Color Flow Doppler Examination Research Articles

The effects of silodosin therapy on the parameters and patterns of ureteric jets in patients with lower urinary tract symptoms.

To our knowledge, there is no study in the literature so far to investigate the effect of silodosin therapy on the ureteric jet parameters. Therefore, the objective of this study was to investigate the effect of silodosin 8 mg/day for medical therapy of lower urinary tract symptoms (LUTS) on the color flow Doppler parameters and patterns of the ureteric jets. This prospective cohort study included 34 male patients who presented to our outpatient clinic with the complaint of lower urinary tract symptoms (LUTS) and received silodosin 8 mg once a day as medical therapy. In the color flow Doppler examinations, ureteric jets were observed and mean flow rate (JETave), maximum flow rate (JETmax), flow duration (JETdura), and flow frequency (JETfre) were examined. In addition, patterns of the ureteric jets (JETpat) were also evaluated. There was no statistically significant difference in JETave; however, JETmax, JETdura and JETfre were significantly higher at post-silodosin treatment. The patterns of ureteric jet were significantly changed following a 6-week treatment with silodosin (p<0.001). One ureter in the monophasic pattern group (9.1%) and three in the biphasic group (13.6%) turned to polyphasic pattern after silodosin use. None of the patients developed side effects that would require discontinuation of the drug. Six-week silodosin 8 mg/day therapy for the treatment of LUTS in men changed the parameters and patterns of ureteric jets at follow-up examination. Furthermore, comprehensive studies are needed on this issue.

Risk of Pulmonary Embolism in Patients With Isolated Great Saphenous Vein Thrombus.

Risks associated with isolated great saphenous vein (GSV) thrombosis remain controversial. The purpose of this study is to identify the risk of pulmonary embolism (PE) in patients with isolated GSV thrombosis, particularly those with thrombus within 3 cm of the sapheno-femoral junction. A retrospective chart review of color flow Doppler lower extremity venous ultrasound examinations from an academic hospital from 2011 to 2016 was conducted. Seventy-eight patients were identified as having acute thrombus in their GSV and were then further stratified based on the presence or absence of concomitant deep venous thrombosis (DVT). A control group of 49 patients who presented with leg swelling and were found to have a normal color flow Doppler examination was also identified. Patients without thrombus (n = 49), patients with isolated GSV thrombus (n = 29), and patients with GSV thrombus with concomitant DVT (n = 49) underwent full chart review to determine whether any patients developed PE. This was diagnosed specifically by computed tomography angiogram or ventilation/perfusion scan, within 60 days of initial diagnosis of lower extremity thrombus. In our analysis, there was no significant difference in the risk of PE in patients with isolated GSV thrombus compared with a control group of normal patients (3.5% vs 2.0%, P = 0.38). However, patients with GSV thrombus and concomitant DVT had a significantly increased risk of PE compared with patients with isolated GSV thrombus (26.5% vs 3.5%, P = 0.01). We found that the risk of PE in patients with isolated GSV thrombus is not significantly increased compared with a normal cohort.

Spontaneous resolution of an umbilical cord arteriovenous fistula

AbstractAn umbilical arteriovenous (AV) fistula is an extremely rare anomaly of the umbilical cord, with only one case being documented in the literature. The purpose of this report is to describe the prenatal sonographic characteristics of such a lesion and its potential complications. We report a case of an umbilical cord AV fistula detected at 24 weeks of gestation in one fetus of dichorionic-diamniotic twins. Color flow and spectral Doppler examinations showed a jet originating from one of the umbilical arteries entering the dilated umbilical vein. Serial ultrasounds revealed relative oligohydramnios and deep A waves in the ductus venosus for the affected twin. Upon performing fetal echocardiography assessment, mild cardiomegaly and dilatation of the inferior vena cava were detected. Chromosomal testing revealed a normal karyotype. The patient continued to be followed for close monitoring of fetal well-being and corticosteroids were administered. Cesarean section was planned for 28–30 weeks, but surprisingly, the oligohydramnios resolved, Doppler studies normalized, and no further intra-uterine growth restriction or fetal compromise was observed. Due to the recurrence of abnormal Doppler studies at 36 weeks of gestation, the patient was admitted for an induction of labor followed by a vaginal delivery of two healthy infants. Given the scarcity of reports regarding umbilical cord AV fistula, it is important to perform an extensive investigation of the affected fetus including karyotype and echocardiography. Furthermore, delivery timing should rely on close surveillance of fetal well-being to avoid the risk of fetal demise.

