Common and uncommon CT findings in rupture and impending rupture of abdominal aortic aneurysms.

The rapid imaging evaluation and diagnosis of rupture and impending rupture of an abdominal aortic aneurysm (AAA) is imperative. This article describes the imaging findings of rupture, impending rupture, and other abdominal aortic abnormalities. It is important not to overlook AAA as the consequences can be life threatening. All patients who had open or endovascular repair of AAA rupture over 6 years (2008-2012) were identified from our departmental database. The computed tomography (CT) images of 99 patients were reviewed for relevant findings. The mean age of the patients was 65 years and 85% were male.

Acute aortic syndrome: CT findings.

Acute aortic syndrome (AAS) is a constellation of potentially life-threatening acute aortic diseases. The spectrum includes penetrating atherosclerotic ulcer, intramural haematoma, dissection, and unstable thoracic aneurysm. AAS cannot be reliably diagnosed clinically and multidetector computed tomography (MDCT) has revolutionized the diagnosis and management of this group of conditions in the acute setting due to its availability, speed, and accuracy. The purpose of this review is to illustrate key MDCT findings of AAS. Imaging techniques, radiological findings, and common pitfalls are also discussed.

Penetrating atherosclerotic ulcer of the aorta: a continuing debate.

Aortic penetrating atherosclerotic ulcer (PAU) is a relatively common incidental finding on thoracic computed tomography (CT) examinations. This is likely to relate to the steady increase in the number of CT examinations performed and also due, in part, to the increasing age of the general population. There is as yet no consensus on the management of incidental PAUs in asymptomatic patients. This article aims to review the literature and discuss the natural history, prognosis, and management of incidental PAU.

Patterns of renal angiomyolipoma regression post embolisation on medium- to long-term follow-up.

OBJECTIVE: To assess the patterns of regression of renal angiomyolipoma (AML) post embolisation and report the outcomes related to the use of different embolic materials. METHODS: A retrospective review of all patients who underwent embolisation for renal AML at our institution between January 2004 and April 2012. RESULTS: 13 patients underwent 16 episodes of embolisation. Coils were used as the primary embolisation material in 10 episodes and microspheres in 6 episodes. The size reduction rate highly correlated on CT follow-up between the two groups, with 25.6% vs 22.7% reduction at 12 months, 27.5% vs 25.1% at 24 months, 35.0% vs 33.0% at 36 months and 35.0% vs 36.8% at 48 months. During follow-up, all tumours reduced in size with one patient requiring subsequent embolisation whose tumour reduced by only 6.5% after 1 year and subsequently exhibited regrowth after 4 years. Two patients presented with rebleeding and underwent repeat embolisation. Our overall retreatment rate (23%) is well within the literature range (up to 37%). None of the patients underwent surgery. CONCLUSION: The majority of AML shrinkage occurs within the first year following embolisation and appears to plateau after 3 years, which could have an impact on follow-up strategy. The percentage reduction at 1 year may reflect the long-term effect of embolisation with tumours demonstrating minor size reduction more likely to relapse at long-term follow-up. Embolisation of renal AML produces durable long-term results regardless of the choice of embolic agent. ADVANCES IN KNOWLEDGE: These findings provide information to guide CT follow-up of renal AML post embolisation.

Primary infrarenal aortic stenting with or without iliac stenting for isolated and aortoiliac stenoses: single-centre experience with long-term follow-up.

PURPOSE: The purpose of this study was to evaluate the technical success, complications, long-term clinical outcome, and patency after primary infrarenal aortic stenting for aortic and aortoiliac stenosis. Between January 1999 and January 2006, 22 consecutive patients underwent endovascular treatment because of infrarenal aortic stenosis with and without common iliac stenosis (10 men; mean age 64 ± 14 years). Eleven (11 of 22) patients had an isolated aortic stenosis, whereas 11 of 22 had aortic stenosis that extended into the common iliac arteries (CIAs). Thirteen patients were Rutherford classification type 3, and 9 patients were type 4. Statistical analysis included paired Student t test and Kaplan-Meier life table analysis; p < 0.05 was considered significant. Technical and initial clinical success was achieved in all patients. There were three (14 %) procedure-related complications, which included two access-point pseudoaneurysms and one non-flow-limiting left external iliac dissection. Patients were followed-up for a mean period of 88 months (range 60-132). Mean preprocedure ankle brachial pressure indexes (ABPI) were 0.60 ± -0.15 (right) and 0.61 ± -0.16 (left). After the procedure they were 0.86 ± -0.07 (right) and 0.90 ± -0.09 (left). The increase in ABPI was significant (p < 0.05), and this continued throughout follow-up. Four (18 %) patients had recurrence of symptoms during follow-up. These occurred at 36, 48, 48, and 50 months after the original procedure. All four patients were successfully treated with repeat angioplasty procedures. There was a significant difference in primary patency between isolated aortic stenosis (100 %) and aortoiliac stenosis (60 %) (p = 0.031). Cumulative follow-up was 1920 months yielding a reintervention rate of 0.025/events/year. CONCLUSION: Primary stenting of infrarenal stenosis is safe and successful with a low reintervention rate. It should be considered as first-line treatment for patients with infrarenal aortic stenotic disease.

