[Frequency and causes of civil and criminal proceedings in radiology. Analysis of a survey]. / Häufigkeit und Ursache zivil- und strafrechtlicher Verfahren in der Radiologie. Auswertung einer Befragung.

The eagerness of German patients to go to court on account of actual or suspected malpractice of their physicians has increased over the years, as is the case in other Western countries. Media coverage has given rise to criticism of physicians and their services rendered more than before. This naturally also concerns the discipline of radiology, even though the probability of a radiologist being accused in a lawsuit is clearly minor in comparison to the surgical disciplines. In contrast to other fields, the X-ray pictures are always available for a second opinion. In this study, 4760 radiologists were sent a questionnaire by mail and 1503 answered. The questionnaires were evaluated regarding interrogative and informative data from pending or completed proceedings. Lawsuits were directed towards the assessment of examinations (38%), the actual performance of an examination (30%) and not towards providing patients with information as we had expected. Angiographies, mammographies, and radiographies were the most frequent reasons for instituting proceedings. The majority of litigating patients was between 40 and 50 years old. The proceedings led to civil convictions in 30% and criminal convictions in 5.5%. Of the physicians accused of incorrect conduct, 73% were of the opinion that they had been treated unjustly, 26% supported the reproach as justified, and the rest had formed no opinion. Physicians in private practice and senior consultants (70%) were most frequently sued.

Virtual intra-arterial angioscopy (VIA) of the carotid artery based on helical CT data.

The purpose of this study was to visualize both the vessel wall and atherosclerotic plaques in virtual intra-arterial angioscopy (VIA) based on helical CT data sets. To achieve this in vitro, the optimal reconstruction threshold of the vessel wall was determined to be 56.4% of the maximum enhancement. Using this threshold, 20 patients suffering from symptomatic carotid disease were examined in a helical CT scanner. The degree of stenosis was defined using the North American Symptomatic Endarterectomy Trial (NASCET) criteria and compared with results from digital substraction angiography (DSA). Grading of stenoses was only possible by adding the separately computed plaque geometry to the geometry of the vessel wall in a second step. Correlation between VIA and DSA in low grade, medium grade and high grade stenosis was 88%, 93% and 71%, respectively. Complete occlusions were diagnosed correctly in all patients. Sensitivity and specificity for the correct diagnosis of high grade stenosis was 93.7% and 91.3%, respectively. A realistic depiction of intraluminal structures in carotid arteries can only be generated by displaying both the vessel wall and plaque structures simultaneously.

[Brain abscesses in diffusion-weighted imaging (DWI)--comparison to cystic brain tumors]. / Der Hirnabszess in der Diffusionswichtung und Unterschiede zum zystischen Hirntumor.

PURPOSE: The clinical usefulness of diffusion-weighted imaging (DWI) was evaluated in patients with brain abscesses in comparison to patients with cystic brain tumors. MATERIAL AND METHODS: Five patients with surgically confirmed brain abscesses underwent beside a brain MRI examination with contrast media application diffusion weighted imaging. Apparent diffusion coefficients (rADC) in three orthogonal diffusion gradient were calculated. The same protocol was used to examine 5 patients with cystic brain tumors. RESULTS: Showing an rADC of 0.33 x 10(-3)/mm(2)/s abscesses have a highly restricted diffusion in comparison to cystic brain tumors with an rADC of 1,67 x 10(-3)/mm(2)/s. CONCLUSION: Diffusion weighted imaging is a usefull diagnostic tool in the work up of brain abscesses.

Endoleaks after endovascular repair of aortic aneurysm: are they predictable?-initial results.

