Dietrich Beitzke

Type II endoleaks after endovascular repair of abdominal aortic aneurysms: fate of the aneurysm sac and neck changes during long-term follow-up.

Purpose To evaluate the frequency of type II endoleaks after endovascular aneurysm repair (EVAR) and to compare sac diameter and neck changes in patients with type II endoleak to endoleak-free patients with at least 3-year imaging follow-up. Methods Among 407 consecutive EVAR patients, 109 patients (101 men; mean age 72.1 years, range 55–86) had at least 3-year computed tomography (CT) data and no type I or III endoleak. In this cohort, 49 patients presented with a type II endoleak at some time and 60 patients had no endoleak. Patients with type II endoleaks were further divided into subgroups based on the vessel origin and the perfusion status (persistent or transient). The course of the perfusion status of type II endoleaks and changes in the aneurysm sac diameters, neck diameters, and renal to stent-graft distances (RSD) were evaluated in the defined groups. Reintervention and death rates were also reported. Results The mean follow-up was 68.1±23.8 months. Compared to the no endoleak group, overall sac diameter increased significantly in the type II endoleak group (p=0.007), but vessel origin did not have any influence. With regard to the perfusion status of type II endoleaks, aneurysm sac changes were significantly higher (p = 0.002) in the persistent endoleak group. During the study period, the increase in the proximal neck diameter was significantly higher in the no endoleak group compared to the type II endoleak group (p=0.025). No significant difference was found in RSD changes between the defined groups. Reinterventions were performed in 20 (18.3%) patients (13 for type II endoleak); 2 (1.8%) patients without type II endoleak died of ruptured aneurysm. Conclusion Persistent type II endoleaks led to significant aneurysm sac enlargement, but without increased mortality or rupture rates.

Dose modulated retrospective ECG-gated versus non-gated 64-row CT angiography of the aorta at the same radiation dose: Comparison of motion artifacts, diagnostic confidence and signal-to-noise-ratios

PURPOSE To compare ECG-gated and non-gated CT angiography of the aorta at the same radiation dose, with regard to motion artifacts (MA), diagnostic confidence (DC) and signal-to-noise-ratios (SNRs). MATERIALS AND METHODS Sixty consecutive patients prospectively randomized into two groups underwent 64-row CT angiography, with or without dose-modulated ECG-gating, of the entire aorta, due to several pathologies of the ascending aorta. MA and DC were both assessed using a four-point scale. SNRs were calculated by dividing the mean enhancement by the standard deviation. The dose-length-product (DLP) of each examination was recorded and the effective dose was estimated. RESULTS Dose-modulated ECG-gating showed statistically significant advantages over non-gated CT angiography, with regard to MA (p<0.001) and DC (p<0.001), at the aortic valve, at the origin of the coronary arteries, and at the dissection membrane, with a significant correlation (p<0.001) between MA and DC. At the aortic wall, however, ECG-gated CT angiography showed statistically significant fewer MA (p<0.001), but not a statistically significant higher DC (p=0.137) compared to non-gated CT angiography. At the supra-aortic vessels and the descending aorta, the ECG-triggering showed no statistically significant differences with regard to MA (p=0.861 and 0.526, respectively) and DC (p=1.88 and 0.728, respectively). The effective dose of ECG-gated CT angiography (23.24mSv; range, 18.43-25.94mSv) did not differ significantly (p=0.051) from that of non-gated CT angiography (24.28mSv; range, 19.37-29.27mSv). CONCLUSION ECG-gated CT angiography of the entire aorta reduces MA and results in a higher DC with the same SNR, compared to non-gated CT angiography at the same radiation dose.

Conventional versus rapid-deployment aortic valve replacement: a single-centre comparison between the Edwards Magna valve and its rapid-deployment successor

