Preoperative portal vein or portal and hepatic vein embolization: DRAGON collaborative group analysis.

BACKGROUND: The extent of liver resection for tumours is limited by the expected functional reserve of the future liver remnant (FRL), so hypertrophy may be induced by portal vein embolization (PVE), taking 6 weeks or longer for growth. This study assessed the hypothesis that simultaneous embolization of portal and hepatic veins (PVE/HVE) accelerates hypertrophy and improves resectability. METHODS: All centres of the international DRAGON trials study collaborative were asked to provide data on patients who had PVE/HVE or PVE on 2016-2019 (more than 5 PVE/HVE procedures was a requirement). Liver volumetry was performed using OsiriX MD software. Multivariable analysis was performed for the endpoints of resectability rate, FLR hypertrophy and major complications using receiver operating characteristic (ROC) statistics, regression, and Kaplan-Meier analysis. RESULTS: In total, 39 patients had undergone PVE/HVE and 160 had PVE alone. The PVE/HVE group had better hypertrophy than the PVE group (59 versus 48 per cent respectively; P = 0.020) and resectability (90 versus 68 per cent; P = 0.007). Major complications (26 versus 34 per cent; P = 0.550) and 90-day mortality (3 versus 16 per cent respectively, P = 0.065) were comparable. Multivariable analysis confirmed that these effects were independent of confounders. CONCLUSION: PVE/HVE achieved better FLR hypertrophy and resectability than PVE in this collaborative experience.

[Paradigm shifts in the treatment of venous thrombosis of the lower limbs : are we moving forward or backward?] / Les changements de paradigme dans le traitement des thromboses veineuses des membres inférieurs : on avance ou on recule ?

The radiological treatment of post-thrombotic syndrome (PTS), complicating venous obstruction of the lower limbs is described. Results obtained by the evolving techniques are discussed.

Les traitements radiologiques du syndrome post-thrombotique (SPT) des obstructions veineuses des membres inférieurs sont décrits. Les résultats obtenus au fil de leur développement technique sont discutés.

Percutaneous sclerotherapy of a giant mediastinal lymphangioma.

The present study reports a case of percutaneous sclerotherapy of a giant mediastinal cystic lymphangioma using Ethibloc (Ethicon, Norderstedt, Germany) and absolute ethanol in a 59-yr-old female. The tumour, situated predominantly in a retrocardiac location, caused dyspnoea and dysphagia by compression and was considered unresectable. Follow-up computed tomography 3 yrs after treatment showed a 90% volume reduction of the tumour. The patient is currently asymptomatic. To the best of the present authors' knowledge, percutaneous transthoracic sclerotherapy of a mediastinal lymphangioma has not previously been reported in the literature available in English.

[Hemobilia]. / L'hemobilie.

Hemobilia or hematobilia is defined by bleeding inside the bile duct. Although rare and misunderstood, it may evolve a life-threatening condition and its frequency is increasing. Clinical presentation commonly includes upper gastrointestinal bleeding, biliary colic and jaundice. The diagnosis must be suggested in a patient with a history of hepatic surgery, trauma or invasive biliary intervention. Key investigation is selective angiogram which allows us to confirm the diagnosis, locate and in most cases treat the vascular lesion responsible of hemobilia. Surgery should remain limited to extra-hepatic or gallbladder bleeding and in case of a failure of intra-vascular embolization.

[Clinical case of the month. Nutcracker syndrome in association with a painful nephrologic disease]. / Le cas clinique du mois. L'anatomie au secours des cliniciens face à une douleur répétitive abdominale: le syndrome de la pince aorto-mésentérique.

Compression of the left renal vein between the aorta and the superior mesenteric artery causes a physiological condition, the so-called nutcracker phenomenon, but it can sometimes lead to left venous hypertension, or "nutcracker syndrome". Classical manifestations of which are an association of left flank pain, unilateral proteinuria and unilateral hematuria, without renal impairment. We report an atypical association of nutcracker syndrome with IgM nephropathy.

Evaluation of CT time-density curves of lower-limb veins.

