Nutcracker syndrome, conservative approach: a case report.

The nutcracker phenomenon (NCP) refers to the compression of the left renal vein, most commonly between the aorta and the superior mesenteric artery (SMA). Nutcracker syndrome (NCS) should be limited to patients who present with the characteristic clinical signs and symptoms alongside diagnostic imaging of the anatomy associated with the syndrome. We report a case of NCS presenting with painless visible hematuria and left flank pain. Imaging showed a left renal vein stenosis at the origin of the SMA with collateralization. Diagnosis of NCP is made by a variety of imaging techniques; approaches to the treatment of NCS include conservative methods, open surgical, laparoscopic or endovascular techniques. Correlation with symptoms, laboratory results and excluding other causes continues to be important in the workup of NCS. Collaboration with the establishment of an International Consortium database will aid in the understanding of this rare disease.

Randomized placebo controlled trial evaluating the safety and efficacy of single low-dose intracoronary insulin-like growth factor following percutaneous coronary intervention in acute myocardial infarction (RESUS-AMI).

BACKGROUND: Residual and significant postinfarction left ventricular (LV) dysfunction, despite technically successful percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI), remains an important clinical issue. In preclinical models, low-dose insulin-like growth factor 1 (IGF1) has potent cytoprotective and positive cardiac remodeling effects. We studied the safety and efficacy of immediate post-PCI low-dose intracoronary IGF1 infusion in STEMI patients. METHODS: Using a double-blind, placebo-controlled, multidose study design, we randomized 47 STEMI patients with significantly reduced (≤40%) LV ejection fraction (LVEF) after successful PCI to single intracoronary infusion of placebo (n = 15), 1.5 ng IGF1 (n = 16), or 15 ng IGF1 (n = 16). All received optimal medical therapy. Safety end points were freedom from hypoglycemia, hypotension, or significant arrhythmias within 1 hour of therapy. The primary efficacy end point was LVEF, and secondary end points were LV volumes, mass, stroke volume, and infarct size at 2-month follow-up, all assessed by magnetic resonance imaging. Treatment effects were estimated by analysis of covariance adjusted for baseline (24 hours) outcome. RESULTS: No significant differences in safety end points occurred between treatment groups out to 30 days (χ2 test, P value = .77). There were no statistically significant differences in baseline (24 hours post STEMI) clinical characteristics or LVEF among groups. LVEF at 2 months, compared to baseline, increased in all groups, with no statistically significant differences related to treatment assignment. However, compared with placebo or 1.5 ng IGF1, treatment with 15 ng IGF1 was associated with a significant improvement in indexed LV end-diastolic volume (P = .018), LV mass (P = .004), and stroke volume (P = .016). Late gadolinium enhancement (±SD) at 2 months was lower in 15 ng IGF1 (34.5 ± 29.6 g) compared to placebo (49.1 ± 19.3 g) or 1.5 ng IGF1 (47.4 ± 22.4 g) treated patients, although the result was not statistically significant (P = .095). CONCLUSIONS: In this pilot trial, low-dose IGF1, given after optimal mechanical reperfusion in STEMI, is safe but does not improve LVEF. However, there is a signal for a dose-dependent benefit on post-MI remodeling that may warrant further study.

Prophylactic Placement of Internal Iliac Balloons in Patients with Abnormal Placental Implantation: Maternal and Foetal Outcomes.

PURPOSE: To report on outcomes following the use of prophylactic internal iliac artery occlusion balloons in patients with abnormal placental implantation. METHODS: A retrospective analysis was undertaken of patients with abnormal placental implantation who underwent prophylactic iliac balloon placement prior to delivery in a University Maternity Hospital. Various clinical and technical factors were analysed, including technical success of balloon placement, blood loss and number of blood units transfused, duration of surgery, length of stay, hysterectomy rates, complications related to the balloon insertion, foetal pH and infant Apgar scores. RESULTS: Twenty-two patients with placenta accreta or a variant thereof underwent caesarean section after first undergoing prophylactic placement of bilateral internal artery balloons. Average follow-up duration was 2.08 years. The average gestational age was 37 weeks 6 days, and the mean gravidity was 2.8. The mean number of previous caesarean sections was 2.4, while the mean maternal age was 35 years. The mean intraoperative blood loss was 1.4 L, and the mean number of blood units transfused was 2. Mean duration of surgery was 90 min, mean total length of hospital stay 7.5 days, while the mean duration of ICU/HDU stay was 1.2 days. The balloons were inflated in 60% of cases and two patients (2/22-9%) underwent subsequent hysterectomy. There were no major maternal complications due to the procedure. CONCLUSION: Prophylactic placement of arterial balloons prior to caesarean section in patients with placenta accreta is well tolerated and leads to satisfactory maternal and foetal outcomes with minimal complications.

