Contrast-Enhanced Ultrasound after Endovascular Aortic Repair: Supplement and Potential Substitute for CT in Early- and Long-Term Follow-Up.

BACKGROUND: Endoleaks are the most common complication after endovascular aneurysm repair (EVAR). Computed tomography angiography (CTA) is presently the golden standard for lifelong surveillance after EVAR. Several studies and meta-analyses have shown contrast-enhanced ultrasound (CEUS) to be a good alternative. The main goal of our study was to further validate the inclusion of CEUS in follow-up examination protocols for the systematic surveillance after EVAR. METHODS: A retrospective analysis of patients who had received CEUS as part of their routine surveillance after EVAR at our center was conducted. Detection rate and classification of endoleak types were compared between available postinterventional CTA/magnetic resonance angiography and follow-up CEUS examinations. Last preinterventional CTAs before EVAR served as baselines with focus on potential cofactors such as age, body mass index, maximum aortic aneurysm diameters, endoleak orientation, and distance-to-surface influencing detection rates and classification. RESULTS: In total, 101 patients were included in the analysis. Forty-four endoleaks (43.5% of cases) were detected by either initial CEUS or CTA, mostly type II (37.6% of the included patients). Initial CEUS showed an endoleak sensitivity of 91.2%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 84.6%. No covariate with an influence on the correct classification could be identified either for CEUS or CT. CONCLUSIONS: CEUS should be considered a valid complementary method to CTA in the lifelong surveillance after EVAR. As type II endoleaks seem to be a common early-term, sometimes spontaneously resolving complication that can potentially be missed by CTA, we suggest combined follow-up protocols including CEUS in the early on postinterventional assessment.

Ultrasonography for the Diagnosis of Carpal Tunnel Syndrome in Diabetic Patients: Missing the Mark?

PURPOSE: Diabetes mellitus (DM) and carpal tunnel syndrome (CTS) are common pathologies. The diagnosis of CTS can be facilitated by the use of an ultrasound-based wrist-to-forearm ratio (WFR) of the nerve diameter. However, the applicability of WFR in DM-patients is not yet clear. MATERIALS AND METHODS: 233 wrists of 153 patients were examined. Cross-sectional areas (CSA) of the median nerve were obtained using a linear array probe. The WFR was calculated. RESULTS: Diabetics with CTS had significantly lower WFR values than non-diabetics with CTS (p = 0.002). There was no difference between the WFR of diabetics with and without CTS (p = 0.06). The diagnostic accuracy between diabetics with and without CTS was low for measurements of WFR (ROC AUC = 0.630, 95 % CI 0.541 - 0.715, p = 0.011). CONCLUSION: Our findings suggest that the WFR has a low diagnostic accuracy in diabetic patients with CTS and should be used with caution in those patients. KEY POINTS: · The diagnostic accuracy of WFR is low in patients with DM. · WFR should not be used in patients with DM. · The sonographic evaluation of the median nerve in patients with DM should focus on morphological changes. CITATION FORMAT: · Steinkohl F, Loizides A, Gruber L et al. Ultrasonography for the Diagnosis of Carpal Tunnel Syndrome in Diabetic Patients: Missing the Mark?. Fortschr Röntgenstr 2019; 191: 117 - 121.

Incidence of arteriovenous fistula closure due to high-output cardiac failure in kidney-transplanted patients.

BACKGROUND: Some hemodialysis patients develop arteriovenous (AV) fistulas with high flows. This volume overload can result in high-output cardiac failure. To date, predisposing access flow rates are unknown. METHODS: A retrospective study of all kidney-transplant recipients at the Medical University of Innsbruck (MUI) from 2005 to 2010 included 797 patients with the following criteria: previous hemodialysis with a native AV fistula or a graft, sufficient function of the kidney transplant up to the time of the data analysis, and follow-up care at the MUI. RESULTS: Twenty-nine of the 113 patients (25.7%) needed an AV fistula closure, mostly because of symptoms of cardiac failure. The mean shunt flow in the intervention group was 2197.2 mL/min, whereas the mean shunt flow in the non-intervention group was only 850.9 mL/min. Shunt closures were most frequently made in patients with upper-arm shunts (41.7%). CONCLUSION: The necessity of shunt closure is not a rarity. Patients who underwent an AV fistula ligature had high access flows with about 2200 mL/min. As the symptoms of cardiac failure greatly improved after shunt closure, patients with high access flow may benefit from such an intervention.

Ultrasound of the median arcuate ligament syndrome: a new approach to diagnosis.

