Varicose vein stripping--a prospective study of the thrombotic risk and the diagnostic significance of preoperative color coded duplex sonography.

Insufficiency of epifascial veins promotes venous ulceration and increases thromboembolic risk in general surgery patients. Epifascial varicose vein stripping is therefore considered the most effective prophylactic procedure. Thromboembolic risk of patients undergoing this surgical procedure has not yet been prospectively evaluated but appears to be lower than in general surgery patients. The gold standard of preoperative assessment of varicose surgery patients is ascending pressure phlebography, but this technique is invasive, time consuming and costly. We prospectively investigated 100 consecutive varicose vein surgery patients for postoperative thrombosis. Ascending pressure phlebography (APP) and colour coded duplex sonography (CCDS) were performed before and 10 to 21 days after the stripping operation in 100 and 70 patients, respectively. APP revealed no postoperative deep vein thrombosis in all 100 limbs investigated (0 percent; 95 percent confidence interval: 0 to 2.95). With regard to epifascial vein reflux there was good agreement between APP and CCDS (quadratic weighted kappa: 0.76). In 67 out of 73 superficial veins investigated excellent agreement of diagnostic accuracy was found for both diagnostic procedures (91.78 percent; 95 percent confidence interval: 82.96 to 96.92). We conclude that thrombotic risk of varicose vein surgery is low in properly selected patients. CCDS provides a high degree of accuracy in diagnosis of reflux and regular vein morphology and should therefore replace APP; however, APP does remain essential in the preoperative workup of atypical anatomical variants.

[Strut fractures in the long-term follow-up of Günther cava filters--the results after 64 filter implantations]. / Strebenbrüche bei der Langzeitkontrolle von Günther-Kavafiltern--Ergebnisse nach 64 Filterimplantationen.

Follow-up of patients with inferior vena cava filters was performed every 3 months with clinical controls, plain radiographs and duplex sonography. Whereas the clinical results were excellent (no recurrence of pulmonary embolism), radiological controls showed broken anchoring legs in 14 cases and a broken filter basket in one patient. In two cases, the broken anchoring prongs had perforated the inferior vena cava wall. All patients with broken filters were clinically asymptomatic. CT showed no morphological changes in these cases. As experience proves, strict follow-up of caval filters for early detection of complications is mandatory even with well-established filter types.

[Pseudo-stenosis of the renal artery: a possible defect of color Doppler sonography]. / Pseudostenose der Nierenarterien: Mögliche Fehler der Farbdopplersonographie.

The diagnostic value of pulsed Doppler sonography for the detection of renal artery stenosis was questioned by recent studies. Until now, the diagnostic value of colour-coded Doppler sonography of the renal arteries is not clearly defined in relation to pulsed Doppler. This study deals with specific problems of colour-coded Doppler sonography in the examination of the renal arteries. Because of basic technical principles of colour-coded Doppler sonography a stenosis can be imitated especially at the origin of the right renal artery by using a ventral approach to the vessel. This pseudo-stenosis is due to a change of colour similar to an aliasing-phenomenon in a curved vessel. In order to avoid false positive results, a laterodorsal approach to the vessel should be applied additionally. A spectral waveform should be also registered routinely.

[The screening of renal artery stenoses. The initial results with the value of color Doppler sonography]. / Screening von Nierenarterienstenosen. Erste Ergebnisse zur Aussagekraft der Farbdopplersonographie.

The value of colour Doppler sonography in the diagnosis of renal artery stenosis has been studied retrospectively. 17 patients were examined (34 main renal arteries and 7 accessory renal arteries; ages 37 to 84 years; 7 males and 10 females). We studied 1) ability to study the main renal arteries, 2) visibility of accessory renal arteries and 3) the sensitivity and specificity of colour Doppler sonography for the diagnosis of renal artery stenosis. The results were compared with intraarterial angiography. Demonstration of the main renal arteries with colour Doppler sonography was possible in 23 of the 34 vessels. Not a single of the 7 accessory renal arteries was demonstrated by colour Doppler sonography. Of 8 angiographically demonstrated stenoses (more than 50% narrowing) 2 were missed by colour Doppler sonography. One stenosis was correctly diagnosed and 5 were incorrectly evaluated by sonography. 16 out of 18 angiographically normal main renal arteries were correctly evaluated by colour Doppler sonography but 2 showed a false positive finding. This results in a sensitivity of 17% and a specificity of 89% per kidney. Colour Doppler sonography cannot be recommended as a screening method for renal artery stenosis in view of its limited accuracy.

