Dragon 1 Protocol Manuscript: Training, Accreditation, Implementation and Safety Evaluation of Portal and Hepatic Vein Embolization (PVE/HVE) to Accelerate Future Liver Remnant (FLR) Hypertrophy.

STUDY PURPOSE: The DRAGON 1 trial aims to assess training, implementation, safety and feasibility of combined portal- and hepatic-vein embolization (PVE/HVE) to accelerate future liver remnant (FLR) hypertrophy in patients with borderline resectable colorectal cancer liver metastases. METHODS: The DRAGON 1 trial is a worldwide multicenter prospective single arm trial. The primary endpoint is a composite of the safety of PVE/HVE, 90-day mortality, and one year accrual monitoring of each participating center. Secondary endpoints include: feasibility of resection, the used PVE and HVE techniques, FLR-hypertrophy, liver function (subset of centers), overall survival, and disease-free survival. All complications after the PVE/HVE procedure are documented. Liver volumes will be measured at week 1 and if applicable at week 3 and 6 after PVE/HVE and follow-up visits will be held at 1, 3, 6, and 12 months after the resection. RESULTS: Not applicable. CONCLUSION: DRAGON 1 is a prospective trial to assess the safety and feasibility of PVE/HVE. Participating study centers will be trained, and procedures standardized using Work Instructions (WI) to prepare for the DRAGON 2 randomized controlled trial. Outcomes should reveal the accrual potential of centers, safety profile of combined PVE/HVE and the effect of FLR-hypertrophy induction by PVE/HVE in patients with CRLM and a small FLR. TRIAL REGISTRATION: Clinicaltrials.gov: NCT04272931 (February 17, 2020). Toestingonline.nl: NL71535.068.19 (September 20, 2019).

Central skull base osteomyelitis: a rare but life-threatening disease.

We present the case of a 70-year-old non-diabetic patient who presented to the emergency department with unrelenting otalgia. A severe otitis externa (OE) and mastoiditis were treated with broad spectrum antibiotics and surgical drainage. No bacteria was isolated from surgical samples. Because the otalgia persisted, a magnetic resonance (MR) was performed and showed an infiltrating process at the skull base. Biopsies failed to prove malignancy or granulomatosis. The patient's neurological state deteriorated. The suspicion of a skull base osteomyelitis (SBO) was raised and proven by CT-guided biopsies that grew Pseudomonas aeruginosa. Meropenem and ciprofloxacin, given for 8 weeks, lead to a fast clinical improvement and a full recovery. SBO is uncommon, often complicating severe OE. Pseudomonas aeruginosa is the main pathogen. Prompt diagnosis and adequate antibiotherapy are required to lower mortality and morbidity. The diagnosis may be delayed because of unawareness and large differential diagnosis including solid neoplasic tumours, malignant hemopathies and granulomatosis.

[Osteoid osteoma in children: 5 cases treated with electrocoagulation]. / L'ostéome ostéoïde de l'enfant : à propos de 5 cas traités par électrocoagulation.

Osteoid osteoma is a benign bone tumor. Its diagnosis is often delayed despite typical symptoms: severe pain mainly situated on the lower limbs and characteristically worse at night. Once diagnosed, an antalgic treatment by aspirin is well known to be very effective in relieving pain. Osteoid osteoma will resolve spontaneously. If symptoms persist despite the use of aspirin, surgery can be performed to remove the tumor. Percutaneous electrocoagulation can be performed instead of surgical resection as a less invasive procedure. The success rate of surgery and percutaneous electrocoagulation is comparable. We reviewed the cases of 5 patients who were hospitalized in our institution for percutaneous electrocoagulation of an osteoid osteoma. We compared them to the literature.

Practice variability in the management of infrarenal arterial stenoses in seven Belgian hospitals.

