Prophylactic Transcatheter Arterial Embolization After Successful Endoscopic Hemostasis in the Management of Bleeding Duodenal Ulcer.

GOALS: The aim of this study was to demonstrate the new strategy of prophylactic transcatheter arterial embolization (TAE) of the gastroduodenal artery after endoscopic hemostasis of bleeding duodenal ulcers. BACKGROUND: TAE is a well-established method for the treatment of recurrent or refractory ulcer bleeding resistant to endoscopic intervention, which increasingly replaces surgical procedures. A new approach for improving outcome and reducing rebleeding episodes is the supplemental and prophylactic TAE after successful endoscopic hemostasis. STUDY: This retrospective study included all patients (n=117) treated from 2008 to 2012 for duodenal ulcer bleeding. After initial endoscopic hemostasis, patients were assessed regarding their individual rebleeding risk. Patients with a low rebleeding risk (n=47) were conservatively treated, patients with a high risk for rebleeding (n=55) had prophylactic TAE of the gastroduodenal artery, and patients with endoscopically refractory ulcer bleeding received immediate TAE. RESULTS: The technical success of prophylactic TAE was 98% and the clinical success was 87% of cases. Rebleeding occurred in 11% of patients with prophylactic TAE and was successfully treated with repeated TAE or endoscopy. The major complication rate was 4%. Surgery was necessary in only 1 prophylactic TAE patient (0.9%) during the whole study period. Mortality associated with ulcer bleeding was 4% in patients with prophylactic TAE. CONCLUSIONS: Prophylactic TAE in patients with duodenal ulcers at high risk for rebleeding was feasible, effective at preventing the need for surgery, and had low major complication rates. Given these promising outcomes, prophylactic TAE should be further evaluated as a preventative therapy in high-risk patients.

A genome-wide association study identifies five loci influencing facial morphology in Europeans.

Inter-individual variation in facial shape is one of the most noticeable phenotypes in humans, and it is clearly under genetic regulation; however, almost nothing is known about the genetic basis of normal human facial morphology. We therefore conducted a genome-wide association study for facial shape phenotypes in multiple discovery and replication cohorts, considering almost ten thousand individuals of European descent from several countries. Phenotyping of facial shape features was based on landmark data obtained from three-dimensional head magnetic resonance images (MRIs) and two-dimensional portrait images. We identified five independent genetic loci associated with different facial phenotypes, suggesting the involvement of five candidate genes--PRDM16, PAX3, TP63, C5orf50, and COL17A1--in the determination of the human face. Three of them have been implicated previously in vertebrate craniofacial development and disease, and the remaining two genes potentially represent novel players in the molecular networks governing facial development. Our finding at PAX3 influencing the position of the nasion replicates a recent GWAS of facial features. In addition to the reported GWA findings, we established links between common DNA variants previously associated with NSCL/P at 2p21, 8q24, 13q31, and 17q22 and normal facial-shape variations based on a candidate gene approach. Overall our study implies that DNA variants in genes essential for craniofacial development contribute with relatively small effect size to the spectrum of normal variation in human facial morphology. This observation has important consequences for future studies aiming to identify more genes involved in the human facial morphology, as well as for potential applications of DNA prediction of facial shape such as in future forensic applications.

Efficacy and safety of treating acute haemoptysis using glue embolization: A retrospective observational study and comparison to the literature.

INTRODUCTION: A retrospective observational study of the short-term efficacy and safety of using glue embolization, namely n-butyl-2-cyanoacrylate (NBCA), in bronchial artery embolization (BAE) and comparison with the literature. The main aim of the study is to display the safety of this embolic material through standardization of interventional procedure for consideration of NBCA as a possible primary embolic agent in cases of BAE. METHODS: A total of 35 BAE was performed in 31 patients with acute haemoptysis after failure of bronchoscopic therapy using NBCA. The mean age was 56 years with 22 male patients. Pre-interventional bronchoscopy and computed tomographic angiography were performed. In 35 cases, embolization was performed exclusively with NBCA. One patient in combination with coils and one with particles and coils. The 1:4 NBCA-to-Lipiodol mixture was most commonly used. Post-interventional bronchoscopy was performed after 24 h. RESULTS: Technical success was possible in all cases. Clinical success was achieved in 94.3%. There was a mortality rate of 6.5% within 48 h. No other embolization related major complications were noticed. A minor complication of temporary ischaemia of the bronchial mucosa. No reperfusion of the embolized vessel, however with rebleeding in four patients from different primarily not embolized bronchial arteries. CONCLUSION: Despite previous concerns about its safety based on previous reports and in line with recent studies, we conclude that NBCA is a safe and effective embolic agent to perform BAE in cases of acute haemoptysis if performed according to a clear standard operating procedure as described with a possible superiority over embolic agents. Further blinded prospective comparative studies are necessary.

