MR angiography of patients with peripheral arterial disease before and after transluminal angioplasty.

OBJECTIVE: This study was performed to evaluate the feasibility of using MR angiography for following up patients who have undergone interventional therapy of the infrapopliteal vascular bed. SUBJECTS AND METHODS: Fourteen patients with peripheral vascular disease underwent MR imaging before and after percutaneous transluminal angioplasty (PTA) using a two-dimensional time-of-flight technique (TR/TE, 33/3.9; section thickness, 2.9 mm). As the gold standard, selective digital subtraction angiography was obtained for all evaluated extremities before and after PTA. For data analysis, the distal peripheral arterial system was divided into 11 segments: the popliteal artery; the tibioperoneal trunk; and the proximal, mid, and distal portions of the three trifurcation vessels. Each segment was characterized as normal, mildly diseased, moderately diseased, severely diseased, or occluded. RESULTS: We found overall agreement between the two techniques in 110 segments (71%) and 123 segments (80%) on data obtained before and after PTA, respectively. Before PTA, our interpretation of MR angiograms overestimated 14 lesions (9%). After PTA, we overestimated five lesions (3%) on MR angiograms. We underestimated lesion severity in 30 cases (19%). The high incidence of agreement between the two techniques was reflected by the high Kendall's tau-beta values of .83 and .87 for data obtained before and after PTA, respectively. CONCLUSION: The excellent depiction of the PTA-induced morphologic changes suggests great potential for the use of MR angiograms during interventional follow-up.

Spontaneous perirenal hemorrhage after rupture of an aneurysm in case of polyarteritis nodosa along with anuric renal failure. Case report and review of the literature.

We report a case of massive perirenal hemorrhage owing to an inferior segmental arterial rupture of an aneurysm, alongside a primarily inapparent polyarteritis nodosa associated with hepatitis B and C. We come to speak of the diagnostic procedure such as angiography, computerized tomography and MRI as well as the intervening measures like catheter embolization and surgical revision.

Azygos blood flow: phase contrast quantitation in volunteers and patients with portal hypertension pre- and postintrahepatic shunt placement.

Flow volume in the azygos venous system was quantitated with Cine-phase contrast (PC) velocity mapping in volunteers and compared with patients with known portal hypertension, who were referred for transjugular intrahepatic portosystemic shunt (TIPS) placement. Subsequently, the TIPS-induced hemodynamic effects on portal and azygos flow were analyzed. To assess intra- and intersubject variability, flow in the azygos veins was measured in each of 10 normal subjects at three different times. Subsequently, portal and azygos flow was quantitated in 20 patients with portal hypertension, before and after TIPS placement. All imaging was performed on a 1.5-tesla magnetic resonance imaging (MRI) system. Azygos flow was measured transaxially at the midthoracic level. Cine-PC flow measurements of the main portal vein followed morphological evaluation of the portal venous system with axial and coronal breath-held magnet resonance angiogram. Azygos flow in normal subjects was characterized by high inter- and low intrasubject variability. Azygos flow in patients with portal hypertension was significantly higher (P < .001). Following successful TIPS placement in 18 patients, Cine-PC revealed a mean decrease in azygos flow of 46.3% (P < .001) and a 134% (P < .001) increase of portal flow. Reflecting the complexity of portal hemodynamics, there was no correlation between the changes in the portal and azygos systems. In 2 patients with early occlusion of TIPS, documented invasively, portal and azygos flow values remained largely unchanged. Cine-PC enables the noninvasive, quantitative assessment of flow within the azygos venous system. Azygos flow was found to be markedly elevated in patients with portal hypertension. Combined portal and azygos PC flow measurements quantitate the therapeutic effect of TIPS placement.

Catheter fracture: a rare complication of totally implantable subclavian venous access devices.

Catheter fracture represents a rare problem among non-infectious complications following the insertion of totally implantable long-term central venous access systems for the application of chemotherapeutic agents. A literature survey revealed a total incidence of catheter fractures of 0-2.1%. Imminent catheter fracture can be identified radiologically, using different degrees of catheter narrowing between the clavicle and the first rib, called pinch-off sign. Two cases of catheter fracture are described and potential causes are discussed. Recommendations to avoid the pinch-off sign with the subsequent risk of catheter fracture and migration include a more lateral and direct puncture of the subclavian vein. In case of catheter narrowing in the clavicular-first rib angle, patients should be followed carefully by chest X-rays every 4 weeks. Whenever possible, the system should be removed within 6 months following insertion.

