[The use of superselective embolization of the maxillary artery in treatment of bleedings in the Rendu-Osler-Weber syndrome]

Rendu-Osler-Weber syndrome is a rare genetically determined disorder that affects blood vessels throughout the body and results in a tendency for bleeding. Authors describe the case of superselective embolization of the left maxillary artery with polyvinyl alcohol particles in a patient with the Rendu-Osler-Weber syndrome hospitalized and treated in the Department of Otolaryngology and the Department of Radiology of the Military Institute in Warszawa, Poland due to persistent, severe and difficult to manage nasal bleeding. After the procedure had been performed patient condition improved and frequency and severity of nasal bleeding significantly diminished. Authors conclude that superselective embolization of the maxillary artery in a patient with Rendu-Osler-Weber syndrome is safe and effective and can be a valuable alternative to the maxillary artery or the carotis externa artery ligation. Authors also describe other methods of nasal bleeding management: laser photocoagulation, argon plasma coagulation, nasal dermoplasty and pharmacological treatment. Authors indicate that treating patients with Rendu-Osler-Weber syndrome is a diagnostic and therapeutic challenge for a physician and surgeon that require special approach to a patient due to difficult to manage symptoms. Patients with Rendu-Osler-Weber syndrome should be treated in a hospital setting due to access to diagnostic imaging techniques that can be helpful in revealing possible life threatening conditions.

[Rendu-Osler-Weber syndrome--a complex systemic disease]

Hereditary hemorrhagic teleangiectasia (HHT or Rendu-Osler-Weber Syndrome) is an inherited autosomal dominant disorder of the vascular connective tissue. The resulting vascular malformations can occur in virtually any organ. Nosebleeds can massively impact on the quality of life of those afflicted. However, visceral manifestations are likely to be more serious, and may be comparable with a "ticking time bomb". Most commonly affected are the vascular systems of the lungs, liver, brain and gastrointestinal tract. Screening is recommended--at least with regard to the lungs. Difficult constellations of this complex condition may be successfully managed by an interdisciplinary approach.

Hepatic involvement in hereditary hemorrhagic telangiectasia: CT findings

Hereditary hemorrhagic telangiectasia (HHT), also known as Rendu-Osler-Weber disease, is an autosomal-dominant vascular disease characterized by mucocutaneous or visceral angiodysplastic lesions (telangiectases and arteriovenous malformations) that may be widely distributed throughout the cardiovascular system. The recognition of mucocutaneous telangiectases, the occurrence of spontaneous and recurrent episodes of epistaxis, the presence of visceral involvement, and a family history of this disease are the clinical criteria that allow diagnosis. In comparison with skin, lungs, gastrointestinal tract, and brain involvement, hepatic involvement defined by clinical criteria alone has long been considered uncommon. Our experience with a large group of HHT patients, even those asymptomatic for liver involvement, demonstrates that it is more frequent than reported and is characterized by the presence of intrahepatic shunts, disseminated intraparenchymal telangiectases, and other vascular lesions. Congestive cardiac failure, portal hypertension, portosystemic encephalopathy, cholangitis, and atypical cirrhosis have been reported as possible serious complications related to this condition. Thus, a correct diagnosis is important, and diagnostic imaging has a fundamental role in detecting alterations involving the liver. The possibilities to perform a multiphasic study and to provide high-quality multiplanar and angiographic reconstructions, gives multidetector row helical computed tomography the ability to detect and characterize the complex anatomopathologic alterations typical of this disease.

High prevalence of hepatic focal nodular hyperplasia in subjects with hereditary hemorrhagic telangiectasia

A vascular pathogenesis of hepatic focal nodular hyperplasia (FNH) has been suggested; this study was aimed to evaluate in families with hereditary hemorrhagic telangiectasia (HHT) the prevalence of FNH, relating it to presence and stage of hepatic vascular malformations (VMs). Fifty-two HHT families underwent a screening program including abdominal Doppler sonography (US) searching for hepatic VMs; we classified them as minimal, moderate and severe, depending on the number and degree of abnormalities found by Doppler US. Presence of focal liver lesions was recorded. Diagnosis of FNH was made if at least two examinations, whether color Doppler US, liver scintigraphy, dynamic computed tomography (CT) or magnetic resonance (MR), showed suggestive findings. FNH was found in five out of 274 subjects (1.8%). All five were affected by HHT. Thus, percentage related to the group of affected patients increased to 2.9; 4/5 presented severe liver VMs. Female-to-male ratio was 4:1. FNH was single in three cases; tumor size ranged between 20 and 90 mm. During follow-up, no lesion showed a reduction in size, three showed an increase. Prevalence of FNH in patients with HHT is far greater than that reported in the general population; Doppler US role in its diagnosis and follow-up is highlighted.

