An 8-year, single-centre experience of primary image-guided insertion of 'button' gastrostomy catheters: Technical and clinical results.

INTRODUCTION: 'Button' gastrostomy insertion is traditionally a two-step procedure with an initial longer gastrostomy tube inserted followed by placement of the shorter 'button' gastrostomy in 6 weeks when the track is mature. The aim of this study is to assess whether the placement of a Button gastrostomy de novo is a safe and effective method of radiologically inserted gastrostomy (RIG) insertion. METHODS: Using our Picture Archive and Communication System (PACS) and electronic patient charts we identified all patients who underwent primary 'button' gastrostomy over an 8-year period with at least a 1-year follow-up period. We evaluated technical success rate, indications for insertion, major and minor complications, 30-day mortality and the number of exchanges performed. RESULTS: Overall, 482 patients underwent a primary button RIG insertion during this period with an overall success rate of 97.1%. Indications for RIG insertion included neurological and neurosurgical disorders 236 (48.9%), head and neck malignancy 182 (37.8%), oesophageal malignancy 27 (5.6%) and other indications in 37 (7.7%). The mean age was 59.55 years (range 18-88 years) with 290 men (60.2%) and 192 women (39.8%). Major complications were recorded in 0.8% and minor complications in 1.7%. A 30-day mortality of 1% was identified (five patients), mortality was directly related to the RIG insertion in one patient (0.2%). A total of 65 exchanges/replacements took place over this period of time, with 33 (50.1%) due to 'inadvertent removal'. CONCLUSION: Primary button RIG insertion is a procedure that has a high success rate and low morbidity and mortality. We believe it is a safe and effective alternative to deliver enteral nutrition.

A single center 9-year experience in IVC filter retrieval - the importance of an IVC filter registry.

BACKGROUND: To evaluate Inferior vena cava (IVC) filter retrieval practices over a 9-year period at an academic hospital with a prospectively maintained IVC filter registry. METHOD: An IVC filter registry was maintained prospectively within our institution. We reviewed cases between August 2011 and June 2020, following filter status, retrieval plans, and eventual retrieval date. The validity of the database was cross referenced with a Picture Archiving and Communication System and patient records. RESULTS: Three hundred forty-three patients had IVC filters inserted. Three filter types were used, Celect (Cook Medical) in 189, Gunther Tulip (GT) (Cook Medical) in 65, ALN (ALN) in 89. 196 (57%) filters were retrieved, 108 (31.5%) were made permanent, 36 (10.5%) died before retrieval, and 3 (1%) were yet to be retrieved. Retrieval rates were 92.5% overall (86% for GT, 93% for Celect and 94.5% for ALN). The mean dwell time for successful retrieval was 59 days with the majority of insertions (85%) removed in under 100 days. Failed initial retrieval occurred in 23 patients, 10 (43%) were retrieved at second attempt, 13/23 filters remained in-situ and were deemed permanent. CONCLUSION: The removal of IVC filters, when indication for insertion has past, is no longer the sole responsibility of the referring physician but also the responsibility of the Interventionalist. Our retrieval rates of 92.5% of eligible IVC filters highlights the value of maintaining a prospective IVC filter registry.

Meta-analysis of outcomes of endoscopic ultrasound-guided gallbladder drainage versus percutaneous cholecystostomy for the management of acute cholecystitis.

BACKGROUND: Endoscopic ultrasound-guided gallbladder drainage is a novel method of treating acute cholecystitis in patients deemed too high risk for surgery. It involves endoscopic stent placement between the gallbladder and the alimentary tract to internally drain the infection and is an alternative to percutaneous cholecystostomy (PC). This meta-analysis assesses the clinical outcomes of high-risk patients undergoing endoscopic drainage with an acute cholecystoenterostomy (ACE) compared with PC in acute cholecystitis. METHODS: A literature search was performed using the preferred reporting items for systematic reviews and meta-analyses guidelines. Databases were searched for studies reporting outcomes of patients undergoing ACE or PC. Results were reported as mean differences or pooled odds ratios (OR) with 95% confidence intervals (95% CI). RESULTS: A total of 1593 citations were reviewed; five studies comprising 495 patients were ultimately selected for analysis. There were no differences in technical or clinical success rates between the two groups on pooled meta-analysis. ACE had significantly lower post-procedural pain scores (mean difference - 3.0, 95% CI - 2.3 to - 3.6, p < 0.001, on a 10-point pain scale). There were no statistically significant differences in procedure complications between groups. Re-intervention rates were significantly higher in the PC group (OR 4.3, 95% CI 2.0-9.3, p < 0.001). CONCLUSION: ACE is a promising alternative to PC in high-risk patients with acute cholecystitis, with equivalent success rates, improved pain scores and lower re-intervention rates, without the morbidities associated with external drainage.

