David P. Brophy

Incidental findings detected on emergency abdominal CT scans: a 1-year review

AbstractIntroduction In recent years, there has been a substantial rise in the use of computed tomography (CT) in the emergency medicine setting. Accordingly, with increased CT usage there has been an upsurge in incidental pathology detection.MethodsA retrospective review of all emergency CT abdominal scans performed at a university teaching hospital was examined. The frequency of incidental findings, their clinical significance and workload effect for the radiology department was assessed.Results1155 patients had an emergency abdominal CT scan of which 700 had incidental findings detected. Of the incidental findings, 143 were deemed indeterminate requiring urgent investigations. Twenty-four occult neoplasms were confirmed subsequently. Additionally, 259 patients were recommended for additional diagnostics. The cumulative effect of the initial emergency abdominal CT was 15,015 relative value units (RVU). Subsequent imaging of incidental findings resulted in another 1674 RVU workload for radiology.ConclusionIncidental findings cause considerable debate and concern over which patients require significant follow-up, investigations, and/or surveillance. This exerts significant pressures on sub-specialties for their expert input, with increased workload and implications on healthcare service provision.

Initial impact of a systematic multidisciplinary approach on the management of patients with gastroenteropancreatic neuroendocrine tumor

According to the international guidelines, a multidisciplinary approach is currently advised for the optimal care of patients with a gastroenteropancreatic neuroendocrine tumor (GEP NET). In our institution (tertiary care center), a systematic multidisciplinary approach was established in May 2007. In this study, we have aimed to assess the initial impact of establishing a systematic multidisciplinary approach to the management of GEP NET patients. We have collected and compared the biochemical, imaging, and pathological data and the therapeutic strategies in GEP NET patients diagnosed, treated, or followed-up from January 1993 to April 2007 versus GEP NET patients attending our institution after the multidisciplinary approach starting, from May 2007 to October 2008. Data of 91 patients before and 42 patients after the establishment of the multidisciplinary approach (total: 133 consecutive GEP NET patients) have been finally collected and analyzed. Before the establishment of the multidisciplinary approach, a lack of consistency in the biochemical, imaging, and pathological findings before treatment initiation as well as during follow-up of GEP NET patients was identified. These inconsistencies have been reduced by the systematic multidisciplinary approach. In addition, the therapeutic management of GEP NET patients has been altered by the multidisciplinary approach and became more consistent with recommended guidelines. We think that a systematic multidisciplinary approach significantly impacts on GEP NET patient care and should be established in all centers dealing with these tumors.

Evaluation of the Particulate Concentration in a Gelatin-Based Phantom for Sonographically Guided Lesion Biopsy

The purpose of this study was to determine the particulate concentration in a gelatin‐based ultrasound phantom for lesion biopsy at 6 cm in depth to reduce visualization of the biopsy needle in the near field, simulating subcutaneous fat and tissue echogenicity, and maintain target lesion visualization.

Chest tube removal after liver transgression.

w OI: 10.1016/j.jvir.2011.10.010 rast medium showed a 30-F chest drain traversing the liver ith its tip adjacent to the porta hepatis. The patient was in hemodynamically stable condition nd was transferred to the interventional radiology unit for emoval of the chest drain. Initial fluoroscopy clearly howed the abnormal drain position (Fig 2). A 10-F vascular sheath was inserted through the chest rain (which was modified by cutting it short), and contrast edium was injected as the chest tube was slowly withrawn. No significant vascular or biliary communication as demonstrated (Fig 3). The tract was then embolized ith five 10-mm coils (Fig 4). The patient made an uneventful recovery and remained igure 3.

Severe Postcoital Bleeding From a Uterine Artery Pseudoaneurysm 4 Months After Cesarean Delivery.

BACKGROUND: Uterine artery pseudoaneurysm is considered a rare complication of gynecologic and obstetric procedures. The delayed diagnosis of this condition may result in life-threatening hemorrhage. CASE: A 34-year-old woman underwent an urgent cesarean delivery for labor dystocia. The procedure was complicated with hemorrhage from the uterine incision angles requiring extra hemostatic suture. She presented with secondary postpartum hemorrhage on day 14 and again with life-threatening postcoital vaginal bleeding 4 months after cesarean delivery. Magnetic resonance imaging and angiography revealed a uterine artery Pseudoaneurysm, which was treated with uterine artery embolization. CONCLUSION: Uterine artery pseudoaneurysm should be considered as a differential diagnosis in patients presenting with postpartum hemorrhage, especially if bleeding is significant and recurrent, particularly after an operative delivery. The diagnosis of a pseudoaneurysm can be made by color Doppler ultrasonography, computed tomography, magnetic resonance imaging, and angiography.