Doppler ultrasonographic grading of hepatic vascular malformations in hereditary hemorrhagic telangiectasia -- results of extensive screening

AIMS

In previous studies, the prevalence of hepatic vascular malformations (VMs) in a large Italian family with hereditary hemorrhagic telangiectasia (HHT) was examined by Doppler ultrasonography (US) as screening technique, and the relevant Doppler US findings were described and classified. Thereafter, Doppler US has been routinely used to screen HHT families for liver involvement. Hepatic VMs were evaluated and classified on the basis of Doppler US findings.

METHODS

Three hundred and forty-six subjects belonging to 64 pedigrees were checked for the presence of signs of HHT. All of them underwent abdominal Doppler US screening for hepatic VMs. Vascular abnormalities were classified as minimal if the hepatic artery was dilated in extrahepatic tract only and measured > 6 mm; as moderate if the hepatic artery was dilated in both intra and extrahepatic tract; and as severe if complex changes of the arterial hepatic branches were associated with hepatic and/or portal vein dilatation. Furthermore, Doppler parameters, both qualitative (flow direction, turbulence) and quantitative (peak flow velocity and resistivity index in hepatic artery, mean velocity in portal vein, diastolic peak flow velocity in hepatic veins), were entered into our VM classification.

RESULTS

HHT was found in 222 subjects, with hepatic VMs detected by Doppler US in 92 (41.4 %) (24 males, 68 females, mean age 52.2). Hepatic VMs were minimal in 11 subjects, moderate in 70, and severe in 11.

CONCLUSIONS

On the basis of our proposed grading, hepatic VMs can be easily classified in subjects with HHT by Doppler US. Depending on the degree of hepatic vascular derangement, appropriate programs for follow up and/or therapy can be designed.

Hepatic involvement in hereditary hemorrhagic telangiectasia: helical computed tomography features in 24 consecutive patients

OBJECTIVE

Among the various organs that may be affected by hereditary hemorrhagic telangiectasia (HHT), the liver can show various degrees of vascular and parenchymal involvement. The purpose of this prospective study comprising a large series of patients was to reassess the computed tomography (CT) features of hepatic involvement in HHT using helical CT.

METHODS

Twenty-four consecutive patients with HHT had prospective helical CT of the liver, including noncontrast, arterial-dominant, and portal-dominant phases. The CT images were analyzed by 2 readers in consensus to determine the presence of vascular and parenchymal abnormalities. The diameter of the proper hepatic artery in these 24 patients was compared with that in 24 healthy subjects (Student t test).

RESULTS

Helical CT was normal in 5 patients (21%) and abnormal in 19 patients (79%). Vascular abnormalities were found in 16 patients (67%), consisting of marked dilatation of the hepatic artery (n = 16), intrahepatic telangiectases (n = 12), arteriovenous shunting (n = 5), and arterioportal shunting (n=3). The diameter of the proper hepatic artery was greater in the patients with HHT than in control subjects (6.12 +/- 2.52 mm vs. 3.29 +/- 0.65 mm, respectively; P < 0.05). Helical CT showed nodular hyperplasia in 1 patient with vascular and parenchymal abnormalities, cavernous hemangiomas in 2 patients (1 in a patient with an enlarged hepatic artery, intrahepatic telangiectases, and arteriovenous shunting and 1 in a patient with an isolated enlarged hepatic artery), and biliary cysts in 3 patients (2 biliary cysts were present in 2 patients with an enlarged hepatic artery and intrahepatic telangiectases, and 1 biliary cyst was present without any manifestations in the third patient).

CONCLUSION

Liver involvement in HHT is associated with a constellation of findings on helical CT, including significant dilatation of the proper hepatic artery, telangiectases, arteriovenous shunting, and focal liver lesions. Familiarity with these findings will result in more accurate diagnosis and allows better therapeutic options if necessary.

Intralesional bleomycin injections for the palliation of epistaxis in hereditary hemorrhagic telangiectasia

Epistaxis is a common complication in patients with hereditary hemorrhagic telangiectasia. Its treatment is generally aimed at controlling the frequency and severity of nasal hemorrhage and involves surgery, transcatheter embolization, topical treatment, or a combination. Despite this multitude of treatment methods, the long-term prognosis for many patients remains poor. We describe a patient in whom direct intralesional injections of bleomycin successfully palliated severe recurrent epistaxis for almost 2 years without the need for adjuvant therapy.

Sonographic findings in hepatic involvement of hereditary haemorrhagic telangiectasia

AIM

Hereditary haemorrhagic telangiectasia, or Rendu-Osler-Weber disease, is an autosomal-dominant disorder characterised by angiodysplastic lesions (telangiectases and arteriovenous malformations) which affect many organs including the skin, lungs, gastrointestinal tract, and brain. A broad spectrum of vascular and structural changes have been reported. Our objective was to systematically examine the prevalence of sonographic findings in hepatic involvement in patients with hereditary haemorrhagic telangiectasia (HHT).

