Augustinus Ludwig Jacob

Massive Pulmonary Embolism: Treatment with Thrombus Fragmentation and Local Fibrinolysis with Recombinant Human-Tissue Plasminogen Activator

AbstractPurpose: To report the results of thrombus fragmentation in combination with local fibrinolysis using recombinant human-tissue plasminogen activator (rtPA) in patients with massive pulmonary embolism. Methods: Five patients with massive pulmonary embolism were treated with thrombus fragmentation followed by intrapulmonary injection of rtPA. Clot fragmentation was performed with a guidewire, angiographic catheter, and balloon catheter. Three patients had undergone recent surgery; one of them received a reduced dosage of rtPA. Results: All patients survived and showed clinical improvement with a resultant significant (p < 0.05) decrease in the pulmonary blood pressure (mean systolic pulmonary blood pressure before treatment, 49 mmHg; 4 hr after treatment, 28 mmHg). Angiographic follow-up in three patients revealed a decrease in thrombus material and an increase in pulmonary perfusion. Two patients developed retroperitoneal hematomas requiring transfusion. Conclusion: Clot fragmentation and local fibrinolysis with rtPA was an effective therapy for massive pulmonary embolism. Bleeding at the puncture site was a frequent complication.

A CT Database for Research, Development and Education: Concept and Potential

Both in radiology and in surgery, numerous applications are emerging that enable 3D visualization of data from various imaging modalities. In clinical practice, the patients images are analyzed on work stations in the Radiology Department. For specific preclinical and educational applications, however, data from single patients are insufficient. Instead, similar scans from a number of individuals within a collective must be compiled. The definition of standardized acquisition procedures and archiving formats are prerequisite for subsequent analysis of multiple data sets.Focusing on bone morphology, we describe our concept of a computer database of 3D human bone models obtained from computed tomography (CT) scans. We further discuss and illustrate deployment areas ranging from prosthesis design, over virtual operation simulation up to 3D anatomy atlases. The database of 3D bone models described in this work, created and maintained by the AO Development Institute, may be accessible to research institutes on request.

CT-guided percutaneous embolization of a lumbar artery maintaining a type II endoleak.

Purpose: To demonstrate the possibility of percutaneous embolization of a type II endoleak guided by computed tomographic (CT) fluoroscopy. Case Report: A type II endoleak maintained by a hypertrophic fourth lumbar artery failed to occlude spontaneously 7 months after stent-graft deployment for endovascular repair of an infrarenal abdominal aortic aneurysm. A percutaneous procedure was performed to eliminate the endoleak using needle puncture and embolization under CT fluoroscopic guidance. The sagittal diameter of the aneurysm sac, which had remained constant after initial endovascular exclusion, shrank from 5.2 to 4.8 cm in the 3 months following embolization. Conclusions: Percutaneous embolization of lumbar branches guided by CT fluoroscopy may be an alternative to other therapies for type II endoleaks.

The multifunctional therapy room of the future: image guidance, interdisciplinarity, integration and impact on patient pathways

Abstract. With few exceptions the interventional rooms of the present are either imaging suites or sterile operating rooms. Their users are restricted to either percutaneous procedures or to two-staged image-guided surgery without intra-operative imaging control. Since interventional therapy of the future will be minimally invasive and since minimally invasive therapy is essentially image-guided therapy, a new physical place for these activities has to be devised: the multifunctional therapy room of the future integrates sophisticated imaging and image guidance modalities together with advanced surgical and life-support equipment in a sterile environment [1, 2, 3]. Even given a high degree of integration, this will be a complex and costly piece of medical technology. These two factors – complexity and cost – require interdisciplinary technological and medical collaboration to bring it into existence, distribute its cost and maximize usage and medical benefit. Yet another dimension of multifunctionality will be introduced and a significant impact on the care of vitally threatened patients will be exerted by using this room not only for elective image-guided therapy but also for emergent one-stop diagnosis and treatment. Motivation, technology, implementation strategies and funding of this image-guided, integrated and interdisciplinary therapy room, as well as a comprehensive approach combining emergency care and elective computer-assisted therapy (CAT), are discussed in this paper.

Protrusion of hardware impairs forearm rotation after olecranon fixation. A report of two cases.

Tension-band wire fixation is a common surgical technique that is used in the treatment of olecranon fractures and during osteotomies1-3. A number of problems that are specifically related to the use of Kirschner wires have been identified, including wire migration, skin ulceration, and the need for hardware removal4-6. We found only one published article that described diminished forearm rotation following the use of the tension-band technique7. Fig. 1 A patient with impaired forearm rotation after tension-band wire fixation of an olecranon osteotomy. A: The true lateral radiograph shows no evidence of undue penetration of the Kirschner wires into the soft tissues (arrow). B: Kirschner-wire protrusion (arrow) as seen in the three-dimensional model derived from the computed tomography scan. Impingement of the wires with the soft tissues is highly probable. We observed several instances of limitation of forearm rotation following tension-band wire fixation of the olecranon at our medical center (Division of Trauma Surgery, University Hospital of Zurich). Hence, we evaluated computed tomography scans of these patients and developed a computational simulation model with use of three-dimensional computed tomography reconstruction of the elbow. Unlike other authors who studied cadaver elbows3,6-9, we employed a virtual three-dimensional bone model to demonstrate the anatomy of the proximal aspect of the ulna and to simulate Kirschner-wire placement. One hundred and seventeen consecutive patients (seventy-one men and forty-six women) who had undergone internal fixation of the olecranon between April 2003 and November 2004 were retrospectively analyzed. The average age of the patients was 52.1 years (range, twenty-five to eighty-eight years). Of the 117 patients, forty-one underwent osteotomy of the olecranon for exposure of an intra-articular fracture of the distal aspect of the humerus and seventy-six had fixation of an olecranon fracture. The …

