Collateral blood supply to an autotransplanted kidney

Collateral lumbar arterial blood supply to an autotransplanted kidney was angiographically documented in a patient with bilateral Wilms' tumor and postoperative transplant renal artery stenosis. During autotransplantation, most collateral pathways are interrupted. The development of a collateral circulation after autotransplantation may be postulated to begin with a vascular response to postoperative inflammation and adhesions. The small anastomotic pathways so formed may then dilate in response to ischemia resulting from renal artery stenosis.     

肝癌的肝外动脉供血及其介入治疗

目的　探讨肝癌肝外动脉供血规律、插管技术及介入治疗。方法　总结７６ 例肝癌肝外动脉供血特征。７６ 例肝癌动脉栓塞术前常规腹腔动脉、肝总动脉、肠系膜上动脉造影,对位于膈顶部肿瘤还作膈动脉造影,发现肝外供血支进一步超选插管,并同时进行肝动脉、肝外动脉双动脉内化疗栓塞术。结果　７６ 例肝外供血支,由肝动脉闭塞引起侧支动脉供血达２１ 例,其余５５ 例为肝脏本身固有的寄生性供血。肝外供血与肿块部位、大小密切相关。Ｃｏｂｒａ、Ｙａｓｈｉｒｏ 导管配合ＳＰ 导管肝外动脉插管成功率为７２ ．４％ ,随访３６ 例,１、２ 年生存率分别为５２ ％ 和２１％ 。结论　１ ． 依据肿块部位积极寻找肝外供血支;２． 在介入治疗中,预防肝动脉闭塞,减少侧支供血形成至关重要;３． 对具有肝外动脉供血的肝癌采取双动脉内化疗栓塞是必要的、有效的     

Infantile hepatic hemangioendotheliomas: significance of portal venous and systemic collateral arterial supply.

This report describes four infants with hepatic hemangioendotheliomas and cardiac failure who had extensive portal venous and systemic collateral arterial supply complicating hepatic arterial embolization. One patient with diffuse hepatic hemangioendothelioma and extensive portal vein supply but minimal systemic collateral arteries showed no improvement after technically successful hepatic artery embolization and died with disseminated intravascular coagulation and sepsis. A second infant with extensive portal vein and collateral supply died without undergoing embolization. Two patients had portal vein-hepatic vein fistulas as well as an extensive systemic arterial supply. Both infants tolerated staged hepatic and collateral artery embolization, although one patient died of congestive heart failure, probably related to pulmonary hemangiomas. The authors conclude that angiographic study of the potential collateral vessels and portal venous circulation should be performed before embolization. Patients with shunting from the portal vein to the hepatic vein and minimal systemic arterial collateral circulation should not undergo hepatic artery embolization.     

Chronic arterial mesenteric ischemia: Doppler color ultrasonography demonstration of collateral flow

Two cases of atypical mesenteric ischemia where color Doppler US demonstration of the underlying arterial abnormality and collateral supply was possible are presented. Significant stenosis of the celiac axis and thrombosis of the SMA were clearly depicted, along with the presence of collateral arterial supply. Endovascular treatment was successful in both cases. These cases confirm the possibility of detecting collateral flow at Doppler imaging in patients with mesenteric ischemia, both for diagnosis of mesenteric ischemia and endovascular treatment planning.     

Bone metastases in Wilms' tumour.

In a series of 81 patients with a diagnosis of Wilms' tumour seen at the Hospital for Sick Children, Great Ormond Street, between 1960-1972, two patients developed histologically proven bone metastases. In one patient a lump on the head was the presenting symptom of his Wilms' tumour. In the second patient an isolated metastasis developed in the iliac bone 2 3/4 years after complete removal of an encapsulated Wilms' tumour. The bone lesion was outside the previously irradiated volume. Response to treatment was poor and both patients died with further widespread disease. A review of other series confirms the low incidence of bone metastases from Wilms' tumour and the poor prognosis of this complication. This contrasts with a high incidence of pulmonary metastases in which the response to treatment and subsequent survival is good. The value of skeletal surveys and scans in detecting this relatively rare site of metastases from Wilms' tumour is discussed.     

