Duplex Ultrasonographic Evaluation of Liver Transplants

Two hundred and twenty-two duplex ultrasonographic examinations were performed on 36 liver transplants in 30 patients over a period of 5 years and 9 months. Positive sonographic findings were correlated with 13 angiographic examinations. Arterial complications included 4 thromboses, 5 stenoses, and one mycotic aneurysm. A false-negative result was obtained in 2 cases of stenosis and a false-positive result in one case of thrombosis. One portal vein thrombosis, 2 stenoses, and 2 cases of portal hypertension were diagnosed correctly. Sensitivity was 87%, specificity 95%, and accuracy 93%. Duplex Doppler was least effective in the diagnosis of hepatic artery stenosis. Five cases showed biliary complications of ischemic origin. Angiography is indicated when duplex Doppler is positive or doubtful, but also when the clinical condition is unclear.

[Endoleak, a specific complication of the endovascular treatment of aortic aneurysms]

Endoleaks represent the most common complication of endovascular aortic aneurysm repair. With the increasing use of endovascular techniques for aortic aneurysm repair, the prevalence of endoleaks has risen. While maintaining pressurization of the aneurysm sac, endoleaks expose to persistent risks of an evolution towards rupture. Long-term surveillance with imaging studies is necessary to reduce the incidence of these specific complications that may require intervention. The objective of this article is to draw the attention to the possible occurrence of these complications and to report the elements of diagnosis and treatment.

Thrombolysis of occluded infra-inguinal bypass grafts: is it worthwhile?

BACKGROUND

Thrombosis of an infra-inguinal bypass graft often results in a limb-threatening ischemia. There is no consensus on the optimal management strategy.

AIM OF THE STUDY

To analyse safety and efficacy of catheter-guided intra-arterial thrombolysis to re-open thrombosed infra-inguinal bypass grafts and to identify factors that influence graft patency and limb salvage rate after thrombolytic procedures.

METHODS

A continuous cohort-study of 106 thrombolytic procedures between 1993 to 2008.

RESULTS

Despite a high initial success rate (76%), the mid-term results are less convincing, with a 58% re-occlusion rate at 45 months follow-up. Thrombosed vein grafts, old (2 weeks or more) occlusions, poor run-off and failure to identify or rectify an underlying causative stenosis are determinant for a poor long-term outcome of thrombolytic procedures.

COMMENTS

The outcome results of author's experience are consistent with literature reports. Thrombolysis of occluded infra-inguinal bypass grafts should be limited to selective cases (recent occlusion, prosthetic or vein graft in place since 1 year or more, critical limb ischemia). Despite its obvious advantages, the long-term outcome of thrombolytic procedures is deceiving. The inherent risk of hemorrhagic complications should also be taken in account at the decision making of treatment strategy. The question whether, in general, catheter-guided selective intra-arterial thrombolysis offers a significant advantage over operative revascularisation (thrombectomy or new bypass) remains unanswered. A more selective approach seems to favour thrombolysis as most appropriate strategy in the management of recent (< 2 weeks) thromboses of grafts in place since at least 1 year.

Intra-arterial thrombolysis of thrombosed popliteal artery aneurysm. A series of six cases

AIM OF THE STUDY

To evaluate the role of perioperative, catheter-guided fibrinolysis in the management of thrombosed popliteal artery aneurysms.

MATERIAL

From 1990 to 2005, six patients suffering subacute limb ischemia, secondary to thrombosis of a popliteal artery aneurysm, benefited selective intra-arterial fibrinolysis, followed by subsequent aneurysm exclusion and bypass grafting. This represents ten percent of all popliteal aneurysms operated on in that time period and 28% of all thrombosed popliteal artery aneurysms.

RESULTS

The lytic procedure was successful in all cases, restituting patency in two (n = 3), one (n = 2) or all (n = 1) crural arteries. The venous bypass graft remained patent in all but one patient. In one patient, the graft occluded at 10 months without limb loss. This outcome compares more favorable than the result obtained with emergent surgery alone for thrombosed popliteal artery aneurysms with profound limb ischemia (eight patients, of whom one required amputation at day 5 and one lost his limb at nine months following graft thrombosis).

