Ultrasound-guided thoracenthesis: the V-point as a site for optimal drainage positioning.

INTRODUCTION: In the latest years the use of lung ultrasound is increasing in the evaluation of pleural effusions, because it makes follow-up easier and drainage more efficient by providing guidance on the most appropriate sampling site. However, no standardized approach for ultrasound-guided thoracenthesis is actually available. AIM: To evaluate our usual ultrasonographic landmark as a possible standard site to perform thoracenthesis by assessing its value in terms of safety and efficiency (success at first attempt, drainage as complete as possible). MATERIALS AND METHODS: Hospitalized patients with non organized pleural effusion underwent thoracenthesis after ultrasound evaluation. The point showing on ultrasound the maximum thickness of the effusion ("V-point") was chosen for drainage. RESULTS: 45 ultrasound guided thoracenthesis were performed in 12 months. In 22 cases there were no complications; 16 cases of cough, 2 cases of mild dyspnea without desaturation, 4 cases of mild pain; 2 cases of complications requiring medical intervention occurred. No case of pneumothorax related to the procedure was detected. In all cases drainage was successful on the first attempt. The collected values of maximum thickness at V-point (min 3.4 cm - max 15.3 cm) and drained fluid volume (min 70 ml - max 2000 ml) showed a significative correlation (p < 0.0001). When the thickness was greater or equal to 9.9 cm, drained volume was always more than 1000 ml. CONCLUSIONS: The measure of the maximum thickness at V-point provides high efficiency to ultrasound guided thoracentesis and allows to estimate the amount of fluid in the pleural cavity. It is also an easy parameter that makes the proposed method quick to learn and apply.  

Prospective evaluation of drug-induced lung toxicity with high-resolution CT and transbronchial biopsy.

PURPOSE: This study compared the results of high-resolution computed tomography (HRCT) and cytohistology after transbronchial biopsy in the evaluation of drug-related interstitial lung disease (DR-ILD). MATERIALS AND METHODS: Patients with a clinical and imaging diagnosis of DR-ILD were prospectively included in a study protocol lasting 5 years. All patients were evaluated by bronchoscopy with transbronchial biopsy or bronchoalveolar lavage (BAL) following an HRCT examination that raised a suspicion of DR-ILD. Two radiologists (one senior and one junior), unaware of the diagnosis, reported the single HRCT findings, their distribution and predominant pattern. In the event of disagreement, the diagnosis was subsequently reached by consensus. Cytohistological examination was considered the gold standard in the diagnosis of DR-ILD. Patients who were unable to undergo the endoscopic procedure were excluded from the study. RESULTS: The study included 42 patients (25 men, 17 women; age range 20-84 years). Transbronchial biopsy was performed in all but four patients (one case of alveolar haemorrhage and three cases of lipoid pneumonia) in whom the diagnosis was established with BAL. Assessment of the HRCT images revealed the following patterns: noncardiogenic pulmonary oedema (n=13); organising pneumonia (OP) (n=9); hypersensitivity pneumonitis (HP) (n=2); alveolar haemorrhage (AH) (n=2); nonspecific interstitial pneumonia (NSIP) (n=5); lipoid pneumonia (LP) (n=1); sarcoid-like pattern (n=1). Cytohistological diagnosis revealed diffuse alveolar damage (DAD) in 11 patients, OP in seven, HP in three, AH in three, chronic interstitial pneumonia (CIP) in eight, LP in three and pseudosarcoidosis in one. Subdivision of the drugs into antineoplastic and nonantineoplastic agents showed that the most common patterns were CIP (n=6), DAD (n=2) and OP (n=2) in the antineoplastic group and DAD (n=9) and OP (n=5) in the nonantineoplastic group. Sensitivity and specificity of the radiological analysis was excellent, especially for patterns such as OP and DAD (sensitivity 0.86 and specificity 0.88 for OP; sensitivity 1 and specificity 0.93 for DAD). CONCLUSIONS: HRCT demonstrated excellent sensitivity and specificity. In cases in which its specificity was low, HRCT was nonetheless useful for biopsy planning and clinical-radiological monitoring after discontinuation of the drug treatment.

