A prospective analysis of the accuracy and cost-effectiveness of digital subtraction angiography for living-related renal donor evaluation

From 1982 to 1984, we conducted a prospective study to evaluate the usefulness of i.v. renal digital subtraction angiography (DSA) for living-related donor (LRD) evaluation. Twenty-eight LRDs were evaluated with the traditional approach of intravenous pyelography (IVP) and standard catheter arteriography (SCA) (group 1). During the same period, 33 LRDs underwent renal DSA and IVP from a single i.v. contrast injection (group 2). If renal arterial imaging with DSA was considered satisfactory, no further radiographic studies were done (group 2-A, n = 23). If renal arterial imaging with DSA was not satisfactory, SCA was then obtained (group 2-B, n = 10). DSA alone accurately defined the number and location of renal arteries in 21 of 23 patients from group 2-A, and in 5 of 10 patients from group 2-B. The major limitation of DSA was in patients with multiple renal arteries; accurate imaging was obtained in only 7 of these 13 patients (54%). In group 2 overall, preoperative renal imaging was not accurate in 2 of 33 patients (6%); in both cases, an unsuspected polar artery was found at nephrectomy. The mean cost per patient of all radiographic renal imaging studies was $953.00 for group 2 and $1721.00 for group 1. These data suggest that the approach of preferentially evaluating LRDs with DSA-IVP, and obtaining SCA only if DSA yields poor visualization, is more cost-effective but not as accurate as the traditional policy of obtaining SCA and IVP in all cases.     

Simultaneous structural and functional imaging of the transplant kidney using digital subtraction angiography

We herein describe our preliminary experience with digital subtraction angiography in the noninvasive evaluation of renal transplant structure and function. A single digital subtraction angiography study was obtained in 38 patients with transplant kidneys and various levels of renal function. The main renal artery was demonstrated well in all studies. Stored digital information was used to generate appearance and clearance rates of contrast medium to produce a functional renal image. There was good correlation between the functional image pattern on digital subtraction angiography and the known degree of renal functional impairment. No adverse effects resulted from the small dose of intravenous contrast material used for angiography. This initial study suggests that digital subtraction angiography is a rapid, safe and noninvasive method for visualization of the transplant kidney, and can afford clinically relevant structural and functional information.     

Renal digital subtraction angiography

Renal digital imaging has progressed rapidly in reliability and potential since its clinical introduction in 1979. The advent of larger image intensifiers has made feasible subtraction imaging of the renal parenchyma and collecting systems as an adjunct to IV-DSA. The growing use of IA-DSA has expanded the utility of the technology to the examination of the intrarenal circulation, contrast-sensitive patients, and the performance of interventional procedures. There are experimental works suggesting that it may be feasible to derive accurate physiologic data reflecting renal blood flow and excretion from sequential alterations in intravascular contrast density. Thus, anatomic abnormalities and their significance might conceivably be determined, with minimal patient discomfort, from the same imaging procedure. The development of digital imaging technology and techniques continues to be of major interest to both academic and commercial investigators. Thus, further improvements in digital imaging and expansion of its capabilities are likely to occur.     

Digital subtraction angiography for renal donor evaluation

A consecutive series of 52 living related renal donors were evaluated preoperatively by angiography. The preoperative angiographic interpretation was compared with the anatomy found at donor nephrectomy. Standard selective renal arteriography was found to be 100 per cent accurate in defining single (25) or multiple (1) renal arteries. Digital subtraction angiography (DSA) alone performed with an intra-arterial injection of contrast material was found to be 82 per cent accurate in determining the number of renal arteries. In five kidneys with multiple renal arteries, only two had the correct number of vessels identified. The errors are inherent in the DSA technology. DSA at the present time is not accurate enough to replace the standard arteriogram in the evaluation of the donor nephrectomy patient.     

Pulmonary embolism in a living-related kidney transplantation donor

Living-related renal transplantation is the optimal therapy for patients with end-stage renal disease (ESRD). Normally, complications are rare in living-related donor nephrectomy. However, we experienced a case of pulmonary embolism (PE). The incidence of PE in living donor nephrectomy is rare, but the total incidence of PE in surgical operations has recently increased. The patient in the case reported here was diagnosed relatively early and recovered with appropriate treatment. It is very important for surgeons to realize that serious complications such as PE can develop in any case of living donor nephrectomy. Received: May 1, 2001 / Accepted: January 8, 2002 Acknowledgment. This work was supported in part by a Grant-in-Aid for Research on Human Genome, Tissue Engineering Food Biotechnology, Health Sciences Research Grants, Ministry of Health, Labor and Welfare of Japan. Reprint requests to: H. Ushigome     

Diagnosis of cerebral aneurysm using 3-dimensional digital subtraction angiography]

Recent rapid advancement in the technology of magnetic resonance angiography and 3-dimensional computed tomography angiography has opened the door to a less-invasive diagnostic routine for the treatment of cerebral aneurysms. However, from the viewpoint of decision making concerning which treatment to use; conservative therapy; surgical intervention; or endovascular treatment, much more precise information is necessary. Recent progress of rotation digital subtraction angiography has introduced 3-dimensional digital subtraction angiography. In the past year, 28 cases involving 39 aneurysms have been studied using 3-dimensional angiography. This study was carried out, using a rotating C-arm, which rotates 220 degrees in 5.8 seconds. All raw data gathered was transferred to the workstation for image reconstruction. The purpose of this study was to evaluate the clinical potential of 3-dimensional digital subtraction angiography for the diagnosis of the cerebral aneurysms.     

