Safety of elective percutaneous peripheral revascularization in outpatients: A 10-year single-center experience.

PURPOSE: To evaluate the safety and feasibility of peripheral percutaneous endovascular procedures in a large group of outpatients with peripheral arterial disease (PAD). MATERIALS AND METHODS: We retrospectively evaluated all consecutive patients who underwent peripheral transluminal angioplasty (PTA) for PAD of the lower extremities as "Out-Patient Admission Protocol" (OPAP) from January 2005 until December 2015. A total of 498 consecutive patients (305 men and 193 women) with mean age of 66±10 (SD) years (range: 37-90 years) were evaluated. By protocol, patients were expected to be discharged 6hours after the procedure. Clinical profile, procedure details and technical success were reviewed. Complications, conversion rate, readmission rate and long-term follow-up were evaluated. RESULTS: Ninety one percent of patients (454/498) suffered from claudication. Unilateral femoral access was performed in 75.4% (493/654) of procedures with a 6-French sheath in 80.7% (528/654) of procedures. Balloon PTA alone was performed in 17.3% (148/857) and stent placement in 82.7% (709/857) of treated segments. Technical success of lesion treatment was 98.2% (857/873). Closure devices were used in 55.4% (362/654) of procedures. Conversion and readmission rates were 1.8% (12/654) and 0.6% (4/654), respectively. Long-term follow-up was obtained in 386 target lesions, 5-year restenosis of lesion was 20.5% (79/386). CONCLUSION: As designed, the OPAP was feasible, safe and effective with very low conversion and complications rates. These results strongly support a larger use of such approaches as routine practice.

The cardiothoracic ratio on post-mortem computer tomography.

In clinical practice, the cardiothoracic ratio (CTR) was first utilized on plain chest radiography, and subsequently with computed tomography (CT) to diagnose cardiomegaly with a threshold of 0.5. Using CTR in forensic practice could help to detect cardiomegaly on post-mortem CT (PMCT) prior to the autopsy. However, an adaption of the threshold could be necessary because of post-mortem changes. Our retrospective study aimed to measure the CTR on PMCT and test the possible influence of variables. We selected 109 autopsy cases in which the heart weight was within normal limits. A forensic pathologist and a radiologist measured separately the CTR on axial and scout views on PMCT. We tested the statistical concordance between the two readers and between the axial and scout view and identified factors that could be associated with a modification of the CTR. The CTR measurements revealed an overestimation of the measurements made on scout compared to axial view. The inter-reader correlation was very high for both views. Among the different variables statistically tested, heart dilatation and body mass index (BMI) were the only two factors statistically associated with an augmentation of the CTR. The CTR can be useful in the diagnosis of cardiomegaly on PMCT. However, dilatation of the cardiac chambers caused by acute heart failure may be misinterpreted radiographically as cardiomegaly. Inter-observer reliability in our study was very high. CTR may be overestimated when measured on the scout view. Further investigations with larger cohorts, including cases with cardiac hypertrophy, are necessary to better understand the relationship between radiological CTR and the morphology of the heart.

Application of multi-phase postmortem CT-angiography in the investigation of vascular pathology and modified vascular anatomy: a special case of "vascular patchwork".

Multi-phase postmortem CT-angiography (MPMCTA) is used routinely for investigating cases of traumatic and natural death at the University Centre of Legal Medicine, Lausanne-Geneva. Here, we report the case of a patient affected by Leriche syndrome, with a history of numerous cardiovascular interventions, including an axillobifemoral bypass. The multiple cardiovascular changes presented by the patient were visualised by this relatively new technique and they were shown not to be related to the cause of death. This case demonstrated the utility of MPMCTA for investigating bodies with suspected vascular pathologies. Moreover, it revealed the advantages of MPMCTA over conventional autopsy to investigate a modified vascular anatomy. This was the first case in which MPMCTA was performed by injecting a contrast-agent mixture into a vascular prosthesis.

[Treatment of critical lower limb ischemia]. / Traitement de l'ischémie critique chronique des membres inférieurs en 2014.

Critical limb ischemia is a major public health problem in our western countries due to the epidemia of (diabesity). The outcome of patients suffering from critical limb ischemia reains poor with an amputation free survival rate at one year of about 50%. The treatment should be multidiciplinary and done in emergency in specialized centers to ensure the limb salvage: this management should be centered aroud 3 axis: the screening of the cardiovascular risk factors, the best medical treatment and the invasive approaches. Due to multiple endovascular technical innovations, more frail patients with com plex diseases can be treated with good results. Therefore, the endovascular treatment is essential in the management of such patients by vascular surgeons.

