11-Oxygenated androgens are not secreted by the human ovary: in-vivo data from four different cases of hyperandrogenism.

Objective: Differentiation of an adrenal from an ovarian source of hyperandrogenemia can be challenging. Recent studies have highlighted the importance of 11-oxygenated C19 steroids to the androgen pool in humans. The aim of this study was to confirm the origin of 11-oxygenated androgens in females and to explore their potential use in the diagnostics of hyperandrogenic disorders. Methods: We measured testosterone and its precursors (dehydroepiandrosterone-sulfate and androstenedione) and 11-oxygenated androgens (11ß-hydroxyandrostenedione (11-OHA4) and 11-ketotestosterone (11-KT)) in the periphery, adrenal and ovarian veins in four different cases of hyperandrogenism in females (polycystic ovary syndrome (PCOS), primary bilateral macronodular adrenal hyperplasia, Sertoli-Leydig cell tumor and ovarian steroid cell tumor). Results: Two patients demonstrate excessive testosterone secretion in neoplastic ovarian tumors which was not paralleled by a significant secretion of 11-oxygenated androgens as determined by adrenal and ovarian vein sampling. In androgen-secreting bilateral adrenal macronodular hyperplasia, steroid profiles were characterized by elevated 11-KT and 11-OHA4 concentrations in adrenal veins and the periphery. In the patient with PCOS, peripheral 11-KT concentrations were slightly elevated in comparison to the other patients, but the 11-KT and 11-OHA4 concentrations were comparable in ovarian veins and in the periphery. Conclusion: This study confirms that 11-OHA4 and 11-KT are not biosynthesized by the ovary. We propose that the testosterone/11-KT ratio as well as 11-OHA4 could help identify predominant adrenal androgen excess and distinguish neoplastic and non-neoplastic ovarian androgen source. Significance statement: This study confirms that 11ß-hydroxyandrostenedione (11-OHA4) and 11-ketotestosterone (11-KT) are not biosynthesized by the human ovary. We propose that the testosterone/11-KT ratio as well as 11-OHA4 could help to identify predominant adrenal androgen excess and distinguish neoplastic and non-neoplastic ovarian androgen source.

Radiological evidence of purulent infections in ancient Egyptian child mummies.

OBJECTIVE: To identify computed tomography (CT) findings of purulent infections in ancient Egyptian child mummies. MATERIALS: Whole-body CT examination of 21 ancient Egyptian child mummies from German (n = 18), Italian (n = 1), and Swiss museums (n = 2). METHODS: CT examinations were evaluated for estimation of age at death and sex of the children. CT examinations were systematically assessed for any CT findings of purulent infection. RESULTS: The estimated age at death of the children ranged from about one year to the age of 12-14 years (mean 4.8 years). Twelve children were assessed as male, seven as female and in two sex was indeterminate. Three out of 21 child mummies (14.3%) had radiological evidence of purulent infections. In one mummy, a bandage-like structure at the right lower leg was detected that most likely represented a dressing of a skin lesion. CONCLUSIONS: This study appears to be the first to describe radiologically visualized structures consistent with dried pus in ancient Egyptian mummies. This study also appears to be the first to physically demonstrate an original ancient Egyptian dressing. SIGNIFICANCE: These cases may serve as models for further paleopathological investigation. The evidence of an original dressing contributes to our knowledge of ancient Egyptian medicine. LIMITATIONS: CT was used as the only examination method as sampling of the wrapped mummies was not possible. SUGGESTIONS FOR FURTHER RESEARCH: Radiological-pathological correlation in mummies in which physical sampling is available may reveal further insights into purulent infections in ancient Egypt.

Corona again? SSC after a severe COVID-disease.

Secondary sclerosing cholangitis (SSC) is a severe complication of intensive care treatment in critically ill patients. It is characterized by rapid onset and severe chlolestasis with elevation of gGT. In contrast to primary sclerosing cholangitis, SSC-CIP has a distinct and timely well defined trigger and can have a rapid progress to cirrhosis and liver failure. In context of the COVID-19-pandemic, there are reports about patients, who developed SSC after a severe COVID-infection and intensive care treatment.We report on a 62-year old patient without any relevant pre-existing illnesses, who suffered from severe COVID-19 pneumonia with the need for long term ventilation. In the course of the disease he developed a critical-illness-polyneuropathy a pronounced cholestasis. After recovery from COVID-pneumonia, the PNP regressed but the cholestasis progressed. MRCP showed only irregular intrahepatic bile ducts, while EUS showed echogenic intraductal longitudinal structures characteristic for intraductal casts and for SSC-CIP. This was confirmed with ERC, where the complete necrotic bile ducts could be extracted and retrieved for histological and molecular analysis.The patient was included in a scheduled ERC-program to prevent a progress of SSC and the concomitant cirrhosis.SSC is an often missed diagnosis, which obviously can also occur in COVID-patients. In case of elevated liver function tests with cholestasis, EUS might be the key diagnostic method to characterize intraductal casts and identify those patients who should undergo ERC.