OBJECTIVES Sutureless and rapid-deployment valves were recently introduced into clinical practice. The Edwards INTUITY valve system is a combination of the Edwards Magna pericardial valve and a subvalvular stent-frame to enable rapid deployment. We performed a parallel cohort study for comparison of the two valve types. METHODS All patients receiving either an Edwards Magna Ease valve or an Edwards INTUITY valve system due to aortic stenosis from May 2010 until July 2014 were included. Patients undergoing bypass surgery, an additional valve procedure, atrial ablation surgery or replacement of the ascending aorta were excluded. Preoperative characteristics, operative specifications, survival, valve-related adverse events and transvalvulvar gradients were compared. RESULTS One hundred sixteen patients underwent rapid-deployment aortic valve replacement [mean age 75 years (SD: 8); 62% female] and 132 patients underwent conventional aortic valve replacement [70 years (SD: 9); 31% female; P < 0.001]. Conventional valve patients were taller and heavier. The mean EuroSCORE II was 3.1% (SD: 2.7) and 4.4% (SD: 6.0) for rapid-deployment and conventional valve patients, respectively (P = 0.085). The mean implanted valve size was higher in the conventional group [23.2 mm (SD: 2.0) vs 22.5 mm (SD: 2.2); P = 0.007], but postoperative transvalvular mean gradients were comparable [15 mmHg (SD: 6) vs 14 mmHg (SD: 5); P = 0.457]. A subgroup analysis of the most common valve sizes (21 and 23 mm; implanted in 63% of patients) revealed significantly reduced mean postoperative transvalvular gradients in the rapid-deployment group [14 mmHg (SD: 4) vs 16 mmHg (SD: 5); P = 0.025]. A significantly higher percentage received minimally invasive procedures in the rapid-deployment group (59 vs 39%; P < 0.001). The 1- and 3-year survival rate was 96 and 90% in the rapid-deployment group and 95 and 89% in the conventional group (P = 0.521), respectively. Valve-related pacemaker implantations were more common in the rapid-deployment group (9 vs 2%; P = 0.014) and postoperative stroke was more common in the conventional group (1.6 vs 0% per patient year; P = 0.044). CONCLUSIONS We conclude that this rapid-deployment valve probably facilitates minimally invasive surgery. Furthermore, a subgroup analysis showed reduced transvalvular gradients in smaller valve sizes compared with the conventionally implanted valve of the same type. The favourable haemodynamic profile and the potentially different spectrum of valve-related adverse events should be addressed in further clinical trials.

Fotemustine Chemoembolization of Hepatic Metastases From Uveal Melanoma: A Retrospective Single-Center Analysis

OBJECTIVE The purpose of the current study was to retrospectively evaluate response and survival in patients with hepatic metastasis from uveal melanoma treated by palliative transarterial chemoembolization (TACE) with fotemustine. MATERIALS AND METHODS During the study period, 21 patients with hepatic metastases from uveal melanoma were treated by TACE. A series of TACE interventions (mean number per patient, 3.29 interventions; range, 1-6 interventions) was performed on each patient with an emulsion of fotemustine dissolved in 10 mL of saline mixed with 10 mL of an oily contrast agent. Tumor response based on the Response Evaluation Criteria in Solid Tumors was evaluated using contrast-enhanced CT scans obtained 6-10 weeks after embolization. RESULTS CT showed partial regression after TACE in three patients (14%). Six patients (29%) presented with stable disease but no significant change in tumor size after TACE, and 12 patients (57%) presented with progressive disease after TACE treatment. The overall response rate was 43%. The mean survival after diagnosis of hepatic metastasis was 28.7 months. CONCLUSION TACE of hepatic metastasis from uveal melanoma with fotemustine is well tolerated, and the survival rates in this study (mean, 28.7 months) are among the longest reported.

Anomalous connection of the inferior vena cava to the left atrium: a surgical error in closing an atrial septal defect.

of the sinus venosus, guarding the upper and anterior end of the inferior vena cava (IVC) may be of various sizes [1, 10]. A large Eustachian valve directs the caval flow toward the interatrial septum and in the presence of an atrial septal defect (ASD) or foramen ovale may cause arterial desaturation [3, 6–8]. This valve may be confusing for the surgeon when closing an ASD. We report a patient with symptoms noted years after the IVC had inadvertently been connected to the left atrium. The misconnection was diagnosed by echocardiography with contrast followed by cardiac catheterization and angiocardiography. The IVC was connected to the left atrium with the superior vena cava supplying the residual right atrium and right ventricle. The patient underwent uneventful correction of his surgically created malformation, which was probably caused by misinterpretation of a large Eustachian valve for the inferior part of the atrial septum.

