Need For Arteriography Research Articles

Vascular surgery, quo vadis?

Vascular surgery, currently a mono-specialty in a large number of countries, is dedicated to the diagnosis and management of all aspects of vascular disease (arterial, venous, and lymphatic), excluding the heart and brain vessels. Vascular diagnosis is complemented by non-invasive tests that are frequently performed by the managing physician, regardless of the intention for interventional treatment. Non-invasive tests, originally limited mainly to vascular ultrasound but now expanded to include computed tomography and magnetic resonance angiography, have largely reduced the need for arteriography and its attendant risks, preserving its diagnostic ability, and even improving preoperative planning and patient selection. The dawn of the new millenium found Vascular Surgery strengthened by the FDA approval of endografts for endovascular aneurysm repair (EVAR), a minimally invasive treatment that proved to be a revolution for the treatment of abdominal aortic aneurysms (AAA). It was clear at that point that a decade of research was successfully translated into clinical practice; however, the adoption of EVAR was really supported by trial evidence that became available the following years (1). Stretching the anatomical indications of EVAR and the need for endless follow-up has been a real challenge, partially addressed by new types of endografts. Around the same time, endoluminal vein ablation (ELVA) of the saphenous veins was also approved. Being further refined as new minimally invasive technology is invented, ELVA has replaced a large number of stripping procedures worldwide. Other areas where endovascular techniques have expanded our treatment armamentarium include the peripheral arteries, in order to prevent limb loss, deterioration of quality of life or death. Drug eluting stents and balloons, covered stents and improved atherectomy devices have been introduced into clinical practice. An area of active debate is the optimum management of extracranial carotid artery stenosis, where endarterectomy is still considered the standard of care, but judicious use of angioplasty and stenting (CAS) might improve outcomes in symptomatic patients. The availability of modern medical treatment has challenged the need for intervention in most patients with asymptomatic carotid artery stenosis and randomized controlled trials (CREST-2) are underway. Selective use of intervention in high-risk groups at a low peri-procedural risk and with sufficient life expectancy is required (2, 3). Vascular surgeons are actively involved in all kinds of trauma involving the blood vessels and also when these are thrombosed, including deep-vein thrombosis. The advent of new oral anticoagulants is expected to simplify the management of venous thromboembolism (4), but the post-thrombotic syndrome (PTS) is expected to be a burden for affected patients, unless pre-emptive thrombus removal becomes popular (5). Finally, vascular access for hemodialysis has been improved with efforts toward preferential construction of native arteriovenous fistulas and increased longevity of maintenance procedures performed for access complications being fruitful; however, there is an unmet need for further improvements, necessary for this challenging patient population. The present Specialty Grand Challenge article officially launches the Vascular Surgery Section of Frontiers in Surgery. The goal is to provide a unique open access forum for publication and rapid dissemination of important research covering the entire spectrum of Vascular Surgery.

Vascular Injuries in Knee Dislocations: The Role of Physical Examination in Determining the Need for Arteriography

Vascular Injuries in Knee Dislocations: The Role of Physical Examination in Determining the Need for Arteriography

The inaccuracy of simple visual interpretation for measurement of carotid stenosis by arteriography

To determine intraobserver and interobserver variability of carotid arteriography interpretation as well as the reliability of simple visual interpretation (SVI) or "eyeballing" of arteriography in the measurement of internal carotid artery stenoses. Intraobserver and interobserver measurements of 200 carotid arteriograms were performed in a blinded fashion by two vascular surgeons (VS1 and VS2) using a digital caliber computer program similar to software available in catheterization laboratories. The distal normal internal carotid artery was used as a frame of reference. These computer-derived measurements were compared with previous SVI measurements, found by retrospective chart review, that were performed at the initial time of arteriography. Intraobserver agreement (VS1a vs VS1b and VS2a vs VS2b) within +/-5% using the computer program was 94% and 92%. Interobserver agreement within +/-5% using the computer program for the four possible combinations ranged from 43% to 48%. Interobserver agreement using the computer program increased to 83% to 88% for correct stenosis interpretation within +/-20%. In the 16% to 49% category (by computer measurement), SVI would have placed the stenosis in a higher category 40% to 56% of the time. Likewise, in the 50% to 79% category, comparing SVI with the four different computer caliber measurements, SVI overestimated the stenosis to the 80% to 99% category by 30% to 44%. In the 80% to 99% category, SVI overestimated lesions in 27% to 51% of the cases. All occlusions seen on SVI correlated with computer program measurements. The computer readings in many cases downgraded the degree of carotid stenosis into a lower category and in some cases, may have led to a different treatment paradigm. SVI never underestimated carotid stenosis compared with all matched computer program measurements. Compared with a method of objective measurement similar to that used in a catheterization laboratory, SVI overestimated most carotid artery stenoses. Given the coming era of carotid stenting and a renewed need for arteriography before carotid intervention, knowledge of variability and correct interpretation of carotid stenosis using available technology remains paramount to warranted treatment.

