Tanzer Sancak

Gadodiamide as an Alternative Contrast Agent in Intravenous Digital Subtraction Angiography and Interventional Procedures of the Upper Extremity Veins

AbstractPurpose: Patients with renal insufficiency or other contraindications to iodine-based contrast agents present a significant management dilemma when angiography or interventional procedures are required. We describe the use of gadolinium as an alternative contrast agent for intravenous digital subtraction angiography (IV-DSA) and interventional procedures of the upper extremity veins. Methods: Sixteen patients with symptoms of with moderate renal insufficiency underwent digital subtraction angiography for upper extremity and subclavian venography. Angiographic studies were obtained using gadolinium as a contrast agent. In six patients we used stents. Results: Diagnostic images were obtained in all cases. No patient suffered a complication related to the use of gadolinium, and no patient demonstrated worsened renal function after the procedure. Conclusion: In the setting of a contraindication to iodine-based contrast agents, gadolinium represents an important alternative contrast material that allows for the visualization of and interventional procedures in the upper extremity veins.

Variations of Patient Doses in Interventional Examinations at Different Angiographic Units

PurposeWe analyzed doses for various angiographic procedures using different X-ray systems in order to assess dose variations.MethodsDose-area product (DAP), skin doses from thermoluminescent dosimeters and air kerma measurements of 308 patients (239 diagnostic and 69 interventional) were assessed for five different angiographic units. All fluoroscopic and radiographic exposure parameters were recorded online for single and multiprojection studies. Radiation outputs of each X-ray system were also measured for all the modes of exposure using standard protocols for such measurements.ResultsIn general, the complexity of the angiographic procedure was found to be the most important reason for high radiation doses. Skill of the radiologist, management of the exposure parameters and calibration of the system are the other factors to be considered. Lateral cerebral interventional studies carry the highest risk for deterministic effects on the lens of the eye. Effective doses were calculated from DAP measurements and maximum fatal cancer risk factors were found for carotid studies.ConclusionsInterventional radiologists should measure patient doses for their examinations. If there is a lack of necessary instrumentation for this purpose, then published dose reports should be used in order to predict the dose levels from some of the exposure parameters. Patient dose information should include not only the measured quantity but also the measured radiation output of the X-ray unit and exposure parameters used during radiographic and fluoroscopic exposures.

Correlation Between the Diameter of the Main Renal Artery and the Presence of an Accessory Renal Artery Sonographic and Angiographic Evaluation

Objective. To evaluate whether the diameter of the main renal artery is an indicator of the presence of an accessory renal artery in sonographic examination. Methods. Of cases undergoing renal intra‐arterial digital subtraction angiography for any reason, those with no renal arterial disease detected on digital subtraction angiography were included in the investigation. Accessory renal arteries were disclosed by digital subtraction angiographic examinations. The dimensions of the kidney were measured sonographically. The lowest, highest, and mean values of diameters of main renal arteries were determined by sonography and angiography in both the group with accessory renal arteries and the group without accessory renal arteries. Results. Of kidneys with sonographically normal dimensions, angiographic evaluation was made in 107, and sonographic evaluation was made in 97, the renal arteries of which could be visualized optimally. Both radiologic methods showed that diameters of main renal arteries were significantly smaller in the presence of the accessory renal artery (P < .001, Student t test, Mann‐Whitney U test, and receiver operating characteristic curve). Conclusions. In sonographic examination, the presence of the main renal artery with a diameter smaller than usual in a kidney with normal dimensions is indicative of the presence of an accessory renal artery. Taking this into account, we can obtain higher rates of detection of accessory renal arteries in sonographic examinations.

The role of contrast enhanced three-dimensional MR angiography in pulmonary sequestration

Pulmonary sequestration is a relatively rare but clinically significant form of congenital broncho-pulmonary foregut malformation. It is characterized by a segment of non-functioning lung parenchyma that receives its blood supply from anomalous systemic arteries. This report shows the role of contrast enhanced three-dimensional MR angiography, which demonstrated abnormal feeding artery to the sequestered from the thoracic aorta with draining pulmonary veins.