Intraoperative angiography using a portable digital subtraction unit. Technical note

A portable digital subtraction unit has been used in the operating room as an important improvement in obtaining high-quality intraoperative angiograms. This digital subtraction system offers several advantages over previously described techniques for intraoperative studies. Not only are the images of good quality, but also the dose of contrast medium is reduced and a real-time imaging capability allows the surgeon to visualize the passage of contrast agent dynamically. Arterial injections may be performed by selective femoral cerebral catheterization, puncture of the cervical carotid artery, retrograde catheterization via the superficial temporal artery, or puncture of an intracranial vessel at the time of surgery.     

Digital subtraction angiography of the kidney

Intravenous and intra-arterial digital subtraction angiography (DSA) was performed in 88 patients: 34 with tumours, 10 with renal trauma, 26 with suspected renovascular hypertension, 6 with vascular impression on the renal pelvis, 8 with nephrolithiasis and 4 with sonographically abnormal kidneys. Venous and arterial DSA always gave diagnostically useful images. Intravenous DSA is valuable in patients with suspected renovascular hypertension or after vascular surgery, percutaneous transluminal angioplasty and transcatheter embolisation. Arterial DSA is preferable to venous DSA in other clinical situations, particularly in the evaluation of renal tumours, and may be recommended in preference to conventional angiography.     

Rapid diagnosis of thoracic aortic transection using intravenous digital subtraction angiography

Rupture of the thoracic aorta associated with blunt trauma remains a frequently lethal injury. Although increasing numbers of patients with ruptured aortas are surviving to reach the hospital, the in-hospital mortality attending this injury remains high. Death due to transected aorta has been related to a delay in diagnosis. In an attempt to decrease the time necessary for diagnosis of this injury, we studied 50 patients using intravenous digital subtraction angiography (IVDSA) and conventional biplane angiography. We found that IVDSA was significantly faster than conventional biplane angiography, and that when IVDSA films are of diagnostic quality, they are sufficient to reliably demonstrate the presence of traumatic aortic transection. Our study was too small to establish whether IVDSA is a sufficiently sensitive test to exclude aortic injury. Further studies in this area need to be performed.     

Evaluation of renal intra-arterial digital subtraction angiography

A total of 68 patients with renal abnormalities and potential donors were examined by intra-arterial digital subtraction angiography (IA-DSA). Compared with the conventional angiography, the advantages of IA-DSA are reduction of volume of contrast material and rate of injection. The image quality is superior to intravenous DSA. For the potential donors, IA-DSA has the same diagnostic value as conventional angiography to depict the number and position of renal arteries. IA-DSA is an effective method for screening hypertensive patients for renovascular disease. However, conventional angiography is necessary when evaluation of smaller intra-renal branch is desired. IA-DSA would be valuable for renal recipients because of good visibility by a smaller volume of contrast material. Another advantage of IA-DSA is the reduction of examination time. Embolization can also be done in a shorter time. Renal vein is easily detected by IA-DSA. Renal vein anomalies and obstruction are diagnosed in the left side without conventional venography. Renal IA-DSA can be replaced by conventional arteriography except when the delineation of tiny arterial change is desired.     

Intravenous digital subtraction angiography in intensive care

Intravenous digital subtraction angiography (IVDSA) was performed in 11 patients aged from 23 to 62 yr to visualize vascular disease that required to be treated without delay: 7 were in shock preceded by a cardiac arrest in 5 of them; 4 suffered from acute renal failure, 8 from acute respiratory failure and one from brain death. 5 pulmonary, 2 thoracic aortic, 3 abdominal aortic, 1 right subclavian and 1 renal arterial angiographies were carried out by this method. In all the cases described, we either confirmed the diagnosis (rupture of thoracic aorta, type I aortic dissection, aneurysm of abdominal aorta, complete occlusion of the distal abdominal aorta, pulmonary embolism) or set aside diagnosis (lesion of the subclavian vessels, pulmonary embolism) or visualized the renal vasculature before removing the organ. No incident was observed. Conventional angiography remained a reference method but it presented risks which were not to be neglected in critically ill patients. Despite the theoretical limits set by the technical demands (absolute motionlessness, apnoea) and few other restrictions found in the literature, IVDSA seemed to offer distinct advantages under such conditions. Only requiring an injection using a catheter placed in a peripheral vein, this method was fast, safe and easy; it gave a close enough approach to the diagnosis to be able to help decide on specific treatment or on orientation towards a specific hospital department.     