[Renal osteodystrophy: the spectrum of the x-ray symptoms in modern forms of kidney transplantation and long-term dialysis therapy]. / Renale Osteodystrophie: Spektrum der Röntgensymptomatik bei modernen Formen der Nierentransplantation und Dauerdialysetherapie.

Plain film radiography and microradioscopy represent standard imaging for diagnosis and grading of renal osteodystrophy. The aim of this retrospective study was to evaluate the effects of modern therapeutic regimens on skeletal abnormalities as diagnosed radiographically. 198 patients were investigated. X-ray findings of 38 patients from 1981-1983 (16-66 years, 40.1 +/- 13.4; 23 male, 15 female) were compared with those of 160 patients from 1991 (20-71 years, 48.4 +/- 12.5; 98 male, 62 female). We found significant differences in respect of the spectrum and the degree of skeletal abnormalities. The prevalence of phalangeal resorptions lowered from 87 to 50%, the prevalence of soft tissue calcification from 68 to 57%. Therefore, renal osteodystrophy is not as extensive as it was ten years ago, but it still continues to be an unavoidable complication of renal insufficiency.

[The value of barium double-contrast study in the aftercare of gastrectomy patients (Roux-Y)]. / Stellenwert der Barium-Doppelkontrast-Untersuchung in der Nachsorge von Gastrektomierten (Roux-Y).

We evaluated 32 patients who had undergone jejuno-oesophagostomy for gastric carcinoma. Double contrast radiography was performed 3 to 36 months after gastrectomy, 3 to 14 days prior to routine endoscopy. Endoscopy is superior to double contrast radiography in detecting tumour recurrence, particularly in small tumours, due to the possibility of biopsy. Double contrast radiography is excellent in demonstrating the afferent loop. We found a high number of jejuno-oesophageal reflux and very different small intestine transit times without correlation to clinical signs and symptoms.

[The long-term changes after the implantation of silicone breast prostheses]. / Langzeitveränderungen nach Implantation von Mammasilikonprothesen.

In a prospective study 60 patients with unilateral or bilateral mammary implants underwent mammography and sonography. Location, form and structure of the implants were evaluated. Additionally capsular fibrosis and its influence on the imaging quality of parenchyma was scored. We found increasing implant deformities and increasing density of the implants with increasing postoperative interval. There was poor statistically significant correlation between the thickness of the periprosthetic capsular and the postoperative interval in prepectoral implants (r = 0.555, p < 0.01); in case of subpectoral implants there was no such correlation. In 88% of the cases imaging quality was scored as adequate by two independent observers, with additional views in all cases. We conclude that sufficient imaging quality for the assessment of parenchyma and of potential implants complications may be obtained by the combination of mammography and sonography.

[Extensive intraductal components of invasive ductal breast carcinoma--value of mammography]. / Die extensiv intraduktale Komponente von invasiven duktalen Mammakarzinomen--Stellenwert der Mammographie.

The presence of an extensive intraductal component (EIC) in patients with infiltrating ductal carcinoma is a major factor for predicting local recurrence after breast-conserving surgery and radiotherapy. A retrospective study including 67 consecutive cases of stage I and II infiltrating ductal carcinomas of the breast was conducted to determine the predictive values of mammographic features associated with the presence or absence of EIC. 43% of the lesions contained a pathologically verified EIC. 63% (25/40) of lesions showing mammographic evidence of calcifications with or without a mass were associated with an EIC. In contrast, only 17% (4/24) of carcinomas without calcifications demonstrated an EIC. This difference was statistically significant (p < 0.001). Lesions with calcifications greater than 3 cm in extent were significantly (p < 0.01) more likely to have an EIC (8/9; 89%) than those with calcifications less than 3 cm in extent (17/31; 55%). Furthermore, no patient with a palpable mass who had normal findings on mammograms was diagnosed to have an EIC.

