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To date, several diagnostic tools allow an accurate non-invasive evaluation of coronary artery disease; this is due to the great progress in echocardiographic and nuclear imaging techniques in the last 10 years. The large availability of different stress imaging techniques allows to choose the most appropriate technique for each patient according to the clinical characteristics. This paper presents the state of the art of echocardiographic and nuclear stress imaging for the diagnosis of coronary artery disease and for the prognostic stratification of infarcted patients. Advantages and limits of the different techniques are described rather than putting in competition echo and nuclear cardiology as has often been done in the past. Cardiologists should select among the various techniques on the basis of clinical characteristics of single patients, center's experience and an objective evaluation of economical aspects.

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AIM: Evaluation of the safety of percutaneous dilational tracheostomy (PDT) for perioperative, early and late complications. DESIGN: we prospectively collected complications in patients who underwent PDT for mechanical ventilation; patients were interviewed 8 months after discharge, symptomatic cases underwent ENT control. SETTING: 10 bed general ICU in a 650 -bed general hospital treating 450 patients per year. PARTICIPANTS AND INTERVENTION: 181 patients admitted between July 1998 and June 2000 who underwent PDT for mechanical ventilation. Prospe-ctive collection of data on patients and procedures and screening by a phone interview for symptoms possibly related to the tracheostomy. Symptomatic patients were referred to the ENT specialist. RESULTA: We found 17 perioperative minor complications and 10 minor during hospital stay complications. We traced 83 patients, alive 8 months after discharge. Sixty-one patients (73.5%) were symptom free. Four (4.8) complained of minimal dysphonia. Eighteen patients (21.7%) complained of symptoms deserving ENT control. Eleven patients came to the ENT control that was positive in 5 cases. In 2 patients swallowing uncoordination was found, in 1 arytenoid movement uncoordination. In 1 case (1.2%) a 25% tracheal stenosis was found. The stenosis was asymptomatic. One patient (1.2%) had a severe tracheal stenosis and had a Montgomery tracheal stent in place. CONCLUSIONS: In our experience Ciaglia PDT had an overall low rate of complications (21.8%). No patient had severe early complication. We found only 1 (1.2%) severe late complication. In selected patients, Ciaglia PDT with endoscopic control guarantees a high safety standard.

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BACKGROUND: Aim of the study was to evaluate the prognostic and decision making value of Holter detected myocardial ischemia after acute myocardial infarction in comparison with clinically detected postinfarction angina and exercise test. METHODS: To this aim the patients consecutively admitted to our coronary care unit with acute myocardial infarction during one year were retrospectively evaluated. One hundred and eighty-nine patients (age 70+/-11 years, 137 male and 51 female) had a 24 hour Holter monitoring. One-year follow up of these patients was obtained. RESULTS: Myocardial ischemia was detected by Holter monitoring in 21 patients (11%), 4 with and 17 without angina. Symptom limited exercise test was obtained before discharge in 116 patients (62%): 45% were positive, 42% non-diagnostic and 13 negative for myocardial ischemia. Post infarction angina was present in 15 patients (9%). Patients with Holter detected myocardial ischemia were older (73+/-10 vs 66+/-11 years, p<0.05) and had higher prevalence of both angina and positive exercise test (p<0.01). One-year follow up was obtained in 186 patients. Holter detected myocardial ischemia positive predictive value for death or reinfarction was 15%, negative predictive value was 90%, similar to the absence of angina (90%) and the absence of positive exercise test (93%). Angina and exercise test identified 62% of patients with Holter detected myocardial ischemia. Residual myocardial ischemia was exclusively observed by Holter monitoring in 4% of the population, particularly in 1 patients with and 7 without exercise test. CONCLUSIONS: The additive contribution of Holter detected myocardial ischemia in the prognosis and decision making of post infarction patients is rather scanty.

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The aortic dissection may be associated with unusual complications such as fistula formation and vascular compression. We describe a case of a 71-year-old patient admitted to our Hospital because of acute chest pain; transthoracic and transesophageal echocardiography revealed the presence of a type A aortic dissection associated with a mass infiltrating the right ventricular outflow and proximal tract of the pulmonary artery. The ultrasonographic morphology and the surgical findings showed the presence of a hematoma which was consequent to acute aortic dissection and which mimicked a tumor infiltrating the right ventricular outflow.

