Bilateral Pretibial Varices with Intraosseous Venous Drainage Anomaly: A Case Report.

We report the case of a 35-year-old male patient who complained of right anteromedial leg pain, after an intensive sport exercise. At physical examination, internal pretibial soft tissue swelling containing prominent painful varices was found. Color Doppler ultrasound, radiographic examinations, followed by CT and MR complementary investigation, were performed.

Fibrous pseudotumor of the tunica vaginalis: contrast enhanced sonography with pathologic correlation.

We report the case of a 28-year-old man who presented at the emergency department with recent left painful scrotal swelling, without history of genitourinary infection or trauma. On physical examination, left scrotal swelling with nodular palpation was noted. Contrast enhanced sonography demonstrated nodular vascularized thickening of the tunica vaginalis. Surgical exploration revealed multiples solid nodules of the vaginal wall, with, at frozen section analysis, fibroblastic tissue, vessels and chronic inflammation without malignity, suggestive of fibrous pseudotumor of the tunica vaginalis. We discuss the sonographic aspect of this rare entity and the difficulty to establish a diagno- sis of benignity without surgical exploration.

Soft tissue chondroma of Hoffa's fat pad.

We report mutimodal imaging findings of an extraskeletal chondroma of the Hoffa's fat pad. Plain radiographic or CT scan studies demonstrate a large soft tissue mass with calcifications and central ossification, characteristic features of these tumors. Magnetic resonance (MR) imaging shows heterogeneous signal due to polymorphic histopathological appearance. Correlation between MR imaging and plain film or CT findings is essential to restrict differential diagnosis. The knowledge of this particular pathology is the key to the diagnosis.

Update on abdominal imaging: contrast enhanced ultrasonography.

Contrast enhanced ultrasonography (CEUS) is a new imaging modality offering new perspectives in the management of abdominal disease. The objectives of this review are to expose briefly principles of CEUS signal acquisition, to illustrate second generation of contrast agent signal, to give a short overview of current clinical applications of CEUS, and to discuss CEUS feasibility.

T.I.P.S.: follow-up imaging and revision procedure.

TIPS patency can be assessed by different imaging techniques: angiography, color Doppler sonography, CT angiography, scintigraphy. Percutaneous angiography with measurement of the portocaval pressure gradient is the gold standard in the diagnosis of shunt failure, but, because its invasive nature and the necessity of frequent control of the shunt function, a noninvasive procedure is preferable for routine checkup. Color Doppler sonography in intervals of 3 to 6 months, with the use of different criteria, is considered as an accurate imaging technique with a high degree of sensitivity and specificity to evaluate TIPS patency. Angiography is indicated when CDS is not successful or in each clinical recurrence. Revision procedure may restore shunt efficiency and is indicated when the TIPS patency is compromised.

Pseudo-occlusion of the external iliac artery after stenting.

A patient with an unknown thoracic aortic coarctation underwent angiography for calf claudication. Percutaneous angioplasty and stenting of an external iliac artery (EIA) stenosis produced flow reversal in the EIA, mimicking occlusion on the angiogram. This aberrant situation resulted from a haemodynamic disbalance between the iliac flow and a dominant compensatory collateral flow through the inferior mammary-epigastric channel produced by the coarctation.

Guidelines to laparoscopic management of acute cholecystitis.

OBJECTIVE: The present work aims at identifying preoperative variables that may help the surgeon choosing the most appropriate operative approach in various clinical presentation of acute cholecystitis. SUMMARY BACKGROUND DATA: Conversion rates up to 60% have been reported for laparoscopic management of acute cholecystitis. Previous works indicate that the severity of the gallbladder inflammatory process represents the main cause of laparoscopic conversion. The influence of converting a laparoscopic cholecystectomy for acute cholecystitis to open surgery on the post-operative course remains questionable. Objective preoperative variables correlated to the severity of cholecystitis and predictive of laparoscopic cholecystectomy failure remain to be identified. METHODS: Seven preoperative and five post-operative variables were compared among a continuous series of 62 patients operated for acute cholecystitis either by a successful laparoscopic procedure (37 patients) or by a laparoscopic procedure converted to open surgery (14 patients) or directly by open surgery (11 patients). The post-operative outcome of patients in the 3 groups were compared. Determinant preoperative factors correlated with the need to convert a laparoscopic procedure were searched by the CHI square test for independance and by a multivariate logistic regression analysis. RESULTS: Converting a laparoscopic cholecystectomy for acute cholecystitis to open surgery does not worsen the patients early post-operative course as long as conversion is decided rapidly and before peroperative complications arise. Three preoperative independent variables predictive of the need to convert a laparoscopic cholecystectomy for acute cholecystitis were identified: The thickness of the gallbladder wall, preoperative C reactive protein seric levels and finally the delay between the start of acute symptoms of cholecystitis and surgery. CONCLUSIONS: The post-operative outcome of patients operated for acute cholecystitis depends more on the severity of the disease than on the type of the surgical procedure. Patients with a perforated cholecystitis (grade III) should better be handled immediately by open surgery. Patients with acute edematous cholecystitis (grade I) or with empyema or gangrenous cholecystitis (grade II) coming early to surgery (within 72 hrs) and having seric preoperative CRP levels less than 10 mg/% represent the best candidates to laparoscopic surgery.