UNLABELLED: Szapiro D, Ghaye B, Willems V, et al. Evaluation of CT time-density curves of lower-limb veins. Invest Radiol 2001;36:164-169. RATIONALE AND OBJECTIVES: To evaluate time-density curves of the lower-limb veins for optimization of CT venography. METHODS: Fifty patients referred for chest CT were randomized into five equal groups. Five anatomic levels (abdomen, pelvis, proximal thigh, knee, and midcalf) were evaluated by a dynamic acquisition during 7 minutes. Computed tomography attenuation values of the veins, arteries, and adjacent muscles were measured for each level and plotted into curves versus time. Venous enhancement was also assessed qualitatively. RESULTS: Mean peak enhancement values of the inferior vena cava and the iliac, femoral, popliteal, anterior tibial, posterior tibial, and peroneal veins were, respectively, 112 +/- 16, 103 +/- 17, 93 +/- 23, 98 +/- 30, 112 +/- 28, 137 +/- 28, and 124 +/- 29 Hounsfield units. These were reached at 93 +/- 9.5, 129 +/- 15, 135 +/- 20, 147 +/- 57, 124 +/- 32, 123 +/- 17, and 123 +/- 18 seconds. Homogeneous opacification was obtained after 210 seconds. An optimal time window for CT venography was obtained between 210 and 240 seconds for the calf level and between 180 and 300 seconds for above-knee veins. CONCLUSIONS: For sequential CT venography, a caudocranial acquisition of the lower-limb veins, starting at 210 seconds, should allow optimal clot detection.

Percutaneous stereotactic en bloc excision of nonpalpable breast carcinoma: a step in the direction of supraconservative surgery.

Recently, the advanced breast biopsy instrumentation (ABBI) system has been introduced as an alternative to conventional breast biopsy techniques. This study was prospectively conducted to evaluate the potential of the ABBI method in locoregional management of a consecutive series of patients with nonpalpable mammographically detected breast carcinomas. Sixty-one consecutive patients underwent an ABBI procedure as a first step before possible surgery for nonpalpable breast lesions that would in any case require complete excision. For the 27 patients in whom the ABBI biopsy revealed malignancy further surgery was recommended, including re-excision of the biopsy site and axillary dissection in cases of infiltrating carcinoma. We calculated the probabilities that the ABBI specimen would have tumor-free margins and that a definitely complete excision had been achieved as a function of the mammographic or pathological diameter of the cancer. For cancer with a pathological diameter less than 10 mm measured on the ABBI specimen, the probability (92%) of obtaining complete resection was significantly better than for larger lesions (P=0.01, Fisher's exact test). Although the therapeutic perspectives for the ABBI method are limited at present, we suggest that this approach is a first step in the direction of a surgical strategy that is better adapted to the pathological characteristics peculiar to these small tumors, whose incidence is increasing.

Percutaneous coil embolization of iatrogenic femoral arteriovenous fistula or pseudo-aneurysm.

Five male patients aged 43-67 years (mean, 60) with four iatrogenic femoral arteriovenous fistula and two pseudo-aneurysms (1 and 4 cm in diameter) were treated by percutaneous embolization, with coils. One coil migrated during placement to the pulmonary artery without clinical symptoms. All lesions remained obliterated after a mean follow-up of 10 months on Duplex-Doppler control. External manual compression under color-coded-Doppler was tried in three patients and failed.

Percutaneous vascular foreign body retrieval: experience of an 11-year period.

Over an 11-year period, percutaneous retrieval of intravascular foreign bodies was performed in 12 patients, using urological forceps and retrieval baskets. No clinically significant complication occurred, success rate was 100%. Review of 176 cases from the literature showed a success rate of 90%.

Local urokinase infusion for total occlusion of the lower abdominal aorta. Report of two cases and a review of the literature.

Two patients with acute occlusion of the lower abdominal aorta have been successfully treated with total of 7,425,000 and 8,850,000 units of urokinase infused locally over 93 and 86 hours, respectively, with restoration of flow. No complication occurred.

Tension mediastinal emphysema: emergency percutaneous drainage with CT guidance.

Four patients aged 8 to 54 years, under mechanical ventilation, presented with sudden tension mediastinal emphysema and exhibited typical clinical symptoms of compromised venous return. Diagnosis of tension mediastinal emphysema was confirmed by CT. A percutaneous catheter with a diameter varying from F12 to F20 was inserted in the anterior mediastinal compartment with CT control and connected to a waterseal aspiration. Emergency treatment was efficient in all patients. Percutaneous aspiration was continued for 3 to 20 days.

Comparison of radiography, magnetic resonance imaging, and surgical findings in dogs with elbow dysplasia.

