José Urbano

Breast and pectoralis muscle hypoplasia. A mild degree of Poland's syndrome.

PURPOSE Polands syndrome is a congenital and unilateral aplasia of the pectoralis major muscle (PMM), with other anomalies of the ipsilateral upper extremity. We present 6 cases in which the only clinical expression was asymmetry of the breasts associated with partial absence of the PMM. MATERIAL AND METHODS We reviewed 95000 mammograms (obtained 1985-1995) to find patients with asymmetrical breast size. Where the asymmetry could not be ascribed to any other cause, the patients were recalled for an examination of the PMM which was conducted at rest and with active contraction of the muscle. RESULTS Unilateral volume reduction of the PMM was found in 5 women of whom 2 were studied with MR. A 6th case was a fortuitous finding in a male patient. CONCLUSION Mild forms of Polands syndrome are more frequent than severe forms, and may go undiagnosed. Hypoplasia of one breast or a horizontal anterior axillary fold may be the sole clinical manifestation of this syndrome.

Lipoma-induced jejunojejunal intussusception: US and CT diagnosis

Abstract. A case study of a patient who presented with abdominal pain and a palpable mesogastric mass is discussed. Ultrasound and computed tomography (CT) demonstrated that the palpable mass was jejunojejunal intussusception of the small intestine. The lead point of the intussusception was a lipoma that appeared in the CT scan as a small intramural mass with an attenuation coefficient of fat.

Percutaneous treatment of benign portal vein stenosis after liver transplantation.

O SCVIR, 1996 PORTAL vein stenosis at the site of anastomosis is a relatively uncommon complication following liver transplantation (1). Although such complications have traditionally been managed surgically, percutaneous transluminal angioplasty (PTA) and placement of vascular endoprostheses have increasingly been used as therapeutic alternatives in selected patients (2,3). We present two cases of anastomotic stenosis of the portal vein in liver transplant recipients. One patient was treated with PTA and the other was managed with balloon dilation and subsequent implantation of a vascular stent.

Selective arterial embolization with ethylene-vinyl alcohol copolymer for control of massive lower gastrointestinal bleeding: feasibility and initial experience.

Abstract Purpose To evaluate the efficacy, safety, and clinical outcomes of superselective embolization using ethylene–vinyl alcohol copolymer (Onyx Liquid Embolic System; ev3 Neurovascular, Irvine, California) as the primary treatment for acute and massive lower gastrointestinal bleeding (LGIB). Materials and Methods Between January 2008 and October 2013, all patients with focal massive LGIB who were treated by embolization were retrospectively analyzed. The study was approved by the hospitals ethics committee; informed consent was obtained in all cases. Onyx was chosen as the embolic agent in all cases in an intention-to-treat fashion. Embolization was indicated in 31 consecutive patients (mean age, 80 y ± 11.1). Multidetector computed tomography and digital subtraction angiography were performed in all patients. Results Active bleeding was detected in all cases. A colonoscopy was performed in 11 patients. The correlation between multidetector computed tomography and angiography findings was 96.7%. The causes of bleeding were diverticula in 15 patients, iatrogenic in 7 patients, neoplasia in 3 patients, hemorrhoids in 2 patients, angiodysplasia in 2 patients, and unknown in 2 patients. Embolization was not possible in one patient, who required urgent left hemicolectomy. The technical success rate was 93.5%. The embolic material refluxed in one patient, causing an undesired embolization, without any clinical consequences. In the 30 patients who received embolization, the immediate bleeding control rate was 100%. Rebleeding at 30 days occurred in three patients (10%). There were no major complications, intestinal ischemia, or deaths attributable to the treatment. No patient needed surgery or new embolization during a mean follow-up period of 23.7 months (range, 1–71 mo). Conclusions Control of massive LGIB using superselective embolization with Onyx is feasible and safe.

Hepatic Arterial Infusion of Doxorubicin-Loaded Microsphere for Treatment of Hepatocellular Cancer: A Multi-Institutional Registry

BACKGROUND Hepatic intra-arterial therapy for unresectable hepatocellular cancer (HCC) has been shown to improve overall survival, but can have significant toxicity. A recent prospective randomized controlled trial demonstrated superior response rates and significantly less morbidity and doxorubicin-related adverse events with drug-eluting beads with doxorubicin (DEBDOX) compared with conventional chemoembolization. The aim of this study was to confirm the efficacy of DEBDOX for the treatment of unresectable HCC. STUDY DESIGN This open-label, multicenter, multinational single-arm study included 118 intermediate-staged HCC patients who were not candidates for transplantation or resection. Patients received DEBDOX at each treatment. Complications and response rates to treatment were analyzed. RESULTS There were 118 patients who received a total of 186 DEBDOX treatments with a median total treatment dose of 75 mg (range 38 to 150 mg), and median overall total hepatic exposure of 150 mg (range 150 to 600 mg). Five lesions were targeted, with a median size of 5.3 cm (range 1.0 to 16.9 cm). Severe adverse events related to liver dysfunction were seen after 4% of treatments. Overall survival was a median of 14.2 months (range 5 to 30 months), with progression-free survival of 13 months and hepatic-specific progression-free survival of 16 months. Okuda class less than 1 at time of treatment, reduction of alpha-fetoprotein of 1,000 ng/mL at the first post-treatment evaluation, delivery of more than 200 mg doxorubicin, and less than 25% liver involvement were all predictors of favorable overall survival assessed by multivariable analyses. CONCLUSIONS Hepatic intra-arterial injection of DEBDOX is safe and effective in the treatment of HCC, as demonstrated by a minimal complication rate and robust and durable tumor response.

