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Purpose: To assess the suitability of tantalum Strecker stents for transjugular intrahepatic portosystemic shunt (TIPS) creation.Methods: TIPS was performed with Strecker balloon-expandable stents in the first 20 patients of our series. A total of 26 prostheses were utilized (average 1.3 per patient).Results: Immediate technical success was achieved in all 20 cases. Nine patients (45%) died during follow-up. The overall average follow-up period was 18.9 months; the 11 survivors were followed for a mean period of 29.8 months. In 4 patients (20%) the stent dislodged towards the hepatic vein during withdrawal of the balloon catheter, and difficulties in recatheterizing the shunt for routine control portal phlebography were frequently encountered. Rebleeding occurred in 5 cases and aggravation of pre-existing encephalopathy occurred in 2 cases. Shunt occlusions or stenosis required further intervention in 4 and 9 patients, respectively.Conclusion: In our opinion the tantalum Strecker stent is not particularly suitable for TIPS. Although it has evident advantages, such as high radiopacity and minimal shortening after deployment, the tendency of the device to dislodge and the difficulty in recatheterization during portal phlebography were important drawbacks. Furthermore, the atraumatic ends of the device did not seem to reduce shunt-related complications, which were comparable to those occurring with other types of stent. [ABSTRACT FROM AUTHOR]

Spurious discharges due to late insulation break in an IS-1 pacing/sensing connector prompted ICD lead removal in 65-year-old man. The tip of the lead was easily freed and pulled back into the SVC by the superior approach. After that, the lead became trapped. The distal part of the lead was caught and easily withdrawn by inferior approach. Superior venous angiography showed extravascular location of the entrapped part of the lead due to the unintentional percutaneous puncture of the innominate vein after piercing the subclavian vein. It may be desirable to use contrast venography before intervention of extraction to ensure venous patency and lead location. [ABSTRACT FROM AUTHOR]

Background: Many studies suggest a major prevalence of atherosclerotic renovascular disease (ARVD), caused by mono or bilateral renal artery stenosis (RAS). Unfortunately, there is no definite therapy to cure this disease to date; therefore, ARVD is burdened by important clinical complications with high social and economic costs. The last few years have seen important advancements in both medical therapy and in interventional radiology (for example, percutaneous transluminal renal artery stenting (PTRS)). All of them could affect, in some way, the natural history of ARVD, but to date the optimal strategy has not been established., Methods: The protocol of a prospective, multicenter, randomized trial "Nephropathy Ischemic Therapy (NITER)" is presented. It enrolls patients with stable renal failure (glomerular filtration rate (GFR) >or=30 ml/min) and hypertension, and hemodynamically significant atherosclerotic ostial RAS (>or=70%) diagnosed by duplex Doppler (DD) ultrasonography and confirmed by magnetic resonance angiography (MRA). This study aims to evaluate whether medical therapy plus interventional PTRS is superior to medical therapy alone according to the following combined primary endpoint: death or dialysis initiation or reduction by >20% in estimated GFR after 0.5, 1, and 2 yrs of follow-up and an extended follow-up until the 4th year. Medical therapy means drugs to control hypertension, improve dyslipidemia and optimize platelet anti-aggregant therapy. The sample size is estimated in 50 patients per group to achieve a statistical significance of 0.05 in case of a reduction by 50% in the combined endpoints.

The purpose of this paper is to illustrate the fundamentals of contrast-enhanced MR angiography, its recent advances and future prospects. The factors influencing contrast-enhanced MR angiography are identified. The main acquisition and timing techniques are described with emphasis on their advantages and drawbacks.