Embolic Protection in Complex Femoropopliteal Interventions: Safety, Efficacy and Predictors of Filter Macroembolization.

OBJECTIVES: To evaluate the safety and efficacy of a filter embolic protection device (FEPD) in endovascular interventions of the femoropopliteal arteries. METHODS: Patients who underwent endovascular interventions of the femoropopliteal arteries between 2008 and 2016 and in whom the SpiderFXTM FEPD was applied were included in this retrospective study. Clinical and angiographic characteristics, filter macroembolization (FME), device-related complications, distal embolization, as well as the early clinical and hemodynamic outcome, were assessed. Potential risk factors for FME were evaluated by multivariate analysis. RESULTS: A total of 244 cases were identified (203 patients, claudication 60.4%, critical limb ischaemia 39.6%, mean lesion length 13.2 ± 12.9 cm, complete occlusions in 72.7%). Balloon angioplasty ± stenting (BAP), directional atherectomy ± balloon angioplasty ± stenting (DA) and rotational thrombectomy ± balloon angioplasty ± stenting (RT) were performed in 141, 61 and 42 cases, respectively. FEPD placement and retrieval were successful in all but one case each. Permanent filter-related vessel damage was not observed. The rate of FME was 37.3% (BAP 36.2%, DA 32.8%, RT 47.7%). Risk factors for FME in the BAP- and DA-group were total occlusion, lesion length > 19 cm, visible thrombus and diabetes mellitus. The distal embolization rate despite filter protection was 4.1 % (BAP 4.9%, DA 1.6%, RT 4.8%) and was higher in cases with FME compared with those without FME (8.7% vs. 1.5%, p = 0.02). CONCLUSION: The Spider FXTM device is safe and effective in capturing embolic debris during femoropopliteal interventions. A residual risk of peripheral embolization remains. LEVEL OF EVIDENCE: III, Cohort study.

Clinical value of [18F]FDG-PET/CT and 3D-black-blood 3T-MRI for the diagnosis of large vessel vasculitis and single-organ vasculitis of the aorta.

BACKGROUND: We aimed to investigate the clinical value of a 3D-T1w turbo-spin-echo (TSE) sequence and [18F]fluorodeoxyglucose positron emission tomography/computed tomography ([18F]FDG-PET/CT) for the diagnosis of active large vessel vasculitis (LVV) and single-organ vasculitis (SOV) of the aorta. METHODS: Twenty-four patients with suspected vasculitis who underwent MRI and PET/CT were retrospectively evaluated. MRI was analyzed for concentric contrast enhancement and wall thickening, and flow artifact intensity (4-point-scales). PET/CT analysis comprised qualitative, quantitative and semiquantitative methods. Imaging findings were correlated with final diagnosis derived from the clinical follow-up data. RESULTS: Fifteen of 24 patients had a clinically confirmed active vasculitis, two had inactive vasculitis and 7 no vasculitis. [18F]FDG-PET/CT and 3D-T1w TSE-MRI revealed both a high diagnostic accuracy of 88% and 83%, respectively. In patients in whom both PET/CT and MRI showed concordant findings (19 patients), the accuracy increased to 95% with a high positive predictive value (92%) and negative predictive value (100%); thus, a correct diagnosis was obtained in 18 of 19 patients. Among the five patients with discordant findings PET/CT correctly identified the two patients without active vasculitis while rated false positive on MRI. Of the three remaining patients with active vasculitis, two were correctly identified by MRI and one by PET/CT. CONCLUSIONS: 3D-T1w TSE-MRI and [18F]FDG-PET/CT are both useful in the diagnosis of active vasculitis with high diagnostic accuracies. The diagnostic accuracy was even optimized by combining the two analysis methods. Therefore, there might be substantial potential for the application of whole-body hybrid PET/MRI in the evaluation of vasculitis in future studies.

Primary and Secondary Hyperparathyroidism in Patients with Primary Aldosteronism - Findings From the German Conn's Registry.