Acoustic Output Measured by Thermal and Mechanical Indices during Fetal Echocardiography at the Time of the First Trimester Scan

We measured acoustic output, expressed as the thermal index (TI) and mechanical index (MI), during fetal echocardiography at the time of the first trimester scan. TI and MI were retrieved from the saved displays during gray-mode, high-definition color flow Doppler and pulsed-wave Doppler (tricuspid flow) ultrasound examinations of the fetal heart and from the ductus venosus assessment. A total of 399 fetal cardiac examinations were evaluated. There was a significant increase in TI values from B-mode studies (0.07 ± 0.04 [mean ± SD]) to color flow mapping (0.2 ± 0.0) and pulsed-wave Doppler studies (0.36 ± 0.05). The TI from ductus venosus assessment (0.1 ± 0.01) was significantly lower than those from Doppler examinations of the heart. MI values from B-mode scans (0.65 ± 0.12) and color flow mapping (0.71 ± 0.11) were comparable, although different, and both values were higher than those from pulsed-wave Doppler tricuspid evaluation (0.39 ± 0.03). There were no differences in MI values from power Doppler assessment between the tricuspid flow and ductus venosus. Safety indices were remarkably stable and were largely constant, especially for color Doppler (TI), tricuspid flow (MI) and ductus venosus assessment (TI, MI). We acquired satisfactory Doppler images and/or signals at acoustic levels that were lower than the actual recommendations and never reached a TI of 0.5.

Echocardiographic measurement methods for left ventricular linear dimensions in children result in predictable variations in results

Precise quantification of left ventricular (LV) cavity dimensions assumes great importance in clinical cardiology. Pediatric guidelines recommend the left parasternal short axis (PSA) imaging plane for measuring LV cavity dimensions, while measuring from the long axis (PLA) plane is the convention in adult echocardiography. We sought to compare measurements obtained by two-dimensional (2D) and M-mode (MM) techniques in the two imaging planes. Healthy subjects were prospectively recruited for research echocardiography. Complete 2D, spectral and color flow Doppler examinations were performed in a non-sedated state. All subjects had structurally and functionally normal hearts. LV cavity dimensions were obtained in PLA and PSA views using 2D and MM yielding four measurement sets for each subject: PLA direct 2D; PLA 2D-guided MM, PSA direct 2D, PSA 2D-guided MM. A commercially available ultrasound system (Vivid E9, GE) was used and data stored digitally for subsequent analysis (EchoPAC BT11, GE). Acquisition and measurements were made by a single observer from at least three consecutive cardiac cycles, and averaged for each of the four categories. The study cohort consisted of 114 subjects (mean age 9 years, range 1-18; mean BSA 1.1 m(2), range 0.42-2.6). The smallest estimate of LV end-diastolic dimension (LVED) was obtained by PLA 2D, with larger estimates by PLA MM, PSA 2D, and PSA MM. Largest estimates of LV end-systolic dimension (LVES) are by 2D methods, with smaller estimates by both MM techniques. The smallest shortening fraction (SF) was by PLA 2D; other methods yielded larger SF. Temporal resolution is limited in 2D methodology and may account for the smaller LVED, larger LVES and smaller SF observed. Long axis methodology may predispose to off-center or non-perpendicular data acquisition and the potential for dimensional underestimation, particularly in diastole. Consistency in method for assessment of LV dimensions in children is an important factor for serial comparisons.

