Ultrasound Imaging of Acquired Myometrial Pseudoaneurysm: The Role of Manipulators as an Unusual Cause during Laparoscopic Surgery.

An acquired uterine artery myometrial pseudoaneurysm can occur due to inflammation, trauma, or iatrogenic causes, such as surgical procedures, and can lead to profuse bleeding. The efficacy of uterine manipulators in gynecological surgery, particularly as a cause of a pseudoaneurysm, has been poorly discussed in the literature. In this paper, we discuss a case of a 39-year-old woman with profuse uterine bleeding that occurred seven days after operative laparoscopic surgery for endometriosis. The color Doppler ultrasound better evoked the arterial-like turbulent blood flow inside this cavity. These sonographic features were highly suggestive of uterine artery pseudoaneurysm, presumably related to a secondary trauma caused by the manipulator. The diagnosis was subsequently re-confirmed by angiography, and the patient was treated conservatively with uterine artery embolization. Ultrasound has been shown to be a valuable and safe tool for imaging pseudoaneurysm and guiding subsequent interventional procedures. Accordingly, we briefly review the most suitable manipulators used in benign gynecological surgeries to verify if the different types in use can guide the surgeon towards the correct choice according to surgical needs and thus prevent potentially dangerous trauma.

Perfusion CT in acute stroke: effectiveness of automatically-generated colour maps.

OBJECTIVE: To evaluate the accuracy of perfusion CT (pCT) in the definition of the infarcted core and the penumbra, comparing the data obtained from the evaluation of parametric maps [cerebral blood volume (CBV), cerebral blood flow (CBF) and mean transit time (MTT)] with software-generated colour maps. METHODS: A retrospective analysis was performed to identify patients with suspected acute ischaemic strokes and who had undergone unenhanced CT and pCT carried out within 4.5 h from the onset of the symptoms. A qualitative evaluation of the CBV, CBF and MTT maps was performed, followed by an analysis of the colour maps automatically generated by the software. RESULTS: 26 patients were identified, but a direct CT follow-up was performed only on 19 patients after 24-48 h. In the qualitative analysis, 14 patients showed perfusion abnormalities. Specifically, 29 perfusion deficit areas were detected, of which 15 areas suggested the penumbra and the remaining 14 areas suggested the infarct. As for automatically software-generated maps, 12 patients showed perfusion abnormalities. 25 perfusion deficit areas were identified, 15 areas of which suggested the penumbra and the other 10 areas the infarct. The McNemar's test showed no statistically significant difference between the two methods of evaluation in highlighting infarcted areas proved later at CT follow-up. CONCLUSION: We demonstrated how pCT provides good diagnostic accuracy in the identification of acute ischaemic lesions. The limits of identification of the lesions mainly lie at the pons level and in the basal ganglia area. Qualitative analysis has proven to be more efficient in identification of perfusion lesions in comparison with software-generated maps. However, software-generated maps have proven to be very useful in the emergency setting. Advances in knowledge: The use of CT perfusion is requested in increasingly more patients in order to optimize the treatment, thanks also to the technological evolution of CT, which now allows a whole-brain study. The need for performing CT perfusion study also in the emergency setting could represent a problem for physicians who are not used to interpreting the parametric maps (CBV, MTT etc.). The software-generated maps could be of value in these settings, helping the less expert physician in the differentiation between different areas.

Intractable haematuria: long-term results after selective embolization of the internal iliac arteries.

OBJECTIVE: To determine the feasibility and efficacy of transarterial embolization (TAE) in haemorrhagic urological emergencies, and to assess the perioperative morbidity, effect of timing of intervention on the requirement for blood transfusion, and the long-term follow-up. PATIENTS AND METHODS: Between October 1997 and March 2009, 44 patients (30 men and 14 women; mean age 79 years, range 51-95) with intractable haematuria secondary to advanced pelvic tumour arising from or invading the bladder, underwent internal iliac TAE. Twenty-four patients had transitional carcinoma of the urinary bladder, 12 adenocarcinoma of the prostate, five carcinoma of the uterus, one cancer of the vagina, two carcinoma of the rectum, three carcinoma of the kidney, two simultaneous carcinoma of prostate and bladder, one simultaneous carcinoma of prostate and kidney and one had haemorrhagic cystitis after radiotherapy. RESULTS: TAE of the internal iliac arteries produced initial complete control of bleeding in 36 of the 44 patients (82%). At a mean (range) follow-up of 10.5 (1-97) months TAE there was permanent control of bleeding in 19 (43%) patients. A second TAE session was use in five (11%) patients and it was successful in two of them. There were 24 patients (55%) who required a mean of 4 (1-17) transfusion units before embolization; only 13 (30%) required more blood products after TAE. The mean haematocrit level before and after TAE was 27% and 31% (P < 0001), and the respective haemoglobin level were 8.7 and 10.3 g/dL (P < 0001). During the follow-up there were no major complications related to TAE; minor complications were post-TAE syndrome in 12 (27%) patients, fever (11%), gluteus pain (14%), nausea (2%), and exterior genital oedema (5%). The 6- and 12-month mortality rates were 66% (29 patients) and 18% (eight), respectively. CONCLUSIONS: TAE should be considered as an alternative less-invasive palliative measure and the treatment of choice in these situations. TAE should always be bilateral, the catheter should advance distally to the origin of the superior gluteal artery and the artery embolized with unresorbable particles. Our study confirms the efficacy and safety of TAE in patients with pelvic malignancy, and indicates that this technique should be considered before surgery. The procedure combines the benefits of a minimally invasive approach in decreasing the cost of surgery and operating time, while maintaining low blood loss and analgesia requirement.