PURPOSE: To evaluate the predictability of endoleak. MATERIALS AND METHODS: Thirteen women and 60 men (mean age, 69.8 years) underwent transfemoral insertion of endoluminal stent-grafts for treatment of aortic aneurysms. Follow-up included helical computed tomography (CT) at 3-month intervals. In the cases of endoleak, angiography also was performed to document the number of leak sites, their size and position, the feeding artery, the size of the aneurysm, the amount of thrombus, and the visualization of the lumbar arteries and inferior mesenteric artery. These data were correlated (Student t test) with the probability of endoleak. RESULTS: A total of seven (10%) endoleaks were identified at CT in 68 patients. The feeding vessels were lumbar arteries in three cases, the inferior mesenteric artery in three cases, and the median sacral artery in one case. Of all factors, only the number of lumbar arteries visualized preoperatively (P <.005) had a significant correlation with probability of endoleak. In 71% (five of seven patients) of the cases of lumbar endoleak, four lumbar arteries were patent, whereas among the 61 patients with successfully repaired aneurysm, only eight (13%) had four patent lumbar arteries. Endoleaks were never found in the primarily thrombosed sections of an aneurysm. CONCLUSION: Prediction of endoleaks with absolute certainty remains elusive. The single correlating risk factor identified from the data was patency of four or more lumbar arteries visualized preoperatively at CT.

Embolization of type II endoleaks fed by the inferior mesenteric artery: using the superior mesenteric artery approach.

PURPOSE: To evaluate the use of a superior mesenteric artery (SMA) approach to embolize type II endoleaks arising from the inferior mesenteric artery (IMA). TECHNIQUE: When reperfusion of the aneurysmal sac via the SMA occurs through the IMA, as shown by computed tomography (CT) and angiography, the IMA origin can be accessed via the marginal artery or the anastomosis of Riolan. The SMA is catheterized with a 5-F catheter, and a coaxial catheter is advanced to the leak to deliver 2- to 8-mm-diameter minicoils to embolize the IMA origin and entire aneurysmal sac. Embolization usually requires from 1 to 2 hours to complete. In our experience with this technique in 11 cases, complications have not occurred, and there has been only one very small residual leak that sealed the next day. Over a 24.5-month follow-up (range 12-39), the endoleaks have remained sealed according to serial color duplex scans. CONCLUSIONS: Successful percutaneous treatment of type II endoleak due to IMA inflow can be accomplished using an SMA access via the Riolan anastomosis or marginal artery. The procedure appears to be safe and has no adverse effects.

CT and arteriography in the evaluation of indirect myocardial revascularization with a free-muscle transplant: initial experience.

PURPOSE: To examine patients with advanced cardiovascular disease with radiology after indirect myocardial revascularization with a free-skeletal-muscle transplant and to determine whether the attached vessel remains patent over the middle and long terms. MATERIALS AND METHODS: In 10 patients with advanced, inoperable cardiovascular disease treated with indirect myocardial revascularization with a free-muscle transplant, radiologic follow-up was performed postoperatively and every 6 months. All 10 patients underwent selective arteriography of the anastomosed vessel and contrast material-enhanced helical computed tomography (CT) (transverse sections and reconstructions). RESULTS: All patients showed adequate vascular conditions postoperatively, as did nine of 10 patients after 1 year. In one patient, the anastomosed artery was occluded. CT showed time-dependent muscle degeneration in all patients. Postoperative, contrast-enhanced, superselective CT showed an area of high-attenuating uptake in the muscle transplant in all patients. After 1 year, CT depicted perfusion defects of the skeletal muscle in two patients. In eight patients, however, small vascular bridges from the skeletal muscle to the myocardium were detected. Radiologic results correlated well with clinical outcome and stress electrocardiograms. CONCLUSION: Helical intraarterial CT and arteriography were sensitive in depicting enhancement and remaining vital function in nine of 10 patients after indirect myocardial revascularization with a free-muscle transplant. This combination seems promising for postoperative examination in such patients.

Treatment of leaks after endovascular repair of aortic aneurysms.