Detection of deep vein thrombosis with Doppler sonography

Sir, I read with interest the recent paper by Ozbudak et al. entitled ‘‘Doppler ultrasonography versus venography in the detection of deep vein thrombosis with pulmonary embolism’’ in the October 2006 issue of Journal of Thrombosis and Thrombolysis [1]. The authors stated that ‘‘The sensitivity and specificity of Doppler ultrasonography in the diagnosis of deep vein thrombosis (DVT) were 76% and 100%, respectively and the negative and positive predictive values were 81% and 100%, respectively. Although Doppler ultrasonography alone is considered sufficient for the diagnosis of DVT, venography still remains the gold standard in the diagnosis of DVT’’ [1]. I’m surprised this results and statement. Although contrast venography (CV) has been considered goldstandard technique for the diagnosis of DVT it is underused currently due to different technical problems (such as to cannulate an appropriate pedal vein is not possible in every patient; difficulty correctly interpretation of venograms; incomplete venous filling and inadequate studies) or its side effects [2]. Post-procedure DVT and skin necrosis may be observed in about 8% of examinations in spite of using non-ionic contrast media. About 5% of CV examinations are inadequate and non-diagnostic [2, 3]. Currently, ultrasound (US) using venous compression is considered the gold standard for confirmation of DVT and compression US has effectively replaced CV for the assessment of patients with suspected DVT [4, 5]. US examination is highly sensitive and specific for the diagnosis of DVT: several series have reported sensitivities and specificities approaching 95–100% for the diagnosis of DVT in the proximal lower extremity [6]. In a large, pooled series of DVT studies, the accuracy of compression US for DVT has been shown to reach 95% with 98% specificity [4]. Additional studies report a sensitivity of 95%, specificity of 99%, and accuracy of 98% for color Doppler flow imaging [7, 8]. Color flow Doppler alone without compression has shown excellent correlation with venography for evaluation of DVT with 95% sensitivity and 99% specificity; 95% of positive predictive value and 99% of negative predictive value [9]. In a recent Meta analysis related with diagnostic accuracy of sonography for DVT shown that while compression US only has 93.8% pooled sensitivity and 97.8% specificity; color Doppler only has 95.8% pooled sensitivity and 92.7% specificity for proximal DVT [10]. We also recently reviewed retrospectively 428 patients with 467 DVT examinations and 120 of 467 examinations were abnormal. About 49 of 120 patients had complete thrombus, 71 of 120 patients had partial thrombus. We observed the thrombus on gray scale ultrasound in all 120 positive patients. Color flow Doppler examinations of these patients were also abnormal [11]. In this published study, it is unclear that which diagnostic equipment and which diagnostic criteria were used for diagnosis of DVT. Who was performed DVT examination? (i.e., vascular surgeon, sonographer, or radiologist) Examination level (such as proximal or calf veins) and experience of examiner is also very important for reliable diagnosis. The American College of Radiology (ACR) Practice Guidelines for lower extremity duplex Doppler sonography includes compression, color, and spectral Doppler E. Kocakoc (&) Department of Radiology, Faculty of Medicine, Firat University, Elazig 23119, Turkey e-mail: ercankocakoc@yahoo.com

Transesophageal Echocardiography in Adult-Type Bland-White-Garland Syndrome

The origin of the left main coronary artery (LMCA) from the pulmonary artery (PA), known as Bland-White-Garland syndrome (BWGS), is a rare anomaly with mortality of 90% during infancy (1). If collateral circulation between right and left coronary systems ensues, BWGS patients may reach adulthood (1,2). However coronary flow directs preferentially into the lower pressure PA, away from the left ventricle (LV) creating “coronary steal,” and left-to-right shunt. Mitral regurgitation (MR) is further common in BWGS most likely due to multiple factors (3). Surgical correction of BWGS is strongly recommended, even in asymptomatic patients, because of the high risk of developing heart failure, myocardial infarction, ventricular arrhythmias, and sudden death (1,2). A 44-yr-old man presented with recent onset of fatigue and atrial fibrillation. Transthoracic echocardiography demonstrated severe MR with a posterior-directed jet, mild anterior mitral leaflet prolapse, a dilated mitral annulus, enlarged left atrium (5.8 cm), preserved global LV function, a moderately dilated right ventricle with moderate tricuspid regurgitation, and estimated right ventricle systolic pressure of 60 mm Hg. Because of the patient’s occasional chest pain, a persantine–thallium study was performed demonstrating a significant perfusion defect of the anterior LV wall. Cardiac catheterization revealed the absence of the LMCA in the left sinus of Valsalva. Contrast dye injected into the right coronary artery (RCA) filled the main branches of the LMCA with anomalous drainage through the LMCA into the PA. The patient was referred for mitral valve (MV) repair and correction of anomalous LMCA. Intraoperative transesophageal echocardiography (TEE) mostly confirmed the preoperative echocardiography findings but now demonstrated a large RCA (17 mm of diameter) that was identified at the right sinus of Valsalva. Color flow Doppler examination showed that the LMCA passed close to the left sinus of Valsalva with no connection to the aortic root. The LMCA origin was identified as arising from the PA, 18 mm distal to the pulmonic valve with retrograde flow into the PA (Figs. 1 and 2; please see video clip available at www.anesthesia-analgesia.org).Figure 1.: Preoperative multiplane transesophageal echocardiography (TEE), mid-esophageal aortic valve long axis view. The large orifice of the right coronary artery can be seen with laminar diastolic antegrade flow demonstrated by Color Doppler mapping. (LA, left atrium; MV, mitral valve; LVOT, left ventricle outflow tract, IVS, interventricular septum; AoV, aortic valve; AO, ascending aorta; RCA, right coronary artery.)Figure 2.: Preoperative multiplane transesophageal echocardiography (TEE), modified mid-esophageal aortic valve short axis view. The ascending aorta just above the aortic valve can be recognized. Color Doppler shows the left main coronary artery (LMCA) passing close to the left sinus of Valsalva however with no identified connection to the Aortic root. (LA, left atrium; RA, right atrium; IAS, interatrial septum; AO, ascending aorta.)The patient underwent uncomplicated reimplantation of the LMCA into the aortic root and MV repair. The postoperative TEE showed LMCA orifice reimplanted into the left sinus of Valsalva, and the MV annuloplasty ring with mild MR (Fig. 3).Figure 3.: Postoperative multiplane transesophageal echocardiography (TEE), mid-esophageal aortic valve short axis view. The LMCA orifice now reimplanted into the left sinus of Valsalva can be seen. (LA, left atrium; RA, right atrium; IAS, interatrial septum; LCC, left coronary cusp; RCC, right coronary cusp; NCC, noncoronary cusp; LMCA, left main coronary artery.)Identification of the coronary orifices and normal coronary flow pattern is an important part of a TEE examination. Young adults with no risk factors for coronary disease may present with MR and unrecognized BWGS. In the presence of a single enlarged RCA orifice, BWGS should be considered.

