Jason J. Clement

Endovascular aortic aneurysm repair via the left ventricular apex of a beating heart.

An elderly man presented with a ruptured aortic arch, left lung compression, and hemoptysis. Multiple comorbidities and inadequate aortoiliac access disqualified him from conventional open repair or hybrid retrograde transarterial thoracic endovascular aortic repair (TEVAR). Because our center has recently reported that a thoracic aortic endograft can be successfully placed through the apex of the LV of a beating heart in a pig model, we received approval for the compassionate use of antegrade transapical TEVAR (TaTEVAR) with bilateral femoral-carotid revascularization to repair the aortic arch. As in our animal model, TaTEVAR was performed with accuracy and minimal hemodynamic compromise. The patient was quickly weaned from inotropic and respiratory support postoperatively and was neurologically intact, but died on the tenth postoperative day from respiratory failure.

MR Arthrography of the Wrist: Controversies and Concepts

Magnetic resonance arthrography (MRA) has become the preferred modality for imaging patients with internal derangement of the wrist. However, several aspects of MRA use need to be clarified before a standardized approach to the imaging of internal derangement of the wrist can be developed. The objective of the study is to evaluate the efficiency of different magnetic resonance (MR) sequences in the detection of lesions of the triangular fibrocartilage complex (TFCC) and scapholunate and lunotriquetral ligaments on direct MRA. Thirty-one consecutive direct magnetic resonance arthrographic examinations of the wrist using a wrist surface coil were performed for the assessment of the TFCC and intrinsic ligaments on a 1.5-T MR imaging system (Signa; 16 channel, Excite, GE Healthcare, Milwaukee, WI, USA). All patients had wrist pain, and in six cases, there was associated clinical carpal instability. The presence, location, and extent of TFCC, scapholunate ligament (SLL), and lunotriquetral ligament (LTL) lesions on T1 fat-saturated, multiplanar gradient recalled (MPGR) and short tau inversion recovery (STIR) images were identified, compared, and analyzed. Forty-one lesions of the TFCC, SLL, and LTL were visualized on contrast-sensitive (T1 fat-saturated) images in 23/31 (74.2%) patients. Twenty-one lesions of the TFCC and intrinsic ligaments were visualized on noncontrast-sensitive (MPGR and STIR) images (15 tears of the TFCC and six tears of the SLL and LTL). All of these lesions were seen on T1 fat-saturated images; 48.8% (20/41) lesions seen on T1 fat-saturated images (eight tears of TFCC and 12 tears of SLL and LTT) were not seen on MPGR and/or STIR images. Superior contrast resolution, joint distention, and the flow of contrast facilitate the diagnosis of lesions of the TFCC and intrinsic ligaments on contrast-sensitive sequences making MRA the preferred modality for imaging internal derangements of the wrist. Little agreement exists regarding the value and location of perforations of the intrinsic ligaments given that both traumatic and degenerative perforations may be symptomatic. Noncommunicating defects of the ulnar attachments of the triangular fibrocartilage (TFC), tears of the dorsal segment of the SLL, and defects at the lunate attachment of the SLL have a higher likelihood of being symptomatic and caused by trauma rather than by degenerative perforation. Although no consensus exists, it would appear that most arthrographies should be started with a radiocarpal injection. Injection into the distal radioulnar joint should be added if no communicational defects are visualized following radiocarpal injection in patients with ulnar-sided wrist pain.

T2 mapping of articular cartilage of glenohumeral joint with routine MRI correlation--initial experience.

