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History A 26-year-old man presented with a 1-month history of chest pain, a palpable and painful right inguinal mass, and edema in the right lower extremity. One month earlier, he started to experience left chest pain with no cough. Pulmonary CT angiography (CTA) revealed a left lower lobe segmental pulmonary embolus. The local hospital made a diagnosis of pulmonary embolism. He received anticoagulants, and his chest pain was gradually relieved. At the time of current presentation, the patient was experiencing right lower extremity swelling and pain. Physical examination revealed a 4 × 3 cm palpable right inguinal mass with no redness. His medical history and family history were negative. The results of laboratory work-up were normal, with a d-dimer level of 0.16 mg/L fibrinogen equivalent units (reference range

BACKGROUND: Previous studies showed that nicotinized electronic cigarettes (hereafter, e-cigarettes) elicit systemic oxidative stress and inflammation. However, the effect of the aerosol alone on endothelial function is not fully understood. PURPOSE: To quantify surrogate markers of endothelial function in nonsmokers after inhalation of aerosol from nicotine-free e-cigarettes. MATERIALS AND METHODS: In this prospective study (from May to September 2018), nonsmokers underwent 3.0-T MRI before and after inhaling nicotine-free e-cigarette aerosol. Peripheral vascular reactivity to cuff-induced ischemia was quantified by temporally resolving blood flow velocity and oxygenation (SvO(2)) in superficial femoral artery and vein, respectively, along with artery luminal flow-mediated dilation. Precuff occlusion, resistivity index, baseline blood flow velocity, and SvO(2) were evaluated. During reactive hyperemia, blood flow velocity yielded peak velocity, time to peak, and acceleration rate (hyperemic index); SvO(2) yielded washout time of oxygen-depleted blood, rate of resaturation, and maximum SvO(2) increase (overshoot). Cerebrovascular reactivity was assessed in the superior sagittal sinus, evaluating the breath-hold index. Central arterial stiffness was measured via aortic pulse wave velocity. Differences before versus after e-cigarette vaping were tested with Hotelling T(2) test. RESULTS: Thirty-one healthy never-smokers (mean age, 24.3 years ± 4.3; 14 women) were evaluated. After e-cigarette vaping, resistivity index was higher (0.03 of 1.30 [2.3%]; P < .05), luminal flow-mediated dilation severely blunted (−3.2% of 9.4% [−34%]; P < .001), along with reduced peak velocity (−9.9 of 56.6 cm/sec [−17.5%]; P < .001), hyperemic index (−3.9 of 15.1 cm/sec(2) [−25.8%]; P < .001), and delayed time to peak (2.1 of 7.1 sec [29.6%]; P = .005); baseline SvO(2) was lower (−13 of 65 %HbO(2) [−20%]; P < .001) and overshoot higher (10 of 19 %HbO(2) [52.6%]; P < .001); and aortic pulse wave velocity marginally increased (0.19 of 6.05 m/sec [3%]; P = .05). Remaining parameters did not change after aerosol inhalation. CONCLUSION: Inhaling nicotine-free electronic cigarette aerosol transiently impacted endothelial function in healthy nonsmokers. Further studies are needed to address the potentially adverse long-term effects on vascular health. © RSNA, 2019 Online supplemental material is available for this article.

Five volunteers and 10 patients suspected of having peripheral vascular disease underwent multistation contrast material-enhanced three-dimensional whole-body magnetic resonance (MR) angiography. The first examination, based on standard protocol, lasted 72 seconds, while the following two examinations, performed with a high-spatial-resolution T1-weighted gradient-recalled-echo sequence for the last two stations (lower extremities) lasted 170 seconds. In the second high-resolution examination, midfemoral venous compression was used. Intraindividual comparison showed the high-resolution protocol with venous compression resulted in the best qualitative and quantitative image quality through higher signal-to-noise and contrast-to-noise ratios in the calf arteries. Despite prolonged acquisition times, there was no venous contamination. The data suggest that midfemoral venous compression should be incorporated in multistation protocols of the lower extremities to improve depiction of calf arteries without disturbing venous overlap.

To retrospectively review bilateral venograms free of thrombus to evaluate the frequency and types of variations seen in venous anatomy.A retrospective review of 404 bilateral (808 limbs) lower limb venograms obtained from medical patients participating in a thromboprophylaxis clinical trial and found to be free of thrombus was performed. Venograms were evaluated according to predetermined criteria for the presence of duplication of vessels and inter- and intraindividual variations in venous anatomy. Variations were assessed with analysis of variance and chi2 tests.Two vessels were seen in the popliteal fossa on 337 (42%) of 808 venograms, and 41 (5%) were true duplicated popliteal veins. There were 253 (31%) duplicated superficial femoral veins (SFVs), with 12 (1.5%) being complex duplicated systems. Of 265 duplicated SFVs, 138 (52%) began in the midthigh region and 80 (30%), in the adductor canal region. The duplicated vessel was medial to the main SFV in 122 (46%), lateral in 131 (49%), and both (ie, triplications) in 12 (4.5%). The length of the duplicated SFV ranged from 1 to 35 cm; 6-15 cm was the most common length in 162 (62%) SFVs. There was no significant association between the incidence of anatomic variations and age or sex (P.1). The presence of multiple vessels in one leg was strongly correlated with the probability of occurrence in the other leg (P.001).Variations in lower limb venous anatomy are common and have important implications for the US diagnosis of deep vein thrombosis.