A prospective comparison of the performance and survival of two different tunnelled haemodialysis catheters: SplitCath® versus DuraMax®.

BACKGROUND: Despite their well-recognised shortcomings, haemodialysis catheters (HDCs) remain an important form of haemodialysis access for many patients. There are several HDCs commercially available, each differing considerably in design, which is known to significantly influence performance and survival. We sought to determine which of two tunnelled HDCs, DuraMax® (Angiodynamics, NY, USA) or SplitCath® (MedComp, PA, USA) delivers the best performance, safety and reliability for dialysis patients. METHODS: Eighty-six patients were prospectively randomised to receive either DuraMax® (DM) or SplitCath® (SC). Outcomes included: (i) mean flow rates (mL/min) averaged over the first 10 weeks of dialysis, and urea reduction ratio (URR); and (ii) long-term catheter survival with appraisal of any events leading to catheter dysfunction and early removal. RESULTS: Median flow rates (interquartile range) in the DM and SC groups were 321 (309-343) and 309 (294-322) mL/min, respectively (p = 0.002). URR values for the DM and SC groups were 71 (65-76) and 74 (70-78), respectively, (p = 0.094). There was no significant difference in long-term survival or frequency of incidents that required early HDC removal (9/43 in the DM group, 5/43 patients SC). A slightly higher incidence of HDC dislodgement was noted in the DM group, although this study was not statistically powered to determine its significance. CONCLUSIONS: We conclude that DM yields slightly higher flow rates in the first 10 weeks of dialysis, and a similar low incidence of complications and long-term survival for both DM and SC HDCs.

Proximal superficial femoral artery occlusion, collateral vessels, and walking performance in peripheral artery disease.

OBJECTIVES: We studied associations of magnetic resonance imaging (MRI)-measured superficial femoral artery (SFA) occlusions with functional performance, leg symptoms, and collateral vessel number in peripheral artery disease (PAD). We studied associations of collateral vessel number with functional performance in PAD. BACKGROUND: Associations of MRI-detected SFA occlusion and collateral vessel number with functional performance among individuals with PAD have not been reported. METHODS: A total of 457 participants with an ankle brachial index (ABI) <1.00 had MRI measurement of the proximal SFA with 12 consecutive 2.5-µm cross-sectional images. An occluded SFA was defined as an SFA in which at least 1 segment was occluded. A nonoccluded SFA was defined as absence of any occluded slices. Collateral vessels were visualized with magnetic resonance angiography. Lower extremity functional performance was measured with the 6-min walk, 4-m walking velocity at usual and fastest pace, and the Short Physical Performance Battery (SPPB) (0 to 12 scale, 12 = best). RESULTS: Adjusting for age, sex, race, comorbidities, and other confounders, the presence of an SFA occlusion was associated with poorer 6-min walk performance (1,031 vs. 1,169 feet, p = 0.006), slower fast-paced walking velocity (1.15 vs. 1.22 m/s, p = 0.042), and lower SPPB score (9.07 vs. 9.75, p = 0.038) compared with the absence of an SFA occlusion. More numerous collateral vessels were associated with better 6-min walk performance (0 to 3 collaterals-1,064 feet, 4 to 7 collaterals-1,165 feet, ≥8 collaterals-1,246 feet, p trend = 0.007), faster usual-paced walking speed (0 to 3 collaterals-0.84 m/s, 4 to 7 collaterals-0.88 m/s, ≥8 collaterals-0.91 m/s, p trend = 0.029), and faster rapid-paced walking speed (0 to 3 collaterals-1.17 m/s, 4 to 7 collaterals-1.22 m/s, ≥8 collaterals-1.29 m/s, p trend = 0.002), adjusting for age, sex, race, comorbidities, ABI, and other confounders. CONCLUSIONS: Among PAD participants, MRI-visualized occlusions in the proximal SFA are associated with poorer functional performance, whereas more numerous collaterals are associated with better functional performance. (Magnetic Resonance Imaging to Identify Characteristics of Plaque Build-Up in People With Peripheral Arterial Disease; NCT00520312).