Angiography of chemodectomas of the neck

In 18 chemodectomas of the neck (6 carotid body tumours, 1 vagal body tumour and 11 tympanojugular tumours) the arterial supply and circulatory characteristics were evaluated at angiography. The arterial supply of the carotid body tumours was derived from all adjacent vessels including direct carotid body branches of the proximal external carotid artery. The arterial supply in tympanojugular tumours constantly came from both the ascending pharyngeal and retroauricular arteries and often also from the anterior tympanic artery. Other branches contributed less constantly and only to a minor degree, except for the vertebral artery in cases with tumour extension intracranially. The circulatory characteristics were constant in the series: a short arterial phase was rapidly followed by a phase of relatively long duration with marked, somewhat granular accumulation of contrast medium and also by an early filling of draining veins. The planning of the angiographic procedure in cases of chemodectoma is discussed.     

Revascularization of tracheal anastomosis following heart-lung transplantation

The mechanism by which tracheobronchial arterial supply is reconstituted following heart-lung transplantation was investigated in seven monkeys (3 allografts, 2 autografts, and 2 nontransplanted control monkeys) and three patients. Descending tracheal branches of the thyrocervical arteries provided the major tracheal vascular supply. A collateral branch arising from atrial branches of the left coronary artery supplied tracheobronchial branches in the region of the carina in one allograft. In the three patients studied to date by coronary arteriography, a similar collateral supply to the region of the carina and proximal bronchi was demonstrated from atrial branches of both the left and right coronary circulation.     

Adult arteriosclerotic moyamoya.

Progressive idiopathic distal internal carotid artery occlusion in children and young adults associated with the development of bridging channels and tortuous, plethoric intracerebral arterial networks has been termed moyamoya or Nishimoto's disease. It is now generally recognized that this unusual angiographic patten results from collateral supply pathways and is not a primary angiomatous process. The authors describe 2 middleaged patients with intracranial arteriosclerotic occlusive lesions demonstrating secondary collateral patterns angiographically identical to moyamoya.     

Hepatic artery pseudoaneurysm treated using stent-graft implantation and retrograde gastroduodenal artery coil embolization

Endovascular treatment options for visceral artery pseudoaneurysms depend on lesion location and size. Exclusion methods fall into two categories, embolization and stent placement, and these procedures aim to exclude the pseudoaneurysm from the circulation and if possible to maintain distal blood flow. Embolization of the afferent artery can be used in pseudoaneurysms that arise from a donor artery without collateral supply such as a visceral branch, whereas in the case of visceral arteries with well-established collateral supply, the embolization of both proximal and distal branches to the pseudoaneurysm is mandatory in preventing backflow from the collateral circulation. A direct embolization delivering coils or glue into the sac can also be performed if the aneurismal neck is narrow. Stent-graft placement represents another option to exclude the pseudoaneurysm, in the case of wide neck, reduced arterial tortuosity and large-diameter arteries. We present a case of common hepatic artery pseudoaneurysm involving the gastroduodenal artery origin treated by a combination of techniques. An hepatic stent-graft implantation plus retrograde embolization of the gastroduodenal artery through the pancreaticoduodenal anastomosis from the superior mesenteric artery was performed.     

Cystic partially differentiated nephroblastoma

Cystic partially differentiated nephroblastoma is a relatively rare tumour of the kidney usually affecting infants. Cystic Wilms' tumour and multilocular cystic nephroma should be distinguished from cystic partially differentiated nephroblastoma. Multilocular cystic nephroma is a benign tumour whereas cystic Wilms' tumour is at the malignant end of the range of classification of such tumours. Cystic partially differentiated nephroblastoma may undergo local recurrence but there is no report of metastasis.     