To assess diagnostic accuracy and interobserver variability at venous enhanced subtracted peak arterial (VESPA) magnetic resonance (MR) venography compared with those at conventional venography for the diagnosis of femoral and iliac deep venous thrombosis (DVT).A single anteroposterior maximum intensity projection (MIP) venogram of the femoral and iliac veins was constructed by using VESPA MR venography in 55 symptomatic patients suspected of having lower limb DVT. All patients also underwent conventional venography, results of which were used as the standard of reference. VESPA MR venograms were interpreted by two independent reviewers (reviewers A and B) who were unaware of other results. Sensitivity and specificity of VESPA MR venography for the diagnosis of thrombus in the femoral and iliac veins were calculated. Interobserver variability was calculated for these observations by using weighted kappa with equally spaced weights for positive, nondiagnostic, and negative studies. Nondiagnostic studies were reinterpreted separately by reviewer A on the basis of source data.Sensitivity of VESPA MR venography for the femoral veins (20 of 20) and iliac veins (seven of seven) was 100% for both reviewers. Specificity was 100% (39 of 39 for reviewer A, 40 of 40 for reviewer B) for the iliac veins and 97% (31 of 32) for the femoral veins for both reviewers. Segments in which the VESPA MR venograms were nondiagnostic were excluded from this analysis. Interobserver variability as calculated by using weighted kappa for positive, negative, and nondiagnostic studies was 0.85 for femoral veins and 0.97 for iliac veins. Interpretation of the source data led to correct diagnosis in six of six cases in which the VESPA MR venograms were nondiagnostic.VESPA MR venography yielded MIP venograms that were highly accurate for the diagnosis of DVT in femoral and iliac veins. Interpretation of the studies was also highly reproducible.

To evaluate preliminary clinical experience in humans with the Recovery nitinol filter (RNF) for the inferior vena cava, especially the efficacy of the device and safety of its retrieval.Thirty-two patients were followed up to assess for filter efficacy and for ability to remove the filter.Sixteen men and 16 women aged 18-83 years (mean, 53 years) underwent treatment with the RNF. Indications for placement were recent pulmonary embolism (n = 16), recent deep venous thrombosis (n = 20), and/or prophylaxis (n = 2). Four patients had contraindications to anticoagulant therapy, and four had complications from anticoagulant therapy. The filter was successfully placed in 32 patients. In 24 (100%) of 24 patients, the filter was successfully retrieved with a jugular approach. The mean implantation period was 53 days (range, 5-134 days). Trapped thrombus was seen within the filter in seven cases. In one patient with a large trapped thrombus, the filter was noted to have migrated 4 cm cephalad. There were no episodes of pulmonary embolism or insertion-site thrombosis.This preliminary experience in humans confirms the efficacy of the RNF. It also demonstrates the feasibility and safety of retrieval up to 134 days after implantation.

Magnetic resonance (MR) angiography with blood-pool superparamagnetic iron oxide (SPIO) particles was evaluated in the whole-body vascular system. In 12 adult patients, three-dimensional fast imaging with steady-state precession was performed in successive steps from the lungs to the calves before and after a standard dose for liver imaging (15 mumol of iron per kilogram of body weight) of AMI-25. On SPIO-enhanced MR angiograms, visualization of the pulmonary arterial, whole-body, and lower extremity venous systems was graded as good or sufficient in all patients, and femoral vein thrombosis was clearly demonstrated in one patient.

To determine whether gamma brachytherapy can prevent in-stent stenosis in hemodialysis grafts.Six-millimeter polytetrafluoroethylene arteriovenous grafts were created bilaterally in six dogs. After 1 month, Wallstents spanning the venous anastomosis were placed to accelerate restenosis. Gamma irradiation (12 Gy) was delivered endoluminally to one of the two grafts by using an iridium 192 source; thus, each animal served as its own control. Fistulography was performed monthly for 10 months or until graft thrombosis, with measurement of stenosis at each time point. At the conclusion of the study period, the treated area was examined histologically, and a computer model was used to calculate the volume of intimal hyperplasia.Delayed stent migration resulted in exclusion of one dog. In the remaining five dogs; maximum stenosis across all time intervals was less for the treated side (P.04), and the volume of intimal hyperplasia was less for the treated side (P.045). In one animal studied at 1 year, this trend reversed in terms of percentage stenosis but not total neointimal volume.Brachytherapy with 192Ir (gamma) delivered at the time of stent placement reduces restenosis in this hemodialysis graft model, but, depending on the parameter evaluated (stenosis vs total volume of neointima), the benefit may wane or even reverse with time.

