External iliac vein aneurysm: a case report and review of the literature.

Iliac vein aneurysms are extremely rare, even amongst vein aneurysms. We discuss the case of a 26-year-old man with an external iliac vein aneurysm, likely secondary to iatrogenic vascular trauma in the neonatal period. It is the first reported case of an iliac vein aneurysm presenting with lower urinary tract symptoms. Attempts at endovenous management were unsuccessful and therefore the patient underwent open aneurysmectomy. A PubMed literature search revealed a total of nine case reports of iliac vein aneurysms published in English since 2011. We discuss the aetiology, presentation, investigation and management of iliac vein aneurysms and compare to our own case.

A Comparison of Accuracy of Image- versus Hardware-based Tracking Technologies in 3D Fusion in Aortic Endografting.

OBJECTIVES: Fusion of three-dimensional (3D) computed tomography and intraoperative two-dimensional imaging in endovascular surgery relies on manual rigid co-registration of bony landmarks and tracking of hardware to provide a 3D overlay (hardware-based tracking, HWT). An alternative technique (image-based tracking, IMT) uses image recognition to register and place the fusion mask. We present preliminary experience with an agnostic fusion technology that uses IMT, with the aim of comparing the accuracy of overlay for this technology with HWT. METHOD: Data were collected prospectively for 12 patients. All devices were deployed using both IMT and HWT fusion assistance concurrently. Postoperative analysis of both systems was performed by three blinded expert observers, from selected time-points during the procedures, using the displacement of fusion rings, the overlay of vascular markings and the true ostia of renal arteries. The Mean overlay error and the deviation from mean error was derived using image analysis software. Comparison of the mean overlay error was made between IMT and HWT. The validity of the point-picking technique was assessed. RESULTS: IMT was successful in all of the first 12 cases, whereas technical learning curve challenges thwarted HWT in four cases. When independent operators assessed the degree of accuracy of the overlay, the median error for IMT was 3.9 mm (IQR 2.89-6.24, max 9.5) versus 8.64 mm (IQR 6.1-16.8, max 24.5) for HWT (p = .001). Variance per observer was 0.69 mm(2) and 95% limit of agreement ±1.63. CONCLUSION: In this preliminary study, the error of magnitude of displacement from the "true anatomy" during image overlay in IMT was less than for HWT. This confirms that ongoing manual re-registration, as recommended by the manufacturer, should be performed for HWT systems to maintain accuracy. The error in position of the fusion markers for IMT was consistent, thus may be considered predictable.

Introduction of a Team Based Approach to Radiation Dose Reduction in the Enhancement of the Overall Radiation Safety Profile of FEVAR.

OBJECTIVES: Fenestrated endovascular aneurysm repair (FEVAR) exposes operators and patients to considerable amounts of radiation. Introduction of fusion of three-dimensional (3D) computed tomography (CT) with intraoperative fluoroscopy puts new focus on advanced imaging techniques in the operating environment and has been found to reduce radiation and facilitate faster repair. The aim of this study is to evaluate the radiation dose effect of introducing a team-based approach to complex aortic repair. METHODS: Procedural details for a cohort of 21 patients undergoing FEVAR after fusion-guided (Modern Group) imaging was introduced are compared with 21 patients treated in the immediate 12 months prior to implementation (Historic Group) at a centre with expertise in FEVAR. Non-parametric tests were used to compare procedure time (PT), air kerma, dose-area product (DAP), fluoroscopy time (FT), estimated blood loss (EBL) and pre- and post-operative estimated glomerular filtration rate (eGFR) between the groups. RESULTS: Change in operative approach resulted in a significant reduction in PT for the Modern group (median 285 mins; interquartile range 268-322) compared with the Historic group (450 mins; IQR 360-540 p = <0.001). There were reductions in skin dose for the Modern group (1.6 Gy; IQR 1.09-2.1) compared with the Historic group (4.4 Gy; 3.2-7.05 p = <0.001), and DAP (Modern 159 Gy.cm2; IQR 123-226 vs 264.93 Gy.cm2; 173.3-366.8 for Historic (p = 0.006). There were no significant differences in FT, and pre- and post-operative eGFR between the two groups. Weight and height were distributed equally across both groups. Structured dose reports including the changes in frame rate were not available for analysis. CONCLUSIONS: Implementation of a team-based approach to radiation reduction significantly reduces radiation dose. These findings suggest that the radiation safety awareness that accompanies the introduction of fusion imaging may improve the overall radiation safety profile of FEVAR for patients and providers.

