Halil Bozkaya

Male breast disease: clinical, mammographic, and ultrasonographic features

PURPOSE To describe and quantitate the radiological (mammographic and ultrasonographic) characteristics of male breast disease and to report the clinical and pathological findings. MATERIALS AND METHODS Two-hundred-thirty-six male patients with different male breast diseases, diagnosed at our institution between January 1990 and July 2001, were retrospectively evaluated. The history, physical examination, mammographic and ultrasonographic findings were analyzed. RESULTS The spectrum of the disease in 236 male patients were gynecomastia (n=206), primary breast carcinoma (n=14), fat necrosis (n=5), lipoma (n=3), subareolar abscess (n=2), epidermal inclusion cyst (n=1), sebaceous cyst (n=1), hematoma (n=1), myeloma (n=1), and metastatic carcinoma (n=2). The distribution of patterns of gynecomastia were; 34% (n=71) nodular, 35% (n=73) dendritic and 31% (n=62) diffuse glandular. Gynecomastia was unilateral in 55% (n=113) and bilateral in 45% (n=93) of the patients. Male breast cancer presented as a mass without microcalcifications in 86% (n=12) and with microcalcifications in 7% (n=1) of patients. The mass was obscured by gynecomastia, partially in two, totally in one patient. The location of the mass was retroareolar in 46% (n=6) and eccentric to the nipple in 54% (n=7) of patients. On ultrasonography (US), the contours were well-circumscribed in 20% (n=3) and irregular in 80% (n=12) of the masses. CONCLUSION Male breast has a wide spectrum of diseases, some of which have characteristic radiological appearances that can be correlated with their pathologic diagnosis. In the evaluation of the male breast, mammography and US are essential and should be performed along with physical examination.

Evaluation of Treatment Response of Chemoembolization in Hepatocellular Carcinoma with Diffusion-Weighted Imaging on 3.0-T MR Imaging

PURPOSE To assess the treatment response of hepatocellular carcinoma (HCC) after transarterial chemoembolization with diffusion-weighted imaging and dynamic contrast-enhanced magnetic resonance (MR) imaging with a 3-T system. MATERIALS AND METHODS Between February 2010 and November 2010, 74 patients were treated with chemoembolization in our interventional radiology unit. Twenty-two patients (29%) who had liver MR imaging including diffusion and dynamic contrast-enhanced MR imaging on a 3-T system before and after transarterial chemoembolization were evaluated retrospectively. Tumor size, arterial enhancement, venous washout, and apparent diffusion coefficient (ADC) values of lesions, peritumoral parenchyma, normal liver parenchyma, and spleen were recorded before and after treatment. The significance of differences between ADC values of responding and nonresponding lesions was calculated. RESULTS The study included 77 HCC lesions (mean diameter, 31.4 mm) in 20 patients. There was no significant reduction in mean tumor diameter after treatment. Reduction in tumor enhancement in the arterial phase was statistically significant (P = .01). Tumor ADC value increased from 1.10 × 10(-3) mm(2)/s to 1.27 × 10(-3) mm(2)/s after treatment (P < .01), whereas the ADC values for liver and spleen remained unchanged. ADC values from cellular parts of the tumor and necrotic areas also increased after treatment. However, pretreatment ADC values were not reliable to identify responding lesions according to the results of receiver operating characteristic analysis. CONCLUSIONS After transarterial chemoembolization, responding HCC lesions exhibited decreases in arterial enhancement and increases in ADC values in cellular and necrotic areas. Pretreatment ADC values were not predictive of response to chemoembolization.

Endovascular treatment of cranial aneurysms with the pipeline flow-diverting stent: preliminary mid-term results.

PURPOSE We aimed to present our initial experience with a new self-expanding flow diverter device designed for wide-neck aneurysm treatment, assess its safety for intracranial deployment and efficacy of occlusion at mid-term follow-up. MATERIALS AND METHODS Forty-five consecutive patients with difficult aneurysmal anatomy underwent an endovascular treatment. Fifty-five intracranial aneurysms were clipped using the Pipeline flow-diverting stent (ev3 Inc., Plymouth, Minnesota, USA) between November 2009 and December 2011. Data including antiplatelet therapy, technical issues, complications, and imaging findings were recorded during the follow-up period. RESULTS Twenty-seven aneurysms were asymptomatic, 13 were symptomatic due to mass effect, seven were recurrent, six had subarachnoid hemorrhage, and two subjects presented with ischemia. There were 45 saccular, six fusiform-dissecting, and four blister aneurysms. The six-month control angiography was available in 34 subjects with an 85.3% (29/34 patients) complete occlusion rate. The overall occlusion rate according to the last angiography was 91.9% (34/37 patients). The following three major technical complications without clinical consequences were encountered: one distal wire fracture of the stent delivery system and two insufficient stent expansion. There was one fatal nonaneurysmal cerebellar hemorrhage. The overall mortality rate was 2.2% with no permanent morbidity. CONCLUSION The Pipeline flow-diverting stent represents an important advancement in endovascular therapy for cerebral aneurysms. Standard endovascular techniques are typically not suitable for these types of aneurysms. The device targets primary parent vessel reconstruction rather than endosaccular occlusion to achieve exclusion of the aneurysm and maintain a relatively high occlusion rate at six months.

