Jochen Vogel

Values and limitations of 18F-fluorodeoxyglucose-positron-emission tomography with preoperative evaluation of patients with pancreatic masses.

The aim of this study was to determine the value and limitations of 18F-fluorodeoxyglucose (FDG)–position-emission tomography (PET) for differentiating benign and malignant pancreatic disease and for staging malignant disease. One hundred fifty-nine patients with 89 malignant and 70 benign pancreatic lesions all received PET, computed tomography (CT), and endoscopic retrograde cholangiopancreatography (ERCP) before pancreatic surgery. The original reports were compared for all patients (group I; N = 159), for a subgroup that neither had fasting plasma glucose levels ≥130 mg/dL or known elevated levels of C-reactive protein ([CRP], group II; n = 123), and for the remaining patients (group III; n = 36). For group I, accuracy values (areas under receiver operating characteristic [ROC] curves) for differentiation of benign/malignant masses were 0.86 (PET), 0.93 (ERCP), 0.82 (CT), and 0.95 for ERCP + PET (N = 159). For group II, ROC areas increased to 0.92 (PET), 0.94 (p < 0.05; n = 123) (ERCP), 0.82 (CT), 0.97 (p < 0.05; n = 123) (ERCP + PET). The results for group III were 0.71 (PET), 0.81 (CT), and 0.93 (ERCP); (n = 36). With 54 patients of group II that either had contradictory or indeterminate/technically unsuccessful CT/ERCP, PET was correct in 43 patients (84%). Sensitivity/specificity for lymph node staging was 49%/63%, respectively. For patients with hepatic metastasis, PET was 70% sensitive and 95% specific, missing some metastasis that were <1 cm. PET detected peritoneal metastasis in 25% of patients, missing poorly localized microscopic spread. For selected patients who have indeterminate pancreatic masses but no hyperglycemia or serologic evidence of active inflammation, FDG-PET is an independent functional assay that significantly adds to the diagnostic accuracy of ERCP and CT in the differentiation of benign and malignant pancreatic disease. PET can reliably detect hepatic, peritoneal, and other distant metastases that are ≥1 cm.

Embolization for gastrointestinal hemorrhages

Abstract. Retrospective evaluation of interventional embolization therapy in the treatment of gastrointestinal hemorrhage over a long-term observation period from 1989 to 1997. Included in the study were 35 patients (age range 18–89 years) with gastrointestinal bleeding (GI) referred for radiological intervention either primarily or following unsuccessful endoscopy or surgery. Sources of GI bleeding included gastric and duodenal ulcers (n = 7), diverticula (n = 3), erosion of the intestinal wall secondary to malignancy (n = 6), vascular malformations (n = 4), and hemorrhoids (n = 2), as well as from postoperative (n = 6), posttraumatic (n = 2), postinflammatory (n = 4) or unknown (n = 1) causes. Ethibloc (12 cases) or metal coils (14 cases) were predominantly used as embolisates. In addition, combinations of tissue adhesive and gelfoam particles and of coils and Ethibloc were used (six cases). Finally, polyvinyl alcohol particles, a coated stent, and an arterial wire dissection were utilized in one case each. Bleeding was stopped completely in 29 of 35 cases (83 %). In one case (3 %) the source of bleeding was recognized but the corresponding vessel could not be catheterized. In five other cases (14 %) there was partial success with reduced, though still persistent, bleeding. The rate of complications was 14 %, including four instances of intestinal ischemia with fatal outcome in the first years, and, later, one partial infarction of the spleen without serious consequences. Gastrointestinal hemorrhage can be controlled in a high percentage of patients, including the seriously ill and those who had previously undergone surgery, with the use of minimally invasive interventional techniques. The availability of minicoils instead of fluid embolization agents has reduced the risk of serious complications.

Short-term Results with Use of the Amplatz Thrombectomy Device in the Treatment of Acute Lower Limb Occlusions☆

PURPOSE To evaluate the clinical efficacy of the Amplatz device for the treatment of acute occlusions of the lower limb arteries. MATERIALS AND METHODS Forty patients with acute occlusion of the lower limb arteries (3 hours to 8 days; mean, 2 days) were treated using the Amplatz clot macerator. Acute thrombotic lower limb occlusion was due to an embolic event in 32 patients and to atherosclerotic disease in eight patients. RESULTS Complete success, with complete clearing of thrombotic material without an adjunctive procedure, was achieved in 75% (30 of 40) of the patients. Mean thrombectomy time in these patients was 75 seconds. Partial success, with incomplete clearing of the thrombus, requiring additional procedures such as local thrombolysis, angioplasty, or atherectomy, was achieved in 20% (eight of 40) of the patients. The Doppler index increased significantly (P < .001) from .45 before intervention to .96 after intervention. There were two failures (5%). No major complications occurred. CONCLUSION Mechanical thrombectomy with use of the Amplatz device is a promising approach for quick recanalization of acute peripheral thromboembolic occlusions. Further studies are needed to prove the long-term patency after mechanical thrombectomy with use of this device.