To evaluate catheter-directed thrombolysis for treatment of symptomatic lower extremity deep venous thrombosis (DVT).From a registry of patients (n = 473) with symptomatic lower limb DVT, results of 312 urokinase infusions in 303 limbs of 287 patients (137 male and 150 female patients; mean age, 47.5 years) were analyzed. DVT symptoms were acute (or = 10 days) in 188 (66%) patients, chronic (10 days) in 45 (16%), and acute and chronic in 54 (19%). A history of DVT existed in 90 (31%). Lysis grades were calculated by using venographic results.Iliofemoral DVT (n = 221 [71%]) and femoral-popliteal DVT (n = 79 [25%]) were treated with urokinase infusions (mean, 7.8 million i.u.) for a mean of 53.4 hours. After thrombolysis, 99 iliac and five femoral vein lesions were treated with stents. Grade III (complete) lysis was achieved in 96 (31%) infusions; grade II (50%-99% lysis), in 162 (52%); and grade I (50% lysis), in 54 (17%). For acute thrombosis, grade III lysis occurred in 34% of cases of acute and in 19% of cases of chronic DVT (P.01). Major bleeding complications occurred in 54 (11%) patients, most often at the puncture site. Six patients (1%) developed pulmonary emboli. Two deaths (1%) were attributed to pulmonary embolism and intracranial hemorrhage. At 1 year, the primary patency rate was 60%. Lysis grade was predictive of 1-year patency rate (grade III, 79%; grade II, 58%; grade I, 32%; P.001).Catheter-directed thrombolysis is safe and effective. These data can guide patient selection for this therapeutic technique.

Compression US is the imaging procedure of choice for patients with clinically suspected DVT of the lower and upper extremities. Clinical trials have validated the safety of the approach of relying on two negative US studies obtained 1 week apart to safely exclude the diagnosis of DVT. In selected low-risk patients, the diagnosis of DVT may be excluded by a single negative US study. US has a role to play in the management of patients with suspected pulmonary embolism who have nondiagnostic pulmonary imaging studies.

To determine the feasibility of diagnosing deep venous thrombosis (DVT) with direct three-dimensional magnetic resonance (MR) imaging of the thrombus.Eighteen patients with proved DVT at conventional venography were evaluated with a magnetization-prepared three-dimensional blood- and fat-suppressed MR imaging sequence. The presence and extent of thrombosis on the MR images were compared with the findings at conventional venography.At MR imaging, DVT was visualized in 17 of the 18 patients. MR imaging demonstrated greater proximal extent of the thrombosis in four patients, asymptomatic contralateral thrombosis in one, involvement of the deep femoral vein in five, and involvement of the superficial venous system in three.Direct MR imaging of clots appears capable of demonstrating venographically diagnosed DVT. This MR imaging technique is noninvasive, quick, and repeatable and allows a survey of the whole lower-limb venous system. Detection of thrombosis relies on the formation of methemoglobin, which appears to be sufficiently rapid to allow use of this technique in the clinical setting. Changes in the signal from clot over time may allow estimation of the age of the thrombus.

To evaluate the technical possibility of creating a percutaneous retroperitoneal splenorenal shunt (PRESS) in swine as a minimally invasive treatment of portal hypertension.Five normal domestic swine underwent creation of a PRESS. A modified transjugular intrahepatic portosystemic shunt puncture set was introduced from the right femoral vein into the left renal vein. The proximal splenic vein was punctured transvenously through the retroperitoneal cavity. Noncovered metallic stents were then placed to connect both veins. The animals were sacrificed 1 hour after the procedure, after follow-up splenic venography and necropsy were performed.Puncture of the splenic vein and stent placement were successfully completed in all cases. In four of five cases, the splenic venogram revealed good flow from the splenic vein to the left renal vein through the shunt track 1 hour after creation of the PRESS, and there was no evidence of leakage. No changes in vital signs were noticed. At necropsy, a small retroperitoneal hematoma along the stent and minimal intraperitoneal bleeding were observed. The stents were found in the retroperitoneal cavity connecting both veins in all animals.Creation of a PRESS is technically possible, and further experimental studies of its efficacy are warranted.

To assess the prevalence of altered venous hemodynamics after spinal cord injury.The authors performed venography in 200 ambulant patients and 107 patients with spinal injury. The hemodynamic characteristics of the paravertebral venous plexus were documented after pedal injection of contrast material. The hemodynamic and clinical data were correlated in patients with spinal cord injury.Abnormal venous return via the paravertebral venous plexus in the absence of iliac or inferior vena caval occlusion was shown in 73 (68%) of the 107 patients with spinal injury. This paravertebral venous flow route is not related to the time between injury and examination. It was demonstrable in the early as well as late post-traumatic period and was reproducible at subsequent examinations. The paravertebral venous flow route was more commonly seen in cervical than thoracolumbar injuries and was closely related to the severity of neurologic deficit (P = .0012).Abnormal vertebral venous hemodynamics occur in most patients with spinal cord injury and are more likely to occur in patients with complete neurologic deficit and cervical injury.

PURPOSE: To develop improved methods of extracting pacemaker electrodes from the femoral vein by using standard equipment and techniques. MATERIALS AND METHODS: Pacemaker electrodes were removed from 61 patients aged 21-91 years (mean, 68 years). In 25 patients (41%), traction was applied to locking stylets to remove electrodes at the subclavian vein entry site. In 30 patients, the electrode tip was freed with traction at the subclavian vein entry site. The electrode was then extracted through a sheath placed in the femoral vein. In six patients (10%), the electrode tip was freed via the femoral vein when traction was applied to grasping devices. The electrode was then removed through a femoral venous sheath. RESULTS: Ninety-nine (95%) of 104 pacemaker electrodes were extracted completely. Two electrodes were trapped in fibrous tissue in the subclavian vein. One right atrial tear occurred. CONCLUSION: Pacemaker electrodes can be removed effectively by using percutaneous techniques.

