm) for symptoms of pain (92%), polycystic ovary disease (4%) and as an incidental finding (4%). Four patients had previously undergone laparoscopic drainage of their cyst. Imaging was performed using an Acuson (128 x P/10) unit with a 7Mz Endocavitary probe. Patients received sedoanalgesia and local analgesia. Cyst puncture was achieved using a 20 gauge Chiba needle advanced through a needle guide under US visualisation. Cysts were aspirated until dry and specimens sent for cytologic evaluation. Patients were followed with ultrasound for a mean period of 11 months (range, 1-17 months).
RESULTS: All cysts were completely anechoic, without septation of nodularity on ultrasound. Cyst puncture and complete aspiration was successful in 26 (96%) of the 27 lesions with failure in 1 patient due to inability to puncture the cyst wall. A mean volume of 127cc (range, 10- 400cc) of fluid was aspirated with no associated procedural complications. No malignant cells were detected from cysts aspirates in any patient. Cysts recurred in 3 (12%) of the 26 lesions aspirated at follow-up.
CONCLUSION: Transvaginal ultrasound guided drainage of ovarian cysts has a high technical success rate of 96% and a cure rate of 88%. Radiological treatment was well tolerated, safe, and can be performed as an outpatient procedure.
Abstract 38
RADIATION DOSES TO THE LOWER EXTREMITIES IN INTERVENTIONAL RADIOLOGY SUITES: A NEED FOR SHIELDING.
Al-Haskima H, Malone L, McGee A, Varghese J, Lee MJ. Academic Department of Radiology, Beaumont Hospital & Royal College of Surgeons in Ireland, Dublin.
PURPOSE: To investigate the radiation doses received by the lower extremities in interventional radiology suites and to evaluate the need for shielding.
MATERIALS AND METHODS: Over a 4 week period 10 interventional radiologists wore TLD's on each leg just above the ankle. Two different suites with Siemens Angioskop undercouch x-ray tubes were used. A range of procedures were carried out including angiography, embolisation, venous access, drainage and biopsy procedures. The total screening time for each procedure was recorded and correlated with the equivalent dose in mSv from the TLD's. A second identical 4 week study was performed after first suspending a 0.25mm lead curtain from the side of each interventional table.
RESULTS: Mean doses received by the legs without shielding as 71.9mSv. Indeed 1 interventionalist exceeded the limit for a Category B worker (150mSv, ICRP 1990 limit) and encroached open Category A status. Mean leg doses received after shielding was 25.77mSv. A reduction in radiation dose by a factor of 3 was seen after leg shielding was installed.
CONCLUSION: C-Arm units in interventional suites should have routine installation of protective lead shielding to reduce leg doses. One such lead shielding device will be discussed.
Abstract 39
INTERVENTIONAL RADIOLOGICAL PROCEDURES IN PATIENTS WITH BACK PAIN AT CASTLE HILL HOSPITAL.
CC Dobson, AD Taylor, E Singleton, L Harrison, A Mohsen and M Karpinski. Department of Radiology, Castle Hill Hospital, Castle Hill Road, Cottingham, E. Yorks HU16 5JQ.
PURPOSE: To investigate the outcome of therapeutic and diagnostic interventional procedures carried out on the lumbar-sacral spine at Castle Hill Hospital on patients with back pain.
MATERIALS AND METHODS: Retrospective analysis of case notes of 67 patients who had undergone either a discogram, facet joint or nerve root injection for back pain at either Castle Hill Hospital between May 1996 and May 1998. The site of injection was determined after a combination of MRI and clinical examination. All three procedures involved the injection of 0.3 mls Omnipaque 240, 0.5-1mls steroid (20-40 mgs Kenalog) and 2.5mls of Marcaine into the respective sites.
RESULTS: Ninety-three procedures were carried out on 67 patients of which 35 were discograms, 30 nerve root blocks and 28 facet joint injections. Positive provocation of the patients' symptom complex was found in 12 of the 35 discograms, 17 of the 30 nerve root blocks and 11 of the 28 facet joint injections. Immediate symptomatic relief was obtained in 2 of the 30 patients undergoing discograms, 20 of the 25 undergoing nerve root blocks and 9 of the 14 undergoing facet joint injections. Complications occurred in 3 of the 35 discograms, 3 of the 30 nerve root blocks and 1 of the 28 facet joint injections. In 5 of the 35 discograms, the procedure was abandoned at some stage.