This multicentre retrospective study describes the variation of therapeutic options, treatment outcomes and costs for treating infrarenal arterial stenoses as observed in daily practice in 1997-99 in seven Belgian hospitals. Data were obtained from clinical record review and from the sickness fund claims database, and included preoperative functional state, presence of acute ischaemia, diabetes and polyvascular disease, state of the lower-leg run-off arteries, anatomical site and type of lesion, type of treatment, result at 30 days and up to 4 years. A total of 442 episodes were studied, but most analyses dealt with a subgroup of 240 lesions in the common iliac up to the superficial femoral artery. The proportion of surgical treatments (as compared to an endovascular or mixed approach) varied from 15% to 81% between the hospitals. In univariate survival analysis, relapse or failure rates at 4 years ranged from 5% for the common iliac artery to 35% for the superficial femoral artery. Polyvascular disease, a poor run-off, multiple stenoses and chronic occlusion were significant risk factors; age and diabetes were not. In the multivariate (stratified Cox regression) analysis, only a location in the superficial femoral artery and a poor preoperative clinical stage were significant risk factors, but type of therapeutic approach was not. The total average cost of treatment was 5300 Euro, of which 15% was contributed by the patient. Surgery was associated with longer stays (median at 12 days) than endovascular treatments (median 2 d), and was 1.9 times more expensive. In conclusion, the results of the present study suggest that a multidisciplinary approach, orienting the patient to the most appropriate therapeutic pathway could increase both the quality and the cost-effectiveness of the care. In many clinical situations, the endovascular approach appears to offer similar long-term results as surgery, but at a substantially lower cost, both for the patient and for society, especially when performed in a (semi-)ambulatory radiology setting.

Practice variability in the management of subrenal arterial stenoses in seven Belgian hospitals.

This multicentre retrospective study describes the variation of therapeutic options, treatment outcomes and costs for treating subrenal arterial stenoses as observed in daily practice in 1997-99 in seven Belgian hospitals. Data were obtained from clinical record review and from the sickness fund claims database, and included preoperative functional state, presence of acute ischaemia, diabetes and polyvascular disease, state of the lower-leg run-off arteries, anatomical site and type of lesion, type of treatment, result at 30 days and up to 4 years. A total of 442 episodes were studied, but most analyses dealt with a subgroup of 240 lesions in the common iliac up to the superficial femoral artery. The proportion of surgical treatments (as compared to an endovascular or mixed approach) varied from 15% to 81% between the hospitals. In univariate patency analysis, relapse or failure rates at 4 years ranged from 5% for the common iliac artery to 35% for the superficial femoral artery. Polyvascular disease, a poor run-off, multiple stenoses and chronic occlusion were significant risk factors; age and diabetes were not. In the multivariate (stratified Cox regression) analysis, only a location in the superficial femoral artery and a poor preoperative clinical stage were significant risk factors, but type of therapeutic approach was not. The total average cost of treatment was 5,300 Euros, of which 15% was contributed by the patient. Surgery was associated with longer stays (median at 12 days) than endovascular treatments (median 2 days), and was 1.9 times more expensive. In conclusion, the results of the present study suggest that a multidisciplinary approach, orienting the patient to the most appropriate therapeutic pathway, could increase both the quality and the cost-effectiveness of the care.

Duodenal ulcer hemorrhage treated by embolization: results in 28 patients.

BACKGROUND: To assess the effectiveness and prospects of transcatheter gastroduodenal artery embolization in the control of massive duodenal bleeding and to relate our experience. METHODS OF STUDY: The study is based on the retrospective analysis of 165 patients with endoscopically detected bleeding duodenal ulcer who presented between 1991-1998. 28 patients were considered eligible for endovascular treatment either at initial presentation or following hemorrhage recurrence after endoscopic therapy. RESULTS: Technical failure was noted in 3 cases, thereafter treated by surgery. In the other 25 patients, embolization was performed: bleeding recurrence occurred in 7 cases. Four were treated only endoscopically. One was reembolized and the last two were treated by surgery. In 6 cases, a coaxial technique was used (guiding catheter in 2 and 3F microcatheter in 4). No complication related to the catheterization was observed. CONCLUSION: Transcatheter embolization of the gastroduodenal artery appears to be an efficient procedure even in the absence of active bleeding at the time of the procedure. Failure and recurrence rates can be reduced by using a coaxial technique in the uneasy cases. Embolization seems to have a low recurrence rate and a very low complication rate.