Inferior vena cava filters were placed in 60 patients. Ultrasound (US) of the venous access site was performed before and 3-5 days after filter placement to determine the prevalence of occlusive and nonocclusive access-site thrombosis (AST). Prevalence of symptoms attributable to AST was also evaluated at 1-month clinical follow-up in 58 of the 60 patients. All filters were placed with delivery sheaths with outer diameters of 12-14 F. US depicted development of occlusive AST in six of the 60 patients (10%). Nonocclusive AST developed in 15 (25%). Symptoms related to AST occurred in two of 58 patients (3%). There was a substantially increased prevalence of occlusive thrombus in patients in whom partially occluding thrombus or extrinsic compression in the inferior vena cava or ipsilateral iliofemoral veins was demonstrated on vena cavograms obtained before filter placement. The prevalence of both symptoms attributable to AST and US-detected occlusive thrombus in this series with smaller delivery systems is lower than that reported after percutaneous placement of stainless steel Greenfield filters via 29.5-F (outer diameter) sheaths.

To determine exemplarily the amount of DNA damage and the repair kinetics after interventional radiologic procedures by using visualization of foci of the phosphorylated form of the H2AX histone variant (gammaH2AX) to quantify DNA double-strand breaks (DSBs) at percutaneous transluminal angioplasty (PTA) of the lower limb arteries.After local ethics committee approval and written informed consent were obtained, five patients (two women, three men; mean age, 64.4 years; age range, 45-76 years) scheduled for computed tomography (CT) and 20 patients (six women, 14 men; mean age, 68.5 years; age range, 53-85 years) scheduled for PTA of lower limb arteries were prospectively entered into the study. Blood samples were taken before the first exposure to ionizing radiation and 5 minutes, 1 hour, 6 hours, and 24 hours after the last exposure. Additional samples were taken from the irradiated limb (femoral vein) of three patients who underwent PTA--before the first radiation exposure, 5 and 10 minutes after the first exposure, and 5 minutes after the last exposure. Lymphocytes were isolated, fixed, and stained with anti-gammaH2AX antibody, and gammaH2AX focus yields were determined with fluorescence microscopy. Data were analyzed with linear regression and two-sample F tests.Mean increase in number of gammaH2AX foci after CT (7.78 per 1 Gy x cm) depended linearly on dose-length product (r = 0.997). Number of foci reached background levels within 24 hours. Mean numbers of gammaH2AX foci per cell increased by factors of 4.08-20.67 in blood samples taken 5 minutes after PTA compared with mean numbers of foci before PTA. Mean radiation dose increase, 6.56/(10 Gy x cm(2)), depended linearly on dose-area product (r = 0.993). Maximal focus yield in cells taken directly from the irradiated limb was higher than that in cells from the systemic circulation (by mean factor of 1.46). Data showed compromised DSB repair capacity after PTA (P.05). Mean number of foci at 24 hours (0.07 focus per cell) was significantly higher than mean number of foci in cell background (0.04 focus per cell, P.05).GammaH2AX focus formation can be used to determine in vivo induction of DNA DSBs after PTA. DSB repair capacity is compromised in patients who undergo PTA of lower limb arteries.

Transpulmonary chemoembolization (TPCE) was evaluated as a new treatment for unresectable lung metastases. Institutional review board approval and patient consent were obtained. In 23 patients, 26 lung metastases of different origins were treated locally by using a transpulmonary approach. After femoral vein puncture, tumor-supplying pulmonary arteries were selectively explored, and 5-10 mg mitomycin C and 5-10 mL iodized oil and microsphere particles were applied with balloon protection. Diagnosis and follow-up (3-month intervals) were performed with unenhanced and contrast material-enhanced computed tomography (CT). Treatment was well tolerated in all patients, with no major side effects or complications. As indicated by using morphologic criteria, volume regression of embolized areas was achieved in eight patients, while stable disease was revealed at follow-up in six patients. In nine patients, progression of treated intrapulmonary metastases was recorded. TPCE could be a well-tolerated palliative treatment option in patients with pulmonary metastases.

PURPOSE: To determine if the ultrasound (US) survey of the lower extremity for deep venous thrombosis (DVT) can be curtailed without compromising diagnostic efficacy. MATERIALS AND METHODS: The authors performed 755 US examinations in 721 patients (1,024 lower extremities) referred for suspicion of lower extremity DVT. The full lengths of the deep veins were studied, and findings were categorized at five locations: common femoral vein (CFV), proximal superficial femoral vein (CFV), mid-SFV, distal SFV, and popliteal vein (PV). RESULTS: Acute thrombus was seen in one or more veins in 131 (17.4%) of the 755 examinations. DVT isolated to a single vein was seen in 28 (21.4%) of the 131 positive examinations: DVT was limited to the CFV in eight studies (61%), to the SFV in six studies (4.6%), and to the PV in 14 studies (10.7%). CONCLUSIONS: DVT limited to a single vein occurs with sufficient frequency that the US screening survey cannot be abbreviated without loss of diagnostic efficacy.