[Arterial hypertension of renovascular origin. The value of color Doppler ultrasonography in the detection of stenosis of the renal artery]. / Hypertension artérielle d'origine réno-vasculaire. Intérêt de l'echographie Doppler couleur dans la détection d'une sténose de l'artère rénale.

Color Doppler sonography is a performant method to detect direct signs of renal artery stenosis with a feasibility rate superior to 90%. The reliability of the method, evaluated with regard to the angiography as reference method, varies, according to the authors, between 80 and 90% with a sensitivity and a specificity between 85-90%. The investigation is above all dedicated to a population where prevalence of renal artery stenosis is high: hypertensive patient with lower limb arteriopathy, or with impairing of the renal function under angiotensin convertase inhibitor, or with hypertension resistant to a multi-therapy, young woman hypertension. The success of the method requires a trained operator, a modern equipment and a precise methodology: a fasting patient, patient positioning adapted to the spectral signal recording, peak velocity measurements at the anatomical sites of stenosis (ostium, first centimeters). Investigation length does not exceed 20 minutes. The exploration is totally atraumatic and does not require any contrast injection.

Transjugular intrahepatic portosystemic shunt after adult liver transplantation: experience in eight patients.

BACKGROUND: Transjugular intrahepatic portosystemic shunting (TIPS) has become an effective treatment for the complications of portal hypertension. We assessed the feasibility and outcome of TIPS in liver transplant recipients. METHODS: During the period from December 1992 to January 1998, eight adults presenting recurrent hepatitis C virus (five patients) and hepatitis B virus (one patient) infection, veno-occlusive disease (one patient), and secondary biliary cirrhosis (one patient) had TIPS because of refractory ascites (five patients), bleeding esophageal varices (one patient), refractory hepatic hydrothorax (one patient), retransplantation (two patients), and redo-biliary surgery (one patient). RESULTS: In two patients, the procedure was difficult due to cavo-caval implantation. Ascites, hydrothorax, and variceal bleeding were controlled in all patients. Moderate to severe encephalopathy developed in four patients; two patients had worsening of their existing encephalopathy. Three of five patients treated with cyclosporine needed a drastic dose reduction due to the development of severe side effects. No long-term survivor developed shunt stenosis or occlusion. Two patients did moderately well at 6 and 14 months, respectively; the former died due to chronic rejection while waiting for a retransplantation. Three did well at 14, 36, and 28 months, respectively; the latter patient died of liver failure 32 months after TIPS. One jaundiced patient died after 1.5 months due to necrotic pancreatitis. Two patients died after 4 and 8.5 months, respectively, due to liver failure; the latter was doing well until 7 months after TIPS. CONCLUSIONS: TIPS is feasible in transplant recipients in cases of decompensated allograft cirrhosis, of allograft veno-occlusive disease or when retransplantation or redo-biliary surgery are scheduled in the presence of portal hypertension. At transplantation, the surgeon should keep in mind the eventuality of a later TIPS procedure. Close immunosuppression monitoring is warranted because modified metabolization of cyclosporine (and probably tacrolimus) may cause serious side effects.

Living-related liver transplantation: is Doppler sonography sufficient to define the hepatic artery anatomy before surgery?

OBJECTIVE: to evaluate the accuracy of colour Doppler sonography (CDS) in the assessment of the left hepatic arterial supply in living donors before hepatic transplantation. MATERIAL AND METHODS: Pre-operative sonographic Doppler data of the left hepatic artery (LHA) were compared retrospectively with the selective hepatic angiographic data and the intra-operative observations in 60 living donors. RESULTS: Pre-operative Doppler data of the LHA were available in 53 cases and incomplete or absent in seven cases. In 51 cases (96%) the origin of the LHA or an accessory LHA were correctly described at Doppler sonography (44 classical LHA in anatomic position, seven accessory LHA). In 11 cases (21%), Doppler data were insufficient or incorrect to define the arterial supply of the hepatic segments II, III and IV. Doppler studies were unable to determine the length or the diameter of the LHA. CONCLUSION: Doppler sonography seems to be able to define the main left hepatic artery anatomy. Selective hepatic angiography is still indicated to determine the length, diameter and intra-hepatic segmental supply.