CONCLUSION

Preoperative intra-arterial lytic therapy, in the setting of subacute limb ischemia caused by thrombosis of a popliteal artery aneurysm, can be considered as safe and effective.

[Clinical case of the month. Cerebrovascular accident related to arterial brachiocephalic trunk stenosis]

The authors report the case of a 47-year old man, admitted for syncope and left-sided motor deficit. Diagnostic investigations revealed a right middle cerebral artery embolic stroke, secondary to a critical stenosis of the arterial brachiocephalic trunk, harboring a floating thrombus. The treatment options for occlusive lesions of the brachiocephalic trunk are discussed, as well as the optimal delay between stroke and brain revascularization.

Traumatic injuries: radiological hemostatic intervention at admission

Blunt trauma victims and selected patients with penetrating trauma are systematically investigated after resuscitation and hemodynamic stabilization with cross-sectional imaging. Computed tomography is a good predictor of the need for hemostatic arteriographic embolization, based on contrast medium extravasation observed on CT. In centers admitting polytrauma patients, the CT and angiography units should be installed together within the emergency environment. Trauma-dedicated interventional radiologists should be on call for optimal patient management. Posttraumatic retroperitoneal and pelvic bleeding is a primary indication for angiographic hemostasis, together with orthopedic fixation of pelvic bone fractures. Angiography should be carried out rapidly, before the patient decompensates for considerable blood loss. In patients with visceral bleeding, arterial embolization can obviate primary surgery or potentializes surgical intervention and contributes to changing hierarchy of injuries to be treated surgically. Failure to achieve primary hemostasis may occur according to the type of specific organ injury and coagulation and metabolic parameters of the patient. Postembolization complications are few and are usually non-life-threatening and rarely carry definitive sequelae.

Sedation, analgesia and anesthesia for interventional radiological procedures in adults. Part I. Survey of interventional radiological practice in Belgium

A questionnaire was mailed to 217 interventional radiologists to evaluate current practice in analgesia and sedation in adults. Response rate was 15% (33/217). Diagnostic angiography was performed with local anesthesia in 94% to 99%; for PTA, local thrombolysis or stent placement, light sedation was added in 0.1%. Premedication was given in 43% of diagnostic angiographies and in 68% of therapeutic procedures. Radiologists consulted an anesthesiologist before administration of intravenous sedation, always in 54% of cases, occasionally in 19% and never in 27%. General anesthesia with artificial ventilation was applied in 56% of TIPS, in 70% of aortic stent grafting and in 82% of neuroradiological interventions. Intravenous sedation was applied given in 53% of percutaneous biliary drainage, in 42% of bile duct dilatation or stenting, in 40% of percutaneous nephrostomy and in 72% of ureteral balloon dilatation. Patient monitoring during an interventional procedure was always carried out by an anesthesiologist in 52% of cases. 21% of radiologists never visited the patient before a therapeutic procedure, and 36% never did so after completion of a procedure. This survey showed that high standard practice of sedation and analgesia, with the assistance of anesthesiologists, is underused by interventional radiologists in Belgium.

Use of a balloon occlusion catheter to facilitate transarterial coil embolisation of a patent ductus arteriosus in two dogs

Two dogs with a history of coughing and exercise intolerance were suspected to have a patent ductus arteriosus (PDA), and the presence of a type III PDA was confirmed by radiography, electrocardiography, ultrasonography and angiography. Transarterial coil embolisation was carried out by using a modified technique. An occlusion balloon catheter was inserted through a femoral vein and placed at the pulmonary side of the ductus before the embolisation coils were put in place. Both dogs remained healthy during a follow-up period of nine months.

