Intra-arterial computed tomography angiography with ultra-low volume of iodine contrast and stent implantation in transplant renal artery stenosis in terms of contrast-induced kidney injury - a preliminary report.

PURPOSE: Traditional digital subtraction angiography is still regarded as the gold standard in the diagnostics of transplant renal artery stenosis (TRAS). However, this procedure requires a high volume of iodine contrast medium for optimal visualisation of the renal artery. The aim of this study was to analyse both the usefulness and the safety of intra-arterial computed tomography angiography (IA-CTA) with ultra-low-volume iodine contrast administration in the diagnostic and therapeutic management of TRAS in patients with impaired renal transplant function. MATERIAL AND METHODS: Thirty-three patients with a suspicion of TRAS based on Doppler-ultrasound and clinical setting underwent IA-CTA with ultra-low iodine contrast volume. A special, author-elaborated CTA protocol was used. The volume of 8-18 ml of diluted iodine contrast medium was administered through a catheter with the tip placed 2 cm below the aortic bifurcation. RESULTS: In six patients the CTA examinations revealed TRAS in three configurations: in the anastomosis, in the trunk (critical and high-grade), or in both sections. Stenoses were treated with primary stenting obtaining favourable anatomical outcome. No intervention-related complications were observed. No contrast-induced acute kidney injury was diagnosed in this study. Mean serum creatinine concentration was 2.93 ± 0.89 mg/dl at the baseline and 2.89 ± 1.73 mg/dl and 2.17 ± 0.51 mg/dl after three and seven days from IA-CTA, respectively. CONCLUSIONS: Intra-arterial CTA with ultra-low volume of iodine contrast seems to be a safe and reliable diagnostic tool to detect and assess TRAS in the aspect of stent implantation. Application of this imaging modality eliminates the need for a high volume of iodine contrast and thus does not adversely influence renal transplant function.

The evaluation of the aortic annulus displacement during cardiac cycle using magnetic resonance imaging.

BACKGROUND: The stress in the ascending aorta results from many biomechanical factors including the geometry of the vessel and its maximum dimensions, arterial blood pressure and longitudinal systolic stretching due to heart motion. The stretching of the ascending aorta resulting from the longitudinal displacement of the aortic annulus during the heart cycle has not been examined in the general population so far. The aim of the study is to evaluate this parameter using cardiovascular magnetic resonance (CMR) imaging in the general population in all age groups. METHODS: The cardiac magnetic resonance images of 73 patients were evaluated. The maximum distance to which the ventriculo-aortic junction was pulled by the contracting heart (LDAA - longitudinal displacement of the aortic annulus) was measured in the cine coronal sequences. Moreover, the maximum dimensions of the aortic root and the ascending aorta were assessed. RESULTS: The LDAA value was on average 11.6 ± 2.9 mm (range: 3-19 mm; 95% CI: 10.9-12.3 mm) and did not differ between males and females (11.8 ± 2.9 mm vs. 11.2 ± 2.9 mm, p = .408). The diameter of the ascending aorta was 32 ± 6.3 mm (range: 20-57 mm). The maximal dimension of the aortic root was 35 ± 5.1 mm (range: 18-42 mm). There was a statistically significant negative correlation between the LDAA and the age of patients (r = -.38, p = .001). There was no significant correlation between the LDAA and aortic root dimension (r = .1, p = .409) and between the LDAA and diameter of the ascending aorta (r = .16, p = .170). CONCLUSIONS: Human aortic root and ascending aorta are significantly stretched during systole and the distance to which the aorta is stretched decreases with age. The measurement of the longitudinal displacement of the aortic annulus using the CMR is feasible and reproducible.

Surgical management of extracranial carotid artery aneurysms.

