[Atrioventricular block and left ventricular wall mobility disorder in a 44-year-old female patient : A case report of a rarity with pitfalls]. / Atrioventrikuläre Blockierung und linksventrikuläre Wandbewegungsstörung bei einer 44-jährigen Patientin : Fallbericht über eine Rarität mit Tücken.

Eosinophilic myocarditis is a rare condition with good treatment options, which can be difficult to diagnose. The clinical presentation can vary from asymptomatic to life-threatening forms. This article describes the case of a 44-year-old woman who suffered from vertigo, chest pain and dyspnea. The woman presented with an intermittent atrioventricular (AV) block II Mobitz type II° and mild impairment of left ventricular ejection fraction. Hypereosinophilia in the peripheral blood, cardiac magnetic resonance imaging (MRI) and endomyocardial biopsy led to the diagnosis of eosinophilic myocarditis, most likely as a result of an allergic reaction to Aspergillus fumigatus. A general treatment recommendation cannot be made due to the lack of evidence-based guidelines; however, recent scientific studies confirmed timely, high-dose steroid administration over several months to be the mainstay of treatment of eosinophilic myocarditis. The following article may be helpful in the early diagnosis and treatment of this underdiagnosed and insidious disease.

[Fever, atrial fibrillation, and angina pectoris in a 58-year-old man]. / Fieber, Vorhofflimmern und Angina pectoris bei einem 58-jährigen Patienten.

Primary cardiac lymphoma (PCL) respresents a very rare type of cardiac tumour. This report illustrates a case of PCL in an immunocompetent 58-year-old man presenting with atrial fibrillation and febrile syndrome. Comprehensive imaging [computer tomography (CT), cardiac magnetic resonance imaging (cMRI), 3-dimensional transesophageal echocardiography (3D-TEE)] identified a large right atrial tumour, leading to pericardial effusion. Isolated cardiac involvement was confirmed by positron emission tomography (PET)-CT. A diffuse large B-cell lymphoma (DLBCL) was diagnosed based on the results of a TEE-guided biopsy. A normalized PET scan (PETAL study) indicated complete remission following R-CHOP 14 immunochemotherapy. Thus, an interdisciplinary and multimodal approach avoided unnecessary cardiac surgery.

[S3 guidelines for diagnostics and treatment of peripheral arterial occlusive disease]. / S3-Leitlinien zur Diagnostik und Therapie der peripheren arteriellen Verschlusskrankheit.

This report summarizes the most important aspects of the new German S3 guidelines for the diagnostics and treatment of peripheral arterial occlusive disease (PAOD) from March 2009. The guidelines include definitions and epidemiology of peripheral arterial occlusive disease, diagnostic methods including clinical and technical procedures as well as imaging methods, treatment by non-invasive, interventional and surgical methods and patient care during follow-up. In key messages recommendations are given which are graded corresponding to the scientific evidence concluded from the literature.

[Medicinal therapy for interventional surgery of the peripheral vascular system]. / Medikamentöse Therapie bei interventionellen Eingriffen am peripheren Gefässsystem.

The aim of medicinal treatment, during and after femoral and crural interventions is to prevent early or late onset arterial thrombosis of the treated vascular segments. Therefore, unfractionated heparin is administered during the intervention by an intra-arterial or intravenous approach. To avoid late onset thrombosis, administration of platelet function inhibitors is recommended. However, valid data are only available for acetylsalicylic acid (ASA). Therefore, ASA is recommended for long term medication. In several cardiological studies on stent implantation in coronary vessels the combination of ASA and clopidogrel for dual platelet inhibition has been proven to be effective. These results have been transferred to antithrombotic therapy of the lower extremities despite the lack of dedicated studies. There is no evidence for the use of vitamin K antagonists after peripheral interventions.

[CT-guided radiofrequency ablation of liver metastases from colorectal cancer]. / CT-gesteuerte Radiofrequenzablation von Lebermetastasen kolorektaler Tumoren.

