Indications for Procedure: Claudication

Procedure Performed: Abdominal Aortogram with Bilateral Lower Extremity Run-Off

Date of Procedure: September 12, 1998

Report of Radiologist: After informed consent was obtained, the patient was placed on the special procedures table in the supine position and prepped and draped in the usual sterile fashion. Using the Seldinger technique, a right femoral puncture was made and a #5 French pigtail catheter was placed over a guidewire and situated with its tip in the mid-abdominal aorta. The catheter was injected with radiopaque contrast medium while AP images of the abdominal aorta and lower extremity run-off were obtained. Subsequently, digital subtraction images of the distal portions of both lower extremities were done.

Today’s examination is compared to a study performed on 8/24/98. The previous exam revealed a trilobed abdominal aortic aneurysm, the largest component of which was situated below the renal arteries. The aneurysm ended just proximal to the aortic bifurcation. On today’s exam, components of the patient’s aneurysm are again seen, but there is substantial filling of the aneurysm lumen by mural thrombus. The iliac arteries are somewhat ectatic and quite tortuous. Bilaterally the common femoral, superficial femoral and popliteal arteries are widely patent. On the right side, all three trifurcation vessels are patent, but the anterior tibial and peroneal arteries taper and end proximal to the ankle joint. On the left side, all three trifurcation vessels are likewise patent, but the only vessel demonstrating clear patency into the foot is the anterior tibial artery. The left posterior tibial artery is probably patent into the foot, however the quality if the image could not definitely demonstrate this. The left peroneal artery tapers and ends above the ankle joint. The patient tolerated the procedure well without immediate complications.

Radiologic Diagnosis: Abdominal aortic aneurysm ending proximal to the aortic bifurcation. Distal to the aneurysm the iliac arteries demonstrate mild ectasia. Three-vessel run-off is demonstrated bilaterally, but on the right side the only vessel clearly patent into the foot is the posterior tibial artery, while on the left side, the anterior tibial artery and probably also the posterior tibial artery are patent into the foot.

Indication for Procedure: Right parotid swelling

Procedure Performed: Parotid Sialogram

Date of Procedure: August 1, 1998

Report of Radiologist: A sialogram needle was placed without difficulty into the distal end of the right parotid duct. Contrast was injected under fluoroscopic control. The main parotid duct as well as the accessory and main parotid duct branches were easily opacified. No stone was seen. No abnormal area of narrowing or dilatation could be detected. Additionally, I saw no evidence of dilatation or beading of the intraglandular ductal peripheral branches. The patient overall tolerated the procedure quite well. I asked him at the termination of the study whether the pressure he intermittently felt during the injections was similar to his right-sided symptomatology, and he said that the pressure was not in the same location.

Radiologic Diagnosis: Normal right parotid sialogram.

Indication for Procedure: Renal vascular hypertension

Procedure Performed: Bilateral renal angiograms and right renal angioplasty

Date of Procedure: October 24, 1998

Report of Radiologist: The risks and benefits of the procedure were discussed with the patient and both oral and written consents were obtained. The right groin was prepped and draped in a sterile fashion and a 15 French pigtail catheter was advanced into the aorta to approximately the L1/L2 level. A cut film angiogram was performed followed by a DSA study. These showed a very tight probably 80%-90% stenosis at the junction of the proximal and middle third of the main right renal artery. The artery showed slight nodularity in this area with a second milder lesion of approximately 20% stenosis just past the more severe narrowing. This appearance coupled with the patient's age makes fibromuscular dysplasia the most likely diagnosis. The patient has single renal arteries on both sides. The left renal artery is normal in appearance. The aorta and proximal iliac arteries are normal.

Next a 5 French Cobra catheter was used to enter the orifice of the right renal artery and a TAD wire was inserted through the catheter across the area of tight stenosis. The patient was given 3,000 units of IV heparin just before the stenosis was crossed. Next a Cobra catheter was advanced through the lesion and the TAD wire was exchanged for a Rosen wire. The Cobra catheter was then exchanged for a 4-mm. diameter by 2-cm. long low profile Meditech balloon. This balloon was inserted to the area of tight stenosis and it was inflated several times to a maximum of 7 atmospheres. After dilatation, the Rosen wire was exchanged for a 021 straight wire and the balloon catheter was withdrawn so that it was proximal to the lesion. An angiogram was done through the balloon catheter which showed no complications and dramatic improvement in the degree of stenosis. Next the wire and the balloon catheter were withdrawn and a 5 French pigtail was reinserted. A repeat DSA angiogram was performed. The final images showed some slight irregularity of the right renal artery in the angioplasty site with minimal residual stenosis measuring approximately 10%. No complications were identified.

Radiologic Diagnosis: Successful angioplasty of very tight lesion in the proximal to mid right renal artery. This lesion is most likely due to fibromuscular dysplasia. After angioplasty there is a mild irregularity of the right renal artery with approximately 10% residual stenosis.