The evaluation of articular cartilage currently relies primarily on the identification of morphological alterations of the articular cartilage. Unlike anatomic imaging, T2 mapping is sensitive to changes in the chemical composition and structure of the cartilage. Clinical evaluation of T2 mapping of the glenohumeral joint has not been previously reported. The objectives of this study were to evaluate the feasibility of magnetic resonance T2 mapping of the glenohumeral joint in routine clinical imaging, to assess the normal T2 mapping appearance of the glenohumeral joint, and to compare the findings on T2 maps to conventional MR pulse sequences. Magnetic resonance imaging (MRI) examinations of 27 shoulders were performed in a routine clinical setting. All studies included acquisition of T2 mapping using a dedicated software. The T2 maps were analyzed along with the routine MR exam and correlation of cartilage appearance on T2 map and on conventional MR sequences. T2 imaging maps were obtained successfully in all patients. T2 maps and routine MRI correlated in cases of normal cartilage and prolonged T2 values and cartilage defects. In four cases, increased T2 relaxation times in the cartilage and cartilage defects were more apparent on T2 maps. Acquisition of T2 maps at the time of routine MRI scanning is feasible and not time-consuming.

Successful ventricular transapical thoracic endovascular graft deployment in a pig model.

PURPOSE Aortoiliac occlusive disease may preclude retrograde thoracic endovascular aortic repair. This study evaluated the physiologic and anatomic feasibility of introducing an aortic endograft in an antegrade manner into the descending thoracic aorta of a pig through the left ventricular apex. METHODS Twelve adult pigs were to undergo antegrade endograft deployment. Under fluoroscopic guidance, a stiff guidewire was introduced past the aortic valve and into the distal abdominal aorta through the left ventricular apex on a beating heart. An 18F introducer sheath containing a 24 x 36-mm aortic endograft was introduced and deployed in the descending thoracic aorta. The accuracy of graft delivery was determined at necropsy by measuring the distance from the trailing edge of the graft to the downstream margin of the ostium of the left subclavian artery. Aortic valve competency was assessed angiographically and at necropsy. Left ventricular function was assessed angiographically. Five hemodynamic and respiratory variables were recorded at 12 stages during the procedure and assessed for significant changes from baseline. RESULTS One animal died during the sternotomy. All remaining pigs survived the experiment with minimal hemodynamic support. A significant drop in systolic blood pressure (75 +/- 2 to 60 +/- 4 mm Hg, P = .05) was noted when the aortic valve was crossed with an 18F sheath. The systolic blood pressure returned to baseline on endograft deployment and at the end of the procedure. Bradycardia was noted at several stages of the procedure, requiring treatment in two pigs. Eleven endografts were deployed; seven grafts were delivered within 5 mm and three grafts within 10 to 20 mm of the intended landing point. One graft was deployed 10 mm too proximally, covering the left subclavian artery. No aortic valvular insufficiency or left ventricular dysfunction was noted. CONCLUSION An aortic endograft can be delivered in an antegrade manner transapically into the descending thoracic aorta in a pig model with a reasonable degree of accuracy and minimal hemodynamic compromise.

Neurosyphilitic gumma in a homosexual man with HIV infection confirmed by polymerase chain reaction

The brain gumma is a rare manifestation of the tertiary stage of syphilis. A case of neurosyphilitic gumma was confirmed by the Treponema pallidum polymerase chain reaction in a 46-year-old HIV-positive homosexual man. The patient presented with a severe headache and was hospitalized. A computed tomography scan was performed which revealed a left frontal lobe mass. Lymphoma was suspected. However, infectious disease diagnostics were performed on the cerebrospinal fluid that included investigations for syphilis and other microbiological agents such as Toxoplasma gondii. This revealed a reactive venereal disease research laboratory test, a reactive syphilis rapid plasma reagin and a reactive T. pallidum particle agglutination test. The patient was treated for syphilis till complete recovery.