Bleeding anorectal varices: successful treatment with transjugular intrahepatic portosystemic shunting (TIPS).

A patient with severe recurrent rectal bleeding from anorectal varices due to portal hypertension because of hepatitis C virus related liver cirrhosis is presented. As illustrated by the report, it is essential to differentiate bleeding anorectal varices from bleeding haemorrhoids because treatment is different. In our patient, implantation of a transjugular intrahepatic portosystemic shunt (TIPS) led to an impressive regression of the anorectal varices, which could be demonstrated by sigmoidoscopy, endosonography, and magnetic resonance imaging. Recurrent rectal bleeding in a patient with portal hypertension should alert the physician to consider anorectal varices. Endoscopic ultra-sound and magnetic resonance imaging are new and non-invasive modalities for diagnosis and post-treatment control.

[Morphology of abdominal aortic aneurysms with reference to endovascular blood vessel prosthesis]. / Die Morphologie abdominaler Aortenaneurysmata unter dem Gesichtspunkt des endovaskulären Gefässersatzes.

The purpose of this report was to describe the frequency and morphology of infrarenal aortic aneurysms suitable for endovascular tube graft repair. Preoperative abdominal CT scans of 89 patients undergoing open tube graft repair were analyzed retrospectively by measurements of lengths and diameters of the aneurysms. The cases were divided into 3 separate groups: most suitable aneurysms with neck and cuff in 10% (9/89), aneurysms (59%, 52/89) with either a neck (92%) or a cuff (8%), and finally aneurysms without a neck or a cuff (31%, 28/89). The anatomically suitable aneurysms have a neck of 31 +/- 19 mm in length and 23 +/- 4 mm in diameter, a cuff of 17 +/- 6 mm in length and 25 +/- 6 mm in diameter. The aneurysms have a nearly saccular nature with a "saccular index" of 0.81 +/- 0.17, p = 0.009. It appears that 10% of aneurysms restricted to the infrarenal aortic segment fulfill all criterias for endovascular straight tube graft repair.

[Significance of arterial anastomoses of the distal calf and proximal foot for compensation of peripheral arterial occlusive disease]. / Bedeutung von arteriellen Anastomosen am distalen Unterschenkel und proximalen Fuss zur Kompensation der peripheren arteriellen Verschlusskrankheit.

The vascular anatomy of the distal calf and proximal foot was studied in 16 preparations obtained by corrosion. Arterial anastomoses between the different vessels are frequently observed and were also detected by digital subtraction arteriography in 14 patients with peripheral arterial occlusive disease. The comparison between anatomy and arteriography revealed that performed anastomoses in the malleolar and proximal foot region are important for compensating crural arterial occlusions. The Ramus communicans posterior, the Ramus perforans of the fibular artery and the Rete calcaneare play an important role. Whereas in other vascular territories collaterals dominate for compensation of occlusions performed anastomoses are of crucial importance at the malleolus.

Aneurysm of the superior mediastinal veins.

A case of true venous aneurysm with saccular dilation of the proximal half of the superior vena cava, the right innominate vein, and the distal two thirds of the left innominate vein in an 18-year-old white woman is presented. At surgery part of the aneurysmal wall was resected, and subsequently the mediastinal venous system was reconstructed with use of the rest of the aneurysmal wall. The postoperative course was uneventful. Operative treatment of mediastinal venous aneurysms is indicated to prevent possible major complications. We strongly suggest performance of this surgery only by means of a heart-lung machine.

Subclinical trauma to perineum: a possible etiology of erectile dysfunction in young men.

