Treatment of malignant tracheoesophageal fistula.

This article addresses the treatment of malignant enterorespiratory fistulas, especially malignant tracheoesophageal fistula (mTEF). mTEF typically occurs after radiochemotherapy for advanced esophageal cancer. Life expectancy is measured in months after successful treatment, and in days to weeks with a persistent fistula. To stop repeated episodes of aspiration and septic pneumonia, single or double stenting of the esophagus and trachea with self-expandable coated stents is the established palliative treatment. The indications, techniques, and pitfalls of esophageal and tracheal stenting are described. Surgical interventions are justified only in very select cases, so this article focuses on interventional rather than surgical treatment.

MRI versus 64-row MDCT for diagnosis of hepatocellular carcinoma.

AIM: To compare the diagnostic capability of multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI) for the detection of hepatocellular carcinoma (HCC) tumour nodules and their effect on patient management. METHODS: A total of 28 patients (25 male, 3 female, mean age 67 +/- 10.8 years) with biopsy-proven HCC were investigated with 64-row MDCT (slice 3 mm native, arterial and portal-venous phase, 120 mL Iomeprol, 4 mL/s, delay by bolus trigger) and MRI (T1fs fl2d TE/TR 2.72/129 ms, T2tse TE/TR 102/4000 ms, 5-phase dynamic contrast-enhanced T1fs fl3d TE/TR 1.56/4.6, Gadolinium-DTPA, slice 4 mm). Consensus reading of both modalities was used as reference. Tumour nodules were analyzed with respect to number, size, and location. RESULTS: In total, 162 tumour nodules were detected by consensus reading. MRI detected significantly more tumour nodules (159 vs 123, P < 0.001) compared to MDCT, with the best sensitivity for early arterial phase MRI. False-negative CT findings included nodules < or = 5 mm ( n = 5), < or = 10 mm ( n = 17), < or = 15 mm ( n = 12 ), < or = 20 mm ( n = 4 ), and 1 nodule > 20 mm. MRI missed 2 nodules < or = 10 mm and 1 nodule < or = 15 mm. On MRI, nodule diameters were greater than on CT (29.2 +/- 25.1 mm, range 5-140 mm vs 24.1 +/- 22.7 mm, range 4-129 mm, P < 0.005). In 2 patients, MDCT showed only unilobar tumour spread, whereas MRI revealed additional nodules in the contralateral lobe. Detection of these nodules could have changed the therapeutic strategy. CONCLUSION: Contrast-enhanced MRI is superior to 64-row MDCT for the detection of HCC nodules. Patients should be allocated to interventional or operative treatment according to a dedicated MRI-protocol.

Ten-year follow-up of endovascular aneurysm treatment with Talent stent-grafts.

The purpose of this study was to evaluate the clinical results, complications, and secondary interventions during long-term follow-up after endovascular aneurysm repair (EVAR) and to investigate the impact of endoleak sizes on aneurysm shrinkage. From 1997 to March 2007, 127 patients (12 female, 115 male; age, 73.0 +/- 7.2 years) with abdominal aortic aneurysms were treated with Talent stent-grafts. Follow-up included clinical visits, contrast-enhanced MDCT, and radiographs at 3, 6, and 12 months and then annually. Results were analyzed with respect to clinical outcome, secondary interventions, endoleak rate and management, and change in aneurysm size. There was no need for primary conversion surgery. Thirty-day mortality was 1.6% (two myocardial infarctions). Procedure-related morbidity was 2.4% (paraplegia, partial infarction of one kidney, and inguinal bleeding requiring surgery). Mean follow-up was 47.7 +/- 34.2 months (range, 0-123 months). Thirty-nine patients died during follow-up; three of the deaths were related to aneurysm (aneurysm rupture due to endoleak, n = 1; secondary surgical reintervention n = 2). During follow-up, a total of 29 secondary procedures were performed in 19 patients, including 14 percutaneous procedures (10 patients) and 15 surgical procedures (12 patients), including 4 cases with late conversion to open aortic repair (stent-graft infection, n = 1; migration, endoleak, or endotension, n = 3). Overall mean survival was 84.5 +/- 4.7 months. Mean survival and freedom from any event was 66.7 +/- 4.5 months. MRI depicted significantly more endoleaks compared to MDCT (23.5% vs. 14.3%; P < 0.01). Patients in whom all aneurysm side branches were occluded prior to stent-grafting showed a significantly reduced incidence of large endoleaks. Endoleaks >10% of the aneurysm area were associated with reduced aneurysm shrinkage compared to no endoleaks or <10% endoleaks (Delta at 3 years, -1.8% vs. -12.0%; P < 0.05). In conclusion, endovascular aneurysm treatment with Talent stent-grafts demonstrated encouraging long-term results with moderate secondary intervention rates. Primary occlusion of all aortic side branches reduced the incidence of large endoleaks. Large endoleaks significantly impaired aneurysm shrinkage, whereas small endoleaks did not.

