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BACKGROUND: Neuroblastoma is the most common extracranial solid tumour in children. Relapsed or refractory neuroblastoma is associated with a poor outcome. We assessed the combination of irinotecan-temozolomide and dasatinib-rapamycin (RIST) in patients with relapsed or refractory neuroblastoma. METHODS: The multicentre, open-label, randomised, controlled, phase 2, RIST-rNB-2011 trial recruited from 40 paediatric oncology centres in Germany and Austria. Patients aged 1-25 years with high-risk relapsed (defined as recurrence of all stage IV and MYCN amplification stages, after response to treatment) or refractory (progressive disease during primary treatment) neuroblastoma, with Lansky and Karnofsky performance status at least 50%, were assigned (1:1) to RIST (RIST group) or irinotecan-temozolomide (control group) by block randomisation, stratified by MYCN status. We compared RIST (oral rapamycin [loading 3 mg/m2 on day 1, maintenance 1 mg/m2 on days 2-4] and oral dasatinib [2 mg/kg per day] for 4 days with 3 days off, followed by intravenous irinotecan [50 mg/m2 per day] and oral temozolomide [150 mg/m2 per day] for 5 days with 2 days off; one course each of rapamycin-dasatinib and irinotecan-temozolomide for four cycles over 8 weeks, then two courses of rapamycin-dasatinib followed by one course of irinotecan-temozolomide for 12 weeks) with irinotecan-temozolomide alone (with identical dosing as experimental group). The primary endpoint of progression-free survival was analysed in all eligible patients who received at least one course of therapy. The safety population consisted of all patients who received at least one course of therapy and had at least one post-baseline safety assessment. This trial is registered at ClinicalTrials.gov, NCT01467986, and is closed to accrual. FINDINGS: Between Aug 26, 2013, and Sept 21, 2020, 129 patients were randomly assigned to the RIST group (n=63) or control group (n=66). Median age was 5·4 years (IQR 3·7-8·1). 124 patients (78 [63%] male and 46 [37%] female) were included in the efficacy analysis. At a median follow-up of 72 months (IQR 31-88), the median progression-free survival was 11 months (95% CI 7-17) in the RIST group and 5 months (2-8) in the control group (hazard ratio 0·62, one-sided 90% CI 0·81; p=0·019). Median progression-free survival in patients with amplified MYCN (n=48) was 6 months (95% CI 4-24) in the RIST group versus 2 months (2-5) in the control group (HR 0·45 [95% CI 0·24-0·84], p=0·012); median progression-free survival in patients without amplified MYCN (n=76) was 14 months (95% CI 9-7) in the RIST group versus 8 months (4-15) in the control group (HR 0·84 [95% CI 0·51-1·38], p=0·49). The most common grade 3 or worse adverse events were neutropenia (54 [81%] of 67 patients given RIST vs 49 [82%] of 60 patients given control), thrombocytopenia (45 [67%] vs 41 [68%]), and anaemia (39 [58%] vs 38 [63%]). Nine serious treatment-related adverse events were reported (five patients given control and four patients given RIST). There were no treatment-related deaths in the control group and one in the RIST group (multiorgan failure). INTERPRETATION: RIST-rNB-2011 demonstrated that targeting of MYCN-amplified relapsed or refractory neuroblastoma with a pathway-directed metronomic combination of a multkinase inhibitor and an mTOR inhibitor can improve progression-free survival and overall survival. This exclusive efficacy in MYCN-amplified, relapsed neuroblastoma warrants further investigation in the first-line setting. FUNDING: Deutsche Krebshilfe.