Replacement tunnelled dialysis catheters for haemodialysis access: Same site, new site, or exchange - a multivariate analysis and risk score.

AIM: To identify variables related to complications following tunnelled dialysis catheter (TDC) replacement and stratifying the risk to reduce morbidity in patients with end-stage renal disease. MATERIALS AND METHODS: One hundred and forty TDCs (Split Cath, medCOMP) were replaced in 140 patients over a 5 year period. Multiple variables were retrospectively collected and analysed to stratify the risk and to predict patients who were more likely to suffer from complications. Multivariate regression analysis was used to identify variables predictive of complications. RESULTS: There were six immediate complications, 42 early complications, and 37 late complications. Multivariate analysis revealed that variables significantly associated to complications were: female sex (p = 0.003; OR 2.9); previous TDC in the same anatomical position in the past (p = 0.014; OR 4.1); catheter exchange (p = 0.038; OR 3.8); haemoglobin <11 g/dl (p = 0.033; OR 3.6); albumin <30 g/l (p = 0.007; OR 4.4); prothrombin time >15 s (p = 0.002; OR 4.1); and C-reactive protein >50 mg/l (p = 0.007; OR 4.6). A high-risk score, which used the values from the multivariate analysis, predicted 100% of the immediate complications, 95% of the early complications, and 68% of the late complications. CONCLUSION: Patients can now be scored prior to TDC replacement. A patient with a high-risk score can be optimized to reduce the chance of complications. Further prospective studies to confirm that rotating the site of TDC reduces complications are warranted as this has implications for current guidelines.

Patient experience, pain, and quality of life after lower limb angioplasty: a multisite prospective cohort study.

PURPOSE: To explore the experience of patients undergoing endovascular lower limb angioplasty and evaluate the improvements in quality of life and disease-related symptoms after the procedure. METHODS: Patients completed a questionnaire before treatment and three questionnaires after the procedure (immediately after the procedure, and again 4 weeks and 3 months later). Anxiety, patient understanding, procedure-related pain, and disease-related pain were assessed by a visual analog score (VAS). Complications, analgesic requirements, and satisfaction were recorded. Changes to quality of life were assessed by the validated SF36 questionnaire. RESULTS: A total of 88 patients (41%) responded. Overall, disease-related pain decreased over 3 months after the procedure. Smokers had more pain both before and after the procedure (P < 0.05). Explanation was considered better if provided by radiologist (P < 0.05). Sixty-nine percent of patients found the procedures less painful (mean VAS 2.5) than they had anticipated (VAS 5.5). Fifty percent of patients experienced adverse effects related to their puncture site, but this was highest among patients who had undergone the procedure before and smokers. The greatest quality-of-life improvements were in emotional and general health. Higher levels of disease-related pain were associated with worse general, emotional, and physical health (P < 0.05). CONCLUSION: Lower limb angioplasty provides symptomatic and quality-of-life improvements. Implementation of simple measures could improve patient satisfaction-for example, treatment should be explained by the radiologist in advance. Routine prescription of analgesics with particular attention to smokers and those undergoing repeat interventions is suggested.

Staged coil embolisation for the management of persistent aneurysmal right subclavian artery.

A 70-year-old patient, who had previously undergone open surgical repair of an aneurysmal aberrant right subclavian artery (ARSA), presented with recurrent symptoms and reperfusion of the aneurysm at the site of proximal ligation. This was successfully treated by a staged endovascular procedure.

Endovascular management of bilateral superior intercostal artery aneurysms following late repair of coarctation of the aorta.

Endovascular management of massive bilateral superior intercostal artery aneurysms following late surgical repair of juxtaductal coarctation of the aorta is described in a 40-year-old male patient. Both aneurysms were successfully treated by coil embolisation without the need for further surgical intervention.

Clinical outcomes following endovascular treatment of the malfunctioning autologous dialysis fistula.

