Percutaneous Transluminal Dilatation Research Articles

Balloon Angioplasty - The Legacy of Andreas Grüntzig, M.D. (1939-1985).

In 1974, at the Medical Policlinic of the University of Zürich, German-born physician-scientist Andreas Grüntzig (1939–1985) for the first time applied a balloon-tipped catheter to re-open a severely stenosed femoral artery, a procedure, which he initially called “percutaneous transluminal dilatation”. Balloon angioplasty as a therapy of atherosclerotic vascular disease, for which Grüntzig and Charles T. Dotter (1920–1985) received a nomination for the Nobel Prize in Physiology or Medicine in 1978, became one of the most successful examples of translational medicine in the twentieth century. Known today as percutaneous transluminal angioplasty (PTA) in peripheral arteries or percutaneous transluminal coronary angioplasty (PTCA) or percutaneous coronary intervention (PCI) in coronary arteries, balloon angioplasty has become the method of choice to treat patients with acute myocardial infarction or occluded leg arteries. On the occasion of the 40th anniversary of balloon angioplasty, we summarize Grüntzig’s life and career in Germany, Switzerland, and the United States and also review the developments in vascular medicine from the 1890s to the 1980s, including Dotter’s first accidental angioplasty in 1963. The work of pioneers of catheterization, including Pedro L. Fariñas in Cuba, André F. Cournand in France, Werner Forssmann, Werner Porstmann and Eberhard Zeitler in Germany, António Egas Moniz and Reynaldo dos Santos in Portugal, Sven-Ivar Seldinger in Sweden, and Barney Brooks, Thomas J. Fogarty, Melvin P. Judkins, Richard K. Myler, Dickinson W. Richards, and F. Mason Sones in the United States, is discussed. We also present quotes by Grüntzig and excerpts from his unfinished autobiography, statements of Grüntzig’s former colleagues and contemporary witnesses, and have included hitherto unpublished historic photographs and links to archive recordings and historic materials. This year, on June 25, 2014, Andreas Grüntzig would have celebrated his 75th birthday. This article is dedicated to his memory.

Interventional radiologic procedures in the treatment of complications after liver transplantation

The aim of this study is to report our interventional radiologic procedures (IRP) in liver transplant (LTX) patients. These include procedures for biliary, arterial, venous, and portal complications, as well as the treatment of infected and non-infected fluid collections. This retrospective study covered 583 patients (mean age: 44 +/- 14 yr) in whom a total of 685 LTX were performed from August 1987 to April 2005. Overall, 182 LTX patients underwent a total of 428 IRP, including digital subtraction angiography (n = 152/35.51%), percutaneous transluminal angioplasty (PTA) (n = 4/0.93%) and PTA + stent (n = 7/1.63%) of arterial anastomosis, PTA + stent of the celiac trunk (n = 2/0.46%), transjugular intrahepatic portosystemic shunt (TIPS) (n = 2/0.46%), arterial lysis (n = 4/0.93%), venous lysis (n = 2/0.46%), inferior vena cava stenting (n = 2/0.46%), percutaneous biliary drainage (n = 34/7.94%), percutaneous transluminal dilatation (PTD) of the choledocho-enteric anastomosis (n = 16/3.73%), biliary stent (n = 5/1.16%), intrahepatic biliary flushing treatment, stone and cast biliary extraction (n = 27/6.30%), other interventions (e.g., embolization in other regions, transjugular liver biopsies, lymphangiographies) (n = 9/2.10%), and ultrasound- and computer tomography-guided biopsies and percutaneous drainage (n = 153/35.74%). The overall success rate was 85.7%. Technical improvements in LTX and interventional radiology permit vascular and biliary complications to be treated successfully by interventional radiology.