CONCLUSION: Lumbar-sacral back pain can be effectively treated using injections of steroid and local anaesthetic. These procedures provide symptomatic relief particularly when the pain involves facet joint and nerve route components.
Abstract 40
"NO MALIGNANT CELLS" - WHAT DOES IT REALLY MEAN IN THE LUNG
G L McCulloch, A R Manhire and R H Gregson, City and University Hospitals, Nottingham.
PURPOSE: A lung biopsy which does not yield malignancy presents a significant dilemma. We have reviewed the ultimate diagnosis in 95 lung biopsies yielding no cytological evidence of malignancy performed between 1986-1995 at the City and University Hospitals, Nottingham. During this time, a total of 568 biopsies were performed to confirm a possible diagnosis of malignancy.
MATERIALS AND METHODS: All were performed with fluoroscopic guidance and fine needle. In 77 patient, the final diagnosis was confirmed by follow up over 1 month to 4 years until either histological proof was obtained or the lesion had remained unchanged for at least 18 months.
RESULTS:
No. % Finally Finally Positive benign malignant predictive value
Specific benign diagnosis 24 31 23 1 96%
No malignant cells 27 35 12 15 44%
Inflammatory cells 5 6.5 5 0 100%
Anthracotic pigment/haemosiderin 14 18 10 4 71%
Inadequate 7 9 3 4 43%
Total 77 - 53 24 69%
14 patients subsequently underwent thoracotomy because of an enlarging mass or other clinical suspicion and malignancy was confirmed in 9 (65%). The majority had an initial cytology report of normal respiratory epithelium.
Of the inadequate biopsies, only 1 was repeated and showed malignancy. Of the others, 3 ultimately had cancer (2 diagnosed on bronchial biopsy, 1 at post mortem), and in 2, radiographs were unchanged over a prolonged period.
CONCLUSION: Our study confirms that only a specific benign diagnosis is reliable. Cytological reports of normal respiratory epithelium and inadequate will be malignant in about 50% indicating probable errors of sampling at biopsy, requiring further biopsy or investigation. Suprisingly, inflammatory cells only appears to be a reliable indicator of benignity.
VASCULAR INTERVENTION Moderator: Tim Buckenham / Andrew Downie
Free papers (8 mins presentation / 2 mins discussion)
Abstract 41
A COMBINED APPROACH TO COMPLEX CAROTID DISEASE
Cleveland T, Gaines P, Brar A, Macierewic J and Beard J. Sheffield Vascular Institute, Northern General Hospital, Sheffield
PURPOSE: To review the technique and early clinical results of a combined surgical/endovascular approach for the treatment of symptomatic tandem lesions of the carotid artery.
MATERIALS AND METHODS: 6 patients presented with cerebral symptoms referable to the carotid artery territory ( 4 TIA's, 1 amurosis fugax, 1 non-disabling stoke ) and investigation revealed tandem lesions, one located at the origin of the aortic arch vessel and a second lesion at the carotid bifurcation. The origin lesions were not considered for endovascular treatment alone due to the embolic risk of selective catheterisation. Surgery required trans-sternal access. All patients had cervical carotid endarterectomy and their origin lesion was treated endovascularly at the time of surgery, using the surgical arteriotomy.
RESULTS: All 6 patients were successfully treated, 5 in the operating theatre and 1 in the angiography suite. In all cases the proximal lesion was primarily stented using a balloon mounted stent ( 5 Palmaz, 1 AVE ), whilst the surgical clamps were in place on the carotid arteries. There were no peri-operative ( 30 day ) strokes or deaths and 2 wound haematomas ( 1 requiring drainage ). Post-operative duplex examination at 6 weeks did not reveal any flow disturbance.
CONCLUSIONS: Tandem stenoses affecting the carotid bifurcation and the aortic branch arteries may be conveniently and safely treated by a combined surgical and endovascular procedure. This may take place in a conventional operating theatre or in an appropriately equipped angiography suite.
Abstract 42
ENDOVASCULAR CAROTID INTERVENTION FOR SYMPTOMATIC ATHEROSCLEROTIC DISEASE: A SINGLE CENTRE AUDIT.
P. Gaines, T. Cleveland, A. Sivaguru, J. Beard, G. Venables.
Sheffield Vascular Institute, Northern General Hospital, Sheffield S5 7AU, England.
PURPOSE: To review the entire experience of this unit performing carotid angioplasty and stenting for symptomatic atherosclerotic disease.