BACKGROUND AND OBJECTIVE: Data on radiofrequency ablation (RFA) of liver metastasis has not been uniform. The goal of this study was to determine medium-term success of CT-guided RFA of liver metastases from colorectal cancer. PATIENTS AND METHODS: 43 consecutive patients (27 men; aged 67+/-10 years) with a total of 87 liver metastases from colo-rectal cancer were included in this retrospective analysis. All patients underwent percutaneous RFA after first- or second-line chemotherapy. The mean follow-up period was 29.8 +/- 22.7 (4 - 85) months. Overall survival and local recurrence-free survival were determined using Kaplan-Meier curves. The effects of primary therapeutic success, number of lesions, maximum lesion size and sum of lesion diameters were assessed. RESULTS: In total, 83 lesions were treated during 56 interventions. Taking into account local recurrence and incomplete ablation 86.7 % of metastases were successfully ablated. The median survival was 46 months with estimated 1-, 3- and 5-year survival rates of 89.0 %, 66.2 % and 41.8 %, respectively. The median interval to hepatic tumor progression was 13 months after RFA. Survival was related to primary treatment success (p = 0.0353), number of lesions (p = 0.0050) and sum of lesion diameters (p = 0.0199). CONCLUSION: CT-guided RFA is an effective treatment of liver metastases from colorectal cancer. These data support the use of RFA in patients considered ineligible for surgery.

[Quantification of extracranial ICA stenoses with vessel ultrasound by CCDS and B-flow in comparison to 64-slice multidector CTA, contrast-enhanced MRA and DSA]. / Quantifizierung von extrakraniellen A. carotis interna (ACI) Stenosen mittels Gefässultraschall mit FKDS und B-Flow im Vergleich zur 64-Zeilen-Multidetektor-CTA, der MRA und DSA.

PURPOSE: To evaluate the value of vascular ultrasound determining the pre-interventional degree of distal stenosis in the extracranial internal carotid artery (ICA) by means of color-coded duplex sonography (CCDS) and B-flow. Comparison with contrast-enhanced 64-line CT angiography (CTA), contrast-enhanced MRA (ceMRA) and digital subtraction angiography (DSA). MATERIALS AND METHODS: Complementary diagnostics and evaluation of the stenosis by means of CCDS, B-flow, CTA, ceMRA and DSA were performed prior to percutaneous stent-assisted PTA in 21 symptomatic ICA stenosis. Ultrasound diagnostics were carried out with high-resolution linear transducers (5-10 MHz and 9-14 MHz). A bolus-triggered contrast-enhanced multislice CTA (collimation 64x0.5 mm) and a ceMRA (1.5 Tesla) as well as selective DSA were performed in every patient. The degree of distal stenosis was established in accordance to NASCET criteria by averaging 5 single measurements per modality and patient. The source images as well as MPR and MIP reconstructions were evaluated in the CTA and ceMRA. Hemodynamic flow parameters were determined with CCDS and B-flow. The images were assessed by two experienced readers in consensus. RESULTS: The extent of stenosis ranged from 45 to 95%, averaging 73% (+/-13%). There was a high degree of agreement between the B-flow results (r=0.938), the CCDS (r=0.852), the measurements from the source data of the ceMRA (r=0.9117) and reconstructions of the CTA (r=0.8598) compared to quantitative DSA as a reference technique. CONCLUSION: Compared to selective DSA, vascular ultrasound in combination with CTA and ceMRA increase the reliability of the diagnostic quantification of ICA stenosis.

[Interventional oncology in urology]. / Interventionelle Onkologie in der Urologie.

Partly because of its rising incidence, but mostly because of the availability of modern examination techniques, the detection rate of small renal-cell carcinomas is increasing more and more. Even though tumors exceeding 4 cm in diameter rarely metastasize, all renal lesions that arouse the suspicion of malignancy should be treated. Operative treatment techniques such as radical and partial nephrectomy are increasingly carried out as laparoscopic procedures and are regarded as the gold standard. Modern thermal ablation techniques may be a helpful treatment option for patients who are unfit for a surgical resection or refuse it. Radiofrequency ablation (RFA) is the most frequently applied of these methods. Modern probes allow ablation of lesions between 2 and 5 cm in diameter. In the vast majority of cases RFA is carried out percutaneously and monitored by ultrasound or CT; it is deemed safe and the complication rate is low. While randomized comparative studies against open resection are yet available, the preliminary results obtained with renal RFA are promising and suggest that RFA may be superior to other thermal ablation techniques. Clinical success rates are over 90% for radiofrequency, and also for cryotherapy, which is performed less often. Local relapse is very uncommon.