Lung manifestation in asymptomatic patients with primary Sjögren syndrome: assessment with high resolution CT and pulmonary function tests.

The authors studied 37 consecutive patients with primary Sjögren syndrome and normal chest radiographs. Thin-section CT images were analyzed using a semiquantitative grading system. The presence, distribution, and severity of 9 morphologic parameters were assessed. In 34 patients, CT findings were correlated to pulmonary function tests (PFTs). Abnormal high resolution CT (HRCT) findings were seen in 24 of 37 patients (65%): interlobular septal thickening, n = 9; micronodules, n = 9; ground glass attenuation n = 4; parenchymal cysts, n = 5. Intralobular opacities, honey combing, bronchial wall thickening, bronchiectasis, and pleural irregularities were less frequent. Both HRCT and PFTs were normal in 10 patients. Computed tomography was normal in four patients with PFTs that indicated the presence of small airway disease. High resolution CT abnormalities were found in seven patients with normal PFT. The overall correlation between HRCT and PFTs was poor. High resolution CT and PFTs appear to be sensitive for both the early detection of parenchymal abnormalities and a decreases in lung function in asymptomatic patients with primary Sjögren syndrome. However, abnormal HRCT findings do not necessarily indicate a substantial alteration in PFTs.

Spiral CT evaluation of deep venous thrombosis.

Spiral CT venography is a technical innovation in vascular imaging that can optimize vessel contrast in the deep venous system and, therefore, is an accurate diagnostic tool to detect deep venous thrombosis. Compared with conventional venography, the amount of contrast material can be reduced by 80%. While using spiral CT as the primary imaging technique for the detection of pulmonary embolism, the cause of embolism can be evaluated within a short period of additional imaging time without further patient mobilization. This review outlines fundamental techniques in spiral CT venography and summarizes our clinical experience at Vienna University Medical Center.

[Preoperative imaging of varicose veins of the lower extremities. Classical pattern of insufficiency and its clinical use]. / Bildgebung zur präoperativen Abklärung bei Varikose der unteren Extremität. Klassische Insuffizienzmuster und klinische Wertigkeit.

UNLABELLED: Venous varicose are one of the most common diseases in industrial countries today. New surgical strategies, tailored to a patient's specific pattern of venous incompetence require more detailed preoperative imaging. METHODS: In this review of current literature we analyzed the value of ascending venography, color coded duplex sonography and descending venography for preoperative planning of varicose surgery. On the other hand, we describe variant anatomy of the superficial venous system like the different levels of escape points and perforating veins. RESULTS: Ascending venography and color coded duplex sonography are both excellent modalities for detection of reflux in the saphenofemoral and saphenopopliteal junction. The results of current literature indicate, that ascending venography is superior to color coded duplex sonography in the detection of incompetent perforators. CONCLUSIONS: Ascending venography and color coded duplex sonography provide improved information, that may be crucial for surgical planning. The high heterogeneity and broad distribution of valvular incompetence confirms the importance of detailed preoperative imaging.

[CT-phlebography. A new method for the diagnosis of venous thrombosis of the upper and lower extremities]. / CT-Phlebographie. Eine neue Methde zur Diagnostik von Venenthrombosen an der oberen und unteren Extremität.

UNLABELLED: Spiral CT venography is a new method in vascular imaging, which is an accurate tool for the evaluation of deep venous thrombosis in the evaluation of deep venous thrombosis in the lower and upper extremity. MATERIALS AND METHODS: 102 lower extremities and 12 upper extremities were evaluated for deep vein thrombosis using spiral-CT-venography. The results were compared with findings of ascending venography, color coded duplex sonography and clinical follow up. RESULTS: Spiral CT venography of the lower extremity showed a sensitivity of 100% and a specifity of 96%. The quality of venous opacification with CT venography compared with ascending venography was superior in all venous segments. DISCUSSION: Spiral CT venography is a valuable tool for the detection of deep venous thrombosis. Advantages of the method are the reduction of the amount of contrast material necessary for opacification and the detection of perivascular soft tissue alterations. The application of CT venography is limited due to higher costs and radiation dosage.