Idiopathic nonspecific interstitial pneumonia: an interstitial lung disease associated with autoimmune disorders?

Recent evidence suggests that idiopathic nonspecific interstitial pneumonia (iNSIP) is a distinct clinical entity amongst other idiopathic interstitial pneumonias, and some data seem to suggest a possible pathogenetic role of autoimmunity. The aim of the present study was to assess if iNSIP might represent an early lung manifestation of an autoimmune disease. After initial review of cases found in the medical records database by searching for the term "NSIP" (n = 63), 37 iNSIP cases were identified, and were re-evaluated using a dynamic integrated multidisciplinary approach. 27 cases with iNSIP were selected for the study. Mean ± sd age at first respiratory symptom was 54.2 ± 8 yrs, 70% were females, and 59% were never-smokers. At follow-up (mean ± sd 59.7 ± 29 months, range 12-138 months), autoimmune diseases occurred in 14 (52%) patients, with seven (26%) cases of autoimmune thyroiditis, six (22%) of undifferentiated connective tissue disease and three (11%) of connective tissue disease. Patients developing autoimmune diseases were older and more frequently never-smoking females. In >50% of patients diagnosed with iNSIP, evidence of autoimmune diseases develops within 2 yrs, suggesting a probable link between the clinical entity of iNSIP and autoimmune disorders.

Transmigrated intrauterine device discovered 17 years after its insertion.

We present the case of an intraperitoneal IUD incidentally noted on lumbar spine X-rays and confirmed by CT. This was secondary to asymptomatic uterine perforation occurred at the time of insertion 17 years before.

Clinical value of multidetector CT coronary angiography as a preoperative screening test before non-coronary cardiac surgery.

OBJECTIVE: Myocardial scintigraphy and/or conventional angiography (CA) are often performed before cardiac surgery in an attempt to identify unsuspected coronary artery disease which might result in significant cardiac morbidity and mortality. Multidetector CT coronary angiography (MDCTCA) has a recognised high negative predictive value and may provide a non-invasive alternative in this subset of patients. The aim of this study was to evaluate the clinical value of MDCTCA as a preoperative screening test in candidates for non-coronary cardiac surgery. METHODS: 132 patients underwent MDCTCA (Somatom Sensation 16 Cardiac, Siemens) in the assessment of the cardiac risk profile before surgery. Coronary arteries were screened for > or = 50% stenosis. Patients without significant stenosis (Group 1) underwent surgery without any adjunctive screening tests while all patients with coronary lesions > or = 50% at MDCTCA (Group 2) underwent CA. RESULTS: 16 patients (12.1%) were excluded due to poor image quality. 72 patients without significant coronary stenosis at MDCTCA were submitted to surgery. 30 out of 36 patients with significant (> or = 50%) coronary stenosis at MDCTCA and CA underwent adjunctive bypass surgery or coronary angioplasty. In 8 patients, MDCTCA overestimated the severity of the coronary lesions (> 50% MDCTCA, < 50% CA). No severe cardiovascular perioperative events such as myocardial ischaemia, myocardial infarction or cardiac failure occurred in any patient in Group 1. CONCLUSIONS: MDCTCA seems to be effective as a preoperative screening test prior to non-coronary cardiac surgery. In this era of cost containment and optimal care of patients, MDCTCA is able to provide coronary vessel and ventricular function evaluation and may become the method of choice for the assessment of a cardiovascular risk profile prior to major surgery.

Multidetector CT: a new gold standard in the diagnosis of pulmonary embolism? State of the art and diagnostic algorithms.