High-flow priapism complicating ischemic priapism following iatrogenic laceration of the dorsal artery during a Winter procedure.

We report a case of a patient who developed high-flow priapism following a Winter procedure performed for the treatment of low-flow ischemic priapism. During the creation of bilateral cavernosal-glandular shunts, the tip of the left dorsal artery was accidentally lacerated. A fistula developed through the shunt between the torn artery and the cavernosal sinusoids of the tip of the left corpus cavernosum. Gray-scale and Doppler sonography and angiography allowed diagnosis and guided the therapeutic approach.

Sexual function after highly selective embolization of cavernous artery in patients with high flow priapism: long-term followup.

PURPOSE: We present 15 cases of high flow priapism treated by selective embolization and evaluate erectile function at long-term followup. MATERIALS AND METHODS: Between 1995 and 2001, 15 patients underwent highly selective embolization of the cavernous artery for high flow priapism. Trauma was reported by 12 of the 15 patients, and no etiologic causes were evident in the other 3. The fistula was unilateral in 13 patients and bilateral in 2. All patients underwent embolization during arteriography. Erectile function was determined using the International Index of Erectile Function (IIEF) at followup after an average of 55 months (range 18 to 93). RESULTS: Postoperative color Doppler ultrasonography showed no recurrence in 11 patients (73%). Repeat pelvic angiography with selective embolization was required at 1 month postoperatively in 3 patients (20%). In 1 case (7%) 3 consecutive embolizations were not conclusive and a surgical operation was required. The IIEF results showed that sexual function was in the normal range in 80% of patients. Three patients (20%) reported a slight change in the quality of erection. Mean postoperative IIEF score was 26.3 (range 18 to 30). CONCLUSIONS: Highly selective embolization of the fistula is an effective and safe treatment option for high flow priapism because it ensures a high level of preservation of pretreatment erectile function.

Endovascular treatment of external iliac artery injuries after hip arthroplasty.

PURPOSE: To report endovascular repair of injuries to the external iliac artery during hip surgery. CASE REPORTS: Two elderly women with histories of chronically infected hip prostheses were found to have iatrogenic leaking pseudoaneurysms of the external iliac artery due to hip surgery trauma in the past. Both were treated successfully with a Jostent Peripheral Stent-Graft. The first patient died 17 months after treatment, and the second was well, with an excluded false aneurysm, at the 6-month follow-up. CONCLUSIONS: Stent-graft repair may be an appropriate and effective treatment for some traumatic arterial lesions.

Color Doppler imaging of posttraumatic priapism before and after selective embolization.

High-flow priapism usually follows perineal or penile trauma with disruption of an intracavernosal artery. Angiographic embolization of the lacerated artery is currently considered the treatment of choice. The contribution of gray-scale and color Doppler ultrasonography (US) in diagnosis and treatment of 10 patients with high-flow priapism was investigated. In patients with recent arterial laceration, the cavernous tissue surrounding the arterial-sinusoidal fistula appears as a hypoechoic region with undefined margins. In long-standing priapism, this area is usually more regular and circumscribed, mimicking a pseudoaneurysm. Color Doppler US is highly sensitive for detection of the arterial-sinusoidal fistula that causes extravasation of blood from the lacerated cavernosal artery. After angiography, color Doppler US allows confirmation of both successful embolization by demonstrating disappearance or size reduction of the fistula and unsuccessful treatment by demonstrating patency of collateral feeding vessels or early recanalization of the embolized artery. Limitations of color Doppler US include underestimation of the number of accessory feeding vessels, which may become patent only after embolization of the main vascular supply, and difficulty in recognizing vessels that feed the fistula from the opposite side.

High-flow priapism: treatment and long-term follow-up.

OBJECTIVES: To determine the long-term follow-up of treatment of high-flow priapism, we reviewed the case records of 10 patients who were examined by the Urologic Clinic in Trieste from 1995 to 1998. High-flow or arterial priapism is a fairly rare dysfunction, generally resulting from penile or perineal trauma. In some cases, the etiology remains unknown. METHODS: Trauma was reported in 6 of 10 cases. No etiologic causes were evident in the other patients. Nine patients underwent selective embolization during arteriography, and in 1 patient, corporotomy and ligature of the cavernous artery were performed. Color Doppler ultrasonography was repeated 1 day, 1 month, and 6 months after the operation. The determination of erectile function at a mean follow-up of 41 months (range 17 to 64) was performed using the International Index of Erectile Function. RESULTS: Postoperatively, color Doppler ultrasonography revealed the absence of recurrence in 6 patients. Fistula recurrence was detected in 4 of 9 patients treated with selective embolization (44%). In three of these patients, a second embolization procedure was conclusive. In 1 case (11%), three consecutive embolizations were not conclusive and surgical ligature of the dorsal artery and collateral at the emergence of the penile root, out of the corpus cavernosum, was required. Sexual function was completely preserved in 80% of patients. CONCLUSIONS: Pudendal angiography with superselective embolization is the treatment of choice. It is well tolerated and ensures a high preservation of premorbid erectile function.