Imaging vascular trauma.

BACKGROUND: Over the past 50 years the management of vascular trauma has changed from mandatory surgical exploration to selective non-operative treatment, where possible. Accurate, non-invasive, diagnostic imaging techniques are the key to this strategy. The purpose of this review was to define optimal first-line imaging in patients with suspected vascular injury in different anatomical regions. METHODS: A systematic review was performed of literature relating to radiological diagnosis of vascular trauma over the past decade (2000-2010). Studies were included if the main focus was initial diagnosis of blunt or penetrating vascular injury and more than ten patients were included. RESULTS: Of 1511 titles identified, 58 articles were incorporated in the systematic review. Most described the use of computed tomography angiography (CTA). The application of duplex ultrasonography, magnetic resonance imaging/angiography and transoesophageal echocardiography was described, but significant drawbacks were highlighted for each. CTA displayed acceptable sensitivity and specificity for diagnosing vascular trauma in blunt and penetrating vascular injury within the neck and extremity, as well as for blunt aortic injury. CONCLUSION: Based on the evidence available, CTA should be the first-line investigation for all patients with suspected vascular trauma and no indication for immediate operative intervention.

How safe is bilateral internal iliac artery embolization prior to EVAR?

PURPOSE: To assess the outcomes of patients after bilateral internal iliac artery (IIA) embolization prior to endovascular aneurysm repair (EVAR). METHODS: Thirty-nine patients (age range 55-88 years, mean 72.5 years; 2 women) underwent IIA embolization/occlusion before EVAR. There were 28 patients with aorto-biiliac aneurysms and 6 with bilateral common iliac artery (CIA) aneurysms. Five patients with unilateral CIA aneurysms had previous surgical ligation of the contralateral IIA or inadvertent covering by the stent-graft of the contralateral IIA origin. Outcomes were assessed by clinical follow-up. RESULTS: Severe ischemic complications were limited to spinal cord ischemia in 1 patient (3%) who developed paraparesis following EVAR. No other severe ischemic complications such as buttock necrosis, or bowel or bladder ischemia, occurred. Buttock and/or thigh claudication occurred in 12 patients (31%) and persisted beyond 1 year in 3 patients (9%). Sexual dysfunction occurred in 2 patients (5%). Patients who underwent simultaneous embolization had a 25% (3/12) ischemic complication rate versus 41% (11/27) in those with sequential embolization (p = 0.48). Embolization limited to the main trunk of the IIA resulted in a significantly reduced ischemic complication rate of 16% (3/19) versus 55% (11/20) of patients who had a more distal embolization of the IIA (p = 0.019, Fisher's exact test). CONCLUSION: Severe complications after bilateral IIA embolization are uncommon. Although buttock/thigh claudication occurs in around 30% of patients soon after the procedure, this resolves in the majority after 1 year. There is no obvious benefit for sequential versus simultaneous IIA embolization in our series. Occlusion of the proximal IIA trunk is associated with reduced complications compared with occlusion of the distal IIA.

A meta-analysis of randomized placebo control trials in Fontaine stages III and IV peripheral occlusive arterial disease.

In patients with Fontaine Stage III and IV POAD unsuitable for arterial reconstruction, Iloprost, a prostacyclin analogue, has been shown in six RCTs to have a significant (p < 0.05) beneficial effect with regards to the probability of being alive with both legs at six months follow-up. Iloprost has significant (p < 0.05) beneficial effects over placebo on ulcer healing and pain relief, but these were relatively soft endpoints to study when side effects may have unblinded many observers and patients. Further studies are indicated to investigate the possible benefit of repeated courses of treatment with Iloprost in patients with non-reconstructable Fontaine Stage III and IV POAD as well as studies looking at patients who may be suitable only for relatively high risk reconstructions. Meta-analysis of all other RCTs of pharmacotherapeutic agents in patients with Fontaine Stage III and IV POAD showed no significant benefit over placebo for any of the endpoints reported.

The differences in early haemodynamic response between surgery and angioplasty after successful re-opening of the superficial femoral artery.

In 40 patients with superficial femoral artery disease we prospectively evaluated the effect of angioplasty (n = 20) or femoropopliteal bypass (n = 20) on the ankle-brachial pressure index (ABI) using the Doppler ultrasound probe. The ABI was measured as a baseline 1 day before the procedure, 1 day after the procedure and 30 days later. In the angioplasty group the baseline ABI was 0.57 (0.11), increasing to 0.74 (0.26) 1 day postangioplasty and increasing further to 0.88 (0.26) after 30 days. The increase in ABI over 30 days was significantly greater than the increase over 1 day. In the femoropopliteal bypass group the baseline ABI was lower at 0.46 (0.17). However 1 day postoperatively it had increased to 0.92 (0.2) with almost no further increase at 30 days [0.95 (0.17)]. We concluded that by contrast to a surgical bypass where there was a large improvement in the ABI over the first day, the ABI following angioplasty continued to improve significantly beyond the first day.

Role of ultrasound in the investigation of haematuria after normal intravenous urography and cystoscopy.

The initial investigation of haematuria in the adult includes intravenous urography and cystoscopy. If these investigations reveal no cause for haematuria we propose that renal ultrasound should be considered, and illustrate this with two series of patients from different hospitals (147 from St. Peter's Hospitals, 35 from St. James' Hospital, Balham, London) with primary adenocarcinoma of the kidney.

Malignant primary pulmonary paraganglioma.

The histological, immunocytochemical, and electron microscopic findings in a case of malignant primary pulmonary paraganglioma are reported. The existence of this rare tumour is evidence for the presence of pulmonary chemoreceptors.