Surveillance of peripheral arterial bypass grafts with three-dimensional MR angiography: comparison with digital subtraction angiography.

OBJECTIVE: The purpose of this study was to use contrast-enhanced three-dimensional MR angiography to assess the patency of peripheral arterial bypass grafts of the lower extremity. SUBJECTS AND METHODS: The study included 39 patients with 45 lower limb grafts. Twenty-eight were saphenous vein grafts, 13 were expanded polytetrafluoroethylene, and two were Dacron grafts. Digital subtraction angiography correlation was available for 30 patients (31 grafts). MR angiography was performed on a 1.5-T system with a multichannel quadrature phased array peripheral vascular coil. The scanning delay was determined with a test bolus technique, using half-time to maximum signal intensity in the graft. Arterial imaging was accomplished with two three-dimensional MR angiography acquisitions with gadopentetate dimeglumine administered using an automated injector. The pelvic and femoral arteries were imaged, the MR table was repositioned, and the lower limb arteries were imaged. The three-dimensional MR angiography sequence used the following parameters: TR/TE, 5.2/1.5 msec; inversion time, 28 msec; flip angle, 30 degrees. The proximal anastomosis, graft, and distal anastomosis were characterized as normal, stenosed, occluded, or ectatic or aneurysmatic. RESULTS: Sensitivity and specificity values for MR angiography regarding the assessment of grafts were 100% for 87 evaluable segments for which digital subtraction angiography correlation was available: stenosis (n = 10), occlusions (n = 9), ectasia or aneurysms (n = 8). Six segments could not be assessed because of the presence of intravascular stents or metallic clips. CONCLUSION: Contrast-enhanced three-dimensional MR angiography is well suited for the characterization of arterial grafts, for planning subsequent vascular interventions, and for excluding further lesions.

Repair of infrapopliteal postembolectomy complications with variant embolization techniques.

Infrapopliteal pseudoaneurysms and arteriovenous fistulae are known complications of Fogarty balloon embolectomy. Management of these complications in two patients with associated critical foot ischemia by modified interventional embolization techniques is described.

Leg ulcers in peripheral arterial disease (arterial leg ulcers): impaired wound healing above the threshold of chronic critical limb ischemia.

BACKGROUND: Peripheral arterial disease is the only identifiable etiology in approximately 10% of leg ulcers. Clinical data on the management of these chronic wounds are scarce. OBJECTIVE: We attempted to outline the threshold of systolic ankle pressure and ankle-brachial-index (ABI) below which arterial leg ulcers can occur and to outline the indication for revascularization in arterial leg ulcers. METHODS: Diagnostic and outcome analysis was performed for 26 consecutive patients with arterial leg ulcers. We calculated sensitivities, specificities, and receiver operating characteristic (ROC) curves for the identification of arterial leg ulcers among all 223 consecutive leg ulcer patients within a 3-year period, as well as the ROC curve for patients who required revascularization. RESULTS: The systolic ankle pressure was 88 (18-130) mm Hg (median; 95% confidence interval) and the ABI was 0.60 (0.15-0.86), respectively. Eighteen patients (69%) were subjected to revascularization. By the end of the study, 24 patients (92%) healed completely, 1 improved (90% wound closure), and 1 patient had to undergo below-knee amputation for chronic osteomyelitis. During this study, the ankle pressure and ABI were poor in distinguishing those patients who required revascularization from those who healed without revascularization. CONCLUSION: Most arterial leg ulcers do not meet the criteria of chronic critical limb ischemia, but they do not heal under conservative measures, either. A majority of these patients benefit from revascularization and should, therefore, be referred for arterial duplex ultrasound investigation or angiography. In our study, an ankle pressure below 110 mm Hg identified all patients (100%) who were subjected to revascularization procedures. However, controlled clinical studies are required to find the systolic ankle pressure and ABI below which revascularization can be recommended to speed up the healing time.

Management of leg ulcers in patients with rheumatoid arthritis or systemic sclerosis: the importance of concomitant arterial and venous disease.