Endovascular Treatment of Iliac Vein Compression (May-Thurner) Syndrome: Angioplasty and Stenting with or without Manual Aspiration Thrombectomy and Catheter-Directed Thrombolysis

PURPOSE May-Thurner syndrome (MTS) is a rare clinical entity featuring venous obstruction of the left lower extremity. The aim of the present study was to report our experience with MTS and to evaluate the utility of treatment using endovascular techniques. MATERIALS AND METHODS We retrospectively analyzed data on 23 MTS patients (21 females, two males; mean age 44 ± 15 years). Eighteen patients presented with deep vein thrombosis (DVT) and five with symptoms associated with chronic venous hypertension (CVH). DVT patients were treated via thromboaspiration, catheter-directed thrombolysis, and angioplasty; followed by stent placement. CVH patients were treated with angioplasty and stent placement alone. All patients were followed-up using Doppler ultrasonography and computed tomography venography. RESULTS Complete left common iliac vein patency was achieved in 21 of the 23 patients (technical success rate: 91,3%). Complete thrombolysis was attained by 14 of the 18 DVT patients (77.7%). The mean clinical and radiological follow-up time was 15.2 ± 16.1 months. Upon follow-up, complete symptomatic regression was observed in 19 of the 23 patients (82.6%). Stent patency was complete in 19 of the 21 patients (90.4%) who received stents. Restenosis occurred in two patients. No treatment-related mortality or morbidity was observed. CONCLUSION Endovascular treatment of MTS is safe and effective and reduces symptoms in most patients, associated with high medium-term patency rates.

Endovascular Management of Vascular Injury during Transsphenoidal Surgery.

Vascular injury is an unusual and serious complication of transsphenoidal surgery. We aimed to define the role of angiography and endovascular treatment in patients with vascular injuries occurring during transsphenoidal surgery. During the last ten-year period, we retrospectively evaluated nine patients with vascular injury after transsphenoidal surgery. Eight patients were symptomatic due to vascular injury, while one had only suspicion of vascular injury during surgery. Four patients presented with epistaxis, two with subarachnoid hemorrhage, one with exophthalmos, and one with hemiparesia. Emergency angiography revealed a pseudoaneurysm in four patients, contrast extravasation in two, vessel dissection in one, vessel wall irregularity in one, and arteriovenous fistula in one. All patients but one were treated successfully with parent artery occlusion, with one covered stent implantation, one stent-assisted coiling method, while one patient was managed conservatively. One patient died due to complications related to the primary insult without rebleeding. Vascular injuries suspected intra or postoperatively must be investigated rapidly after transsphenoidal surgery. Endovascular treatment with parent artery occlusion is feasible with acceptable morbidity and mortality rates in the treatment of vascular injuries occurring in transsphenoidal surgery.

Tailoring platelet inhibition according to multiple electrode aggregometry decreases the rate of thrombotic complications after intracranial flow-diverting stent implantation

Background and purpose Pretreatment with dual antiaggregant drugs is accepted as a standard step in intracranial stent implantation. The aim of this study was to determine whether tailored antiaggregant medication based on platelet reactivity testing with multiple electrode aggregometry (Multiplate) yields superior outcomes after intracranial flow-diverting stent (FDS) implantation compared with standard clopidogrel treatment. Methods We retrospectively analyzed the following data from 100 consecutive patients: endovascular procedure characteristics, antiaggregant medications, procedural variables, and perioperative complications after FDS implantation for intracranial aneurysm. Patients were divided into two groups: uniform treatment with clopidogrel (untailored, early phase) and tailored treatment based on the results of aggregometry (late phase). Statistical comparisons included the Fisher exact test to compare categorical variables between the standard and aggregometry groups and the Mann–Whitney U test to compare ADP test values within the aggregometry group between groups receiving tailored or untailored treatment. Results In the aggregometry group (68 patients, 71 procedures) there were 17 (25%) clopidogrel-resistant patients, according to a cut-off value of 468 area under the aggregation curve; 12 underwent FDS implantation under tailored antiaggregant medication. In the standard treatment group (32 patients, 33 procedures) there were 3 (9.1%) spontaneous thrombotic events and 1 (3.3%) technical hemorrhagic complication. In the aggregometry group there were 2 (2.8%) spontaneous hemorrhagic events and 1 (1.4%) technical ischemic complication. In the aggregometry group, thrombotic complications and morbidity were lower than in the standard (no test) group (p<0.03). Conclusions Tailoring platelet reactivity according to multiple electrode aggregometry decreases the rate of thrombotic complications after intracranial FDS implantation.

Applications of the Amplatzer Vascular Plug to various vascular lesions.