Mid-term Outcomes of Renal Branches Versus Renal Fenestrations for Thoraco-abdominal Aneurysm Repair.

OBJECTIVE/BACKGROUND: The objective was to investigate renal outcomes following endovascular repair of thoraco-abdominal aortic aneurysms (TAAA) comparing fenestrations with branches for the renal arteries. METHODS: Renal outcomes following TAAA endovascular repair performed with renal branches were collected from five high volume European centers and compared with renal outcomes following TAAA endovascular repair performed with renal fenestrations at one center. Renal re-intervention and occlusion rates, and freedom from any renal outcome and death were analyzed by patient and target vessel. Estimated glomerular filtration rate (eGFR) was calculated and collected pre-operatively and at the last available follow up. RESULTS: In total, 449 patients were included in this retrospective study (235 treated with branched devices [BEVAR] and 214 with fenestrated devices [FEVAR]). Altogether, 856 renal vessels were analyzed (445 perfused by branches and 411 by fenestrations). Both groups were comparable except for sex and smoking habits. Technical success rates were 95% and 99%, respectively. Mean ± SD follow up was 19 ± 18 months after BEVAR and 24 ± 20 months after FEVAR. During follow up, renal re-intervention rates were similar in both groups (4.7% vs. 5.2%). The renal occlusion rate was significantly higher following BEVAR (9.6% vs. 2.3%; p < .01), and the 2 year freedom for renal occlusion rate was 90.4% (SE 85.8-95.3%) following BEVAR and 97.1% (SE 94.6-99.7%) following FEVAR (p < .01). During follow up, a 12% median decrease in eGFR was observed following BEVAR versus 9% following FEVAR (non-significant). The 2 year survival rates were 73.4% (SE 66.6-80.9%) and 81.8% (SE 76.1-87.9%) following BEVAR and FEVAR, respectively. CONCLUSION: Mid-term renal outcomes following endovascular repair of TAAA are satisfactory. Endograft designs incorporating renal fenestrations rather than renal branches are associated with significantly lower occlusion rates. A prospective trial is now required to confirm these results.

Editor's Choice - Effect of Branch Stent Choice on Branch-related Outcomes in Complex Aortic Repair.

OBJECTIVES: The use of branched stent grafts for the treatment of thoracoabdominal aneurysms [TAAA] is increasing, but mating stent graft choice has not been studied. This study combined experience of five high volume centres to assess a preferred mating stent. METHODS: Data from five centres were retrospectively combined. Patients were included if they underwent stent graft for treatment of TAAA that used only branches to mate with visceral and renal vessels. All patients with fenestrations in their device were excluded. Perioperative details, reintervention, occlusion, and death were recorded. Outcome of occlusion or reintervention, as well as a composite outcome of any death, occlusion, or reintervention was planned using a per-patient, and per-branch analysis. RESULTS: In 235 included patients, there were 940 vessels available for placement of mating stent. The average age of included patients was 70 years (SD 7.9), and 179 of the 235 were male. Medical comorbidities included diabetes in 29/234 (12.4%), current smoker in 81/233 (34.8%), and COPD in 77/234 (32.9%). The primary stent deployed was self-expanding in 556 branches, balloon expandable in 231 branches, and was unknown in 92 branches. After a mean of 20.7 months (SD 25) follow-up, there have been 44 incidents of occlusion or reintervention, of which 40 culprit stents are known. Where the stent placed is known, the event rate in renal branches (35/437, 8%) is higher than that of visceral branches (8/443, 1.8%). There is no difference in occlusion or reintervention between self-expanding and balloon expandable stents (HR 0.95, p = .91) but there is a statistically significant difference between renal and visceral artery occlusions (HR 3.51, p = 0.001). CONCLUSION: There appears to be no difference in occlusion or reintervention rate for branch vessels mated with balloon expandable compared with self-expanding stents. Renal events appear to outnumber visceral events in this population.