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In patients with left ventricular dysfunction, the prognostic value of both pulmonary hypertension and mitral flow patterns has been recognized. However, the effect of the association of different degrees of pulmonary hypertension on prognosis and the corresponding left ventricular diastolic dysfunction is not clear. Accordingly, we considered the impact on survival of a categorization based on the relationship between pulmonary artery pressure and left ventricular diastolic dysfunction, as assessed by mitral and pulmonary venous flow analyses. Transthoracic Doppler echocardiography was carried out in 92 patients with ejection fraction < 45%, pulmonary artery systolic pressure > 25 mmHg and sinus rhythm. Tricuspid regurgitant velocity and Doppler parameters derived from transmitral and pulmonary venous flows were evaluated. In the case of inadequate baseline tracings, weak or poor Doppler signals were enhanced by intravenous injection of a galactose-based contrast agent (Levovist 8 ml suspension at a concentration of 400 mg/ml). To select those whose pulmonary hypertension was either proportional or unproportional to left side filling pressures, patients were divided as follows: Group 1 (n = 69) with low discrepancies and Group 2 (n = 23) with marked discrepancies between Doppler estimates of pulmonary artery systolic pressure and left side filling abnormalities. The patients of each group were also classified according to their mitral flow pattern: abnormal relaxation, pseudonormal and restrictive. Mean pulmonary artery systolic pressure was 49 +/- 16 mmHg in the total population, 43 +/- 11 mmHg in Group 1 and 68 +/- 14 mmHg in Group 2 (p < 0.0001). Several mitral and pulmonary venous flow variables significantly correlated with pulmonary artery systolic pressure in the total population and in the study groups. The best correlations were observed in Group 1 as regards the ratio of reverse-to-forward atrial wave duration (r = 0.83), E wave deceleration rate (r = 0.81), E wave deceleration time (r = -0.81) and the systolic fraction of pulmonary venous flow peak velocities (r = -0.75). In Group 1, the lower heart failure-free survival rate at 10 months was observed in patients with restrictive pattern (68%) as opposed to those with pseudonormal (94%) and abnormal relaxation patterns (97%). The overall heart failure-free survival rate in Group 2 was 86%. In conclusion, the classification according to the relationship between pulmonary hypertension and the alterations of left chamber filling may contribute to the prognostic stratification of patients with left ventricular dysfunction. The patients with pulmonary hypertension proportional to the increase in left chamber filling pressures and restrictive pattern exhibited the worst prognosis.

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We report the experience of our general hospital in selecting the patients for orthotopic liver transplantation (OLT). Fifty-one patients with cirrhosis were examined and 20 of them submitted to OLT from August, 1992, to November, 1995. For liver studies, the 20 transplant recipients were examined with US and plain and dynamic CT; 15/20 were submitted to CTAP, 10/20 to Lipiodol CT and 17/20 to angiography. The accuracy of these techniques in HCC detection was assessed by correlation with resected whole livers. The accuracy of duplex Doppler and color flow Doppler for portal and/or mesenteric vein thrombosis was evaluated by correlation with resected livers, CT and angiographic findings. Pathologic examinations diagnosed HCC in 5/20 transplant recipients: 2 lesions (1.5 cm and 2 cm; 2 cm and 3.5 cm) were found in 2 resected specimens (total hepatectomy) and 1 lesion was found in 3 cases (2.5 cm, 1.5 cm, 1 cm). The sensitivity of US, plain and dynamic CT in identifying HCC patients was 20%; US and CT specificity rates were 100% and 87%, respectively. CTAP sensitivity was 75% and the sensitivity of Lipiodol CT and angiography was 100%. Therefore, in our series, US was poorly sensitive in the detection of liver cancers, which may depend on the small number of patients, lesion size (< or = 3.5 cm) and the radiologists ignoring clinical and laboratory data on purpose. Nevertheless, the patients with a single HCC not exceeding 5 cm phi or with no more than 3 tumors, none of them exceeding 3 cm phi, are generally considered eligible for transplantation: therefore, our patients chosen for OLT on the basis of US and CT findings were actually eligible for transplantation in spite of US and CT false negative results. At US, the portal vein had an average caliber of 13.5 +/- 2.5 mm in 21/51 patients; the average caliber of the common hepatic artery was 6 +/- 1.5 mm in 49/51 patients; average spleen length was 174 +/- 38 mm. US showed ascites in 28/51 cases. In conclusion, considering also the long stand-by list for OLT, the first selection of transplant candidates could be performed with US and color flow Doppler, plain and dynamic CT. The patients who are ruled out as candidates for OLT on the basis of the findings of these imaging techniques and of clinical and laboratory findings are submitted to no further examination and referred to the transplantation unit. Otherwise, if conventional and color flow Doppler US and conventional CT are not enough to exclude a patient from OLT, the subject is submitted to more invasive (angiography, CTAP, Lipiodol CT) or less widespread (spiral CT, MRI) techniques.