Insertion of balloon retained gastrostomy buttons: a 5-year retrospective review of 260 patients.

PURPOSE: Radiologically inserted gastrostomy (RIG) is an established way of maintaining enteral nutrition in patients who cannot maintain nutrition orally. The purpose of this study was to evaluate the safety and efficacy of primary placement of a wide bore button gastrostomy in a large, varied patient population through retrospective review. METHODS: All patients who underwent gastrostomy placement from January 1, 2004 to January 1, 2009 were identified. 18-Fr gastrostomy buttons (MIC-Key G) were inserted in the majority. Follow-up ranged from 6 months to 4.5 years. RESULTS: A total of 260 patients (M:F 140:120, average age 59.2 years) underwent gastrostomy during the study period. Overall success rate for RIG placement was 99.6 %, with success rate of 95.3 % for primary button insertion. Indications included neurological disorders (70 %), esophageal/head and neck malignancy (21 %), and other indications (9 %). Major and minor complication rates were 1.2 and 12.8 %, respectively. Thirty-day mortality rate was 6.8 %. One third of patients underwent gastrostomy reinsertion during the study period, the main indication for which was inadvertent catheter removal. Patency rate was high at 99.5 %. The maximum number of procedures in any patient was 8 (n = 2), and the average tube dwell time was 125 days. CONCLUSIONS: Primary radiological insertion of a wide bore button gastrostomy is a safe technique, with high success rate, high patency rate, and low major complication rate. We believe that it is feasible to attempt button gastrostomy placement in all patients, once tract length is within limits of tube length. If difficulty is encountered, then a standard tube may simply be placed instead.

Clinical correlates of size and number of collateral vessels in peripheral artery disease.

We studied associations of the number and size of magnetic resonance angiography (MRA)-assessed lower extremity collateral vessels with the ankle-brachial index (ABI), severity of superficial femoral artery (SFA) plaque, and leg symptoms in participants with peripheral artery disease (PAD). A total of 303 participants with PAD underwent time-resolved MRA at the thigh station. Collaterals were categorized by number (Category 1: 0-3 collaterals; Category 2: 4-7 collaterals; Category 3: ≥ 8 collateral vessels) and size (Grade 1: ≤ 5 small collaterals; Grade 2: > 5 small vessels; Grade 3: ≤ 5 large collaterals; Grade 4: > 5 large collaterals). Adjusting for age, sex, race, comorbidities and other covariates, more numerous collateral vessels were associated with lower ABI values (Category 1: 0.79; Category 2: 0.67; Category 3: 0.60; p trend < 0.001). Similarly, larger collateral vessels were associated with lower ABI values (Grade 1: 0.75; Grade 2: 0.65; Grade 3: 0.62; Grade 4: 0.59; p trend < 0.001). More numerous (p < 0.001) and larger (p < 0.001) collateral vessels were associated with greater mean SFA plaque area (p trend < 0.001). More numerous (p trend = 0.007) and larger (p trend = 0.017) collateral vessels were associated with a lower prevalence of asymptomatic PAD. In conclusion, among participants with PAD, larger and more numerous collaterals, measured by MRA, were associated with lower ABI values, greater plaque area in the SFA, and a lower prevalence of asymptomatic PAD. Further study is needed to determine the role of collateral vessels in maintaining functional performance in PAD.

ECG-gated multiecho Dixon fat-water separation in cardiac MRI: advantages over conventional fat-saturated imaging.

OBJECTIVE: The purpose of this pictorial essay is to explore the advantages of multiecho Dixon fat-water separation techniques in cardiac MRI. The clinical indications, potential artifacts, and imaging findings with this technique are reviewed. CONCLUSION: Multiecho Dixon fat-water separation can be used to help characterize cardiac masses, evaluate for myocardial lipomatous infiltration, and diagnose pericarditis. Advantages over conventional fat-saturation techniques include fewer artifacts from background inhomogeneity, improved contrast of microscopic fat, and capability for use in combination with cine and contrast-enhanced imaging.

