Endovascular treatment of obstructive iliac artery dissections.

PURPOSE: To report our results from a study of the endovascular treatment of flow restricting chronic atherosclerotic or catheter-induced segmental iliac artery dissections with bare stents. MATERIAL AND METHODS: Thirty symptomatic patients with 32 lesions, including chronic atherosclerotic (n = 21) and catheter-induced (n = 11) segmental arterial dissections, were treated with primary stenting. The common iliac artery was involved in 19 lesions and the external iliac artery in the remaining 13. Two patients had two lesions in the same vessel. Technical success was defined as restoration of the smooth contoured luminal patency with no more than 20% residual stenosis in diameter in atherosclerotic dissections associated with plaque formation or total obliteration of the false lumen in catheter-induced dissections. Complete relief of, or marked improvements in, presenting symptoms, or at least single category improvement, was assessed for clinical success. RESULTS: Technical success rate was 100%. No procedure-related complications such as distal emboli or early occlusions were observed. Complete symptom relief was achieved in all patients with catheter-induced dissection and in all but three cases with chronic spontaneous atherosclerotic dissection. In two cases, occlusion of the stents occurred during the follow-up period. Clinical and radiological mean follow-up for 24 months (range 3-55) revealed patency of all other stented segments. Cumulative primary patency rate was 97% over 12 months and 90% over 24 months. CONCLUSION: Endovascular treatment of chronic atherosclerotic and catheter-induced short obstructive iliac arterial dissections with bare stents is safe and effective. Patency of the diseased arterial segment with a smooth lumen can be sustained for an extensive period.

High-flow arterioportal fistula: treatment with detachable balloon occlusion.

Transarterial embolization is one of the treatment choices for symptomatic hepatic arterioportal fistula that has low mortality and morbidity. Proper selection of the technique and embolic material is very important for the success of the procedure. We present a case with high-flow arterioportal fistula treated with transarterial embolization using detachable balloons.

Evaluation of osteoporosis in thalassemia by quantitative computed tomography: is it reliable?

This study was conducted to quantify the degree of osteoporosis in thalassemic patients by single energy quantitative computed tomography (SEQCT) and to test the reliability of this method. On 38 thalassemic patients with osteoporosis and 38 normal control subjects, bone mineral density (BMD) measurements were done by SEQCT. BMD and standard deviation (SD) of the x-ray attenuation numbers of pixels within region of interest (ROI) of the measurement areas were compared between two groups. Mean BMD values for thalassemic patients and control group were 173.4 and 158.2 mg/cm3, respectively. Mean BMD value for thalassemic patient group was significantly higher. Mean SD values of ROI for control group and thalassemic patients were 41.4 and 71.1, respectively. The difference between the SD values was also statistically significant. Positive correlation was noted between SD values and patients' ages in the thalassemic group. Results of SEQCT method may not reflect the clinical and conventional radiographic findings of osteoporosis seen in thalassemic patient group and should be used cautiously. Other methods of BMD measurement, such as photon absorbsiometry and x-ray absorbsiometry, should also be investigated for their accuracy in this patient group.

Breast varices: imaging findings of an unusual presentation of collateral pathways in superior vena caval syndrome.

Imaging findings are presented of an unusual pathway of collateral circulation consisting of bilateral and diffuse dilated breast veins from a patient with long standing superior vena caval syndrome. The main importance of this case is the extent of the collateral development through the breast veins, serving as the major pathway of collateral circulation. Identification of this unusual collateral development, which resembles breast varices, was performed with contrast-enhanced chest CT scans, digital subtraction venography, color Doppler ultrasonography, and mammographic studies. Collateral development was secondary to a long segment idiopathic venous occlusion involving bilateral subclavian and brachiocephalic veins as well as vena cava superior. We conclude that dilated breast veins when detected on any imaging modality should raise the suspicion of central venous obstruction.

Lens of the eye: radiation dose in balloon dacryocystoplasty.

PURPOSE: To evaluate the absorbed radiation dose to the lens of the eye, which is the critical organ in the primary beam during fluoroscopically guided transluminal balloon dilation of the lacrimal drainage system (balloon dacryocystoplasty) for obstructive epiphora and to evaluate the possibility of deterministic radiation effect on the lens. MATERIALS AND METHODS: The radiation dose to the lens of the eye during balloon dacryocystoplasty (which includes pre- and postintervention dacryocystography) was measured in 10 consecutive patients by using thermoluminescent dosimeters on the lids of both eyes as close as possible to the lenses. A C-arm angiographic unit coupled with a digital imaging system was used, with similar exposure and geometric parameters in all cases. RESULTS: The mean radiation dose to the lens of the treated eye was 4.6 mGy +/- 2.2 (dose range, 1.9-9.1 mGy) and to that of the untreated eye was 38.5 mGy +/- 17.5 (dose range, 14.7-67.8 mGy). CONCLUSION: The lens of the untreated eye receives a higher dose than that of the treated eye because of its closer proximity to the x-ray tube in a lateral projection. In the lens, even the highest measured radiation dose (67.8 mGy) still was well below the deterministic threshold for lens opacity and cataract formation.