METHODS

We studied 22 consecutive patients with hereditary haemorrhagic telangiectasia by ultrasonography in combination with colour-Doppler and pulsed wave-Doppler for liver involvement. The clinical diagnosis of HHT was based on the Curaçon criteria.

RESULTS

Sixteen of the 22 patients had signs of hepatic involvement including prominent common hepatic artery (14 of 16), dilatation of the intrahepatic part of the hepatic arteries (15 of 16) and intrahepatic AV-shunts (16 of 16). Ectasia of the hepatic vein, fibrotic parenchymal changes, left accessory hepatic artery and focal hepatic lesions were found less frequently.

CONCLUSION

Diagnosis of liver involvement in HHT can be made by sonography with colour-Doppler. The main features of this involvement include prominent common hepatic artery, dilatation of the intrahepatic part of the hepatic arteries and intrahepatic AV-shunts.

Intrahepatic porto-hepatic venous shunts in Rendu-Osler-Weber disease: imaging demonstration

This study describes the imaging features of the intrahepatic portohepatic venous (PHV) shunt, which is a potential cause of portosystemic encephalopathy in Rendu-Osler-Weber disease. Six patients with Rendu-Osler-Weber disease (two men, four women; age range 42-73 years) were retrospectively studied. There were two from one family and three from another family. Of these patients, one was diagnosed with definitive portosystemic encephalopathy because of a psychiatric disorder. We retrospectively reviewed the radiological examinations, including abdominal angiography (n=6), three-phase dynamic helical computed tomography (CT; n=3), and conventional enhanced CT (n=1). In one patient, CT during angiography and CT angioportography were also performed. Evaluation was placed on the imaging features of intrahepatic PHV shunts. On angiography, intrahepatic PHV shunts showing multiple and small shunts <5 mm in diameter in an apparent network were detected in all patents. In two patients, a large shunt with a size of either 7 or 10 mm was associated. These intrahepatic PHV shunts were predominantly distributed in the peripheral parenchyma. Intrahepatic PHV shunts would be characterized by small and multiple shunts in an apparent network on the periphery with or without a large shunt.

Use of gadolinium as an intraarterial contrast agent for pediatric neuroendovascular procedures

OBJECT

The safety and efficacy of Gd as an intraarterial contrast agent for pediatric neuroendovascular procedures were investigated.

METHODS

The authors retrospectively reviewed data regarding pediatric neuroendovascular procedures performed during a 1-year period. Seventeen procedures involving the use of gadodiamide in nine pediatric patients were identified. All angiographic images were of diagnostic quality but usually required minimal postimage processing. In time-consuming cases, the use of gadodiamide allowed the procedure to continue when the dosage of iodinated contrast approached a toxicity level and would have otherwise prompted termination of the procedure. This likely reduced the total number of procedures necessary. No adverse events due to the intraarterial use of gadodiamide were identified.

CONCLUSIONS

Gadodiamide appears to be a safe and effective contrast agent for pediatric patients.

Hereditary hemorrhagic telangiectasia: multi-detector row helical CT assessment of hepatic involvement

PURPOSE

To describe findings obtained with multi-detector row helical computed tomography (CT) of the liver in patients with hereditary hemorrhagic telangiectasia.

MATERIALS AND METHODS

Multiphasic multi-detector row helical CT was performed in 70 consecutive patients (29 females and 41 males; mean age, 48.5 years; age range, 15-75 years): 64 considered to have hereditary hemorrhagic telangiectasia and six suspected of having the disease. Scanning delay was achieved by using a test bolus of contrast medium to obtain early arterial phase, late arterial phase, and portal venous phase images. Multiplanar and angiographic reconstructions were then generated. The presence of shunts, hepatic perfusion disorders, telangiectases, other vascular lesions, indirect signs of portal hypertension, and vascular anatomic variants were evaluated by two radiologists in consensus.

RESULTS

Fifty-two of 70 (74%) patients had hepatic vascular abnormalities. Only four of 52 (8%) patients were symptomatic. Arterioportal shunts were present in 27 of 52 (52%) patients, arteriosystemic shunts in eight of 52 (15%), and both shunt types in 17 of 52 (33%). In 34 of 52 (65%) patients, parenchymal perfusion disorders were detected. Telangiectases were found in 33 of 52 (63%) patients. Large confluent vascular masses were identified in 13 of 52 (25%) patients. In 31 of 52 (60%) patients, indirect CT signs of portal hypertension were detected, but only one had clinical signs of this condition. Vascular anatomic variants were detected in seven patients (13%).

CONCLUSION

Multi-detector row helical CT and reconstructions depict the complex hepatic vascular alterations typical of hereditary hemorrhagic telangiectasia.

