Stent graft surface movement after infrarenal abdominal aortic aneurysm repair: comparison of patients with and without a type 2 endoleak.

OBJECTIVES: The aim was to compare multidirectional stent graft movement in patients with and without a type 2 endoleak. METHODS: This was a retrospective case control study of patients being followed up after elective endovascular aneurysm repair of abdominal aortic aneurysms. The post-procedural and final follow up multislice computed tomography (MSCT) of 69 patients with and 74 without a type 2 endoleak were analyzed. Three dimensional (3D) surface models of the stent graft, delimited by landmarks using custom built software, were derived from these MSCT data. The stent graft was segmented in different zones, and the proportion of the total stent graft surface moving >9 mm between the post-procedural and the final follow up MSCT was calculated, given in percentages, and compared between groups. Changes of infrarenal neck, renal artery to stent graft distance, and freedom from stent graft related endoleaks were evaluated. RESULTS: Overall surface movement was higher in the no endoleak (18.8%, IQR 0.1-45.1%) than in the type 2 endoleak group (5.3%, IQR 0-29.7%; p = .06). Furthermore, significantly higher surface movement in the no endoleak group was found in the proximal anchoring zone (p = .04) and the distal left limb (p = .01), which was the modular limb in 81.1% (p < .01). Neck diameter increase (1.0 mm, IQR 0-3.0 mm; p < .01) and renal artery to stent graft distance difference (0 mm, IQR 0-3.3 mm; p < .01) were significantly higher in the no endoleak group. Five patients in the no endoleak and one patient in the type 2 endoleak group suffered from a stent graft related endoleak (p = .27). CONCLUSIONS: The presence of a type 2 endoleak is associated with decreased surface movement of the proximal anchoring zone and the distal modular limb of bifurcated stent grafts.

[Functional MR imaging of the liver]. / Funktionelle MR-Tomographie der Leber.

The diagnostics of diffuse liver disease traditionally rely on liver biopsies and histopathological analysis of tissue specimens. However, a liver biopsy is invasive and carries some non-negligible risks, especially for patients with decreased liver function and those requiring repeated follow-up examinations. Over the last decades, magnetic resonance imaging (MRI) has developed into a valuable tool for the non-invasive characterization of focal liver lesions and diseases of the bile ducts. Recently, several MRI methods have been developed and clinically evaluated that also allow the diagnostics and staging of diffuse liver diseases, e.g. non-alcoholic fatty liver disease, hepatitis, hepatic fibrosis, liver cirrhosis, hemochromatosis and hemosiderosis. The sequelae of diffuse liver diseases, such as a decreased liver functional reserve or portal hypertension, can also be detected and quantified by modern MRI methods. This article provides the reader with the basic principles of functional MRI of the liver and discusses the importance in a clinical context.

Diagnostic workup of primary sclerosing cholangitis: the benefit of adding gadoxetic acid-enhanced T1-weighted magnetic resonance cholangiography to conventional T2-weighted magnetic resonance cholangiography.

AIM: To evaluate the value of gadoxetic acid-enhanced T1-weighted (T1W) magnetic resonance cholangiography (MRC) versus conventional T2-weighted (T2W) MRC compared to endoscopic retrograde cholangiopancreatography (ERCP) in patients with primary sclerosing cholangitis (PSC). MATERIALS AND METHODS: Based on T1W MRC, PSC patients were classified into a regular (RG) and a delayed (DG) excreting group, with an absence of gadoxetic acid in the common bile duct at 20 min. Beading, pruning, and gradation of central bile duct stenosis, evaluated by T1W and T2W MRC, were compared to ERCP. Liver parenchymal enhancement was measured in both study groups and compared to a reference group (n = 20) without a history of liver disease. Two readers performed all measurements. RESULTS: Based on beading and pruning of the peripheral bile ducts, sensitivities, specificities, and accuracies for reader 1 were 0.17/0.43, 0/0.17, and 0.15/0.31 for T1W MRC, and 0.83/0.86, 1/0.83, and 0.85/0.85 for T2W MRC (p = 0.004). For reader 2 sensitivities, specificities, and accuracies were 0.25/0.57, 0/0.33, and 0.23/0.46 for T1W MRC, and 0.92/1, 1/0.83, and 0.92/0.92 for T2W MRC (p = 0.012). Compared to ERCP, central bile duct stenoses were significantly overestimated (p < 0.001) by T2W MRC. A significantly lower parenchymal enhancement was found in the DG (n = 7) compared to the RG (n = 13), and compared to the reference group (p < 0.001). CONCLUSION: The combined performance of T2W and T1W MRC may provide a comprehensive imaging workup of PSC, including morphological and functional information resulting in optimal management.

Aortomonoiliac endografting after failed endovascular aneurysm repair: indications and long-term results.

OBJECTIVES: To present long-term results of endoleak/endograft migration treatment by aortomonoiliac (AMI) endografting after failed endovascular aneurysm repair (EVAR) of infrarenal abdominal aortic aneurysms. DESIGN: Post hoc analysis of a prospectively gathered database at a tertiary care university hospital. MATERIALS AND METHODS: From March 1995 to November 2010, 23 patients were identified who underwent modification into AMI configuration after failed elective EVAR. Major causes for modification were type I (with/without endograft migration) or type III endoleaks with aneurysm expansion. An average increase in aneurysm size of 1.6 cm (range: -1.5 to 10.5 cm) since initial aneurysm treatment was observed. Interventional outcomes and long-term results were recorded for analysis. RESULTS: Technical success rate of AMI endografting was 95.65% (n = 22). All except two endoleaks could be successfully sealed with this manoeuvre (94.44%). Median time to modification was 5.3 years (interquartile range Q1-Q3: 1.3-9.3 years). No intra-operative conversion to open surgery was necessary and mortality was 0%. Median follow-up was 44 months (interquartile range Q1-Q3: 17-69 months). CONCLUSIONS: Treatment of graft-related endoleaks/endograft migration by AMI endografting after failed EVAR represents a safe and feasible procedure. This approach broadens the minimal invasive opportunities of aneurysm treatment, and open surgical conversion may be avoided except in selected patients.