Spontaneous thrombosis of a vein of Galen aneurysmal malformation: possible effects of contrast media.

A 5-year-old boy with macrocephaly and mental retardation was referred for radiologic evaluation. After cranial CT and MR imaging, the diagnosis of mural type vein of Galen aneurysmal malformation was established by angiography. Two weeks later, preembolization angiography revealed complete thrombosis of the malformation. Although it is a very rare event, vein of Galen aneurysmal malformation may spontaneously thrombose following diagnostic angiography. Possible effects of contrast media on thrombosis were discussed.

Peripheral arterial involvement in neurofibromatosis type 1--a case report.

Neurofibromatosis is a dominantly inherited, progressive, generalized dysplasia of mesodermal and neuroectodermal tissues. Vascular lesions associated with neurofibromatosis type 1 (NF-1) are mainly characterized by stenosis, occlusion, aneurysm, pseudoaneurysm, and rupture or fistula formation of small, medium, and large-sized arteries. The authors hereby present a rare case of NF-1 with bilateral aneurysms and large pseudoaneurysms of the femoral and popliteal arteries and occlusion of the left superficial femoral artery.

Scrotal arteriovenous malformation and its preoperative embolization.

Arteriovenous malformations of the scrotum are extremely rare. A case of scrotal arteriovenous malformation and its preoperative embolization in a child is presented.

Primary stenting for complex atherosclerotic plaques in aortic and iliac stenoses.

PURPOSE: To evaluate the efficacy of primary stenting for complex atherosclerotic plaques in aortic and iliac stenoses that are not amenable to balloon angioplasty alone. METHODS: Nineteen patients with complex atherosclerotic plaques were treated with a Palmaz stent (n = 19), Wallstent (n = 1), Strecker stent (n = 1), or Memotherm stent (n = 1). A total of 22 stenoses presenting with complex plaque morphology including ulcerated plaques, ulcerated plaques with focal aneurysms, plaques with heavy calcification, severely eccentric plaques, plaques with overhanging edge, and plaques with spontaneous dissection were stented. The lesions were in the aorta (n = 1), common iliac artery (n = 19), or external iliac artery (n = 2). RESULTS: Immediate angiography after stent placement revealed restoration of patency of the stented segment. Focal aneurysms and ulcerated areas were occluded in the follow-up angiographies obtained 4-12 weeks after the procedure. In one case with poor distal runoff and multiple complex lesions of the iliac artery, subacute occlusion occurred. Clinical and angiographic follow-up (3-46 months) revealed patency of all other stented segments. CONCLUSION: Primary stenting is an effective and reliable approach for complex plaques in stenoses. Patency of the arterial segment with a smooth lumen can be created without the risk of acute complications such as distal embolization, dissection, or occlusion.

MR imaging and MR angiography in popliteal artery entrapment syndrome.

Popliteal artery entrapment (PAE) syndrome is an uncommon congenital anomaly seen in young adults causing ischemic symptoms in the lower extremities. It is the result of various types of anomalous relationships between the popliteal artery and the neighboring muscular structures. The purpose of this study was to define the role of MR imaging combined with MR angiography in the diagnosis of PAE cases. Four cases with segmental occlusion and medial displacement of popliteal artery in digital subtraction angiography (DSA) examinations were diagnosed as PAE syndrome by MR imaging and MR angiography. The DSA and MRA images are compared. All of the cases showed various degrees of abnormal intercondylar insertion of the medial head of the gastrocnemius muscle. The MR images showed detailed anatomy of the region revealing the cause of the arterial entrapment. Subclassification of the cases were done and fat tissue filling the normal localization of the muscle was evaluated. The DSA and MRA images demonstrated the length and localization of the occluded segment and collateral vascular developments equally. It is concluded that angiographic evaluation alone in PAE syndrome might result in overlooking the underlying cause of the arterial occlusion, which in turn leads to unsuccessful therapy procedures such as balloon angioplasty. Magnetic resonance imaging combined with MR angiography demonstrates both the vascular anatomy and the variations in the muscular structures in the popliteal fossa successfully, and this combination seems to be the most effective way of evaluating young adults with ischemic symptoms suggesting PAE syndrome.

Hepatic color Doppler sonography for hereditary hemorrhagic telangiectasia.

Liver involvement with hereditary hemorrhagic telangiectasis (HHT) is not a rare condition. Its angiographic abnormalities are well known, but reports of the sonographic and, especially, color Doppler sonographic findings are limited. We present a patient with HHT and describe the hepatic color Doppler sonographic findings.

Treatment of recurrent nasolacrimal duct obstructions with balloon-expandable metallic stents: results of early experience.