Calcification of a Synthetic Renovascular Graft in a Child.

INTRODUCTION: Vascular grafts, especially in paediatric cases, need to be durable. Common failures such as thrombosis are well documented with research efforts directed towards them. However, there are lesser known causes of graft failure, such as graft calcification, and these also require further research focus. REPORT: A paediatric case is described in which a synthetic renovascular graft, implanted for mid-aortic syndrome, became calcified, necessitating surgical intervention to resolve graft malfunction. Significant calcification in the limb of a bifurcated polyethylene terephthalate graft was found to be the cause of resistant stenosis and refractory hypertension. Histology conducted on the explanted limb showed the presence of multinuclear giant cells, indicating a chronic foreign body response. DISCUSSION: Calcification of vascular grafts is probably more common than previously recognised. Stenosis typically resistant to angioplasty may result in the long term and thus leading to surgical intervention. In young children, this is suboptimal as these grafts need to last throughout adulthood. Explanted prosthetic grafts should be sent to specialist registries such as that in Strasbourg to be optimally assessed so that contributory factors can be identified.

The role of permissive hypotension in the management of ruptured abdominal aortic aneurysms.

The aim of this review was to explore current literature pertaining to the use of permissive hypotension in the treatment of abdominal aortic aneurysms. A literature search using Metalib, a database search engine, provided at the Royal Free and University College of London (UCL) yielded articles using the keywords "permissive hypotension" and "hypotensive resuscitation" when linked to "abdominal aortic aneurysm" and "rupture". The articles studying permissive hypotension in animals and humans in trauma, and in patients with abdominal aortic aneurysm were reviewed. The result of this search was a large volume of experimental studies of trauma in animals giving satisfactory evidence of the physiological benefit of this concept of resuscitation in trauma. There were some randomized trials in humans in trauma suggesting benefit. The safety of permissive hypotension in patients with ruptured aortic aneurysms was documented and found to be widespread, but there were no randomized trials directly comparing this practice. Evidence from a prospective randomized study on the modality of treatment of ruptured aortic aneurysms suggest that the level of blood pressure is associated with the mortality and a prospective cohort study suggests that, using the complementary concept of "delayed volume resuscitation", the total volume of preoperative fluid resuscitation independent of the blood pressure is predictive of the risk of perioperative death in ruptured aortic aneurysms. To this end, recent clinical publications are now supportive of control of both the volume of preoperative fluid given and blood pressure in this group of patients but clinical studies are few.

Editor's choice - A shaggy aorta is associated with mesenteric embolisation in patients undergoing fenestrated endografts to treat paravisceral aortic aneurysms.

