Intravenous digital subtraction angiography. Collateral circulation to 'empty leg'

Among 60 patients with uni- or bilateral occlusion of the common or external iliac arteries or both, 12 patients had collateral blood supply originating from the internal mammary or lateral thoracic arteries, or both. By means of intravenous digital subtraction angiography the thoracic arterial pathways and the non-occluded arteries of both legs, simultaneously, were easily demonstrated using the 30 cm effective field size of a Sirecon 33 triplex N image intensifier.     

Internal Thoracic Artery Collateral to the External Iliac Artery in Chronic Aortoiliac Occlusive Disease

Objective

To evaluate the incidence and angiographic findings of the collateral pathway involving the internal thoracic artery in patients with chronic aortoiliac occlusive disease.

Materials and Methods

Between March 2000 and Februrary 2001, 124 patients at our hospital underwent angiographic evaluation of chronic aortoiliac occlusive disease, and in 15 of these complete obstruction or severe stenosis of the aortoiliac artery was identified. The aortograms and collateral arteriograms obtained, including internal thoracic arteriograms, as well as the medical records of the patients involved, were evaluated.

Results

In nine patients there was complete occlusion of the infrarenal aorta, or diffuse stenosis of 75% or more in the descending thoracic aorta, and in the other six, a patent aorta but complete occlusion or stenosis of 75% or more of the common iliac artery was demonstrated. Collateral perfusion via hypertrophied internal thoracic arteries and rich anastomoses between the superior and inferior epigastric arteries, reconstituting the external iliac artery, were noted in all fifteen patients, regardless of symptom duration, which ranged from six months to twelve years.

Conclusion

In patients with chronic aortoiliac occlusive disease, the internal thoracic artery, along with visceral collaterals and those from the contralateral side, is one of the major parietal collateral pathways.     

Idiopathic supraclinoid and internal carotid bifurcation steno-occlusive disease in young American adults

We report a series of American adults with idiopathic steno-occlusive disease of the supraclinoid internal carotid artery and its bifurcation. We reviewed the clinical records and imaging of 18 patients, 16 women and 2 men, aged 20–53 years (mean 35 years). There were no predominating risk factors for vascular occlusive disease, such as oral contraceptive use, hypertension, diabetes mellitus, or smoking. Four patients had irregularity of their cervical internal carotid arteries in a pattern not classic but suspicious of fibromuscular dysplasia. Eleven patients met the criteria for moyamoya disease, having both bilateral disease and moyamoya collateral lenticulostriate arteries. Necropsy in one case showed intimal thickening with duplication of the internal elastic lamina involving the internal carotid artery bifurcation bilaterally. We found a marked predominance of young and middle-aged females in our American adults, but our findings do not support the association with birth-control pills previously reported. Received: 3 February 1998 Accepted: 24 December 1998     

Intrathoracic extracardiac shunts

The source of pulmonary collateral circulation varies according to the nature, location and duration of the inciting pathological process. Bronchial, intercostal, internal mammary, brachiocephalic and other arteries that arise in the mediastinum from the aorta or its branches are the major source of pulmonary arterial collateral circulation. The bronchial veins and mediastinal veins are interconnected with the azygos, vertebral, mediastinal, and thoracic wall veins. They constitute the major venous pathways of the collateral circulation. Anomalous arteries and veins may be recognized radiologically as the cause of a variety of intrathoracic, extracardiac shunts.     

Utility of nonselective abdominal aortography in demonstrating ovarian artery collaterals in patients undergoing uterine artery embolization for fibroids.