原发性肝癌肝外动脉供血的临床意义及介入治疗

目的 :探讨肝癌的肝外动脉供血规律、插管技术及介入治疗。方法 :4 6例原发性肝癌患者发现肝外动脉供血5 1条 ,分别超选择插管行化疗栓塞。结果 :肝外动脉供血与肿瘤部位、大小密切相关。治疗三周后复查 ,肿瘤缩小 >5 0 %者 14例 (30 .4 % ) ;肿瘤缩小 <5 0 %而 >2 5 %者 2 2例 (47.8% ) ;肿瘤无明显变化 10例 (2 1.7% )。AFP下降 >5 0 %者 2 8例(80 .0 % )。肝功能损害轻 ,全部患者术后无严重并发症。结论 :肝癌有丰富的肝外动脉供血。对肝外动脉供血支超选择性栓塞治疗 ,对提高中晚期肝癌患者介入治疗疗效具有重要的临床意义     

Colour Doppler ultrasound assessment of the inferior vena cava in patients with Wilms' tumour

OBJECTIVE: To assess the diagnostic accuracy of colour flow Doppler ultrasound in diagnosing inferior vena caval (IVC) extension of tumour thrombus in patients with Wilms' tumour. MATERIALS AND METHODS: Over a 3-year period from June 1994 to June 1997, 74 patients with Wilms' tumour were referred to our institution. In this retrospective study we reviewed the preoperative colour flow Doppler ultrasound reports of 64 of these patients and compared the reports with the intra-operative findings in 51 patients who underwent surgery. RESULTS: Vena caval extension of tumour thrombus was present in 12 patients (18.7%) and in six of these patients (9.4%) there was also atrial extension of the tumour. Colour flow Doppler ultrasound correctly diagnosed IVC extension of tumour thrombus in nine patients and correctly predicted the cranial extent of the tumour thrombus in eight patients. CONCLUSION: Colour flow Doppler ultrasound has an overall positive predictive value of 73.4% in assessing IVC patency and correctly diagnosing IVC extension of tumour thrombus, in patients with Wilms' tumour. However, non-diagnostic ultrasound examinations can occur in over 20% of patients.     

With advances in medical imaging can the radiologist reliably diagnose Wilms' tumours?

AIM: To evaluate whether radiologists can accurately differentiate Wilms' tumours from other paediatric abdominal masses with renal involvement using modern imaging methods alone. METHODS: From February 1993 to June 1997, 23 patients presented to the Paediatric Oncology Service at The Royal Hospital for Sick Children, Edinburgh with an intra-abdominal mass which had renal involvement. Nine patients had Wilms' tumours, 12 had neuroblastomas, one patient had xanthogranulomatous pyelonephritis and there was a single case of a mesoblastic nephroma. In each case, two radiologists retrospectively reviewed the initial imaging examinations and independently reached a radiological diagnosis. RESULTS: The radiologists were concordant and reached the correct diagnosis in 20/23 cases (87%), unsure of the diagnosis in one case (4.3 %) and discordant in two cases (8.7 %). Radiologists should be aware that a mesoblastic nephroma can have identical imaging features to a Wilms' tumour. In most cases, ultrasound and a chest X-ray were sufficient to reach the correct diagnosis although computed tomography (CT) and magnetic resonance imaging were superior for demonstrating the relationship of the mass to the great vessels, retroperitoneum and spinal canal. Inferior vena cava invasion was strongly predictive of a Wilms' tumour. Displacement of the great vessels, extension of the mass across the mid-line, renal displacement and tumour calcification on CT were more suggestive of a neuroblastoma although these features were also seen in a significant number of patients with Wilms' tumours. Encasement of vessels by tumour, a paravertebral mass and spinal canal invasion were highly predictive of neuroblastoma. CONCLUSION: In this study, radiologists were accurate at diagnosing Wilms' tumours using modern imaging methods, however, care should be taken in children who are less than 1 year of age as a mesoblastic nephroma may have identical imaging characteristics.     