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Protocolos de Quimioterapia Combinada Antineoplásica , Dasatinibe , Irinotecano , Recidiva Local de Neoplasia , Neuroblastoma , Sirolimo , Temozolomida , Humanos , Temozolomida/administração & dosagem , Temozolomida/uso terapêutico , Irinotecano/administração & dosagem , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Protocolos de Quimioterapia Combinada Antineoplásica/efeitos adversos , Masculino , Feminino , Neuroblastoma/tratamento farmacológico , Neuroblastoma/mortalidade , Neuroblastoma/patologia , Neuroblastoma/genética , Pré-Escolar , Criança , Dasatinibe/administração & dosagem , Dasatinibe/uso terapêutico , Dasatinibe/efeitos adversos , Adolescente , Recidiva Local de Neoplasia/tratamento farmacológico , Recidiva Local de Neoplasia/patologia , Lactente , Adulto , Sirolimo/administração & dosagem , Sirolimo/uso terapêutico , Adulto Jovem , Alemanha , Resistencia a Medicamentos Antineoplásicos , Intervalo Livre de ProgressãoRESUMO
Background Patients with acute mesenteric ischemia (AMI) often exhibit severe co-morbidities and significant surgical risks, leading to high perioperative morbidity. Purpose To investigate the feasibility of primary percutaneous stent-revascularization (PPSR) in atherosclerotic AMI and its impact on patients' outcome. Material and Methods Retrospective analysis of 19 consecutive patients (7 women, 12 men; median age, 69 years) with AMI caused by atherosclerotic, non-embolic stenoses/occlusions of the splanchnic arteries and PPSR. Alternative minimally invasive techniques were excluded. Clinical characteristics including the Charlson Comorbidity Index adjusted by age (CCIa) and symptom duration, technical and clinical success of PPSR, clinical course, 30-day mortality, and follow-up were evaluated and compared to literature data for surgical approaches. Technical success was defined as residual stenosis of <30% in diameter. Clinical success was defined as resolution of symptoms of AMI and/or normalization of serum lactate after sole PPSR. Results The majority of patients presented with severe co-morbidities (CCIa >4 in 17 of 19 patients, 89%). Median symptom duration was 50 h. Technical and clinical success rates of PPSR were 95% (21 of 22 arteries) and 53% (10 of 19 patients). Seven patients underwent subsequent laparotomy with bowel resection in four cases. Thirty-day mortality was 42% (8 of 19 patients). Conclusion In our study population of patients with atherosclerotic AMI, severe co-morbidities, prolonged acute symptoms, and significant perioperative risks PPSR of splanchnic stenoses were technically feasible and the clinical outcome was acceptable.
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Aterosclerose/complicações , Procedimentos Endovasculares/métodos , Isquemia Mesentérica/complicações , Isquemia Mesentérica/cirurgia , Stents , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Resultado do TratamentoRESUMO
INTRODUCTION: Available assays for quantitation of the Alzheimer's disease (AD) biomarker amyloid-beta 1-42 (Aß [1-42]) in cerebrospinal fluid demonstrate significant variability and lack of standardization to reference measurement procedures (RMPs). We report analytical performance data for the novel Elecsys ß-amyloid (1-42) assay (Roche Diagnostics). METHODS: Lot-to-lot comparability was tested using method comparison. Performance parameters were measured according to Clinical & Laboratory Standards Institute (CLSI) guidelines. The assay was standardized to a Joint Committee for Traceability in Laboratory Medicine (JCTLM) approved RMP. RESULTS: Limit of quantitation was <11.28 pg/mL, and the assay was linear throughout the measuring range (200-1700 pg/mL). Excellent lot-to-lot comparability was observed (correlation coefficients [Pearson's r] >0.995; bias in medical decision area <2%). Repeatability coefficients of variation (CVs) were 1.0%-1.6%, intermediate CVs were 1.9%-4.0%, and intermodule CVs were 1.1%-3.9%. Estimated total reproducibility was 2.0%-5.1%. Correlation with the RMP was good (Pearson's r, 0.93). DISCUSSION: The Elecsys ß-amyloid (1-42) assay has high analytical performance that may improve biomarker-based AD diagnosis.
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Doença de Alzheimer/líquido cefalorraquidiano , Peptídeos beta-Amiloides , Biomarcadores/líquido cefalorraquidiano , Imunoensaio/normas , Luminescência , Fragmentos de Peptídeos , Biomarcadores/análise , Humanos , Imunoensaio/instrumentação , Imunoensaio/métodos , Padrões de Referência , Reprodutibilidade dos TestesRESUMO
PURPOSE: To evaluate the association of inferior mesenteric arterial (IMA) type II endoleaks in patients undergoing endovascular aortic aneurysm repair (EVAR) for infrarenal abdominal aortic aneurysm with several morphologic parameters. MATERIALS AND METHODS: Approval of the institutional ethical review committee was not required. This was a retrospective review of 322 computed tomographic angiographic studies that were performed in patients before they underwent elective EVAR for infrarenal abdominal aortic aneurysm. Morphologic parameters evaluated were IMA patency, origin of the IMA in relation to the aneurysm sac, diameter of the IMA, the cross-sectional area of the contrast material-enhanced aortic lumen at the level of the IMA ostium, and the number of additional patent aortic side branches from the aneurysm sac. The association of IMA type II endoleaks with each variable was analyzed by using univariate and multivariate logistic regression models. RESULTS: The diameter of the IMA did not influence the development of IMA type II endoleaks (P = .51). The incidence of these endoleaks was significantly higher in patients with greater cross-sectional area of the aortic lumen at the IMA ostium (P < .001). Patients with an IMA type II endoleak had significantly more patent aortic side branches before EVAR than did patients without an endoleak (3.6 ± 1.7 vs 2.2 ± 1.4; P < .001). According to the final logistic regression model that included cross-sectional area of the aortic lumen at the IMA and the number of aortic side branches as independent predictors, risk for IMA type II endoleaks was determined with a sensitivity of 78% (39 of 50) and a specificity of 79% (92 of 116). CONCLUSION: Cross-sectional area of the contrast-enhanced aortic lumen at the level of the IMA ostium and the number of additional patent aortic side branches are associated with the development of IMA type II endoleaks.