Six hundred consecutive carotid endarterectomies with temporary shunt and vein patch angioplasty: early and long-term results.

PURPOSE: This retrospective study evaluates the long-term clinical outcome and the survival of 600 consecutive carotid endarterectomies performed with a temporary shunt. All arteriotomies were closed by vein patch angioplasty. MATERIALS AND METHODS: Between November 1989 and November 1998, 600 isolated carotid endarterectomies (CEA) were performed in 540 patients by a uniform surgical technique at the University Clinic of Mont-Godinne. An intraluminal shunt and patch closure were systematically used. The mean age was 68 yr (ranging from 41 to 91 yr), 400 patients were men. The risk factors included hypertension in 73%, smoking history in 60%, coronary artery disease in 51% and hyperlipidemia in 35%. The indications were asymptomatic stenosis in 47%, transient ischemic attack in 40%, vertebrobasilar symptoms in 7% and stroke in 6%. EARLY RESULTS: The combined 30-day stroke and death rate was 0.9%. There were four deaths. The stroke and TIAs rates were 0.2% and 1.5% respectively. The incidence of early carotid occlusion was 0.5%. Cranial or cervical nerve dysfunction was identified in 6.3%. LATE RESULTS: The median follow-up was 49 months with a range of 2-124 months. Cumulative survival rates at 5 and 10 yr were 92+/-1% and 89+/-2% respectively. Thirty-two patients died during long-term follow-up; the death was stroke-related in only three patients. CONCLUSION: Carotid endarterectomy using an intraluminal shunt and vein patch closure is a safe and effective procedure associated with low morbidity and mortality rates at short and long-term follow-up.

[Selective fasicular neurotomy for spastic equinovarus foot deformity in cerebral palsy children]. / La neurotomie fasciculaire sélective dans le traitement du pied varus équin spastique de l'enfant infirme moteur d'origine cérébrale.

Spasticity is usually treated by rehabilitation, orthosis, chemical denervations, orthopaedic surgery and neurosurgery. Selective fascicular neurotomy is a neurosurgical procedure consisting in partial section of selected motor nerves innervating spastic muscles. Neurotomy is indicated in cases of localised disabling spasticity without musculotendinous shortening, resistant to chemical denervation and for which a motor nerve block with anaesthetic has given a good functional result. Neurotomy includes division of the afferent Ia and Ib fibers, unable to recover, leading to permanent disappearance of the spasticity. Neurotomy also includes section of the motor efferent fibers with transient paresis as a result. In adults, neurotomy provides functional improvement in 81 to 97% of cases. In case of posterior tibial neurotomy, improved walking stability and a decrease in foot equinus and knee recurvatum is observed. In children, the risk of deformity recurrence seems higher because of motor axonal reinnervation: indications must therefore be carefully considered and rehabilitation provided after surgery.

Thoracoscopic resection of pulmonary nodules after computed tomographic-guided coil labeling.

BACKGROUND: A limiting factor in performing video-assisted thoracic surgery for resection of peripheral solitary pulmonary nodules has been the recognition of the lesion visually. This study reports our clinical experience of injecting a small metallic marker under computed tomographic scan guidance before the operation, allowing localization of the lesion. METHODS: A series of 14 patients underwent video-assisted thoracic surgery for removal of 15 pulmonary nodules situated in the outer third of the lung. Before operation, a radiopaque microcoil was injected just behind the lesion and then used to locate, under fluoroscopy, the area to be resected during thoracoscopy. The technique was evaluated for accuracy, reliability, and ease of use. RESULTS: Microcoil labeling of peripheral pulmonary nodules allowed in every case a complete resection and a histologic identification of the lesion. It is more stable and accurate than methylene blue dye marking, and it is as easy to perform as computed tomographic scan-guided biopsy. The incidence of complication was small in spite of our inexperience with the technique. CONCLUSIONS: Our experience with microcoil injection shows that it provides consistent and highly accurate marking of pulmonary nodules for video-assisted thoracic surgery, allowing secure resection with a safe margin.

