Louis Boyer

Placenta Accreta: Management with Uterine Artery Embolization in 17 Cases

PURPOSE To report on the management of placenta accreta with uterine artery embolization (UAE) and to analyze the outcomes. MATERIALS AND METHODS A retrospective study was performed over a 128-month period of all women with placenta accreta who underwent UAE in a single center. Seventeen patients were included, and they were further divided into two groups: a preventive group (diagnosis was made in the prenatal period, n = 6) and a curative group (diagnosis was made during delivery, n = 11). The mean patient age was 34.6 years +/- 5.5 in the preventive group and 31.4 years +/- 4.3 in the curative group. The mean term of pregnancy was 35 weeks +/- 2 of amenorrhea in the preventive group and 38 weeks +/- 2 in the curative group. RESULTS The primary success of embolization was 100% in both groups. In the preventive group, massive bleeding occurred in a patient 2 days after unsuccessful manual placenta delivery resulted in an hysterectomy; in a second case, delayed bleeding (2 months after the procedure) was controlled with a second embolization. There were no episodes of repeat bleeding in the curative group. In the preventive group, two patients presented with uterine scarring, with synechiae in one and endometrial atrophy in the other. In the curative group, one patient presented with secondary amenorrhea. The delay before embolization was significantly different in the two groups (23.3 minutes +/- 5.1 in the preventive group vs 73 minutes +/- 44.7 in the curative group, P < .01), and total blood loss was 0.7 L +/- 0.8 in the preventive group and 2.6 L +/- 1.2 in the curative group (P < .01). CONCLUSIONS Prenatal diagnosis of placenta accreta permits its preventive management, which reduces time to embolization and blood loss.

Percutaneous Transluminal Angioplasty of Dysplastic Stenoses of the Renal Artery: Results on 70 Adults

Purpose: Retrospective analysis of the dilatation (PTRA) of renal arterial dysplastic stenosis (RADS). Methods: Seventy patients suffering from hypertension (87 RADS) were treated at our institution for medial (83%) or non-classified fibrodysplasias (17%). Four patients suffered from renal insufficiency. Two endoprostheses were implanted. We evaluated blood pressure with the USCSRH criteria and renal insufficiency with the Martin criteria. Results: Ninety-five percent technical success and 87.9% clinical success for blood pressure were obtained, with worse results for patients older than 57 years or with a history of hypertension greater than 9 years. Results were better when the RADS was responsible for an ipsilateral renal atrophy or for poorly controlled hypertension. No renal insufficiency worsened during the follow-up. Conclusion: PTRA is a first-line treatment for renovascular hypertension caused by RADS. The results were encouraging despite a high average age of the subjects and frequent associated extrarenal vascular lesions.

Diffusion‐weighted magnetic resonance imaging is effective to detect ileocolonic ulcerations in Crohn's disease

Magnetic resonance entero‐colonography enables accurate assessment of ileocolonic Crohns disease, but the need for bowel cleansing and rectal enema limits considerably its use in daily practice.

Origin and initial course of the renal arteries a radiological study

The aim of this study was to determine the topography of the origin, implantation angle and initial course of the renal arteries in the transverse and frontal planes, from a prospective analysis of angiograms and helical CT-scans of 40 patients. In the frontal plane, the implantation angles of the right and left renal arteries were 73.8 ± 17° axsnd 65.6 ± 16° respectively 17.9% of the right renal arteries were straight compared with only 5% of the left ones. The first sinuosity was observed to be at a distance greater than the aortic diameter for 43.6% of right renal arteries and at a distance less than the aortic diameter for 62.5% for the left renal a. In the transverse plane, the right renal a. had an implantation angle of 65.6 ± 15.7° compared with 95.7 ± 16.85% for the left renal a. The artery was rectilinear in 2.6% of the cases on the right side, and in 2.5% of the cases on the left. The first sinuosity occurred before the lateral margin of the spine was reached in 60.5% of right renal arteries and after the margin of psoas major muscle for 55% of left renal arteries. A knowledge of the anatomy of the origin and initial course of the renal arteries is important when considering vessel dilatation and the implantation of stents in the renal arteries. No correlation was observed between the origin, sinuosity or angulation of the renal arteries which could aid interventional procedures.