PURPOSE: From the early 90s, spiral CT technology has considerably changed the diagnostic capability of Pulmonary Embolism (PE), giving a direct vision of intravascular thrombi. Further technological progress has strengthened its diagnostic impact leading to an essential role in clinical practice. The advent of Multi-Detector CT (MDCT) has subsequently increased the reliability of this technique to the point of undermining the role of pulmonary angiography as the gold standard and occupying a central position in diagnostic algorithms. The aim of this paper is to appraise this evolution by means of a meta-analysis of the relevant literature from 1995 to 2004. RESULTS: The review of the literature showed the sensitivity and specificity of CT to have increased from 37-94% and 81-100% (single-detector CT) to 87-94% and 94-100% (4-channel multidetector CT), especially thanks to the possibility of depicting subsegmental clots, with an interobserver agreement of 0.63-0.94 (k). CONCLUSIONS: CT is one of the most reliable and effective methods in the diagnosis is PE, with the advantage of being extremely fast and providing alternative diagnoses. Recent improvements in MDCT technology confers the highest value of diagnostic accuracy with respect to other imaging modalities such as scintigraphy, angiography, MRI, D-dimer assay and Doppler US.

Ultrasonographic localization of occult pulmonary nodules during video-assisted thoracic surgery.

The aim of our study was to evaluate the role of ultrasonography in the localization of pulmonary nodules during video-assisted thoracic surgery (VATS). Ultrasonography was performed in 35 patients for the localization of pulmonary nodules during VATS. Indication for VATS was excisional biopsy of undetermined nodules in 22 patients, single or multiple metastasectomy in 12 patients and resection of primitive pulmonary cancer in 1 patient with reduced pulmonary reserve. A laparoscopic probe with flexible head and multi-frequency transducer (5-7.5 MHz) was used. Intraoperative ultrasonography localized 37 of 40 nodules preoperatively detected by CT and/or by positron emission tomography in 35 patients. Furthermore, ultrasonography localized two nodules not visualized at spiral CT. Eighteen nodules were not visible or palpable at thoracoscopic examination and were found by intraoperative sonography only. In 6 patients in whom thoracotomy was performed, manual palpation did not reveal more lesions than ultrasonography. In our experience, ultrasonography was very helpful when lesions were not visible or palpable during thoracoscopy, showing high sensitivity (92.5%) in finding pulmonary nodules. Since it is not possible to determine preoperatively whether a localization technique will be necessary during the operation or not, and ultrasonography is a non-invasive technique, we think that, at present, this technique can be considered as the first-instance localization technique during thoracoscopic resection of pulmonary nodules.

Traumatic injuries: imaging of thoracic injuries.

Chest trauma is one of the most important causes of death, in particular in individuals under the age of 40 years. The mortality rate for chest trauma, often related to motor vehicle accidents, is approximately 15.5%; it increases dramatically to 77% with associated shock and head injury (Glasgow scores of 3-4). The accurate diagnosis of pathologies consequent to blunt chest trauma depends on a complete knowledge of the different clinical and radiological manifestations. The first diagnostic approach is classically based on chest X-ray often carried out on supine position at the hospital admission. A CT study must then be performed in all chest trauma patients in whom there is even the smallest diagnostic doubt on plain film. In particular, spiral CT (SCT) assumes a fundamental role in the demonstration of mediastinal hemorrhage and direct signs of aortic lesions. At present, SCT is routinely part of a diagnostic evaluation which also includes scans of the brain and the abdomen in polytraumatized patients. Magnetic resonance is the ideal method for visualizing diaphragmatic lesions. Furthermore, recent reports have demonstrated the high diagnostic value of MR in evaluating aortic injuries. The purpose of this article is to review the most common radiological patterns related to chest trauma.

Role of HRCT in the identification of atypical pulmonary mycobacteriosis.