CONTEXT: Recent studies support a bidirectional interaction between aldosterone and parathyroid hormone (PTH), possibly increasing the individual cardiovascular risk. Primary aldosteronism (PA) and primary hyperparathyroidism can occur simultaneously. OBJECTIVE: Our aim was to investigate the prevalence of hyperparathyroidism in PA. PATIENTS: We performed a case finding of primary hyperparathyroidism in a retrospective series of 503 patients with PA (cohort 1). We analysed primary and secondary hyperparathyroidism in 141 prospective PA patients who underwent PTH, serum calcium and phosphate measurements at time of diagnosis of PA (cohort 2). RESULTS: The prevalence for primary hyperparathyroidism was 1.2% in cohort 1, and 2.1% in cohort 2. Secondary hyperparathyroidism was found in 54.6% of the patients. Patients with secondary hyperparathyroidism had significantly higher aldosterone and lower potassium levels and took more antihypertensive medications compared to those with normal PTH levels. In multivariate analysis, aldosterone and 25-hydroxyvitamin D levels were significantly correlated with serum PTH levels. There was a nonsignificant trend to a higher cardiovascular morbidity in patients with secondary hyperparathyroidism. Patients with aldosterone producing adenoma had significantly higher PTH levels compared to patients with bilateral adrenal hyperplasia. After treatment, there was a significant decrease of PTH levels in both groups. CONCLUSION: Patients with PA frequently have primary or secondary hyperparathyroidism, which is alleviated by correction of PA by surgical or medical means. Patients affected by secondary hyperparathyroidism seem to have a more severe phenotype of PA and have a trend towards more cardiovascular co-morbidities.

Patients With Primary Aldosteronism Respond to Unilateral Adrenalectomy With Long-Term Reduction in Salt Intake.

CONTEXT: High dietary salt intake is known to aggravate arterial hypertension. This effect could be of particular relevance in the setting of primary aldosteronism (PA), which is associated with cardiovascular damage independent of blood pressure levels. The aim of this study was to determine the impact of therapy on salt intake in PA patients. PATIENTS AND METHODS: A total of 148 consecutive PA patients (66 with unilateral and 82 with bilateral PA) from the database of the German Conn's Registry were included. Salt intake was quantified by 24-hour urinary sodium excretion before and after initiation of PA treatment. STUDY DESIGN: Observational longitudinal cohort study. SETTING: Tertiary care hospital. RESULTS: At baseline, unilateral PA patients had a significantly higher urinary sodium excretion than patients with bilateral disease (205 vs 178 mmol/d, P = 0.047). Higher urinary sodium excretion correlated with an increased cardiovascular risk profile including proteinuria, impaired lipid, and glucose metabolism and was associated with higher daily doses of antihypertensive drugs to achieve blood pressure control. In unilateral disease, urinary sodium excretion dropped spontaneously to 176 mmol/d (P = 0.012) 1 year after unilateral adrenalectomy and remained low at 3 years of follow-up (174 mmol/d). In contrast, treatment with mineralocorticoid receptor antagonists (MRA) in bilateral PA patients was not associated with a significant change in urinary sodium excretion at follow-up (179 mmol/d vs 183 mmol/d). CONCLUSION: PA patients consuming a high-salt diet, estimated based on urinary sodium excretion, respond to adrenalectomy with a significant reduction of salt intake, in contrast to MRA treatment.

A pitfall of bilateral inferior petrosal sinus sampling in cyclic Cushing's syndrome.

BACKGROUND: Clinical care of patients with cyclic Cushing's syndrome (CS) is challenging. Classical pitfalls include incorrect subtyping, unnecessary surgical procedures and delayed definite treatment. CASE PRESENTATION: A 43-year-old female suffered from a rapidly cycling ectopic CS. She experienced six cycles of severe hypercortisolism within a 2 year period (maximum plasma cortisol 5316 nmol/L, normal range 124.2-662.4 nmol/L; maximum urinary free cortisol 79,469 nmol/24 h, normal range < 414 nmol/24 h) lasting 2-9 weeks. The episodes were associated with pronounced hypokalemia (lowest K+ value recorded 2.4 mmol/l) and progressive signs and symptoms of CS. A bilateral inferior petrosal sinus sampling (BIPSS) performed during a trough phase was false positive for pituitary ACTH overproduction resulting in unnecessary transsphenoidal surgery while a second BIPSS performed during an active phase was indicative for ectopic CS. The 18F-DOPA PET/CT showed a pancreatic lesion, which was subsequently partially removed. Surprisingly, the histopathology was conclusive for ACTH-positive lymph node metastasis located in the retro-duodenal tissue of an occult neuroendocrine tumor WHO grade II. The primary tumor has not been identified so far and, because of the persistent hypercortisolism, the patient underwent bilateral adrenalectomy. Two years later, ACTH levels started to increase progressively. Percutaneous biopsy of a newly identified suspected lesion in the fifth thoracic vertebra revealed a metastasis with positive staining for ACTH, synaptophysin and chromogranin A. Therapy with carboplatin and etoposide was started and, since then, the patient underwent 12 cycles of chemotherapy. CONCLUSIONS: We report the challenging case of a rapidly cycling CS secondary to ACTH-secreting neuroendocrine intestinal tumor of unknown primary. We highlight the importance of performing diagnostic tests only during the phases of active cortisol secretion and as soon as first symptoms appear to avoid pitfalls.

