Men with erectile dysfunction (ED) should be screened for cardiovascular risk factors - Cost-benefit considerations in Swiss men

Background: Current evidence indicates that erectile dysfunction (ED) is an independent risk factor for future cardiovascular events. This study aimed to estimate the cost-effectiveness of screening and subsequent preventive treatment for cardiovascular risk factors among men newly diagnosed with ED from the Swiss healthcare system perspective. Methods: Based on known data on ED and cardiovascular disease (CVD) prevalence and incidence costs and effects of a screening intervention for cardiovascular risk including corresponding cardiovascular prevention in men with ED were calculated for the Swiss population over a period of 10 years. Results: Screening and cardiovascular prevention over a period of 10 years in Swiss men with ED of all seriousness degrees, moderate and severe ED only, or severe ED only can probably avoid 41,564, 35,627, or 21,206 acute CVD events, respectively. Number needed to screen (NNS) to prevent one acute CVD event is 30, 23, and 10, respectively. Costs for the screening intervention are expected to be covered at the seventh, the fifth, and the first year, respectively. Conclusion: Screening and intervention for cardiovascular risk factors in men suffering from ED is a cost-effective tool not only to strengthen prevention and early detection of cardiovascular diseases but also to avoid future cardiovascular events.

Diagnostic accuracy of coronary artery stenosis and thrombosis assessment using unenhanced multiplanar 3D post-mortem cardiac magnetic resonance imaging

BACKGROUND

A 3D sequence was introduced to unenhanced post-mortem cardiac magnetic resonance imaging (PMCMR) to enable multiplanar coronary artery image analysis and to investigate its diagnostic accuracy for the diagnosis of coronary artery stenosis and thrombosis.

MATERIALS AND METHODS

N = 200 forensic cases with suspected coronary artery pathology underwent 3 Tesla PMCMR (sequence used: T2 weighted transversal 3D turbo spin echo) before autopsy. Main coronary artery stenosis and thrombosis were assessed in PMCMR by multiplanar image analysis by two observers. Coronary artery histology was determined as the gold standard and compared to PMCMR. Sensitivity, specificity, negative (NPV) and positive predictive values (PPV) with 95% confidence intervals were calculated.

RESULTS

For all coronary arteries combined, sensitivity was 75% (PPV 73%) for the diagnosis of stenosis and 72% (PPV 71%) for the diagnosis of thrombosis. Specificity was 92% (NPV 90%) for correct diagnosis of non-existing stenosis and 97% (NPV 97%) for non-existing thrombosis. Sensitivity for correct diagnosis of different degrees of stenosis ranged between 67% and 80% (PPVs 67-82%); specificity ranged between 96% and 99% (NPVs 96-99%).

CONCLUSION

Multiplanar PMCMR coronary artery stenosis and thrombosis assessment based on an unenhanced T2 weighted 3D sequence provide moderate sensitivity and high specificity for the diagnosis of coronary artery stenosis and/or thrombosis. Hence, 3D T2w PMCMR cannot reliably detect existing coronary artery stenosis and thrombosis but may be particularly useful for the exclusion of stenosis or thrombosis of the main coronary arteries.

Erectile dysfunction: role of computed tomography cavernosography in the diagnosis and treatment planning of venous leak

BACKGROUND

Venous leak appears to be the most common cause of vasculogenic erectile dysfunction (ED), which can be treated with venous embolization. Traditionally, conventional cavernosography was used for the diagnosis and treatment planning of venous leak. Recently, computed tomography (CT) cavernosography was introduced as a novel cross-sectional imaging method proposed to be advantageous over conventional cavernosography. We created a novel management algorithm for diagnosing venous leak including CT cavernosography as an imaging modality. In order to provide a broader basis for our management algorithm, a systematic literature review was conducted.

MAIN BODY

In this article we systematically review relevant literature on using CT cavernosography for the diagnosis and treatment planning in ED patients with venous leak following the PRISMA selection process. Nine full-text articles were included in the review and assigned a level of evidence grade (all grade II). Two studies (2/9) compared the results of conventional cavernosography with those of CT cavernosography which was superior for site-specific venous leak identification (19.4% vs. 100%, respectively). CT cavernosography is a more detailed imaging method that is faster to perform, exposes the patient to less radiation, and requires less contrast material. In one study (1/9), CT cavernosography was used for diagnostic purposes only. Eight studies (8/9) cover both, diagnostic imaging and treatment planning including embolization (1/9) and sclerotherapy (2/9) of venous leak in patients with venogenic ED. Three studies (3/9) describe anatomical venous leak classifications that were established based on CT cavernosography findings for accurate mapping of superficial and/or deep venous leak and identification of mixed or more complex forms of venous leak present in up to 84% of patients. In addition to treatment planning, one study (1/9) used CT cavernosography also for follow-up imaging post treatment.

CONCLUSION

CT cavernosography is superior to conventional cavernosography for diagnosis and treatment planning in patients with ED caused by venous leak (grade II levels of evidence). Consequently, CT cavernosography should be included in management algorithms for ED patients with suspected venous leak.