Diabetes: the use of color Doppler sonography for the assessment of vascular complications.

The use of color Doppler sonography (CDS) in the assessment of diabetic vascular complications is not yet well established. Among the complications of the disease, retinopathy, nephropathy and peripheral arteriopathy are classically due to a vascular attack, either a micro or a macroangiopathy. The results of CDS in the assessment of retinopathy and nephropathy are correlated with the degree of the disease and the biological findings, but the diagnostic and prognostic benefit of these results remains unclear compared to the conventional tests. Doppler sonography is more helpful in peripheral arteriopathy assessment; it may take the place of arteriography in the most clinical situations. The technique is particularly useful in case of proximal atheromatous-like arteriopathy. When the arteriopathy is distal, mediacalcinosis, specific to diabetes, may interfere with the functional test like the ankle/arm pressure index measurement.

Color Doppler sonography of the temporal arteries in giant cell arteritis and polymyalgia rheumatica.

OBJECTIVE: To test the diagnostic value of color Doppler sonography (CDS) of the superficial temporal arteries in patients suffering from giant cell arteritis (GCA). METHODS: The superficial temporal arteries and their frontal and parietal rami were examined by CDS in 11 patients with GCA, 21 patients with polymyalgia rheumatica (PMR), and 32 controls. The peak systolic velocity (Vmax) was measured at the tragus (proximal superficial temporal artery) and at the temporal bone (distal superficial temporal artery) level. Hypoechoic thickening of the vessel wall was systematically searched for. RESULTS: Mean Vmax in the proximal and distal superficial temporal artery was considerably lower in the GCA group [mean (+/- SEM) 30.9 (+/- 5.6) mm/s proximally and 5.8 (+/- 3.7) mm/s distally] compared to the PMR group [mean (+/- SEM) 64.6 (+/- 3.8) mm/s proximally and 49.3 (+/- 4.2) mm/s distally] and the control group [mean (+/- SEM) 56.9 (+/- 2.2) mm/s proximally and 42.6 (+/- 2.2) distally]. Thickening of the vessel wall was found in only 2 patients: one with GCA and one with PMR. Followup of CDS in 6 GCA patients under treatment produced evidence of a significant increase in the mean Vmax at the distal site. CONCLUSION: Decreased blood flow velocity in the superficial temporal artery is very common in GCA patients and rare in PMR patients. Therefore, CDS examination may contribute to the diagnosis of GCA.

Adult liver transplantation and abnormalities of splanchnic veins: experience in 53 patients.

The aim of this study was to analyze the influence of technical problems resulting from splanchnic venous anomalies on the outcome of orthotopic liver transplantation. From February 1984 until December 1995, 53 (16.3%) of 326 adults underwent consecutive transplantations whilst having acquired anomalies of the splanchnic veins. These consisted of portal vein thrombosis (n = 32, 9.8%), thrombosis with inflammatory venous changes (phlebitis; n = 6, 1.8%) and alterations related to portal hypertension surgery (n = 15, 4.6%). Because of major changes in surgical technique, i.e., eversion instead of blind venous thrombectomy, immediate superior mesenteric vein approach in cases of extended thrombosis, and piggyback implantation with preservation instead of removal of the inferior vena cava, patients were divided into two groups: those who underwent transplantation during the period February 1984 to December 1990 (group 1) and those transplanted between January 1991 and December 1995 (group 2). Surgical procedures to overcome the anomalies consisted of venous thrombectomy (n = 26), implantation of the donor portal vein at the splenomesenteric confluence (n = 5) or onto a splenic (n = 1) or ileal varix (n = 1), interposition of a free iliac venous graft between recipient superior mesenteric vein and donor portal vein (n = 9), and interruption of surgical portosystemic shunt (n = 13). All patients had a complete follow-up. The 1- and 5-year actuarial patient survival rates were similar in patients with (n = 53) and without (n = 273) splanchnic venous abnormalities (75.5% vs 78.1% and 64.3% vs 66.9%, respectively). Early (< 3 months) post-transplant mortality was 24.5% (13/53 patients). Mortality was highest in the portal vein thrombophlebitis group (5/6, 83.3%), followed by the portal hypertension surgery group (5/15, 33.3%) and the portal vein thrombosis group (3/32, 9.4%). Technical modifications significantly reduced mortality in group 2 (10.3%, 3/29 vs 41.7%, 10/24 patients in group 1; P < 0.05) as well as the need for re-exploration for bleeding (13.8%, 4/29 patients in group 2 vs 15/24, 62.5% in group 1; P < 0.01). Mortality directly related to bleeding was also significantly lowered (1/29, 3.4% in group 2 vs 9/ 24, 37.5% in group 1; P < 0.01). We conclude that liver transplantation can be safely performed in the presence of splanchnic vein thrombosis and previous portal hypertension surgery.