A substantial number of young men with erectile dysfunction have neither systemic disease nor a trauma in their history. We are familiar with impotence after major trauma but it is an unanswered question whether subclinical trauma may also induce arterial degeneration with subsequent erectile dysfunction. In a period of 36 months 129 patients underwent penile arteriography. After excluding those with major surgery, trauma or psychogenic impotence 91 angiograms were reevaluated. Special attention was paid to atherosclerotic and to focal occlusive arterial disease (> 50% stenosis) in the hypogastric-cavernous branch. 12 angiograms showed normal arteries, 59 typical atherosclerotic and 20 focal occlusive arterial disease. The mean age of patients with atherosclerosis was 53 +/- 8 years versus 35 +/- 14 years of those with focal lesions (p < 0.0001). 30% with focal arterial lesions were subject to subclinical trauma. 68% with atherosclerotic disease had clinical relevant atherosclerotic risk factors. Latency between onset of erectile dysfunction and presentation at the impotence clinic was 51 months in patients with focal lesions and 39 months in those with atherosclerotic disease (nonsignificant). We conclude that subclinical trauma of the hypogatric-cavernous arteries can induce focal arterial lesions with significant impairment of perfusion. This pathology may contribute to erectile dysfunction. These patients are significantly younger and they suffer from clinically evident impotence approximately 18 years earlier than patients whose impotence is clearly of atherosclerotic origin. Focal arterial lesions due to subclinical trauma are described for the first time as an etiology of erectile dysfunction. Further studies are needed to confirm these results.

[Combination of surgical therapy and interventional radiology in a recurrent myxoid liposarcoma with a 37-year history]. / Kombination von chirurgischer Therapie und interventioneller Radiologie bei einem seit 37 Jahren rezidivierenden myxoiden Liposarkom.

Extreme long-term survivals of low grade liposarcomas are rare. The authors present a case of a 75 year old man with a 37 year history of recurrent myxoid liposarcoma. The tumor dynamics are obviously related to the histology subtype. The clinical and radiological findings of the sixth tumor recurrence are discussed. The combination therapy of surgical tumor reduction and interventional radiology with implantation of endovascular prostheses for iliaco-femoral vein compression due to tumor recurrence is described.

[Which hormone determinations are necessary in the initial assessment of erectile dysfunction?]. / Welche Hormonbestimmungen sind bei der ersten Abklärung einer erektilen Dysfunktion notwendig?

The assessment of an erectile dysfunction (ED) includes the history, a clinical examination and blood tests. There is some confusion about which basic hormonal tests are needed at the beginning of clinical evaluation. We feel that with the results from our patients we could help to answer this question. From 1 January 1990 until the December 31 1993 we evaluated 1134 patients for ED. Those who favoured a surgical correction of their ED were fully evaluated by nocturnal penile tumescence testing, penile arteriography, intracavernosal injection of vasoactive agents and dynamic pharmaco-cavernosometry. The results from these tests were correlated with luteinizing hormone (LH), follicle-stimulating hormone (FSH), testosterone and prolactin. 183 (16.1%) of our patients with a mean age of 45 +/- 14 were fully evaluated. From these patients 76 were excluded because their ED was posttraumatic, undoubtedly psychogenic or could not be proven by the tests mentioned above. From the 107 patients finally included in this study, 90 had normal endocrine parameters. 17 patients had low testosterone. 14 of these patients had otherwise completely normal hormonal tests without evidence of secondary hypogonadism. Three patients had their low testosterone levels confirmed by repeated measurements. In addition, prolactin was significantly increased, and FSH and LH were near or below the lower reference value. When evaluating patients for the first time because of an erectile dysfunction, the measurement of testosterone as a single endocrine test is adequate. If testosterone is low, repeated measurements, combined with LH, FSH and prolactin, will identify patients with an ED due to an endocrine disease.

[Possibilities of catheter therapy in vascular stenosis, vascular abnormalities, tumors and hemorrhages. Synopsis of an interdisciplinary colloquium]. / Möglichkeiten der Kathetertherapie bei Gefässstenosen, Gefässmissbildungen, Tumoren und Blutungen. Zusammenfassung eines interdisziplinären Kolloquiums.

Modern interventional catheter-technics allow amelioration of arterial blood flow by dilatation of narrowed or recanalization of closed coronary and peripheral arteries. Patients with chronic or unstable angina pectoris not responding to therapy can thus be treated successfully by percutaneous dilatation (PTCA). In peripheral occlusive disease balloon catheterization sometimes in combination with local fibrinolysis and thrombectomy may prevent amputation. On the other hand, cerebral malformations of arteries, aneurysms and tumors can be eliminated by artificial occlusion. Therapeutic embolization is also increasingly used in acute or recurrent haemorrhage in lungs, spleen and gastrointestinal tract. It may also be used as palliating therapy in malignancies. Medical indications and limitations of the various catheter techniques in cardiology, angiology, neurology and interventional radiology are discussed.