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Dipyridamole-atropine echocardiography testing is used extensively for the diagnosis of coronary artery disease and it is highly effective in diagnosing "organic" coronary artery disease by inducing myocardial ischemia via three different mechanisms: maximal coronary artery vasodilatation with phoenomena of flow-maldistribution caused by dipyridamole, increase in myocardial oxygen consumption and reduction of the oxygen supply to the myocardium caused by atropine. Moreover, the abrupt withdrawal of the coronary artery vasodilatation caused by aminophylline, which is routinely infused at the end of the test, may trigger coronary artery spasms in patients with variant angina, thus enhancing the diagnostic power of the test. We report two clinical cases of patients with rest angina and angiographically normal coronary arteries, in whom coronary artery spasm was induced by administering aminophylline during the stress test.

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In this paper we report the results we obtained after chemoembolization in 46 patients with HCC in cirrhosis. Chemoembolization is performed by introducing, through an angiographic catheter placed after the origin of the gastroduodenal artery, 20 mg of Doxorubicin Chlorhydrate mixed with 20 ml of Lipiodol and with 10 ml of contrast agent followed by embolization with Spongostan. Chemoembolization results were assessed comparing site, size and local spread of the tumor, hepatic compromission (according to Child's classification) and number of chemoembolization maneuvers with survival in each patient. Overall survival rates are 95.7% at 6 months, 88.5% at 12 months, 60% at 18 months, 36.4% at 24 and 31.8% at 30 months. The best responses were obtained with lesions smaller than 5 cm (100% survival at 6 months, 91.7% at 12 months, 71.4% at 18 and 42.8% at 24 months). Other factors favoring good treatment response were a single lesion (92.9% at 6 months, 91.7% at 12 months, 71.4% at 18 and 42.8% at 24 months), at least 3 cycles of chemoembolization (100% at 6 months, 90% at 12 months, 85.7% at 18 and 42.8% at 24 months) and a low degree of hepatic compromission (Child A and B rather than Child C; in the latter group the survival rates were 75% a 6 months and 0% at 12 months). In conclusion, chemoembolization proves to be the treatment of choice in the HCC patients who cannot undergo surgery.

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Intra-arterial CT of the liver is a valuable method to evaluate hepatocellular carcinoma (HCC). It consists of an infusion of contrast medium into the hepatic artery during CT scanning. Twelve patients with suspected resectable HCCs were evaluated with CT arteriography before surgery. The results of CT arteriography were compared with those of US, of CT with intravenous contrast medium and of angiography; on the rule, all exams had been performed some days earlier. The diagnosis of HCC was confirmed by US-guided fine-needle biopsy. CT arteriography demonstrated liver lesions in 11 patients. The lesions were hyperdense in 3/11 patients (27.3%) and hypodense and surrounded by a hyperdense ring in 8/11 patients (72.7%). In 4 of 11 patients (36.4%) CT arteriography identified additional tumor nodules and thus surgery was excluded. In the latter cases, on the basis of CT arteriographic findings, US, CT with i.v. contrast medium and angiography were repeated but failed to demonstrate the additional nodules, either because they were too small or because of cirrhotic changes in liver parenchyma. Therefore, CT arteriography is recommended in the evaluation of selected patients, especially when detailed information on liver parenchyma is needed--e.g., before surgery. In these patients CT arteriography can be performed together with preoperative angiography.

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A case of a 76-year-old female with a large aneurysm of the main pulmonary artery and initial tract of its branches is reported. Literature is reviewed as to possible etiopathogenesis. Based on past medical history, clinical findings and investigative procedures, we hypothesize a possible congenital origin of the anomaly; its gradual aggravation might be due to the development of pulmonary hypertension.

