Uri Rimon

The role of ECG-gated MDCT in the evaluation of aortic and mitral mechanical valves: initial experience.

OBJECTIVEnThe objective of our study was to evaluate the role of ECG-gated MDCT in the functional evaluation of mechanical prosthetic aortic and mitral valves.nnnMATERIALS AND METHODSnTwenty sequential patients with 23 mechanical prosthetic valves were evaluated with an ECG-gated 40- or 64-MDCT scanner. Multiplanar reformation, maximal-intensity-projection, volume-rendering, and volume-averaging techniques were used for visualization of valve leaflets in systole and diastole. The visibility of each mechanical valve was evaluated by consensus of a radiologist and a cardiologist using a subjective 5-point scale (0-4). MDCT findings were correlated with fluoroscopic opening and closing angle measurements and echocardiographic pressure gradient measurements in 11 and 19 valves, respectively.nnnRESULTSnThe series included 18 bileaflet and five single-leaflet mechanical valves. The visibility score for the bileaflet mechanical valves was excellent (score of 4) in all 18 cases, but it was lower for single-leaflet valves (mean score, 2.8; range, 1-4) (p = 0.04). Bland-Altman plots showed high agreement between MDCT and fluoroscopy for measurements of opening and closing angles of bileaflet mechanical valves. In four patients, a stuck valve was seen on MDCT and was confirmed by fluoroscopy. Doppler echocardiography showed increased transvalvular pressure in two of the four patients with a stuck mitral valve and increased transaortic pressure in four patients with normal prosthetic aortic valve motion.nnnCONCLUSIONnOur preliminary results suggest that MDCT is a promising technique for functional evaluation of bileaflet mechanical valves, allowing reliable measurements of opening and closing leaflet angles. However, the role of MDCT in the evaluation of single-leaflet valves might be limited.

Prophylactic Pelvic Artery Catheterization and Embolization in Women with Placenta Accreta: Can It Prevent Cesarean Hysterectomy?

We present the outcome of a relatively large cohort of women with suspected placenta accreta who underwent prophylactic pelvic artery catheterization prior to cesarean section. All pregnant women with suspected placenta accreta who delivered in one tertiary center were included in this retrospective study. All patients underwent an elective cesarean section with prophylactic pelvic artery catheterization of internal iliac arteries through femoral or brachial approach. Thirty women underwent prophylactic catheterization; placenta accreta was clinically confirmed in 25 (83.3%) cases. Embolization was performed in 23 cases (76.6%) and hysterectomy in 2 (8%). Median estimated amount of blood loss was 2000 mL (500 to 9000 mL). There were no major catheterization-related complications. Three women had a subsequent pregnancy and uncomplicated delivery by cesarean section. Prophylactic pelvic artery catheterization and embolization in women with placenta accreta is safe and effective in prevention of hysterectomy and should be considered in woman wishing to preserve fertility.

Ethanol and Polyvinyl Alcohol Mixture for Transcatheter Embolization of Renal Angiomyolipoma

OBJECTIVEnThe purpose of this study was to assess the immediate and midterm effects of embolization of the angiogenic component of renal angiomyolipoma in which a mixture of ethanol and polyvinyl alcohol is used as a permanent obliterator.nnnMATERIALS AND METHODSnSeventeen patients with 18 renal angiomyolipomas (size range, 5.5-20 cm; mean size, 10 cm) were treated with transcatheter embolization over an 8-year period. Embolization was performed with a mixture of 96% ethanol and polyvinyl alcohol particles. Follow-up with CT (mean follow-up period, 22.4 months) and one (mean, 14 months) or two (mean, 27 months) angiographic examinations were conducted to evaluate changes in the size of the tumor and to look for recurrence of the angiogenic component.nnnRESULTSnAll initial angiograms showed the characteristic tortuous, hypervascular, and aneurysm-forming angiogenic component. Immediate complete obliteration was achieved in 17 tumors (94.4% technical success rate). There was one partial technical failure. Mean tumor size was reduced to 7.6 cm (mean size reduction, 24%). Fourteen patients with 15 tumors underwent one angiographic follow-up examination (mean time after treatment, 14 months), and four patients underwent two angiographic follow-up examinations (mean time after treatment, 27 months). Reduction of the angiogenic component occurred in 10 (66.6%) of the tumors and complete obliteration in five (33.3%) of the tumors. No retroperitoneal hemorrhage or tumor growth was seen during the follow-up period. No complications were encountered.nnnCONCLUSIONnWe found a mixture of ethanol and polyvinyl alcohol an efficient embolizing agent with a sustained midterm effect in the management of renal angiomyolipoma. Repeated embolization was needed in tumors with a large angiogenic component. Tumor shrinkage after embolization was minimal.