Dual pathology proximal median nerve compression of the forearm.

We report an unusual case of synchronous pathology in the forearm- the coexistence of a large lipoma of the median nerve together with an osteochondroma of the proximal ulna, giving rise to a dual proximal median nerve compression. Proximal median nerve compression neuropathies in the forearm are uncommon compared to the prevalence of distal compression neuropathies (eg Carpal Tunnel Syndrome). Both neural fibrolipomas (Refs. 1,2) and osteochondromas of the proximal ulna (Ref. 3) in isolation are rare but well documented. Unlike that of a distal compression, a proximal compression of the median nerve will often have a definite cause. Neural fibrolipoma, also called fibrolipomatous hamartoma are rare, slow-growing, benign tumours of peripheral nerves, most often occurring in the median nerve of younger patients. To our knowledge, this is the first report of such dual pathology in the same forearm, giving rise to a severe proximal compression of the median nerve. In this case, the nerve was being pushed anteriorly by the osteochondroma, and was being compressed from within by the intraneural lipoma. This unusual case highlights the advantage of preoperative imaging as part of the workup of proximal median nerve compression.

Measurement of pulmonary circulation parameters using time-resolved MR angiography in patients after Ross procedure.

OBJECTIVE: The purposes of our study were to retrospectively evaluate the pulmonary circulation parameters of pulmonary transit time and pulmonary blood volume in patients after Ross procedures using time-resolved MR angiography and to investigate associations with right ventricular dysfunction in the same group of patients. MATERIALS AND METHODS: Sixteen patients who had undergone a Ross procedure (12 men, four women; mean age, 42.13 +/- 14.24 years; age range, 21-68 years) and 16 age- and sex-matched control patients (12 men, 4 women; mean age, 42.25 +/- 14.62 years; age range, 21-68 years) were evaluated using cardiac MRI and Argus postprocessing software. Right and left ventricular volumetric parameters, including ejection fraction, end-systolic volume, and end-diastolic volume, were measured from cine true fast imaging with steady-state precession images. Pulmonary circulation parameters, including pulmonary transit time, were measured using dynamic time-resolved MR angiography and pulmonary blood volume was calculated. Pulmonary circulation parameters were correlated with volumetric parameters. The results were statistically analyzed using the Mann-Whitney U test, paired-samples Student's t test, Pearson's correlation, and linear regression. RESULTS: Pulmonary circulation parameters were significantly prolonged in patients after the Ross procedure compared with control patients (p < 0.01). Strong correlations exist between pulmonary circulation parameters and right ventricular function, especially pulmonary transit time and right ventricular ejection fraction (R > 0.60, p < 0.001). CONCLUSION: Patients after undergoing the Ross procedure had prolonged pulmonary transit times compared with normal control patients; this and other pulmonary circulation parameters best correlate with worsened right ventricular ejection fraction and may be predictors of right ventricular dysfunction in this group of patients.

Pulmonary vein imaging with unenhanced three-dimensional balanced steady-state free precession MR angiography: initial clinical evaluation.

