Volumetric evaluation of CT images of adrenal glands in primary aldosteronism.

OBJECTIVES: To investigate whether adrenal volumetry provides better agreement with adrenal vein sampling (AVS) than conventional CT for subtyping PA. Furthermore, we evaluated whether the size of this contralateral adrenal was a prognostic factor for clinical outcome after unilateral adrenalectomy. METHODS: We retrospectively analyzed volumes of both adrenal glands of the 180 CT-scans (88/180 with unilateral and 92/180 with bilateral disease) of the patients with PA included in the SPARTACUS trial of which 85 also had undergone an AVS. In addition, we examined CT-scans of 20 healthy individuals to compare adrenal volumes with published normal values. RESULTS: Adrenal volume was higher for the left than the right adrenal (mean and SD: 6.49 ± 2.77 ml versus 5.25 ± 1.87 ml for the right adrenal; p < 0.001). Concordance between volumetry and AVS in subtyping was 58.8%, versus 51.8% between conventional CT results and AVS (p = NS). The volumes of the contralateral adrenals in the patients with unilateral disease (right 4.78 ± 1.37 ml; left 6.00 ± 2.73 ml) were higher than those of healthy controls reported in the literature (right 3.62 ± 1.23 ml p < 0.001; left 4.84 ± 1.67 ml p = 0.02). In a multivariable analysis the contralateral volume was not associated with biochemical or clinical success, nor with the defined daily doses of antihypertensive agents at 1 year follow-up. CONCLUSIONS: Volumetry of the adrenal glands is not superior to current assessment of adrenal size by CT for subtyping patients with PA. Furthermore, in patients with unilateral disease the size of the contralateral adrenal is enlarged but its size is not associated with outcome.

Validation of the Simulator for Testing and Rating Endovascular SkillS (STRESS)-machine in a setting of competence testing.

AIM: Endovascular skills are an integral part of modern-day vascular surgery. The STRESS machine has been developed to test these skills in vascular surgeons. This study aims to define an optimal pass/fail cutoff value for the STRESS test score. METHODS: The STRESS machine consists of a dry glass model of the abdominal aorta and its tributaries with various stenotic lesions, elongations, and tortuosities. A camera and computer software are used to simulate plain fluoroscopy-mode. The test subjects are given two assignments after which two reviewers use a combination of the ICEPS and MRS to produce the final total score; 43 subjects were tested. According to previous endovascular experience, subjects were classified into four groups: novice-low (no experience, less than 11 performed procedures, less than 50 assisted procedures), novice-high (11-25 performed procedures, more than 50 assisted procedures), intermediate (1-10 performed and >11-25 assisted procedures, 11-25 performed and >1-10 assisted procedures or 25-50 performed procedures) and advanced (more than 50 performed procedures). RESULTS: Test-score and noted experience showed a correlation of 0.794. All intermediate and advanced test subjects scored more than 50 points compared to 4 out of 15 novices. CONCLUSION: We demonstrated that it is possible to determine an optimal cut-off value for competence testing with the STRESS machine.

Acute arterial occlusion after deployment of the Angio-Seal closure device: is it as uncommon as we think?

Angio-Seal is a frequently used vascular closure device after arterial catheterisation. Major complications are infrequently reported. We present four cases occurring within a 2-month period in our hospital with dislodgement of an Angio-Seal causing acute arterial occlusion, resulting in loss of limb in one case. Surgical intervention was necessary in all cases. Acute arterial occlusion after deployment of the Angio-Seal in patients with peripheral arterial disease might be less uncommon than the literature suggests.

Acute myocardial infarction complicating subarachnoid haemorrhage.

An acute myocardial infarction is a rare complication of a subarachnoid haemorrhage. The combination of these two conditions imposes important treatment dilemmas. We describe two patients with this combination of life-threatening conditions. Patient 1 was treated with emergency percutaneous coronary intervention followed by clipping of the anterior communicating artery aneurysm. Six months after discharge the patient's memory and orientation had almost completely recovered. Patient 2 was treated with aspirin until coiling of the aneurysm could be performed. After successful coiling low-molecular-weight heparin was added. One week later the patient died due to a free wall rupture. (Neth Heart J 2009;17:284-7.).