Rationale and Objectives: This study was performed to evaluate the relationship between dose levels of contrast medium and image quality in magnetic resonance (MR) angiography of the carotid arteries with fluoroscopically monitored, manually triggered, elliptically ordered image acquisitions., Materials and Methods: Twenty-five patients with clinical indications for angiography of the carotid arteries were examined with MR at 1.5 T by using a fluoroscopically monitored, manually triggered, elliptically ordered pulse sequence with the administration of one of three different volumes of gadolinium-based contrast medium. The signal intensities of the vessel lumen and the surrounding tissues were measured in single partitions at the origin of the common carotid artery, the carotid bifurcation, and the intracranial internal carotid arteries. The contrast-to-noise ratio in these regions of interest also was measured. Maximum intensity projection image quality was appraised for blurring, artifacts, venous enhancement, background suppression, and contrast medium distribution., Results: No artifacts or venous enhancement was observed. The position of the fluoroscopic section affected the distribution of contrast medium along the vessel, as evidenced by the difference between the contrast-to-noise ratio at the origin of the common carotid artery and the ratio at the carotid bifurcation and the intracranial internal carotid arteries (P < .01). The contrast medium dose administered was strongly correlated with image quality (r = 0.90)., Conclusion: Contrast medium dose is related to image quality in MR angiography of the carotid arteries performed with elliptical ordering, fluoroscopic monitoring, and manual triggering.

Purpose: To evaluate centric ordered MR angiography with fluoroscopic triggering of renal artery disease., Material and Methods: 21 patients underwent MR-Angiography with a fluoroscopically triggered centric ordered sequence. The fluoroscopic trigger was obtained with the parameters that follow: TR/TE/TI: 1000/1.7/500 ms; NEX 1; MTX 141 x 256; SL 10mm; AT 0.83 s. The angiographic sequence was obtained with a CareBolus sequence (TR/TE: 3.9/1.5 ms; NEX 1; MTX 176 x 512; SL 1.1 mm; AT ~20s) after the intra-venous injection of 18 ml of Gd-BOPTA 0.5M followed by saline solution at a rate of 2.5 ml.s-1. Contrast-to-noise ratio (CNR) was obtained at the origin of the renal arteries. Statistical analysis was performed considering image quality, contrast media dose and the CNR., Results: Ringing artifacts never occurred. The collaboration of the patient and the use of the earphones are critical to avoid motion artifacts. Renal veins have never been visualized. High CNR were noticed., Conclusions: This technique allows a more efficient use of the contrast media. MRA with centric ordering and fluoroscopic triggering allows an optimal and easy assessment of the renal arteries.

We present our preliminary experience with the application of covered aortic stents to treat aneurysms and dissections of the thoracic artery, a technique that was developed in 1996. Seven selected patients were treated with World Medical Talent bare spring tip endoprostheses and followed up for a total of 67 months. All prostheses were implanted at the Parma General Hospital Cardiovascular Department. Seven patients, average age 57.8 years, range 44-73 years, were treated; a total of 11 prosthetic segments were implanted. Aortic pathologies included: 2 isthmic atherosclerotic aneurysms, 2 chronic dissections, 1 acute dissection, 1 thoracic aneurysm associated with an aneurysm of the abdominal aorta below the renal arteries. Dilation diameters ranged from 6-9 cm, lengths from 4-12 cm. All patients underwent computerized tomography and angiography before stent implantation. The procedure was carried out in an operating room with the patient under general anesthesia and in controlled hypotension. In 2 cases the common iliac artery, prepared for the extraperitoneal route by application of a No. 10 Dacron introducer sheath, was used as the insertion site; in 4 cases the common femoral artery was used, in the case of the double aneurysm the traditional surgical route was used to correct the abdominal aneurysm, and the thoracic aneurysm was repaired through the abdominal prosthesis. All patients were released in good condition; thrombosis of the aneurysm surrounding the graft was immediate in all cases except one which required the application of a second segment shortly after the initial procedure. There were no major complications; one case of iatrogenic dissection of the femoral artery used as the access site required a prosthetic bypass. No implant-related complications were observed during follow-up. Our initial experience has been favorable and demonstrates that stents can be utilized for aortic pathologies of varying etiologies; we had no mortality or major complications, and hospital stays were short. Long term results must be confirmed before the therapeutic potential of this technique can be fully evaluated.