Intravenous, contrast-enhanced MR colonography using air as endoluminal contrast agent: impact on colorectal polyp detection.

PURPOSE: To compare diagnostic accuracy and patient tolerance of MR colonography with intravenous contrast and luminal air (MRC) to conventional colonoscopy (CC). MATERIALS AND METHODS: IRB approval and written informed consent were obtained. Forty-six patients, both screening and symptomatic, underwent MRC followed by CC. The MRC technique employed 3D T1W spoiled gradient echo sequences performed after the administration of gadopenetate dimeglumine, with parallel imaging. The diagnostic accuracy and tolerance of patients for MRC was compared to CC. RESULTS: Twenty-four polyps were detected in eighteen patients with CC (5 polyps ≥ 10 mm, 4 polyps 6-9 mm, 15 polyps ≤ 5 mm). MRC was 66.7% (12/18) sensitive and 96.4% (27/28) specific for polyp detection on a per-patient basis. When analyzed by polyp size, sensitivity and specificity of MRC was 100% (5/5) and 100% (19/19), respectively, for lesions greater than 10mm, 100% (4/4) and 100% (20/20) for lesions 6-9 mm, and sensitivity of 20% (3/15) lesions less than 5mm. The sensitivity and specificity of MRC for detecting significant lesions (>6mm) was 100% (9/9) and 100% (15/15), respectively. Regarding tolerance of the exams, there were no significant differences between MRC and CC. Thirty-five percent (n=16) of patients preferred MRC as a future screening test compared to 33% (n=15) for CC. CONCLUSION: MRC using air as an intraluminal contrast agent is a feasible and well-tolerated technique for detecting colonic polyps ≥ 6 mm in size. Further studies are warranted.

Coronary multidetector computed tomographic angiography to evaluate coronary artery disease in liver transplant candidates: methods, feasibility and initial experience.

AIMS: In patients undergoing orthotopic liver transplantation (OLT), coronary artery disease (CAD), obstructive and nonobstructive, is associated with high morbidity and mortality. In OLT candidates, stress testing for detecting ischemia is often inaccurate, and this patient population often has relative contraindications for cardiac catheterization. The objective of this study was to describe the methods, assess the feasibility and determine the extent and severity of CAD in OLT candidates without a prior history of CAD using coronary multidetector computer tomographic angiography (MDCTA). METHODS: Sixty-five OLT candidates without known CAD underwent coronary MDCTA with dual source cardiac computed tomography (Siemens Definition). Coronary arteries were divided into 17 segments based on American Heart Association guidelines and evaluated independently by two blinded reviewers. Image quality of coronary MDCTA was assessed on a four-point Likert scale (0 = poor, 1 = fair, 2 = good, and 3 = excellent). Atherosclerotic lesions were evaluated for severity [mild (0-50%), moderate (51-70%), and severe (71-100%)], morphology, extent, location and consistency. RESULTS: Image quality was graded as good or excellent in 73.8%. In this cohort of OLT candidates without known CAD, 9% had normal coronary arteries, 58% had mild CAD and 34% had moderate to severe CAD. Plaque severity and burden scores were high. CONCLUSION: The prevalence of asymptomatic CAD is high in OLT candidates. Coronary MDCTA is feasible in OLT candidates and appears to be a useful technique to diagnose occult CAD in this patient population.

Improved detection of subendocardial hyperenhancement in myocardial infarction using dark blood-pool delayed enhancement MRI.

