Leo J. Schultze Kool

The Adrenal Vein Sampling International Study (AVIS) for Identifying the Major Subtypes of Primary Aldosteronism

CONTEXTnIn patients who seek surgical cure of primary aldosteronism (PA), The Endocrine Society Guidelines recommend the use of adrenal vein sampling (AVS), which is invasive, technically challenging, difficult to interpret, and commonly held to be risky.nnnOBJECTIVEnThe aim of this study was to determine the complication rate of AVS and the ways in which it is performed and interpreted at major referral centers.nnnDESIGN AND SETTINGSnThe Adrenal Vein Sampling International Study is an observational, retrospective, multicenter study conducted at major referral centers for endocrine hypertension worldwide.nnnPARTICIPANTSnEligible centers were identified from those that had published on PA and/or AVS in the last decade.nnnMAIN OUTCOME MEASUREnThe protocols, interpretation, and costs of AVS were measured, as well as the rate of adrenal vein rupture and the rate of use of AVS.nnnRESULTSnTwenty of 24 eligible centers from Asia, Australia, North America, and Europe participated and provided information on 2604 AVS studies over a 6-yr period. The percentage of PA patients systematically submitted to AVS was 77% (median; 19-100%, range). Thirteen of the 20 centers used sequential catheterization, and seven used bilaterally simultaneous catheterization; cosyntropin stimulation was used in 11 centers. The overall rate of adrenal vein rupture was 0.61%. It correlated directly with the number of AVS performed at a particular center (P = 0.002) and inversely with the number of AVS performed by each radiologist (P = 0.007).nnnCONCLUSIONSnDespite carrying a minimal risk of adrenal vein rupture and at variance with the guidelines, AVS is not used systematically at major referral centers worldwide. These findings represent an argument for defining guidelines for this clinically important but technically demanding procedure.

MR-Guided Biopsy of the Prostate: An Overview of Techniques and a Systematic Review

CONTEXTnSystematic transrectal ultrasound-guided biopsy (TRUSBx) is the gold standard for detecting prostate cancer. This systematic approach is characterized by low sensitivity (39-52%) and high specificity (81-82%). Magnetic resonance (MR)-guided biopsy techniques are becoming more and more available, but there is no current consensus on the optimal technique.nnnOBJECTIVEnThis review presents an overview of MR-guided biopsy techniques for prostate cancer detection.nnnEVIDENCE ACQUISITIONnCurrent literature was reviewed regarding MR-guided biopsy for prostate cancer detection. A literature search was performed using the commercially available MedLine online search engine. Combinations of the following search and Medical Subject Headings terms were applied to retrieve relevant articles: magnetic resonance, prostatic neoplasms, and biopsy. Review articles and studies describing techniques other than MR-guided biopsy were excluded.nnnEVIDENCE SYNTHESISnBiopsy of the prostate is an essential procedure for determining optimal treatment. Systematic TRUSBx is the gold standard, but it fails to detect numerous tumors. Diagnostic MR imaging provides more accurate selection of regions in which tumors are suspected. Using these diagnostic images during an MR-directed biopsy procedure improves quality of the biopsy. In open MR scanners, the prebiopsy images often must be registered to the real-time biopsy images because open MR scanners do not provide optimal tissue contrast; thus, the patient must first be examined in a closed MR scanner and then biopsied in an open scanner. The advantage of open MR over closed MR is that the physician has easy patient access. With special equipment, prostate MR-guided biopsy is also possible in a closed system. Closed MR scanners can be used for the prebiopsy scan as well as for the biopsy procedure.nnnCONCLUSIONSnThe combination of a diagnostic MR examination and MR-guided biopsy is a promising tool and may be used in patients with previous negative TRUSBx.

Stent Placement in Patients With Atherosclerotic Renal Artery Stenosis and Impaired Renal Function