CT-guided vertebroplasty: analysis of technical results, extraosseous cement leakages, and complications in 500 procedures.

The aim of this study was to analyze the technical results, the extraosseous cement leakages, and the complications in our first 500 vertebroplasty procedures. Patients with osteoporotic vertebral compression fractures or osteolytic lesions caused by malignant tumors were treated with CT-guided vertebroplasty. The technical results were documented with CT, and the extraosseous cement leakages and periinterventional clinical complications were analyzed as well as secondary fractures during follow-up. Since 2002, 500 vertebroplasty procedures have been performed on 251 patients (82 male, 169 female, age 71.5 +/- 9.8 years) suffering from osteoporotic compression fractures (n = 217) and/or malignant tumour infiltration (n = 34). The number of vertebrae treated per patient was 1.96 +/- 1.29 (range 1-10); the numbers of interventions per patient and interventions per vertebra were 1.33 +/- 0.75 (range 1-6) and 1.01 +/- 0.10, respectively. The amount of PMMA cement was 4.5 +/- 1.9 ml and decreased during the 5-year period of investigation. The procedure-related 30-day mortality was 0.4% (1 of 251 patients) due to pulmonary embolism in this case. The procedure-related morbidity was 2.8% (7/251), including one acute coronary syndrome beginning 12 h after the procedure and one missing patellar reflex in a patients with a cement leak near the neuroformen because of osteolytic destruction of the respective pedicle. Additionally, one patient developed a medullary conus syndrome after a fall during the night after vertebroplasty, two patients reached an inadequate depth of conscious sedation, and two cases had additional fractures (one pedicle fracture, one rib fracture). The overall CT-based cement leak rate was 55.4% and included leakages predominantly into intervertebral disc spaces (25.2%), epidural vein plexus (16.0%), through the posterior wall (2.6%), into the neuroforamen (1.6%), into paravertebral vessels (7.2%), and combinations of these and others. During follow-up (15.2 +/- 13.4 months) the secondary fracture rate was 17.1%, including comparable numbers for vertebrae at adjacent and distant levels. The presence of intradiscal cement leaks was not associated with increased adjacent fracture rates. CT-guided vertebroplasty is safe and effective for treatment of vertebral compression fractures. CT-fluoroscopy provides an excellent control of the posterior vertebral wall. The number of cement leakages alone is not directly associated with clinical complications. However, even small volumes of pulmonary PMMA embolism might be responsible for the fatal outcome in cases with underlying cardiopulmonary insufficiency.

Fluoroscopy-guided removal of pull-type gastrostomy tubes.

These case reports demonstrate a radiologic interventional technique for removal of pull-type gastrostomy tubes. This approach proved to be a safe and efficient procedure in two patients. The procedure may be applicable in situations where endoscopic attempts fail.

Transarterial chemoembolization in patients not eligible for liver transplantation: single-center results.