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This study was aimed at investigating the occurrence of hepatic artery variants, at comparing the diagnostic value of duplex Doppler US with that of angiography, and at correlating the results with the technical problems in portal hypertension surgery. All patients were studied with angiography, conventional and duplex Doppler US. In 162 patients with portal hypertension, 38 hepatic artery variants (23.4%) were observed and classified according to Michaels. The commonest variant recognized by angiography was right hepatic artery arising from superior mesenteric artery (type III according to Michaels). US demonstrated hepatic artery variants in 9/162 patients (5.5%). At surgery, variants were found in 3/162 subjects (1.8%) and caused surgical problems in 2 of them (1.2%) - i.e., right hepatic artery arising from superior mesenteric artery. Arteriography is still the best examination to depict hepatic artery variants, while duplex Doppler US demonstrates only a few types. Moreover, the number of variants detected by imaging techniques (23.4%) differs greatly from that observed at surgery (1.8%). Finally, hepatic artery variants are not correlated with surgical problems, nor can the latter be foreseen by imaging methods. US is useful but not essential to detect hepatic artery variants which are subsequently confirmed by angiography.

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Sixty-nine patients underwent CT for hepatocellular carcinoma (HCC). All subjects were examined with CT before and after bolus injection of contrast medium: 42 HCCs were detected. 13/42 patients underwent also CT arteriography (contrast medium in the hepatic artery) and 29/42 were submitted to CT during arterial portography (contrast medium in the superior mesenteric artery). The results of the three techniques were compared with each other and with surgical and pathologic findings. CT during arterial portography detected other lesions in 5/29 patients while it confirmed CT diagnosis in the extant 24 cases; CT arteriography recognized other lesions in 2/13 subjects while in the extant 11/13 it confirmed CT diagnosis. Both CT arteriography and CT during arterial portography affected treatment protocol in 16.2% of cases. The results had surgical confirmation in all patients but 3 in whom intraoperative US showed some nodules undetected earlier. All the lesions were hypodense on CT during arterial portography. On CT arteriography, they were hyperdense in 4/13 cases and hypodense with an irregular hyperdense halo in 9/13 cases. To conclude, CT during arterial portography and CT arteriography are better diagnostic tools than CT: nevertheless, they are invasive techniques and should be employed in selected cases only.

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Seventy-two patients (52 males and 20 females, mean age: 50.6 years) were studied. They had undergone distal splenorenal shunts according to Warren and its modifications for portal hypertension. All patients were examined with digital and/or conventional angiography preoperatively and 15 days postoperatively. Preoperative and postoperative angiography was employed to evaluate the changes in vessel diameters including the hepatic, splenic and superior mesenteric arteries, the splenic, superior mesenteric and portal veins; the length of the main axis of the spleen was also measured. Furthermore, the degree of hepatic portal venous perfusion was evaluated according to the degree of portomesenteric-gastrosplenic disconnection. After surgery, the length of the main axis of the spleen is reduced and the hepatic artery diameter is increased, which are both signs of preserved hepatic flow and of reduced hypertension in the splanchnic venous system. The postoperative degrees of portal perfusion were correlated with the degrees of disconnection. In conclusion, the role is emphasized of early angiographic examinations after distal portosystemic shunts according to Warren to evaluate postoperative hemodynamic changes.

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We report the results of intra-arterial digital subtraction angiography (DSA) in 100 patients with portal hypertension. The portal venous system was evaluated; all patients underwent angiography of the celiac and superior mesenteric arteries before surgery. Forty-four of them were also examined after Warren splenorenal shunts. Therefore, a total of 144 exams was evaluated. The authors always employed low-osmolality ionic and non-ionic contrast media (iodine concentration: 300-350 mg/ml). In 70 cases pure contrast medium was injected (20-25 ml); in the extant 74 cases it was diluted with an equal volume of saline solution (osmolality and iodine concentration reduced by 50%). Intra-arterial DSA always visualized portal venous system, collateral circulation, shunt location and postoperative changes. The major advantage of intra-arterial DSA is the smaller amount of contrast medium injected, so that local and systemic side effects are rare. According to our experience, it is best to dilute the contrast medium and inject the same amount as in conventional angiography, at the same rate. Other well-known advantages of intra-arterial DSA are quicker execution, less injury to arteries using smaller-caliber catheters, and low cost. The major disadvantage of intra-arterial DSA, as it appeared also in our study, is the field size of the intensifier, which in our case was limited to 6-9 inches. This is an insufficient coverage for the whole portal system to be studied, and some contrast medium injections become therefore necessary. An average of 3 injections were given to each patient. This problem reduces the advantage of less contrast medium per injection. At any rate, even though intra-arterial DSA exhibits this limitation, it can nevertheless yield important information in the pre- and postoperative evaluation of patients with portal hypertension.