PURPOSE: We assessed the etiology and the prevalence of peripheral arterial and venous disease in leg ulcers in patients with rheumatoid arthritis and systemic sclerosis and analyzed the outcome after treatment of macrovascular disease. METHODS: A clinical study on 15 consecutive patients with chronic leg ulcers in collagen vascular disease (nine patients with rheumatoid arthritis, six patients with systemic sclerosis) was carried out in a referral center. Angiography was used when the ankle-arm index was less than 0.8; venography was used when venous reflux was detectable by means of a hand-held Doppler examination. Therapies included percutaneous transluminal angioplasty (seven patients), femoropopliteal bypass grafting surgery (one patient), saphenectomy of the greater saphenous vein (six patients), and split skin graft (11 patients). RESULTS: All patients with rheumatoid arthritis exhibited a multifactorial etiology of their ulcers: four of nine patients had peripheral arterial disease, and five of nine patients had venous insufficiency. In one of these patients, arterial and venous disease was combined. Five of six patients with systemic sclerosis exhibited a multifactorial etiology of their ulcers: three of six patients had peripheral arterial disease, and three of six patients had venous insufficiency. One of these patients had both arterial and venous disease. In patients with rheumatoid arthritis, healing was achieved in six of nine patients, and marked improvement occurred in two of nine patients. A below-knee amputation was necessary in one patient with rheumatoid vasculitis. In patients with systemic sclerosis, healing was achieved in three of six patients, and marked improvement occurred in the other three patients. CONCLUSION: Most leg ulcers in patients with rheumatoid arthritis and systemic sclerosis disclose a multifactorial etiology. Relevant arterial and venous disease can be found in approximately half the patients. Our study suggests that revascularization and vein surgery improve the healing of leg ulcers in patients with collagen vascular disease. A prospective trial is now required to confirm these results.

Juxtaacetabular ganglion as a differential diagnosis in pulsating groin masses.

Ganglion cysts of the hip joint are uncommon synovial-lined fluid-filled juxtaarticular groin lesions. Whereas in the past the correct diagnosis was often made only at surgery there are now valuable imaging methods used for the diagnostic work-up. In experienced hands ultrasonography (US) combined with colour duplex Doppler ultrasonography (CDDS) as a real-time imaging technique easily performed at the patient's bedside is a valid alternative to more expensive or invasive investigations. We report on a patient who presented with a ganglion cyst and in whom first supported by conventional US an aneurysm of the femoral artery was suspected. The diagnosis of a juxtaarticular ganglion was subsequently correctly made at our institution by CDDS and magnetic resonance imaging, respectively, and the cyst was exstirpated successfully. The differential diagnosis of a pulsating groin mass as well as the most useful and specific imaging methods in the diagnostic work-up in this clinical setting are discussed.

Ligating clips for three-dimensional MR angiography at 1.5 T: in vitro evaluation.

Artifact size on three-dimensional (3D) magnetic resonance (MR) angiograms and safety of various vascular clips (15 titanium and three absorbable polydioxanone clips) were assessed. All evaluated clips were completely safe. Biodegradable clips rendered no artifacts; titanium clips were associated with susceptibility effects. Artifact size was dependent on clip size, clip orientation, echo time, and degree of k-space coverage. In the presence of titanium vascular clips, fast 3D MR angiography should be performed with the shortest echo time and full k-space coverage.

The real incidence of percutaneous injuries in the operating room--a prospective study.

Despite the frequent exposure of operating room personnel to blood and other body fluids and the obvious risk of occupational transmission of HIV infection, the real incidence of injuries after needle sticks or cuts in the operating room has not been well investigated. Every injury occurring in the operating room during one thousand consecutive elective and emergency procedures was studied and the risk for acquiring an HIV infection was calculated. There were 50 injuries during 761 elective procedures (6.6%) and 23 injuries during 239 emergency operations (9.6%). There was one single injury during 91 minimally invasive endoscopical procedures (1.1%). The surgeon was the person most frequently injured (3.5%). The injury rate of the scrub nurse varied between 1.4% and 2.8% according to the surgeon's experience. The operating room personnel is at risk for an occupational transmission of blood born pathogens. If the seroprevalence of HIV in surgical patients is estimated at 0.4% the calculated probability for a surgeon to acquire HIV infection over a 30-year career amounts to 0.3%.

Video-assisted thoracoscopy in the treatment of pleural empyema: stage-based management and outcome.

OBJECTIVE: Despite modern diagnostic methods and appropriate treatment, pleural empyema remains a serious problem. Our purpose was to assess the feasibility and efficacy of the video-assisted thoracoscopic surgery in the management of nontuberculous fibrinopurulent pleural empyema after chest tube drainage treatment had failed to achieve the proper results. METHODS: We present a prospective selected single institution series including 45 patients with pleural empyema who underwent an operation between March 1993 and December 1996. Mean preoperative length of conservative management was 37 days (range, 8-82 days). All patients were assessed by chest computed tomography and ultrasonography and underwent video-assisted thoracoscopic debridement of the empyema and postoperative irrigation of the pleural cavity. RESULTS: In 37 patients (82%), video-assisted thoracoscopic debridement was successful. In 8 cases, decortication by standard thoracotomy was necessary. There were no complications during video-assisted thoracic operations. The mean duration of chest tube drainage was 7. 1 days (range, 4-140 days). At follow-up (n = 35) with pulmonary function tests, 86% of the patients treated by video-assisted thoracic operation showed normal values; 14% had a moderate obstruction and restriction without impairment of exercise capacity, and no relapse of empyema was observed. CONCLUSIONS: Video-assisted thoracoscopic debridement represents a suitable treatment for fibrinopurulent empyema when chest tube drainage and fibrinolytics have failed to achieve the proper results. In an early organizing phase, indication for video-assisted thoracic operation should be considered in due time to ensure a definitive therapy with a minimally invasive intervention. For pleural empyema in a later organizing phase, full thoracotomy with decortication remains the treatment of choice.