OBJECTIVE: The purpose of this study was to evaluate the effectiveness of transarterial chemoembolization in the care of patients not eligible for liver transplantation. CONCLUSIONS: Prognosis depends on local response, Okuda score, alpha-fetoprotein level, and tumor size and is independent of the presence of portal venous thrombosis.

Height gain of vertebral bodies and stabilization of vertebral geometry over one year after vertebroplasty of osteoporotic vertebral fractures.

The height gain of vertebral bodies after vertebroplasty and geometrical stability was evaluated over a one-year period. Osteoporotic fractures were treated with vertebroplasty. The vertebral geometry and disc spaces were analysed using reformatted computed tomography (CT) images: heights of the anterior, posterior, and lateral vertebral walls, disc spaces, endplate angles, and minimal endplate distances. Vertebrae were assigned to group I [severe compression (anterior height/posterior height) <0.75] and group II (moderate compression index >0.75). A total of 102 vertebral bodies in 40 patients (12 men, 28 women, age 70.3 +/- 9.5) were treated with vertebroplasty and prospectively followed for 12 months. Group I showed a greater benefit compared with group II with respect to anterior height gain (+2.1 +/- 1.9 vs +0.7 +/- 1.6 mm, P < 0.001), reduction of endplate angle (-3.6 +/- 4.2 vs -0.8 +/- 2.3 degrees , P < 0.001), and compression index (+0.09 +/- 0.11 vs +0.01 +/- 0.06, P < 0.001). At one-year follow-up, group I demonstrated preserved anterior height gain (+1.5 +/- 2.8 mm, P < 0.015) and improved endplate angle (-3.4 +/- 4.9 degrees , P < 0.001). In group II, the vertebral heights returned to and were fixed at the pre-interventional levels. Vertebroplasty provided vertebral height gain over one year, particularly in cases with severe compression. Vertebrae with moderate compression were fixed and stabilized at the pre-treatment level over one year.

MR angiography of the pedal arteries with gadobenate dimeglumine, a contrast agent with increased relaxivity, and comparison with selective intraarterial DSA.

PURPOSE: To compare gadobenate dimeglumine (Gd-BOPTA)-enhanced MR angiography (i.e., contrast-enhanced MRA [CE-MRA]) of the pedal vasculature with selective digital subtraction angiography (DSA) in patients with peripheral arterial occlusive disease (PAOD). MATERIALS AND METHODS: A total of 22 patients with PAOD were prospectively examined at 1.5T. For contrast enhancement, 0.1 mmol/kg body weight of Gd-BOPTA were applied. MRA consisted of dynamic imaging with acquisition of six consecutive data sets. Acquisition time for each data set was 24 seconds, voxel size was 1.0 x 1.0 x 1.3 mm(3). A total of 20 out of 22 patient underwent selective DSA, two patients fine-needle DSA. DSA and MRA were performed within seven days. Image analysis was independently done by two observers with assessment of overall image quality, motion artifacts, detection of patent vessel segments of the distal calf and pedal vessels, and the number of patent metatarsal arteries. After four weeks, a consensus reading of DSA images was done. A second consensus reading of CE-MRA was performed after a further six weeks. RESULTS: Consensus readings of MRA and DSA revealed higher image quality and fewer motion artifacts for MRA (P = 0.021 and P = 0.008, respectively, sign test); interobserver agreement was good (kappa = 0.78) for image quality, and moderate (kappa = 0.46) for motion artifacts. There were no differences between CE-MRA and DSA in detecting patent vessel segments with a high degree of agreement (kappa = 0.89), and interobserver agreement for MRA was substantial (kappa = 0.89). Significantly more vessels were assessed as partially occluded on DSA than on CE-MRA (P = 0.004). There was a good agreement between DSA and CE-MRA for assessment of relevant vessel stenosis (kappa = 0.61); interobserver agreement for MRA was good (kappa = 0.65). CE-MRA detected significantly more patent metatarsal arteries than did DSA (P < 0.001). CONCLUSION: Gd-BOPTA-enhanced MRA is comparable to DSA for assessment of the pedal vasculature, and is able to delineate significantly more patent vessels without segmental occlusions and more metatarsal arteries than selective DSA.

