B. Bessoud

Nonoperative Management of Traumatic Splenic Injuries: Is There a Role for Proximal Splenic Artery Embolization?

OBJECTIVE The objective of our study was to evaluate our experience with transcatheter proximal (i.e., main) splenic artery embolization (TPSAE) in the nonsurgical management of patients with grade III-V splenic injuries, according to the American Association for the Surgery of Trauma (AAST) guidelines, and patients with splenic injuries associated with CT evidence of active contrast extravasation or blush (or cases meeting both criteria). MATERIALS AND METHODS The records of patients with traumatic splenic injuries admitted during a 52-month period were retrospectively reviewed for patient age and sex, mechanism of injury, injury severity score (ISS), RBC transfusion requirements, AAST splenic injury CT grade, presence of active contrast extravasation or blush on CT examination, and amount of hemoperitoneum on CT examination. Demographics, CT findings, transfusion requirements, and outcome were compared using the Students t test or chi-square test in patients undergoing standard nonoperative management and nonoperative management TPSAE-that is, TPSAE followed by nonoperative management. RESULTS Of the 79 identified patients with splenic trauma, 67 were managed nonoperatively. Thirty-seven patients (28 men, nine women; mean age, 40 years; mean ISS, 28.8) underwent nonoperative management TPSAE and 30 patients (27 men, three women; mean age, 37 years; mean ISS, 25.1) underwent nonoperative management. Age, sex, and ISS were not significantly different between the two groups. TPSAE was always technically feasible. Splenic injuries were significantly more severe in the nonoperative management TPSAE group than in the nonoperative management group with respect to the mean splenic injury AAST CT grade (3.7 vs 2, respectively; p < 0.0001), active contrast extravasation or blush (38% [14/37] vs 3% [1/30], respectively; p = 0.0005), and hemoperitoneum grade (1.6 vs 0.8, respectively; p = 0.0006). Secondary splenectomy rate was lower in the nonoperative management TPSAE group (2.7% [1/37] vs 10% [3/30]). No procedure-related complications were encountered during early and delayed clinical follow-up. CONCLUSION TPSAE is a feasible and safe adjunct to observation in the nonoperative management of severe traumatic splenic injuries. The secondary splenectomy rate using nonoperative management TPSAE (2.7%) is among the lowest reported despite a selection of severe injuries.

Malignant Gastroduodenal Obstruction: Palliation with Self-expanding Metallic Stents

PURPOSE To evaluate the feasibility, efficacy, and tolerance of self-expanding metallic stent insertion under fluoroscopic guidance for palliation of symptoms related to malignant gastroduodenal obstruction. MATERIALS AND METHODS Seventy-two patients (38 men, 34 women) aged 25-98 years (mean, 62 years) with duodenal (n = 43), antropyloric (n = 13), surgical gastrojejunostomy (n = 10), or pyloroduodenal (n = 6) malignant obstruction were referred for insertion of self-expanding metallic stents over a 6-year period. Stent insertion was performed with use of a peroral or transgastric approach when necessary (n = 11). RESULTS Stents were successfully inserted in 70 of the 72 patients (97%) and provided symptom relief in 65 patients (90%). Inserted stents were mainly uncovered vascular (n = 55) or enteral (n = 10) Wallstents. One hundred eight stents were initially inserted: one, two, three, or four stents were indicated in 43, 17, nine, and one patient, respectively. Mean follow-up was 119 days (range, 4-513 days). Mean stent patency was 113 days (range, 4-513 days). Mean survival of patients was 120 days. During follow-up, stent obstruction occurred in seven patients as a result of tumoral overgrowth (n = 5) or ingrowth (n = 2). Complications occurred in 12 of the 72 patients (17%), including stent migration (n = 8), stent fracture (n = 1), duodenal perforation (n = 1), and death related to general anesthesia (n = 1). CONCLUSION Despite a significant complication rate, self-expanding metallic stent insertion under fluoroscopic guidance appears to be a feasible and useful technique in the palliative management of malignant gastroduodenal obstruction.

HIGH-FREQUENCY SONOGRAPHY AND COLOR DOPPLER IN THE MANAGEMENT OF PIGMENTED SKIN LESIONS

We aimed to evaluate high-frequency sonography (HFS) coupled with color Doppler in the management of pigmented skin lesions (PSL). HFS examination was performed in 111 patients with 130 PSL. A color Doppler study was conducted in 107 lesions, to assess intralesional vascularization. Imaging findings were compared with histologic diagnosis. In the case of melanoma, sonographic and histologic maximum thickness measurements were compared. HFS showed 114 of the 130 lesions. Among the detected lesions, HFS alone provided 100% sensitivity and 100% specificity in the distinction of melanoma/nevi from other lesions, and 100% sensitivity and 32% specificity in the distinction of melanomas from nonmelanoma lesions. Sonographic and histologic measurement of melanoma thickness strongly correlated (r > 0.96, p < 0.001). Color Doppler detection of intralesional vessels had a 100% specificity and 34% sensitivity in the distinction of melanomas from other PSL. HFS coupled with color Doppler is a simple, reliable tool for PSL management.