PURPOSE: To determine whether unenhanced magnetic resonance (MR) angiography performed with a three-dimensional (3D) segmented steady-state free precession (SSFP) sequence would be an alternative to contrast material-enhanced MR angiography for evaluating pulmonary veins (PVs) prior to and following radiofrequency (RF) ablation for atrial fibrillation. MATERIALS AND METHODS: MR angiographic examinations of PVs, performed in 20 patients (nine men, 11 women; mean age, 56.4 years +/- 12.7 [standard deviation]), were retrospectively reviewed according to an institutional review board-approved protocol. The number of PVs and their orthogonal measurements obtained from the 3D SSFP images were compared with those obtained from contrast-enhanced MR angiography. Signal-to-noise and contrast-to-noise ratios were also compared. Qualitative assessment of both techniques was performed by independent reviewers who scored the image quality (on a scale of 1 to 5) on the basis of PV conspicuity. The presence of cardiac and extracardiac pathologic indicators was also determined. Bland-Altman and Wilcoxon signed rank statistical analyses were performed. RESULTS: The mean difference in PV diameter measurements between contrast-enhanced MR angiography and 3D SSFP was -0.02 cm +/- 0.25. Signal-to-noise and contrast-to-noise ratios were higher for 3D SSFP images than for contrast-enhanced MR angiograms. Qualitatively, there was no significant difference in PV conspicuity between the techniques. Noncardiac pathologic indicators were detected in 10 of 20 patients on 3D SSFP images but not on contrast-enhanced MR angiograms. CONCLUSION: Unenhanced PV MR angiography performed by using a free-breathing 3D SSFP technique is as accurate as contrast-enhanced MR angiography for measuring PV diameter. This technique can be used for patients in whom contrast-enhanced computed tomographic or MR angiography is contraindicated and may be sufficient in all patients.

Uterine artery embolization for ureteric obstruction secondary to fibroids.

This case series examines the safety and efficacy of uterine artery embolization (UAE) in the treatment of obstructive nephropathy caused by large fibroids. Between 2004 and 2007, 10 patients referred with symptomatic uterine fibroids that were found to be causing either unilateral (7 patients) or bilateral (3 patients) hydronephrosis were treated by UAE. Presenting complaints included menorrhagia, dysmenorrhea, bulk symptoms, loin pain, postobstructive atrophy, and mild renal impairment. All had posterior intramural dominant fibroids >11 cm in maximum sagittal diameter and uterine volumes between 3776 and 15,625 ml. Outcome measures at between 12 and 36 months included procedural success, repeat intervention, relief of symptoms, resolution of hydronephrosis, stable renal function and size, and avoidance of hysterectomy. In all cases the cause of renal obstruction was confirmed to be a giant fibroid compressing the ureter at the pelvic brim. In all cases UAE was technically successful, though two patients required a repeat procedure. In eight patients hydronephrosis resolved and the obstruction was relieved, though two still had some bulk symptoms not requiring further treatment. Renal function improved or was stable in all cases. Renal size was stable in all cases. Where menorrhagia was part of the symptom complex it was relieved in all cases. Two patients diagnosed as having postobstructive atrophy of one kidney underwent retrograde ureteric stenting on the nonatrophied side prior to UAE. This was unsuccessful in one of the cases due to the distortion caused by the fibroid. Despite improvement in hydronephrosis this patient underwent hysterectomy at 7 months after a renogram demonstrated persistent obstruction at the pelvic brim. In the second patient a double pigtail stent was inserted with difficulty and eventually removed at 8 months. This patient has had stable renal function and size for 3 years post-UAE. We conclude that UAE is safe and effective in treating patients with obstructive hydronephrosis caused by large fibroids.

Cardiac magnetic resonance imaging findings in a patient with noncompaction of ventricular myocardium.

Noncompaction of ventricular myocardium (NCVM) is a rare cardiomyopathy characterized by numerous prominent trabeculations in the ventricular wall and deep intertrabecular recesses communicating with the ventricular cavity. This article reports a 33-year-old female with a familial history of cardiovascular disease, who presented with shortness of breath and palpitations. Transesophageal echocardiography and cardiac magnetic resonance imaging (MRI) were consistent with the diagnosis of NCVM. The advantages of MRI in depicting both the morphological features and pathological characteristics of NCVM were presented.

Unenhanced MR angiography of the thoracic aorta: initial clinical evaluation.