BACKGROUND: There is limited long-term prospective data on the use of endovascular techniques and the use of thrombolysis in malfunctioning autologous haemodialysis fistulas. PURPOSE: Prospective assessment of clinical outcomes following angioplasty with or without low-dose thrombolysis was undertaken in patients who presented with malfunctioning autologous haemodialysis fistulas. METHODS: Consecutive patients referred to our department over a 6-month period were included. Twenty-five patients underwent percutaneous intervention by angioplasty alone (n = 14), angioplasty and stent (n = 2), thrombolysis alone (n = 2), angioplasty, thrombolysis and stent (n = 2) and angioplasty and thrombolysis (n = 5). Patients underwent clinical follow-up and were reviewed at 6, 12, 18 and 24 months to determine fistula status. Thirty-day mortality in the group was two patients. Statistical analysis was performed with Mann-Whitney, chi-squared and Kruskal-Wallis tests. Kaplan-Meier curves were constructed to compare primary and secondary patency rates. RESULTS: Technical success and initial clinical success rates were 88% and 76%, respectively. Primary and secondary clinical success rates at 6 months were 68% and 72%, at 12 months were 68% and 72%, at 18 months were 60% and 68% and at 24 months were 52% and 68%, respectively. There were no major complications following interventional procedures. There were four minor complications. After an initially successful procedure, five patients required subsequent intervention during the follow-up period. The overall fistula event rate was very low (five per 600 patient months or 0.0996 per access year) with a fistula loss rate of 0.14 per access year. CONCLUSIONS: Our results confirm that excellent clinical results can be achieved by percutaneous endovascular treatment in malfunctioning autologous fistulas, justifying their continued use as first-line management.

Long term follow-up of transcatheter coil embolotherapy for major colonic haemorrhage.

AIM: Therapeutic angiography with embolization is fast becoming the preferred treatment modality for major bleeding in the lower gastrointestinal (LGI) tract. The aim of this study was to determine the long term outcome and complications of percutaneous coil embolization (PCE) and its efficacy as definitive therapy in patients with major LGI bleeding. METHODS: All patients presenting to our institution with a haemodynamically significant LGI tract bleed between 1995 and 2001 that were unresponsive to conservative measures were considered for emergency angiography and coil embolization where appropriate. The outcome of these individuals was determined by case note review and telephone interview. RESULTS: There were 20 patients (11 females) with a mean follow-up period 72 months, mean age was 67 years. All underwent PCE following positive angiogram. The most common site of bleeding was the right colon (40%); haemostasis was successfully achieved in 16 (80%) patients. Five of the 20 patients died within 30 days of the intervention, three following PCE and two following surgery. None of the mortality following PCE was considered procedure related. On long term follow-up four patients required readmission to hospital for further LGI bleeds at 1, 2, 12 and 16 months respectively. Ischaemic complications occurred in 23%. CONCLUSION: Superselective embolization as the primary technique for the treatment of haemodynamically significant LGI bleeding is an effective, feasible and safe technique. Long term follow-up in our series up to 72 months has shown that it should be considered as both a primary and potentially definitive treatment for life threatening LGI bleeds.

Inferior vena cava filter use in pregnancy: preliminary experience.

Thromboembolism is the most common direct cause of maternal mortality in the UK. Inferior vena cava (IVC) filter placement is indicated in conditions where recurrent thromboembolism occurs despite adequate anticoagulation or when anticoagulation is contraindicated. The safety of IVC filter use in pregnancy is uncertain, as there are limited data available. In this study, we have reviewed pregnancy outcome in women with IVC filter use. Twelve pregnancies in six women, delivered in our hospital in the past 11 years, were identified from obstetric and radiology databases to have an IVC filter in situ. In four pregnancies, an IVC filter was placed during pregnancy. In eight pregnancies, an IVC filter was already in situ before pregnancy and continued for the entire duration of pregnancy. There were no antenatal complications noted due to IVC filter placement and no recurrent thromboembolism noted in pregnancies with an IVC filter in situ before conception. The mode of delivery was based on obstetric reasons in all cases. The mean birthweight was 2982 g, and all babies were born in good condition with Apgar scores within normal range. In conclusion, this case series did not identify any problems associated with IVC filter placement or continuation in pregnancy.

Chronic haematoma or soft-tissue neoplasm? A diagnostic dilemma.

Chronic soft-tissue haematomas are infrequently reported in the literature. We present a case of a slowly expanding post-traumatic chronic soft-tissue haematoma located anterior to the knee and leg, occurring in a region previously unreported. Both clinically and radiologically, it was impossible to distinguish the haematoma from an aggressive soft-tissue neoplasm. We review the literature and discuss the diagnostic problems related to this uncommon presentation.

Subclavian vein compression in anaplastic carcinoma of the thyroid.

Anaplastic thyroid cancer is a condition with a dismal prognosis in most cases. We present a case of subclavian vein compression in a case of anaplastic thyroid carcinoma treated with subclavian venous stenting. Subclavian vein compression is a recognized complication in disseminated carcinomatosis particularly in carcinoma of the breast and bronchus. It has never been described in anaplastic thyroid carcinoma.

