Browse Health
Radiologist
32 years of experience

Education ?

Medical School
Ruprecht-Karls-Universitaet Heidelberg (1978)
Foreign school

Awards & Distinctions ?

Awards  
One of America's Leading Experts on:
Interventional Radiography
Associations
American Board of Radiology
Society of Interventional Radiology

Affiliations ?

Dr. Lang is affiliated with 1 hospitals.

Hospital Affilations

Score

Rankings

  • Beth Israel Deaconess Medical Center
    330 Brookline Ave, Boston, MA 02215
    • Currently 4 of 4 crosses
    Top 25%
  • Publications & Research

    Dr. Lang has contributed to 70 publications.
    Title Effect of Team Training on Patients' Ability to Complete Mri Examinations.
    Date February 2010
    Journal Academic Radiology
    Excerpt

    Assess whether staff training in advanced rapport skills and self-hypnotic relaxation techniques reduces noncompletion rates during magnetic resonance imaging (MRI).

    Title Endovenous Laser Ablation of the Saphenous Veins: Bilateral Versus Unilateral Single-session Procedures.
    Date May 2008
    Journal Journal of Vascular and Interventional Radiology : Jvir
    Excerpt

    PURPOSE: To assess the feasibility of bilateral endovenous laser ablation (EVLA) of saphenous veins in a single session with use of diluted lidocaine for tumescent anesthesia. MATERIALS AND METHODS: Among 122 consecutive EVLA procedures (112 patients; mean age, 49 years; 75% women) over a 12-month period, there were 75 unilateral procedures (n = 67) and 47 bilateral interventions (n = 45). Tumescent anesthesia consisted of lidocaine diluted to 0.10% for unilateral procedures versus 0.05% for bilateral cases (lidocaine dose <4.5 mg/kg body weight). Procedural data, immediate success rates on an intent-to-treat basis, and outcomes at 3-6-month follow-up were compared between groups with nonparametric tests. RESULTS: Bilateral procedures could be performed successfully with low lidocaine dilutions with a similar success rate (96%) as unilateral procedures (100%). No significant variation in systolic and diastolic blood pressure and heart rate was observed between bilateral and unilateral groups. No patient experienced signs of lidocaine toxicity. After adjusting for length of vein treated, there were no significant differences in the total lidocaine dose used, tumescent anesthesia volume, or procedure duration. CONCLUSIONS: Bilateral saphenous vein ablation in a single session appears safe and effective when tumescent anesthesia is given with very dilute lidocaine (0.05%). This approach may help meet patients' requests for simultaneous bilateral treatment and reduce duration of postprocedural discomfort.

    Title Hypnosis for Acute Distress Management During Medical Procedures.
    Date August 2007
    Journal The International Journal of Clinical and Experimental Hypnosis
    Excerpt

    The use of hypnosis during medical procedures has a long-standing tradition but has been struggling for acceptance into the mainstream. In recent years, several randomized-controlled trials with sufficient participant numbers have demonstrated the efficacy of hypnosis in the perioperative domain. With the advancements of minimally invasive high-tech procedures during which the patient remains conscious, hypnotic adjuncts have found many applications. This article describes the procedural environment as well as pharmacologic and nonpharmacologic interventions to reduce distress. Current research findings, controversies in the literature, and safety considerations are reviewed. Implications for clinical practice and training as well as directions for future research are discussed. Obstacles and possible reasons for the slow acceptance of nonpharmacologic interventions, mind-body therapies, and patient-centered approaches are addressed.

    Title Fibrin Sheath Removal from Central Venous Catheters: an Internal Snare Manoeuvre.
    Date August 2007
    Journal Nephrology, Dialysis, Transplantation : Official Publication of the European Dialysis and Transplant Association - European Renal Association
    Excerpt

    BACKGROUND: Dysfunction of haemodialysis catheters is most commonly due to a narrowing of the catheter lumen and/or formation of a fibrin sheath around the catheter tip. Reported methods for restoring patency of the catheter lumen include passage of a J-tipped guide wire, passage of a biopsy brush through the catheter, or infusion of a thrombolytic agent into the catheter. While these methods are often effective, they suffer from several limitations. We present a minimally invasive technique to remove thrombi and debris from within the lumen of a partially thrombosed haemodialysis catheter while simultaneously stripping the fibrous sheath. METHODS: A 0.089 cm nitinol wire is bent to create a loop, which is then inserted via the catheters. Upon exiting the lumen of the catheters, the nitinol wire forces a snare open, which disrupts the fibrin sheath and catches intraluminal thrombi and debris. The technique requires no anaesthesia or recovery time. RESULTS: Initial clinical success in our series was achieved in all patients (7/7) as evidenced by restoration of target flow rates on subsequent haemodialysis. None of the patients experienced any complications as a result of the procedure. The catheter 2-, 4-, and 6-week primary success rates were 100% (8/8), 100% (8/8), and 100% (8/8) respectively with a mean duration of 17.1 weeks (range 8-40 weeks). CONCLUSIONS: The internal snare technique is an effective, inexpensive and minimally invasive approach to restoring patency to failed central venous access catheters.

    Title Effects of Age on Responsiveness to Adjunct Hypnotic Analgesia During Invasive Medical Procedures.
    Date March 2007
    Journal Psychosomatic Medicine
    Excerpt

    OBJECTIVES: To assess the effects of age on responsiveness to self-hypnotic relaxation as an analgesic adjunct in patients undergoing invasive medical procedures. MATERIAL AND METHODS: Secondary data analysis from a prospective trial with 241 patients randomized to receive hypnosis, attention, and standard care treatment during interventional radiological procedures. Growth curve analyses, hierarchical linear regressions, and logistic regressions using orthogonal contrasts were used for analysis. Outcome measures were Hypnotic Induction Profile scores, self-reported pain and anxiety, medication use, oxygen desaturation < or =89%, and procedure time. RESULTS: Hypnotizability did not vary with age (p = .19). Patients receiving attention and hypnosis had greater pain reduction during the procedure (p = .02), with trends toward lower pain with hypnosis (p = .07); this did not differ by age. As age increased, patients experienced more rapid pain control with hypnosis (p = .03). There was more rapid anxiety reduction with attention and hypnosis (p = .03). Trends toward lower final anxiety were also observed with attention and hypnosis versus standard care (p = .08), and with hypnosis versus attention (p = .059); these relationships did not differ by age. Patients requested and received less medication and had less oxygen desaturation < or =89% with attention and hypnosis (p < .001); this did not differ by age. However, as age increased, oxygen desaturation was greater in standard care (p = .03). Procedure time was reduced in the attention and hypnosis groups (p = .007); this did not vary by age. CONCLUSIONS: Older patients are hypnotizable and increasing age does not appear to mitigate the usefulness of hypnotic analgesia during invasive medical procedures.

    Title Adjunctive Self-hypnotic Relaxation for Outpatient Medical Procedures: a Prospective Randomized Trial with Women Undergoing Large Core Breast Biopsy.
    Date December 2006
    Journal Pain
    Excerpt

    Medical procedures in outpatient settings have limited options of managing pain and anxiety pharmacologically. We therefore assessed whether this can be achieved by adjunct self-hypnotic relaxation in a common and particularly anxiety provoking procedure. Two hundred and thirty-six women referred for large core needle breast biopsy to an urban tertiary university-affiliated medical center were prospectively randomized to receive standard care (n=76), structured empathic attention (n=82), or self-hypnotic relaxation (n=78) during their procedures. Patients' self-ratings at 1 min-intervals of pain and anxiety on 0-10 verbal analog scales with 0=no pain/anxiety at all, 10=worst pain/anxiety possible, were compared in an ordinal logistic regression model. Women's anxiety increased significantly in the standard group (logit slope=0.18, p<0.001), did not change in the empathy group (slope=-0.04, p=0.45), and decreased significantly in the hypnosis group (slope=-0.27, p<0.001). Pain increased significantly in all three groups (logit slopes: standard care=0.53, empathy=0.37, hypnosis=0.34; all p<0.001) though less steeply with hypnosis and empathy than standard care (p=0.024 and p=0.018, respectively). Room time and cost were not significantly different in an univariate ANOVA despite hypnosis and empathy requiring an additional professional: 46 min/161 dollars for standard care, 43 min/163 dollars for empathy, and 39 min/152 dollars for hypnosis. We conclude that, while both structured empathy and hypnosis decrease procedural pain and anxiety, hypnosis provides more powerful anxiety relief without undue cost and thus appears attractive for outpatient pain management.

