Management of vascular and nonvascular complications following pancreas transplantation with interventional radiology.

Pancreas transplantation exposes to high rates of complications, either vascular (thrombosis, stenosis, pseudoaneurysm, arteriovenous fistula) or nonvascular (fluid collection, graft rejection). With advances in percutaneous and endovascular techniques, interventional radiologists are increasingly involved in the management of these complications. In this article, we review the anatomical considerations relevant to pancreas transplantation, the techniques used for image-guided interventions for vascular and nonvascular complications, and the expected outcomes of these interventions.

Ultrasonographic guidance for portal vein access during transjugular intrahepatic portosystemic shunt (TIPS) placement.

PURPOSE: The purpose of our study was to retrospectively assess the safety and efficacy of percutaneous real-time ultrasound guidance for portal vein puncture during transjugular intrahepatic portosystemic shunt (TIPS) placement. MATERIALS AND METHODS: Between January 2011 and November 2018, procedure details and outcome were retrospectively analyzed for 224 patients who underwent TIPS placement using real-time ultrasound guidance for portal vein puncture. There were 175 men and 49 women with a mean age of 52.7±10.6 (SD) years (range: 22-82 years). For each procedure, technical success, primary ultrasound guidance success, portosystemic pressure gradient, duration of the intervention, procedural complications, radiation exposure, mortality and morbidity rates at day 30 post-procedure were recorded for data analysis. RESULTS: Technical success rate was 100.0% with a success rate of the primary ultrasound guidance of 97.8% (219/224; 95% CI: 95.8-99.7). Mean duration of the procedure was 86.2±41.7 (SD) min (range: 22.0-267.0min). Mean dose-area product was 62.0±50.2 (SD) Gy.cm2 (range: 3.7-306.5Gy.cm2). Twelve complications (12/224; 5.4%) occurred in ten patients during TIPS procedures including 8 arterial punctures (3.6%) and 4 biliary punctures (1.8%). Four complications (4/224; 1.8%) were clinically significant. Mortality rate at day 30 after the procedure was 9.8% (22/224), without any patient dying from technical complications. CONCLUSION: Real-time ultrasound guidance is a safe technique to assist in the creation of TIPS and may allow for lower radiation exposure.

[Goldman Antopol syndrome associated with bilateral congenital severe factor V deficiency]. / Syndrome d'Antopol Goldman bilatéral associé à un déficit congénital sévère en facteur V.

Antopol-Goldman lesions are extremely rare. This kind of lesion is a subepithelial pelvic hematoma. This syndrome is certainly of rare occurrence and that is why a differential diagnosis of urothelial cancer in young patients who had problems with clotting must be raised. We reported a case of a 43-year-old haemophiliac with a severe congenital factor V deficit and presenting a bilateral and asynchronous Antopol Goldman syndrome. The diagnosis has been based on CT scans. The subepithelial aetiology bleeding has been shown on selective renal arteriography that allowed to cover a micro-aneurysm through the setting up of a vascular stent and a selective embolization.

[Contribution of molecular biology and Aspergillus galactomannan antigen assay for the diagnosis of histoplasmosis]. / Contribution de la biologie moléculaire et de l'antigénémie galactomannane aspergillaire au diagnostic de l'histoplasmose.

We report a case of a pulmonary histoplasmosis in an HIV-positive patient usually living in Cambodia, with a positive Aspergillus galactomannan antigenemia resulting from a cross-reaction, that decreased after antifungal therapy. We discuss the potential interest of the detection of fungal DNA by PCR and Aspergillus galactomannan antigenemia for the diagnosis of histoplasmosis, especially in countries where Histoplasma capsulatum antigen testing is not available.

PCDD/F and PCB multi-media ambient concentrations, congener patterns and occurrence in a Mediterranean coastal lagoon (Etang de Thau, France).

Ambient concentrations, congener patterns and multi-media distribution of PCDD/Fs and PCBs were determined in air, water, sediment and mussels in a semi-enclosed marine ecosystem (Thau lagoon, France). Sigma2,3,7,8-PCDD/F and sigma7ICES PCB air concentrations (0.2-1.4 and 31-57 pg m(-3), respectively) were typical of rural areas. Concentrations in the water column were very low for PCDD/Fs (163-476 fg L(-1)) and low for PCBs (138-708 pg L(-1)). PCDD/F and PCB concentrations found in surface sediment (0.15-1.6 and 2.5-33 ng g(-1) d.w., respectively) and mussel (13-21 pg g(-1) d.w. and 10-39 ng g(-1) d.w., respectively) were medium levels. PCDD/F congener patterns observed in air, water particulate phase and sediments were similar suggesting direct coupling among these compartments and atmospheric inputs of PCDD/Fs into the lagoon. Conversely, for the same set of samples, similar patterns were not observed for PCBs in the mentioned compartments.