Risk factors associated with arteriovenous fistula failure after first radiologic intervention

Purpose Improving arteriovenous fistula (AVF) patency is an integral part of the care of hemodialysis patients, often requiring procedures such as percutaneous transluminal angioplasty (PTA). However, these interventions may fail to reduce AVF dysfunction and failure. The purpose of this study was to determine predictive factors for subsequent AVF failure post-PTA. Methods Data from 155 consecutive AVFs in 155 patients at a single institution who had undergone a first PTA and had at least 1 year of follow-up data were analyzed. Using survival analysis, we assessed primary and secondary patency, and identified predictive factors taking into account competing risks. Results Of the 155 patients, 52% required multiple subsequent PTAs; 32% of the AVFs were not in use prior to the first PTA. At first PTA, 83% had outflow vein stenosis (OVS), 26% had multiple stenoses and 43% of stenoses were longer than 2 cm. During follow-up, 1-, 2-, 3-year postintervention primary patency was 41%, 32%, 32% and secondary patency was 80%, 71% and 68%. AVFs with stenoses greater than 2 cm or OVS were at higher risk of requiring multiple PTAs (p = 0.04, 0.006). Factors associated with requiring a second PTA included stenosis greater than 2 cm (hazard ratio (HR) = 1.8, 95% confidence interval (CI) = 1.2-2.9), OVS (HR = 2.5, 95% CI = 1.1-5.4) and primary renal diagnosis of diabetes or renal vascular diseases (HR = 1.8, 95% CI = 1.1-2.9); after adjustments for competing risks, OVS and stenosis length remained associated with requiring subsequent PTAs. Conclusions The location and size of the AVF stenosis at first PTA appear to be consistent factors associated with worse postintervention primary patency.

Radiologic Signs of Weapons and Munitions: How Will Noncombatants Recognize Them?

OBJECTIVE The purpose of this work was to show the radiologic signs named after weapons and munitions along with their military counterparts to help radiologists recognize these signs, which will allow confident interpretation and diagnosis. CONCLUSION Numerous pathologic conditions have classic radiologic manifestations that resemble weapons and ammunition. Most of these signs are highly memorable and easy to recognize. However, the names of the weapons (some of them antique and some not commonly known) may confuse radiologists who are not familiar with the appearance of such weapons as the scimitar, bayonet, or dagger. The value of the signs is reduced if the radiologist is unfamiliar with the appearance of the corresponding weapon.

Percutaneous closure of a para‐anastomotic abdominal aortic graft leak

Para‐anastomotic graft leaks are a potential complication following surgical repair of an aortic aneurysm. Reoperation may be associated with significant morbidity and mortality. We report successful percutaneous transcatheter closure of an anastomotic graft leak utilizing an occluder device.

Stone foreign body—radiographic and CT appearance

Mineral foreign bodies (stones) are infrequent findings in clinical and radiological practice. However, a growing number of reports indicate that they raise clinical and diagnostic concern in ophthalmology, neurosurgery, maxillofacial surgery, otolaryngology, gastroenterology, and vascular surgery. Dense finding in the soft tissue without clear history of foreign body penetration may represent diagnostic challenge mimicking calcifications or bony fragments. The aim of this work is to analyze the appearance of stone foreign bodies on radiographs and computed tomography. A collection of minerals and rocks was used for analysis. The clinical case of a stony foreign body which penetrated into the soft tissue of the leg is used to demonstrate the diagnostic challenge and management. Available literature describing imaging characteristics of stones was reviewed. The results of this work will help in diagnostic interpretation and assessment of stone foreign body composition.

People Behind Exclusive Eponyms of Radiologic Signs (Part II)

We continue with an article that describes the people behind eponyms in radiology. The collection of the biographical details about these people took us on a fascinating search in immigration archives and into contact with family friends and descendants of these people. This search helped to find some previously unpublished data and photographs, which made a fascinating tour to the past exciting and fruitful. We discovered that eponyms sometimes emerged as a result of a single article, which was not necessarily a significant step in the author’s career. Only a few eponyms are used in radiologic practice, unlike in the specialties of neurology or surgery. Lewicki suggested that this fact as well as the end of the eponym era a few decades ago probably paralleled other changes in medicine, with the discipline becoming more scientific and less descriptive. However, eponyms help us to remember that, even today, when our lives are so dominated by technology, advancement of knowledge still depends on people. As mentioned in the first part, we were dedicated to the names behind the exclusive eponyms of radiologic signs.