Tomasz Jargiełło

Changes in cerebral hemodynamics after carotid stenting: evaluation with CT perfusion studies

PURPOSE To determine changes in cerebral perfusion parameters, based on CT perfusion imaging, in patients after unilateral transluminal angioplasty and stent placement. MATERIAL AND METHODS 74 patients with symptomatic high - grade internal carotid artery stenosis (>70%) were studied with CT perfusion imaging before and - on average - 70 hours and 172 days after carotid stent placement. There were 50 patients with unilateral carotid artery stenosis and 24 with stenosis and accompanying contralateral internal carotid artery occlusion. CT examination was performed using a multidetector helical CT scanner (Light Speed Ultra Advantage, GE Healthcare, USA). Maps showing the absolute values of cerebral blood flow (CBF), cerebral blood volume (CBV) and mean transit time (MTT) were generated. RESULTS In a group with unilateral carotid artery stenosis perfusion deficits were present in 84% of patients, ipsilaterally to stenosis. MTT elongation was noted (6.2-6.8s) together with decreased values of CBF (40-46ml/100g/min) and slightly increased CBV (3.2ml/100g). In this group, 3 days after stenting, 30% of patients had perfusion deficits, and after 6 months only 6%. In a group with carotid artery stenosis and contralateral artery occlusion severe perfusion deficits were noted in both hemispheres and they were present in 100% of patients. 6 months after stenting hypoperfusion was observed only in 17% of patients. CONCLUSIONS Brain perfusion deficits, observed in a majority of patients with carotid artery stenosis tend to improve considerably after carotid artery stenting, in long - term follow up.

Power Doppler imaging in the evaluation of extracranial vertebral artery compression in patients with vertebrobasilar insufficiency

OBJECTIVE The recent introduction of Power Doppler Imaging (PDI) made a promise for better visualization of blood vessels lying in regions anatomically difficult for ultrasound imaging, i.e. vertebral arteries. The purpose of our study was to assess usefulness of PDI technique in visualization of vertebral artery course and to assess its utility in the detecting spondylotic vertebral artery compression in patients with vertebrobasilar insufficiency (VBI). METHODS A total of 428 patients with VBI symptoms was evaluated. A total of 282 (66%) patients related their symptoms to a specific head position. Thus, all Doppler examinations were performed in four head positions: hyperextension, flexion and right/left rotation and also in a position reported by a patient to produce symptoms. PDI technique was employed as vertebral artery mapping for precise PW-Doppler range gate placing. RESULTS Vertebral artery compression was found in 73 (17%) patients: 65 unilateral and eight bilateral. The diagnosis was based on flow decrease or its absence shown on PW-Doppler scans, after a specific head turning. CONCLUSION Vertebral artery compression, related to a specific head position is relatively frequent in patients with VBI symptoms, especially in an older population commonly suffering from cervical spondylosis. PDI facilitates noninvasive Doppler US diagnosis by showing the real course of vertebral artery, particularly its intertransverse portion.

Endovascular transcatheter embolization of recurrent postsurgical varicocele: anatomic reasons for surgical failure.

Background Formation or pre-existence of collateral gonadal veins in varicocele patients has been reported as the main cause of surgical treatment failure. Purpose To describe venographic findings in patients with postsurgical recurrent varicoceles and to assess the efficacy of the following minimally invasive endovascular treatment. Material and Methods Thirty-three men with failed surgical treatment of left-sided varicocele were examined between 2006 and 2013, using retrograde venography to assess the anatomy of varicocele draining veins before the attempted transcatheter embolization. Anatomic variants of gonadal veins were categorized according to the classification modified for the purpose of the present study. 3% polidocanol was used as an embolic agent together with pushable fibered coils. Results In 31 (93%) out of 33 patients venography demonstrated incompetence of the gonadal vein or veins draining varicoceles after failed surgical treatment. The most frequent venographic finding was gonadal vein duplication – 66% of cases (39% in its mid-portion). Technical success of embolization was achieved in all 31 patients. No major complications were observed. Conclusion Retrograde varicocele embolization may be superior to surgery because of its ability to detect gonadal vein variants. In our study group, transcatheter embolization with 3% polidocanol and fibered coils allowed successful, minimally invasive treatment of postsurgical varicoceles.

The diagnostic value of levovist in Doppler imaging of visceral arteries in patients with abdominal angina before and after angioplasty.