OBJECTIVES: Bowel ischaemia is a life-threatening complication of endovascular aneurysm repair. This study aims to evaluate the factors associated with mesenteric ischaemia in patients undergoing fenestrated aortic endografts to treat paravisceral aneurysms. METHODS: Consecutive patients undergoing double or triple fenestrated stent graft insertion were retrospectively analysed. No patients were declined surgery based on anatomic complexity. Preoperative demographics, procedure-related variables, and anatomical factors were examined. Using 3D software, the aortic thrombus volume from the coeliac axis to the lowest renal, aortoiliac tortuosity, and aortic irregularity index (as graded by 3 independent assessors, graded 0-3 based on severity) were compared. Univariate analysis was performed to identify risk factors for the development of bowel ischaemia. RESULTS: Ninety-nine patients underwent elective aneurysm repair (64 triple fenestrations and 35 double fenestrations), 5% of which developed bowel ischaemia, and of these 80% (4/5) died. Mesenteric ischaemia was significantly associated with increased aortic irregularity (median [range], 2 [1-3] vs. 1 [0-2], p = .005, ischaemia vs. no ischaemia) and increased thrombus volume (37 ± 8 vs. 21 ± 12, p = .007) but not aortoiliac tortuosity (1.4 [1.2-1.5] vs. 1.30 [1.2-1.7], p = .3), inferior mesenteric or internal iliac artery patency. Mesenteric ischaemia was also associated with a significantly higher preoperative creatinine (mean ± SD: 183 ± 74 vs. 111 ± 43, p = .007). CONCLUSIONS: The presence of aortic irregularity and increased thrombus volume in the paravisceral segment predicts the occurrence of mesenteric and renal ischaemia in patients treated with fenestrated endografts. This is likely to be related to graft manipulation and catheterisation of visceral vessels.

Are there fewer complications with third generation endografts in endovascular aneurysm repair?

Endovascular aneurysm repair (EVAR) is widely accepted as a safe technique for treatment of aortic diseases since the concept was first pioneered by Volodos in 1986 and Parodi in 1991. Numerous registries have shown that this minimally invasive technique is associated with lower mortality when compared to open surgery in short and mid-term follow-up. The first pioneer devices had a high failure rate due to stent migration. This led to the creation of the first generation stent-grafts, which were associated with complications such as thrombosis of the limbs, graft migration and major endoleaks. The majority of these endostents are now withdrawn from the commercial market. However, these patients need lifelong surveillance because of a considerable risk of late complications. The materials used in the stent-graft vary with each manufacturer. Low porous fabric, suprarenal fixation and low profile devices led to the development of the second generation stent-grafts. The improvements with regards to the delivery systems, enabled reposition of the top-stent following deployment in some devices. The number of devices commercially available increased with the second generation. The third generation of stent-grafts, allowed treatment of complex aortic disease. Custom made solutions incorporate small openings, fenestrations for vessels involved in the aneurysmal disease and is already built in today's technology and available as CE marked devices. The device can be built with combinations of various branches and fenestrations in order to best accommodate the aortic anatomy of the patient. However, many issues remain with the development of this technology. There is a need for durable systems with less complicated deployment mechanics in order to be applied and more widespread. In conclusion, the third generation endografts in challenging anatomy has yielded encouraging results. With regards to short and midterm outcome and need for secondary interventions, evaluations shows comparable results with all devices performing well.

Movement, imaging and neurobehavioral assessment as predictors of cerebral palsy in preterm infants.

OBJECTIVE: To study the relative efficacy of three early predictors of cerebral palsy. METHOD: One Hundred and thirty infants with birth weight <1500 g were recruited. Video recordings of spontaneous general movements were made at 36 and 52 weeks postconceptional age. Magnetic resonance imaging and the neurobehavioral assessment of the preterm infant were done at 36 weeks postconceptional age. Follow-up neurological examination and Bayley assessments were made at 18 months corrected age to make early identification of cerebral palsy. RESULTS: Magnetic resonance imaging gave the best specificity and accuracy of 91 and 84% respectively. General movements at 52 weeks showed an improved specificity and accuracy over performance at 36 weeks postconceptional age. The negative predictive value for all methods tested was between 90 and 97%. Combining the results of magnetic resonance imaging and the neurobehavioral assessment improved the sensitivity of prediction to 80%, suggesting that a holistic approach to early detection of cerebral lesions is preferable to a single test. CONCLUSIONS: The majority of infants who appeared to behave within normal limits and exhibit normal brain structure in the newborn period were classified as neurologically intact at follow-up.

PSA testing: an evolving relationship with prostate cancer screening.