[Follow-up of TIPS: evaluation of signs of dysfunction with Doppler ultrasonography]. / Suivi des TIPS: evaluation des signes de dysfonctionnement en echographie doppler.

PURPOSE: to assess the signs of TIPS dysfunction at Doppler sonography. MATERIALS AND METHODS: retrospective study of signs observed in 106 TIPS including 31 TIPS with dysfunction (portoauricular pressure gradient > 12 mmHg). RESULTS: the signs of TIPS dysfunction were a decrease in the mean velocity in the TIPS (for a velocity < 40 cm/sec, 90% sensitivity, 96%), a hepatopetal intrahepatic portal flow (on the right 90% sensitivity, 100% specificity, on the left 95% sensitivity, 92% specificity), a lack of cardiac modulation of the signal in the TIPS (93% sensitivity, 65% specificity), a hepatic vein flow reversal (30% sensitivity, 100% specificity), and, the only direct sign of stenosis, an increase of the mean velocity in the stenosis (42% sensitivity, 95% specificity for a velocity > or = 1 m/sec). CONCLUSION: the most sensitive Doppler signs of tips dysfunction are the indirect signs of stenosis.

Colour Doppler imaging of an ascending pharyngeal artery arising from the internal carotid artery.

We present two cases of an extracranial collateral of the internal carotid artery. The descriptions include Doppler recording and colour flow-mapping. The report underlines the epidemiological, embryological and anatomic features (including Doppler characteristics) of the variant, with a view to helping sonographers whenever the carotid examination proves difficult.

Transjugular intrahepatic portosystemic shunt and liver transplantation.

Transjugular intrahepatic portosystemic stent shunting (TIPSS) appears to be an attractive, nonsurgical procedure to overcome complications of end-stage liver disease. During the period August 1992 to February 1995, 23 adults who had previously undergone TIPSS received liver transplants. These patients were compared to 36 cirrhotic patients, grafted during the same time period, in relation to the implantation technique, the intraoperative use of blood products, and the length of their hospital stay. These groups were comparable for previous right upper quadrant surgery, splanchnic vein modifications, and Child-Pugh classification. Liver transplantation was performed electively in all TIPSS patients. Ten patients (43.4%) presented with a significant shunt stenosis at a median follow-up time of 4.5 months (range 2.5 to 30 months). At transplantation 8 of the 23 TIPSS patients (34.8%) had specific TIPSS-related modifications i.e., extrahepatic portal vein aneurysm formation (n = 2), dislocation of the distal end of the stent into the inferior vena cava (n = 4) or into the main portal vein trunk (n = 1), bilioportal fistula (n = 1), and pronounced phlebitis of the inferior vena cava and hepatic veins due to redilation of shunt stenosis (n = 4). The intraoperative blood product requirement at transplantation was similar in the 23 TIPSS-patients and in the 36 cirrhotic patients who received transplants without the TIPSS procedure during the same time period [median 800 ml (range 0-20300 ml) vs median 620 ml (range 0-7600 ml), respectively]. There was also no difference between the two groups in length of hospital stay [median 18 days (range 0-34 days) vs median 19 days (range 0-66 days), respectively]. We conclude that TIPSS plays an important role in the management of life-threatening complications of end-stage liver disease arising in potential liver transplant candidates. TIPSS should be considered as a temporary, effective bridge to elective transplantation and not as a means to lower the blood product requirement at transplantation. Specific TIPSS-related modifications should be recognized early by the transplant surgeon in order to adapt the technique of graft implantation.

[2 cases of giant aneurysm of the splenic artery: contribution of Doppler echography]. / Deux cas d'anévrisme géant de l'artère splénique: apports de l'écho-Doppler.

Excluding the extremely uncommon cases of completely thrombosed aneurysm, color Doppler US plays a leading part in establishing the diagnosis of splenic artery aneurysm. The color Doppler US patterns are typical, as illustrated in the two reported cases of splenic artery aneurysm larger than 5.0 cm.