Surgical therapy of extracranial carotid artery aneurysms: long-term results over a 24-year period.

BACKGROUND: To evaluate long-term results of surgical therapy of extracranial carotid artery aneurysms (ECCA) and to provide a morphologic classification for individual surgical reconstruction techniques. PATIENT AND METHODS: This retrospective analysis includes 57 patients (43 male, mean age 61.9 years.) with 64 carotid reconstructions for ECCA between 1980 and 2004. In 29 (50.9%) of the patients there was found a cerebral ischemic event as an initial symptom (18 transient ischemic attacks, 11 strokes). In patients without cerebral events, the presenting symptom was pulsatile cervical mass in 19 and cranial nerve dysfunction in 3 cases. ECCA was morphologically stratified in Type I=isolated aneurysms of the internal carotid artery (n=25), Type II=aneurysms of the complete internal carotid artery with involvement of the bifurcation (n=8), Type III=aneurysms of the carotid bifurcation (n=20), Type IV=combined aneurysm of the internal and common carotid artery (n=5) and Type V=isolated aneurysm of the common carotid artery (n=6). RESULTS: Perioperative stroke rate was 1.6%. 4 patients suffered from transient ischemic attacks (6.3%). Permanent and transient cranial nerve injury rate was 6.3% and 20.3% respectively. After 5, 10, 15 and 20 years the actuarial survival was 90%, 77%, 65% and 57%. The ipsilateral stroke-free time was 96%, 96%, 93% and 87%, respectively. CONCLUSIONS: Surgical reconstruction of extracranial carotid aneurysms is a safe procedure with good long-term results. The risk of a permanent, perioperative cerebral neurological deficit is low, but there is a considerable risk of cranial nerve injury.

Evaluation of integrated color-coded perfusion analysis for contrast-enhanced ultrasound (CEUS) after percutaneous interventions for malignant liver lesions: First results.

BACKGROUND:  With the rising number of percutaneous ablation therapies in malignant liver lesions there is a need of reliable diagnostics after the intervention to differentiate between reactive changes and tumor. PURPOSE: To assess the success of percutaneous ablation therapies for malignant liver lesions using CEUS with perfusion analysis. MATERIAL AND METHODS: Retrospective analysis of perfusion analysis for 67 patients with 94 malignant liver lesions, treated with ablation therapies. The lesions were 70 hepatocellular carcinomas (HCC), 18 metastases, 4 cholangiocellular carcinomas (CCC), 2 lesions remained unclear. CEUS was performed after bolus injection of 1.6-2.4 ml of sulfur-hexafluoride microbubbles. The perfusion analysis was calculated using Peak, TTP, mTT and AUC with integrated software during the late arterial to early portal-venous phase for approximately 9 sec (5-15 sec). For the evaluation of the success after percutaneous treatment the perfusion results were compared to the follow-up control after 6 months with CT and MRI and CEUS. RESULTS: Perfusion analyses after percutaneous treatment of malignant liver lesions showed highly significant perfusion differences when comparing the center to the surrounding tissue and the margins (p<0.0001) for Peak and also for AUC. 62 lesions were successfully treated, meaning there was no local recurrence after 6 months. In cases of residual tumor CEUS showed a nodular marginal enhancement, the corresponding perfusion analyses showed nodular red and yellow pseudo-color shades. CONCLUSIONS: Using CEUS and perfusion analysis, a critical analysis of post-ablation defects in malignant liver lesions is possible. With the help of pseudo-colors, remaining tumor-vascularization can be detected.

Evaluation of dynamic effects of therapy-induced changes in microcirculation after percutaneous treatment of vascular malformations using contrast-enhanced ultrasound (CEUS) and time intensity curve (TIC) analyses.