OBJECTIVE: Delayed enhancement MRI using fast segmented k-space inversion recovery (IR) gradient-echo imaging is a well established "bright-blood" technique for identifying myocardial infarction and is used as the reference standard sequence in this study. The purpose of this study was to validate a recently developed dark blood-pool delayed enhancement technique in a porcine animal model, evaluate its performance in human patients, and quantify its performance compared with the reference standard in both. SUBJECTS AND METHODS: In an animal study, the reference standard and dark blood-pool delayed enhancement were assessed in three pigs with induced myocardial infarction. In a human study, 26 patients, 31-81 years old (19 men and seven women), with a known history of myocardial infarction were imaged using the reference standard and dark blood-pool delayed enhancement. Contrast-to-noise ratio (CNR), signal intensity ratio, signal-to-noise ratio (SNR), and qualitative scores of hyperenhancement were recorded. Measurements were compared using paired samples t test and Wilcoxon's signed rank test. RESULTS: In the animal study, the mean CNR of infarct to blood pool was 11 times higher for dark blood-pool delayed enhancement than for the reference standard. The mean SNR was 4.4 times higher for the reference standard. In the human study, the mean CNR and signal intensity ratio of hyperenhancing myocardium to the blood pool were 1.9 (p = 0.04) and 5.5 (p < 0.01) times higher, respectively, for dark blood-pool delayed enhancement compared with reference standard. The mean CNR and signal intensity ratio of hyperenhancing myocardium to normal myocardium and SNR were 2.8 (p < 0.01), 1.3 (p = 0.07), and 2.8 (p < 0.01) higher, respectively, for the reference standard. Qualitative analysis identified seven extra segments with grade 1 scars using dark blood-pool delayed enhancement (p < 0.01). CONCLUSION: Dark blood-pool delayed enhancement is complementary to the reference standard. It can detect more subendocardial foci of hyperenhancement, thus potentially identifying more infarcts and changing patient management.

Skills training after night shift work enables acquisition of endovascular technical skills on a virtual reality simulator.

BACKGROUND: Adoption of residents' working time restrictions potentially undermines surgical training by reduction of operating room exposure. Simulation has been proposed as a way to acquire necessary skills in a laboratory environment but remains difficult to incorporate into training schedules. This study assessed whether residents working successive nights could acquire endovascular skills similar to colleagues working day shifts. METHODS: This prospective observational cohort study recruited 20 junior residents, divided into day shift and night shift groups by their respective call schedule. After initial cognitive skills training, a validated renal artery stent module on an endovascular simulator was completed over a series of seven sequential shifts during 1 week. The primary outcome measure was serial technical skill assessments. Secondary measures comprised assessments of activity, cognitive performance, introspective fatigue, quality, and quantity of preceding sleep. RESULTS: Both groups demonstrated significant learning curves for total time at the first session median vs seventh session median (181 vs 564 seconds [P < .001]; night, 1399 vs 572 [P < .001]), fluoroscopy time (day, 702 vs 308 seconds, [P < .001]; night, 669 vs 313 [P < .001]), and contrast volume (day, 29 vs 13 mL [P < .001]; night, 40 vs 16 [P < .001]). Residents working day shifts reached plateau 1 day earlier in the above measures vs those on night duty. The night shift group walked more steps (P < .001), reviewed more patients (P < .001), performed worse on all cognitive assessments (P < .05), slept less (P < .05), had poorer quality of sleep (P = .001), and was more fatigued (P < .001) than the day shift group. Acquired skill was retained a week after completion of shifts. CONCLUSION: Technical skills training after night shift work enables acquisition of endovascular technical skills, although it takes longer than after day shift training. This study provides evidence for program directors to organize simulation-based training schedules for residents on night shift rotations.

Percutaneous balloon dilatation of stenotic calyceal diverticular infundibula in patients with recurrent urinary tract infections.

AIM: Renal calyceal diverticula are usually detected as incidental findings on intravenous pyelograms (IVPs) and rarely manifest any clinical signs or symptoms. However, they can interfere with patient's quality of life in a number of instances causing pain, recurrent urinary tract infections (UTIs), abscess, systemic sepsis and calculus formation. The purpose of this study was to review the clinical indications, procedure technique and clinical outcome in all patients referred to Interventional Radiology for the percutaneous management of renal calyceal diverticula. MATERIALS AND METHODS: A retrospective review of all patients treated with percutaneous balloon dilatation of calyceal diverticular infundibula in the Interventional Radiology Department over a 10-year period was performed. Data collected included clinical details, laboratory indices, IVP and CT findings, procedure details and clinical outcome. RESULTS: A total of three patients were treated over the course of the study period. All patients were young females who presented as a result of recurrent urinary tract infections. The calyceal diverticula were diagnosed incidentally on routine IVPs, with CT eloquently confirming the plain film findings in two cases. Technical procedure success was achieved in all cases, avoiding surgical intervention. Clinical follow-up revealed no further UTIs following dilatation. CONCLUSION: Fluoroscopic guided percutaneous balloon dilatation of renal calyceal diverticular infundibula following direct diverticular puncture is a safe and well tolerated method to reduce UTI and potentially avoid future stone formation.