Vascular Injuries in Knee Dislocations

Popliteal artery injury is frequently associated with knee dislocation following blunt trauma, an injury that is being seen with increasing frequency. The primary purpose of the present study was to evaluate the use of physical examination to determine the need for arteriography in a large series of patients with knee dislocation. The secondary purpose was to evaluate the correlation between physical examination findings and clinically important vascular injury in the subgroup of patients who underwent arteriography. One hundred and thirty consecutive patients (138 knees) who had sustained an acute multiligamentous knee injury were evaluated at our level-1 trauma center between August 1996 and May 2002 and were included in a prospective outcome study. Four patients (four knees) were lost to follow-up, leaving 126 patients (134 knees) available for inclusion in the study. The results of the physical examination of the vascular status of the extremities were used to determine the need for arteriography. The mean duration of follow-up was nineteen months (range, eight to forty-eight months). Physical examination findings, magnetic resonance imaging findings, and surgical findings were combined to determine the extent of ligamentous damage. Nine patients had flow-limiting popliteal artery damage, for an overall prevalence of 7%. Ten patients had abnormal findings on physical examination, with one patient having a false-positive result and nine having a true-positive result. The knee dislocations in the nine patients with popliteal artery damage were classified, according to the Wascher modification of the Schenck system, as KD-III (one knee), KD-IV (seven knees), and KD-V (one knee). Selective arteriography based on serial physical examinations is a safe and prudent policy following knee dislocation. There is a strong correlation between the results of physical examination and the need for arteriography. Increased vigilance may be justified in the case of a patient with a KD-IV dislocation, for whom serial examinations should continue for at least forty-eight hours.

The Use of Colorflow Duplex Scanning to Detect Significant Renal Artery Stenosis

The purpose of this study was to review our institutional experience with colorflow duplex scanning in detecting significant renal artery stenosis and to validate the criteria used: renal artery peak systolic velocity (PSV) >/=200 cm/sec and renal-to-aortic peak systolic ratio (RAR) >/=3.5. The results of renal artery duplex and arteriography in 58 patients (107 kidneys) who underwent both exams were reviewed. Arteriography revealed 32 main renal arteries with >/=60% stenosis. The PSV criterion detected 29, for a sensitivity of 91%, specificity of 75%, positive predictive value (PPV) of 60%, negative predictive value (NPV) of 95%, and accuracy of 79%. Using RAR >/=3.5 provided a sensitivity of 72%, specificity of 92%, PPV of 79%, NPV of 88%, and accuracy of 86%. In a subset of 36 kidneys that had hilar scans, the criteria of acceleration time (AT) >/=100 cm/sec and index (AI) </=3.78 kHz/sec were evaluated. The AT and AI yielded sensitivity of 50% and 36%, specificity of 86% and 100%, PPV of 70% and 100%, NPV of 73% and 71%, and accuracy of 72% and 75%, respectively. Colorflow duplex scanning is clinically useful in screening for hemodynamically significant renal artery stenosis. The renal artery PSV criterion is highly sensitive, with a high NPV that obviates the need for arteriography in most cases of a negative duplex. The criteria of RAR, AT, and AI are of less value.

State-of-the-art magnetic resonance imaging of the kidneys and upper urinary tract.