BACKGROUNDnLittle is known about the efficacy and safety of renal artery stenting in patients with atherosclerotic renal artery stenosis (ARAS) and impaired renal function.nnnOBJECTIVEnTo determine the efficacy and safety of stent placement in patients with ARAS and impaired renal function.nnnDESIGNnRandomized clinical trial. Randomization was centralized and computer generated, and allocation was assigned by e-mail. Patients, providers, and persons who assessed outcomes were not blinded to treatment assignment.nnnSETTINGn10 European medical centers.nnnPARTICIPANTSn140 patients with creatinine clearance less than 80 mL/min per 1.73 m(2) and ARAS of 50% or greater.nnnINTERVENTIONnStent placement and medical treatment (64 patients) or medical treatment only (76 patients). Medical treatment consisted of antihypertensive treatment, a statin, and aspirin.nnnMEASUREMENTSnThe primary end point was a 20% or greater decrease in creatinine clearance. Secondary end points included safety and cardiovascular morbidity and mortality.nnnRESULTSnForty-six of 64 patients assigned to stent placement had the procedure. Ten of the 64 patients (16%) in the stent placement group and 16 patients (22%) in the medication group reached the primary end point (hazard ratio, 0.73 [95% CI, 0.33 to 1.61]). Serious complications occurred in the stent group, including 2 procedure-related deaths (3%), 1 late death secondary to an infected hematoma, and 1 patient who required dialysis secondary to cholesterol embolism. The groups did not differ for other secondary end points.nnnLIMITATIONnMany patients were falsely identified as having renal artery stenosis greater than 50% by noninvasive imaging and did not ultimately require stenting.nnnCONCLUSIONnStent placement with medical treatment had no clear effect on progression of impaired renal function but led to a small number of significant procedure-related complications. The study findings favor a conservative approach to patients with ARAS, focused on cardiovascular risk factor management and avoiding stenting.

Adrenal vein sampling versus CT scan to determine treatment in primary aldosteronism: an outcome-based randomised diagnostic trial

BACKGROUNDnThe distinction between unilateral aldosterone-producing adenoma or bilateral adrenal hyperplasia as causes of primary aldosteronism is usually made by adrenal CT or by adrenal vein sampling (AVS). Whether CT or AVS represents the best test for diagnosis remains unknown. We aimed to compare the outcome of CT-based management with AVS-based management for patients with primary aldosteronism.nnnMETHODSnIn a randomised controlled trial, we randomly assigned patients with aldosteronism to undergo either adrenal CT or AVS to determine the presence of aldosterone-producing adenoma (with subsequent treatment consisting of adrenalectomy) or bilateral adrenal hyperplasia (subsequent treatment with mineralocorticoid receptor antagonists). The primary endpoint was the intensity of drug treatment for obtaining target blood pressure after 1 year of follow-up, in the intention-to-diagnose population. Intensity of drug treatment was expressed as daily defined doses. Key secondary endpoints included biochemical outcome in patients who received adrenalectomy, health-related quality of life, cost-effectiveness, and adverse events. This trial is registered with ClinicalTrials.gov, number NCT01096654.nnnFINDINGSnWe recruited 200 patients between July 6, 2010, and May 30, 2013. Of the 184 patients that completed follow-up, 92 received CT-based treatment (46 adrenalectomy and 46 mineralocorticoid receptor antagonist) and 92 received AVS-based treatment (46 adrenalectomy and 46 mineralocorticoid receptor antagonist). We found no differences in the intensity of antihypertensive medication required to control blood pressure between patients with CT-based treatment and those with AVS-based treatment (median daily defined doses 3·0 [IQR 1·0-5·0] vs 3·0 [1·1-5·9], p=0·52; median number of drugs 2 [IQR 1-3] vs 2 [1-3], p=0·87). Target blood pressure was reached in 39 (42%) patients and 41 (45%) patients, respectively (p=0·82). On secondary endpoints we found no differences in health-related quality of life (median RAND-36 physical scores 52·7 [IQR 43·9-56·8] vs 53·2 [44·0-56·8], p=0·83; RAND-36 mental scores 49·8 [43·1-54·6] vs 52·7 [44·9-55·5], p=0·17) for CT-based and AVS-based treatment. Biochemically, 37 (80%) of patients with CT-based adrenalectomy and 41 (89%) of those with AVS-based adrenalectomy had resolved hyperaldosteronism (p=0·25). A non-significant mean difference of 0·05 (95% CI -0·04 to 0·13) in quality-adjusted life-years (QALYs) was found to the advantage of the AVS group, associated with a significant increase in mean health-care costs of €2285 per patient (95% CI 1323-3248). At a willingness-to-pay value of €30u2008000 per QALY, the probability that AVS compared with CT constitutes an efficient use of health-care resources in the diagnostic work-up of patients with primary aldosteronism is less than 0·2. There was no difference in adverse events between groups (159 events of which nine were serious vs 187 events of which 12 were serious) for CT-based and AVS-based treatment.nnnINTERPRETATIONnTreatment of primary aldosteronism based on CT or AVS did not show significant differences in intensity of antihypertensive medication or clinical benefits for patients after 1 year of follow-up. This finding challenges the current recommendation to perform AVS in all patients with primary aldosteronism.nnnFUNDINGnNetherlands Organisation for Health Research and Development-Medical Sciences, Institute of Cardiology, Warsaw.