Percutaneous Cervical Vertebroplasty in a MultifunctionalImage-Guided Therapy Suite: Hybrid Lateral Approach to C1 andC4 Under CT and Fluoroscopic Guidance

A 76-year-old patient suffering from two painful osteolytic metastases in C1 and C4 underwent percutaneous vertebroplasty by a hybrid technique in a multi-functional image-guided therapy suite (MIGTS). Two trocars were first placed into the respective bodies of C1 and C4 under fluoroscopic computed tomography guidance using a lateral approach. Thereafter, the patient was transferred on a moving table to the digital subtraction angiography unit in the same room for implant injection. Good pain relief was achieved by this minimally invasive procedure without complications. A hybrid approach for vertebroplasty in a MIGTS appears to be safe and feasible and might be indicated in selected cases for difficult accessible lesions.

Stenting for pulmonary artery stenosis due to a recurrent primary leiomyosarcoma.

Purpose: To report stent implantation for a malignant obstruction within the pulmonary artery (PA) caused by a recurrent leiomyosarcoma in the pulmonary trunk. Case Report: A 62-year-old man with a non-metastatic primary leiomyosarcoma of the right PA underwent pneumectomy of the right lung and postoperative radiotherapy in 1994. Six years later, he presented with symptoms of progressive right ventricular dysfunction. Computed tomography (CT) identified a high-grade stenosis of the left PA due to recurrent tumor within the pulmonary trunk extending into the left PA. Transthoracic ultrasound documented severe pulmonary hypertension with a high pressure gradient across the stenosis. A stent was deployed percutaneously, successfully establishing PA patency. Pressure measurements showed a significantly reduced gradient across the stented area. In follow-up, the patient reported subjective improvement of symptoms; CT scans revealed a fully patent stent. His status remained stable 11 months after stent implantation. Conclusions: PA leiomyosarcoma is a rare and highly malignant tumor. In most cases, surgery can only prolong survival for the short term. Palliative interventional PA stenting performed under local anesthesia can offer improvement in quality of life by reducing excessive pulmonary hypertension.

Medical technology integration: CT, angiography, imaging‐capable OR‐table, navigation and robotics in a multifunctional sterile suite

Technology integration is an enabling technological prerequisite to achieve a major breakthrough in sophisticated intra‐operative imaging, navigation and robotics in minimally invasive and/or emergency diagnosis and therapy. Without a high degree of integration and reliability comparable to that achieved in the aircraft industry image guidance in its different facets will not ultimately succeed. As of today technology integration in the field of image‐guidance is close to nonexistent. Technology integration requires inter‐departmental integration of human and financial resources and of medical processes in a dialectic way. This expanded techno‐socio‐economic integration has profound consequences for the administration and working conditions in hospitals. At the university hospital of Basel, Switzerland, a multimodality multifunction sterile suite was put into operation after a substantial pre‐run. We report the lessons learned during our venture into the world of medical technology integration and describe new possibilities for similar integration projects in the future.

Extensive Iatrogenic Aortic Dissection During Renal Angioplasty: Successful Treatment with a Covered Stent-Graft

An extensive iatrogenic aortic type B dissection during percutaneous transluminal renal angioplasty (PTRA) for bilateral renal artery stenosis was treated with a covered stent placed in the right renal artery. Control angiography confirmed closure of the entry. Postprocedural CT demonstrated a thick intramural hematoma (IMH) up to the left subclavian artery. CT follow-up at 8 months showed an almost complete resorption of the IMH. While medical treatment is the standard therapy for type B dissections, closure of the intimal tear with a covered stent may be an additional option in extensive cases during PTRA.

Delayed union of a sacral fracture: percutaneous navigated autologous cancellous bone grafting and screw fixation.

Delayed or non-union of a sacral fracture is a serious clinical condition that may include chronic pain, sitting discomfort, gait disturbances, neurological problems, and inability to work. It is also a difficult reconstruction problem. Late correction of the deformity is technically more demanding than the primary treatment of acute pelvic injuries. Open reduction, internal fixation (ORIF), excision of scar tissue, and bone grafting often in a multi-step approach are considered to be the treatment of choice in delayed unions of the pelvic ring. This procedure implies the risk of neurological and vascular injuries, infection, repeated failure of union, incomplete correction of the deformity, and incomplete pain relief as the most important complications. We report a new approach for minimally invasive treatment of a delayed union of the sacrum without vertical displacement. A patient who suffered a Malgaigne fracture (Tile C1.3) was initially treated with closed reduction and percutaneous screw fixation (CRPF) of the posterior pelvic ring under CT navigation and plating of the anterior pelvic ring. Three months after surgery he presented with increasing hip pain caused by a delayed union of the sacral fracture. The lesion was successfully treated percutaneously in a single step procedure using CT navigation for drilling of the delayed union, autologous bone grafting, and screw fixation.