AIM: 1) To identify the principal radiological signs of atypical pulmonary mycobacteriosis by means of X-rays and CT/HRCT; 2) to compare the two methods in order to evaluate their reliability with particular interest for the diagnostic role of HRCT in the identification of the disease; 3) to establish any significant differences in the pathology between AIDS and immunocompetent patients. MATERIAL AND METHODS: The chest X-rays and CT/HRCT of 28 atypical pulmonary mycobacteriosis patients (16 with AIDS and 12 immunocompetent) have been studied. The subjects were examined during the period of October 1993 to May 2000 and were found to be positive for atypical mycobacterium and consequently underwent a standard chest X-ray. Twenty cases were followed-up with a chest CT/HRCT; of these only 17 were performed within 30 days of the traditional chest X-ray which was considered to be the time limit in order to validate the comparison between the two methods. RESULTS: The significant semeiotical findings were the parenchymal consolidations observed in 25 patients (89%) by standard chest X-rays; the CT/HRCT confirmed the findings in 4 cases while in 13 it enhanced the evaluation of their extensions. In 9 cases the standard chest X-ray established the presence of cavitations which were confirmed by the CT/HRCT in only 7 cases. Lymphadenopathy was observed in 3/28 patients (10.7%) through standard X-rays and in 15/17 cases (82%) through CT/HRCT. The latter method revealed to be extremely useful in the identification of this pathology. Nodules and micronodules were seen in 5 patients with traditional X-rays and in 9 cases with CT/HRCT. Bronchogenic spread signs of disease became visible only with CT and in particular with HRCT (11/17 patients = 65%). Comparing the two groups (AIDS and immunocompetent) taken into consideration, the most frequent lesion present in both was parenchymal consolidation resulting more bilateral in the AIDS subjects. Cavitation and pleural edema were seen more often in the AIDS group while bronchiectasia, bronchogenic spread and signs of previous pleuro-parenchymal suffering were more frequent in the immunocompetent patients. Lymphadenopathy was frequently found in the total study population but appeared slightly prevalent for the group not afflicted with AIDS. CONCLUSION: Radiological study of the chest permitted the identification of signs useful in the diagnosis of mycobacteriosis in all the patients studied. The application of CT/HRCT added helpful elements in almost all of the cases examined demonstrating to be more effective than the standard chest X-ray not only in terms of improved evaluation of known lesions but also in the identification of lesions which are difficult to determine by means of traditional radiology.

[Non-surgical treatment of aortic aneurysms and dissections: indications, strategies and outcome]. / Trattamento non chirurgico degli aneurismi e delle dissezioni aortiche: indicazioni, strategie, risultati.

PURPOSE: The endovascular treatment of the thoracic aorta is an effective alternative to open surgical repair and offers a therapeutic option even to patients at high risk for surgery. Our experience in the treatment of different diseases of descending thoracic aorta is reported. MATERIAL AND METHODS: Between July 1997 and January 2001, 50 patients were selected for endovascular treatment: 36/50 patients presented high risk for conventional surgery. Six patients presented clinical and imaging features suggesting impending rupture and were treated on emergency basis. The stent-graft prosthesis was individually manufactured or selected on the basis of spiral CT or MRI measurements. RESULTS: Endovascular stent positioning and deployment was technically successful in 49 cases. In one patient the tortuosity of the aortic arch prevented graft deployment. Complete aneurysm exclusion was achieved in 48 cases as assessed by post-procedure angiography and TEE. One proximal endoleak was noted and surgical conversion was performed 40 days later. There were no intraoperative mortality or complications. One patient presented extension of dissection at the 8th postoperative day and required of surgical repair. CT scan showed an endoleak in 4 cases that sealed spontaneously in three cases while the fourth case was treated by graft extension. In the long term two secondary endoleak were observed (12 and 24 months after the procedure). CONCLUSIONS: Endovascular stent-graft repair provides a less invasive opportunity to patients affected by thoracic aortic disease. Careful cases selection is the first postulate for the efficacy and safety of the procedure.

[Unresectable hilar cholangiocarcinoma: combined percutaneous and radiotherapic treatment]. / Colangiocarcinoma dell'ilo inoperabile: protocollo di trattamento combinato percutaneo e radioterapico.