Transjugular intrahepatic portosystemic shunt (TIPS), a new technique for the treatment of portal hypertension, has been successful in preliminary studies to treat acute variceal hemorrhage and to prevent variceal rebleeding. The purpose of this multicenter, randomized controlled trial is to compare the efficacy of TIPS with that of endoscopic sclerotherapy in the prevention of variceal rebleeding in cirrhosis. Eighty-one cirrhotic patients, with endoscopically proven variceal bleeding, were randomized to either TIPS (38 patients) or endoscopic sclerotherapy (43 patients). Randomization was stratified according to the following: if bleeding occurred < 1 week (stratum I); if bleeding occurred 1 to 6 weeks (stratum II); and if bleeding occurred 6 weeks to 6 months (stratum III) before enrollment. Follow-up included clinical, biochemical, Doppler Ultrasound, and endoscopic examinations every 6 months. During a mean follow-up of 17.7 months, 51% of the patients treated with sclerotherapy and 24% of those treated with TIPS rebled (P = .011). Mortality was 19% in sclerotherapy patients and 24% in TIPS patients (P = .50). Hepatic encephalopathy (HE) developed in 26% and 55%, respectively (P = .006). A separate analysis of the three strata showed that TIPS was significantly more effective than sclerotherapy (P = .026) in preventing rebleeding only in stratum I patients. TIPS is significantly better than sclerotherapy in preventing rebleeding only when it is performed shortly after a variceal bleed; however, TIPS does not improve survival and is associated with a significantly higher incidence of HE. The overall performance of TIPS does not seem to justify the adoption of this technique as a first-choice treatment to prevent rebleeding from esophageal varices in cirrhotic patients.

After a brief historical view, we describe the basic technique currently used to create percutaneous portosystemic shunt. Between September 1992 and March 1995, TIPS was achieved in 50 out of 52 patients; main indications included bleeding from esophageal or gastric varices and refractory ascites. The mean portal pressure reduction was 14.9 mmHg and the mean residual portosystemic gradient was 10.5 mmHg. The average follow-up time was 11.8 months; in this period the overall mortality rate was 28%, while rebleeding occurred in 8 patients and new onsets of encephalopathy occurred in 4 cases. The major problems were due to shunt related complications observed in 46% of the patients; close follow-up and reintervention are required to keep the shunt previous. TIPS, developed ad an alternative to surgery and endoscopic sclerotherapy, is an effective and relatively safe procedure for the treatment of symptomatic portal hypertensive patient.

From January to November 1989, 31 iliac and femoro-popliteal atherosclerotic lesions were treated in 29 patients (age range: 33-80 years) by means of percutaneous laser-assisted angioplasty. The lesions were 6 iliac tubular stenoses, 6 iliac occlusions and 19 femoro-popliteal occlusions, 2-20 cm long. The laser equipment employed was in 10 cases a Cardiolase 4000 Nd:YAG "hot tip" unit, and in 21 cases a Nd:YAG "sapphire contact probe" unit. Initial success was achieved in 23/31 lesions (74%); the follow-up, by clinical examination, Doppler US, and ankle-arm pressure index performed every 4th month, showed 1-year actuarial patency of 80% for femoro-popliteal occlusion and 100% for iliac lesion, with 87% cumulative patency. Overall complication rate was 22.5%. There were 6 local complications, 4 of which were hematomas at the arterial puncture site, and 2 were performation of the superficial femoral artery, all without any clinical sequelae; one patient developed rethrombosis within 72 hours from treatment, which needed amputation after an emergency bypass. Our preliminary results show no significant improvement when compared with conventional balloon angioplasty results both in immediate success rate and in short-to-midterm patency; furthermore, laser therapy was burdened by a higher complication rate. We believe that laser angioplasty should be employed only in arterial occlusion uncrossable with angiographic guidance alone.

Multiple peripheral arteriosclerotic aneurysms are relatively rare. This is a report of a case of two arteriosclerotic aneurysms in unusual sites: ulnar artery and anterior tibial artery. Surgical treatment was: simple resection for the ulnar aneurysm; resection with restoration of arterial continuity for the tibial aneurysm.

One hundred consecutive inpatients with clinically suspected deep venous thrombosis (DVT) were examined by US; the last 19 cases were studied also by means of color-Doppler US. In order to evaluate the method reliability, US results were compared with those obtained with contrast venography, which was performed on all patients. The studied region included the femoro-popliteal vein, while no attempt was made to image the calf veins, which are difficult to evaluate with US. In our series, venographic results were in substantial agreement with US findings, with 99% and 100% sensitivity and specificity, respectively. Diagnosis was based only on noncompressibility of the thrombotic vein, despite the absence of visible clots; pulsed Doppler information supported diagnosis by evaluating blood flow. Further diagnostic progress was provided by color-Doppler US, which allows flow lumen to be defined in color. US also allowed the detection of the conditions mimicking DVT, such as muscular ruptures, hematomas, popliteal cysts, or compressive tumors. In conclusion, US and color-Doppler US prove to be valid alternatives to contrast venography in the diagnosis of proximal DVT of the lower limbs.