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Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular , Endoleak/diagnóstico por imagem , Artéria Mesentérica Inferior , Idoso , Angiografia , Meios de Contraste , Feminino , Humanos , Masculino , Valor Preditivo dos Testes , Estudos Retrospectivos , Sensibilidade e Especificidade , Tomografia Computadorizada por Raios X , Grau de Desobstrução VascularRESUMO
OBJECTIVE: In patients with acute necrotizing pancreatitis, we analyzed whether laboratory and clinical findings determined in the early phase of disease and morphologic features on contrast-enhanced CT (CECT) at the beginning of the late phase of disease are helpful in predicting patient outcome and whether CECT findings provide additional information in establishing prognosis compared with the laboratory and clinical findings. MATERIALS AND METHODS: A retrospective analysis of 99 patients with acute necrotizing pancreatitis was performed. Four laboratory variables (albumin, calcium, C-reactive protein, WBC count) and three clinical variables (Acute Physiology, Age, Chronic Health Evaluation [APACHE] II score; Simplified Acute Physiology Score [SAPS] II; persistent organ failure) were assessed. Five morphologic features on CECT including Balthazar grade and CT severity index were reviewed. The endpoints of patient outcome were peripancreatic or pancreatic infection, need for intervention, duration of organ failure, ICU and hospital stays, and death. Based on receiver operating characteristic curve analysis for infection, high-and low-risk groups for each prognostic variable were calculated and univariable and multivariable Cox regression analyses were carried out. RESULTS: In our study population of 99 patients (63 men, 36 women; median age, 52 years; age range, 18-84 years), 25 patients (25%) developed infection, 42 patients (42%) experienced organ failure, and 12 patients (12%) died. Regarding the laboratory and clinical variables, albumin level, APACHE II score, and particularly persistent organ failure were the strongest independent predictors of patient outcome. Regarding the imaging variables, Balthazar grade and a morphologic feature that takes the distribution of intrapancreatic necrosis into account were the strongest independent predictors. In the multivariable analysis of all studied variables, imaging variables were independent and strong predictors of patient outcome and provided additional information in establishing prognosis compared with clinical and laboratory findings. CONCLUSION: In patients with suspected or proven acute necrotizing pancreatitis, performing CECT at the beginning of the late phase of disease is recommended to identify patients at increased risk for adverse outcomes.
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Pancreatite Necrosante Aguda/diagnóstico , Pancreatite Necrosante Aguda/mortalidade , Avaliação de Resultados da Assistência ao Paciente , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Alemanha/epidemiologia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Pancreatite Necrosante Aguda/sangue , Prognóstico , Reprodutibilidade dos Testes , Fatores de Risco , Sensibilidade e Especificidade , Taxa de Sobrevida , Adulto JovemRESUMO
INTRODUCTION: Moyamoya disease (MMD) is an extremely rare neurovascular disorder in Caucasian children. To the best of our knowledge, the aggressive variant including hemorrhagic malignant stroke and consecutive global ischemia has not been reported for this population before. CASE REPORT: We present the case of an 11-year-old girl with sudden neurological deterioration due to intracerebral hemorrhage with early irruption into the ventricular system. MMD with extensive neovascularization was diagnosed by means of computed tomography and magnetic resonance imaging. Despite immediate ventricular drainage, intracranial pressure increased above the mean arterial pressure resulting in malignant bi-hemispheric ischemia. The girl died within 53 h after admission to hospital. DISCUSSION: Intracerebral hemorrhage in young patients is often attributed to vascular malformation. This case shows that MMD may constitute a potential diagnosis in the case of sudden neurological deterioration and loss of consciousness, even in previously healthy children.