Prospective Evaluation of High-Resolution MRI Using Gadofosveset for Stent-Graft Planning: Comparison With CT Angiography in 30 Patients

OBJECTIVE The purpose of our study was to compare high-resolution gadofosveset-enhanced MR angiography (MRA) with the reference standard CT angiography (CTA) in planning endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms. SUBJECTS AND METHODS Thirty consecutive patients were included in this prospective study. CTA was performed routinely before EVAR for stent-graft implantation planning and selection. In addition, first-pass and, after a delay of 10 minutes, steady-state MRA were performed using the blood pool contrast agent gadofosveset for study purposes. Standard diameter and length parameters for stent-graft evaluation rendered from CTA and MRA were compared. According to the results of MRA measurements, stent-grafts were selected for each patient and compared with the device actually implanted. Image quality was assessed using subjective image quality parameters. RESULTS Diameter and length measurements showed small but significant differences (p < 0.001) between MRA and CTA. Stent-graft selection according to these measurements showed 100% concordance between both modalities. Subjective imaging parameters showed significantly better results for CTA compared with MRA (p < 0.001). CONCLUSION In this study, MRA using a blood pool contrast agent has shown the ability to provide reliable and exact measurements before EVAR, allowing noninvasive planning of the intervention despite lower image-quality and without the disadvantages of ionizing radiation and nephrotoxicity.

Carotid artery stenting and follow-up: Value of 64-MSCT angiography as complementary imaging method to color-coded duplex sonography

PURPOSE To compare 64-multi-slice-CT angiography (64-MSCTA) to color-coded duplex sonography (CCDS) in the follow-up after carotid artery stenting (CAS). METHODS Thirty patients who had an MSCTA and CCDS examination prior and after CAS were included. Twelve closed-cell and 24 open-cell stents were implanted. Neointimal surface, in-stent-restenosis (ISR), stent expansion, and fracture were evaluated. In addition, the occurrence of atherosclerotic lesions leading to a>50% stenosis in supraaortic vessels was assessed. RESULTS With MSCTA, >50% ISR was found in 5.6% of cases during a mean follow-up of 41.7 months. Comparing MSCTA and CCDS, grading of ISR and absolute diameters of neointimal surface correlated moderately (Spearman=0.402, p=0.015; Pearson=0.404, p=0.03). Assessment of the neointimal surface was significantly better with MSCTA (100% vs. 80.6%; p=0.011). Stent expansion was significant, compared to the basic value, with both modalities and stent types (p<0.001). Of 237 additionally assessed vessel segments, a>50% stenosis was detected in 38 (16.0%) vessel segments. Findings were stable in 25 (10.5%) and progressed in 11 (4.6%) vessel segments. Five small intracranial aneurysms were detected in four (13.3%) patients. Of 21 incidental findings in 16 (51.6%) patients there was one with malignancy (4.8%). CONCLUSION With regard to ISR and stent expansion, no significant difference was found, when MSCTA and CCDS were compared. CTA is quite applicable as a complementary imaging method for the follow-up of patients with carotid artery stents. Additional advantages are the detection of supraaortic vessel pathologies and incidental findings.

Improved detection of in-stent restenosis by blood pool agent-enhanced, high-resolution, steady-state magnetic resonance angiography

ObjectiveThe aim of this study was to assess whether visualisation of in-stent changes can be improved with high-resolution, steady-state, blood pool contrast-enhanced MR angiography compared with first-pass MR angiography. Intra-arterial digital subtraction angiography (DSA) served as the reference standard.MethodsTwenty patients after stent placement in the superficial femoral artery (SFA) underwent MRA prior to reintervention. MRA of the SFA includes first-pass MRA as well as 3D high-resolution MRA in the steady state (SS-MRA) after injection of Gadofosveset trisodium. Sensitivity and specificity values for the detection of significant in-stent lesions by means of SS-MRA were calculated at the proximal, middle and distal stent segments in comparison to DSA. Kappa statistics were used to determine agreement between the two techniques.ResultsSensitivity and specificity values for the detection of significant stenosis with SS-MRA reached 95% in the proximal, 100% in the middle and 100% in the distal stent segment. Kappa coefficients between SS-MRA and DSA were 0.789, 0.797 and 0.859 for the proximal, middle and distal segments, whereas the Kappa coefficients for FP-MRA were 0,211, 0,200 and 0,594 in these segments, respectively.ConclusionDetection of in stent stenosis is significantly improved using SS MRA, in comparison to state-of-the-art FP-MRA.