PURPOSE: To review the incidence of ovarian collateral supply to uterine fibroids as demonstrated by nonselective abdominal aortography before uterine artery embolization (UAE) and to evaluate the effect of such visualization on interventional management. MATERIALS AND METHODS: The aortograms of 51 consecutive patients (mean age, 42.4 y; range, 30--53 y) undergoing UAE for symptomatic uterine fibroids were reviewed retrospectively for the visualization of ovarian arteries extending into the pelvis. If ovarian arteries were visualized, their size relative to the ipsilateral external iliac artery was measured. Arteries believed large enough to represent a significant blood supply to the uterine fibroids were further evaluated after UAE to determine whether flow persisted. RESULTS: In 13 of 51 patients (25%), a total of 18 ovarian arteries were identified. They were bilateral in five patients and unilateral in eight. Their sizes relative to the ipsilateral external iliac artery ranged from 8% to 57% (mean, 26%). Eight ovarian arteries with a relative size > or = 25% were further evaluated. Five of the eight (62.5%) were not visible after UAE. Of the three persistent ovarian collateral arteries, two were successfully embolized. The patient with the untreated collateral artery experienced persistent menorrhagia. CONCLUSION: Preembolization aortography with the catheter tip at level of the renal arteries demonstrated ovarian collateral arteries in 25% of patients with uterine fibroids. However, their detection influenced treatment in only 6% of the reported cases.     

MR angiography of moyamoya disease before and after encephaloduroarteriosynangiosis

OBJECTIVE: Our purpose was to evaluate the usefulness of MR angiography in revealing moyamoya disease before and after encephaloduroarteriosynangiosis. SUBJECTS AND METHODS: Twenty-six patients (51 hemispheres) with angiographically confirmed moyamoya disease who underwent encephaloduroarteriosynangiosis were included in the study. Findings on preoperative MR angiography were compared with those on conventional angiography. Postoperative neurologic status was categorized as poor, fair, good, or excellent. Postoperative MR angiography was examined for the appearance of the superficial temporal artery, changes in moyamoya vessels, and transdural collateral vessels into the middle cerebral artery territory. RESULTS: Preoperative MR angiography revealed moyamoya disease in all patients (diagnostic accuracy, 100%). MR angiography correctly depicted the degree of internal carotid artery stenosis in 37 arteries (73%), moyamoya vessels in 33 hemispheres (65%), and the degree of stenosis in the middle, anterior, and posterior cerebral arteries in 125 (82%) of 153 arteries. After surgery, 39 hemispheres showed an excellent outcome, eight showed a good outcome, two a fair outcome, and two a poor outcome. On postoperative MR angiography, vascular supply to the middle cerebral artery territory via transdural collateral vessels increased in 28 hemispheres (55%) and decreased in four (8%). The size of the superficial temporal artery increased in 41 (80%) of 51 hemispheres. The extent of moyamoya vessels decreased in 27 hemispheres (53%) after surgery. CONCLUSION: MR angiography can show the changes in the superficial temporal artery and development of transdural collateral vessels after encephaloduroarteriosynangiosis. Because MR angiography is noninvasive, it is valuable for evaluating postoperative changes.     

Mediastinal collateral arteries: important vessels in coarctation of the aorta

Mediastinal collateral arteries are usually present in children with coarctation of the aorta or obstruction of the subclavian artery. These arteries, normally bilateral, connect the subclavian artery, costocervical trunk, or supreme intercostal artery to the descending thoracic aorta. They probably represent hypertrophied preexisting normal vessels of an embryologic origin other than persistence of a dorsal aortic root. Radiologists should be aware of the high frequency of these mediastinal vessels in patients with coarctation of the aorta and subclavian obstruction because they indicate a hemodynamically significant lesion.     

Systemic collateral supply in patients with chronic thromboembolic and primary pulmonary hypertension: assessment with multi-detector row helical CT angiography

