Ilio-Iliac Arteriovenous Fistula with May-Thurner Syndrome: A Case Report.

An ilio-iliac arteriovenous fistula (AVF) is rare. Common factors leading to ilio-iliac AVF include congenital malformations, iatrogeny, and trauma. There is limited documentation in the literature of cases involving ilio-iliac AVF with May-Thurner syndrome. Here, we present a case of an ilio-iliac AVF with May-Thurner syndrome in an 80-year-old male. CT and angiography confirmed extensive ilio-iliac AVF. Successful endovascular procedures for ilio-iliac AVF were performed using several variable-sized coils and 1400-2000 µm gelatin particles. After embolization, follow-up abdominopelvic CT revealed an improvement in edema in the left leg.

Added Value of Structured Reporting for US of the Pediatric Appendix: Additional CT Examinations and Negative Appendectomy.

Purpose: This study aimed to determine the incremental value of using a structured report (SR) for US examinations of the pediatric appendix. Materials and Methods: Between January 2009 and June 2016, 1150 pediatric patients with suspected appendicitis who underwent US examinations of the appendix were included retrospectively. In November 2012, we developed a five-point scale SR for appendix US examinations. The patients were divided into two groups according to the form of the US report: free-text or SR. The primary clinical outcomes were compared between the two groups, including the rate of CT imaging following US examinations, the negative appendectomy rate (NAR), and the appendiceal perforation rate (PR). Results: In total, 550 patients were included in the free-text group and 600 patients in the SR group. The rate of additional CT examinations decreased by 5.3% in the SR group (8.2%, p = 0.003), and the NAR decreased by 8.4% in the SR group (7.8%, p = 0.028). There was no statistical difference in the appendiceal PR (37.6% vs. 48.0%, p = 0.078). Conclusion: The use of an SR to evaluate US examinations for suspected pediatric appendicitis results in lower CT use and fewer negative appendectomies without an increase in appendiceal PR.

Useful Ultrasound Findings of Pediatric Patients with Equivocal Results of Appendicitis: Analysis Based on a Structured Report Form.

Purpose: To identify the features that can be used for differentiating appendicitis from non-appendicitis in pediatric patients with equivocal ultrasound (US) results. Materials and Methods: A total of 53 pediatric patients (≤ 18 years old) with equivocal results on US examination for suspected appendicitis between November 2012 and October 2017 were included. US evaluation was conducted based on information retrieved from a predefined structured report form. Then, the likelihood of appendicitis was prospectively classified into five categories. The equivocal results were considered as grade 3 (indeterminate) and grade 4 (probably appendicitis). Results: Of the 53 patients, 25 (47.2%) and 28 (52.8%) were classified into grade 3 and 4 groups, respectively. Among the individual US findings, increased vascularity of the appendiceal wall and peri-appendiceal fat infiltration were independent findings associated with the diagnosis of appendicitis (p = 0.005, p = 0.045, respectively) in the multivariate logistic regression analysis and showed the highest diagnostic accuracy (69.8% and 62.3%, respectively). Conclusion: Increased vascularity within the appendiceal wall and peri-appendiceal fat infiltration were significant predictors of appendicitis in patients with equivocal US findings.

Transcatheter Removal of Bone Cement Embolism in the Right Atrium after Percutaneous Vertebroplasty: The Embolus Broke in Half and Migrated to the Right Pulmonary Artery Intraoperatively.

Bone cement embolism often occurs during percutaneous vertebroplasty. Bone cement pulmonary arterial embolism generally requires no treatment because of the small size and asymptomatic manifestation. Intracardiac bone cement embolisms are rare but associated with a risk of severe complications. Intracardiac bone cement embolisms are mainly removed through open heart surgery. To the best of our knowledge, only three cases of intracardiac bone cement embolisms removed with interventions have been reported. Here, we report another case of successful transcatheter retrieval of a 6-cm-long cement embolism in the right atrium after percutaneous vertebroplasty. The embolus broke in half and migrated to the right pulmonary artery intraoperatively. Using two snares and a filter retrieval device, we advanced from opposite directions. Further, we gently grasped and pulled the fragments of the right pulmonary artery and aligned them in a linear fashion directly into the sheath for uneventful removal.

Value of Additional Ultrasound Examination in Patients with Equivocal Computed Tomography Findings of Acute Appendicitis: Comparison with Computed Tomography Reassessment.