Percutaneous Transhepatic Endoscopic Holmium Laser Lithotripsy for Intrahepatic and Choledochal Biliary Stones

PurposeTo report our approach for treating complicated biliary calculi by percutaneous transhepatic endoscopic biliary holmium laser lithotripsy (PTBL).Patients and MethodsTwenty-two symptomatic patients (11 men and 11 women, age range 51 to 88xa0years) with intrahepatic or common bile duct calculi underwent PTBL. Nine patients had undergone previous gastrectomy and small-bowel anastomosis, thus precluding endoscopic retrograde cholangiopancreatography. In the other 13 patients, stone removal attempts by ERCP failed due to failed access or very large calculi. We used a 7.5F flexible ureteroscope and a 200-μm holmium laser fiber by way of a percutaneous transhepatic tract, with graded fluoroscopy, to fragment the calculi with direct vision. Balloon dilatation was added when a stricture was seen. The procedure was performed with the patient under general anaesthesia. A biliary drainage tube was left at the end of the procedure.ResultsAll stones were completely fragmented and flushed into the small bowel under direct vision except for one patient in whom the procedure was aborted. In 18 patients, 1 session sufficed, and in 3 patients, 2 sessions were needed. In 7 patients, balloon dilatation was performed for benign stricture after Whipple operation (nxa0=xa03), for choledochalenteric anastomosis (nxa0=xa03), and for recurrent cholangitis (nxa0=xa01). Adjunctive “balloon push” (nxa0=xa04) and “rendezvous” (nxa0=xa01) procedures were needed to completely clean the biliary tree. None of these patients needed surgery.ConclusionComplicated or large biliary calculi can be treated successfully using PTBL. We suggest that this approach should become the first choice of treatment before laparoscopic or open surgery is considered.

Retrievable Vena Cava Filters in Major Trauma Patients: Prevalence of Thrombus Within the Filter

The purpose of this study was to report the prevalence of thrombus within a retrievable vena cava filter inserted prophylactically in major trauma patients referred for filter extraction. Between November 2002 and August 2005, 80 retrievable inferior vena cava filters (68 Optease and 12 Gunther-Tulip) were inserted into critically injured trauma patients (mean injury severity score 33.5). The filters were inserted within 1 to 6 (mean 2) days of injury. Thirty-seven patients were referred for filter removal (32 with Optease and 5 with Gunther-Tulip). The indwelling time was 7 to 22 (mean 13) days. All patients underwent inferior vena cavography prior to filter removal. There were no insertion-related complications and all filters were successfully deployed. Forty-three (54%) of the 80 patients were not referred for filter removal, as these patients continued to have contraindications to anticoagulation. Thirty-seven patients (46%) were referred for filter removal. In eight of them (22%) a large thrombus was seen within the filters and they were left in place, all with the Optease device. The other 29 filters (36%) were removed uneventfully.We conclude that the relatively high prevalence of intrafilter thrombi with the Optease filter may be explained by either spontaneous thrombus formation or captured emboli.

Endovascular Management of Mycotic Aortic Aneurysms

Purpose: We report a single-center experience with the endovascular management of mycotic aortic aneurysms. Case reports: Four cases of mycotic aortic aneurysms are described; all treated with endovascular stent graft with variable configurations. All patients underwent successful placement of stent grafts for their aneurysms. No 30-day perioperative mortality was observed. One patient died during the follow-up period from a cause unrelated to the aneurysm. Conclusion: Repair of mycotic aneurysms can be accomplished with endovascular repair. This may be a valid alternative to open repair particularly in patients who are not candidates for conventional open repair.

Histology of Tissue Adherent to OptEase Inferior Vena Cava Filters Regarding Indwelling Time

The purpose of this paper is to report on the histology of tissues found on retrieved filters with regard to indwelling time. Between February 2006 and January 2007, 28 Optease inferior vena cava filters (Cordis Europa, Roden, The Netherlands) were retrieved from 27 patients. Twenty-two filters were inserted prophylactically for trauma patients and six for patients with venous thromboembolism. Cavography was performed both before and after filter removal to evaluate the presence of thrombi or wall damage. Filters were retrieved with the snare and sheath method. All material adherents to the filters were examined histologically.The mean indwelling time of the filters was 24.9xa0days (range, 6–69xa0days). Red tissue fragments were seen on all the filters, consistent microscopically with clots and fibrin. On five filters (18%; mean indwelling time, 45.4xa0days) white tissue consistent with vascular intima was found. All postprocedure cavographies were normal. We conclude that most material adherent to the retrieved filters is thrombi, while vascular intima can be found in the minority of filters with a longer indwelling time.