Extracorporeal circulation and cardiac arrest in an awake patient: a safe approach for single lung pulmonary artery stenting?

We describe the anesthetic concept and approach in a single lung patient scheduled for pulmonary artery stenting due to recurrence of a pulmonary artery sarcoma after left pneumectomy.

Response to transarterial chemoembolization as a biological selection criterion for liver transplantation in hepatocellular carcinoma.

Criteria to select patients with hepatocellular carcinoma (HCC) for liver transplantation (LT) are based on tumor size and number of nodules rather than on tumor biology. The present study was undertaken to assess the role of transarterial chemoembolization (TACE) in selecting patients with tumors suitable for LT. Ninety-six consecutive patients with HCC were treated by repeatedly performed TACE, 62 of them exceeding the Milan criteria. Patients meeting the Milan criteria were immediately listed, and patients beyond the listing criteria were listed upon downstaging of the tumor following successful TACE. Fifty patients were finally transplanted. Of these 50 patients, 34 exceeded the Milan criteria. In these 96 patients, overall 5-year survival was 51.9%. However, it was 80.9% for patients undergoing LT and 0% for patients without transplantation (P < 0.0001). Tumor recurrence was primarily influenced by the control of the disease through continued TACE during the waiting time. Freedom from recurrence after 5 years was 94.5% in patients (n = 39) with progress-free TACE during the waiting time. Tumor recurrence was significantly higher in patients (n = 11) who after initial response to TACE progressed again before LT (freedom from recurrence 35.4%; P = 0.0017). Progress-free course of TACE during the waiting time (P = 0.006; risk ratio, 8.95), and a limited number of tumor nodules as assessed in the surgical specimen (P = 0.025; risk ratio, 0.116) proved to be significant predictors for freedom from recurrence in the multivariate analysis. Milan criteria were without impact on recurrence. Our data suggest that sustained response to TACE is a better selection criterion for LT than the initial assessment of tumor size or number.

Hemodynamic effects of monomeric nonionic contrast media in pulmonary angiography in chronic thromboembolic pulmonary hypertension.

OBJECTIVE: The purpose of this study was to investigate the hemodynamic safety of the monomeric nonionic contrast agent iomeprol for selective pulmonary angiography in chronic thromboembolic pulmonary hypertension (CTPH), and to investigate the effect of periinterventional oxygen administration. SUBJECTS AND METHODS: Selective pulmonary digital subtraction angiography was performed in 94 patients with CTPH using six bolus injections of iomeprol (posteroanterior, oblique, and lateral projections; both pulmonary arteries; iomeprol, 25 mL at 13 mL/s). Hemodynamics were obtained with Swan-Ganz catheters, and systolic pulmonary artery pressure (PAsyst) was classified into one of three groups: 30 mm Hg or less (control group), greater than 30 but less than or equal to 60 mm Hg (group 1, moderate pulmonary hypertension), and greater than 60 mm Hg (group 2, severe pulmonary hypertension). RESULTS: At baseline, values for PAsyst were 21.4 +/- 2.3 (control group, n = 8), 49.8+/- 8.5 (group 1, n = 18), and 86.5 +/- 18.9 (group 2, n = 68) mm Hg (p < 0.001). Pulmonary vascular resistance indexes (PVRI) were 222 +/- 105 (control), 703 +/- 364 (group 1), and 1,582 +/- 562 (group 2) dyne x s x cm(-5) x m2 (p < 0.001). The mean cardiac indexes were 3.1 (control), 2.8 (group 1), and 2.3 (group 2) L/min/m2 (p < 0.05). Pulmonary capillary wedge pressure (PCw) indicated healthy left heart function. Periinterventional oxygen inhalation improved oxygen saturation in all groups and slightly reduced pulmonary artery pressure and heart rate. Online measurement of pulmonary artery pressure during contrast bolus injection for angiography showed only a minor increase, predominantly in severe pulmonary hypertension (triangle up [difference] PAsyst: 1.3 +/- 1.9 [control], 2.9 +/- 3.4 [group 1], and 3.8 +/- 4.5 [group 2] mm Hg [p < 0.001]). After completion of angiography, right atrial pressure (RAP) and PAsyst were moderately increased: triangle up RAP: 1.4 (control), 2.6 (group 1, p < 0.001), and 3.0 (group 2, p < 0.001) mm Hg; triangle up PAsyst: 3.2 (control), 7.7 (group 1, p < 0.01), and 8.5 (group 2) mm Hg (p < 0.001). PVRI was significantly higher in group 2 (triangle up PVRI: 188 dyne x s x cm(-5) x m2, p < 0.001). CONCLUSION: Selective pulmonary angiography using iomeprol is safe without critical pressure peaks during selective contrast bolus injection or significant hemodynamic derangement in severe CTPH. Periinterventional oxygen inhalation improved pulmonary circulation.

