Is 64-Row Multi-Detector Computed Tomography Angiography Equal to Digital Subtraction Angiography in Treatment Planning in Critical Limb Ischemia?

BACKGROUND: Critical limb ischemia (CLI) represents the end stage of peripheral arterial disease (PAD). It is defined as a chronic ischemic rest pain, ulcers or gangrene, attributable to proven arterial occlusive disease. Intra-arterial digital subtraction angiography (IA DSA) still represents the gold standard for the evaluation of steno-occlusive lesions, but it has greatly been replaced with non-invasive multi-detector computed tomography angiography (MDCTA). The purpose of this prospective study was to compare diagnostic performance of MDCTA versus DSA in treatment planning in patients with CLI according to TransAtlantic Inter-Society Consensus Document on Management of Peripheral Arterial disease (TASC II). SUBJECTS AND METHODS: The study was designed as prospective; it was conducted from March 2014 to August 2016, and included 60 patients with symptoms of CLI, Fontaine stage III and IV. MDCTA of the peripheral arteries was performed first, followed by DSA. The lesions of aorto-iliac, femoro-popliteal and infra-popliteal regions were classified according to the TASC II guidelines, and inter-modality agreement between MDCTA and DSA was determined by using Kendall's tau-b statistics. RESULTS: Inter-modality agreement was statistically significant in all three vascular beds, with excellent agreement >0.81 in aortoiliac and femoropopliteal regions, and a very good agreement >0.61 in infrapopliteal region. Treatment recommendations based on MDCTA findings and DSA findings were identical in 54 (90%) patients. In one patient (1.7%), CTA was not interpretable. In five patients (8.3%), CTA findings disagreed with DSA findings in regard to the preferable treatment option. CONCLUSION: 64-row MDCT angiography is highly competitive to DSA in evaluation of steno-occlusive disease and treatment planning in patients with critical limb ischemia.

Possibilities of differentiation of solitary focal liver lesions by computed tomography perfusion.

AIM: To evaluate possibilities of computed tomography (CT) perfusion in differentiation of solitary focal liver lesions based on their characteristic vascularization through perfusion parameters analysis. METHODS: Prospective study was conducted on 50 patients in the period 2009-2012. Patients were divided in two groups: benign and malignant lesions. The following CT perfusion parameters were analyzed: blood flow (BF), blood volume (BV), mean transit time (MTT), capillary permeability surface area product (PS), hepatic arterial fraction (HAF), and impulse residual function (IRF). During the study another perfusion parameter was analyzed: hepatic perfusion index (HPI). All patients were examined on Multidetector 64-slice CT machine (GE) with application of perfusion protocol for liver with i.v. administration of contrast agent. RESULTS: In both groups an increase of vascularization and arterial blood flow was noticed, but there was no significant statistical difference between any of 6 analyzed parameters. Hepatic perfusion index values were increased in all lesions in comparison with normal liver parenchyma. CONCLUSION: Computed tomography perfusion in our study did not allow differentiation of benign and malignant liver lesions based on analysis of functional perfusion parameters. Hepatic perfusion index should be investigated in further studies as a parameter for detection of possible presence of micro-metastases in visually homogeneous liver in cases with no lesions found during standard CT protocol.

Magnetic resonance urography in children - when and why?

BACKGROUND: The aim of the study was to determine the potential of magnetic resonance urography (MRU) in evaluation of paediatric urinary tract pathologies. PATIENTS AND METHODS.: Twenty-one paediatric urological patients were evaluated with T1, T2 prior and after and 3D gradient echo sequences after the contrast administration. Results were compared with findings obtained with ultrasound which was performed to all of patients, intravenous urography performed to 14 patients with the diagnosis of hydronephrosis and voiding cystouretrography performed to 6 patients where hydronephrosis was suspected to be caused by vesicoureteral reflux (VUR). RESULTS: MRU not only established the cause of hydronephrosis in all 14 cases (5 ureteropelvic junction (UPJ) stenosis, 1 functional stenosis, 3 residual hydronephrosis, 1 combination of UPJ and vesico-ureteric junction (VUJ) stenosis with hydromegaureter, 2 fetal ureters and 3 insufficient broad ureteral orifices), but gave additional information about existing pathological conditions in all of patients compared to other previously performed examination (1 caliceal lithiasis, 4 UPJ stenosis, 1 VUJ stenosis, 1 neurogenic bladder, 1 hypotonic ureter, 1 urinary infection, 1 duplication of pelvis and ureter, 1 urinary retention and 1 fetal ureter). Other MRU findings were: 3 polycystic kidney disease, 1 caliceal cyst, 2 simple renal cysts, 1 long hypotonic twisted ureters and 1 hypertrophied column of Bertini. CONCLUSIONS: Because of the ability to acquire high contrast and spatial resolution images of the whole urinary tract in any orthogonal plane, MRU enables a precise detection and differentiation of pathological urological conditions. We believe that in the future, because of its advantages, MRU will replace traditional methods in the evaluation of urinary tract pathologies.