[Anicteric cholestasis: imaging and diagnostic strategy]. / Une cholestase anicterique: l'apport de l'imagerie au diagnostic étiologique.

Cholestasis is due to abnormal biliary secretion, from hepatic or extra hepatic causes. The diagnostic strategy of anicteric cholestasis will be discussed, defining hepatic biologic abnormalities, and the role and sequence of imaging techniques based on clinical and biological findings. Main causes will be emphasized and illustrated with different radiological techniques (US, CT and MRI).

[Anatomic study and clinical application of the skin paddle of the serratus anterior free flap]. / Etude anatomique et applications cliniques des caractéristiques de la palette cutanée du lambeau libre de grand dentelé.

SUBJECT: Several authors used musculocutaneous free flaps of serratus anterior. However, the localization and dimensions of its skin paddle are not clearly defined in the literature. Thus, we realized an anatomical study trying to prove the reality of this skin paddle and its localisation, before considering clinical applications. PATIENT AND METHODS: Twenty-six dissections on 13 fresh anatomical subjects were realized. The protocol consisted in catheterization the thoracic branch of the thoracodorsal artery to inject a mixture of iodized product and methylene blue. The results were obtained by direct measurement of the blue cutaneous area and by radiographic evaluation of the radiopaque area, compared to reproducible anatomical reference marks. RESULTS: Twenty-five dissections were interpretable with superposable results. The skin paddle was always located compared to the 5th, 6th and 7th ribs between the anterior axillary line and the mamelonnary line. The area of the skin paddle was 11,75 cm of length (10-14), 10,75 cm of width (9-12) and 125 cm(2) from surface (110-140). Then, we realized between January and December 2003 several clinical applications of this anatomical study. We report 12 cases of free flaps of serratus anterior with skin paddle for the monitoring of the flap (4 musculocutaneous, 5 osteo-musculo-cutaneous, 3 of fascia with skin paddle). CONCLUSION: This study comes to the support from the anatomical observations from Salmon, the per-operational observations of several authors and our own clinical experiment. It certifies the autonomy of cutaneous vascularization by branches resulting from the surface fascia of the muscle. It specifies the localization and dimensions of the skin paddle of the serratus anterior flap in its muscular, osteo-muscular or fascial form, which still increases its versatility of use.

[Complications of fluoroscopy-, ultrasound-, and CT-guided percutaneous interventional procedures]. / Complications des gestes interventionnels percutanés sous contrôle radioscopique, echographique ou scanographique.

The purpose of this article is to describe potential complications following the most common image-guided (fluoroscopy, ultrasound or CT) percutaneous interventional procedures, both diagnostic and therapeutic, thoraco-abdominal and musculoskeletal, as well as to review risk factors and the best practice recommendations. Prior to any interventional procedure, it is necessary to ascertain the absence of any abnormality in coagulation, to secure enough time to explain the procedure to the patient, and to adhere to strict sterile technique. Indeed, infections and hemorrhagic complications are the principal causes of mortality and morbidity for all procedures. Following lung biopsy, CT scan detects an immediate pneumothorax in 30% of patients. Major complications following percutaneous liver biopsy occur within 3 to 6 hours. Following a percutaneous drainage, complications occur in less than 10% of cases. Following a radiofrequency thermal ablation of malignant tumors, the mortality rate is low (0,5 to 1,4%), infection and hemorrhage are the most frequent complications. While rare, septic arthritis is the main complication that can follow musculoskeletal procedures and is a cause of medical malpractice lawsuits brought by patients.

[Thrombophlebitis of the right ovarian vein with thrombosis of the inferior vena cava]. / Thrombose de la veine cave inférieure par thrombophlébite de la veine ovarienne droite.