To determine whether magnetic resonance (MR) imaging with MS-325, a recently developed blood pool contrast agent, can depict sexual arousal response in healthy women.Serial MR imaging of the external genitalia was performed in 12 healthy sexually functional women before and after administration of MS-325. MR images were obtained every 3 minutes during a 45-minute examination. During the examination, the subjects viewed neutral and erotic video material while they were in the magnet bore. MR image analysis at each interval consisted of vaginal wall, vaginal mucosa, and clitoris assessments; femoral vein signal intensity measurements; relative regional blood volume (rRBV) calculations; and clitoral volume measurements. Statistical analysis of the results was performed with a t test.On subjective questionnaires, all subjects in the test group reported being sexually aroused. MS-325-enhanced MR images showed strong contrast enhancement of the external genitalia. The rRBV in the glans clitoris of seven of 10 subjects and in the clitoral body of eight of these subjects increased significantly (P.05) during erotic visual stimulation. All 10 subjects had a significant (P.05) increase in clitoral size. There were no significant differences in any measures between the pre- and postmenopausal study groups.The sexual arousal response in healthy women can be monitored at serial MR imaging with MS-325. This examination holds promise for future studies of sexual arousal dysfunction in women.

Two patients with long-term central venous access catheters introduced via the right subclavian vein demonstrated catheter migration into the right internal jugular vein several months after satisfactory catheter placement. One patient developed internal jugular vein thrombosis, which was treated with direct infusion of urokinase before catheter removal. In the other patient, the catheter was repositioned by using an intravascular snare loop, which was introduced via the femoral vein. In the first patient, an interim chest radiograph suggested the mechanism by which the catheter had migrated and provided a clue for early detection of catheter migration.

Vena caval occlusion was evaluated in animal experiments. In five patients with thoracic aortic aneurysms, two balloon catheters were introduced via the femoral vein to the inferior vena cava and superior vena cava and inflated before stent-graft deployment. Aortic pressure and flow were immediately decreased, which minimized the downstream shift of the stent-grafts. Temporary vena caval occlusion is safe and effective for precise aortic stent-graft deployment.

To evaluate whether the release of parathyroid hormone (PTH) from parathyroid tumors during selective parathyroid arteriography can help localize the tumors.In 20 patients (six men, 14 women; age range, 24-72 years) with parathyroid tumors undergoing parathyroid arteriography after failed surgery, serial measurements of PTH were obtained during selective arteriography with nonionic contrast material. PTH levels were measured in the superior vena cava (SVC) before and at varying times from 20 to 120 seconds after arteriography.A 1.4-fold increase in the PTH level of the postarteriographic SVC samples enabled correct prediction of the site of adenoma in 13 of the 20 patients (65%). Of nine patients with positive arteriograms, eight had positive results of postarteriographic sampling. Of 11 patients with negative arteriograms, five had positive results of postarteriographic sampling.Sampling the SVC for PTH gradients after selective parathyroid arteriography correctly indicated the site of the adenoma in 13 of 20 patients (65%).

To determine whether the number of false-negative ultrasound (US) findings of thrombosis is larger when a duplicated femoropopliteal venous system is present.A retrospective review was performed of 381 venograms obtained after initial US findings were considered negative for thigh or popliteal thrombosis in patients in whom deep vein thrombosis was suspected Venograms were evaluated for the presence of thrombosis and the presence and configuration of duplicated superficial femoral veins.Multiple superficial femoral veins were present on 177 (46%) of the 381 venograms; 149 (84%) were duplex systems. False-negative US findings occurred in four (2%) of 204 patients with single femoral veins and in 10 (6%) of 177 patients with duplicated femoral veins (P = .056, not statistically significant).The frequency of missed proximal thrombosis at sonography appears to be increased when duplicated superficial femoral veins are present. Data from clinical and imaging studies are insufficient to support the adoption of a totally noninvasive imaging strategy.

To assess effectiveness of metallic endovascular stents in treatment of venous stenoses and occlusions.Stents were placed intravenously in 56 patients (59 stenoses or occlusions) over a 6-year period. Stent sites included the inferior vena cava (n = 10) and common iliac (n = 31), external iliac (n = 46), common femoral (n = 27), and superficial femoral veins (n = 4). Indications for stent placement included stenoses from pelvic malignancy and its treatment; trauma, surgery, or pregnancy; and idiopathic stenoses. Patients underwent anticoagulation therapy for 3-6 months after stent placement. Follow-up was performed with duplex ultrasound.With use of life-table analysis, overall primary and secondary 1-year patency rates were 50% and 81%, respectively. Primary and secondary 4-year patency rates were and 50% and 75%, respectively. Five patients died of primary disease progression within 6 months after stent placement. Major complications occurred in 6.8% of cases. One-year secondary patency rates were statistically significantly lower (P = .05) for patients with malignant disease, although primary patency rates were comparable. Overall sustained decrease in symptoms (P.0001) was observed 1 year later.Endovascular stent placement is a nonsurgical alternative for reestablishment of venous flow and sustained relief of symptoms in patients with malignant or benign pelvic venous disease.