Main splenic artery embolization using coils in blunt splenic injuries: effects on the intrasplenic blood pressure

Main splenic artery embolization is gaining acceptance in the management of severe traumatic splenic injuries [1, 2]. The technique mimics surgical splenic artery ligation, which has been successfully used to control splenic hemorrhage and allows one to preserve the spleen [3]. It is postulated that coil occlusion of the main splenic artery decreases blood flow and splenic blood pressure, thereby facilitating clots to organize and the spleen to heal. However, perfusion of the spleen after main splenic artery embolization is preserved through the rich collateral circulation from the left gastric and gastroepiploic arteries as well as pancreatic and omental branches [4]. Lowering of the intrasplenic arterial pressure during or after splenic artery embolization has not been demonstrated in reported series [1, 2]. We performed invasive intrasplenic arterial pressure monitoring during main splenic artery embolization in two patients in order to demonstrate the effects of this technique on splenic blood pressure. Both patients were men, aged 38 and 32 years, admitted for blunt abdominal trauma caused by a motor vehicle crash and a 5-m fall, respectively. In both patients, CT examination revealed grade IV splenic injuries according to the AAST Organ Injury Scale, associated with active contrast extravasation in one case; there was no associated injury except rib fractures. Patients were hemodynamically stable. After having obtained the patients’ informed consent, we performed main splenic artery embolization. Access was established via the right femoral artery using the Seldinger technique to place a 6-French introducer sheath (Radifocus Introducer II; Terumo Corporation, Tokyo, Japan). After a diagnostic celiac and splenic angiogram was performed (Fig. 1a) with a 5-French catheter (Cobra Glidecath, Terumo Corporation), a 6-French 55-cm-long guiding catheter (H-stick; Cordis Corporation, Miami, FL) was advanced in the splenic artery over a 0.035-in. guidewire. Through the guiding catheter, we placed a 0.014-in. guidewire with a mounted pressure sensor (Pressure Wire 4; RADI Medical Systems, Uppsala, Sweden) superselectively in the intrasplenic arterial branches to measure intrasplenic blood pressure. A co-axial 3-French microcatheter (SP; Terumo Corporation) was advanced into the main splenic artery through the guiding catheter parallel to the pressure wire (Fig. 1b) and Tornado microcoils (Cook; Bjaeverskov, Denmark) were deployed. The endpoint of coil placement was cease of blood flow in the main splenic artery (Fig. 1c). Intrasplenic blood pressure values were measured beEur Radiol (2004) 14:1718–1719 DOI 10.1007/s00330-004-2234-3 L E T T E R T O T H E E D I T O R

Interventional radiology in the management of complications after liver transplantation

The arrival of new surgical transplantation techniques, such as split living donor or auxiliary liver transplantation, have increased the incidence of vascular and biliary complications. The causes, symptoms, and diagnostic modalities of arterial, portal caval, and biliary complications are detailed. Interventional techniques, such as balloon angioplasty and stent placement in the arterial and portal tree, as well as biliary interventional techniques, are discussed.

Le stercolithe est-il un signe fiable d'appendicite ?

Resume Objectif Determiner la frequence de detection des stercolithes sur appendice normal en scanner multibarrette. Materiels et methodes Un radiologue senior, n’ayant pas connaissance de l’histoire chirurgicale du patient, a examine prospectivement les scanners abdomino-pelviens de 85 patients adultes consecutifs non suspects d’appendicite. La plupart des patients ont eu une injection iodee intraveineuse. Mais aucun n’a eu d’opacification digestive. Toutes les coupes (1 et 5 mm) et les reconstructions multiplanaires etaient analysees sur une console de traitement. La position de l’appendice, son diametre externe, la presence ou non de gaz intraluminal et de stercolithe etaient notes. Resultats Parmi les 85 patients, 57 n’avaient pas ete appendicectomises. Un stercolithe etait detecte dans 13 %, l’air intraluminal dans 87 %. La position etait retrocaecale (47 %), mediocaecale (19 %) ou pelvienne (32 %). Le diametre externe moyen etait de 6,7 mm +/- 1,2 (ecart-type). Conclusion Le stercolithe a ete retrouve en tomodensitometrie multibarrette chez un nombre significatif de sujets sans appendicite aigue et ne represente pas un signe specifique d’appendicite.