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Hemorragias Intracranianas/etiologia , Doença de Moyamoya/complicações , Acidente Vascular Cerebral/complicações , Criança , Eletroencefalografia , Potenciais Evocados , Feminino , Humanos , Angiografia por Ressonância Magnética , Imageamento por Ressonância Magnética , Tomografia Computadorizada por Raios XRESUMO
BACKGROUND: Technological progress has led to the introduction of hand-carried ultrasound (HCU) imagers in clinical workflow. The aim of this study is to analyse whether examination with a HCU device is a rapid and reliable alternative to contrast-enhanced multidetector CT (MDCT) scans in diagnosis of free intra-abdominal fluid and organ lacerations in major trauma patients. METHODS: 31 major trauma patients with an injury severity score >15 and the necessity of a MDCT scan (standard of reference) were enrolled prospectively to this study, and additionally examined with a HCU, according to 'focused assessment with sonography for trauma' principles for the assessment of organ lacerations and free intra-abdominal fluid. The HCU device employed was of the latest generation. Statistical analysis was performed using PASW V.18. RESULTS: Four patients were diagnosed with free intra-abdominal fluid (prevalence 12.9%). HCU showed a sensitivity and specificity of 75% and 100%, respectively. Positive predictive value and negative predictive value were 100% and 96%, respectively. Five patients had organ lacerations (prevalence 16.1%). In these cases, the HCU was able to detect organ lacerations with a sensitivity and specificity of 80% and 100%, respectively. Therefore, a positive predictive value and negative predictive value of 100% and 96%, respectively, were calculated. CONCLUSION: In major trauma patients, examination with HCU according to the 'focused assessment with sonography for trauma' principles for the diagnosis of organ lacerations and free intra-abdominal fluid is a reliable and rapid alternative to MDCT scans and can help save precious time in emergency situations, and should, additionally, be evaluated in the pre-clinical workflow.
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Traumatismos Abdominais/diagnóstico por imagem , Lacerações/diagnóstico por imagem , Derrame Pericárdico/diagnóstico por imagem , Sistemas Automatizados de Assistência Junto ao Leito , Ultrassonografia/instrumentação , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Meios de Contraste , Desenho de Equipamento , Humanos , Escala de Gravidade do Ferimento , Iohexol/análogos & derivados , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Sensibilidade e Especificidade , Tomografia Computadorizada por Raios XRESUMO
Vaccine-induced immune thrombotic thrombocytopenia (VITT) with venous thrombosis is a rare complication of SARS-CoV-2 vaccination with ChAdOx1 (AstraZeneca) and AD26.COV2.S (Johnson & Johnson, New Brunswick, NJ, USA) associated with high mortality. At present, there are no known differences in the pathophysiology or risk factors of VITT with the AstraZeneca vaccine (ChAdOx1) compared with the Johnson & Johnson vaccine (AD26.COV2.S). Herein, we present the case of a healthy 39-year-old patient with VITT after having received the vaccine Ad26.COV2.S. Ten days after vaccination, the patient developed a deep vein thrombosis and subsequent pulmonary embolism. A computed tomography scan of the abdomen showed adrenal gland bleeding and an adrenocorticotrophic hormone stimulation test diagnosed adrenal insufficiency. Therapy with intravenous immunoglobulin, argatroban and hydrocortisone was initiated immediately after diagnosis. The patient left the hospital 22 days after admission with the diagnosis of adrenal insufficiency but otherwise in good health. To the best of our knowledge, five cases of VITT and adrenal bleeding have been described to date in the literature but the presented case was the first to occur after immunisation with the vaccine of Johnson & Johnson. In summary, VITT-associated adrenal dysfunction is a very rare complication of vaccination with an adenoviral vector-based COVID-19 vaccine.