Measurement of leg blood pressure: the most straightforward way to the diagnosis.

Two adult patients with presumed primary hypertension are presented. In the first patient the diagnosis of coarctation of the aorta was straightforward while in the second patient there was a substantial delay in reaching the correct diagnosis. A 32-year-old patient was analysed for hypertension in the outpatient clinic. At physical examination a systolic cardiac murmur was present and leg blood pressure was not measurable. Magnetic resonance imaging angiography showed a severe coarctation of the thoracic aorta with extensive distended collateral blood vessels. A second patient was a 31-year-old man referred with longstanding hypertension and an unsatisfactory blood pressure response to treatment. Previously, a diagnosis of primary hypertension was made. Renal computed tomography angiography excluded renal artery stenosis as a cause of hypertension but disclosed many distended collateral blood vessels in the musculus rectus abdominis and in the upper abdominal area. Leg blood pressure was measured and further analysis revealed a coarctation of the aorta. Both patients illustrate and emphasise the importance of leg blood pressure measurement at a first analysis of adult hypertensive patients and should always be performed when hypertension is accompanied by murmurs or weak femoral pulsations.

[Determining aldosterone in the adrenal veins in order to establish uni- or bilateral aldosterone production in patients with primary hyperaldosteronism]. / Aldosteronbepaling in bijniervenen voor het vaststellen van enkel- of dubbelzijdige aldosteronoverproductie bij patiënten met primair hyperaldosteronisme.

In 3 patients, men aged 60, 55 and 60, respectively, with hypertension due to primary hyperaldosteronism, the aldosterone level in the adrenal veins was determined for the purpose of further diagnosis. In two patients, unilateral adrenal enlargement on the CT-scan was accompanied by overproduction ofaldosterone, in one case in a non-enlarged adrenal gland and in the other case in both adrenals. The first patient underwent adrenalectomy of the non-enlarged adrenal gland, while in the second patient surgery was decided against. The third patient had bilateral adrenal gland enlargement on the CT-scan with a surgically treatable, unilateral overproduction ofaldosterone. Now that determination ofthe aldosterone:renin ratio in plasma as a screening method in selected patients with hypertension is being used more often, primary hyperaldosteronism turns out to be more common than was previously thought. For differentiation between unilateral and bilateral overproduction of aldosterone, imaging of the adrenals, for example with CT, is insufficiently accurate. Aldosterone determination in the adrenal veins can distinguish between unilateral and bilateral overproduction of aldosterone with great accuracy, which has important therapeutic consequences.

The merits of decision modelling in the earliest stages of the IDEAL framework: An innovative case in DIEP flap breast reconstructions.

BACKGROUND: The IDEAL framework aims at improving the evidence base of available surgical innovations. However, the development of such innovations and collection of evidence is costly. Surgical innovation can provide more value for money if innovations are evaluated at an early stage, where evaluations can inform the decision whether to stop or to further develop an innovation. We illustrate how decision modelling can be readily adopted at the earliest stages (0-1) of the IDEAL framework, using an innovation in bilateral DIEP flap breast reconstruction as an example. METHODS: We quantified expected costs and quality-adjusted life years (QALYs) of the current treatment and compared them with an innovation aimed at reducing complications and surgery time. The maximum effect of eliminating all complications (headroom analysis) was explored. Moreover, three scenarios with varying complications and surgery time reductions were modelled. Furthermore, the maximum price of the innovation was estimated in a threshold analysis according to its impact and societal willingness to pay. RESULTS: The headroom analysis showed that when all complications associated with the current treatment are prevented, up to €889 per patient is saved. Scenario analysis showed cost savings between €256 and €828 per patient. When surgery time is reduced by 15 min and complications by 50%, the innovation will remain cost-effective at €671 per patient. CONCLUSION: In a field struggling with cost containment, decision modelling can help to separate promising innovations from costly failures at an early stage. In this example, decision modelling showed that it seems worthwhile to further develop the innovation.

Displaying inguinal lymph nodes before transplantation in a deep inferior epigastric perforator flap breast reconstruction using an innovative projection method.