MRI versus helical CT for endoleak detection after endovascular aneurysm repair.

OBJECTIVE: The objective of our study was to investigate the diagnostic accuracy of MRI and helical CT for endoleak detection. SUBJECTS AND METHODS: Fifty-two patients underwent endovascular aneurysm repair with nitinol stent-grafts. Follow-up data sets included contrast-enhanced biphasic CT and MRI within 48 hr after the intervention; at 3, 6, and 12 months; and yearly thereafter. The endoleak size was categorized as < or = 3%, > 3% < or = 10%, > 10% < or = 30%, or > 30% of the maximum cross-sectional aneurysm area. A consensus interpretation of CT and MRI was defined as the standard of reference. RESULTS: Of 252 data sets, 141 showed evidence for endoleaks. The incidence of types I, II, and III endoleaks and complex endoleaks was 3.2%, 40.1%, 8.7%, and 4.0%, respectively. The sensitivity for endoleak detection was 92.9%, 44.0%, 34.8%, and 38.3% for MRI, biphasic CT, uniphasic arterial CT, and uniphasic late CT, respectively. The corresponding negative predictive values were 91.7%, 58.4%, 54.7%, and 56.1%, respectively. The overall accuracy of endoleak detection and correct sizing was 95.2%, 58.3%, 55.6%, and 57.1% for MRI, biphasic CT, uniphasic arterial CT, and uniphasic late CT, respectively. CONCLUSION: MRI is significantly superior to biphasic CT for endoleak detection and rating of endoleak size, followed by uniphasic late and uniphasic arterial CT scans. MRI shows a significant number of endoleaks in cases with negative CT findings and may help illuminate the phenomenon of endotension. Endoleak rates reported after endovascular aneurysm repair substantially depend on the imaging techniques used.

[Endovascular aneurysm therapy--long-term treatment outcomes after 7 years]. / Endovaskuläre Aneurysmatherapie--Langzeitergebnisse nach 7 Jahren.

BACKGROUND: Stentgrafts for endovascular treatment of abdominal aortic aneurysms (AAA) have been commercially available since 1994, with now large numbers of implantations all over the world. PATIENTS AND METHODS: From 1994-2001, 115 patients were treated with Stentor, Vanguard and Talent stentgrafts in our institution. RESULTS: Late complications of the first- and second-generation stentgrafts as radiologic or surgical interventions to maintain complete exclusion of the aneurysm amounted to 30% with an additional 22% for observed endoleaks and configuration changes of the stentgraft. Third-generation stentgrafts had a lower complication rate of 12.2% for interventions and 18.3% for late endoleaks and graft changes. CONCLUSION: High costs of the devices, a pretty high late complication rate, and the uncertain maintenance of stentgraft function to prevent aneurysm rupture currently limit the widespread application of this new technology, leaving conventional aneurysmectomy the standard for aneurysm treatment and reserving the endovascular method for selected patients.