MATERIALS AND METHODS: 158 patients aged 45-82 yrs, 109 male, 49 female, with symptomatic carotid disease were prospectively investigated. 103 pts had a stenosis of 10-95%, 46 pts >95% and 9 pts 50-69%. Presenting symptoms were; amaurosis fugax 59 pts, retinal artery occlusion 8 pts, TIA 62 pts, minor stroke 11 pts, non-disabling stroke 19 pts, and disabling stroke 9 pts.
RESULTS: Complications at 30 days were; 3 deaths (2 ipsilateral haemorrhage, 1 ipsilateral stroke), 6 disabling stroke, 2 non-disabling stroke, 4 minor stroke, 20 TIA, 1 central and 4 branch retinal artery occlusions, 1 optic ischaemic neuropathy. The total death and disabling stroke rate was therefore 5.7% and the death and all stroke rate was 7%. Complications from 30 days to 4 yrs; 14 deaths (1 due to ipsilateral stroke), 1 ipsilateral disabling stroke and 5 non-disabling stroke.
CONCLUSION: The endovascular management of symptomatic atherosclerotic carotid disease is not a benign procedure but has the same safety profile as surgery. The assessment of efficacy at reducing stroke requires a randomised trial.
Abstract 43
LONG TERM FOLLOW UP OF BALLOON ANGIOPLASTY OF ADULT AORTIC COARCTATION
A.J.Paddon, S.J.Travis, D.F.Ettles, A.A.Nicholson, J.F.Dyet. Radiology Department, Hull Royal Infirmary, Kingston upon Hull.
PURPOSE: To assess the long term outcomes following balloon dilatation of congenital aortic coarctation in adults.
MATERIALS AND METHODS: 17 patients underwent angioplasty. One developed an immediate aortic dissection requiring surgical excision of the coarctation site (with good outcome). This patient is not included in this follow up series. The remaining 16 patients, mean age 28.0 years (range 15-60) were reviewed at a mean interval post angioplasty of 7.3 years (range 1.5-11). Patients were assessed by MRI, echocardiography and clinical examination, current parameters were compared with pre and post angioplasty figures.
RESULTS: Complications included; 1 TIA at 5 days, 1 external iliac stenosis requiring stent insertion, 1 patient developed a false aneurysm close to the coarctation site at 12 months, the false aneurysm being surgically excised. At follow up all 16 patients are alive and well. Mean systolic blood pressure for the group decreased from 174mmHg to 130mmHg. The mean number of antihypertensive drugs required per patient decreased from 0.56 to 0.31. No MRI visible stenoses were seen. Follow up duplex gradients were obtained. In the majority of cases this data was not available from the post angioplasty period for comparison. Small residual gradients were recorded in all patients.
CONCLUSION: This is the longest follow up series of its type in the literature. Long term results demonstrate the technique to be safe and effective.
Abstract 44
THE ENDOVASCULAR MANAGEMENT OF ADULT AORTIC COARCTATION
P. Gaines, J. Gunn, R. Bowes, T. Cleveland, A. John. Sheffield Vascular Institute, Northern General Hospital, Sheffield S5 7AU, England.
PURPOSE: To report a single unit experience managing coarctation of the aorta in adults using endovascular techniques.
MATERIALS AND METHODS: Between 1991-98, 15 unselected patients (M=11, F=4) aged 9-49 yrs (ave. 25 yrs) with coarctation of the aorta and hypertension were treated on 16 occasions in the Radiology Department under general anaesthesia. From 1991-6 10 patients were treated by either a kissing balloon technique or a single balloon. Since 1996, 6 patients were considered for stent placement (6 de-novo, 1 restenosis). Palmaz stents were placed in 4 patients. 2 patients were considered unsuitable for stent placement because of acute angulation of the aorta or proximity to the left subclavian artery. Follow-up is clinical and by MRA or helical CT.
RESULTS: There were no deaths or complications. The mean trans-lesion gradient was reduced from a mean of 34 mmHg to 2 mmHg. The mean systolic blood pressure fell by 30 mmHg. There were 3 recurrences out of the 10 patients treated by the kissing balloon technique. There are no recurrences in the patients treated with either a single balloon or a stent.
CONCLUSION: Single balloon dilatation and stent placement have both been successful and safe forms of treatment in these patients. Kissing balloons have a high recurrence rate.
Abstract 45
PERCUTANEOUS RENAL INTERVENTION FOR REFRACTORY CARDIAC FAILURE OR FLASH PULMONARY OEDEMA: EXPERIENCE IN NINE CASES.