Effectiveness of Sclerotherapy, Surgery, and Laser Therapy in Patients With Venous Malformations: A Systematic Review

PurposeBecause the best possible treatment for venous malformations is unclear, this study systematically reviews the available literature regarding the effectiveness of different treatment options for the patient group. Venous malformations result from incorrect development of the veins during embryogenesis and are present at birth. Venous malformations may exhibit symptoms, such as pain, swelling, and inflammation of the vessel.Materials and MethodsA systematic literature search in PubMed and Embase was performed. Data regarding the design, participants, intervention and, treatment outcome (success and complications) were extracted. The validity of the studies was assessed with the Cochrane Collaboration’s risk of bias tool.ResultsThirty-five studies were identified studying the effectiveness of eight treatments: sclerotherapy/embolization with ethanol, gelified ethanol, bleomycin, polidocanol, sodium tetradecyl sulfate (STS), Ethibloc, surgery, and laser therapy. All of the included studies have a high or unclear risk of bias. The average biased reported success rates for ethanol, gelified ethanol, bleomycin, polidocanol, STS, Ethibloc, surgery, and laser therapy were 74, 89, 88, 90, 86, 65, 90, and 94xa0%, respectively.ConclusionUntil more valid evidence is available, the choice for treatment remains a shared decision between the patient and a multidisciplinary treatment group. From a cost perspective, sclerotherapy with STS or polidocanol should be the treatment of choice.

Hypotensive Hemostatis (Permissive Hypotension) for Ruptured Abdominal Aortic Aneurysm: Are We Really in Control?

The purpose of this study was to investigate whether a protocol for permissive hypotension was feasible for patients admitted with a ruptured abdominal aortic aneurysm (RAAA). It was aimed to limit prehospital intravenous fluid administration to 500 mL and to maintain systolic blood pressure at a range of 50 to 100 mm Hg following admission, using nitrates when indicated. The diagnosis of RAAA was confirmed with sonography, and all patients with uncontrolled hypovolemic shock immediately underwent open aneurysm repair (OAR). In all other cases, computed tomographic (CT) angiography was performed to determine the eligibility for endovascular aneurysm repair (EVAR). From January 1, 2004, to December 31, 2006, 95 patients with a suspected RAAA were admitted. In 77 patients, the diagnosis of RAAA was confirmed. Twenty-eight cases (36%) underwent OAR for uncontrolled hemodynamic instability. Following CT-angiographic evaluation, 25 of the remaining 49 cases were considered unsuitable for EVAR and subsequently underwent OAR. In 24 of 77 cases (31%), the RAAA was treated with EVAR. Preoperative systolic blood pressure recordings in EVAR patients showed median values (± SD) of 98 (± 34.7) mm Hg in the emergency department and 114 (± 26.2) mm Hg in the operating theater. The desired systolic blood pressure range of 50 to 100 mm Hg was reached in 11 of 24 cases (46%). In 13 of 24 cases (54%), a systolic blood pressure higher than 100 mm Hg was recorded for a period longer than 60 minutes. The 30-day mortality was 32 of 77 (42%), with 6 of 24 (25%) in the EVAR group and 26 of 53 (49%) in the OAR group. This is the first published series of RAAA in which a protocol of permissive hypotension has been adopted. The concept appeared to be feasible in the majority of cases. Protocol violations were sparse (n = 5). Uncontrolled hypotension occurred in 36% (28 of 77) of all patients, and the desired systolic blood pressure range was achieved in 46% (11 of 24) of the EVAR patients.

Metastatic potential of an aneurysmal bone cyst

Aneurysmal bone cysts (ABCs) are benign bone tumors consisting of blood-filled cavities lined by connective tissue septa. Recently, the hypothesis that ABCs are lesions reactive to local hemodynamics has been challenged after the discovery of specific recurrent chromosomal abnormalities. Multiple cases of malignant transformation of ABC into (osteo)sarcoma have been described, as well as a number of cases of telangiectatic osteosarcoma which had been misdiagnosed as ABC. We herewith document a case of a pelvic ABC metastatic to the lung, liver, and kidneys. Diagnosis was confirmed by the presence of a break in the USP6 gene, which is pathognomonic for ABC, in a pulmonary metastasis of our patient. Sarcomatous transformation as an explanation for this behavior was ruled out by demonstrating diploid DNA content in both the pulmonary lesion and the primary tumor.

