D. Pezet

Contribution du scanner à la prise en charge des tableaux abdominaux aigus non traumatiques : étude de 90 patients

OBJECTIVES To determine the contribution of computerized tomography (CT) to the management of nontraumatic acute abdomen, to evaluate interobserver agreement and the contribution of CT to cost control, to look for the predictive factors of CT. PATIENTS and method. Ninety prospectively included patients, admitted for nontraumatic acute abdomen and examined by a surgeon, received CT examination. Diagnosis and treatment 1) envisioned before and 2) defined after CT, and 3) finally retained were compared, and the interobserver agreement was calculated after the second reading. The predictive value of the clinical and biological criteria as well as the radiological criteria characterizing these patients was sought. RESULTS CT was contributive in 68.9% of cases, with a reliable diagnosis and treatment strategy, defined after CT examination, for 92.2% and 90%, respectively. Interobserver agreement was 93.3%. CT contributed to reducing costs in 15.5% of patients, for an additional cost estimated at 104-139 euros. The positive predictive factors of the CT contribution were age over 70 years, localized symptoms, fever, and high CRP. CONCLUSION In agreement with the literature, in our study CT appears to be a choice examination to guide patient care in nontraumatic acute abdomen.

[Preoperative portal vein embolization with Amplatzer(®) vascular plugs (AVP): a review of 17 cases].

The purpose was to determine the efficacy and technical particularities related to the use of Amplatzer(®) Vascular Plugs (AVP) for preoperative portal vein embolization. Between 2005 and 2009, a total of 48 type I AVP were embolized into the portal venous system of 17 patients (51-83 years) prior to extended hepatic resection where the residual liver volume (RLV) was deemed sufficient (RLV < 35-40% in patients with underlying hepatocellular disease, < 25-30% in patients with normal liver). AVP were used alone in seven patients and combined to other embolization agents in 10 patients (coils: n=5, microparticles: n=1, resorbable gel foam: n=4). The procedure was technically successful in 100% of cases with immediate success rate of 94.1% (imcomplete embolization of a segmental branch of segment VIII). The procedure was well tolerated clinically in 94.1% of cases, and in 100% of cases based on laboratory values. The rate of recanalization on follow-up CT at 5 weeks (2-22) was 11.7%. The rate of complications, major (left portal vein thrombosis following right portal vein embolization) and minor (one case of portovenous fistula), was 11.7%. The rate of RLV growth was from +13 to +285 cm(3) (mean at +122 cm(3)), or +4.98 to +78.51% (mean at +33.3%) (hepatocellular carcinoma: mean of +30.7%, metastases: mean of +19.7%). The rate of surgical candicacy was 94.1% (two patients were excluded: insufficient growth of RLV, development of peritoneal carcinomatosis). AVP appear to be reliable and effective for the preoperative embolization of the portal vein, with low morbidity and sufficient growth of RLV.

Embolisation portale préopératoire par Amplatzer® Vascular Plugs (AVP) : 17 patients

The purpose was to determine the efficacy and technical particularities related to the use of Amplatzer(®) Vascular Plugs (AVP) for preoperative portal vein embolization. Between 2005 and 2009, a total of 48 type I AVP were embolized into the portal venous system of 17 patients (51-83 years) prior to extended hepatic resection where the residual liver volume (RLV) was deemed sufficient (RLV < 35-40% in patients with underlying hepatocellular disease, < 25-30% in patients with normal liver). AVP were used alone in seven patients and combined to other embolization agents in 10 patients (coils: n=5, microparticles: n=1, resorbable gel foam: n=4). The procedure was technically successful in 100% of cases with immediate success rate of 94.1% (imcomplete embolization of a segmental branch of segment VIII). The procedure was well tolerated clinically in 94.1% of cases, and in 100% of cases based on laboratory values. The rate of recanalization on follow-up CT at 5 weeks (2-22) was 11.7%. The rate of complications, major (left portal vein thrombosis following right portal vein embolization) and minor (one case of portovenous fistula), was 11.7%. The rate of RLV growth was from +13 to +285 cm(3) (mean at +122 cm(3)), or +4.98 to +78.51% (mean at +33.3%) (hepatocellular carcinoma: mean of +30.7%, metastases: mean of +19.7%). The rate of surgical candicacy was 94.1% (two patients were excluded: insufficient growth of RLV, development of peritoneal carcinomatosis). AVP appear to be reliable and effective for the preoperative embolization of the portal vein, with low morbidity and sufficient growth of RLV.