INTRODUCTION: Lymphedema of the arm is a common postoperative complication as a result of breast cancer surgery. One of the surgical treatments comprises modification of a deep inferior epigastric perforator (DIEP) flap breast reconstruction to facilitate additional lymph node transplantation from the inguinal area. Using computed tomography angiography (CTA), the distribution of these lymph nodes can be assessed. A virtual planning based on this CTA created for the DIEP flap is presented, with the inguinal lymph nodes included, followed by preoperatively projecting this information on the patient's abdomen. METHODS: A total of 10 patients underwent the standard imaging protocol: A preoperative CTA to assess the vascular anatomy of the lower abdomen. A three-dimensional (3D) model of the blood vessels was produced, and the inguinal lymph nodes in this reconstruction were included. Preoperative projection of the 3D model onto the patients' abdomen and inguinal area was performed, followed by tracing of this image. Intraoperatively found lymph nodes were identified by touch and compared with the markings on the skin. RESULTS: In all 10 patients, all lymph nodes located preoperatively were found intraoperatively within a 1-cm radius of the marking on the skin; and these were more easily located by two operating surgeons. CONCLUSION: Virtual planning of lymph node transplantations in a deep inferior epigastric artery perforator flap breast reconstruction seems feasible and can be performed quickly. This additional visual support aids the surgeon in locating the lymph nodes in the inguinal area.

[A pregnant patient with spontaneous haemothorax: hereditary haemorrhagic telangiectasia in pregnancy]. / Een zwangere met een spontane hematothorax.

BACKGROUND: The incidence of hereditary haemorrhagic telangiectasia (HHT - Osler-Weber-Rendu disease) in the Netherlands is 1:5000 but approximately 1:1300 in people from the Antilles. The disease is characterised by the development of telangiectasia and arteriovenous malformations (AVMs) that may result in serious morbidity and mortality. CASE DESCRIPTION: A 31-year-old primigravid patient consulted her general practitioner at 31 1/7 weeks gestational age with dyspnoea. She was referred for further diagnostics because of suspected pulmonary embolism. A CT scan showed haemothorax and a bleeding arteriovenous malformation (AVM) in the left lung. Family history suggested the possibility of HHT. After multidisciplinary consideration, a primary caesarean section was performed, followed by embolisation of the AVM during the same surgical session. The patient had a gene mutation consistent with HHT type 2. CONCLUSION: Pregnant patients with HHT are at risk of serious morbidity, especially if they are not screened for AVMs. A multidisciplinary approach for such patients, with consideration of various scenarios, is highly recommended.

[Hypertension due to fibromuscular dysplasia: look for additional disease sites]. / Hypertensie door fibromusculaire dysplasie.

Fibromuscular dysplasia (FMD) is a non-inflammatory, non-atherosclerotic vasculopathy that can lead to arterial stenosis, occlusion, aneurysms, and dissection. FMD of the renal arteries can lead to renovascular hypertension. Percutaneous angioplasty of the renal arteries (PTRA) can lead to normalization of blood pressure in 45% of patients with renal artery stenosis caused by FMD, particularly in younger patients and patients with a short history of hypertension. A considerable number of the patients with renovascular FMD also have cervical FMD, which can lead to ischaemic or haemorrhagic stroke. In this article we discuss diagnostic and therapeutic options, illustrated by two cases of patients with renovascular and carotid FMD. Most of the recommendations are based on data from retrospective studies and expert opinion; prospective studies on the optimal diagnostic strategy and treatment are therefore, urgently required.

Local and systemic thrombolytic therapy for acute deep venous thrombosis.

