Biomedical subjects
Publications and source records attributed to S L Kaufman.
Results of percutaneous transluminal angioplasty of 141 iliac arteries in 112 patients are reported, with a follow-up period extending to 36 months. Initial technical success was achieved in 95.7%, 1-year patency in 91.3%, and accumulated 2- and 3-year patency in 89%. The role of outflow disease and ankle:arm index measurement and the importance of eliminating or significantly reducing the intra-arterial pressure gradients are discussed.
Percutaneous transluminal angioplasty (PTA) was performed as an adjunct to an operation in 43 patients with peripheral arterial insufficiency. This represents 26% of patients undergoing PTA over the past 44 months. In 23 patients PTA was done in conjunction with planned vascular reconstruction. It was successful in all 23 patients, and patency of the vascular graft was maintained in 22 patients during a mean follow-up period of nine months. Fourteen patients had PTA after operation. It was successful in 13 of them, and vascular patency was maintained in all 13 during a mean follow-up period of four months. Six patients had PTA prior to a distal amputation or a skin graft. All healed promptly. The overall initial success rate of PTA was 98%, the complication rate was 2%, with a late failure rate of 2%. It is concluded that PTA is a valuable adjunct to vascular surgery to improve inflow or outflow for bypass grafts, to reduce the extent of the operation in poor risk patients, to facilitate the healing of distal amputations, and to manage late graft stenosis.
Intra-arterial pressure measurements and ankle pressure indices (determined by Doppler ultrasound) were used to evaluate the hemodynamic response after transluminal angioplasty of the iliac and superficial femoral arteries. Intra-arterial pressure was the best determinant of the end point and technical success of the procedure, while improvement in the ankle pressure index was a good predictor of clinical success. Patients with clinical improvement had a significant increase in ankle pressure regardless of the status of peripheral runoff, while those without improvement did not; they demonstrated impaired distal runoff and required further surgical intervention. Peripheral Doppler pressures also provided a convenient noninvasive method of long-term follow-up.
Multiple pulmonary arteriovenous malformations (PAVM) present a difficult management problem, since surgical resection is not feasible in most instances. Embolotherapy offers a viable alternative. Over a 2-year period, the authors used detachable balloons to treat 16 PAVMs in 5 patients, of whom 4 had severe hypoxemia and 1 had hemoptysis. Symptomatic improvement was achieved in all but 1 patient, in whom the largest PAVM could not be occluded because the balloon was too small. Two patients exhibited segmental pulmonary infarctions. Follow-up angiograms 4 months and 2 years after occlusion demonstrated persistent obliteration of 14 PAVMs without development of collateral supply; 2 required re-embolization due to enlargement of existing nonoccluded feeders. The authors feel that balloon embolization is a safe and effective treatment of PAVMs.
Percutaneous biliary drainage was performed in 18 patients with biliary sepsis due to acute obstructive cholangitis and postoperative complications. Internal drainage could be established in 78% of patients, and 22% were managed on external drainage. Nine patients were managed on long-term internal drainage, six underwent uneventful surgery after successful percutaneous decompression, and three died as a result of septic shock. Percutaneous biliary drainage procedures can be lifesaving in biliary sepsis. Once infection and the hyperbilirubinemia are controlled, rational therapy plans can be formulated on the basis of the anatomy and natural history of the underlying disease.
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The usefulness of computerized tomography, lymphangiography and tumor markers has been examined in 20 consecutive patients with pathologic stage I or II nonseminomatous testicular tumors. Computerized tomography had a false negative rate of 40 per cent, a false positive rate of 50 per cent and an over-all accuracy of 69 per cent. Lymphangiography had a false negative rate of 42 per cent, a false positive rate of 0 and an over-all accuracy of 69 per cent. The combination of computerized tomography and lymphangiography did not significantly improve the diagnostic accuracy of either technique alone. Furthermore, because tumor markers usually were elevated in the presence of bulky metastatic disease that was detected easily by either computerized tomography or lymphangiography, they did not add measurably to the sensitivity of either computerized tomography or lymphangiography in the diagnosis of retroperitoneal lymph node metastases. Consequently, retroperitoneal lymphadenectomy remains the only reliable means for accurate staging of patients with nonseminomatous testicular tumors.