To evaluate the utility of limited compression ultrasound (US) in the diagnosis of deep vein thrombosis (DVT).Positive sonograms (n = 160) in 155 symptomatic patients were reviewed retrospectively to assess the distribution of DVT. Fifty-three symptomatic patients underwent 56 limited US examinations of the common femoral and popliteal veins only, followed by traditional US of the entire venous system of the lower extremity from the inguinal ligament to the calf veins.Proximal vein thrombosis was seen in 146 cases (91%); the other 14 cases (9%) showed isolated calf vein thrombosis. In 145 cases (99%), either the common femoral or the popliteal vein was involved. Seven (12%) of 56 examinations showed the presence of thrombosis. Limited examination depicted each case of DVT that was detected with the complete examination, with an average decrease in examination time of 9.7 minutes, or 54%.Limited compression US in patients with symptomatic DVT is a viable alternative to routine US; the examination time is decreased by greater than one-half.

To investigate prospectively with color flow duplex (CFD) sonography the incidence of pseudoaneurysm or arteriovenous fistula (AVF) after transfemoral arterial catheterization with angiography, percutaneous transluminal angioplasty (PTA), or local lysis (LL).CFD sonography was used to examine the puncture site in 565 consecutive patients who had undergone PTA, LL, or angiography (581 procedures).The incidence of pseudoaneurysm in the first 300 procedures in which standard compression was used was 14.0% overall, 27.0% after LL with antegrade-puncture PTA, 18.5% after antegrade-puncture PTA, 9.3% after retrograde-puncture PTA, and 1.2% after angiography. To decrease the high incidence, in the next 281 procedures manual compression was continued for at least 5 minutes after local bleeding had stopped. This significantly reduced the incidence to 1.1% overall, 8.0% after LL in combination with PTA, 0.9% after antegrade PTA alone, 0.9% after retrograde PTA, and 0% after angiography (P.01).The incidence of pseudoaneurysm after transfemoral arterial catheterization depends on the type of intervention. The main risk factor is too brief a period of manual compression.

To evaluate the efficacy of catheter-directed thrombolysis with urokinase in treating symptomatic iliofemoral deep venous thrombosis (DVT).Twenty-one consecutive patients with iliofemoral DVT underwent treatment for 27 affected limbs (acute DVT, n = 20; chronic DVT, n = 7). The average urokinase dose was 4.9 million IU (range, 1.4 million to 16.0 million IU) infused over an average of 30 hours (range, 15-74 hours).Lysis was complete in 18 (72%), partial in five (20%), and not achieved in two (8%) of 25 treated limbs. Two chronically occluded iliac veins could not be crossed with a guide wire and did not receive urokinase. Sixteen limbs had underlying venous stenoses (50%) that were treated with angioplasty (n = 2) or angioplasty and stent placement (n = 14). There were no major complications or clinically detectable pulmonary emboli. The technical and clinical success rates were 85%.This initial experience suggests that catheter-directed thrombolysis with urokinase for treatment of symptomatic iliofemoral DVT is safe and effective.

Creation of a percutaneous intrahepatic portosystemic shunt was attempted in a patient with portal hypertension and acute variceal hemorrhage. Abnormal hepatic venous anatomy precluded formation of the shunt with the standard transjugular method. An alternate technique was devised in which a femoral vein approach was used to construct an intrahepatic channel between the inferior right hepatic vein and the right portal vein. The patient stopped bleeding after the procedure and has not rebled during an 8-month follow-up period.

Forty-six patients with a diagnosis of acute deep venous thrombosis (DVT) established by means of duplex ultrasound (US) were prospectively followed up with serial duplex US examinations during a 6-month period to assess the persistence of venous abnormalities. All patients were asymptomatic. Isolated popliteal DVT was found to be more likely to revert to normal at duplex compression US than thrombosis involving both the femoral and popliteal systems (P less than .05). Increased venous diameter was a sign of acute clot (P less than .005). Clot echogenicity did not help to enable distinction of acute DVT and chronic DVT. At compression US, 10 of 21 patients (48%) who initially had occlusive thrombosis had persistent abnormalities that mimicked findings consistent with acute DVT. Chronic venous changes that persisted after 6 months consisted of either lumen recanalization (with resultant intimal thickening) or persistent venous occlusion. Both of these conditions can result in incomplete compression, the major US indication of acute DVT. This appearance should not be confused with that of acute DVT. Follow-up examinations to establish a baseline appearance can be obtained as early as 6 months after an acute episode of DVT.

The authors describe a technique for removing or repositioning a malpositioned Greenfield inferior vena caval filter. A "monorail" system was used, in which a wire was passed from the femoral vein through the apical hole in the filter and out the internal jugular vein; the wire was held taut from above and below and thus facilitated repositioning or removal of the filter. The technique was used successfully in two cases.