[Bronchiolitis obliterans accompanied by organizing pneumonia: radiologic diagnosis in a case of a 22-year-old female]. / Bronchiolitis obliterans mit organisierender Pneumonie: Radiologische Diagnostik im Fall einer 22jährigen Patientin.

Case report of a 22-year old patient with most severe idiopathic bronchiolitis obliterans and organising pneumonia. We discuss the diagnostic algorithm and emphasise the role of CT.

[Imaging procedures in varicosities]. / Bildgebende Verfahren bei Varikose.

A prospective study was performed to compare the diagnostic potential of color-coded duplex sonography (CCDS) and that of ascending pressure phlebography (APP) in 61 patients before venous stripping. Varicosis of the long saphenous vein was correctly diagnosed and graded by CCDS in 87% of cases, and varicosis of the short saphenous vein in 97%. CCDS was inaccurate in 3 of 4 cases of recurrent varicosis of the long saphenous vein. Anterior femoral cutaneous varicosis (n = 3), mild postthrombotic syndrome (n = 1) and variant venous anatomy (n = 1) were not diagnosed on CCDS. One Baker cyst was diagnosed by CCDS. In the assessment of venous reflux CCDS seems to be superior to APP. Our results suggest that CCDS is a valuable diagnostic tool for routine imaging before venous stripping. However, patients with ambiguous or inconclusive CCDS results (eg. recurrent varicosis, venous variants) should be examined by APP.

[Phlebography of the leg veins. Study quality and sources of error]. / Phlebographie der Beinvenen. Untersuchungsqualität und Fehlerquellen.

In a retrospective study, 198 contrast venographies were evaluated by two blinded observers for quality of opacification of the venous system and quality of documentation. There was good correlation between the two observers in 91% of the cases. They found an adequate contrast quality in 183 cases (92.4%), while in 15 cases (7.6%) incomplete contrast was found in some parts of the calf or pelvic veins. Most venograms (195, or 98.5%) were adequately documented. In conclusion, contrast venography is an excellent method for evaluation of the venous system, if performed adequately. Nevertheless, there is room for improvement of both technique and documentation.

[Magnetic resonance imaging of breast implants. Significance compared to mammography and ultrasonography]. / Kernspintomographie bei Mammaprothesen. Aussagekraft im Vergleich mit Mammographie und Ultraschall.

Magnetic resonance imaging (MRI), mammography and ultrasonography were performed in 44 consecutive women (mean age 45 [29-70] years) with a total of 73 silicone breast implants. The implant had been inserted after mastectomy for cancer in 15 patients, for cosmetic breast augmentation in 29. MRI proved to be superior to the other two imaging modalities with respect to assessing implant content, capsule and surrounding tissues. In 39 patients MRI clearly demarcated the implant from the residual breast tissue. But in four patients the lateral MRI assessment was impaired by phase artefact and in one other by movement artefacts in a restless patient. Implant thickness was underestimated by mammography and ultrasonography compared with MRI. In nine cases mammography showed retromammary parenchyma, while MRI did so in 20. The posterior wall of the implant was visualized by mammography in only one patient, but in all of them by MRI. Ultrasonography failed in all patients to show the entire implant circumference. In three cases MRI was the only imaging method which revealed a defect in the implant capsule with extrusion of silicone.

[Differential diagnosis of diseases of the Achilles tendon. A clinico-sonographic concept]. / Differentialdiagnose von erkrankungen der Achillessehne.

Ultrasound of the Achilles tendon is a suitable means of differentiating various diseases of the tendon and the surrounding tissue. Different forms of degenerative disease (tendinitis, peritendinitis or bursitis, fibroosteitis, and Haglund's disease) can be discriminated from rheumatic and metabolic diseases. Congenital and developmental abnormalities can also be detected. Tendon degeneration mainly occurs in the ventral part of the medial third of the tendon ("critical zone"). Immature tissue in this area leads to temporary [correction of temorary] instability of the tendon with a high risk of rupture ("vulnerable phase"). With sonography, lesions of the Achilles tendon are visible early in the course of the disease.

