Gastric subepithelial masses: evaluation of multidetector CT (multiplanar reconstruction and virtual gastroscopy) versus endoscopic ultrasonography.

OBJECTIVES: To assess the role of multidetector computed tomography (MDCT) with multiplanar reconstruction (MPR) and virtual gastroscopy (VG) for detection and differentiation of gastric subepithelial masses (SEMs) by comparison with endoscopic ultrasonography (EUS). METHODS: Forty-one patients with a suspected SEM were evaluated using EUS and MDCT. MDCT findings were analyzed based on the consensus of two radiologists who were blinded to the EUS findings. The analysis of the CT features included the location, size, and contours of the tumor, the presence of central dimpling, as well as the growth pattern, enhancement pattern, and enhancement degree. The long diameter (LD) and the short diameter (SD) of each lesion were measured and the LD/SD ratios were calculated. EUS and MDCT results were compared with histopathology for the pathologically proven lesions. For the non-pathologically proven lesions, MDCT results were compared with EUS. RESULTS: Among the 41 patients, 34 SEMs were detected using EUS. For the detection of SEMs with MDCT, a sensitivity of 85.3%, a specificity of 85.7%, a positive predictive value of 96.7%, and a negative predictive value of 54.5% were calculated. The overall accuracy of MDCT for detecting and classifying the SEMs was 85.3 and 78.8%, respectively. CONCLUSIONS: MDCT with MPR and VG is a valuable method for the evaluation of SEMs. Specific MDCT criteria for various SEMs may be helpful in making an accurate diagnosis.

Is celiac artery compression syndrome genetically inherited?: a case series from a family and review of the literature.

The median arcuate ligament is a tendinous arch joining the two medial borders of the diaphragm crura together. In 13-50% of asymptomatic subjects it is responsible for significant angiographic celiac trunk compression. The significance of median arcuate ligament-associated celiac artery compression has been a source of some controversy in the past literature, and the etiology remains unclear. We report here a case series from a family that was diagnosed by the use of multidetector computed tomography. The observation of this syndrome in a family suggests that the responsible anatomic relationships are congenital and may be genetically inherited.

Three-dimensional volume rendering digital subtraction angiography in comparison with two-dimensional digital subtraction angiography and rotational angiography for detecting aneurysms and their morphological properties in patients with subarachnoid hemorrhage.

OBJECTIVE: Subarachnoid hemorrhage (SAH), which can cause mortality and severe morbidity, is a serious condition whose underlying cause must be determined. We aimed to compare 2D digital subtraction angiography (2DDSA), rotational angiography (RA) and 3D volume rendering digital subtraction angiography (3DVRDSA) for detecting aneurysms and their morphological properties in patients with subarachnoid hemorrhage. MATERIALS AND METHODS: After an initial diagnosis of SAH with computed tomography, 122 patients (52 males and 70 females with a mean age of 47.77 ± 12.81 ranging between 20 and 83 years) underwent 2DDSA imaging, RA and 3DVRDSA imaging for detection of aneurysms. The location of the aneurysm, the best working angles, the dome/neck ratios, the largest diameter of the aneurysm, the shape of the aneurysm, the presence of spasms or pseudostenoses, and the relationship to the neighboring arteries were recorded. RESULTS: 2DDSA missed 15.6% of the aneurysms that had a mean size of 2.79 ± 0.74 mm. RA was superior to 2DDSA for detecting aneurysm neck, and 3DVRDSA was superior to RA for detecting aneurysm neck. 3DVRDSA conclusively depicted the shape of the aneurysms in all patients. 3DVRDSA imaging was superior to 2DDSA and RA in the detection of the aneurysm relationship to neighboring arteries. The sensitivity and specificity of 3DVRDSA imaging for the detection of vasospasms were 100 and 84%, respectively. CONCLUSIONS: 3DVRDSA imaging is superior to 2DDSA and RA for detecting intracranial aneurysms and their morphological properties, especially those of small, ruptured aneurysms. However, 2DDSA should not be neglected in cases of vasospasm.

Palliative treatment of malignant gastroduodenal obstruction: Applications of self-expandable metal stent.

