Alessandro Cina

Planning Breast Reconstruction with Deep Inferior Epigastric Artery Perforating Vessels: Multidetector CT Angiography versus Color Doppler US

PURPOSE To evaluate the accuracy of multidetector computed tomographic (CT) angiography versus color Doppler ultrasonography (US) for perforating artery identification, intramuscular course of perforator vessel assessment, and superficial venous communication detection before a deep inferior epigastric perforator (DIEP) procedure for breast reconstruction. MATERIALS AND METHODS Informed consent and institutional review board approval were obtained. Forty-five patients underwent multidetector CT angiography and color Doppler US to identify the DIEP vessel prior to breast reconstruction surgery. Findings at surgery were used as a reference for accuracy evaluations. RESULTS The accuracy for identifying dominant perforator arteries was 97% for color Doppler US and 91% for CT angiography. Perforator arteries suitable for surgery were identified in 90% of cases with color Doppler US and in 95% of cases with CT angiography. For measurement of perforator calibers, surgical findings were similar to color Doppler US measurements (P = .33) but were significantly different than CT measurements (P < .0001). The accuracies for intramuscular course of perforator vessel assessment and superficial venous communication detection were 95% and 97% for CT and 84% and 80% for color Doppler US, respectively. In our population, the absence of superficial venous communication was associated with a risk for flap morbidity (P = .009). CONCLUSION Both color Doppler US and CT angiography resulted in accurate DIEP mapping. Color Doppler US was superior for measuring perforator artery calibers, and CT angiography was superior for estimating the intramuscular course of the perforator vessel and identifying superficial venous communications. Considering x-ray exposure and results of this study, employing multidetector CT angiography is suggested only in selected cases.

Ovarian vein incompetence: a potential cause of chronic pelvic pain in women

OBJECTIVE(S) To evaluate whether ovarian vein incompetence may be a source of chronic pelvic pain (CPP) in women. STUDY DESIGN Twenty-two women, aged 19-50 years, with chronic pelvic pain, no laparoscopically detected pelvic pathology, and evidence of reflux in dilated pelvic veins on transvaginal color Doppler ultrasound underwent retrograde ovarian venography and sclerotherapy of the ovarian vein(s) if incompetent. The primary outcome was symptom change as assessed by a symptom questionnaire and visual analog pain scales (VAS) at 3, 6, and 12 months of follow-up. Changes in pelvic circulations after sclerotherapy procedure were also evaluated by serial ultrasound examinations. Differences between baseline and post-procedural VAS scores were analysed using the Wilcoxon signed-rank test. RESULTS Twenty (91%) of the 22 women had venographic evidence of incompetent ovarian vein(s) and received sclerotherapy. There were no immediate or late complications. Variable symptom relief was observed in 17 (85%) of the 20 treated women, with follow-up at 12 months showing marked-to-complete relief in 15 patients and mild-to-moderate relief in the remaining 2 patients. Three (15%) women had no improvement in symptoms. Median VAS scores at 3 (2.0), 6 (2.5), and 12 months (3.0) were significantly lower than at baseline (8.0) (P<.001). Follow-up ultrasound examinations showed absence of pelvic venous reflux in all but 3 patients, in whom recurrence of reflux was seen at 3 months. CONCLUSION(S) Ovarian vein sclerotherapy provided symptomatic relief and improved pelvic circulation in most patients. These findings suggest that ovarian vein incompetence was the likely source of chronic pain in these women, and that sclerotherapy was a safe and effective treatment for this condition. CONDENSATION Ovarian vein incompetence leading to pelvic circulatory changes may be a cause of chronic pelvic pain in women.

The Retrograde Limb of Internal Mammary Vessels as Reliable Recipient Vessels in DIEP Flap Breast Reconstruction: A Clinical and Radiological Study