[Ultrasound morphology of the Achilles tendon and differential diagnosis]. / Die Sonomorphologie der Achillessehne und ihre Differentialdiagnose.

AIM: To correlate sonographic findings and clinical disorders of the Achilles tendon, considering newer aspects of their etiology and pathogenesis. METHOD: In a retrospective cross-sectional study the sonographic findings in 52 patients with tendonitis, heel swelling, or suspected rupture were analysed and correlated with the final diagnosis. Tendon lesions due to lipid storage diseases or rheumatic diseases were analysed on the basis of reports in the literature. RESULTS: Ultrasound abnormalities were found in 41 of the 52 symptomatic patients (40 degenerative changes of the tendon and/or the peritendinous tissue, 1 inflammatory rheumatologic process, 1 metabolic disorder, 8 ruptures, 2 congenital or developmental abnormalities). Ultrasound signs were not specific for each of the diagnoses but typical combinations of distinctive signs together with clinical findings led to the correct diagnoses. CONCLUSION: Patients with suspected lesions of the Achilles tendon should undergo an ultrasound investigation both to promote the exact diagnosis and to define the extent of the disease.

Complications after emergency tube thoracostomy: assessment with CT.

PURPOSE: To assess the spectrum of complications after emergency tube thoracostomy (TT) and show the role of computed tomography (CT) in detection of these abnormalities. MATERIALS AND METHODS: CT scans, chest radiographs, and clinical data were reviewed in 51 patients (77 tubes) who underwent emergency TT after trauma. CT scans were analyzed for chest tube malposition (CTM) and persistent pneumo- or hemathoraces. RESULTS: The complication most often seen after emergency TT, as demonstrated with CT, was CTM (20 of 77 tubes [26%]). Only seven of the CTMs seen at CT were evident on chest radiographs. Two extrathoracic and 18 intrathoracic (five intraparenchymal, nine intrafissural) malpositioned tubes were seen at CT. Other findings included persistent pneumo-and hemathoraces in 16 patients. CONCLUSION: Patients undergoing emergency TT are at increased risk for complications. CTM is the most common abnormality and should be diagnosed promptly to prevent additional problems. CT is more useful than plain radiography for establishing a diagnosis.

Preoperative imaging of lower extremity varicose veins: color coded duplex sonography or venography.

We prospectively examined 137 limbs in 112 consecutive patients with clinical evidence of severe varicosis by color coded duplex sonography and ascending venography (including varicography in 48 limbs) to evaluate the diagnostic capabilities of color coded duplex sonography in the assessment of venous anatomy, variant varicosis, postthrombotic changes, and incompetence of the superficial and perforating venous system. Additionally, descending venography was performed in the first 52 limbs and compared to color coded duplex sonography in the diagnosis of deep and superficial venous reflux. Variant venous anatomy (21 cases) was missed in two limbs and misinterpreted in one limb by ascending venography compared to surgery. Color coded duplex sonography was inconclusive in two cases. Variant varicosis (59 cases) was missed in seven surgically proved cases by venography and in one case by color coded duplex sonography. Color coded duplex sonography was inconclusive in five cases. Ascending venography was slightly superior to color coded duplex sonography in the detection of postphlebitic changes. Good agreement was found between color coded duplex sonography and descending venography in the grading of superficial (k = 0.75) and deep venous reflux (k = 0.79). Excellent agreement was found between ascending venography in the grading of long (k = 0.96) and short (k = 0.94) saphenous vein reflux. More incompetent perforating veins were detected by ascending venography, (and varicography) than by color coded duplex sonography, but the latter technique allows direct preoperative marking of the skin, which is beneficial for the surgeon. We conclude that color coded duplex sonography is a valuable imaging tool before venous stripping and is capable of replacing invasive ascending and descending venography. Only patients with inconclusive color coded duplex sonographic results (e.g., complex variant venous anatomy) should proceed to venography.