Multi-phase postmortem CT angiography: recognizing technique-related artefacts and pitfalls.

BACKGROUND AND PURPOSE: Multi-phase postmortem CT angiography (MPMCTA) is increasingly being recognized as a valuable adjunct medicolegal tool to explore the vascular system. Adequate interpretation, however, requires knowledge about the most common technique-related artefacts. The purpose of this study was to identify and index the possible artefacts related to MPMCTA. MATERIAL AND METHODS: An experienced radiologist blinded to all clinical and forensic data retrospectively reviewed 49 MPMCTAs. Each angiographic phase, i.e. arterial, venous and dynamic, was analysed separately to identify phase-specific artefacts based on location and aspect. RESULTS: Incomplete contrast filling of the cerebral venous system was the most commonly encountered artefact, followed by contrast agent layering in the lumen of the thoracic aorta. Enhancement or so-called oedematization of the digestive system mucosa was also frequently observed. CONCLUSION: All MPMCTA artefacts observed and described here are reproducible and easily identifiable. Knowledge about these artefacts is important to avoid misinterpreting them as pathological findings.

Surgical interventions with fatal outcome: utility of multi-phase postmortem CT angiography.

Cases of fatal outcome after surgical intervention are autopsied to determine the cause of death and to investigate whether medical error caused or contributed to the death. For medico-legal purposes, it is imperative that autopsy findings are documented clearly. Modern imaging techniques such as multi-detector computed tomography (MDCT) and postmortem CT angiography, which is used for vascular system imaging, are useful tools for determining cause of death. The aim of this study was to determine the utility of postmortem CT angiography for the medico-legal death investigation. This study investigated 10 medico-legal cases with a fatal outcome after surgical intervention using multi-phase postmortem whole body CT angiography. A native CT scan was performed as well as three angiographic phases (arterial, venous, and dynamic) using a Virtangio(®) perfusion device and the oily contrast agent, Angiofil(®). The results of conventional autopsy were compared to those from the radiological investigations. We also investigated whether the radiological findings affected the final interpretation of cause-of-death. Causes of death were hemorrhagic shock, intracerebral hemorrhage, septic shock, and a combination of hemorrhage and blood aspiration. The diagnoses were made by conventional autopsy as well as by postmortem CT angiography. Hemorrhage played an important role in eight of ten cases. The radiological exam revealed the exact source of bleeding in seven of the eight cases, whereas conventional autopsy localized the source of bleeding only generally in five of the seven cases. In one case, neither conventional autopsy nor CT angiography identified the source of hemorrhage. We conclude that postmortem CT angiography is extremely useful for investigating deaths following surgical interventions. This technique helps document autopsy findings and allows a second examination if it is needed; specifically, it detects and visualizes the sources of hemorrhages in detail, which is often of particular interest in such cases.

[The complex aortic abdominal aneurysm: is open surgery old fashion?]. / Anévrismes complexes de l'aorte abdominale: la chirurgie ouverte est-elle obsolète?

Open surgery is still the main treatment of complex abdominal aortic aneurysm. Nevertheless, this approach is associated with major complications and high mortality rate. Therefore the fenestrated endograft has been used to treat the juxtarenal aneurysms. Unfortunately, no randomised controlled study is available to assess the efficacy of such devices. Moreover, the costs are still prohibitive to generalise this approach. Alternative treatments such as chimney or sandwich technique are being evaluated in order to avoid theses disadvantages. The aim of this paper is to present the endovascular approach to treat juxtarenal aneurysm and to emphasize that this option should be used only by highly specialized vascular centres.

Detection of hemorrhage source: the diagnostic value of post-mortem CT-angiography.

The aim of this study was to compare the diagnostic value of post-mortem computed tomography angiography (PMCTA) to conventional, ante-mortem computed tomography (CT)-scan, CT-angiography (CTA) and digital subtraction angiography (DSA) in the detection and localization of the source of bleeding in cases of acute hemorrhage with fatal outcomes. The medical records and imaging scans of nine individuals who underwent a conventional, ante-mortem CT-scan, CTA or DSA and later died in the hospital as a result of an acute hemorrhage were reviewed. Post-mortem computed tomography angiography, using multi-phase post-mortem CTA, as well as medico-legal autopsies were performed. Localization accuracy of the bleeding was assessed by comparing the diagnostic findings of the different techniques. The results revealed that data from ante-mortem and post-mortem radiological examinations were similar, though the PMCTA showed a higher sensitivity for detecting the hemorrhage source than did ante-mortem radiological investigations. By comparing the results of PMCTA and conventional autopsy, much higher sensitivity was noted in PMCTA in identifying the source of the bleeding. In fact, the vessels involved were identified in eight out of nine cases using PMCTA and only in three cases through conventional autopsy. Our study showed that PMCTA, similar to clinical radiological investigations, is able to precisely identify lesions of arterial and/or venous vessels and thus determine the source of bleeding in cases of acute hemorrhages with fatal outcomes.