Coil Occlusion of Residual Shunts After Surgical Closure of Patent Ductus Arteriosus

OBJECTIVE; To describe use of coil embolization to occlude residual flow through a patent ductus arteriosus (PDA) after incomplete surgical ligation. Clinical study. Dogs (n=4) with continuous murmur after surgical ligation of PDA. After PDA ligation, residual ductal flow through the PDA was visible on color-flow Doppler examination and left ventricular end-diastolic diameter remained increased. Coil embolization by an arterial approach was performed to achieve complete occlusion of the PDA. Embolization coils were delivered without complications and hemodynamically successful occlusion was achieved. Doppler-visible flow resolved in 2 dogs within 3 months after embolization. Left ventricular end-diastolic diameter indexed to body weight decreased in all dogs. Transcatheter coil embolization appears to be a safe and minimally invasive procedure for complete occlusion of residual PDA flow after incomplete surgical ligation. Transcatheter coil embolization should be considered for correction of hemodynamically significant residual shunts in dogs that have incomplete PDA occlusion after open surgical ligation.

Pressure Half-Time Alternans in Aortic Regurgitation: Effects of Intra-Aortic Counterpulsation

was continued throughout the operation. Intraoperative transesophageal echocardiography of the aortic valve (AV) in the midesophageal short- (30°) and long-axis (130°), transgastric long-axis and deep transgastric left-ventricular (LV) views revealed a tricuspid AV with normal systolic opening. Color-flow Doppler examination in the midesophageal long-axis view (130°) revealed a narrow turbulent jet arising from the base of the AV directed toward the center of the LV outflow tract (LVOT) during diastole. The width of the AR jet was 20% of the diameter of the LVOT. Examination of the descending aorta did not reveal diastolic flow reversal. Based on the previous findings, the AR was graded as mild (1). After bypass, when the IABC was set at a trigger ratio of 1:2, the continuous-wave Doppler signal of the AR jet and the pulse-wave Doppler signal of the LVOT were fluctuating. The AR jet pressure half-time (PHT) decreased with each IABC (Fig 1, top), indicating worsening AR. The LVOT velocity was higher after IABC (Fig 1, bottom). During the same time, there were no obvious changes of AR severity by color-flow echocardiography. Is this a case of worsening AR?