Predictors of permanent ileostomy after restorative proctocolectomy.

BACKGROUND: Proctocolectomy with ileal pouch-anal anastomosis (IPAA) is a surgical approach for ulcerative colitis and familial adenomatous polyposis. This study evaluated predictors of the need for a permanent ileostomy to identify patients at high risk of IPAA failure. METHODS: This was a retrospective analysis of patients who underwent proctocolectomy and IPAA between 1997 and 2008. A logistic regression model was used for multivariable analysis of potential risk factors. RESULTS: Proctocolectomy was combined with IPAA in 185 patients, of whom 169 had a loop ileostomy formed. IPAA and ileostomy closure were successful in 162 patients (87.6 per cent). Reasons for not closing the ileostomy included pouch failure (16 patients), patient choice (5) and death (2). Thus one in eight patients had a permanent ileostomy after planned IPAA. Age was the major predictor of the need for a permanent ileostomy in multivariable analysis (P = 0.002) with a probability of more than 25 per cent in patients aged over 60 years. However, advancing age was associated with colitis, co-morbidity, obesity and corticosteroid use. CONCLUSION: The probability of the need for a permanent ileostomy after IPAA increases with age.

Elective abdominal aortic aneurysm repair: does the aneurysm diameter influence long-term survival?

OBJECTIVES: The aim of this study was to investigate whether initial abdominal aortic aneurysm (AAA) diameter influences long-term survival after elective repair. DESIGN: Retrospective analysis of database. MATERIAL AND METHODS: Between March 1995 and December 2006, a consecutive series of 895 patients underwent elective treatment of an AAA either by open surgical or endovascular repair. An AAA diameter of 5.5cm was chosen as threshold to distinguish between small and large aneurysms, according to the definition given by the UK small aneurysm trial. Patient characteristics and distribution of basic risk factors were assessed. Survival estimates (Kaplan-Meier) and Cox proportional hazards regression results are reported. RESULTS: Patients with small aneurysms were more likely to survive the first 6 years after AAA repair, even after adjustment for treatment modality and baseline risk factors. After adjustment for age and sex aneurysms with smaller diameter were related to a lower risk of death (p<0.0016). CONCLUSIONS: Patients with small aneurysms (< or =5.5cm) have an improved long-term survival than patients with larger aneurysms.

The avascular plane of the Achilles tendon: a quantitative anatomic and angiographic approach and a base for a possible new treatment option after rupture.

INTRODUCTION: Achilles tendon ruptures, especially ruptures caused by pathologic conditions and also by achillotendinitis are often attributed to the alleged hypovascularisation of the Achilles tendon. Anatomic studies often mention an avascular plane. The purpose of this study was to re-investigate the arterial supply of the Achilles tendon. MATERIAL AND METHODS: Lower legs of 28 anatomic specimen were injected with a radiologic contrast agent and subsequently an arterial angiography was performed. Afterwards the legs were embalmed and later anatomically dissected. The origin of arteries entering the paratenon of the tendo calcanei branching off from either the anterior (TA) or the posterior tibial artery (TP) was determined. The distance between the points of commencement of these nutrient arteries and a specific reference point, i.e. the insertion of the Achilles tendon into the tuber calcanei, was measured digitally on the radiographs and again with a slide-gauge on the dissected specimens. RESULTS: As revealed by angiographic analysis, the TA gave off 5 vessels (v) at a frequency and median distance to the tuber calcanei (in cm) of v1: 50%, 6.01 cm; v2: 39.3%, 7.88 cm; v3: 35.7%, 9.71 cm; v4: 17.9%, 12.7 cm; v5: 10.7%, 14.6 cm. The TP contributed to the arterial supply of the Achilles tendon by means of 7 inserting arteries branching off at a frequency and mean distances of v1: 67.9%, 4.53 cm; v2: 60.7%, 6.97 cm, v3: 50%, 9.58 cm; v4: 35.7%, 10.89 cm; v5: 25%, 12.65 cm; v6: 10.7%, 16.94 cm; v7: 3.6%, 18.7 cm proximal to the tuber calcanei. However, due to the small diameter of these branches, by anatomic dissection no nutrient arteries commencing from the TA could be detected. On the other hand, a maximum of 7 vessels originating from the TP, larger than the former vessels, had been also revealed by anatomic dissection (frequency and mean distances, v1: 100%, 6.8 cm; v2: 82.1%, 7.7 cm; v3: 71.4%, 9.5cm; v4: 35.7%, 11.3 cm; v5: 17.9%, 9.9 cm; v6: 7.1, 10.5 cm; v7: 3.6%, 12.0 cm). CONCLUSION: A dense net of small arteries inserts into the paratenon of the Achilles tendon in its lower 20 cm. The angiographic method was more specific and showed vessels that could not be identified as arteries originating from the TA by macroscopic anatomic dissection.