A technique for transluminal implantation of vascular endoprostheses was developed. Using a suitable instrument, 160 spiral-shaped prostheses of various forms and sizes were torsion-reduced in diameter and transluminally inserted under fluoroscopy in our study population consisting of 65 dogs and five calves. At the target, the spirals were enlarged and released from the carrier, whereupon they attached themselves to the vessel wall by elastic expansion. We implanted spirals into the vena cava or the thoracic and abdominal aorta, using the infrarenal aorta and the jugular or femoral vein for access. Angiography (the maximum follow-up was two years) demonstrated that the operation was reproducable and that it could be planned. Angiography also demonstrated that the position of the spiral prosthesis was stable and that the spiral did not lead to stenosis, thrombosis, or perforation, providing an adequate technique was used. The side branches of the main vessels remained patent, even with several spiral coils across their orifices. The method can be clinically implemented and lends itself to many applications in the vascular field.

Recently developed surgical techniques for the correction of lower extremity venous insufficiency have renewed interest in venous valvular functions. To assess the value of descending venography in the evaluation of venous valvular incompetence, this technique was compared with bidirectional Doppler ultrasound and ascending venography in the examination of 32 patients with clinical signs of chronic venous insufficiency. Twelve of these patients underwent surgery to valvular incompetence, and all underwent descending venography and Doppler ultrasound examinations postoperatively. Descending venography proved to be an effective, accurate method of diagnosing venous valvular incompetence of the saphenofemoral system.

Among 227 patients undergoing outpatient balloon embolotherapy for varicocele, venography of the right internal spermatic vein (ISV) was attempted in 48. A percutaneous technique from the right femoral vein was used for all patients. The right ISV was successfully occluded with detachable balloons in 41 of 46 (89%), while in five (11%), the right ISV could not be embolized. A competent valve was found in two patients. The right ISV alone was embolized in ten patients: one had a solitary right varicocele, six had left varicoceles but competent valves in the left ISV, and three had recurrent left varicoceles after successful left ISV occlusion. Bilateral ISV embolization was achieved in 31 patients. Long-term follow-up study was available for 25 patients; 12 couples (48%) achieved a pregnancy. Percutaneous balloon occlusion of right varicoceles is a safe, effective outpatient technique.

In 51 instances, patients underwent radionuclide venography with technetium 99m-labeled macroaggregated albumin followed by contrast venography. The criteria used for diagnosis of a positive radionuclide venogram (flow pattern and retention of radionuclide) were evaluated. Cases in which there were discrepancies between the two studies were analyzed. Multiple factors were found to result in a lack of correlation between the two studies. These are: failure to recognize nonfilling of the deep venous system on the radionuclide venogram, disparate distribution of the venographic imaging agents, presence of varicose veins, large venous valves, previous femoral venipuncture, postsurgical narrowing with obstruction, age of the thrombus, and other factors. These factors and their implications with respect to venographic technique are discussed.

Representative phlebograms from a series of 38 patients (86 phlebograms) followed up from 2 weeks to 6 years after the initial thrombotic episode are presented. The veins cleared earliest and most completely in patients with thrombosis, limited to the calf. Totally occluded veins cleared more slowly and less completely than non- or partially occluded veins. Post-thrombotic restoration of normal venous and valvular structures was commonly seen. The authors describe a phlebographic pattern which corresponds to previously documented pathological material, illustrating intimal thickening as a sequel to organization of thrombi onto the walls of the veins.

Color Doppler imaging was used to identify and localize arteriovenous fistulas in six patients after cardiac catheterization. In all six, there was a focal region of persistent intraarterial flow throughout the cardiac cycle at the site of the fistula, in contrast to normal arterial flow, which is forward only in systole. In all cases, turbulent pulsatile venous flow was present at the site of the fistula and nonturbulent pulsatile venous flow was present proximal to the fistula. In five cases a focal area of apparent extravascular tissue vibration was identified. In four cases the communication between the artery and vein was identified. Familiarity with these color Doppler imaging findings should allow for accurate noninvasive diagnosis of arteriovenous fistulas, at the patient's beside if necessary.

Venography is a simple and rapid technique which can be used in the diagnosis of acute penetrating venous injury. Four cases of venous lesions are presented and indications for venography discussed. Findings consisted of bleeding from lacerations and partial or total occlusion from traumatic thrombosis.

Cervical phlebography via the femoral vein approach was done in patients with spinal tumors, cervical radiculopathies, and myelopathies. Tumors originating from or extending into the spinal canal readily compress and obstruct the epidural venous plexus. Because of the lateral position of the epidural veins, the foraminal veins are deformed when cervical roots are compressed in the intervertebral foramina by spondylosis of the uncinate processes or lateral disk herniation. In congenitally narrow canals without significant spondylotic bars, the epidural veins were not opacified. Nonfilling of veins was also seen when the canal was narrowed by multiple spondylotic bars. With a few or even a single spondylotic bar, the epidural veins opacified but this was interrupted at the affected levels. When a significant spondylotic bar was associated with a narrow canal higher up, filling of the epidural veins at the level of the bar was completely arrested.

The evaluation of mitral or tricuspid insufficiency by analysis of the left or right atrial pressure curve is often unreliable, especially in mixed valve lesions. Left ventriculography is considered the most accurate method of estimating the degree of mitral insufficiency, but the literature is contradictory in respect to whether or not reflux occurs through a normal mitral valve (1, 2). Right ventricular angiography in the assessment of tricuspid insufficiency has received little attention. This study was undertaken to determine the frequency with which tricuspid or mitral insufficiency is demonstrated during ventricular angiocardiography in normal dogs. Method Thirty-six mongrel dogs were anesthetized with 27 mg/kg of sodium pentobarbital. In these animals 107 injections of contrast material were made (Table I), 53 of which were into the right ventricle. This ventricle was entered through the tricuspid valve from the right external jugular vein for 16 injections and from the femoral vein for 18. For the...