BACKGROUND/AIMS: The aim of this study was to evaluate the efficacy, effects on survival and complications of self-expandable metal stent applications in patients with malignant gastroduodenal obstruction. METHODS: Twenty-five patients undergoing metal stent insertion due to malignant gastroduodenal obstruction between February 2005 and July 2009 were included in the present study. In all patients, self-expandable metal stent 22 mm in diameter was inserted under scopic guidance. The patients were evaluated regarding age, gender, etiology, efficacy of stent insertion, complications, and duration of patency of the stent. RESULTS: Of the 25 patients included in the study, 15 were female and 10 were male. Their mean age was 65.9 years (57-81 years). The most common etiological causes were duodenal tumor (n=10, 40%) and pancreatic tumor (n=8, 32%). Duodenal stent was inserted successfully in all patients. In 4 patients, percutaneous biliary metal stent was inserted at the same time due to concomitant obstructive jaundice. No mortality occurred during the procedure. A second stent was inserted in 4 patients due to stent migration. The patients were followed for a mean of 92 days (7 to 258 days) after the procedure. The stents remained clinically patent in all patients during the follow-up period until death. CONCLUSIONS: Insertion of duodenal metal stent is an effective and safe therapeutic approach in the palliative treatment of malignant gastric outlet obstruction.

Triple metallic stenting in hilar malignant biliary obstructions.

PURPOSE: To research the effects of triple stenting on primary patency rates and on clinical and biochemical findings in patients with high-level malignant biliary obstruction. MATERIALS AND METHODS: We analyzed eight patients who had undergone triple stenting for hilar malignant biliary obstruction, mainly with the percutaneous approach, between January 2009, and September 2009. Pre-interventional bilirubin levels and the existence of pruritus or cholangitis were recorded. Patients were examined 15 days and three months post-intervention. Procedure-related mortality and 30-day mortality rates were recorded. Changes in the serum bilirubin levels, pruritis and cholangitis were examined. Primary patency rates were calculated with the Kaplan-Meier method. RESULTS: Pruritis and cholangitis improved within 15 days. There was a significant decrease in serum bilirubin levels, which were very near to normal limits. Two patients died: one in the fourth month and the other in the eighth month. The mean patency rate was 179±18.81 days. There were no procedure-related or 30-day mortalities in the study group. CONCLUSION: Triple metallic stenting did not significantly improve primary patency rates in hilar malignant biliary obstructions. However, the beneficial effects of triple stenting included the rapid improvement in clinical and biochemical signs in select patients. Triple stenting will be beneficial in preventing isolation that might cause cholangitis. Malignant biliary obstruction in patients with a trifurcation anomaly in the hilar region may necessitate triple stenting.

Percutaneous management of malignant biliary disease: factors influencing the ability to overcome the stricture.

PURPOSE: To determine the factors affecting the ability to cross malignant biliary obstructions in percutaneous transhepatic interventions. MATERIALS AND METHODS: In this study, 256 patients with 310 obstructive malignant biliary lesions from May 2006 to January 2009 were analyzed retrospectively. All of the patients had undergone percutaneous transhepatic cholangiography and intervention. Obstructions crossed in two or fewer sessions were classified as technically easy obstructions, whereas obstructions that required more than two sessions for crossing were classified as technically difficult obstructions. Possible factors thought to affect the ability of malignant biliary obstructions to be crossed were compared according to the obstruction type (technically easy or difficult obstructions). RESULTS: Of the 310 malignant biliary obstructions studied, 79% (246) were technically easy to cross, and 21% (64) were technically difficult to cross. Lesions located between the hilum and the cystic duct and beak-shaped malignant biliary lesions were easily crossed, but suprahilar localized lesions and flat or ovoid-shaped lesions were difficult to cross. The histological nature of the malignant biliary obstruction, the direct-to-total bilirubin ratio, the entry segment for the intervention, the largest bile duct diameter proximal to the obstruction, and the length of the obstruction were not found to influence the ability of the stricture to be overcome. CONCLUSION: In patients with malignant biliary obstructions, the factors that can negatively affect obstruction crossing are lesions with suprahilar localization and flat or ovoid-shaped lesions. We also conclude that after five ineffective attempts have been made to pass the stricture, treatment of malignant biliary obstruction should proceed to external biliary drainage.

CT angiography of systemic to pulmonary venous shunt in superior vena cava obstruction.

Superior vena cava obstruction is associated with multiple venous collaterals. There is an unusual pathway involving pulmonary venous collaterals in which systemic veins drain directly into the left heart, resulting in a right-to-left shunt. We report here a rare case of systemic to pulmonary venous shunt on both hemithoraces in superior vena cava obstruction associated with Budd-Chiari syndrome due to coagulopathy which was diagnosed by multidetector computed tomography angiography.