Assessment of left ventricular myocardial scar in infiltrative and non-ischemic cardiac diseases by free breathing three dimensional phase sensitive inversion recovery (PSIR) TurboFLASH.

The purpose of this study was to compare a navigator gated free breathing 3D Phase Sensitive Inversion Recovery (PSIR) TurboFLASH to an established 2D PSIR TurboFLASH method for detecting myocardial late gadolinium hyperenhanced lesions caused by infiltrative and non-ischemic cardiomyopathy. Under an IRB approved protocol; patients with suspected non-ischemic infiltrative myocardial heart disease were examined on a 1.5T MR scanner for late enhancement after the administration of gadolinium using a segmented 2D PSIR TurboFLASH sequence followed by a navigator-gated 3D PSIR TurboFLASH sequence. Two independent readers analyzed image quality using a four point Likert scale for qualitative analysis (0 = poor, non diagnostic; 1 = fair, diagnostic may be impaired; 2 = good, some artifacts but not interfering in diagnostics, 3 = excellent, no artifacts) and also reported presence or absence of scar. Detected scars were classified based on area and location and also compared quantitatively in volume. Twenty-seven patients were scanned using both protocols. Image quality score did not differ significantly (p = 0.358, Wilcoxon signed rank test) for both technique. Scars were detected in 24 patients. Larger numbers of hyperenhanced scars were detected with 3D PSIR (200) compared to 2D PSIR (167) and scar volume were significant larger in 3D PSIR (p = 0.004). The mean scar volume over all cases was 49.95 cm(3) for 2D PSIR and 70.02 cm(3) for 3D PSIR. The navigator gated free breathing 3D PSIR approach is a suitable method for detecting myocardial late gadolinium hyperenhanced lesions caused by non-ischemic cardiomyopathy due to its complete isotropic coverage of the left ventricle, improving detection of scar lesions compared to 2D PSIR imaging.

Technical considerations for lower limb multidetector computed tomographic angiography.

Multidetector computed tomography (MDCT) enables imaging of the entire arterial tree non-invasively. Optimal technical considerations for performing MDCT angiography (MDCTA) are essential for accurate diagnosis and atherosclerotic disease stratification. This review article focuses on the various technical aspects necessary for peripheral computed tomographic angiography (CTA) acquisition. Common clinical indications for peripheral MDCTA and the latest scan protocols are described. The essential issue of radiation dose reduction is discussed, along with methods of optimal contrast bolus detection and delivery. Post-processing techniques are also presented. Previously, digital subtraction angiography was the only established reliable imaging technique to quantify atherosclerotic disease load; however, MDCTA may now challenge this old gold standard, along with other non-invasive techniques such as magnetic resonance angiography (MRA).

Endovascular treatment of delayed type 1 and 3 endoleaks.

PURPOSE: Endovascular aortic aneurysm repair (EVAR) has revolutionized the treatment of abdominal aortic aneurysms. Type I and III endoleaks require prompt, definitive repair or explantation. We review a single center experience of endovascular treatment of type I and III endoleaks. MATERIALS AND METHODS: Retrospective review of 22 patients who underwent endovascular intervention for remediation of proximal or distal seal zone endoleaks. RESULTS: Median age was 77 years. Median time interval from EVAR to reintervention was 4 years (range, 1 month-11 years). Sixteen patients (73%) had radiological evidence of endoleak and/or expanding sac size and 6 (27%) had contained rupture. Nine patients underwent a total of 12 endovascular reinterventions before this salvage procedure. Stent grafts used at the original procedure were: AneuRx (n = 10), Excluder (n = 7), Ancure (n = 3), Zenith (n = 1), and custom made (n = 1). Endoleaks treated were type Ia (n = 11), Ib (n = 12), and type III (n = 3). Interventions included: proximal cuff insertion with or without Palmaz stent insertion (n = 8), distal limb extension (n = 2), stent graft relining (n = 6), embolization of hypogastric artery and iliac limb extension (ILE) (n = 5), and aorto-uni-iliac stent graft (AUI) with femoral-femoral crossover (n = 1). One patient who had a rupture died of multiorgan failure. Two patients needed additional reinterventions for endoleaks. Median length of hospital stay was 1 day. CONCLUSION: Lifelong surveillance after EVAR is advocated because of the potential of delayed type I or III endoleaks, which mandate definitive treatment. Fortunately, most delayed type I and III endoleaks can be successfully corrected with endoluminal interventions rather than resorting to explantation of the endograft.