Doppler evaluation of erectile dysfunction – Part 2

Doppler evaluation in erectile dysfunction (ED) has a significant role in determining the cause of ED. The advantages of penile Doppler and pharmacologic duplex ultrasonography include objective, minimally invasive evaluation of penile hemodynamics at a relatively low cost. Arteriogenic ED may be secondary to peripheral vascular disease and diabetes, or may be seen in association with coronary artery disease. Various parameters, such as diameter of the cavernosal artery, peak systolic flow velocity, degree of arterial dilatation and acceleration time, have been suggested for the diagnosis of arteriogenic ED, but peak systolic flow velocity is the most accurate indicator of arterial disease. This second part of the review article describes the various causes of ED and the interpretation and evaluation of color flow Doppler examination in ED.

Percutaneous ethanol injection treatment in benign thyroid lesions: role and efficacy.

To establish the role of percutaneous ethanol injection (PEI) treatment in benign thyroid lesions by evaluating: (1) the long-term efficacy and side effects of the treatment, (2) the factors predictive of efficacy of PEI, and (3) the cost effectiveness of the procedure. Fifty-eight recurrent cystic nodules, 95 autonomously functioning nodules (AFTN), and 17 hyperfunctioning nodules causing thyrotoxicosis (toxic nodules) were treated by PEI from 1990 to 1996 in our center. Ultrasound (US) and color flow doppler (CFD) examinations were carried out before and after each treatment. In patients with AFTN, serum thyrotropin (TSH), free triiodothyronine (FT3), free thyroxine (FT4), thyroid peroxidase antibody (TPOAb) levels were tested before and after PEI. All patients were independently reexamined by two external reviewers after a minimum follow-up of 5 years (median, 6.9 years). The median number of treatments was 2.0 (range, 1.0-4.0) for cystic nodules, 4 (range, 2.0-6.0) for AFTN, and 5 (range, 3.0-7.0) for toxic nodules. At the 5-year evaluation cystic nodules showed a volume reduction greater than 75% versus baseline in 86.2% of cases and an improvement of local symptoms in 91.4% of cases. AFTN presented serum TSH within normal limits in 60.0% of patients. Toxic nodules showed a detectable serum TSH and normal FT3 and FT4 values in 35.3% of cases. Two cases of transient dysphonia were observed. In cystic lesions no significant correlation was found between the baseline and the final volume (r2 = 0.17) and no significant predictor of treatment efficacy was found. However, unilocularity was associated with a lower number of treatments than multilocularity (median, 2.0 vs. 3.0). Independent predictors of clinical efficacy in both AFTN and toxic nodules were a baseline volume less than 5.0 mL and a fluid component greater than 30% (odds ratio [OR] = 6.1 and 3.3, respectively). Most recurrent cystic lesions of the thyroid can be cured by PEI, which should become the first line of treatment. The majority of AFTN and toxic nodules with volume less than 5.0 mL presented a marked volume decrease and normal serum TSH levels when treated by PEI, which seems a valid alternative to clinical follow-up alone in patients refusing 131I. PEI is not indicated in large or toxic nodules, for which 131I is the treatment of choice.

Intraoperative rupture of the endoaortic clamp balloon in a patient undergoing port-access mitral valve repair

A 66-year-old man (t65 cm, 71 kg) had a 10-year history of mitral valve disease with minimal symptoms. Over the last year, he developed increased shortness of breath and fatigue with physical activity; in the last several months, he was unable to climb a flight of stairs without dyspnea. He underwent a cardiac catheterization, which showed a mildly dilated left ventricle (LV) with an estimated ejection fraction of 83%, 3 + to 4+ mitral regurgitation with a flail posterior mitral leaflet, and a mean pulmonary capillary wedge pressure of 13 mmHg, increasing to 24 mmHg with a V wave to 45 mmHg. Coronary anatomy was normal. He was referred for mitral valve repair or replacement, and a Port-Access, minimally invasive procedure using the Heartport EndoCPB system (Heartport Inc, Redwood City, CA) was planned, The patient was admitted on the same day of surgery. Bilateral radial artery catheters and a pulmonary artery catheter (Swan-Ganz; BaxterEdwards Inc, Deerfield, IL) were inserted. Midazolam, 5 rag, was administered intravenously for sedation. On arrival in the operating room, arterial blood pressure was 125165 mmHg (mean arterial pressure, 80 mmHg); mean pulmonary artery pressure, 30 mmHg; cardiac index, 2.2 L/min/m 2, and heart rate, 60 beats/rain. After preoxygenation, general anesthesia was induced with fentanyl, 500 pg; midazolam, 5 rag; and cisatracurium, 16 mg. The trachea was intubated, and the lungs were ventilated with isoflurane in oxygen. A biplane transesophagoal echocardiography (TEE) probe (Hewlett-Packard, MA) was inserted. The baseline two-dimensional and color-flow Doppler examination confirmed severe mitral regurgitation and valvular changes suggestive of myxomatous degenerative disease, with ruptured chordae and a flail posterior leaflet. The aortic valve appeared normal without regurgitant flow, and the ascending and descending parts of the thoracic aorta were without echocardio~:aphic evidence of significant atheromatous disease. Access to the heart was achieved through a 6-era submammary incision, and the chest was entered through the fourth right intercostal space. The left femoral vessels were exposed through a groin incision, and after systemic anticoagulation with heparin, the Heartport Endoarterial Return cannula was inserted into the femoral artery. A guidewire was advanced from the femoral vein to the right atrium, visualized by TEE, and the Heartport Endovenous Drainage cannula was advanced into the fight atrium with the tip at the superior caval atrial junction. The Heartport Endoaortic Clamp was advanced over a guidewire and positioned in the ascending aorta with the tip slighdy above the sinotubular ridge, as seen by TEE. The surgeon inserted a retrograde cardioplegia catheter through a right atrial purse-string cannulation site into the coronary sinus, guided by TEE and pressure waveform.