Development and validation of a postmortem radiological alteration index: the RA-Index.

This study aimed to derive an index quantifying the state of alteration of cadavers by quantifying the presence of gas in the body using postmortem multidetector computed tomography (MDCT) imaging, and to validate the index by defining its sensitivity and specificity. The RA (radiological alteration)-index was derived from postmortem MDCT data from 118 nontraumatically deceased people. To validate the index, 100 additional scanned bodies (50 % traumatically deceased) were retrospectively examined by two independent observers. Presence of gas at 82 sites was assessed by a radiologist, whereas a forensic pathologist only investigated the seven sites used for the RA-index. The RA-index was highly correlated to the overall presence of gas in all 82 sites (R(2) = 0.98 in the derivation set and 0.85 in the validation set). Semiquantitative evaluation of gas presence in each site showed moderate reliability (Cohen's kappa range, 0.41-0.78); nevertheless, the overall RA-index was very reliable (ICC(2,1) = 0.95; 95 % CI 0.92-0.96). Examiner using the RA-index detected heart cavities full of gas with a sensitivity of 100 % (95 % CI 51.7-100) and a specificity of 98.8 % (92.6-99.9). We conclude that determining the presence of gas at seven sites is a valid means to measure the distribution of gas due to cadaveric alteration in the entire body. The RA-index is rapid, easy-to-use, and reliable for nonexperienced users, and it is a valid method to suspect the normal presence of gas from cadaveric alteration. MDCT can be used to screen for gas embolism and to give indications for gas composition analysis (gas chromatography).

Randomized controlled trial of peripherally inserted central catheters vs. peripheral catheters for middle duration in-hospital intravenous therapy.

INTRODUCTION: Intravenous (i.v.) therapy may be associated with important catheter-related morbidity and discomfort. The safety, efficacy, comfort, and cost-effectiveness of peripherally inserted central catheters (PICCs) were compared to peripheral catheters (PCs) in a randomized controlled trial. METHODS: Hospitalized patients requiring i.v. therapy >or= five days were randomized 1:1 to PICC or PC. Outcomes were incidence of major complications, minor complications, efficacy of catheters, patient satisfaction, and cost-effectiveness. RESULTS: 60 patients were included. Major complications were observed in 22.6% of patients in the PICC group [six deep venous thrombosis (DVT), one insertion-site infection] and 3.4% of patients in the PC group [one DVT; risk ratio (RR) 6.6; P = 0.03]. Superficial venous thrombosis (SVT) occurred in 29.0% of patients in the PICC group and 37.9% of patients in the PC group (RR 0.60; P = 0.20). Patients in the PICC group required 1.16 catheters on average during the study period, compared with 1.97 in the PC group (P < 0.04). The mean number of venipunctures (catheter insertion and blood sampling) was 1.36 in the PICC group vs. 8.25 in the PC group (P < 0.001). Intravenous drug administration was considered very or quite satisfying by 96.8% of the patients in the PICC group, and 79.3% in the PC group. Insertion and maintenance mean cost was 690 US$ for PICC and 237 US$ for PC. DISCUSSION: PICC is efficient and satisfying for hospitalized patients requiring i.v. therapy >or= five days. However, the risk of DVT, mostly asymptomatic, appears higher than previously reported, and should be considered before using a PICC.

Assessment of occlusive arterial disease of abdominal aorta and lower extremities arteries: value of multidetector CT angiography using an adaptive acquisition method.