B-flow and B-flow with 3D and SRI postprocessing before intervention and monitoring after stenting of the internal carotid artery.

OBJECTIVE: To investigate the extent to which B-flow and B-flow with 3D postprocessing and speckle reduction imaging (SRI) have advantages in appraising the morphology of a high-grade stenosis of the internal carotid artery (ICA) for preinterventional planning and for postinterventional ultrasonographic follow-up. MATERIALS/METHODS: A comparative appraisal of flow with CCDS, power Doppler, B-flow and 3D B-Flow with SRI were carried out prospectively in 50 patients with >70% stenosis according to NASCET criteria in contrast medium-enhanced MRA before and after the intervention. After stenting of the internal carotid artery (ICA), i.a. digital substraction angiography (DSA) served as an additional reference method. RESULTS: In >70% ICA stenosis, simultaneous imaging of the pre-stenotic, intra-stenotic and post-stenotic flow was attained with B-flow in 45/90 cases (90%), with power Doppler in 39/50 cases (78%) and with CCDS in only 31/50 cases (62%). After intervention, a complete detection of flow without overwriting or blooming artifacts was achieved in all 50 patients only by B-flow. The intrastenotic flow (p<0.05) could be better demarcated against the lumen and the vessel wall before the intervention, whereas the flow within the stent could be very much better appraised after the intervention (p<0.01) using 3D postprocessing of B-flow with additional SRI. Re-stenoses with hypoechoic vascular wall changes (3/50 patients) were detected at an early stage using B-flow. CONCLUSIONS: B-flow technique with SRI and 3D postprocessing can facilitate the intrastenotic detection of flow in >70% ICA stenosis with fewer flow artifacts. After stenting, the perfused vascular lumen shows less flow artifacts compared with CCDS and power Doppler. In order to elucidate hemodynamic changes, additional Doppler examinations are still necessary.

[Digital ultrasonic diagnosis of lower leg venous thrombosis using harmonic imaging and cross beam technology]. / Digitale Ultraschalldiagnostik der Unterschenkelvenenthrombose mit Harmonic Imaging und Cross-Beam-Technik.

PURPOSE: To evaluate the extent to which Tissue Harmonic Imaging (THI) and spatial averaging (Sono-CT, Cross Beam) facilitate the diagnosis of lower leg venous thrombosis. MATERIALS AND METHODS: In 100 cases of lower leg venous thrombosis, the conventional B-scan, THI, and ultrasonic CT technology (Cross Beam) in examinations using a multi-frequency transducer head (9 - 14 MHz, Logiq 9, GE) were compared during follow-up studies using compression sonography over at least 6 weeks. Two independent examiners performed digital image documentation (PACS connection) without modifying the gray level parameters optimized in the B-scan. A thrombosis was considered to be proven sonographically if at least one ultrasonic modality yielded findings reproducible in follow-up checks at a comparable site in accordance with both examiners. RESULTS: Thromboses in the V. tibialis posterior category (97 %) and the fibular category (81 %) were found most often, followed by muscular venous thromboses (48 %). Thromboses in the V. tibialis anterior category were rare (12 %). The procedure comparison showed an advantage for ultrasonic CT technology in terms of the demarcation of thromboses of the deeper veins (sensitivity 98 %), as compared to THI (sensitivity 87 %, specificity 91 %, PPV: 99 %) and the B-scan (sensitivity 81 %). CONCLUSION: If a high-resolution linear transducer is used, THI and ultrasonic CT-Technology can facilitate the diagnosis of a lower leg venous thrombosis.