State-of-the-art magnetic resonance imaging (MRI) is an excellent examination in several clinical contexts of interest to endourologists. First, it offers a one-stop imaging examination of prospective renal donors, obviating the need for arteriography and conventional excretory urography. Second, it reliably depicts urinary tract obstruction and can usually distinguish acute from chronic obstruction, although it is not as sensitive as helical CT in detecting small, nonobstructing stones. Third, it is an excellent examination for characterizing renal masses, especially complex cystic masses, and for surgical planning. Because MRI does not use ionizing radiation and because gadolinium contrast agents are essentially non-nephrotoxic, MRI is especially useful in children, women of childbearing age, and patients with renal insufficiency or renal allografts. Future developments will likely include MR "fluoroscopy," which will provide real-time imaging guidance for interventional procedures in the urinary tract.

Spontaneous dissection of the internal carotid artery: a nineteen-year clinical experience.

This article reviews our experience with internal carotid artery dissection (ICAD), evaluates the usefulness of Duplex scanning in diagnosis, provides current recommendations for treatment, and better defines long-term prognosis. The records from 1976 to 1995 of 24 patients who had 28 ICAD were reviewed. All diagnoses were confirmed by arteriography. Presenting symptoms, diagnostic tests, clinical management, and outcome were examined. Nine patients had visual symptoms or headache, 10 had transient focal neurologic symptoms (TIA), and five had stroke. Five of the 19 who had visual symptoms or TIA had a stroke before the diagnosis of ICAD. Seventeen patients who had 19 ICAD underwent a Duplex scan at the time of presentation. Duplex scan identified 18 arterial abnormalities consistent with ICAD (sensitivity, 95%). Three patients died from stroke during the initial hospitalization. Of the 21 who survived, 12 were treated with anticoagulation therapy, six with aspirin, and three with aspirin and anticoagulation therapy. None of the 21 patients had a subsequent stroke. Six patients subsequently had an operation for residual occlusive disease or aneurysm. The mean duration of follow-up was 9.3 years. Two patients developed contralateral ICAD. During follow-up, 19 arteries were studied with Duplex scan, and seven had no residual evidence of ICAD. Patients who have ICAD often have prodromal symptoms before stroke. If diagnosed early, treatment with anticoagulation may prevent stroke. Duplex scans are accurate for defining carotid abnormalities consistent with ICAD and for indicating the need for arteriography. Patients should undergo a follow-up Duplex scan to identify contralateral ICAD.

Distinguishing Carotid Artery Pseudo-Occlusion With Color-Flow Doppler

This study was undertaken to determine the impact of color-flow Doppler on the accuracy of noninvasive carotid imaging for distinguishing an internal carotid artery pseudo-occlusion (string sign) from a complete occlusion. From January 1985 to January 1994, review of noninvasive vascular studies, arteriograms, and operative reports of 26 consecutive patients undergoing 27 carotid endarterectomies for carotid pseudo-occlusion was performed. Further review was conducted of all patients identified with carotid occlusion by noninvasive testing who underwent confirmatory arteriography during the same interval. Conventional gray-scale duplex scanning (January 1985 to December 1989) correctly identified 3 of 11 (27%) pseudo-occluded internal carotid arteries compared with 15 of 16 (94%) internal carotid artery pseudo-occlusions correctly identified by color-flow Doppler (January 1990 to June 1994) (P < .01). Similarly, carotid occlusion was more accurately identified by color-flow Doppler (33 of 33, 100%) compared with gray-scale duplex scanning (19 of 27, 90%) (P < .01). The addition of color-flow Doppler to the duplex evaluation of the extracranial carotid circulation improves the accuracy of distinguishing carotid pseudo-occlusion from the occluded internal carotid artery and may obviate the need for arteriography to identify patients with this critical level of carotid stenosis.

Role of arteriography in the preoperative evaluation of carotid artery disease

This retrospective study was undertaken to determine the role of arteriography in the treatment of patients being considered for carotid endarterectomy. The results of preoperative classification of disease severity by duplex ultrasound and arteriography were compared, and the impact of arteriography on patient management was ascertained. We reviewed the records of 83 patients who had carotid surgery planned on the basis of their clinical history and duplex scan results and who then underwent arteriography. Duplex scan results agreed with the classification of stenosis by arteriography in 87% of evaluated sides and were within one category in 98%. In 87% of the cases reviewed, the clinical presentation and duplex scan findings were sufficient for appropriate patient management. In the instances that arteriography was useful (13%), the need for arteriography was evident when the duplex scan (1) was technically inadequate or equivocal; (2) showed an unusual distribution of disease, atypical anatomy, or a recurrent lesion; or (3) demonstrated an internal carotid artery with diameter-reducing stenosis of less than 50% in a patient with hemispheric neurologic symptoms despite antiplatelet therapy.