PURPOSE: To compare retrospectively the frequency of systemic collateral supply in patients who have chronic thromboembolic pulmonary hypertension with the frequency of systemic collateral supply in patients who have primary pulmonary hypertension by using multi-detector row helical computed tomographic (CT) angiography. MATERIALS AND METHODS: For this review, neither institutional board approval nor informed consent was required. Thirty-six consecutive patients, including 22 patients (four men, 18 women; mean age, 46.0 years) with chronic thromboembolic pulmonary hypertension (group 1) and 14 patients (five men, nine women; mean age, 63.0 years) with primary pulmonary hypertension (group 2), underwent multisection spiral CT angiography of the pulmonary and systemic circulations with a four- (n = 17) or 16- (n = 19) detector row scanner. CT angiograms were assessed for the presence of abnormal bronchial and/or nonbronchial systemic arteries, CT features of pulmonary hypertension, and right ventricular dysfunction. Vascular and parenchymal signs of chronic pulmonary embolism were specifically analyzed on CT angiograms of group 1 patients. Comparative analyses were performed by using the chi(2) or the Fisher exact test for categoric data. An unpaired bilateral Wilcoxon rank sum test was used for continuous data. A chi(2) goodness-of-fit test was used to compare observed proportions with equal proportions. RESULTS: The degree of pulmonary hypertension was comparable in groups 1 and 2. Abnormally enlarged systemic arteries were identified in 16 (73%) of 22 patients from group 1 and in two (14%) of 14 patients from group 2 (P = .002). The systemic collateral supply in group 1 comprised enlargement of both bronchial and nonbronchial systemic arteries in nine (56%) of the 16 patients; the remaining seven patients had an exclusive enlargement of bronchial systemic arteries (n = 6, 38%) or nonbronchial (n = 1, 6%) systemic arteries. A total of 31 enlarged nonbronchial systemic arteries were depicted, including 13 inferior phrenic arteries, 10 intercostal arteries, seven internal mammary arteries, and one lateral thoracic artery. The mean +/- standard deviation of abnormal nonbronchial systemic arteries per patient was 1.4 +/- 1.9. No relationship was found between the mean number of abnormally enlarged nonbronchial systemic arteries and the CT angiographic features of chronic pulmonary embolism. CONCLUSION: These results demonstrate the higher frequency of abnormally enlarged bronchial and nonbronchial systemic arteries in patients who have chronic thromboembolic pulmonary hypertension compared with patients who have primary pulmonary hypertension; this finding could help distinguish these two entities on CT angiograms.     

Moyamoya病脑出血与侧支循环的关系研究

目的 探讨Moyamoya病脑出血与侧支循环的关系。资料与方法 分析37例脑出血型Moyamoya病患者的临床资料及DSA，MRA，MRI和CT结果。结果 全部病例在DSA和MRA像上均显示颈内动脉分叉以上狭窄或闭塞，其中双侧病变25例，单侧12例，在62个病变侧中，53侧基底节区可见异常血管网形成，其中丰富者43侧，较少者10侧，极少或没有者9侧，32个病变侧显示扩张的软脑膜吻合支，后交通动脉增粗23支，眼动脉增粗26支，通过前交通动脉供血5侧，所有造影像上均未见血管造影可显示的动脉瘤，在MRI和CT像上显示基底节脑出血12例，脑叶内出血7例，丘脑出血2例，蛛网膜下腔出血6例，脑室内出血10例，脑出血以突发头痛，神志不清，失语，偏瘫为主要症状。结论 Moyamoya病临床表现与其侧支循环有密切关系，丰富的侧支循环对脑循环起重要代偿作用。可以保护缺血的脑组织；另一方面，如果异常扩张的侧支血管破裂，可引起脑出血，笔者认为Moyamoya病脑出血与其丰富的侧支循环关系密切，基底节，丘脑及脑室出血与脑底异常血管网有关，脑叶内出血可能与扩张的软脑膜吻合支破裂有关，而这两种侧支血管破裂均可引起蛛网膜下腔出血。     

Extracranial angiographic findings in giant cell (temporal) arteritis.

Angiograms of 10 patients with giant cell arteritis who had large-artery and aortic abnormalities were reviewed. The affected arteries had multiple stenotic areas, and occlusions were relatively common, usually located at the end of tapered stenotic segments. Bridging collateral arteries usually refilled the distal portion of the occluded artery. The laterations were seen most frequently in the subclavian, axillary, and brachial arters, and the arteriographic lesions reflected the clinical findings. Such arteriographic abnormalities are suggestive of giant cell arteritis in a patient over the age of 50. The differential diagnosis includes Takayasu's disease, arteriosclerosis, thoracic outlet syndrome, and ergotism.     