PURPOSE: Evaluate, in patients with inoperable hilar CLCA, the efficacy of multimodality treatment (brachiotherapy, chemotherapy, external radiotherapy and endoprosthesis positioning) in terms of survival, quality of life and cost/benefit compared to palliative surgical treatment. MATERIAL AND METHODS: 20 patients with inoperable hilar CLCA were evaluated. Ten were considered for combined palliative and radiotherapy treatment according to the following protocol: percutaneous colangiography followed by positioning of right and left internal biliar drainage (10-12 F); intraductal brachiotherapy using Ir-192 needles was performed (7 Gy). A second administration was after 7 days. Total dose was 14 Gy; the biliar drainages were then replaced by endoprosthesis (12-14 F) and left in position for 3 months in order to model the post-attinic fibrosis and to prevent stenosis; external radiotherapy was administered starting 15 days after last brachiotherapy treatment (26 administrations (180 cGy) in 5 weeks, total 46 Gy); chemotherapy (5 FU: 350 mg/mq/die) for 5 days during the first and the fifth week of external radiotherapy; biliar endoprosthesis were removed by endoscopic and, or transhepatic mode after 3 months from end of therapy, verifying. Cholangiography assessed the patency of the biliar duct. Metallic stents were placed if results were not satisfactory; follow-up was by: hepatic lab work-up, tumoral markers, US or TC evaluated disease progression. RESULTS: In 5 of the 10 patients considered for the combined treatment, 5 patients completed the protocol and 5 were treated only with brachiotherapy because of deterioration of clinical conditions. All patients had initial complete remission of jaundice although it recurred with disease progression that led to death. No acute post-radiotherapy complication was observed. Digestive hemorrhage (chronic post-radiotherapy complication) was the cause of death in one patient. DISCUSSION AND CONCLUSIONS: Good results were observed in the patients that completed the protocol, mean survival was 7,5 months instead of 1,75 months as in patients that underwent only percutaneous drainage. Better results may be obtained taking in consideration the poor clinical conditions of the patients at the time of diagnosis. The proposed therapeutic protocol requires an average hospitalization of 10-15 days instead of 15-20 days as for palliative biliar-digestive deviation, being less invasive and thus associated to lower morbidity and no mortality.

[Role of videofluorography in the study of esophageal motility disorders]. / Ruolo della videofluorografia nello studio dei disordini della motilità esofagea.

PURPOSE: To repropose the importance of videofluoroscopy in the study of esophageal motor disorders, comparing the radiologic and manometric results; the manometric results are considered the reference parameters. MATERIAL AND METHODS: From 1996 to 1999, 76 patients (42 males and 34 females), were studied first using manometry and then videofluoroscopy. The patients had symptoms like dysphagia, thoracic pain or both. The manometric study was performed with a perfusional system equipped with 6 tips (4 radial for the study of the esophageal sphincters and 2 placed longitudinally for the study of the esophageal peristalsis). With the patient in a supine position we analysed 5-10 deglutitions with 5 ml water bolus at 20-25 degrees C, administered using a graduated syringe. The radiologic study was performed with a remote-control digital television system, connected to a video recorder. Three 7.5 ml bolues of high density barium suspension (250% weight/volume) were injected orally in the upright position and other three were injected in the prone position following the passage from the oral cavity to the stomach. RESULTS: The comparison of the manometric and videofluoroscopic results suggests that the total sensitivity of the radiological study in the detection of esophageal motor disorders was 92%. In particular dynamic radiologic investigation diagnosed the normal esophageal functionality in 100% of the cases, nonspecific esophageal motility disorders in 89.6%, diffuse esophageal spasm in 100% of the cases, the presence of achalasia in 90%, whereas "nutcraker esophagus" only in 50%. Videofluoroscopy therefore showed high sensitivity in four groups of the five considered. It has some limitations in the diagnosis of initial achalasia, and is not sufficiently sensitive in the diagnosis of "nutcracker esophagus". CONCLUSIONS: Videofluoroscopy is a simple method which presents high sensitivity and specificity in the detection of motility disorders of the esophagus and could therefore be proposed as the first diagnostic method in patients with specific symptoms.

[Lung base disease after orthotopic liver transplantation. Functional ultrasonography of the diaphragm and correlated alterations]. / Malattie della base polmonare dopo trapianto ortotopico del fegato. Ecografia funzionale del diaframma e alterazioni correlate.

