Hybrid repair for Kommerell's diverticulum and right aortic arch with aberrant right vertebral artery.

Kommerell's diverticulum (KD) is a rare aneurysm of the origin of an aberrant subclavian artery. Hybrid aortic arch repair for KD is being performed more often. We report hybrid arch repair for KD in a 63-year-old man with a right aortic arch and aberrant right vertebral artery, an extremely rare variant. We performed total arch replacement to completely reconstruct the five cervical arteries with elephant trunk to create an adequate landing zone, followed by second-stage endovascular stent-grafting from the ascending aorta to the proximal descending aorta.

Three-dimensional Magnetic Resonance Imaging of the Anterolateral Ligament of the Knee: An Evaluation of Intact and Anterior Cruciate Ligament-Deficient Knees From the Scientific Anterior Cruciate Ligament Network International (SANTI) Study Group.

PURPOSE: To determine the visualization rate of the anterolateral ligament (ALL) in uninjured and anterior cruciate ligament (ACL)-deficient knees using 3-dimensional (3D) magnetic resonance imaging (MRI) and to characterize the spectrum of ALL injury observed in ACL-deficient knees, as well as determine the interobserver and intraobserver reliability of a 3D MRI classification of ALL injury. METHODS: A total of 100 knees (60 ACL deficient and 40 uninjured) underwent 3D MRI. The ALL was evaluated by 2 blinded orthopaedic surgeons. The ALL was classified as follows: type A, continuous, clearly defined low-signal band; type B, warping, thinning, or iso-signal changes; and type C, without clear continuity. The comparison between imaging performed early after ACL injury (<1 month) and delayed imaging (>1 month) was evaluated, as was intraobserver and interobserver reliability. RESULTS: Complete visualization of the ALL was achieved in all uninjured knees. In the ACL-deficient group, 24 knees underwent early imaging, with 87.5% showing evidence of ALL injury (3 normal, or type A, knees [12.5%], 18 type B [75.0%], and 3 type C [12.5%]). The remaining 36 knees underwent delayed imaging, with 55.6% showing evidence of injury (16 type A [44.4%], 18 type B [50.0%], and 2 type C [5.6%]). The difference in the rate of injury between the 2 groups was significant (P = .03). Multivariate analysis showed that the delay from ACL injury to MRI was the only factor (negatively) associated with the rate of injury to the ALL. Interobserver reliability and intraobserver reliability of the classification of ALL type were good (κ = 0.86 and κ = 0.93, respectively). CONCLUSIONS: Three-dimensional MRI allows full visualization of the ALL in all normal knees. The rate of injury to the ALL in acutely ACL-injured knees identified on 3D MRI is higher than previous reports using standard MRI techniques. This rate is significantly higher than the rate of injury to the ALL identified on delayed imaging of ACL-injured knees. LEVEL OF EVIDENCE: Level IV, diagnostic, case-control study.

Hybrid repair of an aortocaval fistula and inferior vena cava external compression caused by an inflammatory aortoiliac aneurysm: a case study.

INTRODUCTION: We report a case of aortocaval fistula successfully treated by hybrid operation. CASE DESCRIPTION: A 73-year-old female suffering from malignant lymphoma and painful leg edema was transferred to our institution. Computed tomography revealed an aortoiliac aneurysm. The inferior vena cava was compressed by displacement of the abdominal aortic aneurysm. The bilateral internal iliac and ovarian veins were markedly dilated. Diagnosis was an aortoiliac aneurysm with aortocaval fistula. The treatment options were open surgery or an intervention with bypass surgery. Because of narrow iliac access for a bifurcated stent graft, aorto-uni stentgraft treatment followed by bypass surgery was finally decided. Following stent graft insertion and iliofemoral artery bypass, the aneurysms and fistula were successfully excluded without endoleaks. To treat the inferior vena cava compression, the kissing technique was used to place bare metallic stents across the bilateral common iliac veins and inferior vena cava, which improved the clinical symptoms. DISCUSSION AND EVALUATION: In this aortocaval fistula caused by AAA, a minimally invasive treatment of stentgraft and bypass surgery with venous flow recovery was chosen as a hybrid treatment. Intravascular intervention was the most suitable in this situation. Bare stent placement for venous occlusion was also effective for revascularization of vena cava flow. CONCLUSION: Recent advances in endovascular devices, including stent grafts and bare metallic stents, will be helpful for effective noninvasive treatment for aortocaval fistula circulation.

Frequency analyses of CSF flow on cine MRI in normal pressure hydrocephalus.

Our objective was to clarify intracranial cerebrospinal fluid (CSF) flow dynamics in normal-pressure hydrocephalus (NPH). Frequency analyses of CSF flow measured with phase-contrast cine MRI were performed. The CSF flow spectra in the aqueduct were determined in patients ( n=51) with NPH, brain atrophy or asymptomatic ventricular dilation (VD), and in healthy volunteers (control group; n=25). The changes in CSF flow spectra were also analyzed after intravenous injection of acetazolamide. Moreover, a phase transfer function (PTF) calculated from the spectra of the driving vascular pulsation and CSF flow in the aqueduct were assessed. These values were compared with the pressure volume response (PVR). The amplitude in the NPH group was significantly larger than that in the VD or control group because of a decrease in compliance. The phase in the NPH group was significantly different from that in either the VD or the control group, but no difference was found between the VD and control groups. The amplitude increased in all groups after acetazolamide injection. The PTF in the NPH group was significantly larger than in the control group, and a positive correlation was noted between PTF and PVR. Frequency analyses of CSF flow measured by cine MRI make it possible to noninvasively obtain a more detailed picture of the pathophysiology of NPH.

Measurements of MTF and SNR(f) using a subtraction method in MRI.

A method was developed for accurate measurement of the modulation transfer function (MTF) and signal-to-noise ratio in the spatial frequency domain (SNR(f)) of magnetic resonance images (MRI). The MTF was calculated from the complex images of a line object which were obtained by the subtraction of two separately acquired data sets of a specially designed phantom with a sliding sheet. Moreover, the SNR(f) was calculated from the MTF and Wiener spectrum, both of which were determined using the same phantom configuration. The MTFs and SNR(f)s in the conventional spin-echo (SE) and turbo SE, in which the effective echo time was set to the first echo, were evaluated by changing the T2 of the phantom and the echo train length. The MTFs in the positive and negative frequencies indicated the effect of the k-space trajectory for each pulse sequence. SNR(f)s gave spatial frequency information that was not obtained with conventional methods. In this method, the influence of image nonuniformity and unwanted artefacts (edge and ghost) could be eliminated. An analysis of the MTF and the SNR in the spatial frequency domain provides additional information for the assessment of image quality in MRI.

Embolization in a patient with ruptured anterior inferior pancreaticoduodenal arterial aneurysm with median arcuate ligament syndrome.

In median arcuate ligament syndrome, the root of the celiac artery is compressed and narrowed by the median arcuate ligament of the diaphragm during expiration, causing abdominal angina. Aneurysm may be formed in arteries of the pancreas and duodenum due to a chronic increase in blood flow from the superior mesenteric artery into the celiac arterial region. We report a patient saved by embolization with coils of ruptured aneurysm that developed with markedly dilated anterior inferior pancreaticoduodenal artery due to median arcuate ligament syndrome.