Feasibility of Single-Shot Whole Thoracic Time-Resolved MR Angiography to Evaluate Patients with Multiple Pulmonary Arteriovenous Malformations

ObjectiveTo evaluate the feasibility of single-shot whole thoracic time-resolved MR angiography (TR-MRA) to identify the feeding arteries of pulmonary arteriovenous malformations (PAVMs) and reperfusion of the lesion after embolization in patients with multiple PAVMs.Materials and MethodsNine patients (8 females and 1 male; age range, 23–65 years) with a total of 62 PAVMs who underwent percutaneous embolization for multiple PAVMs and were subsequently followed up using TR-MRA and CT obtained within 6 months from each other were retrospectively reviewed. All imaging analyses were performed by two independent readers blinded to clinical information. The visibility of the feeding arteries on maximum intensity projection (MIP) reconstruction and multiplanar reconstruction (MPR) TR-MRA images was evaluated by comparing them to CT as a reference. The accuracy of TR-MRA for diagnosing reperfusion of the PAVM after embolization was assessed in a subgroup with angiographic confirmation. The reliability between the readers in interpreting the TR-MRA results was analyzed using kappa (κ) statistics.ResultsFeeding arteries were visible on the original MIP images of TR-MRA in 82.3% (51/62) and 85.5% (53/62) of readers 1 and 2, respectively. Using the MPR, the rates increased to 93.5% (58/62) and 95.2% (59/62), respectively (κ = 0.760 and 0.792, respectively). Factors for invisibility were the course of feeding arteries in the anteroposterior plane, proximity to large enhancing vessels, adjacency to the chest wall, pulsation of the heart, and small feeding arteries. Thirty-seven PAVMs in five patients had angiographic confirmation of reperfusion status after embolization (32 occlusions and 5 reperfusions). TR-MRA showed 100% (5/5) sensitivity and 100% (32/32, including three cases in which the feeding arteries were not visible on TR-MRA) specificity for both readers.ConclusionSingle-shot whole thoracic TR-MRA with MPR showed good visibility of the feeding arteries of PAVMs and high accuracy in diagnosing reperfusion after embolization. Single-shot whole thoracic TR-MRA may be a feasible method for the follow-up of patients with multiple PAVMs.     

介入放射学在颈部副神经节瘤的临床评价

目的评价介入放射学在颈部副神经节瘤的术前应用。方法分析13例颈部副神经节瘤病例,对6例副神经节瘤行术前栓塞,对9例行球囊阻断试验,了解Willis环功能。结果6例颈部副神经节瘤术前造影及部分供血动脉栓塞均获成功,术中出血明显减少,9例颈动脉阻断(测定Willis环功能)试验全部成功,在术中施行颈动脉结扎术,术中及术后随访未出现新的神经系统症状或体征。结论颈部的副神经节瘤术前栓塞及术前球囊阻断试验安全、可靠,可作为常规术前准备。     

Pulmonary arteriovenous malformation treated with embolotherapy: systemic collateral supply at multidetector CT angiography after 2-20-year follow-up

PURPOSE: To retrospectively evaluate frequency of systemic arterial collateral supply to treated pulmonary arteriovenous malformations (PAVMs) in long-term follow-up with multi-detector row helical computed tomography (CT). MATERIALS AND METHODS: Institutional review board approval was obtained, with waiver of informed consent. Thirty-two patients (19 male, 13 female; mean age, 43 years) underwent follow-up multi-detector row helical CT angiography of the chest (collimation, 16x0.75 mm) 2 or more years after embolotherapy of PAVMs. The study group had a history of successful embolotherapy of 53 PAVMs and a mean of 9 years of follow-up (range, 2-20 years). A search for abnormal systemic arteries was based on analysis of thin-collimated contiguous transverse CT scans and two- and three-dimensional images including maximum intensity projections and volume-rendered images. Statistical comparison was performed with the Fisher exact test (categoric variables) and Wilcoxon rank sum test (continuous variables). RESULTS: At CT, 13 patients (group 1) had abnormally enlarged systemic arteries and 19 patients (group 2) had no abnormal arteries. In group 1, 32 abnormally enlarged arteries were seen-five bronchial and 27 nonbronchial arteries (14 inferior phrenic, six musculophrenic, five internal mammary, two intercostal). The degree of enlargement was moderate for 26 arteries and marked for six. There were no significant differences between groups for (a) clinical characteristics of patients, including history of surgery before or after embolotherapy (P=.7); (b) anatomic structures of treated PAVMs; and (c) embolization procedures and their effectiveness. The number of patients with features suggestive of lung infarction in the days or months after embolotherapy was significantly higher in group 1 (P=.04). On CT angiograms, the number of patients with features suggestive of sequelae of lung infarction was significantly higher in group 1 (P=.02). There were no symptomatic differences attributable to systemic collateral supply between groups; in particular, there was no hemoptysis in group 1. CONCLUSION: Abnormally enlarged systemic arteries were present in 13 of 32 patients, in whom there was a significantly higher frequency of clinical and/or radiographic features suggestive of lung infarction after embolotherapy.     