[Percutaneous thermal ablation of renal neoplasms]. / Perkutane Thermoablation von Nierentumoren.

Due to modern examination techniques such as multidetector computed tomography and high-field magnetic resonance imaging, the detection rate of renal neoplasms is continually increasing. Even though tumors exceeding 4 cm in diameter rarely metastasize, all renal lesions that are possible neoplasms should be treated. Traditional treatment techniques include radical nephrectomy or nephron-sparing resection, which are increasingly performed laparoscopically. Modern thermal ablation techniques such as hyperthermal techniques like radiofrequency ablation RFA, laser induced thermal ablation LITT, focused ultrasound FUS and microwave therapy MW, as well as hypothermal techniques (cryotherapy) may be a useful treatment option for patients who are unfit for or refuse surgical resection. Cryotherapy is the oldest and best known thermal ablation technique and can be performed laparoscopically or percutaneously. Since subzero temperatures have no antistyptic effect, additional maneuvers must be performed to control bleeding. Percutaneous cryotherapy of renal tumors is a new and interesting method, but experience with it is still limited. Radiofrequency ablation is the most frequently used method. Modern probe design allows volumes between 2 and 5 cm in diameter to be ablated. Due to hyperthermal tract ablation, the procedure is deemed to be safe and has a low complication rate. Although there are no randomized comparative studies to open resection, the preliminary results for renal RFA are promising and show RFA to be superior to other thermal ablation techniques. Clinical success rates are over 90 % for both, cryo- and radiofrequency ablation. Whereas laser induced thermal therapy is established in hepatic ablation, experience is minimal with respect to renal application. For lesions of more than 2 cm in diameter, additional cooling catheters are required. MR thermometry offers temperature control during ablation. Microwave ablation is characterized by small ablation volumes and plays a role as a coagulation tool during resection. Focused ultrasound is the only non-invasive method, but it is still experimental.

Percutaneous radiofrequency ablation of renal cell carcinoma: preliminary results.

PURPOSE: To report early results in percutaneous radiofrequency ablation (RFA) of renal cell carcinoma with an expandable RF probe. MATERIAL AND METHODS: In 14 patients (9 male, mean age 67.9 +/- 9.9 years) CT-guided percutaneous radiofrequency ablation of 15 renal cell carcinomas was performed using an expandable LeVeen probe (diameter 2-4 cm) and a 200-watt generator under general anesthesia and CT control. Tumors exceeding a diameter of 3 cm (n=6) were embolized within 24 h prior to RFA. Average tumor size was 3.0 +/- 1.0 cm. RESULTS: RFA was technically successful in all patients, resulting in a mean size of necrosis of 3.7 +/- 0.7 cm. With the exception of one reno-cutaneous fistula, which was successfully treated conservatively, no major complications were observed. No local recurrence was observed (follow-up: 13.9 +/- 12.4 months) while extrarenal tumor progression occurred in four patients. CONCLUSION: Our preliminary data suggest that nephron sparing percutaneous RFA of renal tumors with an expandable RF probe is safe and effective.

[Local lysis with alteplase for the treatment of acute embolic leg ischemia following the use of the duett closure device: preliminary results]. / Lokale Alteplase-Lyse zur Therapie der akuten embolischen Beinischämie nach Einsatz des Duett-Verschluss-Systems: vorläufige Ergebnisse.