Cross-sectional imaging in ureter tumors: Findings and staging accuracy of various modalities

We present cross-sectional imaging findings in eight patients with ureter tumors. Eight patients were examined by computed tomography (CT), seven by ultrasonography (US), and five by magnetic resonance imaging (MRI). All the lesions were detected by the three modalities. All modalities were accurate in excluding the periureteral invasion and lymphadenopathy in Stages 1 and 2 tumors. While CT and MRI identified the periureteral invasion and lymphadenopathy in four patients with advanced tumors, US failed to show the local invasion in three of four patients. Nevertheless, enlarged retroperitoneal lymph nodes could be detected sonographically in the three Stage 4 tumors. CT and MRI appear to have a high diagnostic sensitivity and staging accuracy in ureter tumors. Although US detects ureter tumors efficiently, this technique seems to be unreliable in showing local invasion in a substantial number of patients.

Endovascular Stent-Graft Treatment of a Traumatic Vertebral Artery Pseudoaneurysm and Vertebrojugular Fistula

An endovascular intervention is a feasible alternative to the technically challenging conventional surgery for the treatment of traumatic vertebral arterial lesions. This report describes a rare case involving a 22-year-old patient with a traumatic vertebral arterial pseudoaneurysm and multiple arteriovenous fistulas which were successfully sealed using the endovascular stent-graft technique.

Ruptured aneurysm of the posterior spinal artery of the conus medullaris.

A case of a posterior spinal artery aneurysm of the conus medullaris is presented. The patient presented with severe lower back pain with radiation into the right leg. Spinal angiography was consistent with a partially thrombosed arteriovenous malformation (AVM) or an aneurysm. At operation a partially thrombosed aneurysm of the posterior spinal artery was found at the level of conus medullaris, which, after review of the literature, is the first case treated with total microsurgical excision.

Fast MRI evaluation of pulmonary progressive massive fibrosis with VIBE and HASTE sequences: comparison with CT.

PURPOSE The aim of this prospective study was to evaluate the diagnostic utility of volumetric interpolated breath-hold examination (VIBE) and half-Fourier-acquisition single-shot turbo spin-echo (HASTE) fast magnetic resonance imaging (MRI) sequences in the evaluation of pulmonary progressive massive fibrosis (PMF) in comparison with computed tomography (CT) imaging. If fast MRI is proven to be diagnostically significant, this modality can be used for diagnosis and follow-up studies of PMF patients. MATERIALS AND METHODS Twenty-two PMF lesions from 20 coal workers were evaluated. After CT imaging, patients underwent pre-contrast VIBE, contrast-enhanced VIBE, and HASTE MRI studies for detection and evaluation of the PMF lesions. Measurements of the three groups were evaluated with intra-class coefficients. Correlation levels between sizes, image quality, and artifact were evaluated with linear Pearson correlation analysis. RESULTS There was almost perfect agreement among radiologists for lesion detection with kappa analysis. There was significant agreement between three MRI study groups and gold standard CT images. We found the best agreement values with contrast- enhanced VIBE images for lesion detection and image quality in comparison with CT imaging. Presence of artifact was also lowest with this protocol. CONCLUSION With fast MRI sequences in pulmonary imaging, image quality has significantly improved being very close to that of CT studies. In this study, contrast-enhanced VIBE protocol provided the best depiction of PMF lesions. This protocol may be an alternative choice for CT, avoiding the use of iodinated contrast material and minimizing exposure to ionizing radiation for follow-up studies.PURPOSE The aim of this prospective study was to evaluate the diagnostic utility of volumetric interpolated breath-hold examination (VIBE) and half-Fourier-acquisition single-shot turbo spin-echo (HASTE) fast magnetic resonance imaging (MRI) sequences in the evaluation of pulmonary progressive massive fibrosis (PMF) in comparison with computed tomography (CT) imaging. If fast MRI is proven to be diagnostically significant, this modality can be used for diagnosis and follow-up studies of PMF patients. MATERIALS AND METHODS Twenty-two PMF lesions from 20 coal workers were evaluated. After CT imaging, patients underwent pre-contrast VIBE, contrast-enhanced VIBE, and HASTE MRI studies for detection and evaluation of the PMF lesions. Measurements of the three groups were evaluated with intra-class coefficients. Correlation levels between sizes, image quality, and artifact were evaluated with linear Pearson correlation analysis. RESULTS There was almost perfect agreement among radiologists for lesion detection with kappa analysis. There was significant agreement between three MRI study groups and gold standard CT images. We found the best agreement values with contrast- enhanced VIBE images for lesion detection and image quality in comparison with CT imaging. Presence of artifact was also lowest with this protocol. CONCLUSION With fast MRI sequences in pulmonary imaging, image quality has significantly improved being very close to that of CT studies. In this study, contrast-enhanced VIBE protocol provided the best depiction of PMF lesions. This protocol may be an alternative choice for CT, avoiding the use of iodinated contrast material and minimizing exposure to ionizing radiation for follow-up studies.

