We performed lower extremity arterial duplex mapping from the aortic bifurcation to the ankle in 150 consecutive patients evaluated for aortic and lower extremity arterial reconstruction and compared lower extremity arterial duplex mapping in a blinded fashion to angiography. On the basis of history, physical examination, and four-cuff segmental Doppler pressures individual lower extremities were classified as normal, isolated aortoiliac disease, infrainguinal disease, and multilevel inflow and outflow disease. For vessels proximal to the tibial arteries, lower extremity arterial duplex mapping was analyzed for its ability to insonate individual arterial segments, detect a 50% or greater stenosis, and distinguish stenosis from occlusion. In the tibial arteries lower extremity arterial duplex mapping was evaluated for its ability to visualize tibial vessels and to predict interruption of tibial artery patency from origin to ankle. Lower extremity arterial duplex mapping visualized 99% of arterial segments proximal to the tibial vessels, with overall sensitivities for detecting a 50% or greater lesion ranging from 89% in the iliac vessels to 67% at the popliteal artery. Stenosis was successfully distinguished from occlusion in 98% of cases. In the tibial vessels lower extremity arterial duplex mapping was better at visualizing anterior tibial and posterior tibial artery segments (94% and 96%) than peroneal artery segments (83%), (p less than 0.001). Overall sensitivities for predicting interruption of tibial artery patency were 90% for the anterior tibial, 90% for the posterior tibial, and 82% for the peroneal. Clinical disease category did not influence in a major way the accuracy of lower extremity arterial duplex mapping in either above-knee or below-knee vessels.

Mesenteric artery duplex scanning appears promising for detection of splanchnic artery stenosis or occlusion or both in patients with symptoms suggestive of chronic intestinal ischemia. However, no specific duplex criteria have been developed for detection of mesenteric artery stenosis. We obtained mesenteric artery duplex scans and infradiaphragmatic lateral aortograms in 34 patients to determine duplex criteria for mesenteric stenosis. Seventy percent or greater angiographic stenosis was present in 10 superior mesenteric arteries and 16 celiac arteries. Duplex scans were reviewed to determine if celiac artery and superior mesenteric artery ratios of peak systolic velocities and end-diastolic velocities to peak aortic systolic velocity, as well as celiac artery and superior mesenteric artery peak systolic velocities and end-diastolic velocities alone, could predict a greater than or equal to 70% angiographic stenosis or occlusion or both. The results obtained by use of receiver operator curves indicated peak systolic velocity alone was an accurate predictor of splanchnic artery stenosis. Specifically, a peak systolic velocity greater than or equal to 275 cm/sec in the superior mesenteric artery and greater than or equal to 200 cm/sec in the celiac artery or no flow signal (superior mesenteric artery and celiac artery) predicted a 70% to 100% stenosis with sensitivity, specificity, and positive predictive values of 89%, 92%, and 80% for the superior mesenteric artery. Similar values for the celiac artery were 75%, 89%, and 85%, respectively. End-diastolic velocities or calculated velocity ratios conveyed no additional accuracy in predicting splanchnic artery stenosis.

Gianturco-Rösch expandable Z-stents were used in 22 patients with superior vena cava syndrome (SVCS). Stents were placed in all patients in the SVC and in 17 patients, also into the innominate veins. Stent placement resulted in complete relief of symptoms in all patients. Twenty-one patients had no SVCS recurrence from 1 to 16 months, to their death, or to the present time. SVCS recurred only in 1 patient 9 months after stent placement due to tumor ingrowth and secondary thrombosis. Based on ours and on other reported experiences, expandable metallic stents are effective devices for treatment of the SVCS which is difficult to manage by other means.

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During a 32-month period, 25 modified self-expandable endovascular stents were placed in 20 hemodialysis access sites to treat 21 stenoses and four occlusions in 19 patients. All stenoses were initially dilated with a high-pressure balloon. The initial success rate was 90% (18 of 20 access sites). The stents were patent from 0 to 960 days (mean duration of follow-up, 309 days). At 2 years follow-up, the patency rates were as follows: primary, 25%; secondary, 34%; and tertiary, 42%. The morbidity rate associated with this procedure was 15% (three of 20 sites); the mortality rate, 5% (one of 19 patients). All five complications (graft or native-vein thrombosis [n = 2], nerve deficits [n = 2], and death secondary to sepsis [n = 1]) occurred in three patients early in the study, before the use of prophylactic antibiotics and refinements in technique. The best results occurred in patients in whom the stenosis or occlusion affected a large vein that had no acute angle and was away from venous confluences such as the femoral and iliac regions.

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Hepatic aneurysms, pseudoaneurysms and fistulas (arterial biliary and arterial portal) causing bleeding or portal hypertension, and arteriovenous malformations causing high output cardiac failure in adults can be successfully managed by embolization techniques. Results of embolization in infantile hemangioendotheliomas are less uniform and tumors with massive arteriovenous shunting are difficult to manage. Transjugular intrahepatic portal systemic shunts using expendable stents have been successfully created in patients and have effectively controlled portal hypertension and variceal bleeding.

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