PURPOSE: To evaluate leaks after the endovascular repair of aortic aneurysms and treat them with occlusive therapy. MATERIALS AND METHODS: Seventy patients (11 women, 59 men), aged 26-82 years (mean, 69.2 years), underwent transfemoral insertion of endoluminal stent-grafts for treatment of aortic aneurysms. Indications were traumatic pseudoaneurysms (n = 5) or arteriosclerotic aneurysms (n = 65). Aneurysms were thoracic (n = 5) or infrarenal (n = 65). To exclude the possibility of leaks, spiral computed tomography (CT) was performed at 3-month intervals. Patients with leaks that persisted unchanged longer than 3 months were referred for angiography and occlusive therapy. RESULTS: At CT, 21 leaks were identified in 17 of 70 patients (24%). Only 11 of those 17 patients (65%) had leaks identified with conventional aortography. Selective angiography, however, depicted all of these. Eighteen of 21 leaks proved amenable to occlusive treatment: surgery (n = 1), further stent implantation (n = 4), or embolization (n = 13). In one leak, spontaneous occlusion occurred after 3 months. Two leaks in either the iliolumbar or the median sacral artery were inaccessible; one remained untreated, and the other was unsuccessfully treated. Mean follow-up of occlusive therapy was 6.8 months (range, 2-14 months). CONCLUSION: Successful occlusion of perigraft leaks is feasible in most cases and can be performed without major complications.

Malpositioned or dislocated aortic endoprostheses: repositioning using percutaneous pull-down maneuvers.

PURPOSE: To present the capabilities and potential complications of 2 percutaneous techniques for repositioning malpositioned or dislodged aortic endografts. METHODS: Seven male patients (median age 67.9 years, range 59 to 78) required correction of misplaced or dislocated endografts in the thoracic (n = 1) or infrarenal abdominal aorta (n = 6). In 1 patient, an infrarenal bifurcated stent-graft was mistakenly deployed across a renal artery; repositioning was accomplished by tugging caudally on a guidewire placed across the endograft bifurcation and exteriorized from both femoral arteries. An inflated balloon catheter was used to reposition 3 dislocated aortic devices (1 thoracic, 2 infrarenal) and 3 iliac graft limbs that had disconnected from the main graft body 6 to 12 months after implantation. RESULTS: Repositioning maneuvers were successful in all cases, with the devices being moved from 5 to 27 mm (median 7.8 mm). There were no procedure-related complications. CONCLUSIONS: Nonsurgical repositioning of misplaced aortic prostheses is technically feasible in individual cases. The risk associated with the procedure, however, cannot yet be evaluated.

Embolization for gastrointestinal hemorrhages.

Retrospective evaluation of interventional embolization therapy in the treatment of gastrointestinal hemorrhage over a long-term observation period from 1989 to 1997. Included in the study were 35 patients (age range 18-89 years) with gastrointestinal bleeding (GI) referred for radiological intervention either primarily or following unsuccessful endoscopy or surgery. Sources of GI bleeding included gastric and duodenal ulcers (n = 7), diverticula (n = 3), erosion of the intestinal wall secondary to malignancy (n = 6), vascular malformations (n = 4), and hemorrhoids (n = 2), as well as from postoperative (n = 6), posttraumatic (n = 2), postinflammatory (n = 4) or unknown (n = 1) causes. Ethibloc (12 cases) or metal coils (14 cases) were predominantly used as embolisates. In addition, combinations of tissue adhesive and gelfoam particles and of coils and Ethibloc were used (six cases). Finally, polyvinyl alcohol particles, a coated stent, and an arterial wire dissection were utilized in one case each. Bleeding was stopped completely in 29 of 35 cases (83%). In one case (3%) the source of bleeding was recognized but the corresponding vessel could not be catheterized. In five other cases (14%) there was partial success with reduced, though still persistent, bleeding. The rate of complications was 14%, including four instances of intestinal ischemia with fatal outcome in the first years, and, later, one partial infarction of the spleen without serious consequences. Gastrointestinal hemorrhage can be controlled in a high percentage of patients, including the seriously ill and those who had previously undergone surgery, with the use of minimally invasive interventional techniques. The availability of minicoils instead of fluid embolization agents has reduced the risk of serious complications.

Angiography of leaks after endovascular repair of infrarenal aortic aneurysms.