[Breast cancer and its psychological approach: family, others, chance and...me]. / Le cancer du sein et son approche psychologique: la famille, les autres, la chance et ... moi.

Since several years already, the scientific literature evoked the psycho-oncological perspective in the psychotherapeutic treatment of the patient suffering of a malignant mammary pathology. The objective of this article is to insist on some characteristics of personality inherent to the individual that suffers of a malignant mammary pathology. Comparing three groups of women (malignant mammary pathology--n = 51, benign mammary pathology--n = 71 and a group controls--n = 30), a set of questionnaires relating to locus of control and to the close circle--family and couple--has been managed. Results indicate that the woman suffering of a breast cancer is less "intern", consider that her health depends on factor "luck" and wish less cohesion and therefore more of distance within her couple and her family.

Pseudoaneurysm of the internal carotid artery: treatment with a covered stent.

Dissection of the cervical segment of the internal carotid artery may occur spontaneously or after trauma. We report the management of a 53-year-old right-handed man with progressive dizziness and neck pain 6 weeks after a motor vehicle collision. The clinical and neurologic examinations were normal. The CT scan led to the diagnosis of a pseudoaneurysm of the right internal carotid artery near the skull base. We successfully treated this post-traumatic lesion with a covered stent. The patient underwent the endovascular procedure under general anesthesia and transcranial Doppler monitoring. No neurologic event was observed. Obliteration of the pseudoaneurysm with preservation of the carotid artery was achieved. The patient was discharged from the hospital 72 hr later with no complications. Clinical and imaging follow-up at 6 months was unremarkable.

Congenital anomalies of the inferior vena cava and left renal vein: evaluation with spiral CT.

PURPOSE: To determine with spiral computed tomography (CT) the incidence and caval location of left renal vein (LRV) variants that may affect inferior vena cava (IVC) filter placement, spermatic vein embolization, and adrenal or renal venous sampling. MATERIALS AND METHODS: Contrast material-enhanced spiral CT scans of 1,014 patients were evaluated for the incidence and configuration of LRV variants and for the distribution of the entrances of these veins into the IVC. RESULTS: In this series, variants detected were as follows: one azygos continuation of the IVC (0.1%), three bilateral IVCs (0.3%), and 102 LRV variants (10%) including 38 retroaortic renal veins (3.7%) and 64 circumaortic venous rings (6.3%). In the retroaortic renal vein group, the distance between the entrance of the LRV into the IVC and the confluence of the iliac veins was +62.5 mm +/- 8.7. In the circumaortic venous ring group, the distance between the entrances of the retroaortic and preaortic limbs into the IVC was -39.0 mm +/- 17.4; the distance between the entrance of the left retroaortic limb into the IVC and the confluence of the iliac veins was +63.2 mm +/- 17.1. CONCLUSIONS: Detailed knowledge of these anomalies is crucial for IVC filter placement, spermatic vein embolization, and adrenal or renal venous sampling.

Differential diagnosis and repair of femoral artery pseudoaneurysms: report of clinical experience using color Doppler imaging.