Rosenfeld KM, Killeen C, Murray D, Sweeny P,Platts AD,Tibballs J,Watkinson AF
Departments of Radiology and Nephrology, Royal Free Hospital, London
PURPOSE: To review patients who presented with flash pulmonary oedema or refractory cardiac failure who on subsequent investigations were found to have either unilateral or bilateral renal artery stenosis and were treated with either renal angioplasty, balloon expandable metal stents or both. The cardiovascular response following renovascular intervention was assessed.
MATERIALS AND METHODS: Nine patients over a five year period were identified to have flash pulmonary oedema or refractory cardiac failure and renal artery stenosis. The patients were identified as they developed renal failure on commencement of ACE inhibitors. The diagnoses were suspected on post captopril isotope renography and confirmed on angiography. They all subsequently underwent renal artery angioplasty or stenting. The cardiovascular response was assessed by measurement of effort tolerance pre and post procedure, changes in diuretic requirement and changes in weight.
RESULTS: Two patients presented with flash pulmonary oedema and seven with refractory cardiac failure. Of this group eight patients had deteriorating renal function on commencement of ACE inhibitors. All nine patients improved their effort tolerance following percutaneous intervention. Of these five patients had partial improvement initially and required re- angioplasty or stent placement. Six patients were recommenced on ACE inhibitors six months following the procedure with no deterioration in renal function.
CONCLUSION: Renal artery stenosis may be the cause of refractory cardiac failure or flash pulmonary oedema. Identifying the underlying renovascular disease and treating with renal angioplasty or metallic stent placement has been shown to improve effort tolerance and has allowed patients to restart ACE inhibitors.
Abstract 46
RENAL ANGIOPLASTY AND STENTING - CLINICAL OUTCOMES.
AA Nicholson, K Baleed, D Eadington, DF Ettles, JF Dyet. Hull Royal Infirmary, Anlaby Road, Kingston upon Hull, HU3 2JZ, UK.
PURPOSE: To evaluate the clinical outcome in patients undergoing PTRA and stenting. We have previously shown good one year patency for these procedures but have not correlated this with an independent assessment of long-term clinical outcome. This study attempts to do that.
MATERIALS & METHODS: Fifty-three patients underwent PTRA and stenting. Forty-five patients underwent the procedure for renal failure and eight for hypertension. All patients were receiving anti-hypertensive medication at the time of the procedure (mean 2.7+ or -l drugs). Serum creatinine was above 120 micromols per litre in eight patients, 120-400 micromols per litre in 33 patients, and greater than 400 micromols per litre in 12 patients. The non-interventional renal artery was normal in 16 patients, and stenosed or occluded in 37 patients. Clinical follow-up was from 1-4 years.
RESULTS: There was a sustained improvement in blood pressure control in 55.5% of the patients treated. Renal function improved in 12.9% of patients with creatinine above 400 micromols per litre, and in 8.3% of patients with a creatinine below 400 micromols per litre. Progressively deteriorating renal function was stabilised in 48.4% of patients with creatinines above 400 micromols per litre, and 8.3% with creatinine below 400 micromols per litre.
CONCLUSION: PTRA and stenting is most clinically useful when used in patients with progressive renal failure whose creatinine is still above 400 micromols per litre. It can also lower blood pressure in patients with renal impairment. The adequate selection of patients with evidence of progressive renal dysfunction for PTRA and stenting is vital in slowing the relentless progression to end stage renal disease.
VASCULAR INTERVENTION Moderator: Wattie Fletcher / Derek Gould
Free papers (8 mins presentation / 2 mins discussion)
Abstract 47
INPATIENT OR OUTPATIENT ANGIOGRAPHY: WHICH DO PATIENTS PREFER?
PD Edwards, HA Cole, DS Appleton. Department of Radiology, Addenbrokes Hospital, Cambridge
PURPOSE: The rapid expansion of outpatient angiography has largely been driven by the need to reduce costs and keep hospital beds available. However, during this shift to outpatient angiography little attention has been directed to the impact on the patient's health other than to quantify any physical complications as a result of the procedure. This is the first study to investigate whether this approach affects anxiety levels, feeling of well-being, patient satisfaction or recovery time.
MATERIALS AND METHODS: 58 patients undergoing in or outpatient femoral angiography completed original and standardised (STAI) questionnaires before and after the procedure. Completed questionnaires were scored for anxiety, social effects and patient satisfaction.
RESULTS: No statistical difference was found in anxiety states before angiography between in and outpatients. A statistically significant decrease in anxiety levels was demonstrated in outpatients following the procedure, whereas an increase in anxiety levels was seen in inpatients. Patients stated a preference for outpatient investigation. No difference in recovery time was demonstrated between the two groups.