Hemobilia as a Late Complication After Blunt Abdominal Trauma: A Case Report and Review of the Literature

BACKGROUNDnBleeding within the biliary tree, called hemobilia, is a rare complication after blunt hepatic trauma.nnnOBJECTIVESnTo report on a patient who developed hemobilia 1 month after a blunt abdominal injury and to discuss the diagnosis and treatment of hemobilia.nnnCASE REPORTnA 17-year-old boy presented with upper gastrointestinal bleeding caused by hemobilia 1 month after a blunt liver injury. Angiography revealed a pseudoaneurysm of the right hepatic artery, which was successfully treated with embolization.nnnCONCLUSIONSnThe diagnosis of hemobilia first requires consideration of the diagnosis, particularly in patients with previous abdominal trauma. Hemobilia should be included in the differential diagnosis of upper gastrointestinal bleeding. Investigations of choice include computed tomography scan followed by angiography. During angiography, treatment can be done by endovascular embolization.

Impact of dynamic computed tomographic angiography on endograft sizing for endovascular aneurysm repair.

Purpose: To quantify dynamic changes in aortoiliac dimensions using dynamic electrocardiographically (ECG)-gated computed tomographic angiography (CTA) and to investigate any potential impact on preoperative endograft sizing in relation to observer variability. Methods: Dynamic ECG-gated CTA was performed in 18 patients with abdominal aortic aneurysms. Postprocessing resulted in 11 datasets per patient: 1 static CTA and 10 dynamic CTA series. Vessel diameter, length, and angulation were measured for all phases of the cardiac cycle. The differences between diastolic and systolic aneurysm dimensions were analyzed for significance using paired t tests. To assess intraobserver variability, 20 randomly selected datasets were analyzed twice. Intraobserver repeatability coefficients (RC) were calculated using Bland-Altman analysis. Results: Mean aortic diameter at the proximal neck was 21.4±3.0 mm at diastole and 23.2±2.9 mm at systole, a mean increase of 1.8±0.4 mm (8.5%, p<0.01). The RC for the aortic diameter at the level of the proximal aneurysm neck was 1.9 mm (8.9%). At the distal sealing zones, the mean increase in diameter was 1.7±0.3 mm (14.1%, p<0.01) for the right and 1.8±0.5 mm (14.2%, p<0.01) for the left common iliac artery (CIA). At both distal sealing zones, the mean increase in CIA diameter exceeded the RC (10.0% for the right CIA and 12.6% for the left CIA). Conclusion: The observed changes in aneurysm dimension during the cardiac cycle are small and in the range of intraobserver variability, so dynamic changes in proximal aneurysm neck diameter and aneurysm length likely have little impact on preoperative endograft selection. However, changes in diameter at the distal sealing zones may be relevant to sizing, so distal oversizing of up to 20% should be considered to prevent distal type I endoleak.

Type III Endoleak Caused by Fabric Tear of a Zenith Endograft after Low-pressure Balloon Modeling

ulcer, along with oozing blood. Thereafter, the perforated area became infected, and the resulting sepsis caused the patient to deteriorate. The catheter was not surgically removed because the patient had the conditions of sepsis, liver cirrhosis, and postoperative status of partial gastrectomy with Billroth-II reconstruction. No attempt to remove the catheter was planned until his condition improved. However, he died of massive hemorrhage 11 days after the catheter perforation was recognized endoscopically. There are several complications related to hepatic arterial infusion chemotherapy such as catheter occlusion, hepatic arterial occlusion, catheter dislocation, and vascular injury, but duodenal perforation caused by an indwelling catheter is extremely rare (1– 4). Some authors have reported cases in which a surgically placed indwelling catheter perforated the duodenum (5–7). However, to our knowledge, few cases have been reported about duodenal perforation caused by an indwelling catheter implanted by Seldinger’s femoral approach. The process of catheter penetration into the duodenum in our case may have been as follows: the indwelling catheter tip was unstable in CHA and its migration was easy. The catheter tip mechanically stimulated the arterial intima, and the anticancer drug flowing from the tip further damaged the artery. The catheter gradually put pressure on the injured arterial wall and finally penetrated the duodenal wall into its lumen. Surgical removal of the catheter was necessary to prevent bleeding and improve the patient’s status. However, this removal was thought to be very difficult, because he had undergone a partial gastrectomy, as well as risky, because of his sepsis and liver cirrhosis. It was also impossible to remove the catheter with an angiographic technique. Weese et al (8) successfully removed a hepatic arterial infusion catheter from a duodenal ulcer by an endoscopic technique. However, the catheter was surgically advanced into the infraduodenal portion of the gastroduodenal artery, not through the CHA, and the port was placed in the abdominal wall nearby. These situations were far different from our case, in which the catheter was advanced into the CHA through the abdominal aorta via the right femoral artery, so the course of treatment was also different. It is important to know that duodenal perforation caused by an indwelling catheter is a very rare but critical complication of hepatic arterial infusion chemotherapy. When it is caused by a transfemoral approach, no treatment is available.