Percutaneous biliary intervention for primary sclerosing cholangitis in a patient with situs inversus totalis.

Situs inversus totalis is a rare condition that may not cause symptoms and often occurs concomitantly with other congenital anomalies. Special attention must be given to these patients when invasive interventions are required. There are only a few reports concerning percutaneous transhepatic biliary interventions in situs inversus totalis, but technical details were not fully explained. In this report, we attempt to explain the technical details of percutaneous transhepatic cholangiography, percutaneous biliary drainage and percutaneous biliary balloon dilatation in a patient with known primary sclerosing cholangitis and situs inversus totalis. While performing percutaneous biliary interventions in patients with situs inversus totalis, the key point is to use the mirror image of the traditional technique in an imaginary line dissecting the midline of the abdomen.

MDCT angiography of isolated right subclavian artery.

Isolation of a subclavian artery is an uncommon congenital anomaly of the aortic arch in which one subclavian artery loses its connection with the aorta and originates from the homolateral pulmonary artery by way of a ductus arteriosus. Isolation of the left subclavian artery in patients with a right aortic arch is well known. However, isolated right subclavian artery with a left-sided aortic arch is an extremely rare condition. In this report, we present multidetector computed tomographic (MDCT) angiography findings of an isolated right subclavian artery associated with a common carotid trunk and an anomalous origin and proximal interruption of the left pulmonary artery.

Endoscopic retrograde cholangiography by double balloon enteroscopy in patients with Roux-en-Y hepaticojejunostomy.

BACKGROUND: In patients with Roux-en-Y hepaticojejunostomy (HJ), endoscopic retrograde cholangiography (ERC) cannot usually be achieved since the anastomosis is not reachable via standard duodenoscope. In this study, we report our experience with ERC using double balloon enteroscope (DBE) (DBE-ERC) in patients with HJ. METHODS: The DBE-ERC procedures performed since the index case done dated May 3, 2006 have been overviewed. RESULTS: Fourteen patients underwent the procedure. DBE-ERC was successful in all but one patient, for whom the anastomosis could not be reached (success rate to reach anastomosis: 92.9%). The remaining 13 patients (7 female, 6 male; age 28-61 years, mean 45.3 years) had 20 sessions of DBE-ERC. The cannulation of the bile duct was achieved in all patients. The procedures, such as sphincteroplasty, dilatation, stone extraction and stent placement, were performed. Therapeutic procedures were all successful, except for in a single patient, who had the common bile duct filled with multiple stones and was referred for surgery. Three patients who had anastomotic stenosis treated by stenting are symptom free on follow-up at 3, 9 and 12 months, respectively, after stent removal. Retroperitoneal air was detected in a patient following stricturoplasty, but recovery was attained with medical treatment alone. Mean duration of the procedures was 75 +/- 62 min. CONCLUSION: DBE-ERCP enables us to perform ERC in a group of patients for whom it was impossible previously. Further experience is needed to evaluate its therapeutic efficacy compared with alternative methods.

Coarctation of the aorta in adults: preoperative evaluation with multidetector CT angiography.

PURPOSE: To evaluate the reliability of 16-slice multidetector computed tomographic (MDCT) angiography for the preoperative morphologic assessment of coarctation of the aorta in adults. MATERIALS AND METHODS: Twenty-four adult patients with clinical suspicion of coarctation of the aorta who underwent both Doppler echocardiography and MDCT angiography were included in this study. The sensitivities of diagnosis were assessed comparing MDCT and Doppler echocardiography with surgical results. RESULTS: The overall sensitivity of three-dimensional MDCT for diagnosis of the coarctation of the aorta was 100%, which was higher than that of Doppler echocardiography (91%). The overall sensitivity of MDCT for the assessment of cardiac defects was 82%, which was lower than that of Doppler echocardiography (100%). CONCLUSION: MDCT angiography with multiplanar and three-dimensional techniques should be the method of choice for preoperative morphologic assessment of coarctation of the aorta in adult patients.

Multidetector CT urography of renal fusion anomalies.