OBJECTIVES: The objective of this study was to find the diagnostic values of additional ultrasound (US) in patients with equivocal computed tomography (CT) findings of acute appendicitis, compared to CT reassessment. MATERIALS AND METHODS: Patients with equivocal CT findings of acute appendicitis (n = 115), who underwent the US, were included in the study. Two abdominal radiologists reviewed CT scans independently. They analyzed CT findings and made a diagnosis of acute appendicitis. The patients were categorized into positive and negative appendicitis based on the previous US reports. The diagnostic performance, interobserver agreement of CT findings, and appendicitis likelihood were calculated. RESULTS: The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of US (100%, 92.1%, 79.5%, and 100%, respectively) were higher than those of CT reassessment (reviewer 1: 51.9%, 87.5%, 56.1%, and 85.6%; reviewer 2: 66.7%, 85.2%, 58.1%, and 89.3%, respectively). In the coexistent inflammation group, the sensitivity, specificity, PPV, and NPV of US (reviewer 1: 100%, 98%, 91.5%, and 100%; reviewer 2: 100%, 98%, 87.7%, and 100%, respectively) were higher than those of CT reassessment (reviewer 1: 27.3%, 94.1%, 49.9%, and 85.8%; reviewer 2: 14.3%, 98.0%, 50.5%, and 88.9%, respectively). CONCLUSION: In patients with equivocal CT findings of acute appendicitis, US shows better diagnostic performance than CT reassessment, and helps differentiate with periappendicitis.

Sonographic Findings of Malignant Appendix Tumors in Seven Cases.

We report the sonographic features of confirmed malignant appendiceal tumors in seven cases. The histologic diagnoses of these tumors were mucinous cystadenocarcinoma (n = 2), colonic type adenocarcinoma (n = 4), and signet-ring cell carcinoma (n = 1). The 2 mucinous cystadenocarcinomas showed mucocele type, which had markedly enlarged inner luminal diameters (mean, 23 mm; range, 15-31 mm) and thick, irregular walls (mean wall thickness, 5.5 mm; range, 5-6 mm). In contrast, the 5 nonmucinous carcinomas (4 adenocarcinomas and 1 signet-ring cell carcinoma) showed nonmucocele type, which had relatively small inner luminal diameters (mean ± standard deviation [SD], 6.6 ± 4.5 mm; range, 2-15 mm) and prominent wall thickening (mean wall thickness ± SD, 6.2 ± 2.3 mm; range, 3-10 mm). Of the 5 nonmucinous tumors, only one had a discernible mass, three had thick irregular walls, two had loss of the wall layer pattern, and four had submucosal hypoechogenicity. Regardless of the histologic type, five of the seven malignant appendiceal tumors showed a severe periappendiceal fat infiltration or periappendiceal abscess, suggestive of perforation. Although the sonographic findings of the malignant appendiceal tumors were nonspecific, some of the sonographic features seen in these seven cases may help radiologists consider the possibility of underlying malignant appendiceal tumors.

CT Predictors of Unfavorable Clinical Outcomes of Acute Right Colonic Diverticulitis.

OBJECTIVE: The purpose of this study was to retrospectively assess CT predictors of unfavorable outcomes of medical treatment in patients with right colonic diverticulitis. MATERIALS AND METHODS: Of 394 patients with right colonic diverticulitis diagnosed on the basis of CT findings from January 2010 through August 2013, we included 328 (190 men, 138 women; mean age, 41.3 ± 12.6 years) who had undergone medical treatment as inpatients. Two radiologists retrospectively reviewed the following CT findings associated with diverticulitis: number of diverticula per 10 cm of colon; length and thickness of affected colonic wall; diameter of inflamed diverticulum and abscess; presence of pericolic fluid collection, spilled feces, and contained air; and extent of fatty infiltration. Logistic regression analysis and the Cox proportional hazards regression model were used to determine significant variables predictive of unfavorable outcomes, including surgery after failed medical treatment, recurrence, and prolonged hospital stay. RESULTS: Of the 328 patients, nine underwent surgery after failed medical treatment. Of the other 319 patients, 35 had recurrence and 49 had a prolonged hospital stay. The spilled feces sign (adjusted odds ratio [OR], 111; p < 0.001) and serum WBC count (adjusted OR, 1.3; p = 0.047) were independent predictors of the need for surgery. More than five multiple diverticula per 10 cm of colon was significantly associated with recurrence (adjusted hazard ratio, 4.1; p < 0.001). Abscess larger than 4 cm (adjusted OR, 18.2; p = 0.01) and inflamed diverticulum larger than 2 cm (adjusted OR, 3.7; p = 0.001) were independent predictors of prolonged hospital stay. CONCLUSION: Some specific CT findings can be useful predictors of unfavorable clinical outcomes of right colonic diverticulitis.

Signet-ring cell carcinoma of the appendix: a case report with an emphasis on sonographic findings.