Magnetic resonance imaging of pelvic entheses—a systematic comparison between short tau inversion recovery (STIR) and T1-weighted, contrast-enhanced, fat-saturated sequences

ObjectiveTo assess the contribution of contrast material in detecting and evaluating enthesitis of pelvic entheses by MRI.Materials and methodsSixty-seven hip or pelvic 1.5-T MRIs (30:37 male:female, mean age: 53xa0years) were retrospectively evaluated for the presence of hamstring and gluteus medius (GM) enthesitis by two readers (a resident and an experienced radiologist). Short tau inversion recovery (STIR) and T1-weighted pre- and post-contrast (T1+Gd) images were evaluated by each reader at two sessions. A consensus reading of two senior radiologists was regarded as the gold standard. Clinical data was retrieved from patients’ referral form and medical files. Cohen’s kappa was used for intra- and inter-observer agreement calculation. Diagnostic properties were calculated against the gold standard reading.ResultsA total of 228 entheses were evaluated. Gold standard analysis diagnosed 83 (36xa0%) enthesitis lesions. Intra-reader reliability for the experienced reader was significantly (pu2009=u20090.0001) higher in the T1+Gd images compared to the STIR images (hamstring: ku2009=u20090.84/0.45, GM: ku2009=u20090.84/0.47). Sensitivity and specificity increased from 0.74/0.8 to 0.87/0.9 in the STIR images and T1+Gd sequences. Intra-reader reliability for the inexperienced reader was lower (pu2009>u20090.05).ConclusionsEvidence showing that contrast material improves the reliability, sensitivity, and specificity of detecting enthesitis supports its use in this setting.

Percutaneous transhepatic lithotripsy with the holmium: YAG laser for the treatment of refractory biliary lithiasis.

Fourteen patients who failed at least 1 endoscopic retrograde cholangiopancreatograpy attempt underwent Holmium laser biliary lithotripsy between 2003 and 2007. Ten had prior biliary surgeries, 7 harbored multiple stones, and 6 had common bile duct strictures. Mean age at surgery was 63.6 years (50 to 80u2009y), biggest stone burden 30u2009mm, mean operative time 58.4 minutes (24 to 105), and stone free rate 85.7%. One patient had postoperative bleeding from the choledochostomy tube that eventually resolved spontaneously and 3 patients had postoperative cholangitis managed conservatively. Neither conversions to open surgery nor mortality was recorded. Two patients were diagnosed with cholangiocarcinoma missed by previous endoscopic retrograde cholangiopancreatograpy. After a mean follow-up of 18.9 months (2 to 43) no de novo strictures were recorded. Percutaneous choledochoscopy with holmium laser lithotripsy is a safe and effective minimally invasive technique to treat complex biliary stone disease and may preclude high-risk open biliary tract surgery.

The Use of ExoSeal Vascular Closure Device for Direct Antegrade Superficial Femoral Artery Puncture Site Hemostasis

PurposeThis study was designed to assess the efficacy and safety of the ExoSeal vascular closure device (VCD) to achieve hemostasis in antegrade access of the superficial femoral artery (SFA).MethodsWe retrospectively reviewed the outcome of ExoSeal VCD used for hemostasis in 110 accesses to the SFA in 93 patients between July 2011 and July 2013. All patients had patent proximal SFA based on computer tomography angiography or ultrasound duplex. Arterial calcifications at puncture site were graded using fluoroscopy. The SFA was accessed in an antegrade fashion with ultrasound or fluoroscopic guidance. In all patients, 5–7F vascular sheaths were used. The ExoSeal VCD was applied to achieve hemostasis at the end of the procedure. All patients were clinically examined and had ultrasound duplex exam for any puncture site complications during the 24xa0h postprocedure.ResultsIn all procedures, the ExoSeal was applied successfully. We did not encounter any device-related technical failure. There were four major complications in four patients (3.6xa0%): three pseudoaneurysms, which were treated with direct thrombin injection, and one hematoma, which necessitated transfusion of two blood units. All patients with complications were treated with anticoagulation preprocedure or received thrombolytic therapy.ConclusionsThe ExoSeal VCD can be safely used for antegrade puncture of the SFA, with a high procedural success rate (100xa0%) and a low rate of access site complications (3.6xa0%).