Artificial Intelligence and Interstitial Lung Disease: Diagnosis and Prognosis

ABSTRACT

Interstitial lung disease (ILD) is now diagnosed by an ILD-board consisting of radiologists, pulmonologists, and pathologists. They discuss the combination of computed tomography (CT) images, pulmonary function tests, demographic information, and histology and then agree on one of the 200 ILD diagnoses. Recent approaches employ computer-aided diagnostic tools to improve detection of disease, monitoring, and accurate prognostication. Methods based on artificial intelligence (AI) may be used in computational medicine, especially in image-based specialties such as radiology. This review summarises and highlights the strengths and weaknesses of the latest and most significant published methods that could lead to a holistic system for ILD diagnosis. We explore current AI methods and the data use to predict the prognosis and progression of ILDs. It is then essential to highlight the data that holds the most information related to risk factors for progression, e.g., CT scans and pulmonary function tests. This review aims to identify potential gaps, highlight areas that require further research, and identify the methods that could be combined to yield more promising results in future studies.

Long-Term Outcomes of Drug-Eluting Stent Implantation for Patients With Atherosclerotic Erectile Dysfunction not Responding to PDE-5-Inhibitors

PURPOSE

Endovascular therapy of erection-related arteries was shown to be a promising treatment option for patients with severe erectile dysfunction. Purpose of this study was to assess the longer-term safety and clinical success rate of endovascular revascularization of erection-related arteries with the Angiolite BTK stent in patients with arteriogenic erectile dysfunction.

MATERIALS AND METHODS

A total of 147 consecutive men (63.5±9.3 years) with erectile dysfunction due to 345 atherosclerotic lesions underwent endovascular revascularization. Patients received an International Index of Erectile Function (IIEF)-15 questionnaire at 30.3±7.2 months (follow-up [FU] period no less than 18 months) after stenting. An improvement by 4 points in the erectile function domain consisting of 6 questions (IIEF-6) was defined as minimal clinically important difference (MCID).

RESULTS

Technical success was achieved in 99% of lesions. One major adverse event occurred after endovascular revascularization. Sixty-eight (46%) patients completed their latest FU at least 18 months following the last intervention. Minimal clinically important difference was achieved in 54% (37/68) of patients.

CONCLUSIONS

In patients with arteriogenic erectile dysfunction not responding to phosphodiesterase-5-inhibitors (PDE-5-Is), endovascular therapy with a novel thin-strut sirolimus-eluting stent is a safe and effective treatment option during short- and longer-term FU.

CLINICAL IMPACT

Patients with severe erectile dysfunction profit greatly from endovascular therapy of erection-related arteries. Stable clinical outcomes are seen beyond a 1-year timeframe. It is proven that, the drug-eluting stent therapy for atherosclerotic ED in patients who have not responded to PDE-5-I therapy is safe and effective during longer-term follow-up.

Role of Lp(a) in patients with erectile dysfunction undergoing angioplasty for symptomatic pelvic artery disease

Background: Atherosclerotic disease of erection-related arteries is a major reason for erectile dysfunction (ED). Lp(a) has been implied in the pathophysiology of atherosclerosis in the coronary and lower limb arteries. Here, we investigated if Lp(a) plays a specific role in ED due with symptomatic pelvic artery atherosclerosis. Patients and methods: Out of 276 consecutive patients treated for ED with angioplasties on proximal (69%) and distal (31%, distal to Alcock channel) erection-related arteries, 236 patients (age: 62±10 years) of which Lp(a) values were available were retrospectively analyzed. Results: The baseline International Index of Erectile Function-15 (IIEF-15) score was 29±15 and significantly increased to 43±20 (increase: 14±21) after treatment at average follow up of 286±201 days. In 25%, Lp(a) values were elevated to more than 30 mg/dL. Hypercholesterolemia, coronary, lower extremity peripheral, and polyvascular disease were more common in patients with Lp(a) ≥60 mg/dl. Anatomic arterial lesion distribution (proximal/distal), improvement in IIEF-15 and clinically driven re-intervention rate (overall 7%) did not differ between patients with <30, 30-59, and ≥60 mg/dL Lp(a). Conclusions: While angioplasty is an effective therapy for ED of arterial origin in patients with obstruction of erection-related arteries, Lp(a) does not seem to play a major role for clinical outcomes in these patients.

Venous Leak Embolization in Patients with Venogenic Erectile Dysfunction via Deep Dorsal Penile Vein Access: Safety and Early Efficacy

PURPOSE

This all-comers registry aimed to assess safety and early efficacy of venous embolization in patients with venogenic erectile dysfunction due to venous leak in an unselected cohort.

METHODS

Between October 2019 and September 2022, patients with venogenic erectile dysfunction resistant to phosphodiesterase-5-inhibitors were treated with venous embolization using ultrasound-guided anterograde access via a deep dorsal penile vein in a single center. A mix of ethiodized oil and modified cyanoacrylate-based glue n-butyl 2 cyanoacrylate (NBCA) monomer plus methacryloxy-sulpholane monomer (Glubran-2, GEM, Italy) was used as liquid embolic agent. Prior to embolization, venous leak had been verified based on penile duplex sonography and computed tomography cavernosography. Procedural success was defined as technically successful and complete target vein embolization. The primary safety outcome measure was any major adverse event 6 weeks after the procedure. The primary feasibility outcome measure was IIEF-15 (International Index of Erectile Function-15) score improvement ≥ 4 points in ≥ 50% of subjects on 6 weeks follow-up post intervention.

RESULTS

Fifty consecutive patients (mean age 61.8 ± 10.0 years) with severe erectile dysfunction due to venous leak underwent venous embolization. Procedural success was achieved in 49/50 (98%) of patients with no major adverse events on follow-up. The primary feasibility outcome measure at 6 weeks was reached by 34/50 (68%) of patients.

CONCLUSION

Venous leak embolization via deep dorsal penile vein access using a liquid embolic agent was safe for all and efficacious in the majority of patients with severe venogenic erectile dysfunction on 6 weeks follow-up.