Patient doses in interventional cardiology in Bosnia and Herzegovina: first results.

Cardiologists at the Cardiac Centre of the Clinical Centre of Sarajevo University performed invasive cardiology procedures in one room equipped with a Siemens Coroskop (Siemens Healthcare, Erlangen, Germany) unit with the possibility of digital cine imaging. The number of procedures performed with this unit is 1126 per year. The number of adults performing only diagnostic procedures is 816, therapeutic procedures 62 and both diagnostic and therapeutic 228. Twenty diagnostic examinations but no therapeutic procedure are performed on children per year. The workload is increasing year by year, with an average increase of 26 % per year. The X-ray system does not have a kerma area product (KAP) meter installed; therefore an external KAP meter was mounted on the X-ray tube. Gafchromic dosimetry films (International Specialty Products, Wayne, USA) were placed under the patient to record the skin dose distribution. The peak skin dose (PSD) was calculated from the maximum optical density of the dosimetry films. Dose measurements were performed on 51 patients undergoing therapeutic procedures (percutaneous transluminal coronary angioplasty and stent placement). Two patients received doses (KAP) larger than 100 Gycm(2). The PSD was higher than 1 Gy in 3 out of 16 evaluations, and one of these patients received a skin dose >2 Gy. No deterministic skin effects were recorded. The dosimetry results are similar to results reported in other countries. Invasive cardiac procedures deliver high doses to the skin that could cause deterministic effects (erythema). Physicians performing these procedures should be aware of these risks. More efforts should be put into the training of cardiologists in radiation protection.

Percutaneous transarterial kidney embolization.

INTRODUCTION: In advanced stage of renal carcinoma especially in right kidney because of proximity of inferior vena cava in most centers preoperative embolization of kidney is performed in purpose of facilitating surgery and reducing pre- and postoperative complications. In certain number of patients with indication for inoperability, complete embolization is performed in order.to prevent complications like bleeding. After intervention, surgical nephrectomy can be performed. In patients with the absolute contraindication for the surgical treatment, embolization represents the treatment of choice. MATERIAL AND METHODS: Material for period of 7 years in Elbeck-Schoen Klinik and CCUS is presented in this paper. There were 72 patients, age range 3 to 92 years old, treated with 77 performed embolizations. Embolization was performed with PVA particles in order of achieving capillary embolization, while the principal trunk of renal artery was occluded with one or more coils until complete occlusion occurred. RESULTS: Patients were divided in two groups: group A consisted of patients with preoperatively performed embolization, and to patients in group B embolization was performed as form of palliative care. In all patients in group A procedure was a success, and in one patient from group B procedure was needed to be repeated several times. DISCUSSION AND CONCLUSION: As it is known from medical history first embolization was performed by Almgard in 1973 with purpose in providing safer surgical treatment to patient. Nowadays, this procedure got its widespread use in interventional radiology. Our experiences indicate successfulness of this procedure in most cases in preoperative management as well as in palliative treatment of patient. Postembolization syndrome occurred in all patients after intervention has been performed, and was successfully treated with symptomatic therapy. More severe complications were sporadic. In conclusion it might be said that embolization of inoperative tumors may increase both survival rate and quality of patients life.

[Color Doppler sonography of focal abdominal lesions]. / Kolor Doppler sonografija fokalnih lezija abdomena.