BACKGROUND: We present the methods and results of the surgical management of extracranial carotid artery aneurysms (ECCA). Postoperative complications including early and late neurological events were analysed. Correlation between reconstruction techniques and morphology of ECCA was assessed in this retrospective study. PATIENTS AND METHODS: In total, 32 reconstructions of ECCA were performed in 31 symptomatic patients with a mean age of 59.2 (range 33-84) years. The causes of ECCA were divided among atherosclerosis (n = 25; 78.1%), previous carotid endarterectomy with Dacron patch (n = 4; 12.5%), iatrogenic injury (n = 2; 6.3%) and infection (n = 1; 3.1%). In 23 cases, intervention consisted of carotid bypass. Aneurysmectomy with end-to-end suture was performed in 4 cases. Aneurysmal resection with patching was done in 2 cases and aneurysmorrhaphy without patching in another 2 cases. In 1 case, ligature of the internal carotid artery (ICA) was required. RESULTS: Technical success defined as the preservation of ICA patency was achieved in 31 cases (96.9%). There was one perioperative death due to major stroke (3.1%). Two cases of minor stroke occurred in the 30-day observation period (6.3%). Three patients had a transient hypoglossal nerve palsy that subsided spontaneously (9.4%). At a mean long-term follow-up of 68 months, there were no major or minor ipsilateral strokes or surgery-related deaths reported. In all 30 surviving patients (96.9%), long-term clinical outcomes were free from ipsilateral neurological symptoms. CONCLUSIONS: Open surgery is a relatively safe method in the therapy of ECCA. Surgical repair of ECCAs can be associated with an acceptable major stroke rate and moderate minor stroke rate. Complication-free long-term outcomes can be achieved in as many as 96.9 % of patients. Aneurysmectomy with end-to-end anastomosis or bypass surgery can be implemented during open repair of ECCA.

Embolization of a True Giant Splenic Artery Aneurysm Using NBCA Glue - Case Report and Literature Review.

BACKGROUND: Although splenic artery aneurysms (SAAs) are common, their giant forms (more than 10 cm in diameter) are rare. Because of the variety of forms and locations of these aneurysms, there are a lot of therapeutic methods to choose. In our case of a giant true aneurysm we performed an endovascular embolization with N-butyl-cyano-acrylate (NBCA) glue. To our knowledge it is the first reported case of this method of treatment of true giant SAA. CASE REPORT: A 74-year-old male patient with symptomatic giant SAA (13 cm) was urgently admitted to our hospital for the diagnostic and therapeutic procedures. Due to the general health condition, advanced age and the large size of the aneurysm we decided to perform an endovascular treatment with N-butyl-cyano-acrylate (NBCA) glue. CONCLUSIONS: The preaneurysmal part of splenic artery was occluded completely with exclusion of the aneurysm. No splenectomy was needed. The patient was discharged in good general condition Embolization with NBCA can be an efficient method to treat the giant SAA.

Intraarterial CT Angiography Using Ultra Low Volume of Iodine Contrast - Own Experiences.

BACKGROUND: High volume of intravenous contrast in CT-angiography may result in contrast-induced nephropathy. Intraarterial ultra-low volume of contrast medium results in its satisfactory blood concentration with potentially good image quality. The first main purpose was to assess the influence of the method on function of transplanted kidney in patients with impaired graft function. The second main purpose of the study was to evaluate the usefulness of this method for detection of gastrointestinal and head-and-neck haemorrhages. MATERIAL/METHODS: Between 2010 and 2013 intraarterial CT-angiography was performed in 56 patients, including 28 with chronic kidney disease (CKD). There were three main subgroups: 18 patients after kidney transplantation, 10 patients with gastrointestinal hemorrhage, 8 patients with head-and-neck hemorrhage. Contralateral or ipsilateral inguinal arterial approach was performed. The 4-French vascular sheaths and 4F-catheters were introduced under fluoroscopy. Intraarterial CT was performed using 64-slice scanner. The scanning protocol was as follows: slice thickness 0.625 mm, pitch 1.3, gantry rotation 0.6 sec., scanning delay 1-2 sec. The extent of the study was established on the basis of scout image. In patients with CKD 6-8 mL of Iodixanol (320 mg/mL) diluted with saline to 18-24 mL was administered at a speed of 4-5 mL/s. RESULTS: Vasculature was properly visualized in all patients. In patients with impaired renal function creatinine/eGFR levels remained stable in all but one case. Traditional arteriography failed and CT-angiography demonstrated the site of bleeding in 3 of 10 patients with symptoms of gastrointestinal bleeding (30%). In 8 patients with head-and-neck bleeding CT-angiography did not prove beneficial when compared to traditional arteriography. CONCLUSIONS: 1. Ultra-low contrast intraarterial CT-angiography does not deteriorate the function of transplanted kidneys in patients with impaired graft function. 2. 3D reconstructions allow for excellent visualization of vascular anatomy of renal transplants. 3. Intraarterial CT-angiography is useful for detection of the bleeding site.