Venogenic erectile dysfunction: diagnosis on computed tomography cavernosography and endovascular treatment using an anterograde access via deep dorsal penile vein

BACKGROUND

The underlying etiologies of erectile dysfunction may be manifold. Among them, vasculogenic etiologies are of increasing relevance and are not strictly limited to the elderly population. According to recent study, venogenic erectile dysfunction appears to be even more relevant than arteriogenic erectile dysfunction. Venogenic erectile dysfunction due to venous leakage causes insufficient penile blood retention. Proper diagnosis of venous leakage should include both color Doppler flow analysis and computed tomography cavernosography for adequate patient selection and treatment planning. Besides surgical ligation of penile draining veins, endovascular treatment methods may demonstrate more promising results. Especially endovascular embolization of venous leakage using an anterograde access via deep dorsal penile veins appears to be more beneficial for patients' clinical outcome and awareness of this technique should be raised among endovascular interventionalists.

CASE PRESENTATION

A 47-year-old man was diagnosed with venogenic erectile dysfunction due to venous leakage on color Doppler flow analysis and computed tomography cavernosography. He did not respond to PDE-5-inhibitors. This patient demonstrated major venous leakage of paired deep dorsal penile veins via periprostatic veins and internal pudendal veins draining into both iliohypogastric veins. This patient's venous leak was treated with endovascular embolization using an anterograde access via deep dorsal penile veins.

CONCLUSION

This patient's erectile dysfunction due to venous leakage, based on findings in color Doppler flow analysis and computed tomography cavernosography, was embolized using an anterograde access via deep dorsal penile veins as a minimally-invasive endovascular treatment option.

Percutaneous Treatment of Venous Erectile Dysfunction

Erectile dysfunction is a defined as recurring inability to achieve and maintain satisfactory erection for sexual intercourse associated with relevant life impairment. The underlying etiologies may be manifold and complex. Currently, vascular etiologies are highly prevalent especially amongst elderly men. Of special interest, especially venogenic causes are of increasing relevance. Therapeutic options comprise risk factor modification, pharmacotherapy, surgical treatment, and endovascular treatment. Especially endovascular treatment options have recently increased in popularity including transcatheter embolization procedures for veno-occlusive dysfunction.

In Vivo; In Vitro Interaction of Silver Nanoparticles with Leucine Aminopeptidase from Human and Plasmodium falciparum

There is increasing requirement for the development of new drug protocols against malaria, a fatal disease caused by the lethal parasite Plasmodium falciparum. Leucine aminopeptidase (Pf LAP) of Plasmodium falciparum, is being pursued as a promising target for the discovery of novel antimalarials. The effects of silver nanoparticles (AgNPs) against P. falciparum leucine amino-peptidase (Pf LAP) and the human homolog (HsLAP) were compared. Pf LAP and HsLAP were expressed in Escherichia coli, and AgNPs (3-10 nm) characterized by ultra-violet spectroscopy and transmission electron microscopy. Pf LAP indicated a Km of 694 μM towards leucine-p-nitroanilide and a Vmax of 57.9 μmol.ml-1 · min-1 while HsLAP had a Km of 1.6 mM and Vmax of 119.6 μmol · ml-1 · min-1. On interaction with AgNPs (670 nM) Pf LAP was selectively inhibited (57.1%; Ki = 610 nM) relative to HsLAP (10.8%; Ki = 5.22 μM). Structural differences between the enzyme variants, particularly the orientation and distance of surface Met349 in Pf LAP and Met306 in HsLAP to the zinc binding sites were significant and may allow for selective targeting of Pf LAP by AgNPs. The viability of P. falciparum parasites was decreased when exposed to silver nanoparticles, with an IC50 value of 6.96 μM, compared to an IC50 value of 647.7 μM for human HeLa cells.

Differential inhibition of adenylylated and deadenylylated forms of M. tuberculosis glutamine synthetase as a drug discovery platform

Glutamine synthetase is a ubiquitous central enzyme in nitrogen metabolism that is controlled by up to four regulatory mechanisms, including adenylylation of some or all of the twelve subunits by adenylyl transferase. It is considered a potential therapeutic target for the treatment of tuberculosis, being essential for the growth of Mycobacterium tuberculosis, and is found extracellularly only in the pathogenic Mycobacterium strains. Human glutamine synthetase is not regulated by the adenylylation mechanism, so the adenylylated form of bacterial glutamine synthetase is of particular interest. Previously published reports show that, when M. tuberculosis glutamine synthetase is expressed in Escherichia coli, the E. coli adenylyl transferase does not optimally adenylylate the M. tuberculosis glutamine synthetase. Here, we demonstrate the production of soluble adenylylated M. tuberulosis glutamine synthetase in E. coli by the co-expression of M. tuberculosis glutamine synthetase and M. tuberculosis adenylyl transferase. The differential inhibition of adenylylated M. tuberulosis glutamine synthetase and deadenylylated M. tuberulosis glutamine synthetase by ATP based scaffold inhibitors are reported. Compounds selected on the basis of their enzyme inhibition were also shown to inhibit M. tuberculosis in the BACTEC 460TB™ assay as well as the intracellular inhibition of M. tuberculosis in a mouse bone-marrow derived macrophage assay.

Superselective transcatheter arterial embolization in patients with acute peripancreatic bleeding complications: review of 44 cases

PURPOSE

To evaluate the efficacy of superselective transcatheter arterial embolization (TAE) in the treatment of acute peripancreatic bleeding complications.