The aim of this follow-up study was to demonstrate the effect of percutaneous interventional treatment on local microcirculation of peripheral vascular malformations using CEUS and TIC analysis. MATERIAL AND METHODS: Retrospective analysis of 197 patients (136 female; 61 male; 3-86 years) with 135 venous (VM), 39 arterio-venous (AVM), 8 lymphatic and 15 veno-lymphatic peripheral vascular malformations before and after the first percutaneous treatment.CEUS was performed after i.v. injection of 1-2.4 ml of sulfur hexafluoride microbubbles (SonoVue®) using a 6-9 MHz linear probe. Digitally stored cine loops (starting in the early arterial phase for 60 sec) were read by independent readers in consensus. Regions of interest (ROI) were defined in the center and at the margins of the malformation, as well as in the healthy surrounding tissue. TIC analyses with Time to Peak (TTP) and Area under the Curve (AUC) were calculated using integrated perfusion software. RESULTS: After the treatment there was a significant decrease for median AUC in VM in the center from 297.8 (14.5-2167.6) rU down to 243.3 (0.1-1678.8) rU (p = 0.043) and in the surrounding tissue down to 107.7 (20.2-660.2) rU (p = 0.018). For the other malformations AUC decreased in the center and the margins as well. TTP rose, however these changes did not reach the level of significance. CONCLUSION: Analyzing the capillary microcirculation TICs offer a possibility of monitoring therapy-induced capillary changes of vascular malformations.

Analysis of arterial dynamic micro-vascularization with contrast-enhanced ultrasound (CEUS) in thyroid lesions using external perfusion software: First results.

AIM: To determine different perfusion characteristics of histo-pathologically proven adenomas and carcinomas of the thyroid gland with CEUS and perfusion software. MATERIAL AND METHODS: Retrospective perfusion analysis of 25 patients with carcinomas and 41 cases of adenomas of the thyroid gland (30 males, 36 females; aged 18 - 85 years, mean 56 years). All cases were histologically analyzed. Perfusion analysis was independently performed using external perfusion software (VueBox®). TTP, mTT, Peak and Rise time were calculated. RESULTS: Lesions' sizes ranged from 0.2 to 10.2 cm in carcinomas (mean 2.18 cm), and from 0.6 to 5.0 cm in adenomas (mean 2.25 cm). In 20 out of 25 carcinomas that were evaluated with CEUS, a complete wash-out in the late venous phase was found. Adenomas showed wash-out at the border.Perfusion analysis in VueBox® revealed some parameters which tend to show differences between adenomas and carcinomas, however did not reach the level of significance.Median Peak in carcinomas was highest at the margins (2945 rU), and lowest in the surroundings (1110 rU). Mean Transit Time (mTT) values showed no differences between center, margin and surrounding.In adenomas healthy tissue showed higher mTT values compared to the center (24.6 vs. 20.7 sec). Median Peak was highest in the surrounding tissue and lowest in the margins (1999 vs. 1129 rU). No statistical differences could be found in the comparisons. CONCLUSION: CEUS with perfusion analysis offers new possibilities for the dynamic evaluation of micro-vascularization in thyroid adenomas and carcinomas. Using VueBox® the perfusion analysis of the arterial phase provides new parameters that help determine a lesion's malignancy or benignity. However a final assessment regarding malignancy and benignity of thyroid lesions using only CEUS and perfusion analysis of the arterial phase is not yet possible.

Gelfoam for closure of large percutaneous transhepatic and transsplenic puncture tracts in pediatric patients.

PURPOSE: Evaluation of the efficacy and safety of Gelfoam for the closure of transhepatic or transsplenic parenchymal puncture tracts with large-bore sheaths in pediatric patients. MATERIALS AND METHODS: Between January 2012 and May 2013, 8 percutaneous transhepatic accesses and 3 percutaneous transsplenic accesses were closed using percutaneous Gelfoam in pediatric patients. The primary study endpoints to determine treatment efficacy and safety were patient survival, technical success defined as successful closure of the puncture tract without signs of bleeding, and complication rates. The secondary study endpoints were the occurrence of local and systemic inflammation. RESULTS: Overall survival was 100 % with a median follow-up of 256 days. The procedure was technically successful in 10 of 11 procedures. One patient suffered from bleeding, which was successfully managed by a single blood transfusion. No re-bleeding was detected during follow-up and no surgical interventions were necessary. No signs of local or systemic infections related to the Gelfoam application occurred. CONCLUSION: Percutaneous Gelfoam application is an effective and safe technique for the closure of transhepatic or transsplenic accesses in pediatric patients. KEY POINTS: Interventional closure of large transhepatic and transsplenic parenchymal accesses in children after interventional treatment is recommended to avoid bleeding. Gelfoam application does not cause artifacts in magnetic resonance imaging and does not increase the risk of local or systemic inflammation in comparison to permanent embolic agents. Thus, especially children under immunosuppressive therapy can benefit from the application of Gelfoam.