Percutaneous hepatic intraparenchymal and hepatic wedge studies, including venography and pressure measurements, were compared. Both techniques provide almost identical radiographic information in most cases. Although a percutaneous transthoracic intraparenchymal study is simpler to perform, the hepatic wedge technique (via the femoral vein) is subject to fewer artifacts of pressure measurement and also allows evaluation of free hepatic vein and inferior vena caval pressures.

Retroperitoneal iliopsoas bursal extension of hip joint disease has been described by Finder (1) and Stephens (2). Such spread may be overlooked in the differential diagnosis of abdominal, pelvic, and inguinal masses. We have observed three patients in whom retroperitoneal extension of hypertrophic villonodular synovitis of the hip via the iliopsoas bursa simulated other abdominal and pelvic lesions. A triad or syndrome was observed, consisting of a palpable mass, extrinsic pressure on adjacent structures, and x-ray changes in the hip characteristic of advanced degenerative or destructive arthritis. In one case, the bursal extension from the right hip extended into the abdomen and displaced the cecum and small intestines. In the second, the distended iliopsoas bursa produced medial displacement of the lower ureter and sigmoid and clinical evidence of compression of the external iliac and/or femoral vein. In our third case a bulging bursal mass anteriorly was believed on separate occasions to represent an ...

Opacification of the left heart and portions of the systemic arterial circulation by a unilateral injection of contrast medium through an antecubital vein needle was first reported by Robb and Steinberg in 1938 (1) and 1939 (2). In 1947, Weens and Florence (3) and in 1951 Wall and Rose (4) noted opacification of the abdominal aorta while performing intravenous nephrography, and in 1954 Evans, Dubilier, and Monteith (5) observed the same phenomenon during the course of nephrotomography. Bernstein, Greenspan, and Loken in 1958 (6) and 1959 (7) described the technic of intravenous aortography by the injection of contrast medium through a unilateral polyethylene catheter advanced to the axillary region from an antecubital or brachial vein cutdown. In 1959 Steinberg, Finby, and Evans (8) utilized the technic of simultaneous bilateral injections of contrast media through antecubital vein needles to opacify the systemic arterial circulation. In 1961 Zerbi-Ortiz and Weldon (9) reported the advantages of intraveno...

Phlebograms diagnostic of deep venous thrombus in 21 patients were compared with those taken three to twelve days later; the phlebograms of 25 additional cases were reviewed; and 13 patients were re-examined four to thirty-four months after the original attack. In the first week the thrombus appears loose; over the next fourteen days it becomes adherent to the wall and retracts. A vein obstructed by adherent thrombus may recanalize after several months. Phlebographic recognition of this progression may help in the management of patients with deep venous thrombus and in the prevention of sequels.

Phlebographic study of the anterior condyloid vein, the posterior condyloid vein, and the vertebral veins by catheterization was carried out to determine the anatomy of the cervicovertebral venous system and the method which gives the most satisfactory opacification of this area. Opacification of the intrarachidian plexuses is not obtained consistently by catheterization of the anterior or posterior condyloid veins. Good opacification is obtained with catheterization of one or both vertebral veins. This technique may prove useful in studying intra- and extrarachidian tumor pathology, cervical disk prolapse, and pathology of the intravertebral foramen.

The authors have experienced considerable difficulty (3) in attempting to catheterize the left atrium and ventricle of the dog by the transseptal approach beginning from a femoral vein (5, 6). Moreover, other purposes necessitated recording left ventricular pressure without obstructing carotid flow (4). These two facts, a low incidence of success when a catheter was introduced by the transseptal route into the left atrium, starting from a femoral vein, and research projects which demanded uncompromised carotid arteries while recording left ventricular pressures, led to the development of the method presented in this communication. The procedure is easily learned and highly successful in the transseptal approach to the left atrium and ventricle of the dog (1, 2). The site of introduction of the catheter into the venous system is the right external jugular vein. This method should be safe (in this case, for the dog) and technically simple and also give consistent access to the left atrium and ventricle. On ...

The history of retrograde arteriography and aortography dates back to 1937, when one of the present authors (Pereiras) was able to delineate the subclavian artery in the living subject by injection of a contrast substance into the axillary artery. The case was reported the following year (2), demonstrating that the radiopaque medium could be introduced counter to the direction of the blood stream providing it were injected under sufficient pressure. In 1937, also,retrograde arteriography was performed by us on various occasions on the cadaver (1) with the object of obtaining angiocardiograms upon which an anatomic diagnosis of congenital heart disease might be based in cases in which autopsy was not available (Fig. 1). In the same year, while attempting angiocardiography in a child, we mistook the femoral artery for the femoral vein, with the result that we obtained not an angiocardiogram but a retrograde arteriogram of the external iliac, common iliac, abdominal aorta, and part of the thoracic aorta. In ...