    Title Pain and Anxiety During Interventional Radiologic Procedures: Effect of Patients' State Anxiety at Baseline and Modulation by Nonpharmacologic Analgesia Adjuncts.
    Date June 2006
    Journal Journal of Vascular and Interventional Radiology : Jvir
    Excerpt

    PURPOSE: To assess how patients' underlying anxiety affects their experience of distress, use of resources, and responsiveness toward nonpharmacologic analgesia adjunct therapies during invasive procedures. MATERIALS AND METHODS: Two hundred thirty-six patients undergoing vascular and renal interventions, who had been randomized to receive during standard care treatment, structured empathic attention, or self-hypnotic relaxation, were divided into two groups: those with low state anxiety scores on the State-Trait Anxiety Inventory (STAI, scores < 43; n = 116) and those with high state anxiety scores (> or = 43; n = 120). All had access to patient-controlled analgesia with fentanyl and midazolam. Every 15 minutes during the procedure, patients rated their anxiety and pain on a scale of 0-10 (0, no pain/anxiety at all; 10, worst possible pain/anxiety). Effects were assessed by analysis of variance and repeated-measures analysis. RESULTS: Patients with high state anxiety levels required significantly greater procedure time and medication. Empathic attention as well as hypnosis treatment reduced procedure time and medication use for all patients. These nonpharmacologic analgesia adjunct treatments also provided significantly better pain control than standard care for patients with low anxiety levels. Anxiety decreased over the time of the procedure; patients with high state anxiety levels experienced the most significant decreases in anxiety with nonpharmacologic adjuncts whereas patients with low state anxiety levels coped relatively well under all conditions. CONCLUSION: Patients' state anxiety level is a predictor of trends in procedural pain and anxiety, need for medication, and procedure duration. Low and high state anxiety groups profit from the use of nonpharmacologic analgesia adjuncts but those with high state anxiety levels have the most to gain.

    Title Central Venous Recanalization in Patients with Short Gut Syndrome: Restoration of Candidacy for Intestinal and Multivisceral Transplantation.
    Date January 2006
    Journal Journal of Vascular and Interventional Radiology : Jvir
    Excerpt

    PURPOSE: To assess feasibility and success of venous recanalization in patients with short gut syndrome who have lost their traditional central venous access and required intestinal or multivisceral transplantation. MATERIALS AND METHODS: Twelve patients between the ages of 7 and 55 years with short gut syndrome and long-standing total parenteral nutrition (TPN) dependency and/or hypercoagulability were treated. All had extensive chronic central venous occlusions and survival was dependent on restoration of access and planned transplantation. Central venous recanalizations were obtained via sharp needle recanalization techniques, venous reconstructions with stents, and/or extraanatomic access to the central venous system for placement of central venous tunneled catheters. RESULTS: Central venous access was restored in all patients without operative-related mortality. Three major hemodynamic perioperative technical complications were recorded and successfully treated. There were three self-limited early infectious complications. With a mean follow-up of 22 months, eight of the 12 patients were alive with successful small bowel or multivisceral transplantation; six of those became independent of TPN. The remaining four patients died of complications related to TPN (n = 3) or transplantation (n = 1). With a mean follow-up of 20 months, all but two of the recanalized venous accesses were maintained, for a success rate of 83%. CONCLUSIONS: Recanalizations of extensive chronic vein occlusions are feasible but associated with high risk. The technique is life-saving for TPN-dependent patients and can restore candidacy for intestinal and multivisceral transplantation. This approach is likely to be increasingly requested because of the current clinical availability of the transplant procedure.

    Title Interpersonal and Communication Skills Training for Radiology Trainees Using a Rotating Peer Supervision Model (microteaching).
    Date December 2005
    Journal Academic Radiology
    Title Adverse Cerebrovascular Effects of Intraarterial Co2 Injections: Development of an in Vitro/in Vivo Model for Assessment of Gas-based Toxicity.
    Date September 2005
    Journal Journal of Vascular and Interventional Radiology : Jvir
    Excerpt

    PURPOSE: To assess whether and how CO(2) can cause ischemic injury in the central nervous system after internal carotid artery injection. MATERIALS AND METHODS: In 14 adult pigs, both internal carotid arteries were catheterized via a transfemoral approach. One carotid artery served as control and the other was injected via a prototype gas injector with defined volumes and pressures of gas. Effects were assessed by clinical observation, repeated magnetic resonance (MR) imaging, histopathology, and vital staining. An in vitro flow circuit was used to model injection parameters. RESULTS: Single injections of CO(2) did not produce persistent clinical symptomatology. In vitro conditions were created in which bubbles adhered to the tubing of the circuit, creating functional stenoses, or coalesced into larger bubbles that became trapped, thereby reducing flow and augmenting potential embologenic effects of subsequent injections. With in vitro-derived dual injection parameters, seven pigs underwent two sequential injections of CO(2). All did well after the first injections, but all had adverse effects after the second injections, including involuntary tonic-clonic muscular movements, cardiopulmonary arrest, recurrent intractable seizure activity during recovery, hemorrhagic venous infarcts on gross and histopathologic examination, and blood-brain barrier breakdown on vital staining. MR imaging was not sensitive even after symptomatic intraarterial air injection. CONCLUSIONS: Absence of adverse effects after single bolus injections in pigs does not prove the safety of intracranial CO(2) injections in human patients. Considering the possible deleterious effects of repeat intravascular injections in the highly sensitive system of the brain, it may be prudent for clinical application at other approved sites to let time pass between boluses sufficient to permit absorption of wall-adherent and coalescent bubbles that could cause gas embolic events.

    Title Can Words Hurt? Patient-provider Interactions During Invasive Procedures.
    Date May 2005
    Journal Pain
    Excerpt

    Patients are often prepared for procedural discomforts with descriptions of pain or undesirable experiences. This practice is thought to be compassionate and helpful, but there is little data on the effect of such communicative behavior. This study assesses how such descriptions affect patients' pain and anxiety during medical procedures. The interactions of patients with their healthcare providers during interventional radiological procedures were videotaped during a previously reported 3-arm prospective randomized trial assessing the efficacy of self-hypnotic relaxation. One hundred and fifty-nine videos of the standard care and attention control arms were reviewed. All statements that described painful or undesirable experiences as warning before potentially noxious stimuli or as expression of sympathy afterwards were recorded. Patients' ratings of pain and anxiety on 0-10 numerical scales (0=No Pain, No Anxiety at All and 10=Worst Pain Possible, Terrified) after the painful event and/or sympathizing statement were the basis for this study. Warning the patient in terms of pain or undesirable experiences resulted in greater pain (P<0.05) and greater anxiety (P<0.001) than not doing so. Sympathizing with the patient in such terms after a painful event did not increase reported pain, but resulted in greater anxiety (P<0.05). Contrary to common belief, warning or sympathizing using language that refers to negative experiences may not make patients feel better. This conclusion has implications for the training in medical communication skills and suggests the need for randomized trials testing different patient-practioner interactions.

    Title Inhaled Nitric Oxide As an Adjunct to Suction Thrombectomy for Pulmonary Embolism.
    Date March 2005
    Journal Journal of Vascular and Interventional Radiology : Jvir
    Excerpt

    Pulmonary suction thrombectomy can be a successful interventional tool in the treatment of pulmonary thromboembolism. Removal of clot burden typically results in prompt recovery of hemodynamic stability and improved oxygenation. However, in rare cases, clot removal does not sufficiently improve the clinical situation. Herein, two patients with massive pulmonary thromboembolism are presented whose condition improved only after they received nitric oxide as an adjunct to pulmonary suction thrombectomy. The treatment with this inhalable vasodilator was based on the hypothesis that prolonged ischemia had induced microcirculatory vasospasm, persistent after removal of the central clot.

    Title Effect of Sex and Gender on Drug-seeking Behavior During Invasive Medical Procedures.
    Date July 2004
    Journal Academic Radiology
    Excerpt

    RATIONALE AND OBJECTIVES: To assess how sex affects patients' drug-seeking, pain, and anxiety during interventional procedures. MATERIALS AND METHODS: Data from 159 patients were derived from two control groups of a prospective randomized trial. Seventy-six patients were male, 83 female. Patients in the standard group (n = 79) received the standard care typical for the institution; patients in the attention group (n = 80) had an additional empathic provider who stayed with them throughout the procedure. All patients were asked every 15 minutes to rate their pain and anxiety on 0-10 self-rating scales. All had access to intravenous sedatives and narcotics through a patient-controlled analgesia model. Univariate analysis of variance with a between-patient factor for group and another between-patient factor for sex was used. RESULTS: There was a significant interaction between group attribution and sex with regard to drug request and pain and anxiety ratings. Patients in the attention group requested significantly fewer drugs than patients in the standard group. Men asked for more drugs than women under standard care, but for less in the attention group. Pain and anxiety ratings for women were significantly lower in the attention group compared with standard treatment, but for men, there was no significant difference. CONCLUSION: Although both men and women benefit from the presence of an empathic provider during invasive medical procedures, men benefit more in terms of medication reduction, whereas women benefit more in terms of pain and anxiety reduction. Awareness of these gender-specific differences can aid in formulation of patient-specific treatment plans.

    Title Tumor Thromboembolism Masquerading As Bland Pulmonary Embolism.
    Date June 2004
    Journal Journal of Vascular and Interventional Radiology : Jvir
    Excerpt

    Catheter-based interventions provide an important alternative to medical surgical management of massive central pulmonary thromboembolism. Because this option is increasingly being used, it is important to recognize that not all pulmonary thromboemboli are bland. The authors describe two cases in which tumor masqueraded as bland thromboembolism. Identification of tumor thromboembolism may help to alter future work-ups, provide useful prognostic information for a patient, and affect future treatment options.