Assessment of Disease Activity in Takayasu Arteritis: Potential Role of Contrast-Enhanced Ultrasound.

PURPOSE: To assess the diagnostic value of intima media thickness measurements and contrast-enhanced ultrasound (CEUS) of the supraaortic arteries in the assessment of disease activity in Takayasu arteritis (TA). MATERIALS AND METHODS: Patients with TA and involvement of the carotid and/or subclavian/axillary arteries underwent CEUS imaging in addition to B-mode and color duplex ultrasound. The maximum IMT (mIMT) was measured and high-resolution CEUS of the most prominently thickened vessel segment was performed. Two blinded readers reviewed the CEUS movies, with semiquantitative assessment of microbubble enhancement of the arterial wall (grade 0: no or minimal; grade 1: moderate; grade 2: pronounced). Clinical symptoms, acute phase reactants, and established indices of clinical disease activity (NIH criteria, ITAS score) were recorded. RESULTS: 40 examinations in 17 patients were analyzed. According to clinical judgement, 27 and 13 cases were classified as clinically inactive and active, respectively. An mIMT-cutoff of > 2.7 mm identified active disease with a sensitivity and specificity of 69.2 % and 88.9 %, respectively (area under the curve 0.83). The interobserver agreement of CEUS analysis was substantial (Cohen's kappa 0.76). By consensus reading, 17, 15, and 8 cases were classified as uptake grade 0, grade 1 and grade 2, respectively. Grade 0 uptake was exclusively present in 17 clinically inactive patients. Grade 1 uptake was seen in 10 patients with clinically inactive disease and 5 patients with clinically active disease. Grade 2 uptake was exclusively present in 8 patients with active disease. CONCLUSION: Both sonographic IMT measurements and high-resolution CEUS are promising in the ad-hoc assessment of disease activity in patients with TA.

Diagnostic accuracy of positron emission tomography for assessment of disease activity in large vessel vasculitis.

AIM: To determine the diagnostic yield of 18 F-fluorodeoxyglucose positron emission tomography (PET) in disease activity assessment of large vessel vasculitides (LVV). METHODS: Patients with LVV who had undergone PET (between 2004 and June 2010) or PET co-registered with computed tomography (PET/CT; since June 2010) were identified. Clinical disease activity was assessed using established scoring systems. PET images were reviewed by two blinded nuclear medicine physicians. Uptake of the aortic wall was compared to the liver uptake utilizing a visual 4-point score, with a vessel wall uptake similar or higher than liver uptake considered as active disease. Various target-to-background ratios were calculated. Receiver operator characteristics analysis was applied to determine the diagnostic accuracy of PET for detecting clinically active disease. Interobserver agreement of visual readings was measured with Cohen´s kappa. RESULTS: Eighty examinations in 62 patients were analyzed, with a mean time between diagnosis and PET of 106 ± 171 weeks. Fifty-seven cases were finally classified as clinically active and 23 cases as clinically inactive. With a cut-off value of 1.3, the aorta-to-liver ratio yielded a sensitivity and specificity of 84.2% and 82.6% (area under the curve 0.9). Overall, sensitivity and specificity of visual analysis were 68.4% and 91.3%, but sensitivity decreased to 54% in patients treated for more than 3 months. Interobserver agreement of visual rating was excellent (κ: 0.93). CONCLUSION: Positron emission tomography is specific and reliable in disease activity assessment of LVV, but lacks sensitivity for detecting active disease in patients under long-term immunosuppressive treatment.

Cortisol Excess in Patients With Primary Aldosteronism Impacts Left Ventricular Hypertrophy.