Primary leptomeningeal lymphoma of the cauda equina: a rare cause of radiculopathy

Primary leptomeningeal lymphoma (PLML) is a particularly rare neoplasm, accounting for only 7% of all primary central nervous system lymphomas. PLML is defined as a syndrome of lymphomatous meningeal infiltration without identification of systemic lymphoma or parenchymal CNS lymphoma in the clinical course of the disease [6, 12]. The diagnosis is challenging and requires a high index of suspicion. Early diagnosis, however, is crucial as immediate treatment may be beneficial. We here report a case of PLML of the cauda equina to raise awareness for this disorder and reduce the delay to diagnosis in similar cases. A 69-year-old immunocompetent man complained about increasing low back pain and moderate weakness of the left leg, which had slowly developed over 1 year. Neurologic examination and electrodiagnostic studies indicated a left-sided L5–S1 radiculopathy. There was no evidence of polyneuropathy. MRI of the spine, the pelvis, and the brain, including contrast-enhanced sequences, was unremarkable. Routine lumbar puncture yielded normal findings. The patient underwent an extensive laboratory and image work-up to rule out malignant, autoimmune, or infectious disease. Due to negative findings, he was discharged to home. High-resolution, contrast-enhanced MR neurography [7, 10] and a second lumbar tap were performed 36 days later. Analysis of the cerebrospinal fluid (CSF) revealed 0 cells/ll with a normal glucose and protein content and imaging findings were again inconclusive (Fig. 1a and b). Short inversion time inversion recovery (STIR) images, however, then illustrated hyperintensity and contrast enhancement of the left piriformis muscle and the left medial gluteal muscle, suggesting acute denervation (Fig. 1c). Subsequent treatment with intravenous methylprednisolone 10 mg/kg/day for 5 days was without clinical benefit at that point. Only 9 months later, the patient was readmitted with a pronounced flaccid lower extremity paraparesis and severe low back pain. Contrast-enhanced MRI of the lumbar spine then disclosed abnormal thickening and marked linear enhancement coating multiple cauda equina nerve roots highly suggestive of leptomeningeal infiltration by tumor (Fig. 2a–c). Urgent analyses of the CSF revealed elevated protein (439 mg/dl; normal range: 15–45) and a lymphocytic pleocytosis (70 cells/ll) with many atypical cells consistent with lymphoma. A biopsy of an anterior cauda equina nerve root as highlighted by immunohistochemistry with S100 (Fig. 2d) and NSE revealed a massive diffuse interstitial infiltrate of atypical lymphocytic cells, that reached the marginal area of the small specimen with epithelial membrane antigen (EMA) positive cells indicating leptomeningeal infiltration [14]. The cells expressed CD20 and CD79, but were negative for Kl-1, EMA, CD56, M. Beitzke (&) C. Enzinger F. Fazekas Department of Neurology, Medical University of Graz, Auenbruggerplatz 22, 8036 Graz, Austria e-mail: markus.beitzke@klinikum-graz.at

Association between osteogenesis and inflammation during the progression of calcified plaque as evaluated by combined 18F-NaF and 18F-FDG PET/CT

18F-FDG is the most widely validated PET tracer for the evaluation of atherosclerotic inflammation. Recently, 18F-NaF has also been considered a potential novel biomarker of osteogenesis in atherosclerosis. We aimed to analyze the association between inflammation and osteogenesis at different stages of atherosclerosis, as well as the interrelationship between these 2 processes during disease progression. Methods: Thirty-four myeloma patients underwent 18F-NaF and 18F-FDG PET/CT examinations. Lesions were divided into 3 groups (noncalcified, mildly calcified, and severely calcified lesions) on the basis of calcium density as measured in Hounsfield units by CT. Tissue-to-background ratios were determined from PET for both tracers. The association between inflammation and osteogenesis during atherosclerosis progression was evaluated in 19 patients who had at least 2 examinations with both tracers. Results: There were significant correlations between the maximum tissue-to-background ratios of the 2 tracers (Spearman r = 0.5 [P < 0.01]; Pearson r = 0.4 [P < 0.01]) in the 221 lesions at baseline. The highest uptake of both tracers was observed in noncalcified lesions, but without any correlation between the tracers (Pearson r = 0.06; P = 0.76). Compared with noncalcified plaques, mildly calcified plaques showed concordant significantly lower accumulation, with good correlation between the tracers (Pearson r = 0.7; P < 0.01). In addition, enhanced osteogenesis-derived 18F-NaF uptake and regressive inflammation-derived 18F-FDG uptake were observed in severely calcified lesions (Pearson r = 0.4; P < 0.01). During follow-up, increased calcium density and increased mean 18F-NaF uptake were observed, whereas mean 18F-FDG uptake decreased. Most noncalcified (86%) and mildly calcified (81%) lesions and 47% of severely calcified lesions had concordant development of both vascular inflammation and osteogenesis. Conclusion: The combination of 18F-NaF PET imaging and 18F-FDG PET imaging promotes an understanding of the mechanism of plaque progression, thereby providing new insights into plaque stabilization.