    Title Postprocedure Pain Management of Interventional Radiology Patients.
    Date March 2004
    Journal Journal of Vascular and Interventional Radiology : Jvir
    Excerpt

    Postprocedure pain management of patients after interventional procedures has to take into account residual drug actions from pre- and intraprocedure medications. A variety of sedatives, narcotics, local anesthetics, nonopioid analgesics, and nonsteroidal antiinflammatory agents can be adjusted to the patient's needs and risk factors. The article addresses the safe use of these agents in addition to reflections on assessment and the cognitive elements of the pain experience.

    Title Adverse Short-term Effects of Attention-control Treatment on Hypnotizability: a Challenge in Designing Controlled Hypnosis Trials.
    Date December 2003
    Journal The International Journal of Clinical and Experimental Hypnosis
    Excerpt

    Characteristics of patients in test and attention-control groups should be comparable and be unaffected by the intervention to be tested in clinical trials. The authors assessed whether this is the case for measures of hypnotizability in the postoperative period. One hundred and forty-six patients undergoing percutaneous peripheral vascular or renal interventions were randomized into 2 groups. One group received structured empathic attention during their procedures; the other was guided to self-hypnotic relaxation. Hypnotizability was assessed postoperatively by the Hypnotic Induction Profile. The eye-roll scores, which measure the biological hypnotic potential, were not significantly different, but the average induction scores, which measure the expression of the hypnotic performance, were significantly lower in the attention group than the hypnosis group (4.9 vs. 5.9). The authors conclude that patients who were aided by an external focus intraoperatively are postoperatively less able or willing to follow suggestions measuring hypnotizability than patients who had guidance to self-hypnotic relaxation.

    Title The Effect of Hyperoxygenation on T1 Relaxation Time in Vitro.
    Date December 2003
    Journal Academic Radiology
    Excerpt

    RATIONALE AND OBJECTIVES: Ventilation with high oxygen (O2) concentrations has been shown to decrease T1 in blood and tissues of patients. This study aims to assess the effect of hyperoxygenation on the T1 relaxation time of blood and other physiologic solutions. MATERIALS AND METHODS: Varied gaseous mixtures of O2 and air between 21% and 100% O2 were created using an experimental circuit at room temperature, and used to saturate human blood, plasma, or normal saline. The samples were studied using an 8.45-Tesla magnetic resonance (MR) system and a 1.5-Tesla clinical MR scanner. RESULTS: MR spectroscopy at 8.45 Tesla showed that the percentage of O2 chosen for saturation correlated negatively with T1 (R2 = 1.00 for blood, 0.99 for plasma, and 1.00 for normal saline). The reduction in T1 between solutions saturated with 21% and 100% O2 was 487 milliseconds (22% of the baseline T1 value) for blood, 391 milliseconds (15%) for plasma and 622 milliseconds (19%) for saline. Similarly, MR measurements at 1.5 Tesla showed T1 reduction with increasing O2 concentration. Conclusion. The decreasing T1 in blood depends strongly on the fraction of dissolved O2 in solution and is largely independent of the hemoglobin content.

    Title Shaping the Experience of Behavior: Construct of an Electronic Teaching Module in Nonpharmacologic Analgesia and Anxiolysis.
    Date February 2003
    Journal Academic Radiology
    Excerpt

    RATIONALE AND OBJECTIVES: The authors' purpose was to develop an electronic teaching module in nonpharmacologic analgesia and anxiolysis for use in the radiology department. MATERIALS AND METHODS: The teaching document was derived from previous training courses validated by patient outcome. Skills in structured empathic attention and guidance of self-hypnotic relaxation were tested in a previous prospective, randomized study with 241 patients and shown to affect positively patients' perception of pain and anxiety. Patients undergoing hypnosis had the greatest relief and most hemodynamic stability. The skills applied also saved, on average, 17 minutes of procedure time and approximately $340 in sedation cost per case. With these validated behavioral skills, an electronic teaching module was constructed. RESULTS: The mode of teaching reflected the content of teaching, which was achieved through a multimedia format containing text, audio, video, pictures, and animation. Advanced navigation tools put the students in control of their learning experience. Inclusion of experiential components, congruity of language with Ericksonian syntax, and provision of an electronic journal catered to the development of greater biobehavioral awareness. CONCLUSION: Electronic teaching modules for biobehavioral skill training are feasible and promise to reduce the time need for life interactions with instructors.

    Title Adverse Effects of Intra-arterial Carbon Dioxide on Perfusion in Vitro and in Vivo.
    Date February 2003
    Journal Academic Radiology
    Title Gas-based Vascular Imaging.
    Date January 2003
    Journal Academic Radiology
    Title Cost Analysis of Adjunct Hypnosis with Sedation During Outpatient Interventional Radiologic Procedures.
    Date May 2002
    Journal Radiology
    Excerpt

    PURPOSE: To compare the cost of standard intravenous conscious sedation with that of sedation with adjunct self-hypnotic relaxation during outpatient interventional radiologic procedures. MATERIALS AND METHODS: Data were reviewed from a prospective randomized study in which patients undergoing vascular and renal interventional procedures underwent either standard sedation (n = 79) or sedation with adjunct hypnosis (n = 82). These data were used to construct a decision analysis model to compare the cost of standard sedation with the cost of sedation with adjunct hypnosis. Multiple sensitivity analyses were performed to assess the applicability of these results to other institutions with different cost structures with respect to the following variables: cost of the hypnosis provider, cost of room time for interventional radiologic procedure, hours of observation after the procedure, and frequency and cost of complications associated with over- or undersedation. RESULTS: According to data from this experience, the cost associated with standard sedation during a procedure was $638, compared with $300 for sedation with adjunct hypnosis, which resulted in a savings of $338 per case with hypnosis. Although hypnosis was known to reduce room time, hypnosis remained more cost-effective even if it added an additional 58.2 minutes to the room time. CONCLUSION: Use of adjunct hypnosis with sedation reduces cost during interventional radiologic procedures.

    Title Impact of Graft Material Configuration on Stent-graft Endoleak in Vitro.
    Date March 2002
    Journal Journal of Vascular and Interventional Radiology : Jvir
    Excerpt

    PURPOSE: To assess the effect of different attachment patterns between graft materials and stents on type I endoleak. MATERIALS AND METHODS: Nitinol stents were covered with a coating of Tegaderm in either a straight-edged pattern across the stent cells or a contoured zigzag pattern conforming to the stent skeleton's honeycomb-shaped cells. The stent-grafts were deployed in an ex vivo circuit across a gap of tubing to simulate an aneurysm cavity. Fluid leaking from the gap for more than 30 minutes was recorded as endoleak. Two contoured attachment patterns (short and long necks) and four straight-edged patterns with necks of varying length were tested. Each experiment was repeated 15 times. RESULTS: The length of the aneurysm neck covered by the graft material was inversely related to the rate of endoleak. The zigzag pattern of graft attachment demonstrated significantly less endoleak than the straight-edged pattern in the setting of a short aneurysm neck (0.25 mL vs 47.3 mL). CONCLUSION: Adopting the contoured (zigzag) attachment of graft material to stents minimizes endoleak in vitro, particularly in the setting of a short aneurysm neck.

    Title Evaluation of a Spiral Nitinol Temporary Inferior Vena Caval Filter.
    Date October 2001
    Journal Academic Radiology
    Excerpt

    RATIONALE AND OBJECTIVES: The authors performed this study to evaluate the (a) ability of a prototype temporary inferior vena caval (IVC) filter to trap and retain emboli in an ex vivo flow circuit, (b) feasibility of filter placement and removal via a superficial vein in sheep, and (c) intermediate-term effects of the filter on the insertion vein and at the filter site. MATERIALS AND METHODS: In an iliocaval circuit, embolus capture with the prototype filter was compared to that with a Greenfield filter. In addition, prototype filters were placed into the infrarenal IVC in six sheep. Placement via a superficial venous route was initially attempted. Inferior vena cavography was performed weekly, and filters were removed after 2, 3, or 4 weeks (n = 2 each). Two weeks after the filters were removed, vena cavograms were obtained, the animals were sacrificed, and the IVC was evaluated at pathologic examination. RESULTS: The prototype filter captured all emboli, and the Greenfield filter captured 70%-100% of emboli. Successful placement via a superficial venous route was accomplished in only two sheep owing to small vein caliber; four filters were placed via a deep vein. Adverse events included perifilter thrombus, insertion site infection, and caudal migration. Two sheep died before filter removal owing to sepsis and anesthetic complications. The filters in the remaining four sheep were easily and successfully removed. Five sheep had stenosis at the filter site, and fibrosis with acute and chronic inflammation was seen at microscopic examination. CONCLUSION: The prototype filter trapped emboli as well as the Greenfield filter. Insertion via a superficial route, however, is possible only if the access vein is of an adequate size.