Context: Primary aldosteronism (PA) represents the most frequent form of endocrine hypertension. Hyperaldosteronism and hypercortisolism both induce excessive left ventricular hypertrophy (LVH) compared with matched essential hypertensives. In recent studies frequent cosecretion of cortisol and aldosterone has been reported in patients with PA. Objective: Our aim was to investigate the impact of cortisol cosecretion on LVH in patients with PA. We determined 24-hour excretion of mineralocorticoids and glucocorticoids by gas chromatography-mass spectrometry and assessed cardiac remodeling using echocardiography initially and 1 year after initiation of treatment of PA. Patients: We included 73 patients from the Munich center of the German Conn's registry: 45 with unilateral aldosterone-producing adenoma and 28 with bilateral adrenal hyperplasia. Results: At the time of diagnosis, 85% of patients with PA showed LVH according to left ventricular mass index [(LVMI); median 62.4 g/m2.7]. LVMI correlated positively with total glucocorticoid excretion (r2 = 0.076, P = 0.018) as well as with tetrahydroaldosterone excretion (r2 = 0.070, P = 0.024). Adrenalectomy led to significantly reduced LVMI in aldosterone-producing adenoma (P < 0.001) whereas mineralocorticoid receptor antagonist therapy in bilateral adrenal patients with hyperplasia reduced LVMI to a lesser degree (P = 0.024). In multivariate analysis, the decrease in LVMI was positively correlated with total glucocorticoid excretion and systolic 24-hour blood pressure, but not with tetrahydroaldosterone excretion. Conclusion: Cortisol excess appears to have an additional impact on cardiac remodeling in patients with PA. Treatment of PA by either adrenalectomy or mineralocorticoid receptor antagonist improves LVMI. This effect was most pronounced in patients with high total glucocorticoid excretion.

Relapses in three patients with Takayasu arteritis under tocilizumab treatment detected by contrast enhanced ultrasound.

Takayasu arteritis (TA) is a rare large vessel vasculitis, affecting the aorta and its major branches, typically in young women. In this case report, we present three cases of young women of Caucasian descent who experienced relapses while under treatment with the monoclonal humanized antibody to the interleukin 6 receptor, tocilizumab. Active vasculitic lesions of the supraaortic (common carotid and axillary) arteries were detected and characterized via high resolution contrast enhanced ultrasound. Based on these cases, we discuss the potential role of contrast enhanced ultrasound in the diagnosis and follow-up of TA as well as the current data on the efficacy of tocilizumab in the treatment of TA.

Rationale and design of the RECording COurses of vasculaR Diseases registry (RECCORD registry).

BACKGROUND: The prevalence of peripheral artery disease (PAD) is increasing worldwide. Revascularization procedures constitute a cornerstone of the therapy in PAD, not only in critical limb ischaemia but increasingly also in patients with intermittent claudication. The German Society of Angiology - Society for Vascular Medicine is establishing a nationwide, prospective, multicentre registry to address the lack of contemporary real life data regarding current practice of medical and interventional care in vascular patients and its subsequent long-term outcome. PATIENTS AND METHODS: The RECording COurses of vasculaR Diseases registry (RECCORD registry) is an observational, prospective, multicentre, all-comers registry platform. In the initial phase, patients referred for endovascular revascularization of PAD of the lower limbs will be prospectively included and followed up for at least one year. At baseline, data on patients' demographic characteristics, comorbidities, previous peripheral interventions, medication, and clinical stage of PAD (Rutherford category), haemodynamic parameters, and procedural data including complications will be assessed. Major adverse cardiac and limb events will be recorded at planned (at six and 12 months) and at any unplanned visits. The therapeutic management will be exclusively left to the discretion of the vascular specialists. RESULTS AND CONCLUSIONS: The RECCORD registry will provide a comprehensive dataset depicting the current real life practice and outcome of vascular care. The seven predefined quality indicators will be used for benchmarking the participating centres. Moreover, identifying factors promoting a favourable outcome might pave the way for an evidence-based therapeutic strategy and a dedicated therapeutic pathway for patients with PAD including patient-oriented best interventional approaches. In the future, the RECCORD registry may provide a general platform to study the courses of various defined vascular diseases in order to get detailed insights into the real life current practice of health care provided to vascular patients.

B-mode sonography wall thickness assessment of the temporal and axillary arteries for the diagnosis of giant cell arteritis: a cohort study.

