Advanced non-contrasted computed tomography post-processing by CT-Calculometry (CT-CM) outperforms established predictors for the outcome of shock wave lithotripsy.

OBJECTIVES: To evaluate the predictive value of advanced non-contrasted computed tomography (NCCT) post-processing using novel CT-calculometry (CT-CM) parameters compared to established predictors of success of shock wave lithotripsy (SWL) for urinary calculi. MATERIALS AND METHODS: NCCT post-processing was retrospectively performed in 312 patients suffering from upper tract urinary calculi who were treated by SWL. Established predictors such as skin to stone distance, body mass index, stone diameter or mean stone attenuation values were assessed. Precise stone size and shape metrics, 3-D greyscale measurements and homogeneity parameters such as skewness and kurtosis, were analysed using CT-CM. Predictive values for SWL outcome were analysed using logistic regression and receiver operating characteristics (ROC) statistics. RESULTS: Overall success rate (stone disintegration and no re-intervention needed) of SWL was 59% (184 patients). CT-CM metrics mainly outperformed established predictors. According to ROC analyses, stone volume and surface area performed better than established stone diameter, mean 3D attenuation value was a stronger predictor than established mean attenuation value, and parameters skewness and kurtosis performed better than recently emerged variation coefficient of stone density. Moreover, prediction of SWL outcome with 80% probability to be correct would be possible in a clearly higher number of patients (up to fivefold) using CT-CM-derived parameters. CONCLUSIONS: Advanced NCCT post-processing by CT-CM provides novel parameters that seem to outperform established predictors of SWL response. Implementation of these parameters into clinical routine might reduce SWL failure rates.

[Liver failure in a 27 years old female patient]. / Leberversagen bei einer 27-jährigen Patientin.

We report about a 27-years old female patient with acute liver failure due to an acute Budd Chiari Syndrom (thrombosis of all three liver veins an vena cava inferior) with caval web, birth control pills and after long distance flight. After successfull aspiration of the caval thrombus and dilatation of caval web liver transplantation could be bypassed. Two weeks after intervention the patient was in a good healthy condition with normal laboratory values, normal liver size, normal perfusion of the V. cava inferior and signs of reperfusion of the middle liver vein.

Abdominal compartment syndrome.

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are frequently encountered in critically ill patients and carry a high morbidity and mortality risk. Despite these facts, IAH/ACS are still overlooked by many physicians and therefore timely diagnosis is not made and treatment is often inadequate. All clinicians should be aware of the risk factors predicting IAH/ACS, the profound implications and derangements on all organ systems, the clinical presentation, the appropriate measurement of intra-abdominal pressure to detect IAH/ACS and the current treatment options for these detrimental syndromes. This comprehensive review provides knowledge about known facts, unresolved issues and future directions for research to improve patient survival and long-term outcome.

Spontaneous pseudoaneurysm of a femoro-popliteal Omniflow II graft treated with a stentgraft.

We report the case of a symptomatic spontaneous leak of a biosynthetic graft (Omniflow (II) treated endovascularly with a stentgraft. Potential degeneration of biosynthetic grafts with aneurysm formation is a well known problem with a reported incidence of up to 7 %. Implantation of a stentgraft for treatment of a pseudoaneurysm is a valuable treatment option in native arteries; however its use in Omniflow II bypass grafts has not been reported so far. Surveillance of peripheral bypass grafts with duplex ultrasound may be helpful to detect morphological alterations of the graft.

Pull-down technique to allow complete endovascular relining of failed AAA Vanguard endografts with Excluder bifurcated endografts.

INTRODUCTION: Endovascular replacement of failed Vanguard endoprosthesis with a newly inserted bifurcated Excluder endograft in 6 selected patients over a 10-year period is reported. REPORT: Six male patients were treated by secondary EVAR procedures for endograft failure (type I and/or III endoleaks caused by endograft disintegration and/or migration). All failed endografts (1 tube, 5 bifurcated) were Vanguard prostheses. Technically, a new bifurcated Excluder endograft was placed within the old failing Vanguard endograft. All reinterventions were performed under local anesthesia supplemented by systemic analgesia/sedation. In 3 patients, insertion of the new Excluder endograft was possible without any additional technical measure as the failing Vanguard endograft trunk had migrated distally. In another 3 patients, the failed Vanguard endograft trunk was still in place. In these patients, the Vanguard main body was pulled caudally with a transfemoral cross-over guide wire in order to gain sufficient length to allow the short limb of the Excluder endograft to open within the trunk of the failed Vanguard endoprosthesis. This guide wire was introduced through a second femoral 5F in the main access and exeteriorized with a snare through the contralateral 12 Fr sheath. The main body and short limb of the Excluder was then deployed whilst pulling on the cross-over wire. RESULTS: Six patients initially treated by a Vanguard endograft underwent complete relining with a newly inserted Excluder bifurcated stentgraft. The mean interval from the first EVAR procedure to the described replacement procedure was 75+/-20.2 months (range: 53-109). The new bifurcated Excluder endografts were successfully deployed in all patients (technical success: 100%). Primary sealing (defined as absence of endoleaks type I, III or IV in the postoperative contrast enhanced CT scan) was achieved in 6 of the 6 patients. There was no operative mortality. No further endovascular or open treatment was needed in the other 5 patients. During the mean follow-up period of 26+/-20.1 months (range 2.5-50 months), 2 patients died from unrelated causes. CONCLUSION: Secondary endovascular replacement of failed Vanguard endografts with a bifurcated Excluder endograft proved to be feasible and safe with no 30-day mortality. Technical detail requires traction on a cross-over wire to pull the old graft caudally and create enough space for the new bifurcated graft to be deployed.

Thrombosis of a superior mesenteric vein aneurysm: transarterial thrombolysis and transhepatic aspiration thrombectomy.

We report the case of a 31-year-old woman presenting with abdominal pain due to acute thrombosis of a superior and inferior mesenteric vein aneurysm, which was treated by a combination of arterial thrombolysis and transhepatic thrombus aspiration. At the last follow-up CT, 21 months following this procedure, there was no evidence of rethrombosis, and the patient continues to do well under oral anticoagulation. The literature regarding these uncommon mesenteric vein aneurysms without portal vein involvement, as well as their treatment options, is reviewed.

Pneumocystis carinii pneumonia in chronic lymphocytic leukaemia.

Pneumocystis carinii pneumonia in patients with chronic lymphocytic leukaemia (CLL) who have not been treated with fludarabin are rare, although clinically relevant CD4 T-cell depletion can occur in longstanding CLL without prior treatment with purine analogues. A 52 year old woman is reported who was on long term treatment with chlorambucil and taking a short course of prednisone for familial CLL before she developed progressive dyspnoea, and P carinii pneumonia was diagnosed in bronchoalveolar lavage fluid. Despite treatment with high dose co-trimoxazole the patient died.

Repair of abdominal aortic aneurysms with the Excluder bifurcated stent-graft.

The design of the Excluder, which is considered a 3rd generation device for endovascular repair of abdominal aortic aneurysms, is described. Based on a literature search, clinical short- to mid-term results are reviewed. So far, efficacy and safety of the Excluder for elective and emergent aneurysm repair have been demonstrated. In none of the studies perioperative conversion to open surgery or late aneurysm rupture has been reported. The cumulative 30-day-mortality rate was below 1%. Compared to the other commercial devices, aneurysm shrinkage is less marked after repair with the Excluder. Whether this is inconvenient remains to be proven on long-term follow-up.