    Title Impact of Unilateral Common Iliac Vein Occlusion on Trapping Efficacy of the Greenfield Filter: an in Vitro Study.
    Date October 2001
    Journal Academic Radiology
    Excerpt

    RATIONALE AND OBJECTIVES: The purpose of this study was to assess the effect of unilateral common iliac vein occlusion on the capturing efficacy of the Greenfield filter in vitro. MATERIALS AND METHODS: A stainless steel over-the-wire Greenfield filter was placed in the Silastic inferior vena cava module of a pulsatile circuit. Three 30-mm blood clots in sets of five were injected through the module's right iliac limb with the circuit in four experimental conditions: vertical position, both iliac limbs patent (VP); vertical position, left iliac limb occluded (VOC); horizontal position, both iliac limbs patent (HP); and horizontal position, left iliac limb occluded (HOC). Each experiment was repeated 15 times, resulting in 75 clots per condition and a total of 300 clot introductions. RESULTS: Clot trapping efficacy was 36 of 75 (48%) for VP, 41 of 75 (55%) for VOC, 32 of 75 (43%) for HP, and 26 of 75 (35%) for HOC. Cross comparisons of the four conditions revealed a marginally significant difference (P = .0138 with a corrected test-wise alpha = .0125) only between horizontal and vertical positions with unilateral common iliac limb occlusion. CONCLUSION: Unilateral common iliac vein occlusion decreases the capturing efficacy of the Greenfield filter in the horizontal position in vitro. In patients with unilateral common iliac vein occlusion, use of inferior vena cava filters with higher capturing efficacy may be considered.

    Title Classifying Complications of Interventional Procedures: a Survey of Practicing Radiologists.
    Date May 2001
    Journal Journal of Vascular and Interventional Radiology : Jvir
    Excerpt

    PURPOSE: To determine the variability of radiologists' classification of complications from interventional procedures. MATERIALS AND METHODS: Fifteen test cases were selected from a database of morbidity and mortality cases that occurred in our department during the past 2 years. Ten cases were selected randomly, and five were chosen because of classification difficulties within our department. A survey with the case descriptions was presented to 145 SCVIR members via the World Wide Web and 48 were distributed to participants at a statewide angiography club meeting. Participants were asked to complete a short assessment of the their clinical background and to classify each case as "no complication," "minor complication," or "major complication." RESULTS: Thirty-eight percent (74 of 193) of the surveys were completed. Seventy percent (52 of 74) of the respondents were affiliated with an academic program, 12% (nine of 74) were affiliated with private practice groups, and 18% (13 of 74) claimed both academic and private affiliation. The consensus rate in classifying the complications for the randomly selected cases varied from 50% to 95%, with a median of 69%, and the consensus rate in classifying the selected cases varied from 46% to 95%, with a median of 85%. The lowest consensus rates occurred when (i) a significant procedural event was followed by a normal outcome, (ii) when a procedure was aborted, and (iii) when a significant event occurred but did not prolong hospital stay. CONCLUSION: Current criteria for reporting complications are associated with moderate rates of disagreement among interventional radiologists.

    Title Clinical Competence Assessment in Radiology: Introduction of an Objective Structured Clinical Examination in the Medical School Curriculum.
    Date March 2001
    Journal Academic Radiology
    Excerpt

    RATIONALE AND OBJECTIVES: Traditional oral and written examinations can be limited in predicting future clinical performance. Therefore Objective Structured Clinical Examinations (OSCEs) have been introduced in other specialties. The authors assessed their value in radiology. MATERIALS AND METHODS: The study includes 122 Harvard medical students who undertook 1-month compulsory clerkships at one of three hospitals (A, B, or C) in their 3rd and 4th year and a compulsory OSCE in their 4th year. The OSCE was constructed from five cases. Each had eight or nine standardized questions designed to test, within a set time, the perception of essential findings, their interpretation, and clinical judgment (maximum possible score, 100). Clerkship grades were high honors (score of 3), honors (score of 2), satisfactory (score of 1), and fail (score of 0). Predictors of OSCE scores-clerkship grade and affiliated hospital-were modeled as linear functions. Time elapsed between clerkship and OSCE was modeled as a nonlinear function. RESULTS: Although there was a positive relation between clerkship grade and OSCE grade, it accounted for an increase of only 5.7% in OSCE score per clerkship grade and did not predict performance of individual students. Students who trained in hospital B showed significantly higher OSCE grades. OSCE scores were highest when the examination was taken 8 months after the clerkship. CONCLUSION: The OSCE may be useful to uncover deficits in individuals and groups beyond the ones detected with traditional clerkship evaluations and provide guidance for remediation. The improved performance after additional clinical exposure suggests that the OSCE may be well suited to test the integration of radiologic and clinical knowledge.

    Title Rapid Anxiety Assessment in Medical Patients: Evidence for the Validity of Verbal Anxiety Ratings.
    Date February 2001
    Journal Annals of Behavioral Medicine : a Publication of the Society of Behavioral Medicine
    Excerpt

    Rapid assessment of patient anxiety is necessary to insure quality care. A number of self-report measures provide valid and reliable measures of anxiety. These measures can be time-consuming to complete, however, and may be burdensome to medical patients who are in pain or acute anxiety states. Many medical procedures are performed in conditions in which written measures are cumbersome (e.g. patient in supine position), and scoring and interpretation of written measures in a busy clinical setting may be difficult for medical personnel. The present study provides validity data for a verbally administered (0-10) anxiety rating. One hundred and ninety-eight adult interventional radiology patients completed standard measures assessing state anxiety, trait Negative and Positive Affect, and the dimensions of the five-factor model of personality. Verbal anxiety rating was highly correlated with Spielberger's State Anxiety Inventory, showed moderate correlations to the related constructs of neuroticism and trait Negative Affect, and was largely unrelated to theoretically distinct constructs. Verbal anxiety ratings made prior to the invasive procedure also predicted pain and anxiety during the procedure. The verbal anxiety rating also demonstrated sensitivity to changes in anxiety that occurred as a result of changes in situation. Findings support the convergent and discriminant validity of verbal anxiety ratings.

    Title Carbon Dioxide Angiography: Effect of Injection Parameters on Bolus Configuration.
    Date July 2000
    Journal Journal of Vascular and Interventional Radiology : Jvir
    Excerpt

    PURPOSE: Predict the intravascular distribution of carbon dioxide during angiography. MATERIALS AND METHODS: Mathematical modeling was used to predict the flow pattern of CO2 in a pulsatile system as a function of the CO2 flow rate. Findings were validated in an in vitro pulsatile circuit. RESULTS: The annular flow pattern with filling of nearly the entire lumen with CO2 is the most desirable, followed by intermittent bubble flow (provided individual bubbles are large). Stratified flow relates to a continuous floating CO2 bubble. Configuration of the CO2 bolus depends on fluid properties, fluid velocity, flow rates, mean intraluminal pressure, pressure amplitude, pulse rate, and vessel diameter. In vessels with less than 10-mm inner diameter, annular flow can be achieved relatively easily with injection rates above 20-30 mL/sec. Higher rates are not expected to produce superior results. When imaging a 2-cm artery, the best that can be realized clinically is intermittent flow with large bubbles. Bubbles size increases with increasing CO2 flow rate. In aneurysms, only stratified flow can be achieved with reasonable injection rates. Periodicity of the flow patterns is determined by the pulsatile circuit and can produce indentations in the CO2 bolus, which can be mistaken for stenoses. CONCLUSIONS: Flow regime maps can be used to optimize bolus configuration during CO2 angiography.

    Title Adjunctive Non-pharmacological Analgesia for Invasive Medical Procedures: a Randomised Trial.
    Date May 2000
    Journal Lancet
    Excerpt

    BACKGROUND: Non-pharmacological behavioural adjuncts have been suggested as efficient safe means in reducing discomfort and adverse effects during medical procedures. We tested this assumption for patients undergoing percutaneous vascular and renal procedures in a prospective, randomised, single-centre study. METHODS: 241 patients were randomised to receive intraoperatively standard care (n=79), structured attention (n=80), or self-hypnotic relaxation (n=82). All had access to patient-controlled intravenous analgesia with fentanyl and midazolam. Patients rated their pain and anxiety on 0-10 scales before, every 15 min during and after the procedures. FINDINGS: Pain increased linearly with procedure time in the standard group (slope 0.09 in pain score/15 min, p<0.0001), and the attention group (slope 0.04/15 min; p=0.0425), but remained flat in the hypnosis group. Anxiety decreased over time in all three groups with slopes of -0.04 (standard), -0.07 (attention), and -0.11 (hypnosis). Drug use in the standard group (1.9 units) was significantly higher than in the attention and hypnosis groups (0.8 and 0.9 units, respectively). One hypnosis patient became haemodynamically unstable compared with ten attention patients (p=0.0041), and 12 standard patients (p=0.0009). Procedure times were significantly shorter in the hypnosis group (61 min) than in the standard group (78 min, p=0.0016) with procedure duration of the attention group in between (67 min). INTERPRETATION: Structured attention and self-hypnotic relaxation proved beneficial during invasive medical procedures. Hypnosis had more pronounced effects on pain and anxiety reduction, and is superior, in that it also improves haemodynamic stability.