AbstractFor many microsurgeons, antegrade internal mammary vessels (AIMVs) represent the recipients of choice in autogenous breast reconstruction. For the past few years, the retrograde internal mammary vessels (RIMVs) have been demonstrated to be a further reliable option when needed, according to many papers focusing more on the vein than on the artery. Besides the clinical evidence, the hemodynamic features of the retrograde system have been very seldom analyzed.In this article, we report our clinical experience with deep inferior epigastric perforator (DIEP) flaps anastomosed to RIMVs, along with a perioperative radiological follow-up to study RIMVs’ hemodynamics and to further support the reliability of the retrograde system with particular focus on the retrograde internal mammary artery.Prospective, preoperative, and postoperative (3 days, 21 days, and 3 months, respectively) color Doppler sonographies of the internal mammary artery (IMA) and DIEPs have been performed to collect the velocity of flow (v) and resistive index (RI) data. Twenty-two patients agreed to undergo this protocol, of which 10 unipedicle flaps were anastomosed to AIMVs (“control” group), 10 bipedicle DIEPs to both AIMVs and RIMVs (“study” group), and 2 DIEPs anastomosed to retrograde internal mammary artery and antegrade internal mammary vein (not statistically analyzed for their paucity). Student t test was performed to compare the “control” and “study” groups.All the flaps survived, and no re-exploration was needed. Internal mammary artery and perforators v showed similar but speculate trend, whereas IMA and perforators RI looked stable during that time. Significant differences have been found in the “study” group for IMA v at 3-day period, for perforator v at 21- and 90-day periods, and for perforator RI at 90-day period, without any clinical implication for flap viability.Retrograde internal mammary vessels can be considered reliable vessels for both arterial flap input and venous flap outflows, either as additional or the sole recipients. However, further and larger studies would be useful to better understand the hemodynamics of the retrograde system.

Doppler sonographic assessment of functional response of the right and left portal venous branches to a meal

The aim of our study was to quantitate by Doppler sonography the blood flow in the right and left portal vein branches before and after a standard meal. We also assessed the functional response of the right and left lobes of the liver.

Proximal Aneurysmal Neck: Dynamic ECG-gated CT Angiography—Conformational Pulsatile Changes with Possible Consequences for Endograft Sizing

PURPOSE To assess the magnitude of variations in size of the proximal neck of the abdominal aortic aneurysm (AAA) in patients selected to undergo endovascular abdominal aortic aneurysm repair (EVAR) and the potential effect on choice of endograft diameter by using 64-section dynamic electrocardiographically (ECG)-gated computed tomographic (CT) angiography. MATERIALS AND METHODS A prospective single-center study was performed in 40 patients with AAA who underwent both static and dynamic ECG-gated CT angiography. The ethical conduct of the study was approved by the departmental review board, and all patients provided written informed consent. Dynamic ECG-gated data sets were acquired with a low-dose acquisition protocol (100 kV) by using a 0.625-mm-section collimation (40 mL iomeprol [400 mg of iodine per milliliter] versus 80 mL). Pulsatility measurements were taken at suprarenal, juxtarenal, and infrarenal levels within the aneurysmal neck. Manual CT angiographic measurements were performed on modified axial images. On static axial images, one vascular surgeon and one interventional radiologist selected the diameter of the main body of the potential infrarenal stent-graft to implant. The diameter of the main body of the stent-graft selected was compared with the dynamic measurements obtained to calculate the potential relative oversizing performed. RESULTS A total of 40 patients were enrolled. Significant aortic pulsatility was demonstrated within the aneurysmal neck (mean variation, 9.01% ± 4.81 [standard deviation]; absolute change, 1.83 mm ± 1.01; P < .05). When compared with dynamic measurements, the diameter of the endograft selected on the basis of static images would be potentially changed in 12 of 40 (30%) patients. Comparing the minimum or maximum diameter of the aneurysmal neck with the diameter of the endograft selected on the basis of static images, the relative oversizing performed was considered inadequate in seven of 40 (18%) patients. CONCLUSION Dynamic ECG-gated CT may provide information in regard to pulsatile motion that could change the diameter of the endograft selected on the basis of static imaging measurements.

Massive facial edema and airway obstruction secondary to acute postoperative sialadenitis or "anesthesia mumps": a case report

IntroductionA case of massive facial edema and airway obstruction secondary to an acute sialadenitis is described that occurred a few hours after a neurosurgical procedure performed in the prone position. Literature on this topic is reviewed.Case presentationA 73-year-old Caucasian woman underwent a right parieto-occipital craniotomy to remove a meningioma. The procedure was performed in the prone position and lasted for 7 hours. One hour after the end of surgery, left submandibular gland swelling was clearly visible and in a few hours, she developed massive facial edema. Imaging (computed tomography and magnetic resonance) showed inflammatory swelling of the submandibular and parotid glands and of the periglandular tissues, undilated excretory ducts, and complete obliteration of the pharynx lumen (pharyngeal mucosa adhered to the endotracheal tube). Analgesics, corticosteroids, and antibiotics were administered. Edema regressed from the 4th postoperative day and the endotracheal tube could be removed on the 7th postoperative day. The patient was discharged from the surgical intensive care unit on the 14th postoperative day and from hospital on the 28th postoperative day.ConclusionThis is the first case report in which acute postoperative sialadenitis caused complete upper airway obstruction: only the presence of a tracheal tube avoided the need for an emergency tracheostomy. Since edema evolves insidiously, we recommend caution when removing the endotracheal tube in patients who are acutely developing postoperative sialadenitis.