METHODS

During a 9-year period, 44 patients with acute bleeding of the peripancreatic arteries underwent TAE in our institution. Thirty-eight patients were treated using microcatheters and 6 patients with a diagnostic catheter. Embolic agents included coils (n = 38), polyvinyl alcohol (PVA) particles (n = 2), isobutyl cyanoacrylate (n = 2), coils plus PVA particles (n = 1), and coils plus isobutyl cyanoacrylate (n = 1). Outcome measures included technical success, clinical success, and the rate of complications.

RESULTS

Identified bleeding sources included gastroduodenal artery (n = 14), splenic artery (n = 9), pancreaticoduodenal artery (n = 6), common hepatic artery (n = 5), superior mesenteric artery branches (n = 4), proper hepatic artery (n = 3), and dorsal/transverse pancreatic artery (n = 3). Technical success with effective control of active bleeding was achieved in 41/44 patients (93 %). Clinical success attributed to TAE alone was documented in 40/44 patients (91 %). The rate of major complications was 2 % including death in one patient.

CONCLUSIONS

Superselective TAE allows effective, minimally invasive control of acute peripancreatic bleeding complications with a low rate of therapeutically relevant complications.

Thermally stable and efficient polymer solar cells based on a novel donor-acceptor copolymer

We report high photovoltaic performance of a novel donor-acceptor (D-A) conjugated polymer poly[2,6[4,8-bis(2-ethyl-hexyl)benzo[1,2-b;4,5-b']dithiophene-co-2,5-thiophene-co-4,7[5,6-bis-octyloxy-benzo[1,2,5]thiadiazole]-co-2,5-thiophene] (PBDTTBTZT) in bulk heterojunctions with [6,6]-phenyl-C71-butyric acid methyl ester (PC70BM). A power conversion efficiency (PCE) of more than 7% is obtained for optimized charge-extracting electrodes. Upon application of thermal stress via annealing, a superior thermal stability is demonstrated as compared to poly[N-9″-hepta-decanyl-2,7-carbazole-alt-5,5-(4',7'-di-2-thienyl-2',1',3'-benzothiadiazole)] (PCDTBT).

Virtuelle Endoskopie der oberen, zentralen und peripheren Atemwege mit Mehrzeilen-Spiral-CT

Virtual endoscopy of the upper, central and peripheral airways (virtual laryngoscopy or virtual bronchoscopy) produces endoluminal images similar to those of fiberoptic endoscopy. In particular, virtual endoscopy is useful for the assessment of endoluminal tumor extent and tracheobronchial stenosis. Especially since the introduction of multirow detector CT, high-resolution virtual-endoscopic images of the airways can be reconstructed. Either surface rendering or volume rendering can be used for realistic depiction of the airways. Semitransparent color-coded volume rendering is advantageous, because adjacent structures can be displayed in addition to endoluminal views. A major advantage of virtual endoscopy over fiberoptic endoscopy is its non-invasiveness. With virtual endoscopy, even a high-grade stenosis is passable, enabling evaluation of the distal airways. Disadvantages are its inability to depict mucosal color and to perform therapeutic maneuvers. In comparison to other CT display modes, virtual endoscopy allows a more realistic assessment of tracheobronchial stenosis than axial CT slices and multiplanar reformats. Virtual endoscopy of the airways can be used complementary to fiberoptic endoscopy before tracheotomy, stent implantation or lung resection and for post-operative follow-up. In the future, virtual airway endoscopy will be increasingly applied for interactive virtual reality guidance of airway procedures such as bronchoscopy and surgery.

Chlorine-free processed high performance organic solar cells

In this work, we demonstrate the successful replacement of a chlorinated solvent system based on a 1 : 1 mixture of chlorobenzene and ortho-dichlorobenzene with the chlorine-free solvent xylene, resulting in chlorine-free processing with a small amount of diiodooctane additive. In fact, the overall power conversion efficiency is improved from 6.71% for the chlorinated solvents to 7.15% for the chlorine-free solvent m-xylene.

In vitro and in vivo imaging characteristics assessment of polymeric coils compared with standard platinum coils for the treatment of intracranial aneurysms

BACKGROUND AND PURPOSE

Conventional platinum coils cause imaging artifacts that reduce imaging quality and therefore impair imaging interpretation on intraprocedural or noninvasive follow-up imaging. The purpose of this study was to evaluate imaging characteristics and artifact production of polymeric coils compared with standard platinum coils in vitro and in vivo.

MATERIALS AND METHODS

Polymeric coils and standard platinum coils were evaluated in vitro with the use of 2 identical silicon aneurysm models coiled with a packing attenuation of 20% each. DSA, flat panel CT, CT, and MR imaging were performed. In vivo evaluation of imaging characteristics of polymeric coils was performed in experimentally created rabbit carotid bifurcation aneurysms. DSA, CT/CTA, and MR imaging were performed after endovascular treatment of the aneurysms. Images were evaluated regarding visibility of individual coils, coil mass, artifact production, and visibility of residual flow within the aneurysm.

RESULTS

Overall, in vitro and in vivo imaging showed relevantly reduced artifact production of polymeric coils in all imaging modalities compared with standard platinum coils. Image quality of CT and MR imaging was improved with the use of polymeric coils, which permitted enhanced depiction of individual coil loops and residual aneurysm lumen as well as the peri-aneurysmal area. Remarkably, CT images demonstrated considerably improved image quality with only minor artifacts compared with standard coils. On DSA, polymeric coils showed transparency and allowed visualization of superimposed vessel structures.