CONCLUSION: Outpatient angiography is preferred by patients, does not impair recovery time and is much cheaper to perform. When the patient is sufficiently fit, this is the investigation of choice.
Abstract 48
A NURSE-LED RADIOLOGY DAY CASE UNIT: ONE YEAR EXPERIENCE WITH ANGIOGRAPHY
E Sanderson, CM Ong, M Worrell, P Baskerville*, H Walters, P Gishen, PS Sidhu
Department of Radiology and Vascular Surgery*, King's College Hospital, London, UK
PURPOSE: To determine the safety, efficiency and patient acceptability of a nurse-led pre-angiographic assessment cinic and radiology day case unit (RDCU).
MATERIALS AND METHODS: Patients referred for peripheral vascular angiography were pre-assessed by a Specialist Radiology Nurse (SRN) in a dedicated nurse-led clinic. The SRNs were responsible for patient care before, during and after angiography and for telephone follow-up at 24 hours. The incidence of immediate and delayed complications was noted. Patient acceptability of nurse-led care was determined in a random sample of 50 patients by telephone survey.
RESULTS: All eighty-seven patients booked for day case angiography had a successful procedure. There were no serious complications. Haematoma at the puncture site occurred in 3 patients (3.9%) before discharge and in 5 patients (6.5%) at 24 hours. The majority of patients preferred the day case approach to angiography. The nurse-led pre-assessment reduced patient anxiety and patients were very satisfied with the sandard of care. There were considerable cost savings associated with nurse-led care.
CONCLUSION: Nurse-led pre-angiographic assessment and peri-procedural care in our dedicated RDCU acheives a high level of safety, comparable to a conventional physician-led service. A nurse-led service is cost-effective, reduces the physicians' workload, improves patient care and is associated with a high level of patient satisfaction. The benefits of nurse-led care in our unit could be further extended to include a range of interventional radiology procedures.
Abstract 49
COMPLICATIONS OF TRANSFEMORAL ANGIOGRAPHIC PROCEDURES: A 12-MONTH PROSPECTIVE STUDY. INTERIM 4/12 RESULTS.
I.J.McCafferty, J.Phillips-Hughes, P.Boardman, E.W.L.Fletcher & C.Woodham. Department of Radiology, John Radcliffe Hospital, Oxford
PURPOSE: To study the complications associated with diagnostic and therapeutic transfemoral angiography (TFA) at the John Radcliffe Teaching Hospital.
MATERIALS & METHODS: A proforma was completed on all diagnostic and therapeutic TFA's, performed in the interventional radiology suite. Patient demographic details, indication for angiography, operator status & interventional procedure (including access site, route, size of catheter/sheath, use of heparin and puncture site compression time) were documented. Local (puncture site) & distal complications were assessed immediately, & at 24hrs post procedure. The local complications were graded using a haematoma scoring system; <3cm (minor), 3-6cm & >6cm (major).
RESULTS: A total of 180, 115 diagnostic and 65 therapeutic, TFA procedures (119 males, 61 females) were performed in the first 4/12 of the study. In the diagnostic group there were 17 local complications (14.5%). Complication rates for consultants were 9.1% (3/33), senior registrars 14.3% (6/42) & registrars 20% (8/40), with major haematomas in 3%, 2% and 10% respectively. The therapeutic group was subdivided into 2 groups: 1. retrograde & 2. antegrade TFA procedures. The complication rate for the retrograde group was 9/50 (18%) 7 local; 2 major haematoma (4%) and 2 distal; 1 embolus (2%) and 1 rupture (2%). The complication rate in the antegrade group was 9/16 (56%), 9 local; 6 major haematoma (37.5%) & 2 distal; 2 emboli (12.5%). All haematoma's resolved spontaneously and all distal complications required surgery.
CONCLUSIONS: Therapeutic TFA is associated with a higher incidence of local and distal complications, with antegrade punctures yielding the highest complication rates. Consultants have a lower complication rate than registrars in diagnostic angiography. At present no relationship between complications & catheter size, compression time or use of heparin has been elicited.
Abstract 50
THE EFFECTS OF HIP FLEXION ON THE EXTERNAL ILIAC AND FEMORAL ARTERIES.
B J Cleary, N Chalmers. Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL
PURPOSE: To assess the effects of hip flexion on the external iliac and femoral arteries. The changes induced may have implications regarding the patency of an endovascular stent deployed in this region.