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PURPOSE: Mesenteric ischemia is a condition well-known among physicians treating patients with abdominal symptoms. Even so, mortality rates have not decreased significantly over the last decades. The purpose of this article is to review current treatment concepts of acute and chronic mesenteric ischemia. RESULTS: Early diagnosis is one of the most important features that determine a patient's prognosis. Conventional angiography and multidetector computed tomography are therefore appropriate to quickly diagnose mesenteric ischemia, the latter being commonly more available. Once a patient presents with signs of peritonitis, instant laparotomy is indicated, and infarcted bowel segments need to be resected, followed by a second-look operation if necessary. If bowel necrosis is clinically not suspected, different approaches should be applied according to source and nature of mesenteric ischemia. Besides established surgical treatment concepts, more and more interventional procedures are developed and evaluated. However, superiority of these new techniques could only be shown for selected patient groups so far. In chronic mesenteric ischemia, interventional approaches seem to be an attractive alternative in patients who are in a condition too bad to undergo surgery. Patients with colonic ischemia are treated best in a conservative manner and by resolving the underlying cause, if identified. CONCLUSION: Patients with acute mesenteric ischemia are still at highest risk for a fatal course of disease. New diagnostic and therapeutic developments have not been tested in larger studies yet, neither has any of these methods led to an increased survival in studies published so far. Taken together, mesenteric ischemia requires high awareness, earliest possible diagnosis, and treatment by an experienced interdisciplinary team of gastroenterologists, radiologists, and surgeons.
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Intestinos/irrigação sanguínea , Isquemia/cirurgia , Mesentério/irrigação sanguínea , Doença Aguda , Angiografia , Doença Crônica , Colo/irrigação sanguínea , Diagnóstico Diferencial , Diagnóstico Precoce , Embolia/diagnóstico , Embolia/cirurgia , Emergências , Humanos , Infarto/diagnóstico , Infarto/cirurgia , Isquemia/diagnóstico , Isquemia/etiologia , Artérias Mesentéricas/cirurgia , Oclusão Vascular Mesentérica/diagnóstico , Oclusão Vascular Mesentérica/cirurgia , Veias Mesentéricas/cirurgia , Peritonite/diagnóstico , Peritonite/cirurgia , Reoperação , Trombose/diagnóstico , Trombose/cirurgia , Tomografia Computadorizada EspiralRESUMO
OBJECTIVES: To evaluate technical success rate and clinical outcome of patients with acute embolic superior mesenteric artery (SMA) occlusion who were treated with primary percutaneous revascularization. METHODS: At three medical centers the radiological information system databases were used to identify all patients in whom primary percutaneous revascularization for the treatment of acute embolic SMA occlusion was attempted between 2001 and 2010. Percutaneous treatment was performed in 15 patients (median age 80 years, range 49-88 years). These patients represent the study population. Eleven patients reported abdominal pain. Five patients exhibited peritoneal signs. Revascularization was defined as complete technical success if (1) patency of the SMA with residual stenosis of not more than 30% in diameter and (2) sufficient perfusion of the entire bowel were obtained. RESULTS: Complete technical success was achieved in eleven patients. After percutaneous revascularization laparotomy was performed in six patients and in three of them bowel resection was carried out (length of resected segments 20-80 cm). The 30-day mortality was 33% (five of 15 patients). None of the surviving patients exhibited short-bowel syndrome. CONCLUSIONS: Primary percutaneous aspiration and thrombolysis constitutes a promising alternative to surgical revascularization in selected patients with acute embolic SMA occlusion.
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Embolia Aérea/terapia , Oclusão Vascular Mesentérica/terapia , Sucção/métodos , Terapia Trombolítica/métodos , Idoso , Idoso de 80 Anos ou mais , Embolia Aérea/complicações , Embolia Aérea/diagnóstico por imagem , Feminino , Humanos , Masculino , Artéria Mesentérica Superior , Oclusão Vascular Mesentérica/diagnóstico por imagem , Oclusão Vascular Mesentérica/etiologia , Pessoa de Meia-Idade , Radiografia , Resultado do TratamentoRESUMO
A 57-year-old woman presented with obscure gastrointestinal bleeding. Double balloon enteroscopy, angiography, and surgery including intraoperative enteroscopy failed to identify the bleeding site. Multidetector computed tomography (CT) depicted active bleeding of a small bowel segment. The bleeding segment was localized by CT-guided percutaneous needle insertion and subsequently removed surgically.