OBJECTIVE: To describe the magnetic resonance imaging (MRI) appearance of medial coronoid process and humeral condyle lesions in dysplastic cubital joints and to compare survey radiography and MRI for evaluation of fragmented medial coronoid process (FMCP) and lesions of the medial aspect of the humeral condyle (MAHC). ANIMALS: 18 dogs with elbow dysplasia. PROCEDURE: Radiography of 22 cubital joints was performed. The 22 joints then underwent MRI. The scans were evaluated with regard to the shape and signal of the coronoid process; articular cartilage change, subchondral bone disruption of the MAHC. Surgical findings were used as the standard to calculate accuracy, sensitivity, specificity, and positive- and negative-predictive values for specific diagnosis of FMCP (free fragment) and lesions of the MAHC. RESULTS: At surgery, 31.8% of the joints had FMCP (free), 36.4% had nondisplaced unmineralized coronoid process, and 27.2% had nondisplaced mineralized coronoid process. Eleven joints had lesions of the MAHC, and wear lesions were observed in 41% of the joints. On radiography, FMCP (free) was visualized in 9% of the joints and lesions of the MAHC were observed in 23%. MRI had the highest accuracy (95.5%), sensitivity (100%), and negative-predictive value (100%) for detection of FMCP (free), and had accuracy (91%), sensitivity (87.5%), specificity (92.5%), and positive (87.5%)- and negative (92.5%)-predictive values for detection of nondisplaced unmineralized coronoid process. CONCLUSIONS AND CLINICAL RELEVANCE: Compared with radiography, MRI was useful for detection of nondisplaced unmineralized coronoid process; images consistently correlated with surgical findings. The technique is accurate and especially useful when radiographic findings are inconclusive.

Magnetic resonance arthrography of the cubital joint in dogs affected with fragmented medial coronoid processes.

OBJECTIVE: To evaluate efficacy of intra-articular injection of gadolinium tetra- azacyclododecane tetraacetic acid (gadolinium-DOTA) for delineating fragmented medial coronoid processes (FMCP) and lesions on the medial aspect of the humeral condyle (MAHC). SAMPLE POPULATION: 14 cubital joints in 9 dogs. PROCEDURE: Magnetic resonance imaging (MRI) was performed with and without intra-articular injection of a solution of 2 mmol of gadolinium-DOTA/L. Arthrographic images obtained after injection of contrast medium were compared with those obtained without contrast medium. Evidence of contrast medium around or in the medial coronoid process and infiltration of contrast medium in subchondral bone lesions was recorded. Twenty-four hours after imaging, arthroscopy was performed, and lesions detected were correlated with results of MRI. RESULTS: An abnormal coronoid process was diagnosed in 13 of 14 joints. A fragmented process (free) was seen in 7 of 14 joints; nondisplaced mineralized medial (in situ) coronoid processes were evident in 4 joints; and nondisplaced unmineralized medial coronoid processes were evident in 2 joints. Lesions on the MAHC were diagnosed in 4 of 12 joints. In 5 joints, a hyperintense signal resulted from contrast medium that infiltrated between the fragmented process and ulna. In 2 joints, contrast medium did not infiltrate completely around the process and was stopped by an isointense structure (ie, abnormal cartilage). Subchondral bone lesions were enhanced by use of contrast medium. CONCLUSION AND CLINICAL RELEVANCE: Use of arthrography enabled us to identify FMCP easily, but did not provide important additional information about changes on the medial coronoid process, compared with MRI performed without contrast medium.

Treatment of patent ductus arteriosus by placement of intravascular coils in a pup.

A 3-month-old female mixed-breed pup was referred for evaluation and treatment of patent ductus arteriosus (PDA). Selective angiography was performed to confirm the diagnosis. A cone-shaped PDA with a large aortic base was outlined. A second selective angiographic procedure was performed to functionally close the PDA by use of thrombotic coils; complete obstruction was obtained. Twenty-four hours after the procedure, the murmur disappeared. One month later, the dog was reexamined and found to be clinically normal.

[Treatment of massive arterial thrombosis caused by thrombocytopenia induced by heparin with local thrombolysis]. / Traitement par thrombolyse locale d'une thrombose artérielle massive par thrombopénie induite par l'héparine.