Radiologic damage control: evaluation of a combined CT and angiography suite with a pivoting table

PURPOSE

To evaluate retrospectively the integrated diagnostic and therapeutic management of severely polytraumatized patients using a combined computed tomography (CT) and angiography suite with a single pivoting table.

METHODS

Eleven patients, aged 16-74 years (median 30 years), were managed with spiral CT and angiography without patient transfer. Four patients were unstable, seven had received blood transfusions (2-18 units) and six were intubated. In 10 patients in whom active bleeding was demonstrated (splenic 5, hepatic 2, renal 2, left inferior epigastric artery 1), hemostatic embolization was obtained.

RESULTS

Total procedure time did not exceed 80 min. Immediate hemostasis was achieved in all patients. Recurrent bleeding from the liver required additional embolization in one patient. Median length of stay in the intensive care unit was 4 days and median hospital stay was 27 days. All patients survived without significant sequelae.

CONCLUSION

The use of a combined CT-angiography suite enables rapid diagnostic investigation and hemostatic embolization in actively bleeding trauma patients.

Arterial embolization of bone metastases: is it worthwhile?

Arterial embolization was performed in ten skeletal metastases occurring in nine patients: eight patients presented with renal cell carcinoma and one with bronchogenic carcinoma. Five metastatic lesions were located in the spine, one in the pelvis, three in the proximal humerus and one in the proximal femur. Selective arterial embolization was performed preoperatively in seven cases and as a palliative treatment in three cases. The embolic material used was polyvinyl alcohol particles, gelatin sponge and coils or a combination of these. Arterial embolization was technically successful in all patients achieving subtotal (> 90%) tumour devascularization in five metastases and a 75% devascularization in the remaining five lesions. In operative patients, median intra-operative volume of blood transfusion was 510 mL. Palliative embolization was followed by major pain relief in two cases and moderate relief in one case lasting from 7 to 26 months. Arterial embolization is an effective and safe adjunctive treatment of hypervascular bone metastases.

Delayed esophageal hemorrhage caused by a metal stent: treatment with embolization

We report a case of life-threatening esophageal hemorrhage after metal stent implantation successfully treated by arterial embolization. An 85-year-old woman was admitted in shock secondary to massive hematemesis and melena. Recent medical history revealed esophageal cancer treated 8 weeks previously by endoesophageal radiotherapy (40 Gy) and endoscopic placement of a covered Wall-stent prosthesis. Selective arteriography of the fifth posterior right intercostal artery showed massive contrast extravasation in the esophagus. Embolization was performed with 150-250-micron polyvinyl alcohol particles. Follow-up at 5 months was uneventful. Arteriography and embolization are advised when severe hemorrhage occurs after esophageal implantation of metal stents.

Thrombolysis of occluded infrainguinal bypass grafts

From January 1993 to December 1995, intraarterial catheter guided urokinase infusion was used as an initial approach in the management of 29 episodes of infrainguinal graft thrombosis (12 venous and 17 prosthetic grafts) in 27 patients. The infusion catheter was embedded inside the occluding clot which was infiltrated by 225.000 U urokinase from distal to proximal. Local low-dose urokinase (1.000 U/kg/hr) was continued for a mean of 39 hours. By this regimen, prompt relief of ischaemia was achieved in 69% (20/29) of cases. Complete recanalization was obtained in 79% of cases. In six cases, the graft remained totally (n = 3) or partially (n = 3) occluded. Two of these patients benefited from secondary surgery, two improved clinically by conservative treatment, and two required amputation. In the 23 successful cases, thrombolysis unmasked an underlying flow-limiting stenosis in 83% (19/23), that was subsequently corrected by percutaneous balloon angioplasty (n = 15), by surgery (n = 3), or by a combination of both (n = 4). One early rethrombosis resulted in an amputation. The immediate limb-salvage rate was 89% (26/29). Surgical intervention was avoided in 17 cases (58%). The main hospital stay was 13 days. The short-term follow-up (mean of 17 months) reveals a high early rethrombosis rate (8/23 or 35%) within one year. Four of these repeated graft failures evolved to amputation. At one year, the overall limb salvage rate dropped to 79%. Thrombolytic management of infrainguinal occluded bypass grafts gives excellent initial technical results (79%), minimizing the need for major surgical revision. It is however characterized by a high procedure-related morbidity (21%). These immediate favourable results are not longstanding. Diffuse graft disease, limited outflow and high recurrence rate of anastomotic stenoses after balloon angioplasty explain poor long-term results after thrombolysis of failed grafts.