Percutaneous Removal of a Dropped Appendicolith Using a Basket Retrieval Device and Concomitant Abscess Drainage

Editor: We describe percutaneous removal of an appendicolith in a 61-year-old man who presented with an abscess related to a dropped appendicolith. This successful percutaneous approach avoided general anesthesia and an open surgical procedure. It was performed in the interventional radiology suite under conscious sedation. A previously well, 61-year-old man presented to the emergency department with a 4-day history of severe right iliac fossa pain. Computed tomography (CT) of the abdomen and pelvis revealed an inflammatory mass involving the appendix consistent with acute appendicitis with an appendicolith visible at the base of the appendix (Fig 1). The patient was initially treated conservatively with intravenous antibiotics for 5 days. He subsequently underwent interval laparoscopic appendectomy, made an uneventful recovery, and was discharged home 2 days after surgery. Over the following 20 months, the patient had insidious onset of chronic, low-grade right iliac fossa and right hip pain. He consulted a sports medicine clinic. Magnetic resonance (MR) imaging was scheduled to assess for hip pathology. The patient became acutely unwell before MR imaging could be performed and presented to our institution complaining of right iliac fossa pain, right hip pain, and general malaise. He was unable to extend his right hip fully. Initial vital signs were temperature 36.9°C, pulse rate 80 beats/ min, and blood pressure 148/80 mm Hg. White blood cell count was 10.8 10 g/dL. The clinical diagnosis was abscess recurrence. A CT scan confirmed the presence of a large (10 cm 15 cm) abscess collection involving the right psoas muscle extending to involve the right iliacus muscle. A 9-mm appendicolith was identified in the dependant portion of the right iliacus abscess (Fig 2). The appendicolith was visible on numerous prior abdominal radiographs obtained over time, varying slightly in position (Fig 3). A procedure comprising

Deep Venous Thrombosis in a Patient with Atresia of the Infrarenal Inferior Vena Cava

From a transjugular route, the path from the native IVC out into the donor IVC and into a hepatic vein is more angulated, significantly limiting the ability to perform traditional passes into the portal vein. From the percutaneous approach, the side-by-side anastomosis is less of an issue because the pass is from the donor portal vein into the donor IVC. This technique may be helpful in those patients with donor livers with similar anatomy to allow for single-pass percutaneous puncture, which, based on previous clinical studies, is often possible.

Endovascular recanalisation of an acute superior mesenteric artery occlusion. A case report and review of the literature

Introduction Acute mesenteric ischaemia (AMI) continues to have a high mortality, ranging from 60 to 80%. Presentation of case A 78-year-old male presented with a 20-hour history of abdominal pain, secondary to a superior mesenteric artery (SMA) thromboembolic occlusion diagnosed on computed tomography (CT) angiography. Following confirmation of bowel viability at laparotomy, endovascular intervention using combined thrombolysis, angioplasty and thromboaspiration was performed. Despite successful recanalisation of the occlusion, his condition continued to deteriorate fatally due to progressive sepsis. Discussion We discuss the role of biphasic CT in diagnosis of AMI, and review the evidence for endovascular interventions now increasingly used in the emergent management of thromboembolic AMI. Conclusion Early diagnosis using CT angiography is essential, as it is highly sensitive in detecting a visceral arterial occlusion. However, laparotomy is often required to accurately determine bowel viability and the need for resection. Endovascular interventions appear to be effective alternatives to open surgery with appropriate patient selection.

Evolution of mycotic aortic aneurysm treatment by endovascular repair.

IntroductionEndovascular intervention for mycotic aortic aneurysms is now an alternative treatment option.Case reportAn 83-year-old male presented with confusion and pyrexia of unknown origin. Acute deterioration and subsequent computed tomography scan of the abdomen revealed a contained rupture of a mycotic aortic aneurysm for which the patient had a successful endovascular repair.Conclusion Endovascular management of aortic mycotic aneurysms provides an alternate and potentially safer method of intervention, particularly in patients deemed unsuitable for open repair.

Midterm Analysis of Survival and Cause of Death Following Endovascular Abdominal Aortic Aneurysm Repair

Purpose: To assess rates of complications, secondary interventions, survival, and cause of death following endovascular abdominal aortic aneurysm (AAA) repair over a 10-year period. Materials and Methods: Single-institution retrospective cohort study of all patients undergoing primary endovascular aortic aneurysm repair (EVAR) between July 2006 and June 2015. The population constituted 175 patients with 163 fusiform and 12 saccular AAAs. Of these, 149 (85%) were male, with mean age 75.4 (±7.1) years. Patients were followed up until June 30, 2016. Cause of death was determined from the national death register. Results: Mean follow-up was 34.4 (±24.4) months. The secondary intervention rate was 9.7%, and there were 4 aneurysm ruptures (0.8% annual incidence). Thirty-day mortality was 0.6%. Survival at 1, 3, and 5 years was 93.1%, 84%, and 64.9%, respectively. Forty-eight patients died during follow-up, 3 secondary to rupture, leading to overall and aneurysm-related death rates of 9.7 and 0.6 per 100 person-years. All other deaths were due to nonaneurysm causes, most commonly cardiovascular (n = 15), pulmonary (n = 13), and malignancy (n = 9). Baseline renal impairment (P < .001), ischemic heart disease (P < .05), age greater than 75 years (P < .05), and urgent/emergency EVAR were associated with inferior long-term survival. Type II endoleak negatively influenced fusiform aneurysm sac regression (P = .02), but there was no association between survival and occurrence of any complication or secondary intervention. Conclusion: The majority of deaths during medium-term follow-up post-EVAR are due to nonaneurysm-related causes. Survival is determined by the following baseline factors: renal impairment, ischemic heart disease, advanced age, and the presence of a symptomatic/ruptured aneurysm.