Sonographic criteria for the diagnosis of hepatic involvement in hereditary hemorrhagic telangiectasia (HHT)

Hepatic involvement in hereditary hemorrhagic telangiectasia (HHT) is highly variable and may lead to severe clinical symptoms such as heart failure. This controlled, prospective study defined sonographic criteria for hepatic involvement in HHT. Color Doppler sonography and pulsed Doppler sonography were used to study 25 patients with HHT and liver involvement, 20 patients with HHT without liver involvement, 25 patients with cirrhosis, and 25 patients without liver disease. The diagnosis of hepatic manifestation was confirmed by computed tomography and/or angiography. Liver size, parenchymal changes of the liver, vessel diameters, and flow velocities of the portal vein and the hepatic artery were determined. Resistance index (RI) and pulsatility index (PI) were calculated. The diameter of the common hepatic artery was significantly dilated without overlap between HHT patients with liver involvement and the 3 control groups (mean 11.3 +/- 2.8 mm [HHT with liver involvement], 4.6 +/- 0.9 mm [HHT without liver involvement], 4.8 +/- 1.0 mm [cirrhosis], and 4.4 +/- 1.0 mm [healthy controls], P <.001). Doppler parameters of the proper hepatic artery differed significantly (all P <.001). In all patients with HHT and liver involvement, areas with intrahepatic hypervascularization caused by dilated intrahepatic arteries were observed in varying intensity. Cardiac output significantly correlated with the diameter of the common hepatic artery (r = 0.53, P =.007) and the portal vein (r = 0.42, P =.05). In conclusion, the diameter of the common hepatic artery (>7 mm) and intrahepatic hypervascularization are suitable sonographic diagnostic parameters of HHT with high sensitivity and specificity. Dilated diameters of the hepatic feeding vessels are indicators for systemic circulatory distress in these patients.

Telangiectatic pulmonary arteriovenous malformation

Telangiectatic pulmonary arteriovenous malformation is defined as a pulmonary arteriovenous malformation involving every segmental artery of at least one lobe of the lung. The authors report a case of telangiectatic pulmonary arteriovenous malformation in the left lower lobe of the lung.

[Pulmonary and hepatic arteriovenous malformations in a case of Rendu-Osler disease]

The authors report one case of Rendu-Osler disease in a 59-year-old woman presenting with pulmonary and hepatic arteriovenous malformations. She suffered from high-output heart failure due to a left-to-right intrahepatic shunt. Diagnosis and treatment by coil embolization of pulmonary and hepatic fistulas were performed by radiological techniques. Pulmonary shunting can produce severe neurologic complications. The disease is hereditary and progressive. Follow-up of treated patients and family screening are recommended.

Contrast echocardiography remains positive after treatment of pulmonary arteriovenous malformations

STUDY OBJECTIVES

Pulmonary arteriovenous malformations (PAVMs) in patients with hereditary hemorrhagic telangiectasia (HHT) can cause hemorrhage, stroke, and cerebral abscess. Therapy consists of transcatheter embolotherapy (TCET) to occlude the PAVMs. Contrast transthoracic echocardiography (TTE) can be used to screen for PAVMs, but little is known about the performance of contrast TTE after TCET has been performed. Our objective was to determine the effect of the successful performance of TCET on the performance of contrast TTE, specifically, in what proportion of patients the findings of contrast TTE normalized or remained positive after the performance of TCET.

DESIGN

Retrospective chart review.

SETTING

HHT clinic at university teaching hospital.

PATIENTS

Patients who have undergone TCET for the treatment of PAVMs.

INTERVENTIONS

Patients were screened for PAVMs with a chest radiograph (CXR), oxygen shunt test (OST), and contrast TTE. Pulmonary angiography was recommended for patients with any positive findings on a screening test. PAVMs > or = 3 mm were occluded by TCET. Contrast TTE, OST, and CXR were performed approximately 1 month later. The results of contrast TTE before and after patients underwent TCET were compared.

MEASUREMENTS AND RESULTS

Thirty-nine patients underwent contrast TTE prior to undergoing TCET, and 29 patients underwent contrast TTE both prior to and after undergoing TCET. In all patients, TTE findings were positive prior to TCET. All PAVMs with feeding vessels > or = 3 mm were successfully occluded based on completion angiography. After TCET, 48% of patients had no detectable residual PAVMs, and the remainder had small (ie, < 3 mm) residual PAVMs. Of the 29 patients, 90% had positive contrast TTE findings after undergoing TCET. In the subset of patients who had no residual PAVMs on the completion angiography, 80% had positive contrast TTE findings after undergoing TCET.

CONCLUSIONS

In most patients, contrast TTE findings remain positive after they undergo TCET, even in patients without residual PAVMs seen on angiography. This may reflect residual PAVMs that are too small to visualize using angiography. These findings have important implications for the follow-up and management of HHT patients.