Percutaneous transluminal dilatation of the renal arteries. Results and indications

Drug Prescribing for Patients with Chronic Kidney Disease in General Practice: a Cross-Sectional Study

Urologic Complications After Renal Transplantation

Background Renal transplantation is associated with several nonimmunological problems. Although urologic complications may be serious and carry a high risk of graft loss, they are amenable to successful treatment if diagnosed early and treated properly. Their incidence in the literature varies from 2.5% to 15%. Objective We sought to assess the incidence, pattern, management options, and outcomes of urologic complications in 560 consecutive renal transplantations performed at a single center between November 1993 and October 2004. Patients and methods Twenty-one (16 male and 5 female) recipients developed posttransplantation urinary complications at 2 days to 76 months after renal transplantation. Their kidney grafts were obtained from 13 living and eight deceased donors. Complications included ureteric stricture in 11 and urine leak in 10 recipients. Ultrasonography and isotope renal scanning were the main diagnostic tools. Complications were treated either conservatively, by percutaneous dilatation and stenting, or by surgical reconstruction. Results The incidence of urologic complications following renal transplantation in the present series was 3.7%. All cases were successfully treated with no graft loss secondary to these complications. Conclusions Posttransplantation urologic complications are associated with a good prognosis if diagnosed early and properly treated. Percutaneous transluminal dilatation of ureteric stenosis in renal transplant patients has good initial success, low morbidity, few recurrences, and long-term effectiveness.

Treatment of renovascular disease with percutaneous stent insertion: long-term outcomes.

Renal artery stenosis is a common, progressive cause of hypertension and renal impairment, and is frequently treated with percutaneous transluminal dilatation and stenting. The outcome of this procedure is still being evaluated. The records of 198 consecutive patients who had stents inserted at the Royal Melbourne Hospital were analysed retrospectively, and adequate follow-up information on 148 (75%), in whom a total of 182 renal arteries had been treated was obtained. Technical success was achieved in 144 patients (97%). Complications occurred in 19 patients (13.3%), with major complications occurring in 10 (7.0%) and one death occurring in relation to the procedure. A fall in average systolic blood pressure of 13.2 mmHg (12.1-14.3 mmHg) was seen and a fall in diastolic blood pressure of 10.1 mmHg (9.3-10.9 mmHg), without an increase in the number of antihypertensive drugs used. Renal function remained stable in the majority of patients, particularly those who had minimal baseline renal impairment. Restenosis was common after 6 months, occurring eventually in 29% of screened patients, but was not shown to affect clinical outcomes. Insertion of renal artery stents is a safe and effective treatment for renal artery stenosis.

Coarctation of the aorta

Controversy still exists in the literature regarding definitive therapy for repair of coarctation of the aorta. Major factors involve not only the timing of repair, but also the method of repair, whether surgical or by percutaneous transluminal balloon dilatation. Results and complications of coarctation repair using various methods of classification present a diversity of results. This report will focus on these issues and attempt to dispel the statement that either one method or the other is the "choice method" of repair for any and all types of coarctation. Also presented is a proposed classification we believe will assist in clarifying the choice of therapy and perhaps improve not only the reporting of results, but also the results themselves. Methods of repair are discussed to provide the surgeon with a complete armamentarium of operations that the surgeon would tailor to the individual anatomicopathological patterns of the patient who presents at the time of surgery. Copyright 2000 by W.B. Saunders Company

Balloon Dilatation of Membranous Obstruction of the Inferior Vena Cava

Membranous obstruction of the inferior vena cava is a rare congenital anomaly that results in the primary type of Budd-Chiari syndrome. We describe the case of an 8-year-old boy initially diagnosed with intrahepatic portal hypertension, who underwent percutaneous transluminal balloon dilatation of an inferior vena cava membrane located in the suprahepatic inferior vena cava, which resulted in successful palliation of his symptoms.

Original extrahilar approach for hepatic portal revascularization and relief of extrahepatic portal hypertension related to later portal vein thrombosis after pediatric liver transplantation. Long term results.

Original extrahilar approach for hepatic portal revascularization and relief of extrahepatic portal hypertension related to later portal vein thrombosis after pediatric liver transplantation. Long term results.