PSA testing has made prostate cancer screening a reality for men in many parts of the world, but its benefit for men's health continues to be debated. In men exposed to PSA testing, there has been a well-documented change in the presentation of prostate cancer with a shift towards earlier pathological stage, not without justifiable concern about over-diagnosis by prostate biopsy. Increasingly, men now diagnosed with early stage cancer have previous PSA exposure and are selected for biopsy based on PSA change in relation to cutoff values. Some recent observations suggest that PSA may no longer be an effective marker for early stage tumours, with PSA elevation failing to discriminate tumour-specific characteristics from benign gland enlargement. Traditionally, variation in pathological stage of clinically localised prostate cancer at diagnosis has related to clinical stage, PSA and biopsy Gleason grade, but with distinctions based upon these three assessments declining and an increasing proportion of organ-confined tumours at presentation, new methods of cancer detection and prognostic assessment are now required. Molecular technologies hold great promise in this respect, and in the future biomarker signatures are likely to overshadow total PSA for guiding early diagnosis and prognostic assessment. While arguments about prostate screening will continue, owing not least to its feasibility, future debate is likely to focus increasingly on technological advances and molecular profiling of these notoriously heterogeneous tumours.

Testicular granulocytic sarcoma, a source of diagnostic confusion.

We report a case of granulocytic sarcoma of the testis without hematologic manifestations. The patient was disease free 7 years after the initial presentation. The initial pathology interpretation favored a diagnosis of high-grade non-Hodgkin's lymphoma but additional histologic staining confirmed the diagnosis of granulocytic sarcoma. Only 2 cases of testicular granulocytic sarcoma without an associated hematologic disorder have been described. To our knowledge, this is the third reported case. The diagnosis of this rare tumor is difficult and should be in the differential diagnosis when non-Hodgkin's lymphoma is considered.

Spontaneous postnatal involution of intraabdominal pulmonary sequestration.

Prenatal ultrasonography in 2 pregnant women identified a suprarenal echogenic mass. The lesions were treated conservatively and involuted with time. These masses were consistent with a suprarenal pulmonary sequestration.

MEG localization of language-specific cortex utilizing MR-FOCUSS.

OBJECTIVE: To demonstrate noninvasive localization of cognitive cortical areas involved in language processing with magnetoencephalography (MEG) interpreted by multiresolution FOCUSS (MR-FOCUSS), a current density imaging technique. METHOD: MEG data were collected during verb-generation and picture-naming tasks from 18 right-handed control subjects and 24 right-handed patients with epilepsy. RESULTS: The averaged epic data from the verb-generation task, analyzed by MR-FOCUSS, showed initial activation in the left supramarginal gyrus, superior temporal gyrus, and angular gyrus at 239 +/- 31 ms in all subjects, consistent with other language mapping studies. Average amplitude of underlying cortical sources was approximately 452 pAm. The averaged epic data from the picture-naming task, analyzed by MR-FOCUSS, showed activation in the left inferior frontal gyrus (IFG) area starting at 436 +/- 40 ms in all subjects. Average amplitudes of underlying cortical sources were approximately 380 pAm. CONCLUSION: The time course of neuronal language processing can be imaged noninvasively with millisecond resolution by magnetoencephalography using the multiresolution FOCUSS technique.

[Insights into brain function though magnetic source imaging: A review of research and clinical applications]. / Aproximación a la función cerebral a través de la imagen de fuente magnética: aplicaciones clínicas y experimentales.