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Meios de Contraste/administração & dosagem , Hemorragia Gastrointestinal/diagnóstico por imagem , Intestino Delgado/diagnóstico por imagem , Iohexol/administração & dosagem , Agulhas , Tomografia Computadorizada por Raios X/instrumentação , Tomografia Computadorizada por Raios X/métodos , Feminino , Humanos , Injeções/instrumentação , Injeções/métodos , Pessoa de Meia-IdadeRESUMO
OBJECTIVE: The purpose of this feasibility study was to prospectively evaluate an optimized multidetector computed tomographic protocol for the diagnosis of active obscure gastrointestinal bleeding (OGIB). METHODS: Between October 2006 and February 2008, patients admitted for active OGIB were included in this prospective unicenter study. Water was administered orally and rectally as neutral luminal contrast material. A contrast-enhanced 16-row multidetector computed tomography (MDCT) was performed in the arterial and venous phases. Mesenteric digital subtraction angiography was carried out immediately after MDCT as standard of reference. RESULTS: Six patients were included in this study. Multidetector computed tomography identified the bleeding site and source in 5 (83%) of the patients. Digital subtraction angiography was performed in 4 patients, and the result was positive in 1 (25%) of the patients. Multidetector computed tomography detected the site and source of bleeding in 2 patients whose digital subtraction angiographic result was negative. CONCLUSIONS: The results of this feasibility study indicate that optimized MDCT is an excellent diagnostic tool for the diagnosis of active OGIB.
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Hemorragia Gastrointestinal/diagnóstico por imagem , Tomografia Computadorizada por Raios X/métodos , Adulto , Brometo de Butilescopolamônio , Meios de Contraste , Extravasamento de Materiais Terapêuticos e Diagnósticos/diagnóstico por imagem , Estudos de Viabilidade , Feminino , Hemorragia Gastrointestinal/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Intensificação de Imagem Radiográfica/métodosRESUMO
BACKGROUND: Delayed visceral arterial hemorrhage caused by inflammatory vessel erosion represents a rare but life-threatening complication after pancreatic head resection. Therapeutic options include reoperation or endovascular minimally invasive techniques such as embolization or stent graft placement. The present article describes our experiences with implantation of newly developed low-profile stent grafts. METHODS: The findings of four patients with delayed visceral arterial hemorrhage are described. All patients were treated with placement of low-profile stent grafts. The patients' medical records, radiological reports, and images were retrospectively reviewed. Technical success was defined as immediate cessation of hemorrhage. Clinical success was defined as hemodynamic stability. RESULTS: A total of seven stent grafts were implanted in four arteries. In detail, one stent graft was placed in the splenic artery of the first and second patients. In the third patient one stent graft was initially implanted in the common hepatic artery. The patient developed recurrent hemorrhages of the common hepatic artery, treated one time surgically and two times by deployment of a second and third stent graft. In the fourth patient two stent grafts were placed in the proper hepatic artery. Technical and clinical success was achieved at every procedure. Apart from recurrent hemorrhage of patient No. 3 there were no major complications. CONCLUSIONS: Minimally invasive therapy using low-profile stent grafts is an effective and safe procedure for the treatment of delayed visceral arterial hemorrhage following Whipple's procedure. The technique is a promising alternative to standard procedures such as surgical repair or embolization.
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Pancreaticoduodenectomia/efeitos adversos , Hemorragia Pós-Operatória/etiologia , Hemorragia Pós-Operatória/terapia , Stents , Adenocarcinoma/cirurgia , Idoso , Prótese Vascular , Implante de Prótese Vascular , Neoplasias do Sistema Digestório/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos , Estudos Retrospectivos , Circulação Esplâncnica , Fatores de TempoRESUMO
PURPOSE: The diagnostic yield of computed tomography angiography (CTA) compared to digital subtraction angiography (DSA) for major obscure gastrointestinal bleeding (OGIB) is not known. Aim of the study was to prospectively evaluate the diagnostic yield of CTA versus DSA for the diagnosis of major OGIB. MATERIAL AND METHODS: The institutional review board approved the study and informed consent was obtained from each patient. Patients with major OGIB were prospectively enrolled to undergo both CTA and DSA. Two blinded radiologists each reviewed the CTA and DSA images retrospectively and independently. Contrast material extravasation into the gastrointestinal lumen was considered diagnostic for active bleeding. Primary end point of the study was the diagnostic yield, defined as the frequency a technique identified an active bleeding or a potential bleeding lesion. The diagnostic yield of CTA and DSA were compared by McNemar's test. RESULTS: 24 consecutive patients (11 men; median age 64 years) were included. CTA and DSA identified an active bleeding or a potential bleeding lesion in 92% (22 of 24 patients; 95% CI 72%-99%) and 29% (7 of 24 patients; 95% CI 12%-49%) of patients, respectively (p<0.001). CTA and DSA identified an active bleeding in 42% (10 of 24; 95% CI 22%-63%) and 21% (5 of 24; 95% CI 7%-42%) of patients, respectively (p=0.06). CONCLUSION: Due to the lower invasiveness and higher diagnostic yield CTA should be favored over DSA for the diagnosis of major OGIB.