Treatment of symptomatic pelvic varices by ovarian vein embolization

PURPOSE

Pelvic congestion syndrome is a common cause of chronic pelvic pain in women and its association with venous congestion has been described in the literature. We evaluated the potential benefits of lumbo-ovarian vein embolization in the treatment of lower abdominal pain in patients presenting with pelvic varicosities.

METHODS

Nineteen patients were treated. There were 13 unilateral embolizations, 6 initial bilateral treatments and 5 treated recurrences (a total of 30 procedures). All embolizations were performed with either enbucrilate and/or macrocoils, and there was an average clinical and Doppler duplex follow-up of 15.4 months.

RESULTS

The initial technical success rate was 96.7%. There were no immediate or long-term complications. Variable symptomatic relief was observed in 73.7% of cases with complete responses in 57.9%. All 8 patients who had partial or no pain relief complained of dyspareunia. The direct relationship between varices and chronic pelvic pain was difficult to ascertain in a significant number of clinical failures.

CONCLUSION

Transcatheter embolization of lumbo-ovarian varices is a safe technique offering symptomatic relief of pelvic pain in the majority of cases. The presence of dyspareunia seemed to be a poor prognostic factor, indicating that other causes of pelvic pain may coexist with pelvic varicosities.

Multiple pulmonary artery pseudoaneurysms: intrasaccular embolization

We report the case of a 32-year-old female presenting with two pulmonary artery false aneurysms of mycotic origin. Considering the natural history and potential complications, we treated the patient by intrasaccular embolization with steel coils. No complication occurred.

Evaluation of colour images printed by a thermal dye diffusion process

Dry printing of medical images, without photochemicals, may be based on the principle of thermal dye diffusion. The Drystar (Agfa Gevaert, Mortsel, Belgium) system was evaluated in colour-coded Doppler examinations of the carotid arteries. A total of 25 consecutive patients were examined for the colour test and 37 patients for the black-and-white test. Colour and black-and-white data were available on the same view. The performances of the Drystar were tested against against laser films, matrix films and two types of glossy paper using the following criteria: grey scale, colour scale, quality of reproduction of vascular colouring, registration, endothelial layer, intraluminal echogenicity, spectral resolution, and artefacts. The overall handiness of the document was graded. A significant difference (p = 0.00005) was noted in favour of the Drystar concerning registration, grey scale, spectral resolution and vascular colouring. The global score for handiness of the colour film was 96%. Radiologists preferred the colour hard copy as compared with glossy paper prints. As in the black-and-white test, blue-base and clear-base films obtained with the Drystar were rated inferior to laser films, a double line print mode was included in the printer, giving a density of 2.3 OD.

A combined CT and angiography suite with a pivoting table

In a suite with fully interactive computed tomography (CT) and C-arm fluoroscopy units, emergency and elective interventional procedures were performed successfully in 41 patients (overall time range, 40-180 minutes [mean, 80 minutes]). The table can be manually pivoted from the fixed CT position to the free-floating angiography position, in an overall working space of about 40 m(2), with room for anesthesiology and monitoring equipment and personnel.

Treatment of Budd-Chiari syndrome by metallic stent as a bridge to liver transplantation

A 49-year-old male with Budd-Chiari syndrome complicated by liver cirrhosis and intractable ascites is reported. The left hepatic vein was stenosed by a short subocclusive ostial web; the right and medial hepatic veins were thrombosed. A spontaneous intrahepatic portosystemic shunt had developed between the left portal and left hepatic veins. After ineffective balloon angioplasty, the left hepatic venous outflow was restored by placement of a 10-mm-diameter Wallstent across the web via a femoral approach. The hepatic venous pressure dropped from 29 to 12 mmHg. Rapid clinical improvement followed. The patient underwent liver transplantation 3 months later in stable condition.