INTRODUCTION AND DEVELOPMENT: The paper presents a brief outline of the rationale behind the use of non invasive functional imaging and of the features that any imaging technique should display in order to make a substantial contribution to the search of the brain mechanisms responsible for cognitive functions. One such technique, magnetic source imaging (MSI), that meets these specifications, is described in more detail. Advantages of MSI include the capacity to provide direct measures of regional neurophysiological activity, a millisecond range temporal resolution, and the capacity to provide images of brain activity on an individual basis. We then describe applications of MSI to the study of brain mechanisms involved in various language functions such as oral comprehension and reading. Among these applications, the accuracy of MSI protocols in determining hemispheric dominance for language functions and in identifying the precise location and extent language specific cortex (Wernicke s area) has been verified through comparison with standard invasive techniques (Wada procedure and electrocortical stimulation mapping) in over 60 consecutive cases. In another series of studies we combined data from MSI and direct cortical stimulation to determine the role of temporoparietal areas in phonological analysis of spoken language and in phonological decoding of print. Finally, we have used MSI to gain unique insights into the brain mechanisms that support reading in developmental reading disability. CONCLUSION: Results from over 21 children diagnosed with this disorder suggest that impaired reading is associated with aberrant functional connections between temporal and temporoparietal areas of the left hemisphere that are normally engaged in reading.

Brain plasticity for sensory and linguistic functions: a functional imaging study using magnetoencephalography with children and young adults.

In this report, the newest of the functional imaging methods, magnetoencephalography, is described, and its use in addressing the issue of brain reorganization for basic sensory and linguistic functions is documented in a series of 10 children and young adults. These patients presented with a wide variety of conditions, ranging from tumors and focal epilepsy to reading disability. In all cases, clear evidence of reorganization of the brain mechanisms of either somatosensory or linguistic functions or both was obtained, demonstrating the utility of magnetoencephalography in studying, completely noninvasively, the issue of plasticity in the developing brain.

Language dominance in children as determined by magnetic source imaging and the intracarotid amobarbital procedure: a comparison.

This study evaluated the validity of data derived from magnetic source imaging regarding hemispheric dominance for language in children and adolescents with intractable seizure disorder by comparison with results of the intracarotid amobarbital procedure. Functional imaging of the receptive language cortex using a whole-head neuromagnetometer was performed in 19 consecutive epilepsy patients, ages 8 to 18 years, who also underwent the intracarotid amobarbital procedure. During magnetic source imaging recordings, patients engaged in a continuous recognition memory task for words in visual and auditory modalities. This task has previously been shown to be valid for the purpose of lateralization and localization of language cortex in adult epilepsy patients who undergo the intracarotid amobarbital procedure and intraoperative language mapping allowing confirmation of magnetic source imaging findings. Results indicated that language laterality indices formed for the intracarotid amobarbital procedure and magnetic source imaging procedures were highly correlated (R = .87). In addition, clinical judgments regarding cerebral dominance for language made by independent raters using the two methods were in excellent agreement. We conclude that magnetic source imaging is a promising method for determination of cerebral dominance for language in children and adults.

Insights into brain function and neural plasticity using magnetic source imaging.

This review outlines the rationale for the use of magnetoencephalography (MEG) or magnetic source imaging (MSI), a noninvasive functional imaging technique, and the features that any imaging method should display to make a substantial contribution to cognitive neuroscience. After a brief discussion of the basic experimental approach used in the authors' studies, the use of early sensory components of brain magnetic responses is reviewed to address issues of the functional organization of the primary sensory cortices, followed by a comment on the clinical use of these components. Second, normative studies focusing on the late components of magnetic responses for establishing the validity and reliability of MSI maps of the language-specific cortex in normal subjects are reviewed. Third, the authors' investigations of fine spatiotemporal features of brain activation maps, specific to receptive language and to reading, are reviewed. Fourth, experience with presurgical mapping of the language-specific cortex in neurosurgery candidates and in patients undergoing the "Wada" procedure is summarized followed by a comment on the perfect agreement of the MSI maps with those derived by more direct invasive brain mapping procedures. Fifth. MSI-derived evidence of often dramatic, functional reorganization of brain areas subserving both simple sensory and linguistic functions is summarized along with comments on the use of MSI as a means for investigating brain plasticity. Finally, in the sixth section of this review, the authors relate their experience with the use of MSI in deriving brain activation profiles during silent reading of real words and pseudowords that are specific to dyslexic children. The review concludes with a discussion on the further use of MSI in assessing, among other issues, the effectiveness of intervention strategies designed to improve reading fluency in dyslexic children.