The authors report the case of a patient treated by subcutaneous injection of calcium heparin after deep vein thrombosis with floating thrombus and pulmonary embolism. She was readmitted to hospital after 16 days' treatment because of a massive aorto-iliac thrombosis due to heparin-induced thrombocytopenia (platelet count = 29.000). This thrombosis was treated by local injection of Urokinase (total dose = 7.425.000 U) over 93 hours without any major complications. The aorto-iliac circulation was completely restored to normal after treatment. Thrombotic complications secondary to immuno-allergic heparin-induced thrombocytopenia are relatively common because of the widespread use of heparin. From the therapeutic point of view, it is imperative to stop the heparin, which makes surgery very difficult, and the platelet-fibrin composition of these thrombi suggests that local thrombolysis with Urokinase is the treatment of choice in this syndrome.

Use of a balloon occlusion catheter to facilitate transarterial coil embolisation of a patent ductus arteriosus in two dogs.

Two dogs with a history of coughing and exercise intolerance were suspected to have a patent ductus arteriosus (PDA), and the presence of a type III PDA was confirmed by radiography, electrocardiography, ultrasonography and angiography. Transarterial coil embolisation was carried out by using a modified technique. An occlusion balloon catheter was inserted through a femoral vein and placed at the pulmonary side of the ductus before the embolisation coils were put in place. Both dogs remained healthy during a follow-up period of nine months.

[Inflammatory spondylodiscitis as a unique radiological manifestation of the SAPHO syndrome]. / La spondylodiscite inflammatoire comme manifestation radiologique unique du SAPHO.

We describe two cases of SAPHO with an exclusive spinal involvement. Diagnosis was established by sterno-clavicular arthralgias, palmar and plantar pustulosis and by radiological signs of inflammatory spondylodiscitis and vertebral osteitis. Spondylodiscitis and medullary edema resolved as shown by MRI after administration of steroids in one case and methotrexate in the other.

[Benefits and limitations of mammography]. / Intérêt et limites du dépistage de masse du cancer du sein par mammographie seule (mammotest).

The literature on screening mammography provides ample opportunity for doubt (the sceptics) and dogma (the screening zealots), and can be interpreted to prove both benefit and harm. The benefit of mammography screening, if any, is modest and the balance between beneficial (potentially, a 20% relative reduction in breast cancer mortality with no significant benefit on all-cause mortality) and harmful (physical and psychological morbidity related to the 15-40% missed cancers and the 80-90% false-positive diagnoses) effects is still delicate. The mammogram alone is a modest weapon. Concurrent clinical breast examination is mandatory. Women that are concerned about breast cancer should be fully informed of the potential benefits and risks of screening mammography. These women should benefit from mammography with concurrent clinical breast examination, and possible whole-breast ultrasound in heterogeneously dense and extremely dense breast patterns.

[Severe complications after cholecystectomy by celioscopy: lessons from yesterday and today]. / Graves complications après cholécystectomie par coelioscopie: leçons d'hier et d'aujourd'hui.

The case of a series of grave complications after a laparoscopic cholecystectomy is reported: a common bile duct section diagnosed rather late, hemoperitoneum, inappropriate common bile duct reconstruction and late anastomic leakage, stenosis of an hepatico-jejunal anastomosis, haemorrhage through the external biliary drainage and iterating sepsis. The final outcome was good. The stenotic hepatico-jejunal anastomosis was dilated by a Gianturco self-expanding prosthesis percutaneously placed. As an evidence, this alternative treatment is only exceptional, the treatment of choice for postsurgical benign strictures being surgical repair.

A short history of non-vascular interventional radiology.

Interventional Radiology can be defined as minimally invasive closed percutaneous procedures for diagnosis or treatment and guided by imaging techniques. Parallel to the development of Interventional vascularRadiology, non vascular techniques have evolved. Margulis coined the term "Interventional Radiology" describing percutaneous extraction of residual gallstones. Fluoroscopy guided biopsy of the lung and mediastinum were described in the thorax by Nordenstrom. Percutaneous approach to the bile ducts was clinically applied by Wiechel, Lunderquist and Wallace. T-Tube extraction of residual gallstones was popularized by Burhenne. Cross sectional imaging, Ultrasonography and Computed Tomography offered the indispensable anatomical precision allowing a percutaneous approach to the deeply located structures in an axial plane. Haaga and Alfidi described percutaneous tissue sampling and drainage procedures guided by CT. Holm developed Ultrasound guided drainage and Otto initiated the perforated transducer. Percutaneous drainage of fluid collections rapidly became a standard. Plastic stents were inserted percutaneously in the bile ducts by Pereiras. Percutaneous neurolysis of the coeliac plexus was described by Hegedus Direct injection of ethanol and laser ablation of liver tumors, diskectomy and tubal recanalization are other more recently developed procedures.