320层CT动态容积扫描对烟雾病侧支循环的评价

目的 探讨320层CT动态容积扫描技术在烟雾病侧支循环诊断中的应用价值.方法 搜集23例经临床、影像综合诊断为烟雾病患者的320层CT扫描图像,并结合病史、DSA检查等进行回顾性分析.结果 23例烟雾病患者320层CT动态容积扫描时表现为单侧或双侧颈内动脉颅内段及大脑前、中动脉狭窄或闭塞,颅底动脉环处见细小、杂乱、迂曲代偿血管网.烟雾病侧支循环途径包括willis环(6例)、眼动脉(4例)、颅底烟雾动脉(23例)、软脑膜吻合动脉(4例)、颈外动脉分支(9例)等.结论 320层CT动态容积扫描技术能显示烟雾病患者侧支循环情况,特别能良好显示来源于颈外动脉的侧支循环,具有肯定的临床应用价值.     

缺血性脑血管病全脑血管造影效果分析

目的 观察缺血性脑血管病患者脑血管造影显示的血管狭窄或闭塞的比率及分布;探讨缺血性脑血管病与侧支循环代偿的关系,为动脉狭窄的诊断和干预提供依据.方法 回顾性分析138例经CT或MRI筛选的缺血性脑血管病患者的DSA资料.分析血管狭窄部位、受累血管数目、血管狭窄形态及侧支循环代偿.结果 血管造影检测出颅内外血管病变患者102例（73.91%）,共累计血管病变有268处.前循环受累158处,后循环受累93处,锁骨下动脉（SUB）受累17处.102例狭窄或闭塞患者中,脑梗死组与TIA组动脉病变分布差异无统计学意义（P〉0.05）.血管狭窄或闭塞与前循环症状相关65例,占65.66%;与后循环症状相关28例,占71.79%.47例严重狭窄或闭塞患者中有39例出现明显代偿,其中仅前交通开放9例,仅后交通开放13例,前后交通同时开放17例,合并其他代偿途径4例.结论 动脉血管病变在缺血性脑血管病中起重要作用.血管狭窄或闭塞与临床症状有密切联系.侧支循环代偿在动脉狭窄或闭塞患者中起着重要作用,其对决定是否进行干预治疗有重要意义.     

Collateral circulation in stenosis or occlusion of the renal artery

The abdominal angiograms of 381 patients were critically reexamined for the existence of collateral circulation in cases of renal artery stenosis or occlusion. Typical renal artery stenosis was found in 39 patients; among these, 17 had a collateral circulation, which was extrarenal in 15 and intrarenal in two. Collateral circulation involving the lumbar arteries was most common. In two patients a collateral circulation was established via the inferior mesenteric artery.     

Moyamoya病侧支途径的DSA评价及其与临床的关系

目的 应用DSA分析Moyamoya病的侧支途径,探讨侧支循环建立情况与临床、CT表现之间的关系。材料与方法 回顾分析30例经脑血管造影确诊的Moyamoya病患者的血管造影表现、CT结果及临床资料。结果 所有病例均出现颈内动脉或其分支不同程度狭窄或闭塞和颅底异常血管网（MMD血管）;7例可见后组MMD血管;20例由Willis环提供侧支血流;14例眼动脉增粗;17例软脑膜吻合支明显增粗;1例脉络膜前动脉增粗。30例中头颅CT显示有脑梗塞灶4例,正常表现3例,脑出血23例。结论 DSA是诊断Moyamoya病的金标准,对其侧支途径的研究提供了可靠方法。Moyamoya病的侧支循环建立情况与临床密切相关。明确Moyamoya病的侧支循环情况,可为临床治疗和预后判断提供可靠依据。     