The Amplatzer® Vascular Plug (AVP) can be used to embolize medium-to-large high-flow vessels in various locations. Between 2009 and 2012, 41 AVPs (device size, 6-22 mm in diameter) were used to achieve occlusion in 31 patients (24 males, seven females) aged 9-92 years (mean age, 54.5 years). The locations and indications for embolotherapy were as follows: internal iliac artery embolization before stent-graft repair for aorto-iliac (n=6) and common iliac artery (n=3) aneurysms, subclavian artery embolization before stent-graft repair for thoracic aorta (n=3) and arcus aorta (n=1) aneurysms, brachiocephalic trunk embolization before stent-graft repair for a thoracic aorta aneurysm (n=1), embolization of aneurysms and pseudoaneurysms (n=5), embolization for carotid blow-out syndrome (n=3), closure of arteriovenous fistula (n=8), and closure of a portosystemic fistula (n=1). Of the 41 AVPs, 30 were AVP 2 and 11 were AVP 4. The mean follow-up duration was 4.7 months (range, 1-24 months). During follow-up, there was one migration, one insufficient embolization, and one recanalization. The remaining vascular lesions were successfully excluded from the circulation. The AVP, which can be used in a wide spectrum of pathologies, is easy to use and causes few complications. This essay presents our experience with the AVP.

Evaluation of Platelet Distribution Width and Mean Platelet Volume in Patients With Carotid Artery Stenosis

Platelets contribute to the pathogenesis of atherosclerosis. Platelet activation has been linked with increased mean platelet volume (MPV) and platelet distribution width (PDW). We investigated the association between PDW, MPW, and the degree of carotid artery stenosis (CS). Patients (n = 229) were divided into 3 groups according to the North American Symptomatic Carotid Endarterectomy Trial criteria. Demographic and clinical features were collected retrospectively. Correlation analysis showed a positive association between PDW and the degree of CS. However, there was no significant correlation between CS and MPV. Moreover, we observed that PDW and low-density lipoprotein cholesterol were independent predictors of the degree of CS. This study showed that PDW, not MPV, is related to the degree of CS. Platelet distribution width could be a useful biomarker for CS. Whether targeting PDW will be of clinical benefit remains to be established.

Magnetic compression anastomosis for patients with a disconnected bile duct after living-donor related liver transplantation: a pilot study.

BACKGROUND AND STUDY AIM We present the use of the magnetic compression anastomosis (MCA) technique for treatment of disconnected bile duct after living-donor related liver transplantation (LDLT) using the recently introduced through-the-scope magnet. PATIENTS AND METHODS The MCA technique was used in patients with disconnected bile duct who could not be treated with either percutaneous or endoscopic procedures. All patients already had a percutaneous external biliary drainage catheter before the procedure. The magnet was placed percutaneously into the proximal side of the obstruction by pushing a 5-Fr catheter over a guidewire. Concurrently, endoscopic retrograde cholangiopancreatography (ERCP) including endoscopic papillary sphincterotomy was performed. The sister magnet was then carefully advanced to the opposite side of the obstruction with a 5-Fr catheter over a guidewire. After the confirmation of biliary recanalization, a guidewire was passed through the stricture and a percutaneous dilation of the stricture was performed with a balloon-tipped catheter. Endoscopic balloon dilation of the stricture, insertion of two plastic stents and the removal of the internal drainage catheter were performed during the first ERCP session. Stent exchange and multiple side-by-side stent placements were planned at regular intervals (3 monthly) for all patients. RESULTS A total of six LDLT patients with disconnected bile duct (aged 37 - 68, four men) underwent the MCA technique between September 2014 and July 2015. Biliary recanalization was achieved 13 - 42 days after the magnet placement procedure. The success rate of the procedure was 100 %. CONCLUSIONS The MCA technique using a small magnet (diameter 2.4 mm) is effective and useful in LDLT patients with disconnected bile duct.

Endovascular management of iatrogenic renal arterial lesions and clinical outcomes

PURPOSE We aimed to evaluate iatrogenic renal arterial lesions, including pseudoaneurysm, arteriovenous fistula, and arteriocaliceal fistula, their management by endovascular embolization, and the clinical results. METHODS Fifty-five patients (forty males, fifteen females) with a median age of 40 years (range, 8-85 years), who underwent endovascular embolization of iatrogenic renal arterial lesions between March 2003 and December 2013 were included in this retrospective study. Types of iatrogenic lesions and details of embolization procedures were reported. Estimated glomerular filtration rate (eGFR), renal function tests, hemoglobin, and hematocrit levels before and after embolization were recorded and compared. RESULTS Median follow-up was 24 months. We identified 53 pseudoaneurysms, 30 arteriovenous fistulas, and 11 arteriocaliceal fistulas in 55 patients, after percutaneous nephrolithotomy (n=26), renal biopsy (n=21), nephrostomy (n=3), renal surgery (n=3), and extracorporeal shock wave lithotripsy (n=2). Median number of pseudoaneurysms was 1 (range, 1-4) with a median size of 7 mm (range, 1.5-35 mm). Fifty-one patients underwent coil embolization. Median number of coils was 5 (range, 2-21) and median renal parenchymal loss was 5% (range, 1%-50%). There were no significant differences between pre- and postoperative eGFR and serum parameters. CONCLUSION Iatrogenic renal arterial lesion can be a life threatening condition. Superselective coil embolization is a safe, minimally invasive treatment option with minimal renal parenchymal loss and without significant change in renal function.