    Title Nitinol Properties Affecting Uses in Interventional Radiology.
    Date April 2000
    Journal Journal of Vascular and Interventional Radiology : Jvir
    Title Imagery Content During Nonpharmacologic Analgesia in the Procedure Suite: Where Your Patients Would Rather Be.
    Date October 1999
    Journal Academic Radiology
    Excerpt

    RATIONALE AND OBJECTIVES: Imagery as a hypnotic technique can produce analgesia and anxiolysis, but effective use may be restricted to select, highly hypnotizable individuals. This study assessed (a) whether patients not selected for hypnotizability can produce imagery during interventional radiologic procedures and (b) the type of imagery produced. A secondary goal of the study was to familiarize health care providers with a simple, time-efficient technique for imagery. MATERIALS AND METHODS: Fifty-six nonselected patients referred for interventional procedures were guided to a state of self-hypnotic relaxation by a health care provider according to a standardized protocol and script. Patient hypnotizability was assessed according to the Hypnotic Induction Profile test. RESULTS: Patients as a group had average distribution of hypnotizability. The induction script was started in all patients and completed in 53. All patients developed an imagery scenario. Chosen imagery was highly individual, but common trends were nature and travel, family and home, and personal skills. Being with loved ones was an important element of imagery for 14 patients. Thirty-two patients chose passive contemplation, and 24 were action oriented. CONCLUSION: Average patients who present for interventional radiologic procedures and are not preselected for hypnotizability can engage in imagery. Topics chosen are highly individual, thus making prerecorded tapes or provider-directed imagery unlikely to be equally successful.

    Title Sharp Recanalization of Central Venous Occlusions.
    Date April 1999
    Journal Journal of Vascular and Interventional Radiology : Jvir
    Excerpt

    PURPOSE: To describe a sharp puncture technique for recanalization of chronic central venous occlusions that could not be traversed by a guide wire. MATERIALS AND METHODS: Five patients presented with six longstanding central venous occlusions that could not be traversed with a guide wire after thrombolysis. The occlusions occurred following radiation for lung carcinoma (n = 2) and indwelling venous catheters (n = 4). The length of venous occlusion was determined by simultaneously advancing transbrachial and transfemoral catheters to the site of occlusion. Initially, a curved guiding catheter with a Rosch-Uchida needle and, in subsequent patients, a coaxial sheathed needle with a 21-gauge stylet were used for recanalization. The recanalized veins were then balloon dilated and stents were placed. RESULTS: With use of this technique, recanalization was successful in five of the six occlusions. One occlusion was too long to traverse safely in one patient. Two patients were asymptomatic 16-18 months after the recanalization. CONCLUSION: This new technique offers an effective alternative to surgery in the treatment of central venous occlusion.

    Title Gas Lock Obstruction of the Colon: Ogilvie's Syndrome Revisited.
    Date October 1998
    Journal Ajr. American Journal of Roentgenology
    Title Determinants of Intravenous Conscious Sedation for Arteriography.
    Date July 1998
    Journal Journal of Vascular and Interventional Radiology : Jvir
    Excerpt

    PURPOSE: To assess factors that determine the amount of drugs given for intravenous conscious sedation during arteriography. MATERIALS AND METHODS: Data from 254 patients undergoing infradiaphragmatic arteriography at three institutions were evaluated. The effect of age, sex, procedure time, attending physician, and institution on drug use was assessed by analysis of variance and covariance with repeated measures. In a subset of 34 patients, pain and anxiety scores before and after medication were correlated with drug scores. RESULTS: Institution identity and procedure time significantly affected the amount of medication used (both, P = .000). Patient's age and sex, and identity of the physician had no significant effects. While drug use was relatively constant in each institution among different staff physicians, the institutional differences prevailed when the same physicians performed procedures at different institutions. Drug deliveries did not correlate with anxiety and pain scores before or after medication. CONCLUSION: Habits and philosophies of particular institutions, rather than physician guidance or patients' needs, tend to govern the use of intravenous sedatives and analgesics. There is a need for a more patient-oriented standardization of intravenous conscious sedation and analgesia.

    Title Bone Metastases from Renal Cell Carcinoma: Preoperative Embolization.
    Date May 1998
    Journal Journal of Vascular and Interventional Radiology : Jvir
    Excerpt

    PURPOSE: To assess the effect of preoperative embolization on blood loss during surgical repair of bone metastases from renal cell carcinoma and provide long-term follow-up. PATIENTS AND METHODS: Sixteen patients with bone metastases underwent preoperative embolization. Polyvinyl alcohol (PVA) particles were used for 13 patients (three with additional coils), and coils alone were used in three patients. Surgery was performed within 24 hours in four patients, and within 36-120 hours in 12 patients. Bone healing was evaluated radiographically and clinically. RESULTS: Tumor stain was obliterated by more than 70% in 12 patients, 51%-69% in two patients, and less than 50% in two patients. Estimated blood loss (EBL) during surgery ranged from 100 to 1,000 mL (mean, 533 mL). EBL was significantly less when more than 70% of the tumor stain was obliterated (460 mL vs 750 mL; P < .01 ). There were no significant differences in EBL between the patients who underwent surgery within 24 hours (575 mL) and those who underwent surgery more than 36 hours after embolization (402 mL) when PVA was used. Bone healing was achieved in all patients. Survival ranged from 3 to 56 months (median, 12 months). CONCLUSION: Preoperative embolization reduced intraoperative blood loss without adverse effects on healing. Best results were achieved when more than 70% of the tumor stain was obliterated.

    Title [stent-graft Placement for Saccular Aortic Aneurysm: Case Reports]
    Date January 1998
    Journal Nihon Igaku Hōshasen Gakkai Zasshi. Nippon Acta Radiologica
    Excerpt

    Stent-graft placement was performed in 2 patients with saccular aortic aneurysm. A Dacron-covered nitinol stent-graft was deployed in the thracoabdominal and infrarenal abdominal aorta. These procedures were successfully performed. The aneurysm disappeared on intraoperative angiogram immediately after deployment. Follow-up CT showed thrombosis or disappearance of aortic aneurysm. Distal embolization occurred in one patient, who required resection of the small bowel on the following day and renal dialysis due to renal infarction. Both patients were still alive one and a half years and one year after the procedure, respectively. Stent-graft placement is a feasible alternative to surgery for aortic aneurysm in selected patients.

    Title Educating Interventional Radiology Personnel in Nonpharmacologic Analgesia: Effect on Patients' Pain Perception.
    Date December 1997
    Journal Academic Radiology
    Excerpt

    RATIONALE AND OBJECTIVES: The purpose was to evaluate the effects on patients' pain perception of educating interventional radiology personnel in nonpharmacologic analgesia. MATERIALS AND METHODS: Ninety-six patients undergoing lower-extremity arteriography or percutaneous nephrostomy were asked to rate the pain they experienced during the procedure on a scale of 0 to 5 (0 = no pain, 1 = mild pain, 2 = moderate pain, 3 = severe pain, 4 = very severe pain, 5 = worst pain possible). Patients were studied at two baseline sessions (baseline 1, December 1993 to August 1994, n = 15; and baseline 2, September 1995 to January 1996, n = 11) and after the staff underwent one of two training sessions (posttraining 1, January 1995 to July 1995, n = 34; posttraining 2, January 1996 to April 1996, n = 36). Training targeted nurses and technologists and included rapport skills, correct use of language and suggestions, distraction, relaxation training, and self-hypnosis. Data were evaluated with analysis of variance for repeated measures. RESULTS: The mean pain scores reported after training were lower (1.48) and matched an "acceptable" pain score of 1.52 more closely than those reported under baseline conditions (2.54, P = .001). There was a tendency toward reduced use of intravenously administered agents for conscious sedation after training. There were no statistically significant differences in the pain scores between patients who underwent arteriography and patients who underwent nephrostomy overall (1.76 and 1.78, respectively), at baseline (2.58 and 2.43, respectively), and after staff training (1.49 and 1.42, respectively). CONCLUSION: Interventional radiology personnel trained in nonpharmacologic analgesia methods can help reduce patients' pain perception during interventional procedures.

    Title Intercostal Artery Aneurysm Associated with Coarctation of the Aorta: Specific Finding on Mr Imaging.
    Date October 1997
    Journal International Journal of Cardiac Imaging
    Excerpt

    Aneurysm formation has been described in association with aortic coarctation in approximately 10% of patients. The incidence increases with age and reaches 42% in patients over 40 years of age. To our knowledge, only six radiologic reports have described aortic coarctation in association with an intercostal artery aneurysm and none of these reports has described an intercostal artery entering the aneurysm. We present a case in which MR imaging helped identify this unusual abnormality.

    Title Percutaneous Pulmonary Thrombectomy.
    Date July 1997
    Journal Journal of Vascular and Interventional Radiology : Jvir
    Title 1996 Aur Memorial Award. Densitometric Analysis of Eccentric Vascular Stenoses: Comparison of Co2 and Iodinated Contrast Media.
    Date April 1997
    Journal Academic Radiology
    Excerpt

    RATIONALE AND OBJECTIVES: The authors compared the accuracies of CO2 and iodinated contrast material in the densitometric quantification of eccentric vascular stenoses. METHODS: Five precision-machined eccentric phantom stenoses of 50%, 60%, 70%, 80%, and 90% cross-sectional area narrowing were integrated into a pulsatile ex vivo flow model, imaged with digital subtraction angiography (DSA), and analyzed with densitometry. Relationships between the actual and measured (densitometric) degree of cross-sectional area narrowing were evaluated by using linear regression analysis and paired Student t tests. Comparison measurements were obtained in en face and profile projections. In addition, the effect of iodinated contrast material concentration was evaluated over a range of dilutions (47-282 mg iodine per milliliter). RESULTS: CO2 yielded significantly more accurate results than did iodinated contrast material (282 mg iodine per milliliter) in the 50%, 60%, and 70% stenosis models when imaging was performed en face (P < .005). The best overall correlation was observed with CO2 DSA when imaging in profile (slope = 0.91, intercept = 2.42% actual stenosis, r = .99). The accuracy of densitometric stenosis estimation was inversely related to the concentration of iodinated contrast material. CONCLUSION: CO2 DSA densitometry, under the conditions of these experiments, yields quantitative measures of relative cross-sectional area narrowing that are comparable with, and under some circumstances surpass, those obtained with iodinated contrast material-based DSA. In this model, CO2 was more useful than iodinated contrast material in 50%-70% stenosis when imaging in the least-optimal plane of stenosis quantification, the en face projection.