CONCLUSIONS

This initial experimental study showed improved imaging quality with the use of polymeric coils compared with standard platinum coils in all imaging modalities. This might be advantageous for improved intraprocedural imaging for the detection of complications and posttreatment noninvasive follow-up imaging.

Diagnosis and therapy of acute hemorrhage in patients with pelvic fractures

Within the past 15 years, significant advances in the imaging of multiorgan and complex trauma primarily due to the improvement of cross-sectional imaging have resulted in the optimization of the expedient diagnosis and management of the polytrauma patient. At the forefront, multidetector computed tomography (MDCT) has become the cornerstone of modern emergency departments and trauma centers. In many institutions, MDCT is the de facto diagnostic tool upon trauma activation. In the setting of pelvic imaging, MDCT (with its high spatial resolution and sensitivity as well as short acquisition times) allows for rapid identification and assessment of pelvic hemorrhage leading to faster triage and definitive management. In trauma centers throughout the world, angiography and minimally invasive catheter-based embolization techniques performed by interventional radiologists have become the standard of care for patients with acute pelvic trauma and related multiorgan hemorrhage. In an interdisciplinary setting, embolization may be performed either alone or as an adjunct procedure with open or closed reduction and stabilization techniques. A team-based approach involving multiple disciplines (e.g., radiology, traumatology, orthopedic surgery, intensive care medicine) is crucial to monitor and treat the actively bleeding patient appropriately.

Comparison of arterial and venous coronary artery bypass flow measurements using 3-T magnetic resonance phase contrast imaging

OBJECTIVE

Comparison of arterial and venous coronary artery bypass flow measurements using 3-T magnetic resonance (MR) phase contrast in correlation with intraoperative Doppler flow measurements.

METHODS

Fifty-six coronary bypasses (right coronary artery n=18, left internal mammary artery to left anterior descending artery n=16, marginal artery n=7, circumflex artery n=7, diagonal artery n=6, left anterior descending artery n=1, and right internal mammary artery to right coronary artery n=1) were studied in 27 asymptomatic patients. In this prospective study, each bypass was studied intra-operatively using Doppler flow measurement. Within one week post surgery, patients were studied using a 3-T MR scanner (Magnetom Verio, Siemens, Erlangen, Germany) using velocity encoded phase-contrast flow measurements.

RESULTS

Intraoperative Doppler flow measurements demonstrated regular flow patterns in all vascular territories supplied. All bypasses were patent on MRI and flow measurement results were as follows: median flow 60ml/min (interquartile range (IQR): 37.5-78.5ml/min). For comparison, the corresponding median intraoperative flow was 58ml/min (IQR: 41-80ml/min) (p<0.001; R=0.44). Linear regression analysis demonstrated a significant correlation for venous bypasses (p=0.0002; R=0.48), but not for arterial bypasses (p=0.09; R=0.24).

CONCLUSION

This study demonstrated that MR flow measurements of venous bypass grafts agreed more with Doppler than arterial bypass grafts. However, bypass patency was confirmed for all patients. In the future, this technique may be used for non invasive coronary bypass graft follow-up.

Preoperative mapping of arterial spinal supply using 3.0-T MR angiography with an intravasal contrast medium and high-spatial-resolution steady-state

INTRODUCTION

Preoperative mapping of the arterial spinal supply prior to thoracoabdominal aortic aneurysm repair is highly relevant because of high risk for postoperative ischemic spinal cord injuries such as paraparesis or paraplegia.

METHODS

Twenty-four consecutive patients prior to surgical thoracoabdominal aortic aneurysm repair were investigated. All patients underwent steady-state MR angiography (MRA) of the spinal vasculature with 3-T MRI. The sequence used was a steady-state coronary 3D FLASH with 0.7-mm isotropic voxels. MRA was performed using an intravasal contrast agent. Studies were evaluated by three readers including delineation of arterial spinal supply including both aortic origin and spinal canal entry by three readers.

RESULTS

Identification and localization of the Adamkiewicz artery and its spinal canal entry was successful in all patients. Overall depiction of the vascular anatomy was graded as very good in 3 (12.5%), good in 14 (58.4%), sufficient in 5 (20.8%), and poor in 2 (8.3%) patients. Depiction of segmental artery aortic exit level was graded as good in 6 (25.0%), sufficient in 10 (41.7%), poor in 4 (16.7%) and not identifiable in 4 (16.7%) patients. Delineation of segmental artery entry level into the spinal canal was graded as very good in 4 (16.7%), good in 11 (45.8%), sufficient in 6 (25.0%), and poor in 3 (12.5%) patients.

CONCLUSIONS

The use of 3-T MRA with an intravascular contrast agent and steady-state enables AKA localization including its segmental arteries with regard to the level of aortic origin and spinal canal entry in most patients.

Bronchial artery embolization in patients with hemoptysis including follow-up

BACKGROUND; Hemoptysis can be an acute medical emergency, which can be localized angiographically and controlled by therapeutic intervention.

PURPOSE

To evaluate the effectiveness and safety of bronchial artery embolization, and including follow-up in patients with hemoptysis.

MATERIAL AND METHODS

Thirty-five vascular interventions were performed in 28 patients (nine women and 19 men, mean age 42 years, age range 20-82 years) treated for hemoptysis between January 1998 and October 2008. Underlying diseases were cystic fibrosis (n = 9), lung cancer (n = 6), chronic inflammatory disease (n = 4), bronchiectasis (n = 3), chronic obstructive pulmonary disease (n = 2), and other (n = 4). Bronchial artery embolization was performed using particles. Patients were followed up for a median of 23 months (range 1 month to 8 years).