门静脉癌栓肝脏血供变更的CT表现

目的探讨门静脉癌栓血流动力学变化及肝脏周边区动脉期异常强化的发生机制.方法回顾分析30例经CT和血管造影证实的中晚期肝癌28例,转移癌2例同时并发门静脉癌栓形成的影像学资料.结果30例门静脉癌栓中在主干、左、右支同时存在的有18例,主干癌栓3例,左、右支癌栓9例.门静脉海绵样变26例,CT表现为肝门、肝裂、胆囊窝增粗成团的血管影.在30例中,肝脏周边区动脉期异常强化10例.结论门静脉癌栓后侧枝循环形成海绵样变,仍能维持肝脏的血供,肝脏周边区动脉期异常强化提示肝脏血供变更,门静脉血供减少,动脉血供代偿增加.     

Chemoembolization of the left inferior phrenic artery in patients with hepatocellular carcinoma: radiographic findings and clinical outcome

The purpose of this study was to evaluate the radiographic findings of hepatocellular carcinoma (HCC) supplied by the left inferior phrenic artery (LIPA) and the safety and efficacy of transcatheter arterial chemoembolization (TACE) of the LIPA. From September 2002 until August 2004, 11 patients with LIPA supplying HCC were identified and successfully treated with TACE of all LIPAs. LIPA collateral vessels may supply HCC, particularly when the tumors are in the left lobe of the liver in patients who have undergone previous TACE procedures. In this setting, such collateral vessels should be sought on preprocedural imaging. These LIPA collateral vessels may be safely embolized with very good clinical results.     

Anterior spinal artery as a collateral channel in cases of bilateral vertebral arterial steno-occlusive diseases

BACKGROUND AND PURPOSE: We report 6 cases of retrograde flow through the anterior spinal artery (ASA) from cervical vertebral artery (VA) to intracranial distal VA because the perfusion from bilateral vertebral arteries was tenuous. Its hemodynamic and clinical implications are discussed. METHODS: In association with bilateral steno-occlusive disease of vertebral arteries, 6 cases of retrograde flow through ASA were reviewed in terms of clinical and angiographic characteristics. All 6 patients presented with stroke in the posterior fossa and underwent conventional angiography as part of diagnostic evaluation and/or therapeutic intervention. RESULTS: On the angiography, 2 patients showed bilateral VA occlusion, and the other 4 patients showed VA occlusion on 1 side and severe stenosis in the other VA. Distal perfusion by ASA was prominent in 2, and not prominent in 4. Reversal or disappearance of the retrograde flow through ASA was observed after successful recanalization of the occluded VA in 4 patients. In 1 patient, increased perfusion through ASA was observed because the stenosed VA was completely occluded. CONCLUSION: When the vertebral arteries were occluded bilaterally or when a single VA was occluded and the other carried a severe stenosis and, as a result, the basilar arterial blood supply was tenuous, retrograde flow through ASA could be observed. This is a potentially important source of collateral supply to the posterior fossa neural contents. The degree and extent of perfusion via this collateral channel varied depending on presence of other collateral routes and patency of the vertebrobasilar junction.     

Accessory Meningeal Arterial Supply to the Posterior Nasal Cavity: Another Reason for Failed Endovascular Treatment of Epistaxis

A patient with intractable posterior epistaxis was treated with embolization of the ipsilateral sphenopalatine and facial arteries and contralateral sphenopalatine artery. She continued to bleed despite a seemingly adequate embolization procedure. A second angiogram revealed a significant collateral blood supply to the posterior nasal cavity from the accessory meningeal artery not identified during the first procedure. This was then embolized with no further epistaxis encountered. This case demonstrates yet another collateral arterial pathway that might account for a failed embolization.     

Collateral circulation imaging: MR perfusion territory arterial spin-labeling at 3T