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Angiografia Digital/métodos , Angiografia por Tomografia Computadorizada/métodos , Hemorragia Gastrointestinal/diagnóstico por imagem , Tomografia Computadorizada Multidetectores/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Trato Gastrointestinal/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Reprodutibilidade dos Testes , Estudos Retrospectivos , Sensibilidade e EspecificidadeRESUMO
PURPOSE: This study was designed to evaluate the technical success and the early clinical outcome of patients undergoing percutaneous aspiration thrombectomy (PAT) for the treatment of arterial thromboembolism following percutaneous infrainguinal transluminal angioplasty (PTA). METHODS: In this single-center study, during a period of 7 years retrospectively, 47 patients (22 male, 47 %) with a mean age of 73 (range 53-96) years were identified in whom PAT was performed for the treatment of thromboembolic complications of infrainguinal PTA. Primary technical success was defined as residual stenosis of <50 % in diameter after sole PAT, whereas secondary technical success was defined as residual stenosis of <50 % in diameter after PAT and additional PTA and/or stenting. Clinical outcome parameters (e.g., need for further intervention, minor/major amputation) were evaluated for the 30-day postinterventional period. RESULTS: Primary technical success was achieved in 64 % of patients (30/47); secondary technical success was obtained in 96 % of patients (45/47). Clinical outcome data were available in 38 patients. In 87 % of patients (33/38), there was no need for further intervention within the 30-day postinterventional period. In three patients, minor amputations were conducted due to preexisting ulcerations (Rutherford Category 5 respectively). CONCLUSIONS: PAT enables endovascular treatment of iatrogenic thromboembolic complications after PTA with good technical and early clinical results and minimal morbidity.
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Angioplastia/efeitos adversos , Trombectomia/métodos , Tromboembolia/etiologia , Tromboembolia/cirurgia , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Sucção , Resultado do TratamentoRESUMO
INTRODUCTION: As total hip arthroplasty is now applicable for younger, healthier, and more active patients, bone preservation becomes even more essential, and proximal fixation, resulting in less stress shielding, draws special attention with focus on new strategies and implant designs. Recently, a new type of non-cemented fixation of the femoral component, featured with the locking screw hip (LSH) stem, was developed by Scyon Orthopaedics AG (Au-Waedenswil, Switzerland). The idea to rigidly fix the femoral component of a prosthesis for total hip replacement in this fashion evolved from the very good results achieved with the internal point-contact fixator PC-Fix. The purpose of this study was to investigate the unique characteristics of the LSH-stem and to assess its biomechanical performance in comparison to a conventional cemented prosthesis (Mueller straight stem). MATERIAL AND METHODS: Six paired human cadaveric femora were preserved with the method of Thiel, split in two study groups, implanted with either cemented Mueller straight stem or LSH-stem prostheses and biomechanically tested under progressively increasing axial loading until catastrophic failure. Bone mineral density (BMD) of all femora was evaluated in the femoral head prior to implantation. Axial construct stiffness, failure load and cycles to failure were calculated from the machine data and statistically evaluated at a level of significance p = 0.05. RESULTS: No statistically significant difference between the LSH-stem and the Mueller straight stem was found in terms of axial construct stiffness (2031.5 N/mm ± 483.1 N/mm and 2403.6 N/mm ± 705.2 N/mm, p = 0.115), failure load (4958.8 N ± 1094.1 N and 5907.2 N ± 1562.8 N, p = 0.138) and cycles to failure (7917.7 ± 2188.1 and 9814.3 ± 3125.6, p = 0.138). BMD showed no significant difference between the two study groups, p = 0.616. CONCLUSION: The LSH-stem seems to be stable enough to carry loads experienced during the rehabilitation period of a patient after THR. Its stability, which is similar to that of the Mueller straight stem, may justify the clinical application of the LSH-stem under thorough investigation.