Renal fusion anomalies, in which both kidneys are fused togeher in early embyronic life, are rarely encountered. Once a fused kidney is diagnosed or suspected, further laboratory and imaging evaluation should be performed to assess the status of the kidneys and to look for treatable causes of renal pathology. The early dignosis of potential complications that can accompany this anomaly must be made in order to prevent permanent renal damage. The advantage of multidetector computed tomographic (MDCT) urography is its ability to depict the normal urinary tract anatomy, including both the renal parenchyma, and collecting structures and ureters. MDCT urography is helpful to screen for the presence of stones, hydronephrosis or masses. Additionally, it provides information about the vascular supply of the fused kidneys. Therefore, MDCT urography enables a comprehensive evaluation of patients with renal fusion anomalies in a single examination. Especially three-dimensional reformatted images can provide good delineation of congenital fusion anomalies of the kidney. In this study we report our experience with MDCT urography for the anatomic demonstration of renal fusion anomalies.

Multidetector CT angiography in spontaneous popliteal artery dissection.

Primary dissection of the femoropopliteal or popliteal arteries is rare in the absence of involvement of the aorta or aneurysmal arterial changes. In this report, we present multidetector CT angiography findings of a case of a spontaneous nonaneurysmal dissection limited to the left popliteal artery in an otherwise healthy 40-year-old woman.

Preoperative staging of renal cell carcinoma with multidetector CT.

PURPOSE: To evaluate the diagnostic accuracy of multidetector computed tomography (MDCT) for preoperative staging of renal cell carcinoma (RCC) using the 1997 TNM (tumor, node, metastasis) classification. MATERIALS AND METHODS: We conducted a retrospective review of MDCT in 57 consecutive patients with RCC performed for tumor staging before radical (n = 51) or partial nephrectomy (n = 6). The scanning protocol of MDCT consisted of unenhanced and biphasic contrast-enhanced scans during corticomedullary and nephrographic phases. MDCT and surgical-histopathologic staging were performed using the 1997 TNM staging system. The results of MDCT were compared with the histopathological results. Agreement between the two staging methods was evaluated using the kappa (kappa) statistic. RESULTS: Consistency between MDCT and histopathologic staging was excellent for T staging (kappa= 0.87), fair for N staging (kappa= 0.40), and excellent for M staging (kappa= 1.00). Fifty-one of 57 tumors were correctly staged, five overstaged and one understaged by MDCT, with an overall accuracy of 89%. MDCT was able to correctly identify and localize the extension of the tumor thrombus in all 10 patients. In the evaluation of nodal involvement, 42 of 57 patients (74%) were correctly staged, 11 (19%) overstaged, and four (7%) understaged. CONCLUSION: MDCT with a dynamic contrast enhancement protocol is an accurate method for preoperative staging of RCC. MDCT with multiplanar reconstruction capability enables a reliable detection and characterization of the tumor, but the involvement of lymph nodes by tumor is still difficult to predict because it is based on node size criterion only.

Noninvasive evaluation of coronary artery bypass grafts and native coronary arteries: is 16-slice multidetector CT useful?

PURPOSE: To investigate the diagnostic accuracy and limitations of 16-slice multidetector computed tomography (MDCT) in the detection of significant ( > 50%) stenosis of coronary artery bypass grafts (CABG) and native coronary arteries. MATERIALS AND METHODS: One hundred two patients with 236 grafts were investigated by 16-slice MDCT. Native coronary arteries were also investigated. The image quality was assessed in terms of artifact, and the evaluable segments were screened for the presence of occlusion and significant ( > 50%) stenosis. MDCT results were compared with conventional coronary angiography. RESULTS: The evaluability of MDCT was 90.4% for CABG and 71.2% for native coronary arteries. The most frequent causes of nonevaluable segments were motion artifact in venous grafts, metallic clip artifact in arterial grafts, and severe calcification in native coronary arteries. MDCT correctly diagnosed all of the 46 occluded grafts. The sensitivity, specificity, and the positive and negative predictive value of MDCT for the detection of significant CABG stenoses were 91.4%, 98.5%, 84.2%, and 99.2%, respectively. Including nonevaluable segments in the analysis, overall sensitivity was 84.2%. For the evaluation of native coronary arteries, MDCT had a sensitivity of 82.1% and a specificity of 75.3%, but evaluability was only 71.2%, resulting in overall sensitivity of 62.1%. CONCLUSION: Use of 16-slice MDCT angiography allows very accurate evaluation of CABG patency and has high diagnostic accuracy in detecting graft stenoses. But evaluation of native coronary artery stenosis is limited, particularly in patients with advanced coronary artery disease with severe calcification.