Iatrogenic hemobilia in 10-year-old boy.

BACKGROUND: Hemobilia in children is a rare phenomenon which has been described mostly in the context of traumas. The descriptions of massive hemobilia in children after liver biopsy are a rarity in the scientific literature because there are only a few examples of it. Hemobilia rarely develops spontaneously. Generally, this is a complication after a blunt abdominal trauma or after medical (especially surgical) procedures. Correct diagnosis and treatment of hemobilia are essential, especially in the case of patients with severe - sometimes life-threatening - haemorrhage from biliary ducts. It should be remembered that the symptoms of hemobilia do not necessarily occur immediately after surgery or trauma. In some cases hemobilia occurs after a changeable, asymptomatic period of time. CASE REPORT: We would like to present a case of a severe form of hemobilia caused by arterio-biliary fistula which developed incidentally after liver biopsy in a 10-year-old boy with chronic hepatitis B. Symptoms of hemobilia appeared on the seventh day after the diagnostic biopsy when the patient's general condition began to deteriorate. The diagnosis of arterio-biliary fistula was established after angio-CT examination of the liver. A selective embolization of the right hepatic artery was carried out. Hemobilia in children is a rare phenomenon which has been described mostly in the context of traumas. The cases of massive hemobilia in children after liver biopsy are a rarity in the scientific literature because there are only a few examples of it. Hemobilia very rarely develops spontaneously. Generally, this is a complication after a blunt abdominal trauma or after medical (especially surgical) procedures. RESULTS: Correct diagnosis and treatment of hemobilia are essential, especially in the case of patients with severe - sometimes life-threatening - haemorrhage from biliary ducts. It should be remembered that the symptoms of hemobilia do not necessarily occur immediately after surgery or trauma. In some cases hemobilia occurs after a changeable, asymptomatic period of time.

Native Renal Arteries Denervation as a Therapy of Refractory Hypertension in Patient after Heart and Kidney Transplantation-5 Years of Observation.

This case report describes a 59-year-old male patient after heart and kidney transplantation, subsequently diagnosed with refractory hypertension since implemented antihypertensive pharmacotherapy consisting of six agents did not provide a substantial therapeutic response. Elevated blood pressure and its impact on a hypertrophied transplanted heart and impaired renal graft function have led to a significant deterioration in the patient's cardiovascular risk profile. To address this issue, a native renal arteries denervation was performed. It resulted in a noteworthy decrease in both systolic and diastolic pressure values, thus manifesting a positive hypotensive effect. Furthermore, a sustainable reduction of left ventricular mass and stabilization in kidney graft function were noticed. The presented case provides evidence that renal denervation can be an efficacious complementary treatment method in individuals who received kidney and heart grafts as it leads to a decrease in cardiovascular risk.

[Atypical biliary stenting in patient with obstructive biliary jaundice]. / Przypadek niestandardowego stentowania dróg zólciowych w zóltaczce mechanicznej o etiologii nowotworowej.

Obstructive biliary jaundice is a common complication in patients with malignancies which infiltrate biliary ducts. If untreated efficiently the jaundice is fatal a short period of time. We present a case of 60-year-old male patient who had undergone Whipple procedure in the past and presented with local recurrence treated successfully by percutaneous stenting of obstructed biliary duct. When passing through the obstruction we observed a contrast-bile leakage at the level of occluded segment and instability of implanted stent which was a complication that extorted atypical approach. We applied a covered stent in association with oversized nitinol stent which allowed to form a funnel-like construction efficiently decompressing biliary tree. Thanks to this management we also avoided further complications.

[Endovascular treatment of recurrent hemorrhage after tonsillectomy]. / Embolizacja wewnatrznaczyniowa w nawracajacym krwawieniu po tonsillektomii.