MATERIALS AND METHODS: Two additional angiographic views were performed on twenty patients (aged over fifty) undergoing angiography for peripheral vascular disease. The views were a coned lateral through the pelvis first with the legs straight then with the left hip in ninety degrees of flexion. The changes in the arteries induced by hip flexion were observed.
RESULTS: A spectrum of change was induced with varying amounts of flexion and tortuosity in the proximal femoral and external iliac arteries. The range of changes is illustrated. The most striking aspect of the study was the extent of flexion and tortuosity of the external iliac in some patients. Flexion frequently occurred in the proximal superficial and deep femoral arteries with relatively little flexion in the common femoral.
CONCLUSION: The external iliac artery is subject to considerable angulation during hip flexion. This phenomenon should be taken into account when considering the effects of stent placement in the external iliac artery.
Abstract 51
PATHOLOGICAL DIAGNOSIS OF THE MEDIASTINAL MASS: CAN CT GUIDED BIOPSY AVOID SURGICAL BIOPSY?
H.A.Moss*, M.C.Patel, M.Goddard, R.A.Coulden. Papworth Hospital, Cambridge and St James's Hospital Leeds*
PURPOSE: The best method of obtaining tissue for pathological diagnosis of a mediastinal mass is debated. The object of this study was to compare CT guided biopsy with surgical biopsy in obtaining diagnostic pathology specimens.
MATERIALS AND METHODS: We retrospectively analysed mediastinal biopsies performed over a 3 year period in our institution where traditionally all patients with a mediastinal mass would have a tissue diagnosis obtained surgically. The type of surgical procedure, needle type used in the CT guided cases, length of stay and complications were recorded. In surgical cases, imaging was reviewed to see if a CT biopsy would have been attempted.
RESULTS: Thirty two mediastinal biopsies were performed under CT guidance and 44 surgically. CT guided biopsy success was 93.5%. Only 2 patients in the CT group required subsequent surgical biopsy. In all 5 patients with lymphoma there was sufficient tissue on cutting biopsy to enable subclassification. Success of the surgical biopsy was 97.7%. One patient had an unsatisfactory surgical biopsy, a diagnosis of lymphoma was made on CT guided biopsy. In 25 (68%) of the case performed surgically, a needle biopsy could have been attempted. There were no major complications in either group.
CONCLUSION: CT guided biopsy of mediastinal masses is safe and provides accurate diagnostic information which can avoid the need for a more invasive and expensive procedure. CT guided biopsy can be recommended as the initial diagnostic procedure, even if a diagnosis of lymphoma is suspected.
Abstract 52
CARBON DIOXIDE DIGITAL SUBTRACTION ANGIOGRAPHY: THE ST GEORGE'S EXPERIENCE OF AN AUTOMATED INJECTOR.
RC Beese, NR Bees and AM Belli. Department of Diagnostic Radiology, St George's Hospital, Blackshaw Road, London, SW17 0QT.
PURPOSE: The recently developed C02 ject (Angiodynamics, Glen Falls, USA) was on trial in our department with the aim of establishing whether C02 and the C02 ject could practically and safely provide diagnostic arteriograms whilst exploiting the advantages of C02, in particular, lack of nephrotoxicity, allergenicity and osmotic load.
MATERIALS AND METHODS: 63 patients underwent peripheral arteriograms for evaluation of peripheral and renovascular disease. 30 patients later underwent renal arteriograms for investigation of hypertension and chronic renal failure. C02 was injected via a 4F pigtail or Sos Omni catheter using the C02 ject (C02 DSA) closed system which prevents air contamination. 82 patients also underwent the arteriogram with iodinated contrast medium (I2DSA). C02 DSA images were assessed in comparison with I2DSA for diagnostic quality.
RESULTS: 66% of non-selective peripheral arteriograms were completed with 34% not completed due to intolerable patient symptoms. 84% were diagnostic in the iliac vessels but this fell to 41% in the below knee vessels due to poor arterial filling with C02 . All selective studies were completed and 84% were diagnostic. 83% of renal arteriograms were diagnostic. 2 patients had intolerable symptoms with C02. 7 patients had minor tolerable symptoms. No major complications occurred
CONCLUSION: The C02 ject provides a safe and practical way of performing C02 DSA. There is a learning curve in obtaining diagnostic images but in selected patients, particularly those with renal impairment, iodine allergy and diabetics on metformin, C02 DSA is an advantageous and diagnostic alternative to I2DSA.
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Last Update: 21st October 1998
Author: Dr Andrew Downie
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