OBJECTIVES: We aimed to determine the diagnostic accuracy of B-mode compression sonography of the temporal arteries (tempCS) and B-mode sonographic measurement of the axillary artery intima media thickness (axIMT) for the diagnosis of giant cell arteritis (GCA). METHODS: After having established measurement of tempCS and axIMT in our routine diagnostic workup, 92 consecutive patients with a suspected diagnosis of GCA were investigated. Clinical characteristics were recorded and wall thickening of the temporal arteries (tempCS) and axillary arteries (axIMT) was measured (mm). Using the final clinical diagnosis as the reference standard, receiver operator characteristics (ROC) analysis was performed. In a subgroup of 26 patients interobserver agreement was assessed using Spearman's rank correlation. RESULTS: Cranial GCA, extracranial GCA, and combined cranial/extracranial GCA were diagnosed in 18, 7, and 9 individuals, respectively. For the diagnosis of cranial GCA, tempCS had an excellent area under the curve (AUC) of 0.95, with a cut-off of ≥0.7 mm offering a sensitivity and specificity of 85% and 95%. The AUC of axIMT for the diagnosis of extracranial GCA was 0.91 (cut-off ≥1.2 mm: sensitivity and specificity 81.3 and 96.1%). Applying a combined tempCS/axIMT cut-off of ≥0.7mm/1.2 mm, we calculated an overall sensitivity and specificity for the final clinical diagnosis of cranial and/or extracranial GCA of 85.3% and 91.4%. Interobserver agreement was strong for both parameters assessed (Spearman's rho 0.72 and 0.77, respectively). CONCLUSIONS: The combination of tempCS/axIMT allows objective sonographic assessment in suspected GCA with promising diagnostic accuracy.

Evolution of patency rates of self-expandable bare metal stents for endovascular treatment of femoro-popliteal arterial occlusive disease: Does stent design matter?

OBJECTIVE: To analyse the patency rates of femoro-popliteal stenting with different self-expandable Nitinol stent-designs. METHODS: Two hundred and twenty-two patients (142 (64%) male; age 72.4 ± 11.6 years) with symptomatic femoro-popliteal peripheral arterial occlusive disease (PAOD) underwent percutaneous transluminal angioplasty (PTA) and stenting with three different Nitinol stents (interwoven IW: n = 70; closed-cell CC: n = 85; open-cell OC: n = 67). One-year post-procedural target lesion revascularization (TLR_12M) rates were investigated with regard to co-morbidities: diabetes (DBM), hyperlipidaemia (HLP), hypertension (RR), coronary artery disease (CAD) and degree of calcification. RESULTS: Twelve-month follow-up data were available for 60, 69 and 50 patients in the IW, OC and CC groups (179 patients in total). The cumulative patency (IW: 52 (86.7%); OC: 50 (72.5%); CC: 23 (46.0%); P < 0.001) and the TLR_12M rates (IW: 8 (13.3%); OC: 19 (27.5%); CC: 27 (54.0%); P < 0.001) differed significantly, as did the subgroup analyses (DBM: P = 0.05; RR: P = 0.003; HLP: P = 0.005; CAD: P = 0.02; localization: P < 0.001; calcification: P < 0.001), with the best patency for the IW stent and the highest TLR_12M for the CC stent. CONCLUSION: The interwoven stent-design was superior to the standard open- and closed-cell stent-designs in endovascular treatment of femoro-popliteal PAOD in a follow-up period of 12 months. KEY POINTS: • Results of femoro-popliteal stenting are still unsatisfactory. • Comparative studies for currently available different Nitinol stent-designs are lacking. • This is a first comparative study on long-term patency of different Nitinol stent-designs. • Interwoven stent-design leads to improved long-term patency. • Interwoven stent-design leads to lower TLR than other stent-designs.

3D-black-blood 3T-MRI for the diagnosis of thoracic large vessel vasculitis: A feasibility study.