Bleeding from the lodge after tonsillectomy is a rare complication--approximately 3% of all cases. In most cases pharmacological treatment or reoperation is effective. In unique situ. ations, when particular severe bleeding is observed, it is necessary to perform endovascular therapy. We present a case of efficient endo-vascular embolization in 31-year-old patient with a recurrent bleeding after tonsillectomy. Superselective embolization of the ascending palatine artery can be an effective therapeutic method in severe bleeding after tonsillectomy

[Aortocaval fistula in abdominal aorta aneurysm treated by stentgraft and embolization with histoacrylate glue]. / Przetoka aortalno-czcza w tetniaku aorty brzusznej leczona stentgraftem i embolizacja przy pomocy kleju histoakrylowego.

Aortocaval fistula (ACF) associated with abdominal aortic aneurysm (AAA) constitutes a relatively uncommon complication of AAA, nevertheless it worsens to a great extent the prognosis and its curable treatment is difficult. The fistula itself, in particular high-output ACF, deteriorates the general patient condition and requires an emergency intervention. The simultaneous exclusion of AAA fromcirculation and closure of site of the fistula is the treatment. The typical treatment includes open surgery or alternatively stentgraft implantation. We report a case of a giant non-thrombosed AAA complicated by formation of ACF at the level of origin of the right common iliac artery. Bifurcated stentgraft implantation did not result in closure of ACF. The fistula was definitely closed by means of injection of cyanoacrylate glue between the stentgraft limb and the wall of the native vessel.

[Simultaneous manifestation of thrombocytopenia -induced endoleak type IV and II as late complication following abdominal stentgraft implantation]. / Jednoczasowe wystapienie indukowanego maloplytkowoscia zacieku typu IV oraz II jako pózne powiklanie po implantacji stentgraftu brzusznego.

Endoleak type IV occurs very rarely and typically was observed 4-8 weeks following implantation of previous generation stentgrafts. Endoleak type II, although relatively common, typically presents early after stentgraft implantation. In our case combined thrombocytopenia-induced endoleaks type II and IV manifested 22 months following stentgraft implantation. The patient presented with abdominal pain and rapid increase in aneurysm diameter. The patient did not require endovascular intervention, medical treatment proved sufficient to relieve clinical symptoms and to prevent progression of the aneurysmal sac. Thrombocytopenia has not manifested itself again so far. The patient is followed-up with increased frequency. It should be noted that occurrence of type IV endoleak, in particular when associated with other type of endoleak, can result from thrombocytopenia. This type of endoleak should be included in differential diagnosis not only in early postinterventional period but also in long-term follow-up, first of all in patients with first generation stentgrafts implanted, featured by porosity of covering material.

[Endovascular treatment of haemorrhagic complication of HELLP syndrome]. / Wewnatrznaczyniowe leczenie powiklania krwotocznego zespolu HELLP.

HELLP syndrome, which consists of haemolytic anaemia, elevated liver enzymes and thrombocytopenia, typically occurs in women in perinatal period. Rare life-threatening complications of this syndrome include haemorrhages, in particular these originating from hepatic artery branches for they usually result in subcapsular hematoma formation. The rupture of hepatic capsule secondary to hepatomegaly results in intraperitoneal haemorrhage. In case of suspicion of HELLP syndrome complicated by hepatic haemorrhage it is crucial to perform imaging modalities as emergency, first of all US and CT of abdomen and pelvis. Selective embolization of hepatic artery branches seems to be a valuable, alternative or complementary to surgery method of stopping the bleeding.

[Use of Gianturco-Wallace and tornado coils in perforators embolisation in chronic venous ulcers treatment]. / Zastosowanie spirali Gianturco-Wallace i Tornado w embolizacji niewydolnych zyl przeszywajacych jako metody leczenia przewleklych owrzodzeí zylnych.

AIM OF THE STUDY: Embolisation is a endovascular technique of vessels closure using embolisation material, which is applied into vessels throw catheter. As an embolisation material coils Gianturco-Wallace i Tornado (Cook) were used. Length and size of coils was determined individually during precedure. MATERIALS AND METHODS: 38 patients of Vascular Surgery Department and Radiology Department of Medical University in Wroclaw were treated by endovascular embolisation of insufficient perforators. Procedures were made on 40 limbs with post-thrombotic complex and venous ulcers (6th degree of CEAP classification). 68 endovascular procedures were made, 143 metal coils were used. RESULTS: Using endovascular method 85% of ulcers were comletely cured. CONCLUSIONS: Endovascular embolisation is safe and effective method of veonous ulcers curing. Itmay be used at outpatients clinic.