Two-year results after lung volume reduction surgery in alpha1-antitrypsin deficiency versus smoker's emphysema.

Lung volume reduction surgery (LVRS) improves exercise capacity and relieves dyspnoea in patients with smoker's emphysema (SE). It is unclear, however, whether LVRS similarly improves lung function in alpha1-antitrypsin-deficiency emphysema (alpha1 E). To address this question, this study prospectively compared the intermediate-term functional outcome in 12 consecutive patients with advanced alpha1E and 18 patients with SE who underwent bilateral LVRS. Before surgery there were no statistically significant differences between the two groups in the six-minute walking distance, dyspnoea score, respiratory mechanics or lung function data, except for the forced expiratory volume in one second, which was lower in the deficient group (24 versus 31% of the predicted value; p<0.05). In both groups, bilateral LRVS produced significant improvements in dyspnoea, the six-minute walking distance, lung function and respiratory mechanics. In the alpha1E group, the functional data, with the exception of the six-minute walking distance, returned to baseline at 6-12 months postoperation and showed further deterioration at 24 months. The functional status of the SE group remained significantly improved over this period. In conclusion, the functional improvements resulting from bilateral lung volume reduction surgery are sustained for at least 2 yrs in most patients with smoker's emphysema, but this type of surgery offers only short-term benefits for most patients with alpha1E.

Infrainguinal aneurysm formation in arterialized autologous saphenous vein grafts.

True aneurysm formation in arterialized autologous veins is an unusual complication. We studied a patient with 2 aneurysms occurring in the mid and distal portion of an in situ femoropopliteal bypass. The first aneurysm led to graft occlusion 4 years after the primary intervention, requiring replacement of the ectatic graft segment. The graft was still patent when the patient was examined 7 years after the primary intervention and 3 years after the first aneurysm. In the mid portion of the graft, a true aneurysm measuring 5 by 8 cm had developed. The aneurysm was replaced by a reversed segment of the contralateral greater saphenous vein. Recovery was uneventful. Advanced atherosclerotic changes with extensive intimal fibroplasia, subendothelial cholesterol deposits, and ulcerations were revealed by means of histopathology of the aneurysm wall. Atherosclerosis is considered to be the main cause of aneurysm formation in vein grafts, but a review of the literature suggests the additional etiopathogenic factors should be further investigated.

Catamenial hemoptysis. Diagnosis with MRI.

Thoracic endometriosis is a rare disorder. We report a case of a 26-year-old woman with a 4-year history of catamenial hemoptysis due to thoracic endometriosis which was diagnosed by MRI and treated successfully by means of video-assisted thoracoscopic wedge-resection of the solitary pulmonary lesion. Medical therapy with hormones was not necessary. There is no evidence of recurrence 10 months after the operation. This case demonstrates that MRI of the chest may be considered for the diagnostic work-up of patients with catamenial hemoptysis. It also shows that wedge-resection of pulmonary endometriosis foci by means of video-assisted thoracoscopy-an approach that has not been described in the literature thus far-is an effective therapy in localized peripheral pulmonary parenchymal endometriosis.

Thoracoscopic mediastinal lymph node dissection: an experimental study in pigs.

Thoracoscopic lobectomy is feasible and can be performed correctly in terms of anatomy. Its application in bronchial carcinoma is often criticized, partly because of incomplete mediastinal lymph node dissection (MLD). We therefore developed the technique and studied the completeness of MLD in an animal experiment. Ten pigs were anesthetized and intubated with a double-lumen tube and the left lung was excluded from ventilation. Four trocars were inserted. Using a modified endo-Babcock clamp for traction we resected all ipsilateral tracheobronchial, pretracheal and paratracheal and paraesophageal lymph nodes (LNs) as well as nodes in the aortopulmonary window. An average of 19 +/- 5 mediastinal LNs were removed. Macroscopic control through a thoracotomy did not show any residual LNs at the site of operation. Complete resection of all ipsilateral LNs in the paratracheal and paraesophageal region as well as the aortopulmonary window can be performed thoracoscopically in pigs. This may offer further perspectives in the thoracoscopic treatment of bronchial carcinoma.