The basilic vein and the cephalic vein perform equally in upper arm arteriovenous fistulae.

OBJECTIVE: To compare the brachiocephalic (BC) and basilic vein transposition (BVT) arteriovenous fistula (AVF) with regard to maturation, patency, blood flow and complication rates. DESIGN: A retrospective chart review. MATERIALS AND METHOD: Between January 2000 and December 2010, consecutive patients undergoing BC or BVT AVF were included. Patient characteristics were collected retrospectively from digital patient files and a prospective database of haemodialysis patients. RESULTS: A total of 173 autologous upper arm AVFs (87 BC and 86 BVT) were created in 151 patients. Mean (±SEM) follow-up was 19 ± 1.4 months (range 0-100). There were no differences between the groups in respect to brachial artery and cubital fossa vein diameters, time to first use, flow and the number of secondary interventions. Operative time was significantly longer (P < 0.001) and the mid upper arm vein diameter before bifurcation greater (P = 0.038) in BVT patients. The 1- and 2-year primary patency rates for the whole cohort was 40.8% and 30.2% with secondary patency rates of 78.0% and 72.4%. There was no difference between the groups for these outcomes (P = 0.951, P = 0.516, respectively). CONCLUSION: With the exception of the efferent vein diameter in the mid upper arm and operative time, there was no difference between a BC and BVT AVF.

Perforating veins: an anatomical approach to arteriovenous fistula performance in the forearm.

OBJECTIVES: Arteriovenous fistulae (AVFs) play a key role for people who rely on chronic haemodialysis. Stenosis in the venous outflow of the AVF will cause an alternative route of the subcutaneous blood flow via the deeper venous pathways by means of side branches and the perforating veins (PVs). The purpose for the present study was to define the number and anatomical localisation of the perforating veins in the forearm. METHODS: Twenty forearms were dissected to study the venous anatomy. The localisation, size and connections of the perforators were recorded and stored digitally. RESULTS: In total, 189 PVs were defined (mean, 9.5 per arm; range, 6-19), with 60 (32%) PVs connected to the cephalic vein, 97 (51%) connections to the basilic vein and 32 (17%) PVs to the median vein of the forearm. Most PVs originate from the basilic vein and connect with the ulnar venae comitans. The cephalic vein connects equally to the radial venae comitans, interossea veins and the muscles. CONCLUSION: The cephalic vein has the fewest PVs and almost a third of them connect to the muscles. This is probably important for the maturation of the AVF, the superficial flow volume and the accessibility for puncture.

Multi-slice computed tomographic angiography for stenosis detection in forearm hemodialysis arteriovenous fistulas.

PURPOSE: A method of diagnosing the extent and severity of arteriovenous fistula (AVF) stenoses is multislice computed tomographic angiography (MS-CTA). The aim of this prospective study was to assess the accuracy of MS-CTA for the detection and grading of stenoses in AVF in comparison to digital subtraction angiography (DSA), which was used as the gold standard of reference. METHODS: Fifteen hemodialysis (HD) patients with dysfunctioning forearm AVF were included. These AVFs were evaluated by both DSA and MS-CTA and were read in a prospective, blinded manner by two radiologists experienced in vascular imaging. RESULTS: ROC analysis revealed areas under the curve of 0.90+/-0.07 for observer I and 0.87+/-0.08 for observer II at a stenosis cut-off level of >or=50% diameter reduction. The combined results for MS-CTA showed sensitivity, specificity and positive and negative predictive values of 82%, 98%, 82% and 98% for stenoses>or=50% and 71%, 99%, 77% and 98% for stenoses>or=75%. Inter-observer agreement for the detection of stenoses>or=50% diameter reduction was 0.70 and 1.0, for MS-CTA and DSA, respectively. CONCLUSION: MS-CTA can provide good visualization of forearm HD access AVF and has moderate sensitivity, but high specificity for the detection of flow-limiting stenoses.

Increased anticoagulation during cardiopulmonary bypass by aprotinin.