PURPOSE: To analyze retrospectively the result of the alteplase lysis therapy of embolic complications following the use of the Duett closure device. METHODS AND MATERIALS: For 3.5 years, the Duett closure device was used in 1,398 angiographies to close the femoral puncture site. The Duett device consists of a balloon and a liquid procoagulant containing collagen and thrombin, which is injected into the puncture tract under endovascular balloon protection of the arterial puncture site. In 9 patients (0.64 %), the procoagulant was incidentally injected into the femoral artery causing acute leg ischemia. Eight patients received local lysis therapy with alteplase via a contralateral femoral access. One patient underwent surgery. On average, 21 mg alteplase (4 - 35 mg) were administered within 14 h (4 - 21 h). The course of the lysis was followed angiographically and clinically. All patients were interviewed by telephone 23 months (4 - 35 months) later. RESULTS: In 3 patients, lysis was complete. In 5 patients, only little thrombotic material remained. In all patients, symptoms of ischemia resolved completely within the first hours after initiation of lysis. In 5 cases, bleeding occurred at the puncture site closed with the Duett device during lysis, including development of a false aneurysm in 2 cases. Complications led to premature termination (n = 2) or interruption of the lysis (n = 3). All complications were treated conservatively. Clinically, long-term sequelae were paresthesia and hypoesthesia in the lower leg and foot in 2 patients treated with lysis, and in the patient who underwent surgery. CONCLUSION: Very rarely occurring embolic complications after use of the Duett closure device can be effectively treated with alteplase lysis. A high rate of complications is to be expected at the puncture site closed with the Duett device.

[Percutaneous radiofrequency ablation of renal cell cancer]. / Perkutane Radiofrequenzablation von Nierentumoren.

Renal cell cancer is the most frequent malignant tumor of the kidney. Depending on tumor size, extension and general condition, radical or partial nephrectomy, which meanwhile can be performed laparoscopically, is still the therapy of choice. Patients with an increased surgical risk, or suffering from additional renal tumors or tumor in a single kidney, percutaneous tumor ablation is a helpful therapeutical option. Among all thermal ablation procedures, most experiences exist with radiofrequency ablation (RFA). A significant advantage of this technique is the possibility of direct puncture of the tumor without Seldinger technique and track ablation. This helps to reduce the risk of bleeding and tumor seeding within the puncture track. By use of modern ablation probes, lesions of up to 5 cm in diameter can be created without repositioning of the probe. Initial superselective particle embolization is recommended in tumors beyond 3 cm in size, because renal cell cancer is often hypervascularized and devasularization helps to reduce ablation time. Furthermore, the tumor location within the kidney is influencing the ablation result. Exophytically growing lesions or tumors within the renal parenchyma can be treated with a safety margin. Tumors in a central location or with broad contact to the collecting system are no candidates for thermal ablation, because of an increased risk of thermal collateral damage. Computed tomography is an optimal imaging modality and crucial to planning, performing and controlling of a successful percutaneous RFA. Based on the previous experiences of 300 published cases, renal RFA results in an over 90% success rate associated with a low complication rate. A randomized controlled study comparing RFA and surgery is necessary to answer the question whether RFA can be considered therapy of first choice even for patients, who are according to the actual evidence surgical candidates.

Multipolar radiofrequency ablation: first clinical results.

Common systems of radiofrequency ablation (RFA) are monopolar devices which require grounding pads on the thighs in order to close the electrical circuit. Bipolar RFA does not require grounding pads, because both electrodes are located on one probe and alternating current circuit is confined within the target tissue. In this paper we report on the first clinical application of a new ablation device which enables both, bipolar (1 probe) and multipolar (up to 3 internally cooled probes simultaneously) radiofrequency ablation. We report on bi- and multipolar applications in liver tumors (9 patients), osteoid osteoma (2 patients) and renal cell cancer (1 patient).

MR urography today.

Magnetic resonance (MR) urography is performed by pursuing two different imaging strategies. On the one hand, heavily T2-weighted turbo spin-echo sequences are employed for obtaining unenhanced static-water images of the urinary tract. On the other, the T(1)-weighted MR urographic technique imitates conventional intravenous pyelography and is, therefore, referred to as excretory MR urography. For this reason, a gadolinium contrast agent is injected intravenously and, after its renal excretion, the gadolinium-enhanced urine is imaged with fast T1-weighted gradient-echo sequences. Both MR urographic techniques can be combined for a comprehensive examination of the upper urinary tract. This article reviews the current technical principles, imaging capabilities, and clinical applications of T2- and T1-weighted MR urography in adult and pediatric patients.

[Percutaneous radiofrequency ablation -- clinical indications and results]. / Perkutane Radiofrequenzablation -- klinische Indikationen und Ergebnisse.