Color Doppler sonography (CDS--spectral, color and power), harmonic imaging techniques (THI, PHI), possibility of 3D analysis of picture, usage of contrast agents, have raised the values of ultrasound as a diagnostic method to a very high level. THI--non-linear gray scale modality, is based on the processing of higher reflected frequencies, that has improved a picture resolution, which is presented with less artifacts and limiting effects of obesity and gases. Ultrasound contrast agents improve analysis of micro and macro circulation of the examined area, and with the assessment of velocity of supply in ROI (wash in), distribution and time of signal weakening (wash out), are significantly increasing diagnostic value of ultrasound. Besides the anatomical and topographic presentation of examined region (color, power), Color Doppler sonography gives us haemodynamic-functional information on vascularisation of that region, as well as on pathologic vascularisation if present. Avascular aspect of a focal pathologic lesion corresponds to a cyst or haematoma, while coloration and positive spectral curve discover that anechogenic lesions actually represents aneurysms, pseudoaneurysms or AVF. In local inflammatory lesion, abscess in an acute phase, CDS shows first increased, and then decreased central perfusion, while in a chronic phase, a pericapsular vascularisation is present. Contribution of CDS in differentiation of hepatic tumors (hemangioma, HCC and metastasis) is very significant. Central color dots along the peripheral blood vessels and the blush phenomenon are characteristics of capillary hemangioma, peritumoral vascular ring "basket" of HCC, and "detour" sign of metastasis. The central artery, RI from 0.45 to 0.60 and radial spreading characterize FNH. Hepatic adenoma is characterized by an intratumoral vein, and rarely by a vascular hallo. Further on, blood velocity in tumor defined by Color Doppler, distinguishes malignant from benign lesion, where 40 cm/s is a rough border value. Values of DPI (Doppler perfusion index) over 0.3 and tumor index over 1.0 characterize primary, and lower values characterize secondary liver malignancies. In differentiation of benign and malign tumors of kidneys, besides the aspect of vascularisation, the maximal frequency altitude in tumor artery (the limit around 2.5 kHz) is very important. However, peripheral and penetrating blood vessels are most usually seen in RCC, less often in AML and bigger oncocytomas. CDS with contrast agent is very useful in making differential diagnosis of the focal lesions with 95% specificity for some lesions.

[Ultrasound in the diagnosis and differential diagnosis of acute appendicitis in childhood]. / Ultrazvuk u dijagnostici i diferencijalnoj dijagnostici akutnog apendicitisa u djecijoj dobi.

UNLABELLED: Acute appendicitis represents a leading cause of an abdominal pain in children which requires urgent surgical treatment. AIM OF THE STUDY: To investigate into value of ultrasound (US) in diagnostics and differential-diagnostics of acute appendicitis in children. PATIENTS AND METHODS: A prospective study during a two-year period, was conducted to analyse abdominal US findings in 95 patients, 3-16 years of age who had acute abdominal pain. In all patients we were checking for clinical symptoms of an acute abdomen: pain, nausea, vomiting, fever, frequent urination, diarrhea, duration of symptoms and count of leukocytes. US findings were compared with pathohistological results We have used Toshiba Sonolayer SAL 77 ultrasound machine with a convex 3.75 MHz probe and a linear 8 MHz probe. RESULTS: In 50 patients sonographic diagnoses were confirmed by surgery .36 patients had other pathological conditions that lead to an acute abdomen. Nine findings were false-negative. The study results reveal that the US scanning enables not only reliable diagnosis of acute appendicitis, but also reliable differential-diagnosis of other pathological conditions and diseases. CONCLUSION: US should be the imaging method of choice in diagnostic evaluation of little patients with acute abdominal pain. This method represents a great help in differential diagnosis not only to eliminate acute appendicitis but also to confirm accuracy of the diagnosis.

[Magnetic resonance cholangiopancreatography (MRCP): correlation with diagnosis using ERCP]. / MRCP: korelacija sa dijagnostickim ERCP-om.

Magnetic resonance cholangiopancreatography (MRCP) is non invasive imaging technique able to provide projection images of the bile and pancreatic ducts. Using breath--hold and non-breath--hold acquisition techniques, have been employed in order to obtain MRCP images. Clinical applications of MRCP are evaluated from presenting references and from personal experience. The main indication for MRCP imaging was in evaluation of common bile duct obstruction, with aim of present the level, and its cause. The utility of conventional MR images to MRCP in the malignant lesion is already discussed. At the end, the utility of MR pancreatography in evaluation of the patients with pancreatic disease is discussed from both the literature and personal experiences. The clinical indications to perform ERCP in patients with pancreatic cancer may include palliative stent placement in patients with known non-resectable pancreatic carcinoma invading the common bile duct; obtaining tissue material in patients with atypical masses in the pancreatic head, particularly in the periampullary area; suspicion of intraductal neoplasm; difficult differential diagnosis between pancreatic cancer and chronic pancreatitis. The place for ERCP in future will be reserved for interventional procedures.