PURPOSE: To evaluate the efficacy of Palmaz balloon-expandable metallic stents for the maintenance of luminal patency in the treatment of recurrent nasolacrimal duct, obstructions after failed transluminal balloon dilatation. METHODS: Metallic stents were implanted in the nasolacrimal duct of four patients with recurrent epiphora. All the patients had already undergone transluminal balloon dilatation of the nasolacrimal duct with no or only temporary improvement. In two eyes, 9.5-mm-long Palmaz stents were used; in the other two eyes, 20-mm-long articulated-design Palmaz stents were placed under digital fluoroscopic monitoring. In each case, the upper tip protruded slightly into the lacrimal sac and the lower end was positioned inside the nasolacrimal duct. RESULTS: The stents were placed accurately in all cases, and no complications were observed. After stent placement, all patients had complete resolution of epiphora. During the follow-up period of 10 months, although complete obstruction did not occur in any case, complete resolution of epiphora was maintained only in one of four eyes. In two eyes, improvement was remarkable. In one eye with partial improvement, intrastent balloon dilatation was performed. CONCLUSION: Treatment of recurrent nasolacrimal duct obstructions with balloon-expandable metallic stents is a noninvasive, efficient, and safe outpatient procedure that may be an alternative to surgery as a means for managing epiphora.

Transluminal balloon dilatation of the lacrimal drainage system for the treatment of epiphora.

OBJECTIVE: The purpose of this study was to evaluate the efficacy of transluminal balloon dilatation done under digital subtraction fluoroscopic monitoring in the treatment of incomplete and complete obstruction of the lacrimal drainage system (LDS) in patients with epiphora. SUBJECTS AND METHODS: Transluminal balloon dilatation of the LDS was attempted in 19 eyes with incomplete and 61 eyes with complete obstruction, including six cases of anastomotic obstruction after failed dacryocystorhinostomy. A soft plastic arterial sheath over a stump-guiding metal probe was introduced through the superior canaliculus into the nasolacrimal apparatus. A 0.016-in. specially angled steerable guidewire was introduced through the sheath and across the site of obstruction, advanced into the nasal cavity, and brought forward through the external nare. A low-profile angioplasty balloon dilatation catheter was passed retrograde over the guidewire through the nasal aperture to the site of obstruction and inflated for dilatation. RESULTS: Technical success was achieved in all 19 eyes with incomplete obstruction and in 46 (75%) of 61 eyes with complete obstruction. Initial success was achieved in all 19 eyes with incomplete obstruction and in 36 (59%) of 61 eyes with complete obstruction. In a follow-up period of 6-18 months (mean, 13 months), reobstruction occurred in none of the eyes with incomplete and in two eyes with complete obstruction. CONCLUSION: Our experience shows that transluminal balloon dilatation is an effective treatment for incomplete obstruction of the LDS. The procedure has a high failure and recurrence rate when the obstruction is complete.

Bilateral perirenal urinoma with mediastinal extension.

We report a unique case of adult-type polycystic kidney disease (PKD) having bilateral chronic perirenal fluid collection with unusual extension. Fluid collections at both sides are connected across the midline anterior to the abdominal aorta and inferior vena cava. In addition, supradiaphragmatic extension through aortic hiatus was well demonstrated by computed tomography (CT). Antomical boundaries and relations between two perirenal spaces are evaluated.

Computed tomographic evaluation of surgically significant vascular variations related with the temporal bone.

Variations of the vascular structures related with the temporal bone may cause important problems in diagnosis, treatment planning and surgery. High resolution computed tomography (CT) scans of 700 temporal bones of 350 patients were retrospectively examined for the incidence of dehiscent jugular bulb, high jugular bulb, diverticulum of jugular bulb, anteriorly located sigmoid sinus and dehiscent internal carotid artery. Dehiscent jugular bulb was seen in 27 (3.9%), high jugular bulb was seen in 142 (20.3%), jugular bulb diverticulum was seen in 55 cases (7.9%). The average distance between external acoustic canal and sigmoid sinus was found to be 13.3 mm and in 12.4% of the cases this distance was < 10 mm. Of 700 temporal bones, 10 (1.4%) showed dehiscent carotid canal. To aid diagnosis, treatment planning and surgery, CT scanning is currently a very reliable tool in determining these conditions. Special attention should be paid to the position of the vascular structures in the preoperative temporal bone CT scans.

Parasternal sonography of the internal mammary lymphatics in breast cancer: CT correlation.

The purpose of this study was to evaluate the efficacy of parasternal ultrasonography (US) in diagnosing internal mammary lymph node metastases in breast cancer, an important site of occult metastases, adversely affecting the disease-free interval and long-term survival. Thirty-five patients who were diagnosed with breast cancer were examined for internal mammary lymph node (IMLN) involvement with parasternal US, and results were correlated with computed tomography (CT). Longitudinal and transverse images of the first through sixth parasternal rib interspaces were evaluated with a 7.5-MHz linear-array transducer. The enlarged nodes were demonstrated as discrete, spherical or ovoid hypoechoic lesions in six cases with parasternal US, and corresponding CT scans confirmed the presence of lymphadenopathy. Our results suggest that parasternal US may be helpful in the evaluation of IMLN metastases in breast cancer as a part of staging the disease.