Value of digital subtraction angiography in cerebrovascular diseases

Digital Angiography was done on 1 000 patients with cerebral vascular diseases at the cervical or cerebral level. This was done by intravenous injection in 800 cases and by intra-arterial injection in 200 cases. The study of the cervical carotid bifurcation is favorably compared to the one obtained by the conventional arteriography. The intracranial aneurysms of 1 centimeter are well visualized and this method is valid to eliminate a giant aneurysm before transsphenoidal surgery. The digital angiography also allows the study of venous and sinus malformations. The postoperative controls of the aneurysms, carotid endarterectomies and extra-intracranial bypass are perfectly shown and can be repeated. The comparative study between the intravenous digital angiography and the conventional angiography have shown a good correlation between both tests in 80% of the cases. This rate can be risen by intra-arterial injection. It is a non-invasive method, reliable and economical with very little complications. This test can be done on an external basis and repeated if necessary. The disadvantages are the overlapping of the vessels, the necessity of the strict immobilisation of the head and the difficulty of evaluating the vessels whose diameter is inferior to 1 mm.     

Applications of digital subtraction angiography in cardiovascular diagnosis

Both intravenous and intra-arterial DSA have widespread applications in the field of cardiovascular diagnosis. The definition of carotid artery stenosis or severe peripheral vascular disease in the patient undergoing coronary artery bypass surgery might dictate the need for simultaneous carotid and coronary artery surgery or demonstrate the best route for insertion of an intra-aortic balloon. DSA also might find further application in the definition of thoracic aortic dissection, thoracic aortic trauma, and coarctation of the thoracic aorta, as well as in showing the adequacy of repair of thoracic coarctation in patients who remain hypertensive postoperatively. Left ventricular imaging using intravenous or intraventricular injections of contrast material provides an accurate method of calculating ejection fraction and an excellent picture of left ventricular wall motion. In addition, because smaller amounts of contrast material may be used for intraventricular infections, patients with renal failure or severe impairment of the left ventricle might fare better with the reduced contrast load. Multiple ventriculograms can be performed following interventions such as pacing or exercise to allow a more adequate definition of left ventricular performance. Intravenous DSA still has not achieved satisfactory visualization of the coronary arteries or coronary artery bypass grafts. However, aortic root injections of contrast material can provide adequate definition of these structures and has been recommended as a screening technique for coronary disease in patients undergoing arteriography for other vascular disease. Current work on the development of DSA techniques for the quantitation of coronary artery blood flow and myocardial perfusion is quite promising. Accurate, reproducible measurement of coronary artery blood flow, patterns of myocardial perfusion, and areas of myocardium supplied by specific coronary vessels with obstructions may soon provide physiologic information about anatomically defined coronary artery disease. A variety of congenital heart defects have been defined by intravenous DSA. Shunt lesions such as atrial septal defects, ventricular septal defects, and patent ductus arteriosus have been defined anatomically, and the severity of their shunts has been estimated by placing windows of interest over the various cardiac chambers. It is possible that certain congenital malformations might be studied adequately by intravenous DSA, eliminating the need for cardiac catheterization.(ABSTRACT TRUNCATED AT 400 WORDS)     

Carotid artery surgery based on digital subtraction angiography

This study shows that digital subtraction angiography provides the morphologic criteria necessary for surgical intervention in most patients with carotid atheroma. Digital subtraction angiography provides a safe means of studying patients, with an overall sensitivity of 96 percent and specificity of 86 percent. Radiopaque casts of the operative specimen have been used as the gold standard, providing a suitable means of comparing the findings on digital subtraction angiography with the operative findings. Failure to obtain good visualization of the vessels with biplanar views required conventional angiography to properly evaluate the vessels in 12 percent of patients. This technique represents a major advance in the study of carotid artery disease which may replace many of the current imaging techniques.     

Preoperative evaluation of living kidney donors using multirow detector computed tomography: comparison with digital subtraction angiography and intraoperative findings

To assess the accuracy of multirow detector computed tomography (MDCT) for the evaluation of renal anatomy for preoperative donor assessment in living related kidney transplantation. MDCT-scans (4- and 16-slice-CT) of 51 consecutive living kidney donors (age, 51.6 +/- 9.7 years; range, 28-68 years) were analysed by three blinded observers and compared with digital subtraction angiography (DSA) and surgery. Contrast-enhanced MDCT was performed with 1 mm slice thickness reconstruction interval during arterial and venous phases. Supernumerary renal arteries, veins, early branching of vessels and abnormalities of the ureters were documented. The overall accuracy of computed tomography angiography (CTA) for detection and classification of surgically relevant arterial variants was 97% (99/102). The interpretation of 16-channel MDCT images was correct in all cases (accuracy, 100%), while the four-channel CTA had three incorrect results regarding the differentiation of early branching vessels from double renal arteries (accuracy, 93%). The overall accuracy of DSA was 91%. Renal vein abnormalities were correctly diagnosed with MDCT in 100% compared with 89% correct findings with DSA. There were three kidneys with incomplete ureter duplication, detected both with MDCT and DSA. MDCT demonstrated superior accuracy compared with non-selective DSA for the preoperative assessment of renal anatomy in living kidney donors; and for the distinction of supernumerary arteries versus early branching patterns, 16-channel CTA data were better than those of the four-channel system.