Renal pedicle torsion after simultaneous kidney-pancreas transplantation

Background: Simultaneous kidney-pancreas transplantation has become a recognized therapy for type I diabetes mellitus patients with diabetic nephropathy, neuropathy, and retinopathy. In the vast majority of these procedures, both grafts are placed intraperitoneally, which reduces posttransplant morbidity. Recently, in some of our recipients, we noted renal dysfunction related to complications of the renal pedicle. Our objectives in this study were to identify the cause of this renal dysfunction and to prevent its occurrence in future recipients. Study Design: We undertook a retrospective chart review of simultaneous kidney-pancreas recipients who experienced renal dysfunction related to renal pedicle complications. Results: We found four recipients with renal dysfunction related to renal pedicle torsion, diagnosed by serial ultrasound scans and kidney graft biopsies. Early diagnosis allowed salvage of three kidney grafts, but one was lost after late diagnosis. Conclusions: A high level of suspicion is needed to diagnose renal pedicle torsion. If simultaneous kidney-pancreas recipients have recurrent renal dysfunction, and rejection has been excluded, serial ultrasound scans with color flow Doppler examinations are needed. Once the diagnosis is made, a nephropexy to the anterior abdominal wall is indicated to prevent further torsion and save the kidney graft. We recommend prophylactic nephropexy of left renal grafts if the renal pedicle is ≥5 cm long and if there is a 2 cm or more discrepancy between the length of the artery and the vein.

Predicting Hemodialysis Access Failure with Color Flow Doppler Ultrasound

Color flow doppler ultrasound examination of the hemodialysis access was conducted in 2,792 hemodialysis patients to evaluate its value in predicting hemodialysis access failure. After baseline assessment of vascular access function with clinical and laboratory tests including color flow doppler evaluation these patients were followed for a minimal of 6 months or until graft failure occurred (defined as surgery or angioplasty intervention, or graft loss). The patient demographics and vascular accesses were typical of a standard hemodialysis patient population. On the day of the color flow doppler examination systolic and diastolic blood pressure, hematocrit, urea reduction ratio, dialysis blood flow, venous line pressure at a dialysis blood flow of 250 ml/min, and access recirculation rate were measured. At the conclusion of the study 23.5% of the patients had access failure. Case mix predictors for access failure were determined using the Cox Model. Case mix predictors of access failure were race, non-white was higher than white (p < 0.005), younger accesses had a higher risk than older accesses (p < 0.025), accesses with prior thrombosis had a higher risk of failure (p = 0.042), polytetrafluoroethylene (PTFE) grafts had a higher risk than native vein fistulae (p < 0.05), loop PTFE grafts had a higher risk than straight PTFE grafts (p < 0.025), and upper arm accesses had a higher risk than forearm accesses (p = 0.033). Most significant, however, was decreased access blood flow as measured by color flow doppler (p < 0.0001). The relative risk of graft failure increased 40% when the blood flow in the graft decreased to less than 500 ml/min and the relative risk doubled when the blood flow was less than 300 ml/min. This study has shown that color flow doppler evaluation, quantifying blood flow in a prosthetic graft, can identify those grafts at risk for failure. In contrast, color doppler volume flow in native AV fistulae could not predict fistula survival. This technique is noninvasive, painless, portable, and reproducible. We believe that preemptory repair of an anatomical abnormality in vascular access grafts with decreased blood flow may decrease patient inconvenience, associated morbidity, and associated costs.