PURPOSE To assess the diagnostic value of Levovist in the ultrasound imaging of visceral arteries in patients with clinical symptoms of abdominal angina, before and after percutaneous transluminal angioplasty (PTA). MATERIAL AND METHOD During a 12-month period (2000/2001) five patients with visceral arterial stenoses had ultrasound examinations and a subsequent PTA procedure. Indications for ultrasound examination were abdominal angina symptoms persisting for 3-5 years, (postprandial abdominal pain, diarrhea, and vomiting). In all patients ultrasound examinations were performed using color and spectral Doppler before and after Levovist injections. Color Doppler images and maximum blood flow velocity in stenosed visceral arteries were assessed. Patients underwent control Doppler examinations with Levovist injections to assess the effect of PTA. RESULTS In three patients conventional Doppler examination did not allow proper evaluation of visceral arteries, because of weak color and spectral Doppler signal and in two remaining patients visceral arteries were not visualized at all. In all five patients strong enhancement of color and spectral Doppler signal was observed after Levovist administration. In all these cases a hemodynamically significant stenosis was diagnosed: coeliac trunk-2 and superior mesenteric artery-3. PTA was performed successfully in these patients. In one of them ultrasound examination done before Levovist injection allowed good visualization of treated SMA and showed good PTA result. In the remaining four patients Doppler examination with the use of Levovist demonstrated visceral arteries well and confirmed successful PTA procedures. CONCLUSIONS The use of Levovist makes the diagnostic efficiency of Doppler examinations much higher. In most cases it allows an unequivocal diagnosis of visceral artery stenosis in patients with abdominal angina symptoms. The Doppler examination with the use of Levovist is the method of choice in follow-up after PTA.

Head and neck cancer: Value of perfusion CT in depicting primary tumor spread

Summary Background The aim of this study was to assess head and neck squamous cell cancer and surrounding tissue in computed tomography contrast enhanced and perfusion studies, and to examine the role of perfusion imaging in depiction of tissue infiltration. Material/Methods We prospectively evaluated 43 primary malignant head and neck tumors, using standard CT followed by perfusion. Blood flow, blood volume, mean transit time, and permeability values were obtained using regions of interest (ROIs) over lesions and surrounding tissue. Results were compared with histological analysis of resected tissue. Sensitivity, specificity, accuracy, positive and negative predictive values were calculated for both methods. Results We found significant differences between infiltrated and non-infiltrated tissue, especially with regard to muscles. In case of bone and salivary gland infiltration, change in perfusion parameters did not allow proper diagnosis. Conclusions CTP shows promise in depicting malignant infiltration. The combined use of CECT plus CTP results in correct staging of the majority of head and neck tumors.

Saccular Aneurysm of Superior Vena Cava Treated with Percutaneous, Transcatheter Thrombin Injection

We report the case of successful endovascular treatment of large saccular aneurysm of SVC in a patient with vascular malformation of right hand and chest. Considering the high risk of surgery, the patient was referred for percutaneous intervention. Venography showed communication between the aneurysm and SVC, just below brachiocephalic confluence. That is why the decision of balloon-protected transcatheter thrombin injection was made. Selective catheter was placed in the aneurysm and balloon occlusion catheter in SVC. Both catheters were withdrawn right after thrombin injection. During follow-up, aneurysm slightly enlarged in early observation and after a year shrinkage was observed.

Embolisation in the Therapy of Post-Partum Haemorrhage in a Patientwith a Massive Myoma

Study background: The world prevalence of post-partum haemorrhage is approx. 10.5% of pregnancies, and it is the leading mortality cause among young women, accounting for approx. 25% of fatalities. Post-partum haemorrhage is defined as over 500 ml blood loss from genitals, occurring within the first 24 hours post partum. The presented case is an example of efficacy of the embolisation procedure in the management of post-partum haemorrhage. A 29-y.o. female patient was referred to the hospital in her third pregnancy. Because of the presence of a massive myoma the patient was qualified for delivery by Caesarean section. The child was delivered. The uterine muscle was sutured. Haemostasis control - no signs of active bleeding. Three hours after the Caesarean section a massive postpartum haemorrhage developed. Oxytocin and Methylergometrin were administered intravenously, and Mizoprostol per rectum. The bleeding from the uterine cavity was still massive, and a decision was made on embolisation of uterine arteries. Methods: The procedure was performed with access via the right femoral artery, under local anaesthesia. A selective injection of a contrast medium to the left uterine artery was performed, which allowed visualisation of the uterine vascular bed with the myoma, as well as of the site of the active, massive bleeding. First the left uterine artery was embolised with particles, in order to close the vascular bed of the myoma. Then, a part of the vessel supplying the uterine muscle with the bleeding site, was closed with Spongostan gel. Results: Control angiography indicated a correctly closed left uterine artery, with no filling of the uterine vascular bed. No other sites of bleeding were detected. Conclusion: The selective embolisation of vessels in course of a postpartum haemorrhage in that case was a safe, minimally invasive and highly effective therapeutic method, that ensures an option of further pregnancies.