During a three-year period, 107 patients undergoing renal arteriography were studied to evaluate the influence of renin sampling techniques and contrast material administration on renal venous renin activity. Plasma renin activity was nearly equal in three extrarenal sampling sites (antecubital vein, aorta, and lower inferior vena cava). Values for renal vein renin activity obtained with a single catheter (nonsimultaneous sampling) did not differ significantly from those obtained with two catheters (simultaneous sampling). Similarly, contrast material had no significant effect on renal vein renin activity levels. Thus, in hypertensive patients, sampling for renal venous renin activity can be performed accurately with a single venous catheter after renovascular disease has been demonstrated by arteriography.
Fifty-two varicoceles in 50 outpatients were treated by occlusion of the internal spermatic vein (ISV) using detachable balloons 1-2 mm in diameter. The primary reason for treatment was pain in 7 patients and subfertility in 43. All achieved satisfactory occlusion, and only one recurrence was noted in 8 months of follow-up. Limited pre-occlusion venograms allowed precise balloon placement relative to collateral veins which could cause recurrence. This is a safe and effective nonsurgical method of obliterating varicoceles in outpatients.
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Hypertension caused by 90% stenosis of a transplant renal artery was effectively treated by percutaneous transluminal angioplasty of the stenosed artery. Following dilation no pressure gradient existed across the stenosis. Hypertension had developed in a 10-year-old girl with caudal regression syndrome and recurrent pylonephritis five months following homograft transplantation for chronic renal failure. Since percutaneous transluminal angioplasty was performed, the blood pressure has remained within age-related normal limits.
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Two patients were studied who had aortic dissections and chest roentgenograms not suggestive of that diagnosis. Since a normal chest roentgenogram does not necessarily exclude this diagnosis, aortography is indicated, if aortic dissection is strongly suspected clinically.
In our first 18 months' clinical experience with embolization in the chest and abdomen using detachable balloons, successful results were obtained in 34 of 38 patients. One and 2-mm detachable silicone balloons, which can occlude vessels 4--8 mm in diameter, were employed. Prolonged balloon inflation was routinely achieved using iso-osmotic iodipamide meglumine as the filler and limiting inflation volumes to experimentally determined maximums. Improvements in introducer catheter design simplified delivery of the balloon into a variety of circulations. Detachable balloons are not suitable for all embolization purposes, and they are frequently used in conjunction with other agents. When used properly, balloons produce a permanent occlusion that is extremely selective and potentially reversible up to a certain point in the procedure. The balloon technique enables the angiographer to occlude vessels at distances of 2--10 mm beyond the introducer catheter, thus avoiding the need for subselective catheterization and minimizing the dangers of inadvertent embolization.
A system of detachable silicone balloons for therapeutic vascular embolization is described together with applications in the extracranial head and neck. Embolization was performed in 8 cases, 5 of which were preoperative and 3 for definitive treatment. The preoperative embolizations were to reduce intraoperative blood loss and to facilitate limited surgery. Advantages of detachable balloon embolization are flow directibility, selectivity and correctibility prior to balloon detachment. These advantages are used best in the case of AV-fistulas. The present balloon system allows occlusion of vessels 1--4 mm in diameter. Balloons are filled with isoosmolar contrast material.
Congenital arteriovenous malformations (AVMs) with multiple arterial feeders in eight patients were managed by transcatheter embolization with a combination of polyvinyl alcohol foam (Ivalon), detachable silicone balloons, and wool coils. Due to the extensive number of arterial feeders often present, multiple procedures with several days in between were frequently necessary. When possible, surgical resection after embolization is the procedure of choice. Inoperable AVMs are best managed by segmental distal embolization of all arterial feeders with a permanent occluding material. Embolization therapy as a primary form of management is considered palliative and temporary relief of symptoms is usually achieved.
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