A new therapeutic approach to popliteal artery entrapment syndrome (PAES)

An alternative therapeutic approach to popliteal artery entrapment syndrome (PAES) with vascular complications. Three male patients (16, 42 and 68 years) with thrombotic and/or embolic obstructions of popliteal or crural vessels as a consequence of popliteal entrapment syndrome. Combined catheter treatment consisting of percutaneous transluminal thrombembolectomy (PTEE), local thrombolysis (LTL) and percutaneous transluminal dilatation (PTA) was performed for thrombotic and embolic obstructions of popliteal or crural vessels. The aberrant tendomuscular structures were surgically corrected at a later date. After the procedure systolic ankle/arm pressure ratios in the three patients improved from 0.66 to 1.13, 0.57 to 1.07 and 0.46 to 1.10. Twelve, 8 and 4 months later the patients were asymptomatic. None of the patients showed popliteal artery compression during plantar flexion on Duplex scanning. This new therapeutic approach avoids direct vascular surgery with bypass or patch implantation in patients with PAES who are often young. The long term results remain to be evaluated.

Echocardiographic Determinants of Outcome After Percutaneous Transluminal Balloon Dilatation of Discrete Subaortic Stenosis

Echocardiographic Determinants of Outcome After Percutaneous Transluminal Balloon Dilatation of Discrete Subaortic Stenosis

Radiological Intervention for the Failing In Situ Vein Bypass

With close surveillance, deteriorating hemodynamics may signal a failing in situ bypass that can be salvaged by timely intervention. The purpose of this report is to summarize our experience with in situ bypass salvage using interventional radiology. Twenty-nine patients underwent arteriography following bypass occlusion or when an ankle/brachial index reduction of greater than 0.15 was detected between two consecutive office visits. Eighteen percutaneous transluminal dilatations were performed; one patient underwent repeat dilatation after 36 months, a second had four dilatations over 40 months. Ten significant arteriovenous fistulae were identified and were successfully embolized with 3 mm coils. One patient underwent excision of a retained valve. Six patients had initial fibrinolytic therapy for graft occlusion. The morbidity of these interventions was low; one bypass was disrupted following percutaneous transluminal dilatation but was successfully salvaged surgically. The average time from the original surgery to intervention was six months (one to 26 months); and the average follow-up after intervention was 22 months (three to 62 months) over which time patency was maintained in the majority. When a correctable problem is identified with appropriate vascular lab surveillance, interventional radiology is a useful alternative to surgery for bypass salvage.

Das Verhalten der Kollateralen bei der perkutanen transluminalen Angioplastie

The fate of 106 collaterals was investigated following percutaneous transluminal dilatation of 113 stenoses and occlusions. Following dilatation, 78% of collaterals were unchanged and 22% could no longer be demonstrated. The success of the dilatation had no bearing on the fate of the collaterals. Collaterals beginning or ending in a dilated portion of vessel disappeared more frequently (30%) than the others (11%). Following five dilatations, some vessels were demonstrated in the area of stenosis, which had not been demonstrated previously. Evidently local events, such as displacement of arteriosclerotic plaques may lead to occlusion or reopening of vessels. Remaining collaterals may be of great importance in saving a limb if there is an acute occlusion complicating a dilatation.

The hypotensive mechanism of percutaneous transluminal dilatation (PTD) in renovascular hypertension due to bilateral renal artery stenosis.

The hypotensive mechanism of percutaneous transluminal dilatation (PTD) in renovascular hypertension due to bilateral renal artery was investigated in two patients. Blood pressure was monitored continuously before, during and after PTD by use of a new automated blood pressure monitoring device based on finger volume-oscillometry. Plasma renin activity was measured repeatedly before, during and after PTD. A hypotensive effect appeared immediately after PTD and blood pressure remained low in the following observation period without any hypotensive medication. In these cases, the hypotension was accompanied by a transient decrease in heart rate immediately after PTD. The hypotensive response to PTD was not parallel to the basal plasma renin activity, suggesting that the renin-angiotensin system is not necessarily involved in the maintenance of the hypertension before PTD. The autonomic nervous system seemed to play a certain role. Since the hypotension was accompanied by a transient decrease in heart rate immediately after PTD, the hypotension may be induced either by a decrease in sympathetic tone or by an increase in vagal tone at least just after PTD. It is hypothesized that these changes in autonomic nervous activity are mediated centrally through the renal afferent mechanism in response to rapid changes in renal hemodynamics induced by PTD.