A 39-years-old woman was admitted with pelvic pain and fever occurring one month after a caesarean. An echography-doppler and an abdominal tomodensitometry were performed. Thrombophlebitis of the right ovarian vein was diagnosed with extension of a floating thrombus into the inferior vena cava. We decided to perform a surgical thrombectomy due to a pulmonary embolism which occurred while the patient was under heparin and antibiotic treatment. A temporary percutaneous caval filter was successfully used in the peri-operative period, preventing a second embolism. This observation focuses on a rare pathology occurring in young women and emphasises the safe use and removal of a temporary percutaneous caval filter in the peri-operative period.

[Massive hemoperitoneum from rupture of an intra-peritoneal varix]. / Hémopéritoine massif par rupture d'une varice intra-abdominale.

Rupture of an intra-abdominal varix in a patient with portal hypertension is a rare but severe cause of massive hemoperitoneum. The authors report the case of a patient with alcoholic cirrhosis that presented to the emergency department with hypovolemic shock. Imaging showed massive hemoperitoneum, severe portal hypertension and suggested the diagnosis of spontaneous rupture of an intra-abdominal varix, confirmed at laparotomy.

[Subfascial lipomatous tumors: management in a series of 37 consecutive cases]. / Tumeurs graisseuses sous-aponévrotiques: stratégie de prise en charge à propos d'une série continue de 37 cas.

PURPOSE OF THE STUDY: The prognosis of subfascial lipomatous soft tissue tumors depends greatly on their histological type ranging from benign lipomas that cause little local or general problems to the severe prognosis of liposarcomas that exhibit both local and distant extension. However, the clinical presentation of the two types of tumors may be similar and thus quite misleading, sometimes leading to inappropriate management and severe consequences. The main objective of this study was to determine whether the preoperative work-up in patients treated for musculoskeletal tumors within our recruitment zone is adequate, allowing appropriate therapeutic decisions. In addition, we wanted to know what explorations are most pertinent for the differential diagnosis between benign and malignant subfascial lipomatous soft tissue tumors. MATERIAL AND METHODS: Thirty-seven patients with subfascial tumors were included in this study. There were 16 with benign lipomas and 21 with liposarcomas. All the patients with benign lipomas but only 9 (43%) of those with liposarcoma had received initial care within our recruitment zone before final diagnosis. Two cases had been referred after biopsy and 1 after resection by morcellation; the 9 others were secondary referrals after tumor recurrence. Only 5 of these 12 referred patients had had an MRI exploration prior to surgery, 2 with an erroneous interpretation. An MRI series was obtained for all the patients with benign lipoma and for the 9 with liposarcomas who attended our units directly. A biopsy was also obtained in case of suspected liposarcoma. Two radiologists blinded to the final diagnosis reviewed the available MRI to assess their diagnostic value for subfascial lipomatous soft tissue tumors. RESULTS: No case of recurrence, after marginal resection (10 cases) was noted for lipomas. Six are under observation with regular MRI (with no change in size or signal). Four patients with liposarcoma died from their disease (19%) and 2 who had undergone "curative" resection had a recurrence (12%). Incorrect or imprecise (incomplete, incorrectly interpreted or no MRI) preoperative diagnosis led to additional morbidity with 3.4 surgical procedures (mean per patient) compared with 1 in patients who had had undergone a complete work-up and whose diagnosis was established after multidisciplinary discussions. Among the diagnostic elements available before pathology, only MRI findings had diagnostic value for subfascial lipomatous soft tissue tumors: for benign lipoma positive predictive value=92% and negative predictive value=93%. DISCUSSION: The clinical course of the benign lipomas and the sarcomas in this series confirm the radically different prognosis of these two tumors, both in terms of local extension and survival. Inadequate management in the initial diagnostic stages-i.e. lack of MRI with contrast injection, biopsy and multidisciplinary interpretation prior to treatment-raises the risk of higher morbidity, particularly a significantly greater number of reoperations, and progression to a higher grade of malignancy for two tumors. Our retrospective analysis enabled us to develop a decision making tree for patients with subfascial lipomatous tumors. Prospective validation will be necessary.

Gadolinium-enhanced MR imaging of normal renal transplants. An evaluation of a T1-weighted dynamic echo-planar sequence.