Article originalCardiovasculaireEmbolisation portale préopératoire par Amplatzer® Vascular Plugs (AVP) : 17 patientsPreoperative portal vein embolization with Amplatzer® vascular plugs (AVP): A review of 17 cases

The purpose was to determine the efficacy and technical particularities related to the use of Amplatzer(®) Vascular Plugs (AVP) for preoperative portal vein embolization. Between 2005 and 2009, a total of 48 type I AVP were embolized into the portal venous system of 17 patients (51-83 years) prior to extended hepatic resection where the residual liver volume (RLV) was deemed sufficient (RLV < 35-40% in patients with underlying hepatocellular disease, < 25-30% in patients with normal liver). AVP were used alone in seven patients and combined to other embolization agents in 10 patients (coils: n=5, microparticles: n=1, resorbable gel foam: n=4). The procedure was technically successful in 100% of cases with immediate success rate of 94.1% (imcomplete embolization of a segmental branch of segment VIII). The procedure was well tolerated clinically in 94.1% of cases, and in 100% of cases based on laboratory values. The rate of recanalization on follow-up CT at 5 weeks (2-22) was 11.7%. The rate of complications, major (left portal vein thrombosis following right portal vein embolization) and minor (one case of portovenous fistula), was 11.7%. The rate of RLV growth was from +13 to +285 cm(3) (mean at +122 cm(3)), or +4.98 to +78.51% (mean at +33.3%) (hepatocellular carcinoma: mean of +30.7%, metastases: mean of +19.7%). The rate of surgical candicacy was 94.1% (two patients were excluded: insufficient growth of RLV, development of peritoneal carcinomatosis). AVP appear to be reliable and effective for the preoperative embolization of the portal vein, with low morbidity and sufficient growth of RLV.

Place du traitement endovasculaire des sténoses symptomatiques d'artères digestives chez les sujets infectés par le VIH : trois cas

Patients with HIV or AIDS frequently present with GI symptoms, sometimes due to early and diffuse atherosclerosis. We report 3 cases of HIV patients with abdominal pain due to severe splanchnic arterial stenosis. Only one patient presented typical clinical findings of mesenteric ischemic. Endovascular treatment was performed in all three cases. Good clinical outcome was immediate in 2 cases. In the third case, subsequent bowel resection was required due to irreversible ischemic injury in spite of local thrombolysis and endovascular revascularization in a patient presenting with acute severe mesenteric ischemia. In all three cases, vascular patency was demonstrated at follow-up. Mesenteric ischemia is a severe complication requiring early diagnosis in HIV patients, especially those with vascular risk factors, especially since endovascular treatment is a valid therapeutic option.

Le radiologue et les complications vasculaires de la transplantation hepatique

Objectifs pedagogiques Connaitre les points cles du bilan vasculaire pre-greffe. Connaitre les modalites du diagnostic a la periode utile des complications arterielles, portes et cavo-sus-hepatiques chez le transplante. Discuter la place de l’angiographie therapeutique dans la prise en charge de ces complications. Messages a retenir La qualite du bilan pre-greffe conditionne la realisation technique et le succes de la transplantation ; elle eclaire aussi la detection des complications vasculaires. Le suivi post-operatoire precoce repose sur un echo-Doppler quotidien, eventuellement complete d’une angio-TDM hepatique. Les complications vasculaires doivent etre rapidement traitees. La concertation multi-disciplinaire permet de poser les indications therapeutiques, les gestes endovasculaires constituant souvent les techniques de premiere intention.