Sonographic assessment of abdominal vein dimensional and hemodynamic changes induced in human volunteers by a model of abdominal hypertension.

Objective:In patients affected by intra-abdominal hypertension, bladder or gastric pressure measurement may be usefully integrated by ultrasounds in order to detect early hemodynamic impairment. The purpose of this study was to search for changes in abdominal vein size and flow induced by intra-abdominal hypertension. Design:Physiologic study. Setting:Postoperative intensive care unit of a university hospital. Subjects:Sixteen healthy volunteers. Interventions:Four echographic assessments of vessel sizes and blood velocities were randomly performed in the following settings: 1) baseline, 2) intra-abdominal hypertension simulated by a tight pelvic stabilizer around the waist, 3) noninvasive ventilation with a facial mask, and 4) intra-abdominal hypertension plus noninvasive ventilation. Measurements and Main Results:The model of intra-abdominal hypertension was validated in eight subjects by measuring gastric pressure. During intra-abdominal hypertension, 1) the inferior vena cava was compressed (significant decrease of both anteroposterior and lateral diameters) and deformed (decreased anteroposterior/lateral diameter ratio), and deformation, but not compression, was attenuated by noninvasive ventilation associated with intra-abdominal hypertension; 2) the portal vein was also compressed (decreased diameter); and 3) blood velocities did not change significantly in the inferior vena cava, portal vein, right suprahepatic vein, or right external iliac vein. In the receiver operating characteristic curve analysis, an inferior vena cava section area (normalized for body surface) of lower than 1 cm2/m2 discriminated between intra-abdominal hypertension presence and absence with a sensitivity of 65.6% and a specificity of 87.5% (p = .0001). Noninvasive ventilation alone did not significantly affect vein sizes and velocities. The resistive index, calculated by pulse wave Doppler signal from segmental branches of the right renal artery, increased slightly, but significantly, during intra-abdominal hypertension alone, suggesting an increase of intrarenal pressure. Conclusions:Simulated intra-abdominal hypertension was associated with decreased inferior vena cava section area and increased resistive index in renal arteries. Further studies are now needed to investigate whether these changes may be of value to integrate bladder or gastric pressure measurement in clinical practice.

The effect of liposuction on inferior epigastric perforator vessels. a prospective study with color doppler sonography.

The authors investigated the effect of abdominal liposuction performed by superficial subdermal liposuction technique on inferior epigastric perforators. We aimed to determine whether previous liposuction is a contraindication to the use of an abdominal flap. The perforators in the abdominal region in 6 patients were marked preoperatively by color and pulsed-wave Doppler sonography (CDS), which gave a morphologic and flowmetric representation. The parameters studied with CDS were the location of the perforators, the diameters of the arteries and veins, and the flow velocity. These parameters were evaluated by the same method preoperatively and 6 months postoperatively. The Student t test was employed to assess differences between pre- and postoperative values of variables. The results of our study led us to conclude that prior abdominal liposuction does no significant injury to most perforating vessels. However, CDS aimed to study the existence and the quality of perforators should be done before planning an abdominal flap.

Computed tomography imaging of vena cava filter complications: a pictorial review.

Caval filters are widely used in the prevention of pulmonary embolism. Filters have proved to be effective, but the complication rate is not negligible. Computed tomography (CT) provides a complete evaluation of the filter, including both caval and extracaval complications. In this review, we describe the normal CT aspect of cava filters, the classification of complications and their CT findings. Technical considerations for adequate CT imaging are also highlighted.

Proximal Ureteric Obstruction Caused by Glue Migration following Selective Renal Artery Embolization

weaker antiaggregatory effect of NICAs compared with ionic contrast agents. Possible prothrombogenic mechanisms include platelet degranulation and formation of fibrin fibers, which are resistant to lysis (1). Previous comparisons between various types of NICAs suggested that degree of osmolality may be a determinative factor causing aggregation of platelets. High osmality causes more platelet aggregation, and monomeric nonionic contrast agents cause more platelet activation than dimeric NICAs (4). NICAs are subdivided into low-osmolar agents such as iopromide (monomeric) and iso-osmolar agents such as iodixanol (dimeric). Platelet aggregation and subsequent thrombosis induced by contrast agents are rarely reported in literature. NICAs were blamed in reported cases. When perfoming angiography, checking syringes for potential thrombosis is essential to prevent contrastinduced thrombosis. Heparinization and high active clotting times may not be sufficient to prevent contrastinduced thrombus formation. Use of different NICAs may overcome this problem.