Quelle est l’épaisseur de l’appendice normal au scanner multibarrette ?

Resume Objectif Determiner les valeurs de l’epaisseur parietale et du diametre externe de l’appendice normal au scanner multibarrette. Materiels et methodes Un radiologue senior, n’ayant pas connaissance de l’histoire chirurgicale du patient, a examine prospectivement les scanners abdomino-pelviens de 57 patients adultes consecutifs non suspects d’appendicite. La plupart des patients (50/57) ont eu une injection iodee intraveineuse. Mais aucun n’a eu d’opacification digestive. Toutes les coupes (1 et 5 mm) et les reconstructions multiplanaires etaient analysees sur une console de traitement. Le diametre externe de l’appendice, l’epaisseur des deux parois appendiculaires, et la presence ou non de gaz intraluminal etaient notes. Resultats L’appendice a ete visualise dans 82 % des cas (47/57). Le diametre externe moyen etait de 6,7 mm ± 1,2 (echelle de 5,0 a 11,0 mm). L’epaisseur moyenne des deux parois etait de 4,8 mm ± 1,0 (echelle de 2,6 a 6,4 mm). L’air intraluminal etait visualise dans 87 % des cas (41/47). Conclusion Contrairement au diametre externe, l’epaisseur biparietale de l’appendice normal en ne depassant quasiment pas le seuil de 6 mm semble une mesure fiable pour identifier un appendice normal au scanner multibarrette.

Enterobiliary fistula after radiofrequency ablation of liver metastases

A 46-year-old man underwent radiofrequency (RF) ablation of three liver metastases 7 months after undergoing right colectomy for a pT2N0Mx colon adenocarcinoma. Three months after the procedure, he developed hepatic abscesses related to a fistula between the distal ileum and segment V biliary branches.

Interventional management of gastroduodenal lesions complicating intra-arterial hepatic chemotherapy

Herein we report the efficacy of embolization of small patent gastric or duodenal vessels for treating gastroduodenal complications after hepatic arterial infusion therapy (HAIC). Catheter ports were implanted percutaneously from a femoral approach in three cases or surgically in the gastroduodenal artery in two cases. Acute abdominal pain developed on average after four HAIC courses of 5FU-oxaliplatin, mytomycin, oxaliplatin or fotemustine. Esophagogastroduodenoscopy showed gastroduodenal lesions (gastroduodenitis with or without ulcerations) in all cases. Despite the interruption of the HAIC, symptoms persisted and led to selective hepatic arteriography showing a patent right gastric artery (n = 4) or a recanalized gastroduodenal artery (n = 1) responsible for gastroduodenal misperfusion. Successful embolizations of the arteries responsible for gastroduodenal misperfusion (right gastric artery in four cases and gastroduodenal artery in one case) using 0.018 platinium coils relieved the patients’ symptoms and allowed the HAIC to continue. In gastroduodenal complications of HAIC, a selective hepatic arteriography should be performed to search any artery responsible for the misperfusion of the toxic agent in the gastroduodenal area. Embolization of these arteries allowed the HAIC to be restored.

Imagerie scanographique des troubles de perfusion hépatique

Resume Des troubles de perfusion hepatique sont frequemment rencontres dans les hepatopathies et/ou associes a des tumeurs hepatiques benignes et malignes. Il s’agit d’anomalies du rehaussement parenchymateux apres injection, dont la cinetique est transitoire et variable dans le temps. Une compression vasculaire, une thrombose ou une fistule peuvent etre a l’origine de ces troubles de perfusion. Ils temoignent de la richesse de l’autoregulation entre les systemes vasculaires. Certaines regles existent : ainsi l’obstruction d’une branche portale est immediatement suivie d’une augmentation du debit arteriel, alors que l’inverse n’est pas vrai. L’obstruction portale se manifeste par un rehaussement parenchymateux precoce, disparaissant a la phase portale. Les fistules arterio-portales sont tres frequentes et peuvent etre confondues avec des tumeurs hypervasculaires. L’obstruction des veines hepatiques entraine une congestion vasculaire a l’origine d’un foie en mosaique. La prevalence des troubles de perfusion hepatique a nettement augmente depuis l’etendue des scanners multidetecteurs qui permet une analyse de la cinetique de rehaussement du parenchyme hepatique. Savoir les reconnaitre est essentiel car ils peuvent d’une part etre a l’origine de faux positifs de tumeurs hypervasculaires, et d’autre part nous orienter vers tel ou tel type d’hepatopathie chronique.