Postpartum Spontaneous Coronary Artery Dissection: A Case of Pseudoaneurysm Evolution Detected on MDCT

Postpartum Spontaneous Coronary Artery Dissection: A Case of Pseudoaneurysm Evolution Detected on MDCT Spontaneous coronary dissection predominantly affecting young women is rare but is often dramatic. A third of the cases occur at the end of pregnancy or during the postpartum period [1]. Its treatment remains empiric [2], usually depending on the symptoms, hemodynamic state, and angiography results. A 31-year-old woman, gravida 2, para 2, without medical history of cardiovascular disease or cardiovascular risk factors presented with an acute myocardial infarction 3 days postpartum. The angiography images obtained in the emergency department showed a left main artery dissection extending to the proximal left anterior descending (LAD) coronary artery with good distal flow and occlusion of the first diagonal artery. Once the patient received medical treatment, the initial clinical and ECG evolution were favorable. The next day, MDCT showed the same dissection with recanalization of the diagonal artery (Fig. 1A). The diagnosis was confirmed on angiography. At 6 weeks, MDCT showed a pseudoaneurysm of the left main artery in addition to the LAD artery dissection (Figs. 1B and 1C). Because of this fast evolution, we chose to treat the lesion with stenting guided by the MDCT images and measurements. After angiographic confirmation, the proximal LAD and left main arteries were treated using two short paclitaxel-eluting stents (3.5 × 8 and 4 × 8 mm; Taxus Express, Boston Scientific) to allow intimal flap correction and closure of the pseudoaneurysm. The stent placement showed satisfactory exclusion of the pseudoaneurysm, which was confirmed at 6 months using angiography and MDCT (Fig. 1D). At 1 year after stent placement, the patient remains asymptomatic. To our knowledge, this is the first observation of pseudoaneurysm complicating a spontaneous coronary dissection in which MDCT allowed an early diagnosis and was used to guide the therapeutic strategy. A B

Prévalence des sténoses des artères rénales dépistées au cours de coronarographies diagnostiques : dans quels cas doit-on réaliser une aortographie abdominale ?: À propos de 467 patients

PURPOSE To define a subgroup of patients at increased risk of renal artery stenosis (RAS) in a population of patients undergoing cardiac catheterization. MATERIALS AND METHODS A total of 467 patients (mean age of 64 Years +/-11) underwent cardiac catheterization and aortography Results were evaluated to detect correlations between the presence or absence of RAS and clinical and biological parameters. RESULTS A total of 42 (9%) patients had a renal artery stenosis. Univariate analysis defined parameters correlated with the presence of RAS: systolic blood pressure (p=0.03), pulse pressure (p=0.005), age (p<0.0001), creatinine clearance (p<0.0001), 2-vessel (p=0.028) and 3-vessel (p=0.037) coronary artery diseases. Multivariate analysis showed that the presence of RAS correlated to creatinine clearance (p=0.02) and 2-vessel coronary artery disease. A creatinine clearance between 30 and 60 ml/min and multi-vessel coronary artery disease defined a subgroup at increased risk of RAS with sensitivity, specificity, positive and negative predictive values of: 47.6, 90.1, 32.3 and 94.6%. The prevalence of renal artery stenosis was 5.2% when both parameters were absent. CONCLUSION Patients with mild renal insufficiency and multi-vessel coronary artery disease defined a subgroup of patients at increased risk of RAS (32.5%) that may benefit from abdominal aortography performed at the time of cardiac catheterization.

Reduced Radiation Dose with Model-based Iterative Reconstruction versus Standard Dose with Adaptive Statistical Iterative Reconstruction in Abdominal CT for Diagnosis of Acute Renal Colic.