Percutaneous embolotherapy in life-threatening hemoptysis

Percutaneous embolization of the bronchial arteries to control massive or recurrent hemoptysis has become an accepted procedure, especially in treating patients with chronic pulmonary disease who are poor candidates for lung resection. Nonbronchial systemic collateral arteries and pulmonary arteries may contribute significantly to pulmonary hemorrhage, but embolization of these vessels has not been stressed in recent literature. When embolization of the bronchial artery fails to control hemoptysis, nonbronchial systemic collateral arteries should be embolized. If no systemic collaterals are present, then embolization of segmental pulmonary arteries may prove helpful.     

Dipyridamole-induced increased glucose uptake in patients with single-vessel coronary artery disease assessed with PET

BACKGROUND: The aim of this study was to determine the relationship between vasodilatation-induced ischemia and poststress glucose uptake. Coronary vasodilators may induce myocardial ischemia due to coronary steal through collateral circulation or transmural blood flow redistribution with diminished subendocardial perfusion. Myocardial ischemia can be demonstrated by increased glucose uptake as previously shown in patients with exercise-induced ischemia. METHODS AND RESULTS: We studied 11 patients with single-vessel disease and no history of myocardial infarction. Five patients had no collateral circulation, and 6 had angiographic evidence of collateral vessels. We measured myocardial blood flow (MBF) and glucose uptake at baseline and after the administration of dipyridamole (0.56 mg/kg) with positron emission tomography, using O-15 water and fluorine 18 deoxyglucose (FDG) as perfusion and glucose tracers. MBF at baseline was 0.82 +/- 0.13 mL/g/min in normal areas and 0.80 +/- 0.15 mL/g/min in areas supplied by stenotic arteries. MBF during dipyridamole was 2.05 +/- 0.66 and 1.19 +/- 0.66 mL/g/min in normal areas and areas with stenotic arteries, respectively (P < or = .001). FDG uptake at baseline was 1.36 +/- 0.55 in normal areas and 1.57 +/- 0.62 in areas supplied by stenotic arteries. FDG uptake after dipyridamole infusion was 1.79 +/- 1.1 and 4.04 +/- 0.84 in normal areas and areas with stenotic arteries, respectively (P < or =.001). MBF and FDG uptake were not different between patients with collateral circulation and those without collateral circulation. CONCLUSIONS: Increased myocardial glucose uptake was consistently observed after dipyridamole administration in those areas with diminished coronary vasodilatory capacity. The similar MBF and FDG findings in patients with and without collateral circulation may indicate that transmural blood flow redistribution appears to be a possible mechanism of dipyridamole-induced myocardial ischemia.     

Detection of coronary thrombosis after multi-phase postmortem CT-angiography

The aim of this study was to compare postmortem angiography-based, autopsy-based and histology-based diagnoses of acute coronary thrombosis in a series of medicolegal cases that underwent postmortem angiographies according to multiphase CT-angiography protocol. Our study included 150 medicolegal cases. All cases underwent native CT-scan, postmortem angiography, complete conventional autopsy and histological examination of the main organs and coronary arteries. In 10 out of the 150 investigated cases, postmortem angiographies revealed coronary arterial luminal filling defects and the absence of collateral vessels, suggesting acute coronary thromboses. Radiological findings were confirmed by autopsy and histological examinations in all cases. In 40 out of 150 cases, angiograms revealed complete or incomplete coronary arterial luminal filling defects and the presence of collateral vessels. Histological examinations did not reveal free-floating or non-adherent thrombi in the coronary arteries in any of these cases. Though postmortem angiography examination has not been well-established for the diagnosis of acute coronary thrombosis, luminal filling defects in coronary arteries suggesting acute thromboses can be observed through angiography and subsequently confirmed by autopsy and histological examinations.