Non-operative management of arterial liver hemorrhages

Abstract. A retrospective evaluation of embolotherapy in patients with arterial liver hemorrhages was carried out. Twenty-six patients, ranging in age from 10 days to 77 years with active arterial liver hemorrhages, underwent non-surgical embolotherapy. Bleeding was attributed to trauma (n = 21), tumor (n = 3), pancreatitis (n = 1), or unknown cause (n = 1). Twenty-nine embolizations were performed via a transfemoral (n = 26) or biliary (n = 2) approach. One bare Wallstent was placed into the common hepatic artery via to an axillary route to cover a false aneurysm due to pancreatitis. Treatment was controlled in 4 patients by cholangioscopy (n = 2) or by intravascular ultrasound (n = 2). Prior surgery had failed in 3 patients. Intervention controlled the hemorrhage in 24 of 26 (92 %) patients within 24 h. Embolotherapy failed in 1 patient with pancreatic carcinoma and occlusion of the portal vein. In 1 patient with an aneurysm of the hepatic artery treated by Wallstent insertion, total occlusion was not achieved in the following days, as demonstrated by CT and angiography. However, colour Doppler flow examination showed no flow in the aneurysm 6 months later. Complications were one liver abscess, treated successfully by percutaneous drainage for 10 days, and one gallbladder necrosis after superselective embolization of the cystic artery. Embolization is a effective tool with a low complication rate in the treatment of liver artery hemorrhage, even in patients in whom surgery has failed.

Endovascular stenting in patients with Iliac compression syndrome. Experience in three cases.

The authors report their experience in the percutaneous treatment of the iliac compression syndrome in three women (20-53 years old) with acute iliofemoral deep venous thrombosis; in one case, there was an additional thrombus in the inferior caval vein. They were treated by percutaneous implantation of Palmaz stents in the left common iliac vein 1 day after surgical thrombectomy and construction of an arterial venous fistula. All patients showed marked improvement, as determined from venograms obtained immediately after stent implantation. The arteriovenous fistulae were closed 3 months later. At 6 months follow-up, the median clinical and color-coded duplex ultrasound indicates that all stents are patent and all patients are free of symptoms.

Percutaneous transluminal rotational atherectomy in the treatment of peripheral vascular disease using a transluminal endatherectomy catheter (TEC) : Initial results and angiographic follow-up

PurposeTo evaluate the clinical results of percutaneous transluminal rotational atherectomy in the treatment of peripheral vascular disease.MethodsRotational atherectomy was performed in 39 patients aged 39–87 years (mean 66.6 years). A total of 71 lesions (43 stenoses and 28 occlusions) were treated in 40 limbs. Additional balloon angioplasty was required in 54% of lesions. Fifteen patients (37.5%) presented in Fontaine stage II, 10 patients (25%) in Fontaine stage III and 15 patients (37.5%) in Fontaine stage IV. Rotational atherectomy at 750 rpm was carried out over a 0.014-inch guidewire with continuous aspiration into a vacuum, bottle. Follow-up angiography and color flow Doppler examinations were performed in 22 patients (23 limbs) after a mean period of 6 months (range 2–14 months)ResultsThere was one primary technical failure. In 36 of 40 lesions there was a good angiographic result with residual stenoses in less than 30%. In 70 lesions treated by rotational atherectomy, however, 54% showed residual stenoses of 30%–50% and these cases required additional balloon angioplasty. The mean ankle-brachial index improved significantly (p<0.001), from 0.49 before the procedure to 1.01 after the procedure. A single distal embolus, related to primary recanalization, occurred and there were two large inguinal hematomas. Cumulative clinical patency after 6 months was 83.8% and cumulative angiographic patency after 6 months was 79.1%.ConclusionPercutaneous rotational atherectomy is a promising approach for the treatment of chronic peripheral vascular disease. Further prospective, randomized studies are necessary to compare percutaneous transluminal angioplasty with this new technical approach.

Massive Hemorrhage: Treatment with Forced Wire Manipulation☆

Johannes Gorich, MD ARTERIAL bleeding may respond utes. In three cases, a .O16-inch Norbert Rilinger, MD to transvasal embolization or the Tracker 18 wire with an indepenJochen Vogel, MD intraarterial administration of vasodent, prebent tip (Rehaforum) was Andrik J. Aschoff, MD constrictors. Reports in the literaused. In the last patient, a .016Hans-Jurgen Brambs, MD ture cite success rates up to 90% inch Terumo wire (Terumo, FrankRoman Sokiranski, MD depending on the type of hemorfurt, Germany) was employed. Stefan C. Kramer, MD rhage. Disadvantages include the During the cannulation attempt in relatively high costs of materials the irregular vascular course, the and a complication rate averaging guide wire often stuck in the vas

Computed tomographic measurements of the nasal sinuses and frontal bone in mummy-heads artificially deformed in infancy.

The purpose of the present study was to ascertain whether artificial skull deformation, carried out during infancy, has an effect on the pneumatization of the frontal and maxillary sinuses and on the osseous structure of the frontal bone. Thus, two normal and 12 artificially deformed adult human skulls (12 males, two females) from the collection of pre-Columbian Peruvian skeletons and mummies in the Institute of Anthropology and Human Genetics (University of Munich) were investigated by computed tomography. These skulls had been excavated from four sites on the Peruvian coast: Las Trancas, Cahuachi, Pacatnamú, and Estaqueria. The volumes of the maxillary sinuses varied from 5.18 mL to 17.19 mL. Those of the frontal sinuses varied from zero to 6.21 mL. The artificial deformation of the skull, which occurred during infancy, had no influence on the size of the maxillary and frontal sinuses. There was also no difference in the average bone thickness of the os frontale; however, artificial deformation in infancy had an influence on the bone structure, resulting in a tremendous rarefication of the diploe of the frontal bones. Based on these findings we conclude that the various types of skull deformation instituted in infancy seem to exert no inhibitory effect on the pneumatization of either the frontal or maxillary sinuses.