111Indium-thrombocyte scintigraphy and percutaneous transluminal dilatation (angioplasty) of supra-aortic vascular stenoses. A new method for deciding therapy and for follow-up control

Scintigraphy with 111indium-marked autologous platelets has been used during percutaneous transluminal dilatation of supra-aortic arterial stenoses; there were 14 successful dilatations and one attempted dilatation. The material consisted of nine stenoses of the internal carotid artery, two stenoses at the origin of the vertebral artery and four stenoses of the first part of the left subclavian artery. Deposition of thrombi could be demonstrated by scintigraphy, both before and after catheter dilatation. The value of this method for deciding on the type of treatment and for observing the course of percutaneous dilatation of cerebral vessels is discussed.

Factors that determine the long-term results of percutaneous transluminal dilatation for peripheral arterial occlusive disease.

Seven hundred thirty-one percutaneous transluminal dilatations (TLDs) for peripheral arterial occlusive disease were performed between 1978 and 1984. From this prospective study 666 dilatations were analyzed with a combination of clinical and objective vascular laboratory tests to determine which factors could be used to predict long-term successful results. Eleven variables were recorded at the time of TLD. The proportional hazards model (Cox regression) identified four significant variables predictive of long-term success: the indication for the procedure (claudication or salvage), site of the dilatation (aortoiliac or femoropopliteal), runoff (poor or good), and whether a previous TLD was done at the same site. With these significant variables, the Cox model was used to estimate the chances of success at 1, 2, and 3 years for all combinations of variables. The accuracy of the Cox model was confirmed by the close approximation between the number of observed and predicted successful TLDs at 1, 2, and 3 years. We concluded that the chances of success of TLD in terms of percentage at 1, 2, and 3 years can be predicted from the combinations of these four significant variables. Knowledge of these factors should permit better selection of patients for this procedure.

Factors that determine the long-term results of percutaneous transluminal dilatation for peripheral arterial occlusive disease

Seven hundred thirty-one percutaneous transluminal dilatations (TLDs) for peripheral arterial occlusive disease were performed between 1978 and 1984. From this prospective study 666 dilatations were analyzed with a combination of clinical and objective vascular laboratory tests to determine which factors could be used to predict long-term successful results. Eleven variables were recorded at the time of TLD. The proportional hazards model (Cox regression) identified four significant variables predictive of long-term success: the indication for the procedure (claudication or salvage), site of the dilatation (aortoiliac or femoropopliteal), runoff (poor or good), and whether a previous TLD was done at the same site. With these significant variables, the Cox model was used to estimate the chances of success at 1, 2, and 3 years for all combinations of variables. The accuracy of the Cox model was confirmed by the close approximation between the number of observed and predicted successful TLDs at 1, 2, and 3 years. We concluded that the chances of success of TLD in terms of percentage at 1, 2, and 3 years can be predicted from the combinations of these four significant variables. Knowledge of these factors should permit better selection of patients for this procedure.

Long-Term Experience in Percutaneous Transluminal Dilatation of Renal Artery Stenosis

Percutaneous transluminal dilatation was attempted in 65 patients with renovascular hypertension. In five cases (6 percent), percutaneous transluminal dilatation could not be performed for technical reasons. In the remaining 60 patients (35 with atherosclerotic stenosis and 25 with fibromuscular dysplasia), both mean systolic and diastolic pressure fell immediately after percutaneous transluminal dilatation and remained significantly lower for a period of up to five years. Cure rates after a mean control period of 21.6 months were higher in patients with fibromuscular dysplasia (50 percent) than in those with atherosclerotic stenosis (29 percent). Improvement of blood pressure was observed in 32 percent of patients with fibromuscular dysplasia and in 46 percent of patients with atherosclerotic stenosis. Follow-up angiography in 33 cases showed occlusion of the dilated artery in two patients and recurrence of slight renal artery stenosis in nine patients. Successful redilatation could be performed in five of these cases. Furthermore, renal vein renin determinations were only of limited diagnostic or prognostic value. These results document the good long-term effect of percutaneous transluminal dilatation in patients with renal artery stenosis. Percutaneous transluminal dilatation should, therefore, be the favored procedure in patients with renovascular hypertension.

