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.

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.