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Ninety patients with cirrhosis undergoing elective distal splenorenal shunt (DSRS) for variceal bleeding between January, 1977 and September, 1988 comprised the study group. In 63 cases, the original technique of Warren was used and, in 15, the modified Britton procedure was employed. Twelve patients had a DSRS plus splenopancreatic disconnection. Thirty-four had alcoholic cirrhosis and 56 had nonalcoholic cirrhosis. Intraoperative portal pressure remained high after the shunt (29.4 cm H2O) even if its initial value was probably decreased by the loss of the splenic flow. Splenic pressure was reduced to 21 cm H2O. The hepatic artery diameter enlarged even after selective shunt (from 6.5 to 7.1 mm). The persistence of a high portal pressure allowed for the preservation of hepatopedal portal flow in 87% of cases. Disconnection between the high-pressure mesenteric area and the low-pressure splenic area seemed to be ideal in only 17% of cases. Fifty-five percent of cases had the early development of minimal or moderate portomesenteric gastrosplenic (PM-GS) collateral pathways. In 33%, the PM-GS collaterals were generally abundant and often allowed visualization of the splenic and caval veins during the venous phase of the superior mesenteric arteriograms. In this group, portal flow was generally highly reduced and even abolished. The incidence of portal thrombosis was 11%. Early angiographic checks after DSRS did not show a different hemodynamic behavior between alcoholics and nonalcoholics. Splenopancreatic disconnection seems to prevent the development of collaterals and the loss of portal perfusion after shunt surgery.

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Intravenous and intra-arterial digital subtraction angiography (DSA) was performed in 88 patients: 34 with tumours, 10 with renal trauma, 26 with suspected renovascular hypertension, 6 with vascular impression on the renal pelvis, 8 with nephrolithiasis and 4 with sonographically abnormal kidneys. Venous and arterial DSA always gave diagnostically useful images. Intravenous DSA is valuable in patients with suspected renovascular hypertension or after vascular surgery, percutaneous transluminal angioplasty and transcatheter embolisation. Arterial DSA is preferable to venous DSA in other clinical situations, particularly in the evaluation of renal tumours, and may be recommended in preference to conventional angiography.

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Cholangiographically-enhanced CT scans were performed on nine patients with biliary obstruction or suspected pancreatic masses. The opacification of the biliary tree was obtained by slow infusion of 25 ml of cholangiographic contrast medium diluted in 75 ml of saline and administered 45 mins before the CT examination. Two separate CT sequences were obtained, one with cholangiographic contrast alone, the other with associated parenchymal enhancement. The tolerability of the overall procedure was very good. The measurement of the HU values of the biliary ducts showed a marked increase in bile density. These structures could easily be appreciated within the liver and in the porta hepatis; the pancreatic head and its relationships with the main bile duct were evident. The densitometric measurement of the liver parenchyma before and after contrast enhancement did not show any variation with respect to the standard HU values. Cholangiographically-enhanced CT proved to be useful for the diagnosis of biliary obstruction; it may also be a promising diagnostic tool for the evaluation of pancreatic masses.

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In order to validate an angioscintigraphic method for the evaluation of the components of hepatic blood flow, the results of angioscintigraphy were compared with splanchnic angiography in 25 cirrhotics. Two indices of hepatic portal perfusion and a splenohepatic arterial index were calculated. These were correlated with portal diameter and hepatic artery diameter, respectively. No correlation was found between grades of portal perfusion according Nordlinger's criteria and these indices. The method is very simple and could be applied to evaluate the changes of liver hemodynamics induced by drugs or shunt surgery.

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