The Authors, as they present two rare cases of pheochromocytoma of Zuckerkandl's organ, prove how patient's history physical examination and laboratory findings can at the most address towards a presumptive diagnosis of pheochromocytoma; they also prove that for a sure diagnosis is necessary first echotomography and after arteriography.

The authors report four cases of renal oncocytoma investigated by echography and proved by histology after surgery. Describing the clinical cases, after a brief review of the literature, the radiologic findings are analysed with particular regard to the sonographic signs that can preoperatively differentiate oncocytomas from carcinomas. The authors conclude that the only sonographic distinguishing feature is a quite characteristic central hyperechoic streak corresponding to the fibrous scar, frequently found in this benign tumor.

The Authors expose the technical aspects of the double contrast enema in the colonic diseases. They describe the patient preparation, the use of hypotonic agents and the radiographic technique. They discuss also the accuracy of the method and its diagnostic value. On the bases a four year program 3.500 patients were examined; the ichonography enclosed demonstrated the efficaciousness of this method, particularly in the diagnostic of small parietal lesions.

In all the patients was performed angiography, while only 11 were studied by the means of Abdominal Ultrasonography. The Authors' aim is to evaluate the accuracy of these two methods and to define a correct diagnostic procedure. The results obtained with Angiography were 15 correct diagnosis and 1 false positive, whereas those obtained with Sonography were 7 correct diagnosis, 2 indicative diagnosis and 2 false negative. Therefore, when a patient is clinically suspected of having a traumatic spleen injury, the Authors suggest to perform an Abdominal Sonography at first. In case of evident spleen lesion, laparatomy will be directly carried out. However, if the sonographic result is negative or aspecific, it will be necessary for the patient to undergo Angiography in order to rule out possible false negative or establish the origin of endoabdominal bleeding correctly.

The authors reviewed critically the radiologic diagnosis and the investigation methods (plain abdomen, barium follow-through, small bowel enema, angiography, lymphography, abdomen c.t.), of 60 patients operated for small bowel tumors, either benign or malignant. They compare the radiologic diagnosis with the surgical findings and discuss the validity of the different methods on the basis of the results obtained.

Echography has been employed in 10 patients with knee effusions and in two patients with Baker's cysts. In all instances, echography clearly identified the effusions. In four patients, the presence of connective tissue septa were also shown. This technique appears to be preferred to arthrography or the intra-articular injection of isotopes. Nevertheless, echography provides only "morphologic" information which complements other methods of investigation.

The AA. describe an unusual form of severe grahm negative bacterial infection of the renal parenchima that occurs infrequently in adult patients, most of whom are diabetics. During the acute phase, the kidney becomes smoothly enlarged, with marked impairment of contrast material excretion. The urographic and echographic findings simulated a renal neoplasm; on the contrary the selective renal angiography excluded the presence of a neoplastic blood circulation. This bacterial infection produces an inflammatory infiltrate surrounding and occluding the interlobular arteries in the cortex, with secondary ischemy. A precious and appropriate antibiotic therapy causes a rapid return of renal function; on the contrary this process may produce a globally small kidney in the long run.

The Authors describe one case of duplex and separated hepatic abscesses secondary to perforated appendicitis and peritonitis. A contemporary literature review confirms the actual rarity of this entity. The patient was treated by percutaneous and transhepatic puncture and drainage of abscesses under sonographic control in two different stages. Material and methods of this technique are herein reported, in particular those concerning the management of the smaller of the two abscesses, located posteriorly into the lower segment of the right lobe of the liver, having a more difficult approach. The therapeutic results were excellent: either few days later percutaneous treatment than two months later after the patient was discharged, the clinical and sonographic controls confirmed a successful recovery.