RESULTS

Bronchial artery embolization was technically successful in all patients (bleeding halted within 24 hours). Recurrent bleeding occurred in four patients with cystic fibrosis (14%) at one, 16, 19 and 48 months, respectively. Within this subset, multirecurrence bleeding occurred in one patient with cystic fibrosis. Cumulative patient survival rate was 74% at eight years. No patient died due to hemoptysis but due to underlying disease.

CONCLUSION

Bronchial artery embolization was highly effective in patients with hemoptysis. It may help to avoid surgery in patients who are poor candidates for surgery. Should hemoptysis recur in these patients, repeated embolization can be performed.

Pacemakers and magnetic resonance imaging: Current status and survey in Switzerland

Electromagnetic fields arising from magnetic resonance imaging (MRI) can cause various clinically relevant functional disturbances in patients with cardiac pacemakers. Consequently, an implanted pacemaker is generally considered a contraindication for an MRI scan. With approximately 60 million MRI scans performed worldwide per year, MRI may be indicated for an estimated majority of pacemaker patients during the lifetime of their pacemakers. The availability of MR conditional pacemakers with CE labelling is of particular advantage since they allow the safe use of pacemakers in MRI. In this article the current state of knowledge on pacemakers and MR imaging is discussed. We present the results of a survey conducted among Swiss radiologists to assess current practice in patients with pacemakers.

Superior vena cava syndrome in thoracic malignancies

The superior vena cava syndrome (SVCS) comprises various symptoms due to occlusion of the SVC, which can be easily obstructed by pathological conditions (eg, lung cancer, due to the low internal venous pressure within rigid structures of the thorax [trachea, right bronchus, aorta]). The resulting increased venous pressure in the upper body may cause edema of the head, neck, and upper extremities, often associated with cyanosis, plethora, and distended subcutaneous vessels. Despite the often striking clinical presentation, SVCS itself is usually not a life-threatening condition. Currently, randomized controlled trials on many clinically important aspects of SVCS are lacking. This review gives an interdisciplinary overview of the pathophysiology, etiology, clinical manifestations, diagnosis, and treatment of malignant SVCS.

Endovascular treatment for chronic atherosclerotic occlusive mesenteric disease: is stenting superior to balloon angioplasty?

BACKGROUND

Endovascular treatment is an increasingly used therapeutic option in patients with chronic atherosclerotic occlusive mesenteric disease. Purpose of this study was evaluation of patency and mortality in patients treated with visceral artery percutaneous transluminal angioplasty (PTA) or stenting including follow-up.

PATIENTS AND METHODS

A retrospective review of 17 consecutive patients (4 women, 13 men) with endovascular treatment for symptomatic chronic mesenteric ischemia from 1998 to 2004 was performed. Mean follow-up period was 42 months. Patient demographics, interventional details, primary and/or secondary patency and mortality were recorded. Cumulative mortality and patency rates were determined using Kaplan-Meier life table analysis.

RESULTS

Twenty-six interventions (PTA alone n=13, PTA and stenting n=13) were performed in 17 patients. Interventions were performed in the superior mesenteric artery (n=13) and celiac artery (n=13). The re-intervention rate was 30% (6/26). Re-interventions were performed for the superior mesenteric artery (n=4) and celiac artery (n=2). Cumulative overall 1-year results were primary patency rate 81%, secondary patency rate 94%, and survival rate 82%. Cumulative 10-year results were primary patency rate 73%, secondary patency rate 94%, and survival rate 65%. The 10-year secondary patency rate was 100% in patients post initial stenting and 86% in patients post initial PTA.

CONCLUSIONS

Long-term follow-up post endovascular treatment for chronic mesenteric ischemia demonstrated a considerable overall secondary patency rate of 94%. However, the long-term secondary patency rate was higher in patients post initial stenting compared to PTA alone.

Cost effectiveness of centralised and decentralised storm water treatment

As part of a research & development project commissioned by the Land of North Rhine-Westphalia's Ministry for the Environment and Nature Conservation, Agriculture and Consumer Protection (MUNLV) an examination is being carried out of the general possibilities for centralised and decentralised treatment storm water runoff to be discharged into (canalised) receiving waters and the costs ensuing from this. The examination of the different options is being carried out under real conditions, with the Briller Creek (Wuppertal/Germany) and Müggen Creek (Remscheid/Germany) catchment areas being used as models. The range of investigations deals with a comparison between 'decentralised, semicentralised, centralised' storm water treatment, centralised storm water treatment involving a separate sewer and parameter-specific pollution based storm water runoff control. In the framework of the research project each of the variants is to be elaborated and the costs are to be calculated so as to permit a comparison between the different system designs. In particular, the investigations are to take into account the actual requirements to be met by storm water drainage systems involving separate sewage systems.

A real-time control strategy for separation of highly polluted storm water based on UV-Vis online measurements--from theory to operation

'Classical' real-time control (RTC) strategies in sewer systems are based on water level and flow measurements with the goal of activation of retention volume. The control system rule of 'clean (storm water) runoff into the receiving water - polluted runoff into the treatment plant' has been thwarted by rough operating conditions and lack of measurements. Due to the specific boundary conditions in the city of Wuppertal's separate sewer system (clean stream water is mixed with polluted storm water runoff) a more sophisticated--pollution-based--approach was needed. In addition the requirements to be met by the treatment of storm water runoff have become more stringent in recent years. To separate the highly-polluted storm water runoff during rain events from the cleaner stream flow a pollution-based real-time control (P-RTC) system was developed and installed. This paper describes the measurement and P-RTC equipment, the definition of total suspended solids as the pollution-indicating parameter, the serviceability of the system, and also gives a cost assessment. A sensitivity analysis and pollution load calculations have been carried out in order to improve the P-RTC algorithm. An examination of actual measurements clearly shows the ecological and economic advantages of the P-RTC strategy.