Below knee angioplasty in elderly patients: predictors of major adverse clinical outcomes.

AIM: To determine predictors of clinical outcome following percutaneous transluminal angioplasty (PTA) in elderly patients with below knee atherosclerotic lesions causing intermittent claudication (IC) or critical limb ischaemia (CLI). MATERIALS AND METHODS: Over 7.5 years, 76 patients (CLI 72%, n = 55) underwent below knee PTA. The composite end-point of interest was major adverse clinical outcome (MACO) of the treated limb at follow-up which was defined as clinical failure, need for subsequent endovascular or surgical revascularization or amputation. Actuarial freedom from MACO was assessed using Kaplan-Meier curves and multivariable Cox proportional hazards regression. RESULTS: IC was improved in 95% at mean 3.4 years (range 0.5-108 months). Successful limb salvage and ulcer healing were seen in 73% with CLI. Most failures were in the CLI group (27% CLI vs. 5% IC), with an amputation rate of 16% for CLI vs. 5% for IC and persistent ulceration in 24% of CLI. Significant independent predictors of MACO were ulceration (hazard ratio 4.02, 95% CI = 1.55-10.38) and family history of atherosclerosis (hazard ratio 2.53, 95% CI = 1.1-5.92). CONCLUSION: Primary below knee PTA is a feasible therapeutic option in this elderly population. Limb ulceration and family history of atherosclerosis may be independent predictors of adverse outcome.

Low dose dual-source CT angiography of the thoracic aorta.

The purpose of this study was to investigate the effects of a prospective ECG-gated, low kilovoltage and low mAs protocol on image quality and radiation dose when acquiring CT angiography of the thoracic aorta (CTTA). Sixty patients with a body mass index (BMI) of less than 30 and a heart rate of less than 100 beats per minute (bpm) were included in the study. Thirty consecutive patients were examined with retrospective ECG-gating and standard parameters (group A) (120 kVp, 340 reference effective mAs).The next thirty (group B) were examined with prospective ECG-gating, 100 kVp and 170 mAs. Quantitative analysis included measurements of image resolution of the thoracic aorta at three levels, mean attenuation in the aorta and signal to noise ratio (SNR). Qualitative analysis assessed image artifact and graded image quality on five point scales. Effective radiation doses were estimated. The radiation dose of group A was 26.2 ± 6.0 mSv (mean ± standard deviation). For group B it was 2.9 ± 0.5 mSv (P < 0.001). Mean aortic attenuation was significantly higher in group B than group A (487 ± 100 Hu and 372 ± 74 Hu) (P < 0.01).SNR was significantly higher in group A (21.7 ± 5.7 compared to 14.5 ± 5.3) (P < 0.01). Image resolution was significantly higher in group B at all measured anatomical levels (P < 0.01). There was no significant difference in the final subjective scores between group A and group B (Mann-Whitney U = 438, P = 0.79). High quality low dose CTTA is clinically achievable, in patients with a BMI less than 30 and a heart rate less than 100 bpm, using a prospective ECG-gated, low kilovoltage, low mAs technique.

Down syndrome: a risk factor for mycotic aneurysm?

Down syndrome, or trisomy 21, has a characteristic constellation of clinical findings, including various congenital heart defects. We report a case of an adult male with Down syndrome who presented with a 3-week history of lower limb pain and swelling, attributed to cellulitis. Clinical and angiographic evaluation identified a below-knee mycotic pseudoaneurysm secondary to infective endocarditis. Surgical aneurysmal repair and revascularization were performed. Various management options are outlined in this report.