This article presents a review of the treatment of lower-extremity deep venous thrombosis (DVT) with systemic and catheter-directed thrombolysis (CDT) and percutaneous mechanical thrombectomy (PMT). Standard treatment including anticoagulation therapy and compression stockings may not be entirely adequate, because a significant proportion of patients eventually develop post-thrombotic syndrome (PTS). Thrombolytic agents might offer a potential advantage because they cause faster and more complete clot resolution, which may reduce or prevent residual vein stenosis and valve damage. Thrombolytic therapy results in greater lysis, but also in higher complication rates than does anticoagulation alone. Major bleeding occurs in 11% of patients treated with thrombolytic therapy. The incidence of PTS tends to be lower in patients treated with thrombolytics. However, several methodological flaws limit the conclusions with respect to reduction in PTS. No adequate randomised controlled trials have been performed comparing CDT or PMT with conventional therapy. Given the current data, thrombolytic treatment, CDT or PMT should not be applied except in extraordinary cases. First, the long-term effectiveness in terms of reducing PTS, although possible, remains uncertain. Second, the risks of thrombolytic therapy and PMT are higher. Third, current conventional therapy is relatively inexpensive, convenient and safe.

Preliminary results using a newly developed projection method to visualize vascular anatomy prior to DIEP flap breast reconstruction.

INTRODUCTION: In a deep inferior epigastric perforator (DIEP) flap breast reconstruction, computed tomography angiography (CTA) is currently considered as the gold standard in preoperative imaging for this procedure. Unidirectional Doppler ultrasound (US) is frequently used; however, this method does not distinguish the main axial vessels from perforator arteries at the height of the fascia, it has a limited penetration depth, and it cannot assess the branching patterns of the deep inferior arteries. A new method and system were developed, which consisted of a video projector preoperatively displaying the location and intramuscular course of the artery perforators and subcutaneous branching on the patient's abdomen. METHOD: All patients (n=9) underwent a standard protocol: a preoperative CTA was performed and the DIEPs were localized using a unidirectional Doppler probe. In addition, a three-dimensional (3D) reconstruction of the perforator locations based on CTA was projected on the abdomen of the patients. All projected perforator locations were assessed using a unidirectional Doppler probe. The intraoperative results were collected for comparison. RESULTS: A total of 88 locations were marked with the use of unidirectional Doppler and a total of 100 perforators were projected (p=0.38). In 98 out of 100 projected perforator locations, a Doppler signal was audible. The intraoperative results demonstrate that 19 out of 34 transplanted perforators were correctly identified with unidirectional Doppler (56.9%±31.4%), where the projection method properly revealed 29 locations (84.3%±25.8%) (p=0.030). CONCLUSION: The projection method is not only capable of providing more information and identifying more perforators used for transplantation than unidirectional Doppler probing but also more accurate in pointing out the corresponding perforator found intraoperatively.

Reduction in the number of sentinel lymph node procedures by preoperative ultrasonography of the axilla in breast cancer.

Currently, breast cancer patients without clinically suspicious lymph nodes are candidates for sentinel lymph node procedures (SLNPs). The aims of this study were to investigate whether preoperative axillary ultrasonography and fine-needle aspiration cytology (FNA) can reduce the number of the more time-consuming SLNPs, and to identify a subset of quantitative nodal features to predict metastatic involvement. 268 axillae were ultrasonographically examined. FNA was performed on suspicious nodes (smallest diameter > or =5 mm or atypical cortex appearance). SLNP was omitted if a tumour-positive node was found on FNA. Length, width, maximum cortex thickness and appearance of cortex and hilus were ultrasonographically established. In 93 axillae (35%), at least one node was detected with ultrasound. FNA was performed once per axilla on 66 nodes; 37 (56%) contained tumour cells. 31% of all tumour-positive axillae (macro-+micrometastases) was found by ultrasound and FNA (37/121). 41% of all axillae containing macrometastases was found by ultrasound and FNA (36/87). SLNPs were reduced by 14% (37/268). Maximum cortex thickness is the main feature to predict metastatic involvement (area under Receiver Operating Characteristic (ROC) curve (A(Z))=0.87).

Superimposed peripheral pulmonary vasculature in anthropomorphic chest phantoms.