[Recurrent acute occlusions of the popliteal artery before age 50: popliteal entrapment syndrome?]. / Rezidivierende akute Verschlüsse der Arteria poplitea vor dem 50. Lebensjahr: Popliteales Entrapment-Syndrom?

Compression of the popliteal artery by the medial head of the gastrocnemius muscle is termed "Popliteal Artery Entrapment". The anatomical course of the artery can be normal or abnormal. The entrapment can cause occlusion of the artery or peripheral embolism. This syndrome is an important differential diagnosis in younger patients with recurrent peripheral arterial ischemia. Diagnosis is made by history, clinical findings, arteriography and CT-scan of the knees. All cases of popliteal artery entrapment, whether the artery is occluded or not, should be operated on.

[Acute ischemia of the lower extremity in an adolescent with Crohn disease]. / Akute Ischämie der unteren Extremität bei einem Jugendlichen mit Morbus Crohn.

The authors report a case with a rare form of peripheral ischaemia. A 25-year-old man with Crohn's disease suffers from sudden ischaemia of his right leg. There is no evidence of entrapment of the popliteal artery, of arterial embolism or Buerger's disease. Thrombocytosis in combination with hypercoagulability as described previously in patients with Crohn's disease seems to be the most probable cause. - In this case percutaneous transluminal thrombectomy and thrombolysis were more successful than surgical thrombectomy using balloon catheters.

[The accuracy of the imaging procedures (sonography, MRT, CT, angio-CT,nuclear medicine) in characterizing liver tumors]. / Treffsicherheit bildgebender Verfahren (Sonographie, MRT, CT, Angio-CT, Nuklearmedizin) bei der Charakterisierung von Lebertumoren.

In a prospective study, an attempt was made to determine the specificity of various imaging methods for defining tumours of the liver rather than their ability to demonstrate them. It was based on 130 patients with histologically confirmed lesions (33 haemangiomas, 17 FNH, 4 hepatocellular adenomas, 28 HCC, 36 adenocarcinoma metastases). The methods were MRT (130 cases), sonography (119), CT (122), dynamic arterial angio-CT (15), 99TC-EHIDA or blood pool scintigraphy (4 FNH, haemangiomas, HCC, 44 cases). MRT showed somewhat better results (accuracy 80%) than CT (73%) and angio-CT (73%) in demonstrating the type of lesion. The results of scintigraphy (53%) and sonography (69%) were rather worse. The range of accuracy for MRT, CT and sonography varied from 94% (haemangiomas with MRT) to 47% (FNH with sonography).

[Post-traumatic hemobilia in childhood]. / Posttraumatische Hämobilie im Kindesalter.

We observed three patients with a hemobilia after surgically or conservatively treated liver lacerations. The diagnosis was suspected on clinical grounds and verified by ultrasonography, computed tomography or angiography or a combination thereof. Depending on the findings therapy was planned reaching from conservative treatment to liver resection. Because this complication is rare it should be cared for in a specialized institution.

[Temporary percutaneous nephrostomy in pregnancy]. / Die temporäre perkutane Nephrostomie in der Schwangerschaft.

Engorged kidneys in pregnancy call for relieving nephrostomy, if locally delimited or systemic effects threaten to be a risk to mother and/or child. Five women were treated over the past five years, with percutaneous nephrostomy being performed on them for acute pyelonephritis gravidarum (n = 4, among them two with one kidney) or asymptomatic collateral excessive ectasia of the pyelo-calyceal system (n = 1). The intervention was followed by antegrade splinting in two cases. Soon clinical but less sonographic improvement was recordable from four patients as a result of renal relief. Delivery was necessary in one case, six days after nephrostomy. Widening application of nephrosonography also in pregnancy should not become a temptation for percutaneous nephrostomy to be performed also on cases of symptomatic urinary stasis. A more generous approach should be taken only to functionally or anatomically solitary-kidney cases.