Congenital anomalies of the aortic arch: evaluation with the use of multidetector computed tomography.

Congenital anomalies of the aortic arch have clinical importance, as the anomalies may be associated with vascular rings or other congenital cardiovascular diseases. Multidetector computed tomography (MDCT) angiography enables one to display the detailed anatomy of vascular structures and the spatial relationships with adjacent organs; this ability is the greatest advantage of the use of MDCT angiography in comparison to other imaging modalities in the evaluation of the congenital anomalies of the aortic arch. In this review article, we illustrate 16-slice MDCT angiography appearances of congenital anomalies of the aortic arch.

Inferior mesenteric arteriovenous fistula with ischemic colitis: multidetector computed tomographic angiography for diagnosis.

Inferior mesenteric arteriovenous fistula is rare and may be congenital or acquired. Two serious manifestations may occur in the course of the disease: portal hypertension and bowel ischemia. The diagnosis is generally established by conventional angiography. In this report, we present a case with multiple inferior mesenteric arteriovenous fistulas, considered idiopathic due to no known cause related to the etiology, and associated ischemic colitis, which were clearly demonstrated by multidetector computed tomographic angiography. We also review the available literature.

Multidetector computed tomographic angiography of aberrant subclavian arteries.

The purpose of this study was to evaluate the utility of 16-slice multidetector computed tomographic (MDCT) angiography for identifying anatomic features of aberrant subclavian arteries. Seventeen patients with aberrant subclavian arteries were assessed by MDCT angiography. The aortic arch position, the presence of a Kommerell's diverticulum, aneurysm, vascular compression of trachea and oesophagus and associated cardiovascular abnormalities were evaluated. MDCT findings were confirmed by surgery in eight patients but in the other nine patients no further evaluation or management was warranted as the aberrant subclavian artery had no significant clinical consequence. Eleven patients had an aberrant right subclavian artery arising from the left aortic arch and six patients had an aberrant left subclavian artery arising from the right aortic arch. Kommerell's diverticulum was identified in three patients with an aberrant right subclavian artery and in five patients with an aberrant left subclavian artery. In two patients it was aneurysmal. Oesophageal compression was detected in eight patients, and tracheal compression was identified in only one paediatric patient. An aberrant subclavian artery was associated with complex congenital heart disease in one patient, intracardiac defects in two patients, aortic coarctation in two patients, patent ductus arteriosus in two patients and an aberrant vertebral artery in one patient. In conclusion, MDCT angiography is superior to digital subtraction angiography for the assessment of aberrant subclavian arteries since digital subtraction angiography has only a poor ability to visualize adjacent structures completely and is invasive in nature. MDCT angiography or magnetic resonance angiography are the current standard in the initial evaluation of thoracic vascular anomalies.

Multidetector computed tomography for preoperative evaluation of vascular anatomy in living renal donors.

BACKGROUND: Currently, multidetector computed tomographic (MDCT) angiography has become a noninvasive alternative imaging modality to catheter renal angiography for the evaluation of renal vascular anatomy in living renal donors. In this study, we investigated the diagnostic accuracy of 16-slice MDCT in the preoperative assessment of living renal donors. METHODS: Fifty-nine consecutive living renal donors (32 men, 27 women) underwent MDCT angiography followed by open donor nephrectomy. All MDCT studies were performed by using a 16-slice MDCT scanner with the same protocol consisting of arterial and nephrographic phases followed by conventional abdominal radiography. The MDCT images were assessed retrospectively for the number and branching pattern of the renal arteries and for the number and presence of major or minor variants of the renal veins. The results were compared with open surgical results. RESULTS: The sensitivity and specificity of MDCT for the detection of anatomic variants of renal arteries including the accessory arteries (n = 9), early arterial branching (n = 7) and major renal venous anomalies including the accessory renal veins (n = 3), late venous confluence (n = 4), circumaortic (n = 2) or retroaortic (n = 3) left renal veins were 100%. However, the sensitivity for identification of minor venous variants was 79%. All of three ureteral duplications were correctly identified at excretory phase conventional abdominal radiography. CONCLUSION: Sixteen-slice MDCT is highly accurate for the identification of anatomic variants of renal arteries and veins. Dual-phase MDCT angiography including arterial and nephrographic phases followed by conventional abdominal radiography enables complete assessment of renal donors without significant increase of radiation dose. However, the evaluation of minor venous variants may be problematic because of their small diameters and poor opacification.