Combined two-dimensional ultrasound Doppler technique. New possibilities for the screening of renovascular and parenchymatous hypertension?

A combination of a real time phased array sector scanner and a range-gated 16-channel pulsed Doppler system was used for the evaluation of renal artery flow patterns in 25 echogenic subjects. Eight of these had renal artery stenosis, 5 an increased peripheral resistance in the kidney, and 12 showed normal renal flow patterns with consistent forward flow during the entire heart cycle. In normals, the ratio of end systolic (S2) versus early peak systolic (S1) velocity was 0.52 +/- 0.11 (range 0.37-0.84). In the patients with renal artery stenosis S2/S1 ranged from 0 to 0.30. Five of the 8 patients with renal artery stenosis could be evaluated before and after percutaneous transluminal dilatation (PTA). After successful PTA (diameter reduction less than 50% and pressure gradient less than 20 mm Hg) S2/S1 returned to normal. The patients with increased peripheral resistance due to an angiographically proven small kidney exhibited a variety of flow patterns with S2/S1 ranging from 0 to 0.29, similar to the ones with renal artery stenosis. The results suggest that the noninvasive determination of the ratio S2/S1 with the aid of ultrasound Doppler measurements permits a differentiation between normal and abnormal flow patterns and can be applied for the follow-up of patients after PTA. In utilizing the described method, neither the angle between the Doppler beam and the vessel axis, nor the vessel diameter must be evaluated.

Complications in percutaneous transluminal dilatation of renal arteries.

We propose a classification of the complications in renal artery percutaneous transluminal angioplasty (PTA) according to their severity and their direct or indirect relationship to PTA. Minor complications are reversible within the normal recovery period after PTA, while major complications are irreversible or reversible but necessitate extended hospitalization or surgery. The following complications are reported in the literature as being directly related to PTA: hemorrhage at the puncture site, hemorrhage from renal or access artery perforation or rupture, occlusive or nonocclusive dissection of the renal or access arteries, renal artery thrombosis, renal artery spasm or embolism leading to segmental renal infarction, peripheral artery embolisation, and balloon rupture complications. The indirectly related complications include transient or irreversible renal insufficiency, contrast media hypersensitivity, pressure-drop-related cerebral or myocardial ischemia, and anticoagulation-related hemorrhage infections. In our own series of 105 PTA in 80 patients, complications occurred in 11% of which 4% were major, 1% indirectly related to PTA leading to death. In the reports available, the rate of major complication ranges between 3 and 10%, and the death rate around 1%.

Long-term experience in percutaneous transluminal dilatation of renal artery stenosis

Percutaneous transluminal dilatation was attempted in 65 patients with renovascular hypertension. In five cases (8 percent), percutaneous transluminal dilatation could not be performed for technical reasons. In the remaining 60 patients (35 with atherosclerotic stenosis and 25 with fibromuscular dysplasia), both mean systolic and diastolic pressure fell immediately after percutaneous transluminal dilatation and remained significantly lower for a period of up to five years. Cure rates after a mean control period of 21.6 months were higher in patients with fibromuscular dysplasia (50 percent) than in those with atherosclerotic stenosis (29 percent). Improvement of blood pressure was observed in 32 percent of patients with fibromuscular dysplasia and in 48 percent of patients with atherosclerotic stenosis. Follow-up angiography in 33 cases showed occlusion of the dilated artery in two patients and recurrence of slight renal artery stenosis in nine patients. Successful redilatation could be performed in five of these cases. Furthermore, renal vein renin determinations were only of limited diagnostic or prognostic value. These results document the good long-term effect of percutaneous transluminal dilatation in patients with renal artery stenosis. Percutaneous transluminal dilatation should, therefore, be the favored procedure in patients with renovascular hypertension.