In this prospective study, the effect of the antiproteinase aprotinin on anticoagulation during cardiopulmonary bypass was compared with placebo treatment in a randomized double-blind fashion. The kallikrein-inhibiting capacity was significantly increased in aprotinin-treated patients and decreased in the control patients. The intrinsic clotting system was also inhibited by aprotinin. We demonstrated during cardiopulmonary bypass and in vitro a significantly prolonged activated clotting time and a remarkable prolongation of the activated partial thromboplastin time by aprotinin at low heparin concentrations, whereas the antithrombin III consumption was significantly reduced. Aprotinin synergistically enhanced the anticoagulation by heparin, which allowed reduced heparinization. This is of clinical importance for use in both heparin-resistant and heparin-sensitive patients undergoing cardiopulmonary bypass and may also have advantages for routine use during bypass to reduce the adverse effects of heparin-protamine complexes.

A radiographic model for simulating rheumatoid erosions.

Lesions were mechanically created in bone specimens to find a radiographic model for skeletal disease. Drilling, sawing, and filing of the bones did not satisfactorily simulate skeletal pathology. Chipping of the juxta-articular cortex resulted in cortical defects that closely resemble rheumatoid erosions. The radiographs of 25 patients with rheumatoid arthritis were reviewed using optical magnification to determine the size and distribution of actual rheumatoid erosions. Using the pattern of erosions in the patient population, lesions can be distributed in varying sizes to produce a radiographic model for rheumatoid erosions. This model can be used for observer performance studies and to evaluate imaging technology.

Collagen-induced arthritis in rats. Assessment by serial magnification radiography.

Serial whole body and lateral hindpaw magnification radiographs were obtained on 15 rats with collagen-induced arthritis. The radiographs were evaluated for findings of inflammatory arthritis. Soft tissue swelling and juxta-articular osteopenia usually developed two weeks after immunization. The swelling remained stable for the remaining seven weeks of the study, but the osteopenia apparently improved. Three weeks after immunization, erosions and periostitis began to develop in ten of the rats. These latter radiographic changes rapidly worsened over the next three weeks and then stabilized. The most frequent and severe changes were seen in the intertarsal, tibiotalar, and metatarsophalangeal joints. The toes, forepaws, and knees were infrequently involved. Other peripheral joints and the axial skeleton were spared. Five rats developed soft tissue swelling but had no articular erosions or periostitis. Serial radiography has potential usefulness for monitoring the effects of treatment in this experimental model for inflammatory arthritis.

Comparison of two detail screen-film systems using a rheumatoid erosion model.

Two detail screen-film systems, Lanex Fine/Ortho M and Lanex Fine/Ortho G, were evaluated using a radiographic model for rheumatoid erosions. Radiographs of hand bones with cortical defects using both screen-film systems were obtained. Seven observers analyzed 48 sites on each of 22 films for the presence of these cortical defects. Using analysis of variance techniques and receiver operating characteristic curves, no significant difference was found between the two systems for the detection of these subtle cortical defects. The authors conclude that although the Lanex Fine/Ortho M system provides better definition of laboratory test objects than Lanex Fine/Ortho G, the two systems do not differ when used for detection of cortical lesions.

A method for minimizing the radiation exposure from scoliosis radiographs.

The radiation exposure resulting from standard scoliosis radiographs was determined for eighteen adolescent girls. The risk of inducing breast cancer was estimated from the skin-exposure doses. The average skin exposure to the breasts was 59.6 millirads (0.59 mGy) for the anteroposterior radiograph. Assuming a total of twenty-two anteroposterior radiographs during a course of treatment, the cumulative exposure would result in a 1.35% relative increase in the risk of development of breast cancer. By utilizing collimation of the x-ray beam and proper selection of grids, films, and screens, the radiation risk of scoliosis radiographs is minimized.

MR of the postoperative knee.

There have been multiple recent refinements in the arthroscopic techniques of meniscal surgery and anterior cruciate ligament (ACL) reconstruction, and these are now allowing many postoperative patients to resume an active lifestyle. A result is an increasing number of postoperative patients who are referred for a magnetic resonance (MR) scan of the knee because of a recurrent injury. In this article, we will discuss some of the MR findings of retorn menisci and the role of MR arthrography. We will also review the changes that occur in the MR appearance of the ACL graft during the first year after surgery, and its effect on the accuracy of diagnosing graft tears. The MR findings after other less common knee procedures will also be described.

