Ischemic Muscle Necrosis of Lower Extremities in Peripheral Arterial Disease: The Impact of 99mTc-MDP Scintigraphy on Patient Management.

Background and objectives: The objective of this study was to assess the value of a whole-body bone scintigraphy using 99m technetium labelled-methyl diphosphonate (99mTc-MDP) for the diagnosis and the assessment of grades of muscle damage after prolonged acute or chronic obstruction of the main arteries in lower extremities. Material and Methods: Fifty consecutive patients were selected for the study. The patients' condition had not improved after primary peripheral arterial reconstruction operation or limb amputation and after conservative treatment. The clinical suspicion was of arterial obstruction and muscle necrosis. All the patients underwent whole-body scintigraphy with 99mTc-MDP. Muscle necrosis was identified as an increased soft tissue uptake of 99mTc-MDP. Results: Forty-five patients had gross muscle necrosis detected on whole-body scintigraphy with 99mTc-MDP and were histologically confirmed after repeated surgery (necrectomy or amputation) or by muscle biopsy, if only fasciotomy was performed. The location and extent of muscle injury were assessed preoperatively and the findings were confirmed in all 45 patients. Twelve patients with clinically suspected minor muscle damage, which was confirmed as relatively minor muscle necrosis on 99mTc-MDP scintigraphy, were treated conservatively. The clinical outcome of all 50 patients was favorable. The 99mTc-MDP scintigraphy, in detection of muscular necrosis, demonstrated sensitivity, specificity, and accuracy of 97.3% (95% confidence interval (CI) 85.4% to 99.3%), 30.77% (95% confidence interval (CI) 9.09% to 61.43%), and 80% (95% confidence interval (CI) 66.28% to 89.97%), respectively. Conclusion: The 99mTc-MDP scintigraphy is a valuable tool in the detection of muscular necrosis. It is able to define location, extent, and grade of involvement. Therefore, it has a clinical impact in patient management, allowing clinicians to select adequate treatment policy and specify the scope of necrectomy.

Complicated congenital gluteal arteriovenous malformation with hemorrhage in pregnancy.

Extracranial congenital arteriovenous malformations (AVMs) are rare clinical entities that can be progressive in nature. The influence of pregnancy on lesion progression has been discussed in the past. This report presents an unusual case of 23-year-old primigravida woman who presented at 36 weeks' gestation with complicated necrotic ulceration and hemorrhage of the right gluteal region. A hyperpigmented mark with varicosities was initially noted at birth, but during pregnancy it showed remarkable progression and was first identified as an AVM. After hemorrhage control and induced delivery, the lesion was successfully treated with several embolizations. Complete wound healing was achieved, but because of partial recurrence at 3 years, repeat embolization was performed, with satisfactory clinical improvement and residual 25% arteriovenous shunting on transarterial lung perfusion scintigraphy study. AVM complications during pregnancy are uncommon, and this case supports the prior opinion that pregnancy can stimulate lesion progression. Especially in undiagnosed and previously untreated cases, this can lead to life-threatening complications for the mother and fetus. Long-term lesion management usually requires combined endovascular and surgical treatment.

Diagnostic methods, treatment modalities, and follow-up of extracranial arteriovenous malformations.