Optimization of the method of measuring left ventricular end-diastolic diameter in cardiac magnetic resonance as a predictor of left ventricular enlargement.

The objective of the study was to optimize the method of measuring left ventricular end-diastolic diameter (LVEDD) in cardiac magnetic resonance (CMR) as a predictor of left ventricular end-diastolic volume (LVEDV). The study group consisted of 78 patients (age 55.28 ± 17.18) who underwent 1.5 T CMR examination. LVEDD measurements in the short axis, in the long axis in the 2-chamber, 3-chamber and 4-chamber views were made by 2 radiologists. The repeatability of LVEDD measurements was assessed. The sensitivity and specificity of various methods of measuring LVEDD as a predictor of left ventricular enlargement (diagnosed based on LVEDV) were assessed. The correlation coefficients between LVEDD measurements made by researcher A and B were 0.98 for the long axis measurements in the 2-chamber and 3-chamber view, and 0.99 for measurements made in the short axis and in the long axis in the 4-chamber view. The lowest LVEDD measurements variability was recorded for the short axis measurements (RD 0.02, CV 1.38%), and the highest for the long axis measurements in the 3-chamber view (RD 0.04, CV 2.53%). In the male subgroup, the highest accuracy in predicting left ventricular enlargement was characterized by the criterion "LVEDD measured in the long axis in the 2-chamber view > 68.0 mm" (accuracy 94.1%). In the female subgroup, the highest accuracy in predicting left ventricular enlargement was achieved by the criterion "LVEDD measured in the short axis > 63.5 mm" (96.3%). In summary, the measurement made in the short axis should be considered the optimal method to LVEDD measure in CMR, considering the repeatability of measurements and the accuracy of left ventricular enlargement prediction.

[Application of cyanoacrylate glue and ethylene vinyl alcohol copolymer for the treatment of vascular malformations of the central nervous system]. / Zastosowanie kleju cyjanoakrylowego i kopolimeru etylenu z alkoholem winylowym w leczeniu malformacji naczyniowych osrodkowego ukladu nerwowego.

Arterio-venous malformations (AVMs) and dural arterio-venous fistulas (AVFs) are relatively rare developmental vascular system disorders and constitute the majority of vascular malformations of the nervous system. The malformations are characterized by a large variety of vascular architecture. Intracranial or intramedullary hemorrhage constitute the most serious complications of the malformations. The algorithm of management aiming at complete recovery or hemorrhage prevention has not been completely established yet due to considerable individual variability of malformations. The obliteration of malformations pathological vessels using cyanoacrylate glue or ethylene vinyl alcohol copolymer (EVOH)--so called endovascular embolization--has been the most dynamically developing treatment method recently. The procedure, unlike classical surgical resection of pathological vessels, is significantly less invasive and associated with shorter hospitalization period. The features and properties of embolization agents (cyanoacrylate and EVOH) as well as application of the agents for treatment of the vascular pathologies of the central nervous system are discussed in the paper. The procedure of endovascular introduction of embolization agents into the lumen of malformation vessels is also presented in the article. The analyzed literature and own experiences allow to claim that the application of cyanoacrylate and EVOH is a relatively safe therapeutic method that in part of the cases enables complete embolization of pathological vessels. The development of endovascular systems and the advances in embolization agents should trigger further intensive improvement of the technique.

Interventionally implanted port catheter systems for hepatic arterial infusion of chemotherapy in patients with colorectal liver metastases: a Phase II-study and historical comparison with the surgical approach.