Transcatheter occlusion of secundum atrial septal defects with the self-centering Amplatzer Septal Occluder

A new approach to transcatheter occlusion of secundum atrial septal defects uses the self-centering and repositionable `Amplatzer Septal Occluder'. This report presents our initial clinical experiences with this device, made from a 0.005-inch Nitinol mesh and polyester fabric. During a 2-year period, 98 patients (median age 6.3 years, range 1–43 years, median weight 22 kg, range 10–82 kg) with secundum atrial septal defects were evaluated for transcatheter closure of the defect using the Amplatzer Septal Occluder. The diameters of the defects measured by transesophageal echocardiography ranged from 5 to 23 mm (median 12 mm) and the stretched diameters measured by balloon catheter ranged from 7 to 28 mm (median 15 mm). Established criteria for interventional treatment were met in 98 patients and defect implantation was successful in 88 of them (89.8%). Median fluoroscopy time was 15 min (range 7–64 min) and the total procedure time was 90 min (range 55–16 min). After 24 h, colorflow Doppler examination showed complete defect closure in 72 of the 88 (82%) patients. Complete closure was demonstrated in 55 (96.5%) of 57 patients followed for at least 3 months after implantation. In all 10 patients followed for more than 1 year, no residual shunts were found. No clinical complication, fracture of the device wires, or embolization of the device has occurred.

Percutaneous transluminal rotational atherectomy in the treatment of peripheral vascular disease using a transluminal endatherectomy catheter (TEC): Initial results and angiographic follow-up

To evaluate the clinical results of percutaneous transluminal rotational atherectomy in the treatment of peripheral vascular disease. Rotational atherectomy was performed in 39 patients aged 39-87 years (mean 66.6 years). A total of 71 lesions (43 stenoses and 28 occlusions) were treated in 40 limbs. Additional balloon angioplasty was required in 54% of lesions. Fifteen patients (37.5%) presented in Fontaine stage II, 10 patients (25%) in Fontaine stage III and 15 patients (37.5%) in Fontaine stage IV. Rotational atherectomy at 750 rpm was carried out over a 0.014-inch guidewire with continuous aspiration into a vacuum bottle. Follow-up angiography and color flow Doppler examinations were performed in 22 patients (23 limbs) after a mean period of 6 months (range 2-14 months). There was one primary technical failure. In 36 of 40 lesions there was a good angiographic result with residual stenoses in less than 30%. In 70 lesions treated by rotational atherectomy, however, 54% showed residual stenoses of 30%-50% and these cases required additional balloon angioplasty. The mean ankle-brachial index improved significantly (p << 0.001) from 0.49 before the procedure to 1.01 after the procedure. A single distal embolus, related to primary recanalization, occurred and there were two large inguinal hematomas. Cumulative clinical patency after 6 months was 83.8% and cumulative angiographic patency after 6 months was 79.1%. Percutaneous rotational atherectomy is a promising approach for the treatment of chronic peripheral vascular disease. Further prospective, randomized studies are necessary to compare percutaneous transluminal angioplasty with this new technical approach.

Left ventricular pseudoaneurysm with left atrium tamponade: A rare postinfarction complication

A 65-year-old man was readmitted to the hospital with deep-vein thrombophlebitis 3 weeks after suffering a small infarction. Two days after the patient was readmitted severe symptoms of cardiac failure developed. Transthoracic echocardiographic examination showed an unusual echo-free space adjacent to the lateral wall of the left atrium. No further diagnostic information could be obtained from precordial examinations. Single-plane transesophageal echocardiography demonstrated the presence of a ruptured aneurysm in the posterolateral wall of the left ventricle and a pseudoaneurysm, which was severely compressing the left atrial cavity. On color-flow Doppler examination a tear was detected in the wall of the left ventricular aneurysm close to the posterior atrioventricular sulcus. Pericardial adhesions because of coronary artery bypass grafting performed 10 years before may have contributed to the unusual location of this left ventricular pseudoaneurysm, complicated with left atrium tamponade after myocardial infarction. (J Am Soc Echocardiogr 1997;10:582-7.)