Is Arterial Proximity a Valid Indication for Arteriography in Penetrating Extremity Trauma?

Three hundred seventy-three patients with a penetrating extremity injury were studied to assess the yield of arteriography. Patients underwent arteriography if any of the following was present: bruit, history of hemorrhage or hypotension, fracture, hematoma, decreased capillary refill, major soft-tissue injury, or nerve or pulse deficit. In the absence of these findings, arteriography was performed if the injury was in "proximity" to a major neurovascular bundle. In 216 patients, arteriography was performed when an abnormal finding was noted. Sixty-five injuries were identified, 19 requiring intervention. Proximity was the indication for arteriography in 157 patients. Seventeen injuries were identified, of which one required repair. In penetrating extremity trauma, the need for arteriography is based on clinical findings. The use of arteriography to screen for an arterial injury when proximity alone is the indication rarely identifies a significant injury and should be abandoned.

Can Duplex Scanning Replace Arteriography for Lower Extremity Arterial Disease?

This preliminary study was undertaken to determine if surgeons would choose different intervention for lower extremity occlusive disease when given basic clinical information and data from either a duplex scan or arteriogram. Information on degree of stenosis from duplex scans and arteriograms of 29 patients was indicated on an anatomical line drawing along with the ankle blood pressures and a brief clinical description. Based on these data sheets, six vascular surgeons chose a clinical plan in a blinded fashion for each patient. Each plan was placed into one of eight possible categories for comparison using the kappa statistic. Intraobserver agreement between surgeons' decisions based on duplex scanning versus those based on arteriography was very good (mean kappa .70 with exact agreement in 76%). Interobserver agreement between different surgeons' decisions based on the same studies was significantly less (mean kappa 0.56, p less than .05). Significant disparity in clinical approach occurred in 43% of the patients with nearly identical duplex scan and arteriogram reports, suggesting that much of the discrepancy lies in the clinical decision-making process. Clinical decisions made using duplex scans are very similar to those made using arteriograms. This technique can limit the need for arteriography in assessing patients with lower extremity arterial occlusion disease.

MR Imaging of Basilar Artery Occlusion

We studied six patients with basilar artery occlusion using magnetic resonance imaging. Two patients also had arteriography. All had signs consistent with pontine infarction; three had a "locked in" syndrome. Magnetic resonance imaging (five done within 24 h of onset of progression of neurologic symptoms) revealed a linear structure of increased signal intensity in the pontine cistern on T1-weighted parasagittal images and absence of flow void phenomena. Hyperintense signals at various brain stem levels corresponding to the course of the basilar artery were noted on T2-weighted images. Multiple parenchymal abnormalities were noted in the brain stem (six), cerebellum (four), occipital lobes (two), and thalamus (two). Magnetic resonance performed early in the course of basilar artery occlusion is a high-yield, safe procedure and might eliminate the need for arteriography.

Penetrating popliteal artery injuries in children

Two children, aged 8 and 12, were seen recently at the Vanderbilt University Medical Center and Metropolitan Nashville General Hospital with gunshot injury to the popliteal artery. Both patients presented with late complications following missed penetrating injury to the popliteal artery. At presentation, distal pulses were palpable despite significant proximal arterial injury. Arteriography detailed traumatic popliteal artery aneurysms in both children, and an arteriovenous fistula in one child. These two children represent the youngest patients recorded in the surgical literature with gunshot trauma to the popliteal artery, subsequent formation of traumatic aneurysms, and an arteriovenous fistula. The increasing availability of guns and rifles in the household will likely increase the incidence of such injuries to children. As evidenced by these children, palpable pulses distal to an injury do not obviate the need for arteriography when arterial injury is suspected. Autogenous repair of the injured artery or reconstruction with autogenous vein graft is preferable for repair of vascular injuries in children.