OBJECTIVE: We examined whether leaks that persist after stent grafting are associated with outflow arteries. SUBJECTS AND METHODS: Selective angiography was performed in 21 patients with persistent leaks after undergoing endovascular repair of infrarenal aneurysms of the abdominal aorta. Late leaks occurred in five patients whose prostheses were originally sealed. Before angiography, the size and position of leaks were determined with CT and color Doppler sonography. RESULTS: Superselective angiography was successful in 19 of 21 patients. In two patients, angiography was performed over the afferent artery supplying the leak. We found one outflow artery at the site of the leak in 10 patients (47%); two outflow arteries in five (23.8%); and as many as five outflow arteries in three (14%). Angiography overlooked outflow arteries in three patients (14%). The lumbar and inferior mesenteric, urethral, and testicular arteries were identified as outflow arteries. CONCLUSION: Other than feeder arteries, persistent leaks are associated with outflow vessels that contribute to the patency of leaks.

[Pancreatic interventions: biopsy, drainage, necrosectomy--from the viewpoint of the radiologist]. / Interventionen am Pankreas: Biopsie, Drainage, Nekrosektomie--Sicht des Radiologen.

The following publication is an overview looking at diagnostic and therapeutic possibilities related to interventional procedures for diseases of the pancreas. We emphasize the description of the technique and show meaningful indications and limitations.

Leakages after endovascular repair of aortic aneurysms: classification based on findings at CT, angiography, and radiography.

PURPOSE: To ascertain whether the configuration and location of leakages identified at computed tomography (CT) could provide evidence of their angiographically and fluoroscopically confirmed causes. MATERIALS AND METHODS: Fifty patients aged 26-79 years underwent endovascular repair of traumatic (n = 4) or arteriosclerotic (n = 46) aortic aneurysms (four thoracic, 46 infrarenal). Radiographic examinations in three planes and helical CT were performed 1 week after implantation and every 3 months thereafter. Angiography was performed when there was evidence of a leakage at CT. RESULTS: CT demonstrated evidence of leakages in 13 patients. Broad-based leakages immediately adjacent to the prosthesis were termed "perigraft leakages." If the area most affected by the leakage lay along the border of the aneurysm, then retrograde leakages were apparent at angiography. If the leakage was ventral to the prosthesis, then its source was the inferior mesenteric artery; if it was dorsolateral, then it was supplied by either the lumbar arteries or the median sacral artery through the hypogastric artery. One circumferential leakage could not be evaluated adequately at CT or angiography. Radiography depicted a rupture of the stent mesh in the middle of the prosthesis. Selective angiography demonstrated all types of leakages and permitted CT classification. CONCLUSION: The cause of a leakage can be determined with CT on the basis of its configuration and location in the majority of cases.

[Interventional treatment of hemorrhages in advanced cervical carcinoma]. / Interventionelle Behandlungsmöglichkeiten von Blutungen bei fortgeschrittenen Karzinomen der Cervix uteri.

PURPOSE: Retrospective evaluation of percutaneous interventional treatment of locally advanced cervical carcinoma. MATERIALS AND METHODS: Since 1991, 13 patients with advanced tumor disease have been referred to our department for diagnosis and therapy of an acute blood loss. In all patients (age 40-88 years, mean 61 years) hemorrhage was detected by decrease in red blood cell count. In all cases patients suffered from locally advanced or recurrent disease after surgery and/or additional radio- or chemotherapy. Embolization was performed by transfemoral access using minicoils in most cases, liquid agents less often and a covered vascular stent in one patient. RESULTS: The site of the hemorrhage or the blood pooling of the tumor could be seen in all cases angiographically. Twenty-seven treatment cycles (2.1 per patient) were performed at intervals of 3 days to 6 months. The maximum time of follow-up and additional treatments if necessary was 1 year. In 9 of 13 patients (69%) the bleeding could be stopped immediately with a single treatment or initial treatment via both iliac arteries. One patient (7,7%) died during therapy because of an uncontrollable bleeding and consecutive decrease in red blood cells count. The remaining three patients (23%) showed slight persistent or recurrent bleeding, which could be managed interventionally until the following episode. There were two complications (15%) during therapy, representing a coil misplacement and a coil wash-out, which both could be managed interventionally. CONCLUSION: Hemorrhage following locally advanced or recurrent cervical carcinoma can be stopped interventionally in about 70% of cases. Even in partial success it is possible to manage the acute life-threatening situation. Follow-up examinations of up to 1 year justify this therapeutic concept.