Percutaneous interstitial tumor ablation therapy is a relatively new and steadily growing field within interventional radiology. Radiofrequency ablation (RFA) became one of the most accepted techniques among hyperthermal ablation procedures, presumably due to its superior relation between probe diameter and efficacy. The first part of this review provided an overview of the underlying principles, technical background and application techniques. This second part describes the indications, techniques and results of clinical RFA applied to primary and secondary liver tumors as well as experiences with extrahepatic RFA applied to kidney, bone and lung, together with a discussion of the current literature.

[Selective CT mesentericography in the diagnostics of obscure overt intestinal bleeding: preliminary results]. / Selektive CT-Mesenterikographie zur Diagnostik schwerer Darmblutungen unklaren Ursprungs: Vorläufige Ergebnisse.

AIM: To evaluate intra-arterial CT mesentericography (CTM) in the diagnostics of severe obscure overt intestinal bleeding in comparison with conventional mesentericography (MG) and surgery. METHODS: In 8 patients (23 - 82 years, mean 59 years), CTM was performed via the catheter left in the superior mesenteric artery after MG to detect the source of bleeding. Early and late-phase spiral CT scans were acquired after administration of contrast medium. Active bleeding was considered to be present if extravasation of contrast medium into the bowel was found. The results of MG and CTM were compared with the results of surgery. RESULTS: With MG active bleeding was found in one patient, with CTM in five patients. In three patients, both MG and CTM were negative. Six patients underwent surgery. Five cases of bleeding detected with CTM were confirmed by surgery. In one case, bleeding found with CTM was not confirmed by surgery. One patient underwent surgery although all imaging procedures were negative. The source of bleeding remained unknown. Surgically, the site of bleeding was located in the jejunum in 3 patients (jejunitis, jejunal ulcers, carcinoid), one patient had a diverticulum in the ascending colon. The colonic bleeding site was correctly localized with CTM, whereas the small bowel bleeding could only roughly be assigned to the proximal or distal jejunum or jejunoileal transition area. CONCLUSION: Preliminary results indicate that selective CTM is superior to MG in the evaluation of severe obscure overt intestinal bleeding.

[Percutaneous radiofrequency ablation of liver malignancies: first experience with a 200-W radiofrequency generator]. / Perkutane Radiofrequenzablation maligner Leberläsionen: Erste Erfahrungen mit einem 200-W-Generator.

PURPOSE: To evaluate the effectiveness of a percutaneous radiofrequency ablation device, consisting of a LeVeen probe and a newly developed 200-W radiofrequency generator. MATERIAL AND METHOD: In 20 patients (9 male, 11 female), 30 primary and secondary liver malignancies were treated by CT-guided percutaneous radiofrequency ablation. The patients were separated in a potentially curable (n = 10) and a palliative (n,= 10) treatment group. The treatment was performed using an umbrella-shaped LeVeen probe with a diameter of 3.5 cm or 4 cm and a 200-W generator (Radiotherapeutics, Mountain View, CA, USA). All interventions were performed under general anesthesia by a standardized treatment protocol. The size of the lesions treated ranged from 2.2 x 2 x 2 cm to 10.8 x 10.1 x 10.5 cm. RESULTS: In all patients, the correct placement of the probe and radiofrequency ablation was technically successful. In two patients more than one treatment session was necessary to achieve the intended treatment result. In all patients of the potentially curable group a complete tumor necrosis could be achieved, whereas in the palliative treatment group complete tumor necrosis was only achievable in one patient. The achieved necrosis size ranged from 2.4 x 2.8 x 2.5 cm to 9.2 x 8 x 10.5 cm. In one patient a colon fistula was observed 4 weeks after treatment. No further complications were observed. The follow-up period ranges from 1 to 15 months (mean 4.5 months). CONCLUSION: By use of a powerful generator in combination with a LeVeen probe percutaneous treatment of even large liver tumors is possible. Radiofrequency ablation is a safe procedure for the minimal-invasive therapy of non resectable liver neoplasms.