PURPOSE: To demonstrate the greater accuracy of B- and M-probe ultrasound (US) compared to traditional examinations in the evaluation of diseases of the lung-base, a frequent localisation of pathology in patients undergoing orthotopic liver transplantation (OLT). MATERIAL AND METHODS: Twenty-one patients, 13 males and 8 females aged 24 to 63, awaiting OLT were examined using the three modalities. B-mode US was performed as a preliminary study to identify the districts of interest and the profile of the diaphragm wall, searching for any related alterations. This was followed by M-mode US, with an approach along the left and right posterior axillary lines during spontaneous and forced maximal expiration, to calculate and document the curve representing diaphragm mobility. All patients were also studied pre- and postoperatively by standard chest X-ray double projections. The parameters evaluated by US were diaphragmatic inspiratory slant and diaphragm range while the standard chest X-ray was used to assess hypoventilation, diaphragm range and pleural effusion. RESULTS: For each parameter considered we obtained the following results: presence or absence of pleural effusion (sensitivity: 100% with US vs 64% with chest X-ray) and diaphragmatic hypomobility with related hypoventilatory phenomena (sensitivity: 85% with US, with 15% false negatives). In 15 cases the chest X-ray revealed a clear elevation of the diaphragm, a finding supported by US in 11 cases. In 7 cases US showed a reduction in the diaphragm range curve without, however, any radiological evidence of any ventilatory dysfunction of the lung base and/or elevation of the corresponding hemidiaphragm. CONCLUSION: Our results suggest that radiology, B-mode US and color Doppler US, which are widely used for monitoring OLT patients, can be usefully integrated by M-mode US to evaluate diaphragmatic mobility both pre- and post-operatively. This method is fast, easy to use and widely available.

[CT angiography for the evaluation of adult orthotopic liver transplantation arterial complications].

PURPOSE: In this study we compared duplex Doppler sonography, conventional angiography and CT angiography for the evaluation of hepatic arterial complications following orthotopic liver transplantation (OLT). MATERIAL AND METHODS: CT angiography, with Maximum Intensity Projection (MIP) and Volume Rendering reconstructions, was performed in 11 patients with well-grounded suspect of hepatic artery stenosis or thrombosis after routine duplex Doppler examination. Eight patients underwent conventional angiography. RESULTS: CT detected three out of four duplex doppler false positives and confirmed the diagnostic suspect in four cases. In two cases it showed a shift of the blood flow towards the splenic artery with hepatic hypoperfusion. In one case a wrong delay rendered the study unuseful. In seven out of eight patients conventional angiography confirmed CT angiography findings. DISCUSSION. The follow up of OLT arterial complications is now performed with duplex doppler sonography; this technique has a satisfactory sensitivity and specificity, but far from 100%. Therefore in some patients the diagnosis of arterial obstruction might be delayed, with the risk of serious complications; in other cases with ultrasonographic false positive findings, useless angiographic examinations are performed. In our experience CT angiography proved to be a precious tool, which might be included in the diagnostic algorithm of arterial complications after OLT. Particularly CT angiography seems to be suitable for the cases of discordance between clinical and duplex doppler findings, to improve the overall diagnostic accuracy. CONCLUSION: In our experience CT-angiography proved to be accurate and satisfactory as a second step examination after duplex-doppler in the diagnostic algorythm of adult OLT arterial complications.

Evolution of aortic dissection after surgical repair.