Endovascular repair of aortic aneurysms: treatment of complications.

PURPOSE: To evaluate the use of interventional procedures for treating complications following endovascular repair of aortic aneurysms. METHODS: Fifty-five patients (49 men; mean age 67.5 years) underwent endoluminal stent-graft repair of traumatic (n = 4) or arteriosclerotic (n = 51) aortic aneurysms in the thoracic (n = 3) or infrarenal (n = 52) aorta. Follow-up of therapeutic success included periodic clinical examination, angiography, and spiral computed tomography. RESULTS: Discounting the 25 (45%) cases of postimplantation syndrome that did not require treatment, there were 22 complications observed in 20 (36%) patients over a mean 10-month follow-up (range 1 to 27). There were 2 transrenal endograft maldeployments, 1 case of twisted graft limbs, 2 access site problems (1 patient), 12 endoleaks (11 patients), 1 late graft limb thrombosis, 1 symptomatic internal iliac artery occlusion, 2 myocardial infarctions, and 1 transient psychosis. Seven (13%) patients did not undergo specific therapy, while 4 (7%) required operation (2 crossover bypass grafts, 1 suture revision, and 1 graft replacement). Among 9 (16%) patients treated with interventional techniques, 7 underwent percutaneous coil embolization for 8 endoleaks (7 successfully resolved). One late stent-graft disconnection required an additional stent-graft, and 1 of the 2 malpositioned endografts was repositioned. All patients remain alive with no increase in the diameter of the aneurysm in any patient. CONCLUSIONS: Technical problems resulting from the endovascular repair of aortic aneurysms often respond to interventional treatment.

Non-operative management of arterial liver hemorrhages.

A retrospective evaluation of embolotherapy in patients with arterial liver hemorrhages was carried out. Twenty-six patients, ranging in age from 10 days to 77 years with active arterial liver hemorrhages, underwent non-surgical embolotherapy. Bleeding was attributed to trauma (n = 21), tumor (n = 3), pancreatitis (n = 1), or unknown cause (n = 1). Twenty-nine embolizations were performed via a transfemoral (n = 26) or biliary (n = 2) approach. One bare Wallstent was placed into the common hepatic artery via to an axillary route to cover a false aneurysm due to pancreatitis. Treatment was controlled in 4 patients by cholangioscopy (n = 2) or by intravascular ultrasound (n = 2). Prior surgery had failed in 3 patients. Intervention controlled the hemorrhage in 24 of 26 (92%) patients within 24 h. Embolotherapy failed in 1 patient with pancreatic carcinoma and occlusion of the portal vein. In 1 patient with an aneurysm of the hepatic artery treated by Wallstent insertion, total occlusion was not achieved in the following days, as demonstrated by CT and angiography. However, colour Doppler flow examination showed no flow in the aneurysm 6 months later. Complications were one liver abscess, treated successfully by percutaneous drainage for 10 days, and one gallbladder necrosis after superselective embolization of the cystic artery. Embolization is a effective tool with a low complication rate in the treatment of liver artery hemorrhage, even in patients in whom surgery has failed.

[The percutaneous transarterial embolization therapy of traumatic kidney hemorrhages]. / Perkutane transarterielle Embolisationstherapie von traumatischen Nierenblutungen.