    Title Pedal Arterial Imaging.
    Date April 1997
    Journal Journal of Vascular and Interventional Radiology : Jvir
    Title Adjunct Transjugular Cholangiography for Transjugular Intrahepatic Portosystemic Shunt in Chronic Portal Vein Occlusion.
    Date March 1997
    Journal Ajr. American Journal of Roentgenology
    Title Communicating with the Patient: Luxury or Necessity?
    Date January 1997
    Journal Academic Radiology
    Title Self-hypnotic Relaxation During Interventional Radiological Procedures: Effects on Pain Perception and Intravenous Drug Use.
    Date January 1997
    Journal The International Journal of Clinical and Experimental Hypnosis
    Excerpt

    The authors evaluated whether self-hypnotic relaxation can reduce the need for intravenous conscious sedation during interventional radiological procedures. Sixteen patients were randomized to a test group, and 14 patients were randomized to a control group. All had patient-controlled analgesia. Test patients additionally had self-hypnotic relaxation and underwent a Hypnotic Induction Profile test. Compared to controls, test patients used less drugs (0.28 vs. 2.01 drug units; p < .01) and reported less pain (median pain rating 2 vs. 5 on a 0-10 scale; p < .01). Significantly more control patients exhibited oxygen desaturation and/or needed interruptions of their procedures for hemodynamic instability. Benefit did not correlate with hypnotizability. Self-hypnotic relaxation can reduce drug use and improve procedural safety.

    Title Percutaneous Colostomy for Treatment of Mechanical Bowel Obstruction: Factors Affecting Feasibility.
    Date December 1996
    Journal Journal of Vascular and Interventional Radiology : Jvir
    Excerpt

    PURPOSE: To assess the feasibility of large-bore tube colostomy in the presence of bowel obstruction in a pig model. MATERIALS AND METHODS: Porcine spiral colon was isolated, obstructed, pressurized to 18 mm Hg, punctured with 24-F radial dilators or balloon-sheath combinations in randomized sequences, and assessed for leakage. In another experimental set, T tacks were used. The effects of various drainage configurations and systems (open vs closed) on drainage and leakage were assessed during continued gut perfusion. RESULTS: Pressurized colon leaked 0-19.8 mL during radial dilation, 0-210 mL during balloon-sheath dilation, and 7.4-29.8 mL/min at T-tack sites. Leakage increased with minor motion. Leak-free drainage during perfusion could be obtained only with open systems or with closed systems that were inserted at least 10 cm proximal to the obstruction. CONCLUSION: Percutaneous colostomy should only be attempted in very select cases with extreme attention to detail.

    Title Treatment to Minimize Skin or Subcutaneous Injury if Extravasation Occurs.
    Date July 1996
    Journal Ajr. American Journal of Roentgenology
    Title Access Systems for Puncture at an Acute Angle.
    Date February 1996
    Journal Journal of Vascular and Interventional Radiology : Jvir
    Title In Vitro Evaluation of White Blood Cell Labelling with 99tcm Radiopharmaceuticals.
    Date February 1995
    Journal Nuclear Medicine Communications
    Excerpt

    Several commercially available 99Tcm radiopharmaceuticals were tested as possible white blood cell labelling agents. Labelling efficiency, labelling stability and white blood cell adherence were measured in vitro. White blood cells were not successfully labelled with mebrofenin, disofenin, gluceptate or dimercaptosuccinic acid but were successfully labelled with exametazime, albumin colloid, sulphur colloid, sestamibi and teboroxime. Exametazime had the highest mean labelling efficiency of 79%. Labelling efficiency was 5-14% with albumin colloid, sulphur colloid, sestamibi and teboroxime. Labelling stability was high (> 95% at 4 h and > 80% at 24 h) for all agents except sestamibi (52% at 4 h and 5% at 24h). Exametazime did not alter white blood cell adherence. Albumin colloid, sestamibi and teboroxime decreased adherence and sulphur colloid increased adherence. Exametazime appears to be the best agent for labelling white blood cells. Teboroxime, however, is a new agent for labelling white blood cells which deserves further investigation.

    Title Acceleration of White Blood Cell Imaging by Adjunct Use of Radiographic Contrast Media.
    Date October 1994
    Journal Investigative Radiology
    Title Anodyne Imagery: an Alternative to I.v. Sedation in Interventional Radiology.
    Date May 1994
    Journal Ajr. American Journal of Roentgenology
    Excerpt

    OBJECTIVE. Pain and anxiety are to be expected in patients undergoing interventional procedures, and they are usually treated by IV conscious sedation. Insufficient treatment of pain and anxiety can cause cardiovascular strain and restlessness, which may jeopardize the success of the procedure. On the other hand, pharmacologic oversedation can provoke respiratory and cardiovascular depression, thereby increasing the procedural risks and delaying the patient's recovery. We therefore evaluated a nonpharmacologic method, which we call anodyne imagery (anodyne: able to soothe or relieve pain; soothing the feelings; relaxing), as an alternative to the use of drugs in interventional radiology. SUBJECTS AND METHODS. Anodyne imagery technique consists of conditioned relaxation, induction of a trance state, and guided processing of the patient's internal imagery. An intrapatient comparison of drug use was made in five patients who had equivalent procedures with and without anodyne imagery and an intergroup comparison was made between a group of 16 other patients undergoing anodyne imagery and a group of 16 control patients matched for factors affecting use of drugs and recruited from 100 interventional cases analyzed for patterns of drug use. For statistical analysis, drug unit scores (weighting: 1 mg of midazolam = 1 unit and 50 micrograms of fentanyl = 1 unit) were compared within patients by paired t-test and between groups of patients by analysis of variance in two-sided tests, with p less than .05 considered to be significant. RESULTS. The 100 patients who did not have anodyne imagery received 0-6 mg of midazolam (median, 1.4 mg), 0-500 micrograms of fentanyl (median, 80 micrograms), and 0.5-9 drug units (median, 2.5). Drug administration was insignificantly affected by the physician conducting the procedure, the type of procedure, or the patient's age, but significantly increased with longer table times. Ten of the 21 patients undergoing anodyne imagery associated fear-provoking images with their interventional procedure that were generally intense, vivid, and dramatic. Intrapatient comparison showed significantly lower median drug use with anodyne imagery than without (0.1 vs 5.3 drug units, p = .01). Intergroup comparison also yielded significantly lower median drug use during procedures with anodyne imagery than without (0.2 vs 2.6 drug units, p = .0001). CONCLUSION. Patients having interventional radiologic procedures frequently experience intense and frightening imagery related to the procedure. Our initial experience with anodyne imagery suggests that this alternative method of analgesia can mitigate patients' anxiety and fears and reduce the amount of drugs used during interventional radiologic procedures, and thereby has the potential to improve procedural safety and increase the speed of recovery.

    Title Viability and Biodistribution of 68ga Mpo-labelled Human Platelets.
    Date February 1994
    Journal Nuclear Medicine Communications
    Excerpt

    The viability and biodistribution of 68Ga-mercaptopyridine-N-oxide (MPO)-labelled autologous platelets was studied in 10 patients. The average platelet labelling yield was 36 +/- 12% and injected activity was 2.0 +/- 0.9 mCi 68Ga. The % activity in platelets per ml whole blood was 64 +/- 20% at 15 min-1.0 h postinjection and 76 +/- 14% at 2-4h. The average recovery of platelets (% injected platelets circulating in peripheral blood) was 31 +/- 21% at 15 min-1 h and 39 +/- 20% at 2-4 h. The positron emission tomographic (PET) images showed high circulating vascular background. Two patients had technically inadequate scans, and six were false negative due to high blood background. One patient with a massive pulmonary embolus occurring 24 h prior to scanning had marked uptake of 68Ga platelets in a large clot in the superior branch of the right main pulmonary artery. A second patient, with 68Ga platelets circulating during angioplasty of a left posterior tibial artery stenosis, had intense uptake in the lesion shown on the PET scan obtained 4 h following the procedure. These results indicate good viability of 68Ga-MPO-labelled autologous human platelets, but poor visualization of clots by PET imaging, due to the high blood background at early times.