INTRODUCTION: The currently accepted pathophysiological concept behind median arcuate ligament syndrome (MALS) is vascular compromise by atypically positioned median arcuate ligament. Despite many articles on MALS, only sparse data on the outcome in general and the rather poor outcome after intervention have been reported and this makes at least questionable the current concepts of the underlying disease. MATERIAL AND METHODS: A total of 364 patients with suspected celiac trunk pathology underwent a standardized ultrasound assessment procedure: suspected diagnostic features for MALS such as typically elevated peak flow velocities (PV) in the celiac trunk or atypical celiac trunk deflection-angles (DA) were defined in patients and in 20 matched volunteers. RESULTS: All the 6 retrospectively clearly diagnosed MALS-patients as well as 40% (8/20) of volunteers presented a DA of over 50°. MALS-patients presented a mean inspiratory PV of 172cm/s (+/- 40.9 cm/s), a mean expiratory PV of 425cm/s (+/-130.1 cm/s) with a PV-amplitude of 249.1% (+/-68.9%). Volunteers presented a mean inspiratory PV of 126.9cm/s (+/-42 cm/s), a mean expiratory PV of 209.9cm/s (+/-80.1 cm/s) with a PV-amplitude of 169.4% (+/-54.3%). CONCLUSIONS: The combination of a maximum expiratory PV of over 350 cm/s and a DA higher than 50° seems to be a most reliable indicator for MALS in this small series of patients. Based on these data we propose that functional ultrasound should be the first line in screening for MALS. However, a clear pathophysiological definition of MALS remains still obscure.

Effect of the dual endothelin receptor antagonist bosentan on Raynaud's phenomenon secondary to systemic sclerosis: a double-blind prospective, randomized, placebo-controlled pilot study.

OBJECTIVE: To investigate the efficacy of the endothelin receptor antagonist, bosentan, in patients with RP secondary to SSc without pre-existing digital ulcers. METHODS: Single-centre, randomized, prospective, double-blinded comparison of bosentan and placebo. Patients received either 62.5 mg bosentan twice daily for 4 weeks, followed by 125 mg twice daily for 12 weeks or matching doses of placebo. RESULTS: Of the 17 patients enrolled, 16 completed the study and 1 withdrew from the study due to the reversible development of peripheral oedema. Compared with placebo, bosentan did not improve the frequency, duration, pain or severity of RP attacks. However, in contrast to placebo, bosentan significantly improved the functional scores. With respect to baseline, the scleroderma HAQ disability index changes were in favour of bosentan at Weeks 12 (P = 0.03) and 20 (P = 0.01), and the United Kingdom functional score changes at Weeks 8 (P = 0.038) and 16 (P = 0.039). CONCLUSIONS: Bosentan is not effective in SSc-related RP without pre-existing digital ulcers, but it might benefit functional impairment in those patients. TRIAL REGISTRATION: European Union Drug Regulating Authorities Clinical Trials, https://eudract.emea.europa.eu, EudraCT-Nr 2004-002686-21.

Association between the UGT1A1 TA-repeat polymorphism and bilirubin concentration in patients with intermittent claudication: results from the CAVASIC study.

BACKGROUND: Bilirubin has antioxidative and cytoprotective properties. Low plasma concentrations of bilirubin are reportedly associated with the development of coronary and cerebrovascular disease, and bilirubin concentrations are strongly correlated with the enzyme activity of the hepatic uridine diphosphate glucuronosyltransferase (UGT1A1). The activity of UGT1A1 is influenced by a TA-repeat polymorphism in the promoter of the UGT1A1 gene (UDP glucuronosyltransferase 1 family, polypeptide A1). In a case-control study, we investigated the association between the UGT1A1 polymorphism, bilirubin concentration, and intermittent claudication. METHODS: We included 255 consecutive male patients presenting with intermittent claudication in the investigation and matched the patients by age and diabetes mellitus with 255 control individuals. RESULTS: Plasma bilirubin concentrations were significantly lower in patients than in controls [mean (SD), 12.5 (5.3) micromol/L vs 15.4 (7.9) micromol/L; P < 0.001]. We found a clear association between the number of TA repeats and plasma bilirubin concentration. Considering the 6/6 TA-repeat genotype as the wild type, we observed a slight increase in bilirubin concentration individuals with the heterozygous 6/7 genotype and pronounced increases for those with the homozygous 7/7 genotype. This association occurred in both controls and patients; however, patients and controls were not significantly different with respect to UGT1A1 TA-repeat genotype frequencies. CONCLUSIONS: Our study of a well-phenotyped group of patients with intermittent claudication and control individuals revealed a clear association between low bilirubin concentrations and peripheral arterial disease but no association between the UGT1A1 polymorphism and the disease.

Endovascular therapy of distal anterior cerebral artery aneurysms-an effective treatment option.