We evaluated 16-detector-row CT in the assessment of occlusive peripheral arterial disease (PAD) of the abdominal aorta and lower extremities using an adaptive method of acquisition to optimise arterial enhancement especially for the distal foot arteries. Thirty-four patients underwent transcatheter angiography (TCA) and CT angiography within 15 days. For each patient, table speed and rotation were selected according to the calculated optimal transit time of contrast material obtained after a single bolus test and two dynamic acquisitions at aorta and popliteal arteries. Analysis included image quality and detection of stenosis equal or greater than 50% on a patient basis and on an arterial segment basis. Sensitivity and specificity of CT were calculated with the TCA considered as the standard of reference. CT was conclusive in all segments with no technical failures even in difficult cases with occluded bypasses and aneurysms. On patient-basis analysis, the overall sensitivity and specificity to detect significant stenosis greater than 50% were both 100%. Segmental analysis shows high values of sensitivity and specificity ranging from 91 to 100% and from 81 to 100%, respectively, including distal pedal arteries. Sixteen-detector-row CT angiography using an adaptive acquisition improves the image quality and provides a reliable non-invasive technique to assess occlusive peripheral arterial disease, including distal foot arteries.

[CT-angiography of peripheral arterial diseases: principle and current indications]. / Angio-CT des membres inférieurs: principes et indications.

Recent advances in multi-detector CT technology, improving the spatial resolution and the acquisition time, provide basis for CT-angiography of the abdominal aorta and peripheral vessels of the lower extremities. The objective of this review is to help the clinician to understand principle of CT-angiography of peripheral vessels and to provide an overview of the current clinical applications as well as the futures directions in diagnosis, treatment planning and post-therapeutic surveillance in peripheral vascular diseases.

[Iliac vein compression syndrome, the "May Thurner Syndrome"]. / Syndrome de compression de la veine iliaque primitive "May Thurner Syndrome".

The May Thurner Syndrome is a thrombosis of the left iliac vein due to the compression of the common iliac vein by the right common iliac artery. This results in intimal wall changes of the vein with secondary thrombosis. The treatment of choice is enovascular with thrombolysis followed by angioplasty with stenting.

[Management of critical limb ischemia]. / Prise en charge de l'ischémie critique des membres inférieurs.

Critical limb ischemia (CLI) is the leading cause of major leg amputation. Diabetes, smoking and end stage renal disease are the main risk factors for CLI. Despite their reduced survival rate, most CLI patients should be treated by surgical or endovascular arterial reconstruction, since amputation rate with conservative treatment alone is as high as 95% at 1 year in surviving patients with tissue loss, and can be reduced to 25% with successful reconstruction. When arterial reconstruction is impossible or fails, spinal cord stimulation also allows to avoid major amputation in up to 75% of precisely selected patients. Timely management and multidisciplinary approach are advised to reduce the risk of major amputation.

[Radiofrequency tumor ablation: from the liver to the lung passing by the kidney]. / Destruction tumorale par radiofréquence: du foie au poumon en passant par le rein.

Tumor ablation using radiofrequency technique is an interventional radiology method for the treatment of liver renal or pulmonary tumors. The size of the lesion is the limiting factor of this technique. Tumors below 3 cm are treated with a 90% efficacy in one session. Complications are variable according to the organ treated.

[Interventional neuroradiologic procedures]. / Neuroangiographie thérapeutique.

Intracranial aneurysms, cervical carotid stenosis and acute cerebral ischemia constitute the three main and more frequent diseases in which the endovascular approach is considered a valuable alternative to the surgical or pharmacologic treatment. With the introduction of balloon assistance techniques, even intracranial large neck aneurysms can be currently suitable to endovascular treatment. Stent angioplasty is widely used in whole Europe in the treatment of cervical carotid artery stenosis. Mechanical endovascular embolectomy techniques are actually available to be used alone or in combination with pharmacologic thrombolysis in the treatment of acute cerebral ischemia. This article discuss on the new technical possibilities concerning the endovascular approach in these aforementioned diseases.

[Non invasive multidetector CT angiography of coronary arteries: when and how should I do?]. / Angiographie non invasive des coronaires en scanner multibarrette: comment, quand et pour qui?

Recent advances in multi-detector computed tomography technology offer a reliable tool for coronary arteries visualization and atherosclerotic plaque assessment. The objective of this article is to describe the principle of coronary angiography using multi-detector computed tomography, review the current diagnostic performances and help the reader to understand current applications and future challenges of multi-detector computed tomography in coronary artery disease diagnosis and management.

[Liver anatomy: CT and MRI]. / Anatomie du foie: Tomodensitométrie et Imagerie par Résonance Magnétique.

Computed tomography and magnetic resonance imaging are widely used tools to appreciate liver anatomy. Vascular and segmental anatomy are adequately appreciated with CT, while biliary anatomy is mainly seen with MR imaging. Basic principles of techniques and anatomical landmarks will be detailed.