Diagnosis of vascular injury in children with supracondylar fractures of the humerus

Four children with suspected vascular injury after supra-condylar fractures of the humerus are presented. A non-invasive technique has been used in the diagnosis of vascular injury. A simple non-invasive method using the Doppler equipment connected to a spectrum analyser may exclude the need for arteriography and surgical exploration.

Diagnosing Pulmonary Embolism Using Clinical Findings

To determine the value of clinical findings in the diagnosis of pulmonary embolism, we analyzed the records of 82 patients from three different hospitals who underwent pulmonary arteriography to rule out pulmonary embolism. We recorded 92 items of clinical information, including lung ventilation-perfusion scan results, for each patient. Although the diagnostic power of any single variable was marginal, an eight-item decision rule derived using discriminant analysis correctly predicted the outcome of arteriography in 82% of the cases. When tested on a different group of 68 patients from four hospitals, the rule accurately identified patients with low or high likelihood of having positive arteriograms. Clinical use of such a rule could reduce the need for arteriography in this population and would expedite decisions about anticoagulant therapy and further diagnostic testing.

The need for arteriography in diabetic patients with gangrene and palpable foot pulses.

A group of five diabetic patients had gangrene or failed limited amputations and palpable foot pulses in a total of seven limbs. Because a failure to heal persisted and gangrene progressed, arteriography was performed and disclosed occlusion of all three infrapopliteal arteries. Tibial bypass grafting resulted in complete healing in four of the five patients. The fifth patient refused surgery and died with progressive sepsis. The incidence of this unusual syndrome is unknown, but presumably it is rare. The mechanism of pulse formation in the foot, despite occlusion of the infrapopliteal vessels, is dependent on good flow to the popliteal artery, collateral flow to the rigid distal tibial-peroneal vessels, compliant ankle arteries, and highly resistive distal foot vessels. Although healing of limited amputations is usual in diabetic patients with foot pulses, it is not universal. We recommend that arteriography be performed routinely if gangrene is present and the foot is salvageable, irrespective of pedal pulse status.

Noninvasive detection of internal carotid artery occlusion.

Flow in the common carotid artery is normally quasisteady with flow never approaching zero during diastole. With total occlusion of the internal carotid artery, flow in the common carotid assumes the pattern observed in the external carotid, which supplies a relatively high-resistance vascular bed. In 34 instances of total internal carotid obstruction, flow went to zero in diastole in 33 cases and also demonstrated flow reversal in 22. In addition, there was a significant reduction in peak systolic velocity when the low-resistance internal carotid was obstructed. These observations, which are simple to determine using an ultrasonic duplex scanner, are of value in suspecting total occlusion of the internal carotid artery, thus obviating the need for arteriography in some cases.

Computerized arteriography of the cerebrovascular system: its use with intravenous administration of contrast material.

A unique method of computerized image enhancement makes it possible to visualize the arterial system by intravenous (IV) injection of small doses of standard contrast agent. This technique has been used to study the intracranial and extracranial circulation of more than 100 patients. Occlusion, stenosis, aneurysmal change, plaquing, and ulceration can be identified by computerized IV arteriography. Failures (less than 10%) results from inadequate venous access, extravasation of dye, or patient motion. This technique avoids the need for arteriography. The major risk of IV arteriography is contrast medium reaction. There is a close correlation between IV and standard arteriographic images. Intravenous arteriography does not require hospitalization, is suited for repetitive testing, and has promise as a method of diagnostic screening for stroke prevention.

Computerized tomographic diagnosis of aneurysms of the thoracic aorta

Accurate diagnosis of aneurysms of the thoracic aorta and its major branches can easily be performed by CT scanning of the mediastinum. The use of contrast enhancement aids in the diagnosis and allows distinction between flowing and clotted blood within the aneurysm. CT scanning of these lesions seen on chest radiographs may obviate the need for arteriography for diagnosis.

Computed tomography of the kidney.

The application of computed tomography to the diagnosis of kidney disease and the features of renal neoplasms, cysts, hydronephrosis, inflammatory parenchymal lesions and other pathological processes are described. The diagnostic accuracy of computed tomography is excellent when compared with ultrasound and selective renal arteriography. This new non-invasive technique can obviate the need for arteriography in a significant number of morphological diseases of the kidney and is especially useful in defining the extent of malignant tumours.