Patients after aortic dissection repair still have long-term unfavorable prognosis and need careful monitoring. The purpose of this study was to analyze the evolution of aortic dissection after surgical repair in correlation to anatomic changes emerging from systematic magnetic resonance imaging (MRI) follow-up. Between January 1992 and June 1998, 70 patients underwent surgery for type A aortic dissection. Fifty-eight patients were discharged from the hospital (17% operative mortality) and were followed by serial MRI for 12 to 90 months after surgery. In all, 436 postoperative MRI examinations were analyzed. In 13 patients (22.5%) no residual intimal flap was identified, whereas 45 patients (77.5%) presented with distal dissection, with a partial thrombosis of the false lumen in 24. The yearly aortic growth rate was maximum in the descending aortic segment (0.37 +/- 0.43 cm) and was significantly higher in the absence of thrombus in the false lumen (0.56 +/- 0.57 cm) (p <0.05). There were 4 sudden deaths, with documented aortic rupture in 2. Sixteen patients underwent reoperation for expanding aortic diameter. In all but 1 patient, a residual dissection was present (in 13 without any thrombosis of the false lumen). Close MRI follow-up in patients after dissection surgical repair can identify the progression of aortic pathology, providing effective prevention of aortic rupture and timely reoperation. Thrombosis of the false lumen appears to be a protective factor against aortic dilation.

Pulmonary complications of liver transplantation: radiological appearance and statistical evaluation of risk factors in 300 cases.

The aim of this study was to evaluate the incidence, radiographic appearance, time of onset, outcome and risk factors of non-infectious and infectious pulmonary complications following liver transplantation. Chest X-ray features of 300 consecutive patients who had undergone 333 liver transplants over an 11-year period were analysed: the type of pulmonary complication, the infecting pathogens and the mean time of their occurrence are described. The main risk factors for lung infections were quantified through univariate and multivariate statistical analysis. Non-infectious pulmonary abnormalities (atelectasis and/or pleural effusion: 86.7%) and pulmonary oedema (44.7%) appeared during the first postoperative week. Infectious pneumonia was observed in 13.7%, with a mortality of 36.6%. Bacterial and viral pneumonia made up the bulk of infections (63.4 and 29.3%, respectively) followed by fungal infiltrates (24.4 %). A fairly good correlation between radiological chest X-ray pattern, time of onset and the cultured microorganisms has been observed in all cases. In multivariate analysis, persistent non-infectious abnormalities and pulmonary oedema were identified as the major independent predictors of posttransplant pneumonia, followed by prolonged assisted mechanical ventilation and traditional caval anastomosis. A "pneumonia-risk score" was calculated: low-risk score ( < 2.25) predicts 2.7% of probability of the onset of infections compared with 28.7% of high-risk (> 3.30) population. The "pneumonia-risk score" identifies a specific group of patients in whom closer radiographic monitoring is recommended. In addition, a highly significant correlation (p < 0.001) was observed between pneumonia-risk score and the expected survival, thus confirming pulmonary infections as a major cause of death in OLT recipients.

Primary endoleakage in endovascular treatment of the thoracic aorta: importance of intraoperative transesophageal echocardiography.

OBJECTIVES: Endovascular treatment of the thoracic aorta has developed as an efficacious alternative to open surgical repair. However, despite the high primary success rate, perigraft leakage constitutes the major concern in long-term follow-up. Endoleaks are widely reported both in abdominal and thoracic endovascular series and are usually identified by intraoperative angiography. Transesophageal echocardiography is a sensitive imaging technique in the evaluation of aortic diseases, widely used to monitor cardiac surgery. The aim of this study was to evaluate the efficacy of transesophageal echocardiography in leakage detection during endovascular stent procedures of the thoracic aorta. METHODS: Intraoperative transesophageal echocardiography was used in conjunction with angiography in 25 patients subjected to endovascular stent treatment of the descending thoracic aorta. Spiral computed tomographic scanning was performed before discharge and 3, 6, and 12 months after treatment. RESULTS: Information from transesophageal echocardiography was relevant in the selection of the landing zone in 62% of cases. In 8 patients, transesophageal echocardiography with color Doppler sonography showed a perigraft leak, 6 of which were not visible on angiography, suggesting the need for further balloon expansion or graft extension. Postoperative computed tomographic scanning in the 25 patients showed 1 endoleak, which sealed spontaneously. At 3 months, computed tomographic examination confirmed the absence of perigraft leakage in all patients. CONCLUSIONS: During implantation of a stent-graft in the descending thoracic aorta, transesophageal echocardiography provides information in addition to that provided by angiography, improving immediate and late procedural results.