PURPOSE: To evaluate the potential usefulness of dynamic MR with echoplanar imaging (EPI) in assessing the renal function in patients with renal allografts. MATERIAL AND METHODS: Using a T1-weighted sequence, EPI was performed after injection of a Gd-chelate in 17 patients with normally functioning renal allografts. Time-intensity curves were plotted from the signal intensity (SI) measurements of the cortex and the medulla. RESULTS: The pattern of corticomedullar differentiation (CMD) observed after contrast enhancement was divided into four phases using the T1-EPI. After a rapid decrease in the SI of cortical structures, and a subsequent return to precontrast levels, a gradual fall in the SI of the medulla was observed. The average time between the two periods of signal loss was 60 s. CONCLUSION: This study illustrated the potential use of dynamic T1-EPI to demonstrate contrast-induced CMD in renal allografts.

[MR cholangiopancreatography in choledochal cysts]. / Cholangio-pancréatographie par IRM des kystes du cholédoque.

PURPOSE: To assess the value of MR cholangiopancreatography (MRCP) in the diagnosis and preoperative evaluation of choledochal cysts. MATERIAL AND METHODS: Five patients (aged between 6 days and 28 years) were investigated by MRCP, referred for ultrasonographic detection of a bile duct dilatation or a cystic structure, of antenatal diagnosis (1 case), for jaundice or abdominal pain (3 cases) or in late follow-up of a choledochal cyst surgery. Two endoscopic-ultrasonographic studies were performed. The five patients underwent surgery without preoperative biliary cholangiography. MRCP was performed using a HASTE sequence in frontal, oblique, axial planes (1,5 Tesla MR unit). RESULTS: MRCP allowed to confirm choledochal cyst, helps to specify the anatomical type (2 type I, 3 type II), detects choledocholithiasis (3 cases). Anatomic correlation was perfect. MRCP allowed to exclude gastrointestinal duplication. Anomalous junction of the pancreaticobiliary duct was found in one case. CONCLUSION: MRCP diagnoses choledochal cysts, specifies type, helps surgery and can avoid endoscopic retrograde cholangiography or endoscopic sonographic examinations especially for children. It may find an anomalous junction of the pancreaticobiliary duct.

[Direct carotid-cavernous fistula. Clinical, radiologic and therapeutic studies. Apropos of 49 cases]. / Fistule carotido-caverneuse directe. Etudes clinique, radiologique et thérapeutique. A propos de 49 cas.

MATERIALS AND METHODS: From 1977 to 1996, 49 direct carotido-cavernous fistulae were studied among the sixty some cases diagnosed over these 20 years. Five were caused by spontaneous rupture of an intracavernous aneurysm and the others were caused by trauma. RESULTS: The clinical presentation in 37 patients was exophthalmia with pulsating conjunctival hyperhemia and vascular murmur. Some cases had a neurological syndrome suggesting cavernous involvement. A bilateral presentation was observed in 2 cases. One patient had no ophthalmologic syndrome but had a vascular murmur. Prior to 1982, all patients were treated and cured by occlusion of the internal carotid after direct access via the neck using a 3 F Fogarty catheter. Since 1982, patients have been treated with the detachable balloon technique. The carotid was preserved in 16 cases. In one case, secondary thrombosis occurred due to major dissection. In one case, the size of the breach was too small for the balloon so a coil was used. In one other case, insertion of the guide wire and catheter was sufficient to occlude the fistula. There was one death during treatment due to fistula rupture and one partially regressive right hemiplegia which could not be explained. This patient also developed left hemiplegia two years later, again with no explaining cause. Cure was achieved in the other patients without sequellae. DISCUSSION: Direct carotido-cavernous fistulae due to rupture of an aneurysm or trauma are uncommon. When flow through the breach is minimal, vascular treatment may not be necessary unless clinical signs appear since this type of fistula heals spontaneously. In other cases, an endovascular balloon procedure is indicated. There are few complications. Embolization with coils or other devices should only be used in selected cases when the breach is too small for the balloon.

[Vertebral vacuum phenomena]. / Vides rachidiens.

The spinal vacuum phenomenon is a collection of gas within the disk space, the vertebral body, the apophyseal joint or the spinal canal. The intradiscal vacuum phenomenon is frequently observed in degenerative disk disease and crystal-induced diskopathy. This has obvious significance to the radiologist, who, on observing a narrowed disk space or collapsed vertebral body, might otherwise consider infectious or neoplastic spondylitis, a likely possibility. The presence of vacuum phenomenon militates against the diagnosis of infection or tumor.