BACKGROUND: Surgical treatment of APAs is associated with relatively high morbidity and mortality. The aim of this study was to illustrate the technical achievements of endovascular procedures in the distal anterior cerebral artery area, technical difficulties and how they can be overcome, and the outcome of endovascular treatment of APAs. METHODS: Between 1997 and 2006, of 49 patients with APAs at our institution, 29 were treated endovascularly (4.1% of all endovascularly treated aneurysms; F:M = 3.8; mean age, 52.8 +/- 11.5 years), and 12 were treated surgically. Twenty-one (72.4%) of the endovascularly treated patients had a subarachnoid hemorrhage. The mean observation period was 25 +/- 22.8 months. RESULTS: In 27 (93.1%) cases, complete occlusion of the aneurysm was achieved. The intervention led to 5 (17.2%) cases of minor complications with no neurologic deficits: 2 thromboembolisms, 1 local thrombus, 1 occlusion, and 1 recurrent hemorrhage. Mortality related to the intervention was 3.4%. There was no morbidity associated with the elective procedures. The dome-to-neck ratio is the main predictor of reperfusion. The most important factor impairing the outcome in terms of the GOS status is the presence of an intraparenchymal hematoma, followed by thrombembolic complications. CONCLUSION: Endovascular treatment of APAs is feasible, safe, and effective. Mortality and morbidity are comparable with surgical therapy. An intraparenchymal hematoma has a severe negative influence on the patient's condition after rehabilitation. In these cases, surgical intervention should be considered. In case of incomplete occlusion of the aneurysm, prompt reintervention is required.

Serum levels of ischemia-modified albumin in healthy volunteers after exercise-induced calf-muscle ischemia.

BACKGROUND: Ischemia-modified albumin (IMA) is an emerging marker of ischemia. To investigate the applicability of IMA for the diagnosis of skeletal muscle ischemia, we examined IMA changes as measured by the albumin-cobalt binding test, in a group of healthy volunteers after standardized exercise-induced calf muscle ischemia. METHODS: A total of 12 healthy volunteers underwent standardized exercise on a plantar flexion pedal. Ischemic conditions were achieved by inflating a femoral blood pressure cuff at incremental pressures of 0, 60, 90, 120 and 150 mm Hg. Calf muscle ischemia was identified by synchronous 31P magnetic resonance spectroscopy, measuring intracellular concentrations of phosphocreatine (PCr) and inorganic phosphate (Pi). In addition, IMA, serum albumin, lactate, troponin T (TnT) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) were measured at baseline and at 5, 10, 30, 360 and 720 min after cuff release. RESULTS: Magnetic resonance spectroscopy showed calf muscle ischemia in all participants upon exercise and cuff inflation. Circulating IMA concentrations increased significantly after cuff release (p=0.03) and returned to baseline within 30 min. While we found a significant negative correlation with albumin, there was no association of IMA levels with lactate or intracellular levels of PCr or Pi in samples obtained at baseline and post-ischemia. TnT and NT-proBNP remained within the normal range throughout the observation period in all participants. CONCLUSIONS: IMA may represent a clinical marker for skeletal muscle ischemia, although its lack of specificity requires careful clinical interpretation of data. The short period of IMA elevation after ischemic exercise requires standardized conditions for use as a diagnostic tool and hints at IMA applicability as a marker of prolonged or chronic ischemia.

Prevalent esophageal body motility disorders underlie aggravation of GERD symptoms in morbidly obese patients following adjustable gastric banding.

HYPOTHESIS: Preexisting gastroesophageal reflux disease (GERD) and esophageal motility disorders may affect the outcome of laparoscopic adjustable gastric banding (AGB). DESIGN: Prospective cohort study. SETTING: Tertiary referral center. PATIENTS: Between January 1, 1996, and December 31, 2002, AGB procedures were performed in 587 patients (mean body mass index, 46.7 [calculated as weight in kilograms divided by the square of height in meters]). The study population was composed of patients with preoperative GERD (assessed by a symptom-score questionnaire) and was divided into group 1 (those with preoperative GERD symptoms only) and group 2 (those with preoperative and postoperative GERD symptoms). INTERVENTIONS: Laparoscopic AGB was performed according to the pars-flaccida technique. MAIN OUTCOME MEASURES: All patients underwent preoperative and annual postoperative symptom scoring, endoscopy, esophageal barium swallow tests, esophageal manometry, and 24-hour pH monitoring. RESULTS: Mean follow-up time was 33 months (range, 12-49 months). A total of 164 patients (27.9%) were diagnosed as having preoperative GERD symptoms. In 112 (68.3%) of these patients GERD symptoms vanished postoperatively (group 1), whereas 52 patients (31.7%) remained symptomatic after undergoing laparoscopic AGB implantation (group 2). Preoperatively, group 2 patients showed significantly poorer esophageal body motility compared with group 1 patients (20.8% vs 12.8% defective propagations; P = .007). In group 2 the mean symptom scores for dysphagia (0.4 vs 0.9) and regurgitation (0.6 vs 1.4) deteriorated significantly following laparoscopic AGB implantation, respectively. Eighteen patients (34.6%) in group 2 developed esophageal dilatation. CONCLUSIONS: Adjustable gastric banding provides a sufficient antireflux barrier in most of the obese patients with GERD. However, in patients with preoperatively defective esophageal body motility, AGB may aggravate GERD symptoms and esophageal dilatation. Alternative bariatric surgical procedures should be considered in these patients.