Continuous administration of sorafenib in combination with transarterial chemoembolization in patients with hepatocellular carcinoma: results of a phase I study

BACKGROUND AND AIM

It is unknown whether sorafenib can be combined with transarterial chemoembolization (TACE) in patients with hepatocellular carcinoma. This study assesses the safety and tolerability of a continuous regimen of sorafenib combined with TACE.

METHODS

This was an open-label phase I study testing a continuous administration of sorafenib (dose escalation from 200 mg twice daily [bid] to 400 mg bid) starting 7 days prior to TACE with doxorubicin (50 mg).

RESULTS

Twenty-one patients were screened and 14 received sorafenib combined with TACE. Because there were no dose-limiting toxicities in the first three patients who received sorafenib at a dose of 200 mg bid, subsequent patients received 400 mg bid. Twenty-seven procedures were performed (median, two per patient) and two local therapy-related severe adverse events occurred. The median duration of sorafenib therapy was 246 days (range, 14-547 days). Sorafenib-related adverse events of grade ≥3 were hand-foot skin reaction (n = 3), weight loss (n = 2), diarrhea (n = 1), abdominal pain (n = 1), and thrombocytopenia (n = 3). After treatment with sorafenib and TACE, there was a significant decrease in the concentration of plasma vascular endothelial growth factor (VEGF) from 93 ng/l to 67 ng/l.

CONCLUSIONS

Continuous administration of sorafenib at a dose of 400 mg bid combined with TACE was tolerable. The adverse event profile of this regimen was comparable with that of sorafenib monotherapy with the exception of thrombocytopenia, which may be more frequent. There were no increases in the circulating VEGF levels after TACE with this combined regimen. (Swiss Association for the Study of the Liver study number 25; ClinicalTrials.gov trial identifier, NCT00478374).

Management of blunt injuries to the spleen

Background

Non-operative management (NOM) of blunt splenic injuries is nowadays considered the standard treatment. The present study identified selection criteria for primary operative management (OM) and planned NOM.

Methods

All adult patients with blunt splenic injuries treated at Berne University Hospital, Switzerland, between 2000 and 2008 were reviewed.

Results

There were 206 patients (146 men) with a mean(s.d.) age of 38·2(19·1) years and an Injury Severity Score of 30·9(11·6). The American Association for the Surgery of Trauma classification of the splenic injury was grade 1 in 43 patients (20·9 per cent), grade 2 in 52 (25·2 per cent), grade 3 in 60 (29·1 per cent), grade 4 in 42 (20·4 per cent) and grade 5 in nine (4·4 per cent). Forty-seven patients (22·8 per cent) required immediate surgery. Transfusion of at least 5 units of red cells (odds ratio (OR) 13·72, 95 per cent confidence interval 5·08 to 37·01), Glasgow Coma Scale score below 11 (OR 9·88, 1·77 to 55·16) and age 55 years or more (OR 3·29, 1·07 to 10·08) were associated with primary OM. The rate of primary OM decreased from 33·3 to 11·9 per cent after the introduction of transcatheter arterial embolization in 2005. Overall, 159 patients (77·2 per cent) qualified for NOM, which was successful in 143 (89·9 per cent). The splenic salvage rate was 69·4 per cent. In multivariable analysis age at least 40 years was the only factor independently related to failure of NOM (OR 13·58, 2·76 to 66·71).

Conclusion

NOM of blunt splenic injuries has a low failure rate. Advanced age is independently associated with an increased failure rate.

Computed tomographic coronary angiography in patients with surgically treated type A aortic dissection: preliminary results

Acute type A aortic dissection is a serious emergency with a mortality rate of up to 40% within the first 24 h when left untreated. Surgical therapy needs to be initiated promptly. Due to this urgent situation, preoperative evaluation of the coronary arteries is not routinely performed in these patients. The aim of this study was to evaluate the accuracy of 64-slice computed tomography angiography (CTA) for postoperative coronary artery assessment in these patients. Ten consecutive patients with two or more cardiovascular risk factors were prospectively enrolled. Patients had type A aortic dissection treated surgically with a supracoronary graft of the ascending aorta. Performance of CTA to exclude significant stenosis (>50% lumen narrowing) and/or coronary artery dissection was compared with quantitative coronary angiography. A total of 147 segments were evaluated. Three segments (2%) were excluded from analysis. CTA correctly assessed one of three significant stenoses in three patients and correctly excluded coronary artery disease (CAD) in six of ten patients. One patient was rated false positive. Overall accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of CT for identifying coronary artery disease by segment was 98%, 33%, 99%, 50%, and 99%, respectively (P<0.05). By patient, it was 70%, 33%, 86%, 50%, and 75%, respectively. No coronary artery dissection was found. Noninvasive CTA may be a viable alternative to conventional angiography for postoperative coronary artery evaluation in patients with surgically treated type A aortic dissection and cardiovascular risk factors. An NPV of 99% should allow for reliable exclusion of CAD. Further studies with higher patient numbers are warranted.

Optional vena cava filters: indications, management, and results

BACKGROUND

When anticoagulation is contraindicated or ineffective, optional vena cava filters can be used to prevent pulmonary embolism. These devices can be removed within a defined period of time or can remain in the vena cava permanently.