DIG16 Diagnostic et prise en charge radiologiques des complications vasculaires de la transplantation hepatique : revue illustree

Objectifs Preciser et illustrer la place des techniques d’angiographie therapeutique dans la prise en charge des complications vasculaires de la transplantation hepatique. Materiels et methodes Revue retrospective des complications prise en charge dans notre centre depuis 10 ans (15 cas). Resultats La connaissance du bilan morphologique pre-transplantation (cartographies arterielle hepatique, veineuse systemique, permeabilite du systeme porte, importance des anastomoses porto-systemiques) est indispensable pour le diagnostic des complications. La qualite du suivi post-operatoire immediat conditionne la precocite du diagnostic et le pronostic. A partir de nos observations radio-cliniques, les techniques endovasculaires pour traiter stenoses et occlusions arterielles, faux anevrismes, stenoses et occlusions portes, et occlusions des anastomoses caves superieure et inferieure, ainsi que les embolisations pour hemodetournement seront presentees. Conclusion La transplantation hepatique peut etre compromise par des complications vasculaires dont le pronostic est largement conditionne par la precocite du diagnostic. La realisation d’echo-Doppler systematiques doit amener au moindre doute a l’angio-scanner, l’evolution des techniques de catheterisme interventionnel permettant d’envisager la prise en charge endovasculaire percutanee de la majorite des complications arterielles et veineuses, portes ou cavo sus hepatiques.

Embolisation arterielle des lesions spleniques traumatiques : 20 patients

Objectifs Evaluer nos resultats techniques immediates et morphocliniques a distance. Materiels et methodes Etude retrospective monocentrique incluant 20 patients (01/2000-10/2005) âge moyen : 48,6 ans (20-103) embolises pour lesions spleniques traumatiques (15 AVP, 9 chutes), qui etaient hemodynamiquement stables ou repondaient au remplissage a l’admission. L’indication etait portee apres classification selon l’American Association of Trauma (7 grade IV, 10 grade III, 2 grade II), ou l’existence d’une extravasation de contraste en TDM (17). Le bilan initial recensait 4 traumatismes crâniens, un traumatisme renal, un pneumothorax, deux fractures complexes du bassin. Resultats Tous les patients ont ete traits : 16 par microparticules, 3 par coils proximaux pour lesions multiples, un par coils pour FAV. Aucune splenectomie n’etait necessaire. Quatre deces survenaient dans les 30 jours, lies a l’evolution pejorative des lesions associees. A 18 mois (1-48), aucun patient ne presentait d’asplenie fonctionnelle ; les controles morphologiques n’objectivaient que 2 hypotrophies et une collection liquidienne sterile non compliquee. Conclusion L’embolisation splenique pour lesions traumatiques chez des patients hemodynamiquement stables ou repondant au remplissage est fiable, et d’autant plus conservatrice qu’une occlusion distale elective est possible. La faible morbi-mortalite fait recommander d’integrer cette procedure dans la prise en charge des traumatises.

CV31 Embolisation d’anevrysmes des territoires arteriels mesenterique superieur et hepatique

Objectifs Evaluer nos resultats techniques et cliniques apres embolisations percutanee des anevrysmes portees par une artere viscerale abdominale (a l’exclusion de l’artere splenique). Materiels et methodes De 1996 a 2005, nous avons chez 12 patients traite 7 anevrysmes ou faux anevrysmes arteriels hepatiques, 2 cœliaques, 3 mesenteriques superieurs. Ces lesions etaient prises en charge en urgence devant des tableaux aigus pour 4 patients. Pour les 8 autres les lesions avaient ete diagnostiquees pour 3 en echographie, pour 5 en TDM. Resultats Toutes les lesions ont pu etre traitees par coils chez 8 patients, par stent chez 3 patients. Aucune chirurgie secondaire n’etait necessaire. Nous ne deplorons aucune complication immediate ou deces dans les trente jours. Apres un suivi de 39 mois (1-108) ces patients restaient asymptomatique sans procedure complementaire. Nous ne deplorons aucune complication du vaisseau porteur ou des territoires d’aval. Conclusion Les anevrysmes ou faux anevrysmes portes par le tronc cœliaque, l’artere hepatique et l’artere mesenterique superieure, moins frequents que les anevrysmes spleniques, beneficient comme eux des techniques therapeutiques endovasculaires. Leur diagnostic repose sur l’imagerie non invasive. L’arteriographie, immediatement pre-therapeutique, permet de determiner la faisabilite de cette exclusion.