OBJECTIVES: To evaluate the feasibility of T1w-3D black-blood turbo spin echo (TSE) sequence with variable flip angles for the diagnosis of thoracic large vessel vasculitis (LVV). METHODS: Thirty-five patients with LVV, diagnosed according to the current standard of reference, and 35 controls were imaged at 3.0T using 1.2 × 1.3 × 2.0 mm3 fat-suppressed, T1w-3D, modified Volumetric Isotropic TSE Acquisition (mVISTA) pre- and post-contrast. Applying a navigator and peripheral pulse unit triggering (PPU), the total scan time was 10-12 min. Thoracic aorta and subclavian and pulmonary arteries were evaluated for image quality (IQ), flow artefact intensity, diagnostic confidence, concentric wall thickening and contrast enhancement (CWT, CCE) using a 4-point scale. RESULTS: IQ was good in all examinations (3.25 ± 0.72) and good to excellent in 342 of 408 evaluated segments (83.8 %), while 84.1 % showed no or minor flow artefacts. The interobserver reproducibility for the identification of CCE and CWT was 0.969 and 0.971 (p < 0.001) with an average diagnostic confidence of 3.47 ± 0.64. CCE and CWT were strongly correlated (Cohen's k = 0.87; P < 0.001) and significantly more frequent in the LVV-group (52.8 % vs. 1.0 %; 59.8 % vs. 2.4 %; P < 0.001). CONCLUSIONS: Navigated fat-suppressed T1w-3D black-blood MRI with PPU-triggering allows diagnosis of thoracic LVV. KEY POINTS: • Cross-sectional imaging is frequently applied in the diagnosis of LVV. • Navigated, PPU-triggered, T1w-3D mVISTA pre- and post contrast takes 10-12 min. • In this prospective, single-centre study, T1w-3D mVISTA accurately depicted large thoracic vessels. • T1w-3D mVISTA visualized CWT/CCW as correlates of mural inflammation in LVV. • T1w-3D mVISTA might be an alternative diagnostic tool without ionizing radiation.

Altered renal functions in patients with occlusion of an accessory renal artery after endovascular stenting of an infrarenal aneurysm.

OBJECTIVE: Coverage of an accessory renal artery (ARA) during endovascular aneurysm repair (EVAR) may result in renal infarction (RI) or decline in renal function. Until now, it remains vague which patients are at risk to develop these complications. We therefore analyzed the effect of ARA sealing by EVAR with respect to the occurrence of RI and renal function. METHODS: A retrospective analysis of the medical records and computed tomographic scans of patients who underwent EVAR within a period of 5 years was performed. Particular attention was paid to the presence or absence of accessory renal arteries and renal function before EVAR. Thirty-four patients with ARA were matched 1:3 to 102 patients without ARA. The results after EVAR were analyzed in patients with and without ARA. In patients with ARA, we further examined the results after EVAR in patients with an estimated glomerular filtration rate (eGFR) ≥ 60 mL/min and eGFR < 60 mL/min before EVAR. RESULTS: Before EVAR, the median eGFR was 74 mL/min (25th/75th percentiles, 57/89) in patients with ARA and 72 mL/min (25th/75th percentiles, 63/87) in patients without ARA. Alterations in eGFR were significantly pronounced in patients with ARA when compared with patients without ARA 1 week after EVAR (ARA, -10.7 ± 16.9 mL/min vs without ARA, 1.2 ± 13.3 mL/min; P = .002) and after 6 months (ARA, -10.8 ± 17.4 mL/min vs without ARA, 1.2 ± 13.3 mL/min; P = .001). RI only occurred in patients with ARA. Within the group of patients with ARA, patients with normal renal function (NF) showed a more pronounced decline in eGFR preoperatively when compared with patients with impaired renal function (IF) 1 week after EVAR (NF, -14.3 ± 18.0 mL/min vs IF, -1.3 ± 10.8 mL/min; P = .02) and after 6 months (NF, -15.8 ± 17.9 mL/min vs IF, 0.1 ± 15.2 mL/min; P = .007). CONCLUSIONS: The decrease in renal function was more pronounced in patients with ARA after EVAR when compared with patients without ARA undergoing EVAR. In patients with ARA, the observed decline in renal function was significantly distinct in patients presenting NF preoperatively. Consequently, the risk of IF after EVAR seems to be increased in patients with ARA and normal preoperative renal function.

Ultrasound Assisted Endovascular Thrombolysis in Adolescents: 2 Case Reports.