    Title Transcatheter Therapy of Severe Acute Lower Extremity Ischemia.
    Date September 1993
    Journal Journal of Vascular and Interventional Radiology : Jvir
    Excerpt

    PURPOSE: Transcatheter methods of revascularization were performed in 11 patients with severe acute lower extremity ischemia and extensive vascular occlusions in whom surgical revascularization was not possible (10 patients) or was not preferred (one patient). PATIENTS AND METHODS: The acute ischemia was considered category 2 in nine patients and category 3 in two. Vascular occlusions were located in the superficial femoral artery in four patients, popliteal artery in 10, all three crural arteries in 10, and two crural arteries in one. Transcatheter methods included accelerated thrombolysis with 325,000 to 1.75 million U of urokinase, adjunct angioplasty, use of intraarterial vasodilators, and creation of pedal arterial flow loops. RESULTS: Initial success was 100% in the nine patients with category 2 ischemia. Eight limbs were saved; one occlusion at 10 days necessitated below-knee amputation. For the two patients with category 3 ischemia, one procedure failed and the other reduced the level of amputation. CONCLUSION: In patients with severe acute ischemia, transcatheter revascularization is a viable treatment option when strategies for reperfusion establish both inflow and microcirculatory outflow.

    Title Quality Assurance of White Blood Cell Labeling with a Test Based on Adherence.
    Date March 1993
    Journal Journal of Nuclear Medicine : Official Publication, Society of Nuclear Medicine
    Excerpt

    A new quality control assay was developed based on the premise that proper radioactive labeling should not affect the adherence characteristics of white blood cells to nylon fibers. Heparinized whole blood with trace amounts of radioactively labeled white blood cells was passed over nylon fiber columns and eluted in eight fractions. Percent radioactive adherence (%RA) and percent white blood cell adherence (%WBCA) were determined for each fraction. Regression lines (%RA versus %WBCA) were calculated for 9 samples labeled properly with 111In-oxine and for 17 samples intentionally subjected to improper labeling. Properly labeled preparations had a median slope = 1.05 and an intercept = 1%. Improperly labeled preparations had significantly lower slopes and/or higher intercepts. By the use of +/- 2 s.d. ranges as indicators of proper labeling (slope of 0.71-1.74; intercept of -35%-37%), the test had 100% sensitivity and 94% specificity. We conclude that proper labeling with 111In-oxine preserves the adherence characteristics of white blood cells, that improper labeling may affect the binding strength of white blood cells (decrease in slope) and/or lead to formation of sticky cell subgroups (increased intercept) and that the quality control assay can objectively assess the impact of labeling on adherence.

    Title Functional Imaging of Peripheral Vascular Disease: a Comparison Between Exercise Whole-body Thallium Perfusion Imaging and Contrast Arteriography.
    Date November 1992
    Journal Journal of Nuclear Medicine : Official Publication, Society of Nuclear Medicine
    Excerpt

    Whole-body thallium scintigraphy was used to study leg muscle perfusion in 12 healthy individuals and 31 patients with peripheral vascular disease. Subjects were scanned immediately after exercise and 4 hr later. Buttock, thigh and calf perfusion were measured in terms of fractional uptake relative to whole-body activity, percent change in fractional uptake over 4 hr and interextremity symmetry ratios. The results were compared to contrast arteriography on a region by region basis. The overall sensitivity and specificity of thallium scintigraphy were 80% and 73%, respectively. The results suggest that thallium scintigraphy may provide useful information about the hemodynamic significance of noncritical anatomic lesions.

    Title Effect of Contrast Agents on Adherence Characteristics of Granulocytes.
    Date May 1992
    Journal Investigative Radiology
    Title Massive Upper Gastrointestinal Hemorrhage with Normal Findings on Arteriography: Value of Prophylactic Embolization of the Left Gastric Artery.
    Date March 1992
    Journal Ajr. American Journal of Roentgenology
    Excerpt

    During a 5-year period, 13 patients who presented with massive upper gastrointestinal hemorrhage had normal findings on arteriography. Seven had prophylactic embolization of the left gastric artery, and six had conservative therapy. Normal angiographic findings were associated with clinical cessation of bleeding in 12 of 13 patients. Lesions not treated by embolization or other invasive therapy had a high rate of massive recurrent hemorrhage (four of six). Of lesions subsequently found to be supplied by the left gastric artery, two of four cases not treated by embolization or surgery had clinically significant recurrent hemorrhage, whereas none of six cases treated by embolization had recurrent hemorrhage. Prophylactic embolization of the left gastric artery appears warranted when (1) there is definite prior identification of a lesion in the left gastric artery territory or (2) there is no prior localization of a lesion but the patient is at risk for multiorgan failure if bleeding recurs.

    Title Effect of Flow Rate on Adherence of Unlabeled and Indium-111 Oxine-labeled Leukocytes.
    Date March 1992
    Journal Investigative Radiology
    Excerpt

    Uptake of radioactively labeled leukocytes has been observed in ischemic noninfected regions. Since this may be a flow-related phenomenon, the authors investigated the effect of flow rate on adherence of indium-111 oxine-labeled leukocytes with a model based on the elution patterns of radioactivity and granulocytes from nylon fiber columns. Relative radioactivity adherence (%RA) and relative granulocyte adherence (%GA) agreed closely, indicating that radioactivity retained by the columns is predominantly in the form of viable labeled granulocytes, and that labeled and unlabeled granulocytes have the same adherence characteristics. When other conditions were held constant, but passage speed was varied, %GA and %RA were related to the flow rate in an inverse linear fashion. Decrease in flow rate can lead to increased accumulation of leukocytes.

    Title Spontaneous Resolution of Bile-plug Syndrome.
    Date June 1991
    Journal Ajr. American Journal of Roentgenology
    Title Delayed Rupture of a Pseudoaneurysm of the Costocervical Trunk: Treatment with Therapeutic Embolization.
    Date February 1991
    Journal Radiology
    Excerpt

    Fourteen days after removal of an internal jugular catheter inserted prior to renal transplantation, a patient presented with brisk arterial hemorrhage from the insertion site. The hemorrhage, caused by a ruptured pseudoaneurysm of the costocervical trunk, was controlled by transcatheter embolization with gelatin particles. One year later the patient reported no problems related to the pseudoaneurysm or its management.

    Title Massive Arterial Hemorrhage from the Stomach and Lower Esophagus: Impact of Embolotherapy on Survival.
    Date October 1990
    Journal Radiology
    Excerpt

    The authors retrospectively reviewed the clinical courses in 36 patients referred for angiographic evaluation of massive arterial hemorrhage from the stomach, gastroesophageal junction, and lower esophagus. Twenty-four patients underwent embolotherapy, and 12 were treated with nontranscatheter therapy such as surgery, Sengstaken-Blakemore tube placement, endoscopic submucosal injection of epinephrine, or supportive medical therapy. Bleeding was controlled completely in 15 (62%) and partially in three (13%) of the patients who underwent embolotherapy. In nine of the patients treated with nontranscatheter therapy (75%), bleeding control was complete. Sixteen patients died, including seven of 28 in whom bleeding was controlled. There was no significant difference in the mortality rates of patients treated with nontranscatheter therapy (46% and 42%, respectively). Survival correlated with the clinical condition at the time of intervention. All patients with multiorgan failure died, while 87% of the other patients, even those with serious cardiovascular compromise, survived. The results imply that massive gastric hemorrhage should be treated aggressively, before it results in multiorgan failure.

    Title Fluoroscopically Guided Percutaneous Gastrostomy and Gastroenterostomy: Analysis of 158 Consecutive Cases.
    Date April 1990
    Journal Ajr. American Journal of Roentgenology
    Excerpt

    We reviewed our experience with 158 consecutive patients who underwent either percutaneous gastrostomy or percutaneous gastroenterostomy during a 2-year period. The catheters used included Foley catheters (36), Cope-type gastric catheters (86), or Carey-Alzate-Coons gastrojejunostomy catheters (36). Gastrojejunostomy tubes were placed in patients with gastroesophageal reflux or aspiration, gastric atony, or partial gastric obstruction. Ninety percent of the tubes were placed for feeding purposes. The technical success rate was 100%. Thirty-day follow-up was obtained in 89%. Thirty-day mortality was 26%, reflecting the substantial number of debilitated patients. No deaths were directly related to tube placement. Major morbidity was 6% and included hemorrhage, peritonitis, tube migration, and sepsis. Minor morbidity was 12%. There was no difference in 30-day mortality or feeding tolerance between the tube types (p less than .05). Patients with Foley catheters had more complications necessitating surgical intervention and an increased incidence of tube changes required within 30 days. These were the only statistically significant differences between the tubes (p less than .05). Our results show that percutaneous gastrostomy is a safe and effective means of gastroenteric feeding or decompression. Because of the fewer complications and ease of insertion, the Cope type of gastrostomy tube has become our preferred catheter for percutaneous feeding or decompression.

    Title The Anterior Wall Stripe of the Left Lower Lobe Bronchus on the Lateral Chest Radiograph: Ct Correlative Study.
    Date January 1990
    Journal Ajr. American Journal of Roentgenology
    Excerpt

    We designed a study to determine whether thickening or effacement of the anterior wall stripe of the left lower lobe bronchus on the lateral chest radiograph implies adjacent disease, as it does for the posterior wall stripe of the right bronchus intermedius. The anterior wall stripe of the left lower lobe bronchus originates from the inferior anterior aspect of the end-on left bronchus and descends in a gentle posteriorly convex curve. The left lower lobe bronchus was identified on routine lateral chest films in 86 of 90 consecutive patients who also had chest CT. In those cases the anterior wall stripe was measured and categorized on chest films. On the CT scans, the length of the left lower lobe bronchus and its relationship to the left lower lobe artery and left upper lobe, lingular, and lower lobe veins were assessed. The presence of adjacent disease was noted. A complete anterior wall stripe was seen in 59 of 86 cases. It was effaced by anterior soft tissue in 15 of 86 cases; in 12 of 86 cases only the superior 0.5-1.5 cm was effaced. A normal anterior wall stripe was as thick as 12 mm in one case, but was 6 mm or less in 90%. Shapes other than linear were common. Anatomic variation accounted for nearly all of these findings. There was no focal abnormality in the 12 cases with partial effacement or in nine of the 15 cases with complete effacement; disease was significant in only two of these six. We concluded that thickening or effacement of the anterior wall stripe is an unreliable sign of disease.