PURPOSE To evaluate the accuracy of reduced-dose abdominal computed tomographic (CT) imaging by using a new generation model-based iterative reconstruction (MBIR) to diagnose acute renal colic compared with a standard-dose abdominal CT with 50% adaptive statistical iterative reconstruction (ASIR). MATERIALS AND METHODS This institutional review board-approved prospective study included 118 patients with symptoms of acute renal colic who underwent the following two successive CT examinations: standard-dose ASIR 50% and reduced-dose MBIR. Two radiologists independently reviewed both CT examinations for presence or absence of renal calculi, differential diagnoses, and associated abnormalities. The imaging findings, radiation dose estimates, and image quality of the two CT reconstruction methods were compared. Concordance was evaluated by κ coefficient, and descriptive statistics and t test were used for statistical analysis. RESULTS Intraobserver correlation was 100% for the diagnosis of renal calculi (κ = 1). Renal calculus (τ = 98.7%; κ = 0.97) and obstructive upper urinary tract disease (τ = 98.16%; κ = 0.95) were detected, and differential or alternative diagnosis was performed (τ = 98.87% κ = 0.95). MBIR allowed a dose reduction of 84% versus standard-dose ASIR 50% (mean volume CT dose index, 1.7 mGy ± 0.8 [standard deviation] vs 10.9 mGy ± 4.6; mean size-specific dose estimate, 2.2 mGy ± 0.7 vs 13.7 mGy ± 3.9; P < .001) without a conspicuous deterioration in image quality (reduced-dose MBIR vs ASIR 50% mean scores, 3.83 ± 0.49 vs 3.92 ± 0.27, respectively; P = .32) or increase in noise (reduced-dose MBIR vs ASIR 50% mean, respectively, 18.36 HU ± 2.53 vs 17.40 HU ± 3.42). Its main drawback remains the long time required for reconstruction (mean, 40 minutes). CONCLUSION A reduced-dose protocol with MBIR allowed a dose reduction of 84% without increasing noise and without an conspicuous deterioration in image quality in patients suspected of having renal colic.

Endovascular treatment of eight renal artery aneurysms

Background Renal artery aneurysms (RAA) are a relatively rare vascular entity. Treatment could be either surgical or via an endovascular route. The main aim of therapy is to prevent lethal rupture. Purpose To evaluate the angiographic and clinical results after endovascular treatment (EVT) of eight renal artery aneurysms. Material and Methods From January 2000 to June 2011, 18 patients presented with 18 renal artery aneurysms. One was classified as Rundback type I, 15 were type II, and two aneurysms were type III. Endovascular treatment was considered unsafe in 10 cases (all were Rundback type II), and were referred to surgery. The remaining eight aneurysms were treated endovascularly during altogether nine sessions. Among these, four patients were asymptomatic, three were hypertensive, and one presented with ipsilateral flank pains. Aneurysmal sac diameter varied between 12 and 50 mm. EVT included selective coil embolization in five cases, covered stents in two cases, and parent artery occlusion in one. Results Follow-up with CT angiography was obtained in all endovascularly treated aneurysms (range 6–54 months, mean 15 months). Complete durable occlusion was achieved in all aneurysms except one, which showed re-expansion after 20 months and was retreated with covered stent implantation. Clinically silent, branch occlusion occurred after four procedures with subsequent limited (less than 25%) ischemic parenchymal loss. All patients were discharged with preserved renal function. Clinical improvement was noted in all symptomatic patients. Conclusion Endovascular treatment of renal artery aneurysms is an adequate treatment and can be proposed, if feasible, as first step.

Placenta percreta: urologic complication after successful conservative management by uterine arterial embolization: a case report

We report a case of placenta accreta that was managed conservatively by uterine arterial embolization and subsequently was complicated by hematuria. Ultrasound revealed a calcified mass at the posterior bladder wall. A careful resection under cystoscopy was carried out without hemorrhagic complication. Pathologic examination showed placental tissue that confirmed placenta percreta.

Revascularization of traumatic renal artery dissection by endoluminal stenting: Three cases:

Traumatic injury of renal arteries is rare and can induce renal dysfunction and hypertension. Management options include observation, nephrectomy, surgical repair, and, more recently, percutaneous angioplasty. We report three cases of renal artery thrombosis occurring in young multitrauma patients (mean age 28.7 years) treated with stenting. Immediate satisfactory results were obtained in all cases. Postprocedure anticoagulant and antiplatelet treatment were given according to associated contraindicating lesions. During follow-up, in-stent restenosis occurred in one patient and was treated successfully with a second stenting procedure. No renal dysfunction or hypertension was observed after 28.6 months follow-up. Percutaneous angioplasty is a valuable alternative to surgical treatment in selected patients.