OBJECTIVE: Arteriovenous malformations (AVMs) are an uncommon vascular pathology that remains challenging to accurately diagnose and successfully treat. This study introduces a novel way to evaluate AVM treatment outcomes using transarterial lung perfusion scintigraphy (TLPS) and reports our treatment results. MATERIAL AND METHODS: The patients treated for extracranial AVMs were studied retrospectively. Diagnosis and outcomes were based on clinical data, ultrasonography, magnetic resonance imaging, computed tomography, angiography, and TLPS studies. The influence of gender; location, form, and stage of AVMs; first attempt at treatment; and treatment modalities was analyzed. Outcomes were defined as positive (cure, improvement, and remission) or negative (no remission and aggravation). RESULTS: Of the 324 patients with congenital vascular malformations, 129 (39.8%) presented with AVMs, and the data of 56 treated patients with AVMs were analyzed. Of the 29 patients in the endovascularly treated group, 15 in the surgically treated group, and 12 in the combined treatment group, 24 (82.8%), 14 (93.3%), and 10 patients (83.3%), respectively, had positive outcomes (P>0.05). All outcomes were positive in surgically treated patients with extratruncular limited AVMs, and these patients were more likely to be cured as compared with those who had other forms of AVMs (OR, 5.8; 95% CI, 1.1-29; P=0.02). The patients with more advanced AVMs (stages III and IV) and with AVMs in the gluteal and pelvic region were more likely to have the worst outcomes than those with stage II AVMs (OR, 8.2; 95% CI, 1-72; P=0.03) and with AVMS in other locations (OR, 5.8; 95% CI, 1.1-29; P=0.02), respectively. Gender and age did not significantly influence treatment results (P>0.05). The TLPS data of 17 patients showed AV shunting ranging from 0% to 92%, which combined with other results helped identify 9 patients who needed further interventions, 6 who were treated successfully, and 2 who had insignificant shunting. CONCLUSIONS: The best outcomes were achieved in surgically treated patients with localized lesions and less advanced AVMs. For the first time in Lithuania, a modified TLPS method has been introduced that enhances a hemodynamic assessment of AV shunting and provides with a more accurate evaluation of AVMs to better serve in planning future treatments.

Classic dissection of thoracic aorta complicated by ascending aortic intramural hematoma: promt diagnosis and successful endovascular repair.

We reported a case of 68-year-old man, with a previous history of hypertension. Patient was admitted to our institution for evaluation of a severe, constant, tearing anterior chest pain radiated to the neck with suspicion of acute aortic dissection. A multidetector computed tomography scan of thorax and abdomen demonstrated a dissection starting from the middle part of aortic arch and extending downward to the descending aorta till the middle part of the thoracic aorta. The dissection was classified as Stanford A, De Bakey I. Surgical treatment of patient was started with bypass graft from the right common carotid artery to the left common carotid with subsequent revascularization of left subclavian artery. Lower parts of above-mentioned arteries were ligated. At the second stage an emergent prosthetic stent-graft was placed distally from the truncus brachiocephalicus up to the proximal part of the descending aorta. We reported a case report to present diagnostic and possible interventional treatment for patient with acute aortic type A dissection.

Orthotopic liver transplantation: the first experience and results of the Vilnius University Hospital Santariskiu Klinikos.

BACKGROUND: Liver transplantation has become the treatment of choice for chronic and acute end-stage liver failure as well as for selected cases of malignancies and metabolic disorders. We report our first experience of the orthotopic liver transplantation. MATERIAL/METHODS: Between 2005 and 2008 16 cadaveric orthotopic liver transplantations in 16 adults (12 males, 4 females, mean age 44 years) were performed. Main indications for orthotopic liver transplantation were cholestatic liver disease (31%), viral-induced cirrhosis (25%), alcoholic liver disease (19%), hepatocellular carcinoma associated with hepatitis virus infection (13%), autoimmune cirrhosis (6%), cryptogenic acute liver failure (6%). Mean follow-up was 15 month (range: 4 days - 43 month). RESULTS: Intraabdominal haemorrhage was observed in 6 patients (37.5%). Vascular complications were observed in 3 patients (18.75%). Biliary complication were observed in 3 patients (18.75%). Overall 1 year patient survival was 87,5%. Four (25%) patients died during follow-up. All patients died because of sepsis and multiorgan system failure. CONCLUSIONS: Our first results showed that secret of successful liver transplantation is perfect interdisciplinary team approach, including selection of the recipient and timing of transplantation, the operative procedure itself, prevention and treatment of complications, the perioperative anaesthesiological and intensive-care management, and careful follow up after transplantation.