RATIONALE AND OBJECTIVES: Comparative radiologic studies often involve the use of phantoms. However, in most chest phantoms, the lack of sufficient peripheral vessels results in unrealistic images. This can impair the reliability of conclusions drawn from the studies performed. The authors present a method of improving the simulation of the peripheral pulmonary vasculature in anthropomorphic chest phantoms. METHODS: The appearance of peripheral vessels was simulated using red lead painted on transparent foils. Several of the foils were taped to the back of the phantom to give the impression of superimposed blood vessels. RESULTS: Subjectively, a more realistic appearance of peripheral vasculature was obtained in the radiograph. CONCLUSIONS: Our method improves the quality of widely available anthropomorphic chest phantoms, and the modification is easily implemented. However, the use of lead limits the modified phantom to comparative studies with constant exposure voltage.

Displacement of breast tissue and needle deviations during stereotactic procedures.

RATIONALE AND OBJECTIVES: The aim of this study was to quantify the displacement of breast tissue and the inaccuracy of needle positioning for biopsy (14-gauge) and localization (19.5-gauge) needles. METHODS: For displacement of breast tissue, differences between the coordinates of identifiable microcalcifications in the images before (baseline) and after needle positioning were analyzed (n = 52). For accuracy of needle positioning, differences between the coordinates of the needle tip and the target were analyzed in breast tissue (n = 97) and in air (n = 246). RESULTS: Average target displacement was 2.1 mm for biopsy needles (95% prediction interval [PI] 0.6-7.8) and 1.0 mm (95% PI 0.3-3.9) for localization needles. Mean inaccuracy of needle positioning in breast tissue was 1.1 mm (95% PI 0.4-3.0) and 1.8 mm (95% PI 0.7-4.6) for biopsy and localization needles, respectively. CONCLUSIONS: Tissue and needle displacements cause a total positioning error of 2.4 mm in stereotactic core biopsy, which will limit the attainable diagnostic accuracy.

Quantitative analysis of computed tomography scans of the lungs for the diagnosis of pulmonary emphysema. A validation study of a semiautomated contour detection technique.

RATIONALE AND OBJECTIVES: To develop an analytic software package based on automated contour detection for the objective and reproducible assessment of emphysema from computed tomography (CT) scans. METHODS: A semiautomated technique was developed for the definition of lung contours in CT cross-sections followed by the assessment of pulmonary CT parameters describing the disease state. For 78 images, the semiautomated contour detection was performed and compared with contours drawn by an experienced radiologist by calculating the systematic area difference (bias) and differences in pulmonary CT parameters such as the mean lung density (MLD). In addition, intraobserver and interobserver variabilities were determined in a subset of 15 images. RESULTS: The areas enclosed by the semiautomatically detected contours were slightly larger than the manual ones (bias < 2.1%). The biases in the observer studies were smaller in the semiautomated versus the manual case (0.3% vs. 1.3%). The standard deviation of the MLD differences with a manual analysis was larger by a factor of five than in the semiautomated case. On average, manual analysis required 2 minutes, 18 seconds per lung; this time was reduced to 11.5 to 29 seconds with the semiautomated approach, depending on the respiration state. CONCLUSIONS: The semiautomated approach is preferred over the manual approach because of its higher consistency and its shorter analysis time.

Assessment of the progression of emphysema by quantitative analysis of spirometrically gated computed tomography images.

RATIONALE AND OBJECTIVES: The authors assessed the progression of pulmonary emphysema by means of quantitative analysis of computed tomography images. METHODS: Twenty-three patients suffering from emphysema due to an alpha 1-antitrypsin deficiency, aged 45 +/- 7 years and exsmokers, were scanned twice with a 1-year time interval. At 90% of the vital lung capacity, slices with a thickness of 1.5 mm were acquired at the level of the carina and 5 cm above the carina; slices with a thickness of 1 cm were acquired 5 cm below the carina. The entire lung was scanned spirally at a respiratory status, corresponding with 75% of the total lung capacity at baseline. The mean lung densities (MLD) were calculated in an objective manner with new analytic software featuring automated detection of the lung contours. RESULTS: Mean lung densities decreased by 14.2 +/- 12.0 Hounsfield units (HU; P < 0.001) above the carina, by 18.1 +/- 14.4 HU (P < 0.001) at the carina level, by 23.6 +/- 15.0 HU (P < 0.001) below the carina, and by 12.8 +/- 22.2 HU (P < 0.01) for the entire lung. The decrease in MLD was most obvious in the lower lung lobes. For the same patient group, the annual decrease in the forced expiratory volume (FEV1) and the carbon monoxide-diffusion were 120 +/- 190 mL (P < 0.01) and 10 +/- 70 mmol/kg/minute ( P < 0.2), respectively. No significant correlation was found between the decrease in MLD and the decrease in FEV1. CONCLUSIONS: Progression of emphysema can be assessed in an objective manner based on the mean lung density (MLD), measured from computed tomography volume scans as well as from single-slice scans. Mean lung density has proved to be more sensitive than FEV1 and carbon monoxide-diffusion.