In this report, we present a rare case of primary signet-ring cell carcinoma of the appendix in a 51-year-old woman with right lower quadrant pain. Since non-specific concentric appendiceal wall thickening was found in a radiologic evaluation, it was misdiagnosed as non-tumorous appendicitis. An in-depth examination of the correlation between sonographic and histopathologic findings demonstrated that a single markedly thickened hypoechoic layer was well correlated with the diffuse infiltration of tumor cells in both the submucosal and muscle layers. If this sonographic finding is observed in certain clinical settings, such as potential ovarian and peritoneal metastasis, submucosal infiltrative tumors, including signet-ring cell carcinoma, should be considered in the differential diagnosis.

Differential diagnosis of pancreatic cancer from other solid tumours arising from the periampullary area on MDCT.

PURPOSE: To investigate CT features and differential diagnosis of pancreatic adenocarcinoma compared to other solid tumours arising in the periampullary area. MATERIALS AND METHODS: One hundred and ninety-five patients with pathologically proven, solid periampullary tumours, including pancreatic adenocarcinoma (n = 98), neuroendocrine tumours (n = 52), gastrointestinal stromal tumours (n = 31), and solid pseudopapillary neoplasms (n = 14), underwent preoperative CT. Two radiologists reviewed CT features and rated the possibility of pancreatic adenocarcinoma. RESULTS: Statistically common findings for pancreatic adenocarcinoma included: patient age >50 years; ill-defined margin; completely solid mass; homogeneous enhancement; hypoenhancement on arterial and venous phases; atrophy; and duct dilatation. Statistically common findings for GIST included: heterogeneous enhancement; hyperenhancement on arterial and venous phases; rim enhancement; and prominent feeding arteries. The hyperenhancement on arterial and venous phases is statistically common in NET, and heterogeneous enhancement, hypoenhancement on the arterial and venous phases are statistically common in SPN. Diagnostic performance of CT for differentiating pancreatic adenocarcinomas from other solid periampullary tumours was 0.962 and 0.977 with excellent interobserver agreement (κ = 0.824). CONCLUSION: CT is useful not only for differentiating pancreatic adenocarcinoma form other solid tumours but also for differentiating between other solid tumours, including NET, SPN, and GIST, arising in the periampullary area. KEY POINTS: • Periampullary tumours arise within 2 cm of major duodenal papilla. • Many mass-forming periampullary tumours can be completely removed by minimal surgery. • Accurate differentiation of pancreatic adenocarcinoma from other solid tumours is important. • CT is useful for differentiating pancreatic adenocarcinoma from other solid tumours. • CT is useful for characterization of periampullary tumours other than adenocarcinomas.

Hepatic fibrosis: prospective comparison of MR elastography and US shear-wave elastography for evaluation.

PURPOSE: To compare magnetic resonance (MR) elastography and ultrasonographic shear-wave elastography ( SWE shear-wave elastography ) for the staging of hepatic fibrosis ( HF hepatic fibrosis ) in the same individuals. MATERIALS AND METHODS: This prospective study was approved by the institutional review board, and informed consent was obtained from all patients. The technical success of and reliable liver stiffness ( LS liver stiffness ) measurement rates at MR elastography and SWE shear-wave elastography were compared in 129 patients who underwent both examinations. For mutual validation, LS liver stiffness values measured at both examinations were correlated by using Pearson correlation. The diagnostic performance of the two techniques for the assessment of substantial HF hepatic fibrosis (stage ≥ F2) was compared by using nonparametric receiver operating characteristic analysis. RESULTS: The technical success rates of MR elastography and SWE shear-wave elastography were 95.35% (123 of 129) and 97.67% (126 of 129), respectively (P = .51). MR elastography provided significantly more reliable LS liver stiffness measurements than did SWE shear-wave elastography (95.35% [123 of 129] vs 75.2% [97 of 129], P < .001). The two examinations showed moderate correlation (r = 0.724). In patients with HF hepatic fibrosis stages of F3 or lower, the two examinations showed moderate-to-strong correlation (r = 0.683 in normal livers, 0.754 in livers with stage F0 or F1 HF hepatic fibrosis , and 0.90 in livers with stage F2 or F3 HF hepatic fibrosis ; P < .001); however, they did not show significant correlation for stage F4 HF hepatic fibrosis (r = 0.30, P = .31). MR elastography and SWE shear-wave elastography showed similar diagnostic capability in depicting HF hepatic fibrosis of stage F2 or greater (P = .98) when LS liver stiffness measurements were reliably performed. CONCLUSION: MR elastography and SWE shear-wave elastography showed moderate correlation and similar diagnostic performance in the diagnosis of HF hepatic fibrosis of stage F2 or greater; however, MR elastography yielded more reliable LS liver stiffness measurements than did SWE shear-wave elastography .