Sixty-two sonograms of the groin in 58 patients referred after cardiac catheterization (n = 45) or local surgical by-pass (n = 13) were reviewed retrospectively to determine the accuracy of color Doppler imaging in distinguishing femoral artery pseudoaneurysms from other causes of groin masses (e.g. hematomas) and to evaluate the therapeutical impact of US-guided compression. Thirty-seven cases of pseudoaneurysm, three arteriovenous fistulae (one isolated and two associated with a pseudoaneurysm), sixteen hematomas and eight other conditions were studied; US-guided compression repair was considered to treat thirteen pseudoaneurysms. The sensitivity and specificity of color Doppler imaging by comparison with angiography and/or surgery in the detection of femoral artery pseudoaneurysm was 100% and 94% respectively. US-guided compression repair was not attempted in 2/13 cases (one critical leg ischemia and one unsuitable anatomy) and successful in 7/11 cases. We conclude that color Doppler imaging is of great value in the differential diagnosis of groin masses, reducing the number of diagnostic and pretherapeutic angiographies. However, in our experience, US-guided compression repair is effective in the treatment of no more than 54% (7/13 cases) of nonselected femoral pseudoaneurysms.

[Benign osteonecrosis of vertebral body versus neoplastic lesions. Limitations of CT and magnetic resonance imaging]. / Osteonécrose bénigne du corps vertébral versus lésion néoplasique. Limites de l'imagerie en CT-scan et résonance magnétique.

A case of vertebral necrosis of L4 is reported in a young woman without previous steroid therapy. Only the intraoperative histological examination was able to confirm the diagnosis as a benign vertebral collapse, because the CT scan and MR imaging were suggestive of a malignant involvement. The authors report the various criteria proposed to distinguish benign and malignant vertebral collapse with magnetic resonance imaging. These equivocal criteria should be viewed within the context of tissue replacement within the necrotic area during the evolution. Transpedicular biopsy is emphasized. Only the histological examination is specific and allows right planning of the surgical procedure.

Radiologic findings of normal and compromised thoracic venous catheters.

We review the radiologic findings of normal positioning, malpositioning, and complications related to the more commonly used thoracic venous catheters. These include central venous catheters, long-term central venous access catheters, and pulmonary artery catheters. The radiologist plays an important role in the early recognition of the complications of these catheters. The daily practice of chest radiology is intimately related to the evaluation of the integrity and correct placement of thoracic venous catheters. The purpose of this pictorial essay is to review radiologic findings of normal positioning, malpositioning, and complications related to the more common devices used, including central venous catheters, long-term central venous access catheters, and pulmonary artery catheters. Many of the complications described are serious and may remain unrecognized for a long time; this may cause incorrect diagnosis and delayed treatment. The radiologist plays an important role in the early recognition of these complications. Malpositioning and complications often are more easily diagnosed with contrast-enhanced studies and computed tomography.

Anatomic relationship between the popliteal artery and vein: a guide to accurate angiographic puncture.

The anatomic relationship between the popliteal artery and vein means that an arteriovenous fistula can be created when a popliteal artery approach is used for endovascular interventions. To determine the best site for retrograde puncture of the popliteal artery, we studied six cadaveric specimens, CT scans of 31 patients at 280 levels, and 30 plain radiographs of the knee. In the cadaveric specimens, the vessels were enclosed in a common sheath. In 92% of all levels studied on CT, the artery was anterior to the vein (anterolateral in 9%, anteromedial in 43%, strictly anterior in 40%), and more than 25% of the diameter of the artery overlapped the vein in 87% of these levels. However, at the most cranial level analyzed (64 mm above the femorotibial joint space level), such an overlap occurred in only 60%, and the artery was medial in 25%, resulting in a relationship between the artery and the vein that involved less risk of fistula. On radiographic study, the popliteal crease was located above the level of the joint space (considered the most reliable landmark of the popliteal fossa anatomy) in 97% of cases, although the values were scattered (mean, 2.9 +/- 1.5 cm). In order to minimize the risk of creating an arteriovenous fistula, we recommend a skin incision be located 3-4 cm above the joint level as determined by fluoroscopy, and a puncture directed obliquely from caudal to cranial and from medial to lateral.