Percutaneous radiological gastrostomy in patients with head and neck cancer.

AIM: To evaluate the results of percutaneous radiological gastrostomy in patients with head and neck cancer. PATIENTS AND METHODS: This was a retrospective study design. One hundred and eighteen patients with head and neck cancer were referred 130 times for gastrostomy tube placement between 1 April 1993 and 17 August 1998. Mean age was 60 years. All data were analysed by using the following parameters: success rate, complications and mortality. Complications were divided into major, minor (complication that needed only conservative treatment) and tube-related. RESULTS: The success rate of percutaneous radiological gastrostomy was 97%. Major complications occurred in 6% of patients after gastrostomy tube placement. Minor complications occurred in 15% of patients. There was one tube-related complication. Procedure-related mortality occurred in one patient. The results of this study show no difference from those known from the literature for the percutaneous method and confirm that radiological gastrostomy has significantly lower rates of major complications than other methods of gastrostomy placement. CONCLUSION: Percutaneous radiological gastrostomy tube placement is, in our opinion, an effective and reliable method for placing a feeding tube in patients with head and neck cancer.

An experimental minimally invasive perfusion technique for the treatment of liver metastases.

AIM: Isolated hepatic perfusion (IHP) is an invasive, technically difficult, non-repeatable and demanding operation. In this study we report the development of a less invasive alternative for the surgical IHP in a pig model. METHODS: Our technique was tested in 8 Yorkshire pigs (60 kg). The liver was isolated from the systemic circuit using minimally invasive techniques: an occlusion stent-graft and balloon catheters, with reversal of the blood flow through the liver during IHP. RESULTS: Tests with varying pressures applied at the PV revealed a clear relation between the suction pressure at the outflow site (PV), intrahepatic pressure and systemic leakage of 99mTc. A leakage-free IHP could be obtained in seven separate experiments. CONCLUSION: Isolated hepatic perfusion using minimally invasive techniques is feasible in pigs when the intrahepatic pressure is controlled. This technique has yet to be tested in patients.

The benefit of STent placement and blood pressure and lipid-lowering for the prevention of progression of renal dysfunction caused by Atherosclerotic ostial stenosis of the Renal artery. The STAR-study: rationale and study design.

BACKGROUND: Atherosclerotic renal artery stenosis (ARAS) is associated with progressive loss of renal function and is one of the most important causes of renal failure in the elderly. Current treatment includes restoration of the renal arterial lumen by endovascular stent placement. However, this treatment only affects damage caused by ARAS due to the stenosis and ensuing post-stenotic ischemia. ARAS patients have severe general vascular disease. Atherosclerosis and hypertension can also damage the kidney parenchyma causing renal failure. Medical treatment focuses on the latter. Lipid-lowering drugs (statins) could reduce renal failure progression and could reduce the overall high cardiovascular risk. The additional effect on preserving renal function of stent placement as compared to medical therapy alone is unknown. Therefore, the STAR-study aims to compare the effects of renal artery stent placement together with medication vs. medication alone on renal function in ARAS patients. METHOD: Patients with an ARAS of > or = 50% and renal failure (creatinine (Cr) clearance < 80 mL/min/1.73 m2) are randomly assigned to stent placement with medication or to medication alone. Medication consists of statins, anti-hypertensive drugs and antiplatelet therapy. Patients are followed for 2 yrs with extended follow-up to 5 yrs. The primary outcome of this study is a reduction in Cr clearance > 20% compared to baseline. This trial will include 140 patients.