Assuntos
Artroplastia de Quadril , Cimentação , Fêmur/cirurgia , Prótese de Quadril , Artroplastia de Quadril/métodos , Fenômenos Biomecânicos , Cimentos Ósseos , Parafusos Ósseos , Cadáver , Cimentação/métodos , Fêmur/patologia , Humanos , Masculino , Desenho de Prótese , Estresse MecânicoRESUMO
PURPOSE: This study was designed to evaluate the efficacy and safety of Amplatzer Vascular Plug type 4 (AVP-4) for embolization of the inferior mesenteric artery (IMA) before endovascular aneurysm repair (EVAR) of the abdominal aorta to prevent endoleaks. METHODS: A single-center retrospective review of 31 patients who underwent IMA embolizations before EVAR using the AVP-4 was performed. We analyzed the insertion and detachment procedure, the technical success, and the final position of the plug. Technical success was defined as complete occlusion of the IMA. To compare the incidence of IMA-related type II endoleaks in patients with and without preoperative IMA embolization, we additionally reviewed the course of 43 patients with a preoperatively patent IMA who underwent no IMA embolization. RESULTS: Plugs with a diameter of 5, 6, and 8 mm were used in 5 (16.1 %), 21 (67.7 %), and 5 (16.1 %) patients, respectively (50-100 % oversizing). In 29 of 31 patients (93.5 %), we observed complete occlusion of the IMA within 10 min (mean 5.1 min). Precise placement of the plug in the proximal segment of the IMA without occlusion of the first IMA branches was achievable in all patients. The distance between the AVP-4 and the first branches was on average 12 (range 2-57) mm. Preoperative IMA embolization with AVP-4 significantly reduced the incidence of complex IMA-lumbar type II endoleaks after EVAR (0/31 vs. 11/43; p = 0.002). CONCLUSIONS: The AVP-4 is a safe, feasible, and technically effective embolization device for IMA embolization before EVAR.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Embolização Terapêutica , Procedimentos Endovasculares , Artéria Mesentérica Inferior , Dispositivo para Oclusão Septal , Idoso , Idoso de 80 Anos ou mais , Angiografia , Meios de Contraste , Humanos , Incidência , Iohexol/análogos & derivados , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Estudos Retrospectivos , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Grau de Desobstrução VascularRESUMO
PURPOSE: To determine the feasibility and efficacy of transarterial endoleak embolization using the liquid embolic agent ethylene vinyl alcohol copolymer (Onyx). METHODS: Over a 7-year period eleven patients (6 women, 5 men; mean age 68 years, range 37-83 years) underwent transarterial embolization of a type II endoleak after endovascular aortic aneurysm repair using the liquid embolic agent Onyx. Two patients (18 %) had a simple type II endoleak with only one artery in communication with the aneurysm sac, whereas 9 patients (82 %) had a complex type II endoleak with multiple communicating vessels. We retrospectively analyzed the technical and clinical success of transarterial type II endoleak embolization with Onyx. Complete embolization of the nidus was defined as technical success. Embolization was considered clinically successful when volume of the aneurysm sac was stable or decreased on follow-up CT scans. RESULT: Mean follow-up time was 26.0 (range 6-50) months. Clinical success was achieved in 8 of 11 patients (73 %). Transarterial nidus embolization with Onyx was technically successful in 6 of 11 patients (55 %). In three cases the nidus was embolized without direct catheterization from a more distal access through the network of collateral vessels. CONCLUSION: Onyx is a favorable embolic agent for transarterial endoleak embolization. To achieve the best clinical results, complete occlusion of the nidus is mandatory.
Assuntos
Aneurisma da Aorta Abdominal/terapia , Embolização Terapêutica/métodos , Endoleak/terapia , Polivinil/uso terapêutico , Complicações Pós-Operatórias/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Endoleak/diagnóstico por imagem , Procedimentos Endovasculares/métodos , Estudos de Viabilidade , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Tomografia Computadorizada por Raios X/métodos , Resultado do TratamentoRESUMO
PURPOSE: Evaluation of the efficacy and safety of percutaneous treatment of vascular stenoses and occlusions in pediatric liver transplant recipients. METHODS: Fifteen children (mean age 8.3 years) underwent interventional procedures for 18 vascular complications after liver transplantation. Patients had stenoses or occlusions of portal veins (n = 8), hepatic veins (n = 3), inferior vena cava (IVC; n = 2) or hepatic arteries (n = 5). Technical and clinical success rates were evaluated. RESULTS: Stent angioplasty was performed in seven cases (portal vein, hepatic artery and IVC), and sole balloon angioplasty was performed in eight cases. One child underwent thrombolysis (hepatic artery). Clinical and technical success was achieved in 14 of 18 cases of vascular stenoses or occlusions (mean follow-up 710 days). CONCLUSION: Pediatric interventional radiology allows effective and safe treatment of vascular stenoses after pediatric liver transplantation (PLT). Individualized treatment with special concepts for each pediatric patient is necessary. The variety, the characteristics, and the individuality of interventional management of all kinds of possible vascular stenoses or occlusions after PLT are shown.