Three-dimensional analysis of right thoracic idiopathic scoliosis.

Three-dimensional spinal analysis was performed on thirty-one female patients with untreated right thoracic idiopathic scoliosis to determine the relationship between the degree of scoliosis and the degree of kyphosis, maximal curvature, and apical vertebral displacement. The degree of scoliosis did not correlate with the degree of thoracic kyphosis. Six patients had thoracic kyphosis over 50 degrees, 19 patients had a kyphosis between 20-50 degrees, and the last six patients had a thoracic kyphosis less than 20 degrees. The apex of the scoliosis was at or below the apex of the thoracic kyphosis in all patients except one. The degree of displacement of the apical vertebrae had a positive correlation (r = 0.732) with the degree of scoliosis. The maximal curvature of the spine was correlated (r = 0.613) with the degree of scoliosis.

Magnetic resonance imaging of Achilles tendon ruptures.

Preoperative magnetic resonance images of three acute Achilles tendon ruptures were correlated with the findings observed during surgical repair of the tendon. Specific comparisons were made regarding the condition (shredded, uniform, etc.) and orientation (antegrade, retrograde, etc.) of the torn fibers, and the width of the diastasis (with and without ankle flexion) between the ends of the tendon. Magnetic resonance imaging (MRI) accurately assessed all of these parameters.

"Bone bruises" on magnetic resonance imaging evaluation of anterior cruciate ligament injuries.

Magnetic resonance imaging of the knees of 98 consecutive patients with clinically diagnosed anterior cruciate ligament injuries revealed 47 patients (48%) with focal signal abnormalities consistent with the diagnosis of a "bone bruise." Seventy-one percent of the magnetic resonance images taken within 6 weeks of injury demonstrated a bone bruise, whereas no scans done longer than 6 weeks after injury showed a bruise (P < 0.0001). Also significant was the tendency for lesions to be located in the lateral compartment (P < 0.0001). In the sagittal plane, lesions were most likely to be in the middle third of the lateral femoral condyle and the posterior third of the lateral tibial plateau (P < 0.0001). In 31 patients evaluated arthroscopically, there was no correlation between the presence or location of a bone bruise and articular alterations or meniscal tears observed at surgery.

"Dem bones": osteochondral injuries of the knee.

MR imaging plays a valuable role in the diagnosis and staging of osteochondral injuries of the femorotibial joint. Bone contusions may be the source of a patient's pain, and MR imaging characteristics of certain types may help to predict which contusions might progress to more serious osteochondral lesions. MR imaging also is vital in the diagnosis of occult osteochondral fractures and in accurately classifying displaced intra-articular fractures. Although osteochondral dissecans usually is diagnosed radiographically, MR imaging is the best noninvasive test for determining if an osteochondral fragment is unstable. Unstable lesions are a treatable cause of knee pain.

Evaluating painful osteopenia in the elderly.

Osteopenia is a frequent finding on radiographs of elderly patients. When the exam is performed for skeletal pain, this finding may be significant. The differential diagnosis for osteopenia is extensive, but individualizing the patient work-up begins with a careful clinical history and laboratory studies. Appropriate radiographic exams can then be requested. A plain radiograph is always the starting point, followed by--as indicated--a nuclear bone scan, computed tomography, and magnetic resonance imaging.

The hypothenar hammer syndrome: update and literature review.

The hypothenar hammer syndrome is a rather rare vascular injury. It is seen in posttraumatic digital ischaemia caused by irregularity or occlusion of the distal ulnar artery at the level of the hamate bone. It characteristically occurs in the dominant hand of middle-aged men whose occupational or recreational activities require the use of the hand as a hammer. Three typical cases are presented along with literature review. The different aspects of this syndrome are described such as the cause and pathogenesis, the most important clinical characteristics and differential diagnosis, the role of angiography and Doppler mapping in establishing the diagnosis and the various therapeutic options, ranging from conservative treatment to resection of the thrombosed artery segment with vein graft interposition.