Fibroid calcification after uterine artery embolization: ultrasonographic appearance and pathology.

PURPOSE: To describe the ultrasonographic (US) appearance of fibroid calcification occurring after uterine artery embolization (UAE) and discuss its etiology and pathology. MATERIALS AND METHODS: Twenty-seven of a total of 38 patients were followed up clinically and with duplex US for longer than 6 months after UAE for uterine fibroids. At US, changes in uterine size, fibroid vascularity, and morphology have been recorded. Pathologic studies were performed by one of the authors on resected specimens from a different cohort of patients, at intervals ranging from 4 months to 1 year after UAE. RESULTS: Twenty patients reported complete resolution of symptoms. In 16 of these, a reduction in fibroid volume of 70%-85% was recorded and, at US, the development of a peripheral hyperechoic rim around an increasingly hypoechoic fibroid was noted. Computed tomography in two patients revealed it to be a rim of calcium. Histologic studies in a different cohort of patients who had undergone hysterectomy at variable intervals after UAE demonstrated early aggregation of polyvinyl alcohol (PVA) particles, an intermediate giant cell inflammatory reaction, and calcification in the periphery of the infarcted fibroid at 6-12 months. CONCLUSION: Calcification is the end stage of hyaline degeneration. However, its peripheral location is unlike that of natural fibroid involution and hyaline necrosis. Pathologic studies in resected human fibroids after embolization suggest that its development is the end result of aggregation of PVA particles in peripheral fibroid arteries.

Recurrent superior vena caval obstruction due to invasion by malignant thymoma: treatment using a stent-graft.

A stent-graft was used to palliate superior vena caval obstruction in a 50-year-old patient with histologically proven ingrowth of malignant thymoma through three previously inserted non-covered stents. The stent-graft is still patent 12 months later. This is the first report of such a procedure where histological evidence of tumour ingrowth is available and long-term patency is verified.

Long-term follow-Up of percutaneous balloon angioplasty in adult aortic coarctation.

PURPOSE: To assess long-term outcomes following percutaneous transluminal angioplasty (PTA) of congenital aortic coarctation in adults. METHODS: Seventeen patients underwent PTA for symptomatic adult coarctation of the aorta. Sixteen patients, with a mean age of 28 years (range 15-60 years), were reviewed at a mean interval after angioplasty of 7.3 years (range 1.5-11 years). Assessment included magnetic resonance imaging (MRI), Doppler echocardiography, and clinical examination. Current clinical measurements were compared with pre- and immediate post-angioplasty measurements. RESULTS: At follow-up 16 patients were alive and well. The patient not included in follow-up had undergone surgical repair and excision of the coarctation segment following PTA. Mean brachial systolic blood pressure for the group decreased from 174 mmHg before angioplasty to 130 mmHg at follow-up (p = 0.0001). The mean gradient had fallen significantly from 50.9 to 17.8 at follow-up (p = 0.001). The average number of antihypertensive drugs required per patient decreased from 0.56 to 0.31 (p = 0.234). No significant residual stenoses or restenoses were seen at MRI. Small but clinically insignificant residual pressure gradients were recorded in all patients using Doppler echocardiography. Complications included one transient ischemic attack at 5 days, one external iliac dissection requiring stent insertion, and a further patient who developed a false aneurysm close to the coarctation site at 12 months which subsequently required surgical excision. CONCLUSION: PTA of adult coarctation is safe and effective in the long term. Although primary stenting has recently been advocated in the treatment of this condition, our results suggest that PTA remains the treatment of choice.

Vascular imaging and intervention in peripheral arteries in the diabetic patient.

Diabetic patients are four times more likely to develop peripheral vascular disease than the general population. This disease is likely to be more aggressive, with five times more patients developing critical limb ischaemia. Early diagnosis and treatment allows up to 80% of these patients to have some form of surgical or endovascular re-vascularisation. The primary imaging modalities to be used should be duplex ultrasound followed by angiography. Magnetic resonance angiography, however, holds out promise for the future as being a good method of non-invasive imaging. Endovascular (interventional radiological) procedures have a major role to play in treatment of vascular stenoses and occlusions. Thrombolytic agents can be used to dissolve thrombus within occluded vessels and so restore patency. Percutaneous transluminal angioplasty is of value in dilating the stenotic lesions within the vessels and so restoring normal blood flow. Endovascular stents may be inserted to ensure longer term patency. There is indirect evidence to suggest that the outcomes of endovascular procedures in the diabetic patient are less good than those in the general population, but nevertheless such procedures may save the diabetic patient from primary amputation and allow healing of ischaemic ulcers.