Uterine artery embolisation for the treatment of symptomatic uterine fibroids

Introduction. Uterine fibroids are the most common benign uterine tumours which can be treated with conservative, surgery or minimally invasive methods. Selection of patients for embolisation seems to be essential. Aim. Assessment of efficacy and safety of uterine artery embolisation with hydrogel microparticles coated with an anti-inflammatory agent for reduction in symptomatic uterine fibroid volumes. Material and methods. In the prospective observational study carried out between January 2011 and December 2013, 206 patients with symptomatic fibroids were qualified for uterine artery embolisation. 118 aged 32 to 51 (average 39), who reported for follow-ups 3-4 months after procedures, were evaluated. According to the number of fibroids, patients with 2/4 fibroids predominated (78 patients), followed by those with single fibroids (25) and with myomatous uteri (14 patients). According to fibroid sizes, 4 groups were distinguished: < 7 cm in 77 patients, 7-12 cm in 19, > 12 cm in 8, and myomatous uteri in 14 patients Results. A mean decrease in fibroid volume in the entire study population was 62%, ranging from 9% in the patient with a hyalinised fibroid to 100% in patients with separated submucosal fibroids. Conclusions. UAE is a safe and effective treatment for symptomatic uterine fibroids. In addition to reducing the symptoms, significantly reduces their volume. The key to success is proper qualification, as well as cooperation between the radiologist and the gynecologist.

A new option for endovascular treatment of leg ulcers caused by venous insufficiency with fluoroscopically guided sclerotherapy.

Introduction Ulcers of lower legs are the most bothersome complication of chronic venous insufficiency (CVI). Aim To assess the effectiveness of endovascular fluoroscopically guided sclerotherapy for the treatment of venous ulcers. Material and methods Thirty-eight limbs in 35 patients with crural venous ulcers were treated with guided sclerotherapy under the control of fluoroscopy. Patients with non-healing ulcers in the course of chronic venous insufficiency, with and without features of past deep vein thrombosis, were qualified for the study. Doppler ultrasound and dynamic venography with mapping of venous flow were performed. Ambulatory venous pressure measurements, leg circumference and varicography were performed just before and following the procedure. Results In 84% of cases, ulcers were treated successfully and healed. Patients with post-thrombotic syndrome (n = 17) healed in 13 (76.5%) cases, whereas patients without post-thrombotic syndrome (n = 21) healed in 19 (90.5%) cases. The mean time of healing of an ulcer for all patients was 83 days (in the first group it was 121 days and in the second group 67 days). Recurrence of an ulcer was observed in 10 limbs: 6 cases in the first group and 4 cases in the second group. Occurrence of deep vein thrombosis associated with the procedure was not observed. Temporary complications were reported but none giving a serious clinical outcome. Conclusions Endovascular fluoroscopically guided sclerotherapy can be an alternative method of treatment of venous ulcers, especially in situations when surgical procedures or other options of treatment are impossible.

Management of carotid stenosis. History and today.

Internal carotid stenosis constitutes a significant clinical challenge, since it is the cause of 20–25% of ischemic brain strokes. The management of the internal carotid stenosis for many years has been raising controversies amongst neurologists, vascular surgeons and interventional radiologists mainly due to the introduction of endovascular stenting as an alternative to surgical treatment. Its application, however, requires knowledge of specific selection criteria for this kind of treatment as well as of the methods of monitoring patients after stent implantation into the internal carotid artery. Duplex Doppler ultrasound examination is currently a basis for the diagnosis of the arterial stenosis of precranial segments of the carotid arteries. It allows a reliable assessment of not only the course and morphology of the walls, but also of the hemodynamics of blood flow. Interventional treatment is applicable in patients with internal carotid stenosis of ≥70%, which is accompanied by an increase of the systolic flow velocity above 200 cm/s and the end-diastolic velocity above 50–60 cm/s in the stenotic lumen. In most cases, such a diagnosis in duplex Doppler ultrasound examination does not require any confirmation by additional diagnostic methods and if neurological symptoms are also present, it constitutes a single indication for interventional treatment. When deciding about choice of surgical or endovascular method of treatment, the following factors are of crucial importance: morphology of atherosclerotic plaque, its size, echogenicity, homogeneity of its structure, its surface and outlines. By means of ultrasound examinations, patients can be monitored after endovascular stent implantation. They enable evaluation of the degree of stent patency and allow for an early detection of symptoms indicating stenosis recurrence or presence of in-stent thrombosis. When interpreting the findings of the US checkup, it is essential to refer to the initial examination performed in the first days after the procedure and the next ones conducted during the monitoring period.