Testis Sparing Surgery for Steroid Unresponsive Testicular Tumors of the Adrenogenital Syndrome

Surgical management of steroid unresponsive testicular tumors of the adrenogenital syndrome has been orchiectomy. Magnetic resonance imaging (MRI) of these tumors accurately delineates the extent of disease. Testis sparing surgery is an important consideration, since male individuals with congenital adrenal hyperplasia are potentially fertile. We present our results of surgical management of this tumor based on MRI findings. Four boys with steroid unresponsive testicular tumors of the adrenogenital syndrome were evaluated with MRI, testicular ultrasound and color flow Doppler examinations preoperatively and postoperatively. Three patients had 21-hydroxylase deficiency and 1 had 3-beta-hydroxysteroid dehydrogenase deficiency. Contralateral testicular abnormalities included a vanished testis, testicular atrophy due to trauma and bilateral tumors in 1 boy each. Bilateral orchiectomy and surgical enucleation were performed in 1 and 3 patients, respectively. Followup ranged from 8 to 18 months. Postoperative MRI of the testis in 2 of 3 patients showed no evidence of recurrent tumor. Postoperative testicular sonography revealed no tumor and vascular flow in 2 of 3 patients. All 3 patients who underwent testis sparing surgery have a viable testis in the scrotum without evidence of recurrent disease. MRI of the testis in patients with testicular tumors of the adrenogenital syndrome accurately defines the extent of disease. Surgical enucleation of this tumor has been performed successfully without recurrent disease. This surgical approach should be considered for any patient with a steroid unresponsive tumor and contralateral abnormalities. We believe that surgical enucleation is the procedure of choice for all patients with this tumor, since it maximizes future fertility potential.

Assessment of Resectability of Pancreatic Head and Periampullary Tumors by Color Flow Doppler Sonography

To examine the sensitivity of color flow Doppler ultrasonography in assessing resectability of pancreatic head and periampullary tumors. Validation cohort study. Tertiary care public hospital. Thirty-seven patients with pancreatic head or periampullary cancer were studied by color flow Doppler examination of the relevant blood vessels. A pancreatic Doppler score (PDS) was defined as the closest circumferential contact of the tumor to the superior mesenteric vein, superior mesenteric artery, or portal vein. A PDS of 1 indicated no contact (n = 9); PDS 2, less than 50% contact (n = 10); PDS 3, 50% to 99% contact (n = 7); and PDS 4, encasement (n = 11). The PDS was compared with operative and histologic resection margins. The lack of vascular invasion was confirmed operatively in 7 of 7 patients with a PDS of 1, and 6 patients who underwent resection had clear histologic margins. Nine (90%) of 10 patients with a PDS of 2 were confirmed to have no vascular invasion, and 3 (43%) of 7 patients who underwent resection had clear margins. Five (83%) of 6 patients with a PDS of 3 had correct operative findings, and both patients who underwent resection had positive margins. Operative confirmation of encasement was found in all 7 patients with a PDS of 4 who had operative exploration, and none underwent resection. Color flow Doppler sonography and PDS predicted resectability and the histologic margin status (positive predictive value, 97%). Patients with a PDS of 1 are predicted to have clear histologic margins after resection. Patients with a PDS of 4 have unresectable tumors, and nonoperative palliation should be considered. Patients with a PDS of 2 or 3 have a high likelihood of positive histologic margins after resection and may be candidates for neoadjuvant chemotherapy.

Doppler evaluation of central venous lines in the superior vena cava

Thrombus formation in the superior vena cava (SVC) complicates the use of central venous catheters. Visualizing the thrombus by two-dimensional echo-cardiography is often difficult. Flow in the SVC can be recorded by using color flow Doppler examinations. Hence SVC flow was evaluated by color flow Doppler in 12 patients before and within 48 hours of central venous catheters. Five patients with catheters in their SVCs, with suspected thrombus or obstruction to the SVC, were also studied. The SVC flow in the subjects before catheter placement was characterized by two distinct peaks, respiratory variability, and maximal velocities between 0.5 and 1.5 m/sec; these were unchanged by the catheters. The five patients with thrombus or obstruction had turbulent flow, loss of a distinct biphasic profile, and increased velocity downstream to the thrombus and decreased velocity upstream. It appears that Doppler study is a worthwhile adjunct to two-dimensional echocardiography in the evaluation of catheter-related thrombus, and that an altered SVC flow profile with increased velocity suggests thrombus formation or obstruction or both.