[Spiral tomodensitometry applied to interventional radiology]

Spiral CT can be applied to many interventional procedures. Rapid scanning time reduces the duration of percutaneous CT guided biopsy and examination time of polytrauma patients. 3D reconstructions are applied to the planning and follow-up of vascular interventional procedures such as embolization of aneurysms or arteriovenous fistulae, stent grafting of aortic aneurysms or dissection, percutaneous transluminal angioplasty of the renal arteries, supra-aortic or iliac arteries. TIPS, percutaneous biliary procedures and percutaneous treatment of liver tumors do largely benefit from 3D reconstructions as a planning method.

Results of an exclusion technique for treatment of abdominal aortic aneurysm

An exclusion technique for the treatment of abdominal aortic aneurysm was used in six patients considered to be at high operative risk mainly because of chronic pulmonary disease. There were no deaths or immediate major complications. Thrombosis of the aneurysm was achieved in four of the six patients. However, in three cases, repeated percutaneous embolization was required to produce thrombosis. One patient developed a secondary rupture of a persisting infrarenal sac resulting from a patent inferior mesenteric artery. This patient was successfully managed by ligature of the infrarenal portion of the abdominal aorta through a median laparotomy. This study emphasizes the limits and the risks of the exclusion technique.

Duplex ultrasonographic evaluation of liver transplants

Two hundred and twenty-two duplex ultrasonographic examinations were performed on 36 liver transplants in 30 patients over a period of 5 years and 9 months. Positive sonographic findings were correlated with 13 angiographic examinations. Arterial complications included 4 thromboses, 5 stenoses, and one mycotic aneurysm. A false-negative result was obtained in 2 cases of stenosis and a false-positive result in one case of thrombosis. One portal vein thrombosis, 2 stenoses, and 2 cases of portal hypertension were diagnosed correctly. Sensitivity was 87%, specificity 95%, and accuracy 93%. Duplex Doppler was least effective in the diagnosis of hepatic artery stenosis. Five cases showed biliary complications of ischemic origin. Angiography is indicated when duplex Doppler is positive or doubtful, but also when the clinical condition is unclear.

Echographic characterization of carotid plaques

The histology of the endarterectomy specimen was compared with the preoperative echopattern of 154 plaques. Thirty-four ultrasound images were of poor quality. The 120 adequate echographies revealed 22 dense hyperechogenic homogeneous plaques, 28 soft hypoechogenic homogeneous plaques, 53 inhomogeneous plaques, and 13 mixed plaques. According to the surface, lesions were subdivided as smooth (n = 63) or irregular (n = 57). Echography recognized fibrous plaques (dense homogeneous hyperechogeneous lesions), with a specificity of 87% and a sensitivity of 56%. Recent intraplaque haemorrhage is echographically apparent as a hypoechogenic area in 88% of cases, what corresponds to a specificity of 79% and a sensitivity of 75%. Echography proved to be more accurate than angiography in determining the presence or absence of ulceration. The ability to characterize the pathology of carotid atheroma by duplex scan make the clinicopathologic correlation of carotid plaques of practical importance.

Pathological aspects of carotid plaques. Surgical and clinical significance

We examined 134 carotid plaques microscopically in 125 consecutive patients, and found 21 (15.7%) had simple fibrous plaques versus 113 (84.3%) complicated plaques. The following plaque characteristics were present: intraplaque hemorrhage (73 plaques), ulceration (83 plaques), fresh thrombus (93 plaques), and recanalized thrombus (22 plaques). An average of 2.4 characteristics were observed in each complicated plaque. The only significant (p less than 0.05) clinico-pathologic correlation was the presence of fresh thrombi, found in 80% of the plaques from patients with a previous transient ischemic attack, in 93% of those with nonfocal neurologic symptoms, and in 80% of those with amaurosis fugax. Analysing the localization of the fresh thrombus (mural or intraluminal), we found that fresh thrombus in symptomatic plaques was most frequently (NS) (71 to 77%) exposed to the vessel lumen. Ulceration without fresh thrombus, plaque hemorrhage and recanalized thrombus were also found in a considerable number of asymptomatic patients, of whom 85% (33/41) presented a form of complicated plaque.