Descending iliofemoral thrombosis in children is a rare event. Anticoagulation therapy with low-molecular-weight-heparin is standard of care. However, patency cannot be achieved in all cases, increasing the risk for rethrombosis and postthrombotic syndrome. To reduce the risk of venous valve failure in adults, local catheter-directed thrombolysis is used to reopen vessels. Two adolescent girls (17 and 15 years old) presented with acute descending iliofemoral thrombosis of the left common iliac, external, and common femoral veins. Anticoagulation with enoxaparin was started until insertion of an EkoSonic Mach 4e catheter for ultrasound-assisted local thrombolysis with recombinant tissue plasminogen activator and administration of unfractionated heparin. Success was monitored by increases in D-dimer levels and ultrasound findings. After 24 hours respectively 48 hours, complete recanalization was obtained. No complication occurred except minimal local bleeding. Screening for hereditary thrombophilia revealed a heterozygous antithrombin mutation in 1 girl (ie, the 15-year-old). May-Thurner syndrome was identified in both girls, necessitating stenting of the left common iliac veins and continuation of anticoagulation therapy with enoxaparin and acetylsalicylic acid. No rethrombosis or complications occurred during the follow-up period. Ultrasound-assisted catheter-directed local thrombolysis with the EkoSonic Mach 4e system was effective in achieving immediate recanalization of the occluded veins and should be considered in children experiencing descending iliofemoral thrombosis. The fast recanalization might reduce the incidence of postthrombotic syndrome. May-Thurner syndrome is regularly found in these patients, and if present, requires stenting of the common iliac vein to avoid early reocclusion. However, long-term patency of iliac vein stenting in children remains to be examined.

Worsening of lipid metabolism after successful treatment of primary aldosteronism.

Primary aldosteronism (PA) describes the most frequent cause of secondary arterial hypertension. Recently, deterioration of lipid metabolism after adrenalectomy (ADX) for aldosterone-producing adenoma (APA) has been described. We analysed longitudinal changes in lipid profiles in a large prospective cohort of PA patients. Data of 215 consecutive PA patients with APA (n = 144) or bilateral idiopathic adrenal hyperplasia (IHA, n = 71) were extracted from the database of the German Conn's Registry. Patients were investigated before and 1 year after successful treatment by ADX or by mineralocorticoid receptor antagonists (MRA). Glomerular filtration rate (GFR), fasting plasma glucose and components of lipid metabolism including triglycerides (TG), total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C) were determined at 8.00 after a 12-h fasting period. One year after initiation of treatment mean serum potassium levels and blood pressure normalized in the patients. HDL-C and TG developed inversely with decreasing HDL-C levels in patients with APA (p = .046) and IHA (p = .004) and increasing TG levels (APA p = .000; IHA p = .020). BMI remained unchanged and fasting plasma glucose improved in patients with APA (p = .004). Furthermore, there was a significant decrease of GFR in both subgroups at follow-up (p = .000). Changes in HDL-C and TG correlated with decrease in GFR in multivariate analysis (p = .024). Treatment of PA is associated with a deterioration of lipid parameters despite stable BMI and improved fasting plasma glucose and blood pressure. This effect can be explained by renal dysfunction following ADX or MRA therapy.

Combined Carotid Endarterectomy and Retrograde Stenting of the Supra-Aortic Trunk: Does Cervical Block Offer Advantages?

BACKGROUND: Atherosclerosis of the carotid artery is a major source of stroke. In some cases, atherosclerosis occurs at several positions within the carotid artery. Carotid endarterectomy (CEA) in combination with retrograde balloon angioplasty and stenting of a brachiocephalic or common carotid artery stenosis has been described as efficacious and safe procedure to prevent stroke in these cases. The aim of this study was to analyze the impact of anesthetic techniques on hemodynamic factors, operation time, duration of clamping, and postoperative pain. METHODS: A retrospective analysis of patients undergoing CEA in combination with retrograde stenting under either general anesthesia (GA) or cervical block (CB) was carried out. Preoperative risk factors were analyzed as well as operating and cross-clamping time, hemodynamic factors, perioperative complications, postoperative pain, application of pain killers, and duration of intensive care unit (ICU) and hospital stay. RESULTS: Operating (GA: 193 ± 91 min vs. CB: 125 ± 52 min, P = 0.029) and cross-clamping time (GA: 34 ± 12 min vs. CB: 26 ± 9 min, P < 0.001) were shorter under CB. Patients under CB were hemodynamically more stable and required less norepinephrine (GA: 1.1 ± 0.6 mg vs. CB: 0.1 ± 0.1 mg, P < 0.001) and crystalloids (GA: 2,813 ± 1,173 mL vs. CB: 1,088 ± 472 mL, P < 0.001). Postoperative pain levels (GA: numeric rating scale 4.3/10 vs. 2.0/10; P = 0.004) and requirement of pain killers were also lower within the CB group. CONCLUSIONS: Synchronous CEA and retrograde balloon angioplasty and stenting of a brachiocephalic or common carotid artery stenosis under CB is associated with reduction of operating and cross-clamping time, improved hemodynamical stability, lower postoperative pain, shorter ICU and hospital stay, and it offers the advantage of a continuous neurological monitoring.