Sclerosis and varicocele embolization with N-butyl cyanoacrylate: experience in 41 patients

Background Embolization is an established treatment for varicocele. Coils are most frequently used in the procedure. Liquid embolic and sclerosing agents seem to have a number of advantages over coils. Purpose To report our experience and explain the technique of using N-2-butyl-cyanoacrylate (N2BCA) in varicocele treatment. Material and Methods From January 2010 to July 2011, 42 gonadal veins in 41 consecutive patients (age range, 11–41 years; mean, 18 years) with a diagnosis of varicocele were treated with N2BCA as an embolic agent. The clinical diagnosis was confirmed by Doppler ultrasound in all patients. Institutional review board approval was obtained, and all the patients signed informed consent for this retrospective review. In all cases, a 4-F hydrophilic catheter was used to catheterize the distal portion of the gonadal vein through which N2BCA, emulsified with lipiodol, was injected. Results The technical success was 100%. No complications or non-targeted embolizations were reported. Seven patients reported moderate post-embolization pain that required oral analgesic treatment for 7–10 days. After 12-month follow-up, all patients exhibited varicocele resolution in the Doppler ultrasound examination as well as relief of all previous symptoms. We have no fertility-related data for patients treated for this condition. Conclusion N2BCA as an embolic agent is a therapeutic alternative for the endovascular treatment of varicocele. This technique is uncomplicated, inexpensive, efficient, and safe.

Cholesterol Embolism Evaluated by Polarized Light Microscopy after Primary Renal Artery Stent Placement with Filter Protection

PURPOSE Cholesterol microembolization may explain some treatment failures after renal artery stent placement. The identification of cholesterol crystals may provide significant help in diagnosing the real frequency and severity of this complication. The aim of the present study was to examine the efficacy of polarized light imaging in the detection of cholesterol emboli trapped in a protection device. MATERIALS AND METHODS During a period of 18 months, 15 significant atherosclerotic stenoses of the ostium of the main renal artery were treated with primary stent placement with embolic protection. The filter device used was made of polyurethane, with a pore size of 115 ?m. The device was mounted over a 0.014-inch guide wire. For pathologic analysis, the recaptured filter basket was compressed between two slides and examined in a microscope under polarized light. RESULTS All the stenoses were successfully treated without clinical complications. All the filters were deployed and recaptured without difficulty. Cholesterol crystals were detected in 12 filters and no cholesterol was found in three. In one case, trouble with filter manipulation precluded pathologic analysis. No worsening of renal function was detected in any patient during follow-up. CONCLUSIONS Microscopic analysis with polarized light easily detects the cholesterol crystals trapped in the filter device. This provides evidence that renal cholesterol microembolism is highly prevalent during renal artery stent placement.

Breast and Pectoralis Muscle Hypoplasia

Purpose: Polands syndrome is a congenital and unilateral aplasia of the pectoralis major muscle (PMM), with other anomalies of the ipsilateral upper extremity. We present 6 cases in which the only clinical expression was asymmetry of the breasts associated with partial absence of the PMM. Material and Methods: We reviewed 95000 mammograms (obtained 1985–1995) to find patients with asymmetrical breast size. Where the asymmetry could not be ascribed to any other cause, the patients were recalled for an examination of the PMM which was conducted at rest and with active contraction of the muscle. Results: Unilateral volume reduction of the PMM was found in 5 women of whom 2 were studied with MR. A 6th case was a fortuitous finding in a male patient. Conclusion: Mild forms of Polands syndrome are more frequent than severe forms, and may go undiagnosed. Hypoplasia of one breast or a horizontal anterior axillary fold may be the sole clinical manifestation of this syndrome.

Endovascular repair of mycotic aneurysms of the aorta: an alternative to conventional bypass surgery in patients with acute sepsis.

Treatment of mycotic aneurysms of the aorta includes excision of infected tissue followed by anatomic or extra-anatomic bypass. However, operative mortality remains high particularly in elderly patients with comorbidities. We describe here 2 patients with mycotic aneurysms of the descending aorta in whom endovascular repair was successfully performed. In 1 of these patients, stent grafting was attained during the acute, bacteraemic phase of infection. After 12 and 20 months, respectively, of diagnosis, both patients are doing well.

New advances in lower gastrointestinal bleeding management with embolotherapy

Lower gastrointestinal bleeding (LGIB) is associated with high morbidity and mortality. Embolization is currently proposed as the first step in the treatment of acute, life-threatening LGIB, when endoscopic approach is not possible or is unsuccessful. Like most procedures performed in emergency setting, time represents a significant factor influencing outcome. Modern tools permit identifying and reaching the bleeding site faster than two-dimensional angiography. Non-selective cone-beam CT arteriography can identify a damaged vessel. Moreover, sophisticated software able to detect the vessel may facilitate direct placement of a microcatheter into the culprit vessel without the need for sequential angiography. A further important aspect is the use of an appropriate technique of embolization and a safe and effective embolic agent. Current evidence shows the use of detachable coils (with or without a triaxial system) and liquid embolics has proven advantages compared with other embolic agents. The present article analyses these modern tools, making embolization of acute LGIB safer and more effective.