OBJECTIVE: In patients with difficult i.v. access or renal insufficiency, or in those who are pregnant, we hypothesized than an unenhanced 3D segmented steady-state free precession (SSFP) MR angiography (MRA) technique would be an alternative to contrast-enhanced MR angiography (CE-MRA) for the evaluation of vasculature. MATERIALS AND METHODS: MRA examinations of the thoracic aorta were retrospectively reviewed in 23 patients in whom both CE-MRA and 3D SSFP were performed. CE-MRA was performed using an ECG-gated gradient-echo FLASH sequence. Three-dimensional SSFP MRA was performed during free breathing using a motion-adaptive navigator technique. Quantitative assessment of the 3D SSFP and CE-MRA image sets was performed by comparing the aortic lumen diameter. The quality of the images of the aortic root (scale of 1-5) and the presence of cardiovascular and noncardiovascular pathology were independently determined for both techniques by two reviewers. Bland-Altman and Wilcoxon's signed-rank analyses were performed. RESULTS: The difference in orthogonal measurements of the aortic diameter between those made on images from the 3D SSFP and those made from the CE-MRA sequences was -0.042 cm. The aortic root was better visualized with 3D SSFP: score of 3.78 (of 5) for CE-MRA versus score of 4.65 (of 5) for 3D SSFP (p < 0.05). CONCLUSION: In patients in whom contrast material is contraindicated, unenhanced MRA using a 3D SSFP technique can be performed.

Percutaneous transsplenic access in the management of bleeding varices from chronic portal vein thrombosis.

Three patients with life-threatening variceal hemorrhage secondary to portal vein (PV) thrombosis underwent endovascular treatment via the transsplenic route. The indications, techniques, and early outcomes are described. Each patient had successful portal/splenic vein recanalization with or without transjugular intrahepatic portosystemic shunt (TIPS) creation and variceal embolization with conventional catheter and wire techniques. The transsplenic approach is a useful addition to the interventional armamentarium that can be used in cases refractory to endoscopic management and unsuitable for surgical shunt procedures or conventional TIPS procedures. Longer-term follow-up will be needed to establish the durability of these procedures.

Comparison of 3D free-breathing coronary MR angiography and 64-MDCT angiography for detection of coronary stenosis in patients with high calcium scores.

OBJECTIVE: The objective of our study was to compare the diagnostic performance of coronary MR angiography (MRA) and 64-MDCT angiography (MDCTA) for the detection of significant stenosis (> or = 50%) in patients with high calcium scores. MATERIALS AND METHODS: Eighteen patients (12 men, six women; mean age, 56 y; age range, 38-77 y) who had at least one calcified plaque with a calcium score of > 100 underwent coronary MRA and conventional coronary angiography (CAG) within 2 weeks of MDCTA. Coronary MRA image quality of the calcified segments was assessed by two observers in consensus on a 4-point scale (1 = not visible, 2 = poor, 3 = good, 4 = excellent) using a 10-segment model from the modified American Heart Association classification. Three experienced radiologists, unaware of the results of conventional CAG, independently assessed for the presence of significant stenosis on MDCTA images and the corresponding MRA images. Receiver operating characteristic (ROC) curves were calculated for each reader using conventional CAG as the gold standard. RESULTS: Thirty-three calcified plaques with a calcium score of > 100 were detected on MDCTA in the 18 patients. The coronary segments with nodal calcification (n = 17) showed a higher mean image quality score than the segments with diffuse calcification (n = 16) (3.47 +/- 0.62 vs 2.94 +/- 0.77, respectively; p < 0.05). Of the 33 coronary segments with calcification, 12 significant stenoses were identified on conventional CAG. The sensitivity, specificity, and area under the ROC curve (AUC) for MRA and MDCTA, respectively, were as follows: reader 1, 75%, 81%, 0.82 versus 75%, 48%, 0.68; reader 2, 83%, 71%, 0.82 versus 67%, 52%, 0.63; and reader 3, 83%, 71%, 0.85 versus 83%, 43%, 0.65, respectively. The average AUC of MRA for the three readers was significantly higher than that of MDCTA (p = 0.030). CONCLUSION: Coronary MRA has higher image quality for coronary segments with nodal calcification than for coronary segments with diffuse calcification. Coronary MRA has better diagnostic performance than coronary MDCTA for the detection of significant stenosis in patients with high calcium scores.