METHODS

The status of optional vena cava filters was studied by a review of the relevant literature found in a selective Medline search from 2000 to 2008, including a Cochrane review and published guidelines.

RESULTS

Optional vena cava filter can be removed up to 20 weeks or even longer after insertion (depending on the filter model) in a small interventional radiological procedure if therapeutic anticoagulation has been achieved or the patient is no longer at risk for venous thromboembolism. Current studies show comparable results for optional filters and permanent filters, but there have not yet been any prospective studies comparing the two filter types.

CONCLUSIONS

Optional vena cava filters are an important addition to the management of venous thromboembolic disease. As only limited data are available to date, the use of optional filters should be considered on an individual case basis.

Options and limits of quantitative and qualitative online-monitoring of industrial discharges into municipal sewage systems

In some cities, industrial enterprises' discharges into municipal sewage systems have a major impact on the quantity and quality of inflows to the municipal treatment plants. In many cases, industrial discharges stand out on account of the great fluctuations in their volumetric rates of flow, pollution loads and temperatures. As a result, these discharges put a great strain on the sewage system, the treatment plant, and ultimately the receiving waters. The enterprises concerned have to pay the treatment plant operators fees based on the load and/or volume discharged. In most cases, qualitative monitoring operations merely consist of spot checks. This means that continuously surveillance is not possible and infringements of the permissible limit values are only discovered by accident. If impermissible discharges are carried out that may be susceptible to causing a treatment plant failure, the rapid initiation of countermeasures is not possible. Hence, spectrometer probes and mobile flowmeters were used in order to determine volumetric rates of flow, COD concentrations, and ultimately the loads discharged. The possibilities for, and limits to, online monitoring as well as shortcomings of spot-checks are discussed in the course of this paper, which also includes an uncertainty analysis.

Optional vena cava filter with disengaging centering struts: retrieval in an animal model

An optional inferior vena cava (IVC) filter prototype was evaluated for safety and long-term retrievability as an initial feasibility study in an animal model. This filter has four centering struts that have the ability to disengage from the filtering cone portion, allowing the legs to slide out of endothelial growth. Retrieval of six filters in three animals was successful up to 27 weeks. There was no substantial filter tilt, migration, or IVC damage. In conclusion, this filter design may help overcome some of the shortcomings in currently approved optional IVC filters, including long-term retrieval difficulties, tilting, or migration.

Factors favouring palliative treatment multidisciplinary decisions for newly diagnosed visceral and soft tissue sarcomas

AIMS

The multidisciplinary medical decision-making process is a key element of the clinical management of cancers, especially rare cancers such as visceral and soft tissue sarcomas. One of the most important decisions stated is to discriminate patients considered for palliative-intent treatment. The aim of this retrospective study was to establish the rationale parameters that justify this decision for newly diagnosed sarcomas.

PATIENTS AND METHODS

From a retrospective cohort of 341 patients we investigated the parameters justifying a palliative-intent strategy decision in univariate and multivariate analyses, based on the logistic regression model. We also measured the effect of this decision on overall survival using the Cox model.

RESULTS

Seventy-one of 341 patients (20%) were considered for a palliative-intent strategy. In multivariate analysis, five variables justified this decision: contraindication for general anaesthesia (adjusted odds ratio 10.5), head and neck location (odds ratio 3.7), visceral sarcoma (odds ratio 2.8), tumour size over 8 cm (odds ratio 3.5) and presence of metastasis (odds ratio 39.5). In the Cox model we found that two independent factors were associated with poor outcome: grade 3 (hazard ratio 2.7) and palliative-intent strategy (hazard ratio 3.3).

CONCLUSIONS

About 20% of newly diagnosed sarcomas were considered for palliative strategy by multidisciplinary committee. This decision was based on rationale parameters and had an intrinsic prognostic value.

Stent-grafts in the treatment of emergent or urgent carotid artery disease: review of 25 cases

PURPOSE

To report the authors' initial experience with carotid artery stent-grafts in a comparatively large patient series for the treatment of acute bleeding and impending rupture or the prevention of distal embolization.

MATERIALS AND METHODS

This retrospective study was approved by the institutional review boards and performed according to HIPPA standards. Twenty-five patients were treated with 27 carotid artery stent-grafts (Gore Viabahn, n = 10; Bard Fluency, n = 9; polytetrafluoroethylene-covered Palmaz, n = 5; and Wallgraft, n = 3). Thirteen stent-grafts were placed in patients with carotid blow-out syndrome (including three patients with carotid-airway fistula), 12 in patients with either pseudoaneurysm (n = 9) or true aneurysm (n = 3), and two in patients with intractable high-grade bare stent restenosis.

RESULTS

The technical success rate was 100% (27 of 27 cases). No acute procedural transient ischemic attacks or strokes occurred. Procedural dissections occurred in two of the 27 cases (7.4%). Short-term complications occurred in three of the 27 cases (11%) (repeat hemorrhage, n = 2; common carotid artery occlusion, n = 1). The overall patient mortality rate was 36% (nine of 25 patients, all with carotid blow-out syndrome). Six-month follow-up in 15 of the 16 living patients demonstrated widely patent stent-grafts. Two patients with pseudoaneurysm also demonstrated patent stents at 18- and 33-month follow-up.

CONCLUSIONS

Stent-grafts may be useful in the treatment of carotid artery bleeding syndrome, aneurysm, and stenosis, with a high procedural success rate in selected cases. The results of mid-term follow-up are encouraging, but results of long-term follow-up must be evaluated in future studies.