BACKGROUND: The high complication rates of surgically implanted port catheter systems (SIPCS) represents a major drawback in the treatment of isolated liver neoplasms by hepatic arterial infusion (HAI) of chemotherapy. Interventionally implanted port catheter systems (IIPCS) have evolved into a promising alternative that enable initiation of HAI without laparatomy, but prospective data on this approach are still sparse. Aim of this study was to evaluate the most important technical endpoints associated with the use of IIPCS for the delivery of 5-fluorouracil-based HAI in patients with colorectal liver metastases in a phase 2-study, and to perform a non-randomised comparison with a historical group of patients in which HAI was administered via SIPCS. METHODS: 41 patients with isolated liver metastases of colorectal cancer were enrolled into a phase II-study and provided with IIPCS between 2001 and 2004 (group A). The primary objective of the trial was defined as evaluation of device-related complications and port duration. Results were compared with those observed in a pre-defined historical collective of 40 patients treated with HAI via SIPCS at our institution between 1996 and 2000 (group B). RESULTS: Baseline characteristics were balanced between both groups, except for higher proportions of previous palliative pre-treatment and elevated serum alkaline phosphatase in patients of group A. Implantation of port catheters was successful in all patients of group A, whereas two primary failures were observed in group B. The frequency of device-related complications was similar between both groups, but the secondary failure rate was significantly higher with the use of surgical approach (17% vs. 50%, p < 0.01). Mean port duration was significantly longer in the interventional group (19 vs. 14 months, p = 0.01), with 77 vs. 50% of devices functioning at 12 months (p < 0.01). No unexpected complications were observed in both groups. CONCLUSION: HAI via interventionally implanted port catheters can be safely provided to a collective of patients with colorectal liver metastases, including a relevant proportion of preatreated individuals. It appears to offer technical advantages over the surgical approach.

[Catheter malposition in the renal vein--a rare complication related to a peripherally inserted central catheter]. / Niezamierzona lokalizacja cewnika w zyle nerkowej--rzadkie powiklanie kaniulizacji zyl centralnych z dostepu obwodowego.

In cardiology intensive care units central venous access is often needed for intravenous infusion of multiple strong acting or hypertonic therapeutic agents such as catecholamines, antibiotics, kalium chloride solutions or parenteral nutrition, as well as for central venous pressure measurements. Currently, access devices include centrally inserted central venous catheters (CVC) and peripherally inserted central venous catheters (PICC). Because of the relative ease of placement, reduced rates of severe complications, such as pneumothorax, great vessel perforation or bleeding, and lower costs in comparison to CVCs, PICCs have been widely used. The PICC has risks, however, with the most frequently occurring complications being catheter malposition followed sometimes by thrombosis, infection or even perforation of the vessel. We present a case of an uncomplicated unsatisfactory location of the catheter tip in the right renal vein, found accidentally during chest angio-CT. Although PICCs are considered to be safe and easy to insert, the proper catheter tip placement is highly unreliable and should be carefully assessed.

Diagnosis and treatment of pelvic congestion syndrome: Single-centre experiences.

BACKGROUND: One of the underestimated causes of chronic pelvic pain (CPP) in women may be pelvic congestion syndrome (PCS) that is defined as the presence of varicose of ovarian and pelvic veins associated with chronic pain in the region of the pelvis. This pain is present longer than 6 months and intensifies with prolonged standing, coitus and menstruation. The disease constitutes a diagnostic as well as therapeutic problem, thus posing a challenge for the clinician. Transcatheter ovarian vein embolization might be a safe and effective option for PCS treatment. OBJECTIVES: The objective of this study was to evaluate the efficacy of ovarian vein embolization ovarian as a method of the PCS treatment. MATERIAL AND METHODS: Between 2002-2012, 11 embolization procedures were performed in 10 women (age range: 34-43; median age 39) with the diagnosis of PCS. One patient underwent embolization procedure twice. In 1 case the combined therapy of endovascular embolization and surgical phlebectomy of vulvar varices was performed. RESULTS: There were no major intrainterventional complications. In all the patients (100%) a significant improvement in the clinical status was noted. The procedure improved the quality of life in the patients. Three women (30%) had a mild recurrence of the symptoms at mid-term follow-up. Among 8 women who had complained of dyspareunia prior to embolization 6 patients reported complete pain relief, in other 2 cases the pain subsided partially. There was a significant decrease in the severity of symptoms associated with hemorrhoids. CONCLUSIONS: We consider embolization of insufficient ovarian veins an effective and safe way of treatment in a well-selected group of patients with PCS.