    Title Percutaneous Cholecystolithotomy: Preliminary Experience and Technical Considerations.
    Date November 1989
    Journal Radiology
    Excerpt

    Surgical cholecystectomy is associated with a high morbidity and mortality in elderly patients with acute calculous cholecystitis and underlying cardiac or pulmonary disease. Currently there are few alternatives for treating these patients. The authors have used percutaneous cholecystolithotomy in 11 such high-risk patients for definitive treatment of gallbladder calculi. In all 11 patients all stones were successfully removed from the gallbladder and cystic duct. The entire procedure--from initial tube placement to final tube removal--lasted 17-40 days (mean, 21 days). There were two complications: one minor--local wound infection--and one major--bile peritonitis with eventual death. Percutaneous cholecystolithotomy is an effective alternative therapy for acute calculous cholecystitis in elderly, debilitated patients.

    Title Accelerated Thrombolysis and Angioplasty for Hand Ischemia in Buerger's Disease.
    Date August 1989
    Journal Cardiovascular and Interventional Radiology
    Excerpt

    A patient with severe hand ischemia due to Buerger's disease was treated by a rapidly effective modification of percutaneous catheterization. Accelerated mechanical and pharmacologic thrombolysis of an occluded palmar arch with 200,000 U urokinase and subsequent small vessel angioplasty abolished pain and restored digital perfusion within 40 min.

    Title Contrast Medium Induced Changes in Granulocyte Adherence in Vitro and During Angiography.
    Date November 1988
    Journal Acta Radiologica (stockholm, Sweden : 1987)
    Excerpt

    The effect of ioxaglate and diatrizoate on per cent granulocyte adherence to nylon fibers was investigated in blood to which contrast medium was added in vitro and in blood from patients undergoing angiography. Very high concentrations of contrast medium, added to blood in vitro, directly abolished granulocyte adherence to nylon fibers. Intraaortic bolus injections of ioxaglate, but not of saline, transiently increased granulocyte concentrations in the femoral vein. Fractional granulocyte adherence to nylon fibers increased significantly above the baseline when angiographic dosages of contrast medium were diluted by circulation within the human body. On the other hand, dilute concentrations of contrast medium had no effect on per cent granulocyte adherence when added to whole blood in vitro. This indicates that the increased adherence produced in vivo is an indirect effect, which, usually, cannot be simulated in vitro.

    Title Adherence of Granulocytes to Nylon Fibers. Evidence for a Plasma Granulocyte Adherence Factor.
    Date August 1988
    Journal Thrombosis Research
    Title Thrombosed Dialysis Grafts: Efficacy of Intrathrombic Deposition of Concentrated Urokinase, Clot Maceration, and Angioplasty.
    Date July 1987
    Journal Ajr. American Journal of Roentgenology
    Excerpt

    Forty-one thrombosed polytetrafluoroethylene hemodialysis grafts in 26 patients were treated by a modified method of fibrinolytic therapy and transluminal angioplasty. The modifications included the use of highly concentrated urokinase, intrathrombic injection of urokinase into mechanically macerated thrombi, use of a crossed two-catheter technique, observation of the patient in the angiography suite during the entire procedure, and transluminal angioplasty to correct underlying stenosis immediately after partial or complete thrombolysis. Lysis was initially successful in 37 (90%) of 41 procedures. Successful treatment, defined as a functional graft for longer than 6 months without intervening surgery, was achieved in 16 (62%) of 26 patients. In comparison with previous transluminal or surgical regimens, this modified method permits marked acceleration of thrombolysis, immediate transluminal angioplasty, and sparing of potential future graft sites.

    Title Penile Magnification Pharmacoarteriography: Details of Intrapenile Arterial Anatomy.
    Date May 1987
    Journal Ajr. American Journal of Roentgenology
    Excerpt

    To establish a base of normality against which state-of-the-art penile arteriograms can be assessed, we analyzed selective magnification penile pharmacoarteriograms from 23 men who were not believed to have arteriogenic impotence. The penile arteries showed no evidence of acquired obstructive disease, and all individuals had had normal sexual function in the recent past. The vascular patterns were highly variable and frequently differed from classic descriptions found in textbooks of anatomy. Normal variations that could be easily confused with arterial obstruction were unilateral origin of all cavernosal branches, unilateral hypoplasia of a dorsal penile artery, and aberrant origin of bulbar or cavernosal arteries. Multiple potential collateral routes were shown, including transverse collaterals at the root of the penis and communications between cavernosal and dorsal penile arteries. Appreciation of the type and frequency of anatomic variants and potential collateral routes is important in correctly interpreting penile angiograms and in evaluating the hemodynamic significance of suspected stenoses.

    Title Beneficial Effects of Hypnosis and Adverse Effects of Empathic Attention During Percutaneous Tumor Treatment: when Being Nice Does Not Suffice.
    Date
    Journal Journal of Vascular and Interventional Radiology : Jvir
    Excerpt

    PURPOSE: To determine how hypnosis and empathic attention during percutaneous tumor treatments affect pain, anxiety, drug use, and adverse events. MATERIALS AND METHODS: For their tumor embolization or radiofrequency ablation, 201 patients were randomized to receive standard care, empathic attention with defined behaviors displayed by an additional provider, or self-hypnotic relaxation including the defined empathic attention behaviors. All had local anesthesia and access to intravenous medication. Main outcome measures were pain and anxiety assessed every 15 minutes by patient self-report, medication use (with 50 mug fentanyl or 1 mg midazolam counted as one unit), and adverse events, defined as occurrences requiring extra medical attention, including systolic blood pressure fluctuations (> or =50 mm Hg change to >180 mm Hg or <105 mm Hg), vasovagal episodes, cardiac events, and respiratory impairment. RESULTS: Patients treated with hypnosis experienced significantly less pain and anxiety than those in the standard care and empathy groups at several time intervals and received significantly fewer median drug units (mean, 2.0; interquartile range [IQR], 1-4) than patients in the standard (mean, 3.0; IQR, 1.5-5.0; P = .0147) and empathy groups (mean, 3.50; IQR, 2.0-5.9; P = .0026). Thirty-one of 65 patients (48%) in the empathy group had adverse events, which was significantly more than in the hypnosis group (eight of 66; 12%; P = .0001) and standard care group (18 of 70; 26%; P = .0118). CONCLUSIONS: Procedural hypnosis including empathic attention reduces pain, anxiety, and medication use. Conversely, empathic approaches without hypnosis that provide an external focus of attention and do not enhance patients' self-coping can result in more adverse events. These findings should have major implications in the education of procedural personnel.

    Title Hemolysis Comparison Between the Omnisonics Omniwave Endovascular System and the Possis Angiojet in a Porcine Model.
    Date
    Journal Journal of Vascular and Interventional Radiology : Jvir
    Excerpt

    PURPOSE: To compare the degree of hemolysis generated during use of the ultrasound-based OmniSonics OmniWave Endovascular System and the Possis AngioJet connected to an Xpeedior-6 catheter. MATERIALS AND METHODS: Twelve 64-145-kg Yorkshire pigs were used as the model because their weight, blood volume, and vessel diameters are comparable to that of adult humans. Six pigs were treated with the OmniWave and six with the AngioJet; half of the pigs in each group were treated in the contralateral iliofemoral arteries and half in the ipsilateral iliofemoral veins. Devices were activated for 10 minutes in patent vessels to represent a worst-case scenario for hemolysis generation. Plasma-free hemoglobin (PfHgb) levels, red blood cell counts, white blood cell (WBC) counts, and platelet counts were measured before and after the procedure, and PfHgb levels were measured every 2 minutes during treatment. RESULTS: The OmniWave generated significantly lower PfHgb levels than the AngioJet (average, 228 vs 1,367 mg/dL; P < .001). The location of activation (arterial vs venous) had no significant effect (P = .575). Compared with OmniWave use, AngioJet use was associated with significantly greater changes from pre- to posttreatment values in WBCs (P = .002), platelets (P = .004), and creatinine (P = .002). AngioJet use was associated with a significant postprocedure decrease in the WBC count (mean, -8,000/microl; 95% confidence interval [CI]: -3,830, -12,170; P = .004) and platelet count (mean, -72,000; 95% CI: -25,000, -120,000; P = .011). With the OmniWave device there were no significant differences between pre- and posttreatment WBC count (P = .127), platelet count (P = .493), and creatinine level (P = .317). CONCLUSIONS: The OmniWave generated approximately one-sixth of the hemolysis the AngioJet created. In addition, animals treated with the AngioJet exhibited a decrease in WBC and platelet counts.

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