Placement of an Inferior Vena Cava Filter in a Patient with Azygos Continuation Complicated by Pulmonary Embolism

A 53-year-old man presented with dyspnea, hemoptysis, and a painful, swollen left leg. During physical examination the left leg was tender. He had a history of inguinal hernia 1 month previously. Tests for thrombophilia, including protein C, protein S, antithrombin III, homocysteine, antiphospholipid antibody, and tumor markers, were all within normal limits. Thus, a thrombotic tendency was not detected. Duplex sonography of the lower extremities demonstrated multiple acute thrombi in the left deep venous system. The deep and superficial veins of the right leg were all patent. A contrast-enhanced CT scan showed extensive thrombosis in the right and left main pulmonary arteries, and lack of contiguity between the prerenal and the hepatic segments of the IVC. An enlarged azygos vein (Fig. 1) and a retroaortic left renal vein were also identified. The pulmonary and cardiac pattern did not show any congenital anomalies. A diagnosis of infrahepatic IVC interruption with azygos continuation was made. The patient was given anticoagulation therapy with intravenous unfractionated heparin and oral warfarin. He was discharged after a short hospitalization. However, 6 months later he returned to the hospital complaining of bilateral leg swelling and pain. Duplex sonography showed multiple thrombi in the deep venous structures of both lower extremities. Placement of an IVC filter for prophylaxis against PE was suggested because deep venous thrombosis (DVT) had progressed despite adequate anticoagulant therapy. A right transfemoral inferior vena cavogram performed with 6 Fr pigtail catheter to determine the level of the renal veins prior to filter placement, demonstrated the enlarged azygos vein draining into the superior vena cava (SVC) (Fig. 2). The right common femoral vein was used as a route for placement of a TrapEase filter (TrapEase, Cordis Europa, Roden, The Netherlands). A guidewire was directed, under fluoroscopic guidance, beyond the orifices of the renal veins into the enlarged azygos vein. The hemiazygos and paravertebral collateral veins were not enlarged. The TrapEase filter carrier was then passed over the guidewire, and the filter was discharged at the level of the third lumbar vertebra (Fig. 3). A final venogram revealed continued patency of the azygos vein following placement of the filter. In the 6 months since the placement of the filter, there has been no clinical evidence of pulmonary emboli. On follow-up abdominal radiographs, there has been no evidence of filter migration.

Stent angioplasty of closed mesocaval shunt in a patient with Budd-Chiari syndrome.

Abstract Budd-Chiari syndrome (BCS) is an uncommon disorder caused by hepatic venous outflow obstruction. It is characterized by ascites, hepatomegaly and abdominal pain. Percutaneous interventions have recently been used for the treatment of BCS. We present a case of BCS with a closed mesocaval shunt which was reopened with a self-expandable metallic stent.