PURPOSE: To demonstrate the possibility of transarterial, superselective embolization after traumatic kidney injury and hemorrhage in patients usually treated by surgery. METHODS: In a series of 16 patients aged 21 to 86 years (mean 37 years) external trauma led to kidney damage and consecutive bleeding. After diagnostic angiography (5 F) the exact site of hemorrhage was detected and treated by superselective embolization via a coaxial catheter system (2.7 F) either by coils (n = 5) or liquid agents (ethibloc, n = 11). RESULTS: In all patients bleeding was stopped interventionally. Additional surgical treatment was not necessary in any case. In one older patient with preinterventionally known reduced kidney function, the excretion function decreased to creatinine levels of about 3.6 mg/dl after therapy and led to compensated nephric insufficiency. Other complications were not observed. CONCLUSION: Interventional embolization is a well-tolerated and effective treatment modality after traumatic kidney hemorrhage. After exclusion of other injuries obligate for surgery, percutaneous transarterial therapy may help to avoid an operation. This reduces the risk of narcosis and treatment especially in multimorbid patients.

Left iliac venous thrombosis caused by venous spur: treatment with thrombectomy and stent implantation.

PURPOSE: To determine the frequency of iliac venous spurs in left iliofemoral venous thrombosis and to report the results of interventional management of venous spurs after transfemoral venous thrombectomy. METHODS: From 1990 through 1996, 77 patients with acute iliac venous thrombosis (61 left and 16 right) underwent surgical treatment. Patients with malignant disease were excluded from this series. All patients had transfemoral venous thrombectomy with construction of an inguinal arteriovenous fistula and perioperative anticoagulation with heparin with a switch to warfarin sodium for at least 12 postoperative months. Immediate results of thrombectomy were documented by means of intraoperative completion venography. Arteriovenous fistulas were ligated 3 months after control arteriovenography. Since 1995 venous spurs eventually detected during thrombectomy were treated immediately by means of stent implantation. RESULTS: Among 61 patients with left-sided thrombosis, intraoperative phlebography revealed common iliac venous obstruction suggestive of venous spurs in 30 patients (49%). In 16 of 22 patients (73%) with untreated spurs, postoperative rethrombosis of the iliac vein was documented despite adequate anticoagulation. Only one of eight patients (13%) with stented spurs had reocclusion (chi2 test P < .01). CONCLUSION: Venous spurs are found among about half of patients with left-sided iliac venous thrombosis. As long as the underlying venous pathologic process is left untreated, thrombectomy will not restore patency. Stent implantation is a simple and safe means to correct central venous strictures and provides excellent long-term results.

Diagnostic value of spiral-CT angiography in comparison with digital subtraction angiography before and after peripheral vascular intervention.

To evaluate spiral-computed tomography (CT) angiography in primary diagnosis and/or in noninvasive follow-up after vascular intervention, we compared spiral-CT angiography and conventional angiography before and after vascular intervention. Helical-CT examinations before and after percutaneous transluminal angioplasty (PTA) or stent implantation were performed in 10 patients (mean age 63 years) with symptomatic peripheral arteriosclerotic disease. Stenoses were located in the iliac, femoral, or popliteal artery. CT examinations were done with a spiral-CT in double detector technique (CT Twin, Elscint). The parameters were as follows: slice thickness: 5.5 mm, increment: 2.7 mm, pitch: 1.5, contrast medium: 150 mL, flow rate: 2.5 mL/second, delay: 30 seconds. For evaluation, transverse planes as well as maximum intensity projections and 3-D reconstructions were used. The possible scan length reached from the aortic bifurcation down to about 10 cm below the ankle trifurcation. Preinterventional digital subtraction angiography (DSA) was superior to CT angiography (CTA: 94%, maximum intensity projection [MIP] alone: 65%), although high-grade stenoses were detected by both methods. After intervention, a resolved stenosis and improved peripheral flow could be detected by helical-CT as well as by intraarterial angiography in every patient (100%). In the primary diagnosis of vascular changes, intraarterial DSA remains the method of choice. Nevertheless, spiral-CT angiography shows comparable results after percutaneous intervention and becomes a noninvasive alternative in the postinterventional follow-up.