Transversus abdominis plane block: a cadaveric and radiological evaluation.

BACKGROUND AND OBJECTIVES: The abdominal wall is a significant source of pain after abdominal surgery. Anterior abdominal wall analgesia may assist in improving postoperative analgesia. We have recently described a novel approach to block the abdominal wall neural afferents via the bilateral lumbar triangles of Petit, which we have termed a transversus abdominis plane block. The clinical efficacy of the transversus abdominis plane block has recently been demonstrated in a randomized controlled clinical trial of adults undergoing abdominal surgery. METHODS: After institutional review board approval, anatomic studies were conducted to determine the deposition and spread of methylene blue injected into the transversus abdominis plane via the triangles of Petit. Computerized tomographic and magnetic resonance imaging studies were then conducted in volunteers to ascertain the deposition and time course of spread of solution within the transversus abdominis fascial plane in vivo. RESULTS: Cadaveric studies demonstrated that the injection of methylene blue via the triangle of Petit using the "double pop" technique results in reliable deposition into the transversus abdominis plane. In volunteers, the injection of local anesthetic and contrast produced a reliable sensory block, and demonstrated deposition throughout the transversus abdominis plane. The sensory block produced by lidocaine 0.5% extended from T7 to L1, and receded over 4 to 6 hours, and this finding was supported by magnetic resonance imaging studies that showed a gradual reduction in contrast in the transversus abdominis plane over time. CONCLUSIONS: These findings define the anatomic characteristics of the transversus abdominis plane block, and underline the clinical potential of this novel block.

Use of provocative angiography to localize site in recurrent gastrointestinal bleeding.

BACKGROUND: While the source of most cases of lower gastrointestinal bleeding may be diagnosed with modern radiological and endoscopic techniques, approximately 5% of patients remain who have negative endoscopic and radiological investigations [1]. CLINICAL PROBLEM: These patients require repeated hospital admissions and blood transfusions, and may proceed to exploratory laparotomy and intraoperative endoscopy. The personal and financial costs are significant. METHOD OF DIAGNOSIS AND DECISION MAKING: The technique of adding pharmacologic agents (anticoagulants, vasodilators, fibrinolytics) during standard angiographic protocols to induce a prohemorrhagic state is termed provocative angiography. It is best employed when significant bleeding would otherwise necessitate emergency surgery. TREATMENT: This practice frequently identifies a bleeding source (reported success rates range from 29 to 80%), which may then be treated at the same session. We report the case of a patient with chronic lower gastrointestinal hemorrhage with consistently negative endoscopic and radiological workup, who had an occult source of bleeding identified only after a provocative angiographic protocol was instituted, and who underwent succeeding therapeutic coil embolization of the bleeding vessel.

Initial clinical experience using the Amplatzer Vascular Plug.

BACKGROUND AND PURPOSE: The Amplatzer Vascular Plug (AVP) is a self-expanding nitinol wire mesh vascular embolization device derived from the Amplatz septal occluder. We assessed the results of vascular embolization obtained using the AVP. METHODS: A retrospective review was carried out of 23 consecutive cases of vascular embolization using the AVP in a variety of different clinical settings. The AVP was chosen to have a diameter approximately 30-50% greater than the target vessel. The device was delivered via an appropriately sized guide catheter and was released when satisfactorily positioned. Additional embolic agents were used in some cases. RESULTS: All target vessels were successfully occluded with no device malpositioning or malfunction. In 14 (61%) patients the AVP was the sole embolic material. In the remaining patients additional agents were used, particularly in preoperative embolization of highly vascular renal tumors. The AVP does not cause instantaneous thrombosis and in high-flow situations thrombosis typically takes up to 15 min. CONCLUSION: The AVP is a safe, effective embolization device that provides a useful adjunct to the therapeutic armamentarium. It is particularly suited to the treatment of short high-flow vessels where coil migration and catheter dislodgment might occur. In the majority of cases no additional embolic agents are necessary but it may take up to 15 min for complete thrombosis to occur.