Left main coronary dissection after mild chest trauma. Favorable evolution with fibrinolytic and surgical therapies

A 32-year-old woman had acute anterior myocardial infarction after a mild chest trauma (automobile accident). Unstable angina recurred shortly after admission, and extensive dissection of the left coronary artery was demonstrated. Medical therapy including systemic fibrinolysis was started but clinical stabilization and good long-term result was achieved only by aortocoronary bypass grafting.

Usefulness of thromboendarterectomy in association with coronary artery bypass grafting

Thromboendarterectomy is sometimes performed in association with coronary artery bypass graft surgery (CABG). Right coronary arteries and severely narrowed coronary arteries mainly undergo thromboendarterectomy, but perioperative acute myocardial infarctions (AMI) are possible complications. One hundred seventy-six consecutive patients with rest and stress thallium-201 scintigraphy and angiography were studied before and after surgery. To compare patients with and without thromboendarterectomy, 48 patients who had undergone thromboendarterectomy and whose characteristics matched closely those of patients who had not were selected. Twenty patients had previous AMI before CABG in each group. Analysis accounted for the severity of vessel lesion (complete or incomplete) and for the patency of the graft and of the native coronary artery. In these 96 patients, graft patency was lower than in the overall group and similar among patients with and without thromboendarterectomy among the 56 patients without previous AMI. In patients with previous AMI and thromboendarterectomy, however, reperfusion was achieved more often through the native vessel than through the graft. New AMI or residual ischemia occurred in 32% of the areas undergoing thromboendarterectomy and in only 5% of the standard grafts (p less than 0.001). Best results were obtained in patients with incomplete occlusion after AMI. Patients without previous AMI had worse results. Thus, thromboendarterectomy can yield 64 to 75% good results in selected subgroups when CABG is otherwise impossible, but should be avoided in mildly or moderately stenotic arteries perfusing noninfarcted myocardium.

Predicting the extent and location of coronary artery disease in acute myocardial infarction by echocardiography during dobutamine infusion

The feasibility, safety and usefulness of 2-dimensional echocardiography (2-D echo) during dobutamine infusion for identifying patients with multivessel coronary artery disease (CAD) after acute myocardial infarction (AMI) were evaluated in 30 patients 5 to 10 days after AMI. Patients underwent 2-D echo under basal conditions and during dobutamine infusion at each dose from 5 to a maximum of 40 micrograms/kg/min, limited multilead submaximal bicycle exercise testing and coronary and left ventricular angiography. Echocardiograms were analyzed independently by 2 observers. The test response was considered positive if abnormal wall motion and reduced myocardial thickening were observed during dobutamine infusion in vascular distributions other than the area of infarction identified during basal conditions. Exercise testing was considered positive when more than 1 mm of ST depression occurred 80 ms after the J point. Dobutamine stress testing was well tolerated; no complications and no significant arrhythmia were observed. Echocardiographic recordings were adequate in all patients during the entire test; the concordance in interpretation between the 2 observers was perfect for the prediction and location of ischemic segments during dobutamine infusion. In 15 of 17 patients without multivessel CAD, no asynergy was observed outside the infarct zone during dobutamine infusion (specificity 88%). In 11 of 13 patients with multivessel CAD, new wall motion abnormalities were identified in the segments corresponding to the arterial lesions diagnosed by angiography (sensitivity 85%).(ABSTRACT TRUNCATED AT 250 WORDS)