Medullary thyroid carcinoma: a rare presentation as a hypervascular tumour.

Sporadic medullary thyroid carcinoma (MTC) usually presents with a thyroid mass, cervical lymphadenopathy or other local cervical symptoms. Often the diagnosis is unsuspected pre-operatively. We report a unique case of a mixed follicular medullary thyroid carcinoma presenting as a tumour with extreme vascularity. The management of hypervascular thyroid tumours is discussed together with current controversies regarding persistent hypercalcitoninaemia.

Contrast-enhanced magnetic resonance angiography of the iliac arteries: optimization by injection simulation.

Protocols for contrast-enhanced magnetic resonance angiography (CE-MRA) of the iliac arteries were optimized by computer simulations based on an impulse response function (IRF) of contrast agent (CA) concentration as a function of time obtained for 20 patients. Protocols with sequential, centric, and elliptical k-space coverage, different repetition rates (5 and 10 ms), and CA doses (0.1, 0.2, and 0.3 mmol/kg b.w.) were compared in terms of signal-to-noise ratio (SNR), distortion of vessel profiles, and sensitivity to timing errors. IRF-based simulations successfully characterized CA recirculation. Slow-rate CA infusions were found to achieve relatively high enhancement. In terms of SNR, there is no advantage in increasing the repetition rate. Distortion of vessel profiles is more likely in elliptic and centric k-space coverage. Protocols based on sequential k-space coverage and relatively long CA infusions proved to be particularly suited to large-FOV iliac examinations as they are relatively insensitive to timing errors.

Endoluminal embolization of bilateral atherosclerotic common iliac aneurysms with fibrin tissue glue (Beriplast).

The standard surgical approach to nonleaking iliac aneurysms found at repair of a leaking abdominal aortic aneurysm is to minimize the operative risk by repairing the abdominal aorta only. This means that the bypassed iliac aneurysms may have to be repaired later. As this population of patients are usually elderly with coexisting medical problems, interventional radiology is being used to embolize these aneurysms, thus avoiding the morbidity and mortality associated with further general anesthesia and surgery. Various materials and stents have been reported to be effective in the treatment of iliac aneurysms. We report the successful use of endoluminal fibrin tissue glue (Beriplast) to treat two large iliac aneurysms in a patient who had had a previous abdominal aortic aneurysm repair. We discuss the technique involved and the reasons why we used tissue glue in this patient.

Sequential retroperitoneal venous hemorrhage and embolism of an angio-seal puncture closure device complicating iliac artery angioplasty.

PURPOSE: To present a case of iatrogenic puncture closure device embolization complicating surgery for retroperitoneal hemorrhage (RPH) secondary to angioplasty-induced common iliac vein trauma. METHODS AND RESULTS: A 78-year-old woman with rest pain underwent successful kissing balloon dilation of her aortoiliac bifurcation for a calcified ostial stenosis of the left common iliac artery. Hemostatic puncture closure devices (Angio-Seal) were used to secure both femoral punctures. A right-sided retroperitoneal hematoma developed, and during surgical exploration of the right groin, the Angio-Seal device was removed. The only bleeding site found was the external iliac artery puncture and it was repaired. She again became hypovolemic 18 hours later and was returned to surgery, where bilateral groin explorations and laparotomy by the vascular surgical team found a tear in the left common iliac vein. After repair, the patient was stable for 48 hours when the left leg became critically ischemic. Angiography detected a new high-grade stenosis in the left profunda femoris artery; embolectomy retrieved a footplate from the left puncture closure device. The patient died 11 days later from multiorgan failure. CONCLUSIONS: RPH should be considered early as an occult cause of hypovolemic shock developing soon after even technically straightforward iliac angioplasty. Interventionists should be aware that using the Angio-Seal device risks acute limb ischemia if footplate embolization occurs.

Peripheral thrombolysis for acute-onset claudication. Thrombolysis Study Group.

BACKGROUND: The aim of this study was to determine the outcome of patients who presented with sudden onset of incapacitating claudication of less than 2 weeks' duration and who were treated with peripheral arterial thrombolysis. METHODS: The database of the Thrombolysis Study Group was searched retrospectively for patients who received thrombolysis for acute-onset claudication. Some 108 patients (65 men, median age 69 (range 29-94) years) were treated with intra-arterial tissue plasminogen activator at 14 hospitals. The median duration of symptoms was 72 h (range from 2 h to 2 weeks). There were 52 graft and 56 native vessel arterial occlusions. RESULTS: The immediate outcome of thrombolysis for native vessel arterial occlusion was thrombus clearance in 50 patients (89 per cent) and failed lysis in six (11 per cent). Thirty-six patients (64 per cent) had a secondary radiological or surgical procedure carried out after lysis. After 30 days four patients (7 per cent) had a major amputation, eight (14 per cent) had died, 38 (68 per cent) were symptom free and seven (12 per cent) continued to have claudication. Three patients (5 per cent) suffered a major haemorrhage. The immediate outcome of thrombolysis for graft occlusion was thrombus clearance in 48 patients (92 per cent) and failed lysis in four (8 per cent); 27 patients (52 per cent) had a secondary procedure. After 30 days four patients (8 per cent) had a major amputation, seven (13 per cent) had died, 32 (62 per cent) were symptom free and nine (17 per cent) had persistent claudication. Three patients (6 per cent) suffered a major haemorrhage. CONCLUSION: Patients who presented with acute onset of incapacitating claudication had an outcome similar to that after thrombolysis for critical ischaemia. It is recommended that patients who present in this way should be observed and treated with thrombolysis only if they progress to critical ischaemia. Presented to the Association of Surgeons of Great Britain and Ireland, Edinburgh, UK, May 1998, and published in abstract form as Br J Surg 1998; 85(Suppl 1): 24

Insertion of a chest drain: how to do it.

Drainage of the pleural space with a chest drain is a commonly required procedure, but complications are common, and management of the drain is often unsatisfactory. This article aims to give guidance on avoiding complications by safe technique and resolving any subsequent problems.