BACKGROUND AND PURPOSE: Current knowledge of the collateral circulation remains sparse, and a noninvasive method to better characterize the role of collaterals is desirable. The aim of our study was to investigate the presence and distal flow of collaterals by using a new MR perfusion territory imaging, vessel-encoded arterial spin-labeling (VE-ASL).MATERIALS AND METHODS: Fifty-six patients with internal carotid artery (ICA) or middle cerebral artery (MCA) stenosis were identified by sonography. VE-ASL was performed to assess the presence and function of collateral flow. The perfusion information was combined with VE maps into high signal-intensity-to-noise-ratio 3-colored maps of the left carotid, right carotid, and posterior circulation territories. The presence of the anterior and posterior collateral flow was demonstrated by the color of the standard anterior cerebral artery/MCA flow territory. The distal function of collateral flow was categorized as adequate (cerebral blood flow [CBF] ≥10 mL/min/100 g) or deficient (CBF <10 mL/min/100 g). The results were compared with those of MR angiography (MRA) and intra-arterial digital subtraction angiography (DSA) in cross table, and κ coefficients were calculated to determine the agreement among different methods.RESULTS: The κ coefficients of the presence of anterior and posterior collaterals by using VE-ASL and MRA were 0.785 and 0.700, respectively. The κ coefficient of the function of collaterals by using VE-ASL and DSA was 0.726. Apart from collaterals through the circle of Willis, VE-ASL showed collateral flow via leptomeningeal anastomoses.CONCLUSIONS: In patients with ICA or MCA stenosis, VE-ASL could show the presence, the origin, and distal function of collateral flow noninvasively.

The protective effect of collateral circulation influences final clinical outcomes for patients with hemodynamically significant arterial stenosis. The principal source of collateral flow of cerebral arteries is through the arteries of the circle of Willis. Secondary collateral pathways include the external carotid artery via the ophthalmic artery and leptomeningeal anastomoses at the brain surface. However, the size and patency of these arteries are quite variable.Doppler sonography is the most common tool used to investigate the presence of collateral flows. MR angiography (MRA) can be used for determining the collaterals through the circle of Willis. However, both sonography and MRA do not show leptomeningeal collateral pathways, distal collateral flows, or the actual contribution of collateral flow to brain perfusion. Intra-arterial digital subtraction angiography (DSA) shows the presence and distal arteries of the collateral pathways.¹ However, to visualize all the collateral pathways, this technique requires an invasive and selective 3-vessel approach and is typically not performed in patients with acute stroke or cerebral arterial stenosis. Therefore, a noninvasive method that demonstrates selectively angiographic information may be desired to investigate collateral blood flow.²In MR perfusion territory arterial spin-labeling (ASL),^3–7 blood in individual or groups of feeding arteries is tagged by using ASL methodology, and images are acquired that map the vascular distribution of those feeding arteries. Recently, vessel-encoded ASL (VE-ASL) MR imaging⁸ was introduced as a more time-efficient method for mapping multiple vascular territories. The aim of our study was to investigate the presence and distal flow of collateral blood supply by using the VE-ASL technique at 3T on patients with carotid stenotic disease.     

Development of a New Subclavian Arterial Infusion Chemotherapy Method for Locally or Recurrent Advanced Breast Cancer Using an Implanted Catheter–Port System After Redistribution of Arterial Tumor Supply

Locally or recurrent advanced breast cancers can receive arterial blood supply from various arteries, such as the internal thoracic artery (ITA), the lateral thoracic artery, and the other small arterial branches originating from the subclavian artery. Failure to catheterize and subsequent formation of collateral arterial blood supply from various arteries are some of the reasons why the response to conventional selective transarterial infusion chemotherapy is limited and variable. To overcome this problem, we developed a new subclavian arterial infusion chemotherapy method using an implanted catheter–port system after redistribution of arterial tumor blood supply by embolizing the ITA. We named this technique (“redistributed subclavian arterial infusion chemotherapy” (RESAIC)). Using RESAIC, patients can be treated on an outpatient basis for extended periods of time. Eleven patients underwent RESAIC, and the complete remission and partial response rate in 10 evaluable patients was 90%: complete remission [CR] n = 4, partial remission n = 4, stable disease n = 1, and not evaluable n = 1. Three of four patients with CR had no distant metastasis, and modified radical mastectomy was performed 1 month after conclusion of RESAIC. The resected specimens showed no residual cancer cells, and pathologically confirmed complete remission was diagnosed in each of these cases. Although temporary grade-3 myelosuppression was seen in three patients who were previously treated by systemic chemotherapy, there was no other drug-induced toxicity or procedure-related complications. RESAIC produced a better response and showed no major complications compared with other studies despite the advanced stage of the cancers.     

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.