Anatomic locations of ureterovascular fistulae: a review of 532 patients in the literature and a new series of 8 patients.

INTRODUCTION: Ureterovascular fistula (UVF) is a rare but potentially life-threatening condition. Since its primary description by Moschkowitz in 1908, many case reports, studies and reviews have been written about this condition with the suggestive symptoms and risk factors repeatedly discussed. This study will be focusing on the different locations of 532 out of 605 fistulae published from 1908 up to 2022 besides eight new patients of our own. MATERIAL AND METHODS: A systematic review of the literature started using PubMed database searching for "ureteroarterial fistula", "arteriovascular fistula" and "uretero vascular fistula" was performed yielding 122, 62 and 188 results respectively. Those studies and the cited literature in each study were examined to include studies, which did not appear in the primary search. A total of 605 patients in 315 publications were gathered. Only studies mentioning new patients, a clear indication of the location of the UVF, the presence/absence of urinary diversion (UD) as well as the type of UD if present were included. Ten duplicates as well as studies lacking information regarding the UVF and/or the UD (seven publications with 63 patients) were excluded, with 298 publications including 532 external patients remaining. Eight internal cases were included with a total of 540 cases. RESULTS: From the 540 included cases, 384 patients (71.1%) had no UD compared to 156 patients (28.9%) with UD. Due to the anatomical ureteral course, the common iliac artery (CIA) was the most common vascular component of UVF, irrespective of the presence or absence of UD. Any dispute to whether the crossing point is the common or the external iliac artery (EIA) was settled for the CIA. Further common vascular components besides CIA include the aorta, EIA, internal iliac artery (IIA) including its branches and vascular bypasses including the anastomosis sites. Other unusual arterial localizations were stated under the "others" category. CONCLUSION: Identifying the location of the bleeding artery in UVF is critical and represents the most important step for successful management. We present the largest summary of described locations up to date including our own.

Normal breast parenchyma: contrast enhancement kinetics at dynamic MR mammography--influence of anthropometric measures and menopausal status.

PURPOSE: To study T1 baseline signal intensity (SI) and contrast material enhancement kinetics of normal breast parenchyma by using dynamic contrast-enhanced (DCE) magnetic resonance (MR) mammography and to determine the influence of anthropometric measures and menopausal status on the variability of these features. MATERIALS AND METHODS: Institutional review board approval and written informed consent were obtained. Between June 2008 and September 2011, 345 women (age range, 26-81 years; mean age, 51.3 years ± 11.6 [standard deviation]) underwent DCE MR mammography, with T1-weighted three-dimensional MR images (repetition time msec/echo time msec, 8.86/4.51; flip angle, 25°) acquired with a 1.5-T whole-body MR unit before and 1, 2, 3, 4, and 5 minutes after a gadobutrol bolus injection of 0.1 mmol per kilogram of body weight. Regions of interest were traced manually, and T1 SI of parenchyma was recorded. The influence of different predictors of T1 baseline SI and contrast enhancement was studied by using random-effects models. RESULTS: T1 baseline SI varied considerably between women, with a mean of 167.7 ± 49.2 (71.4-424.7 [range]) and 175.9 ± 48.9 (51.8-458.3) in the right and the left breast, respectively (P < .01). T1 baseline SI increased linearly with age (P < .0001) and body weight (P < .0001). After contrast material delivery, relative percentage of enhancement was 8.1%, 13.8%, 18.2%, 22.1%, and 24.6% at 1, 2, 3, 4, and 5 minutes, respectively, but varied considerably between women. Contrast enhancement was 9.3% in the lowest quintile and 47.4% in the highest. Contrast enhancement increased with body weight (P < .01) but decreased in postmenopausal women (P < .01). Women with higher baseline T1 SI tended to have a higher contrast enhancement slope. CONCLUSION: Anthropometric measures and menopausal status contribute to a large variability in contrast enhancement of normal breast parenchyma. This might influence the interpretation of contrast enhancement kinetics of breast lesions and current strategies for determining contrast medium dose for breast MR imaging.

R2* estimation using "in-phase" echoes in the presence of fat: the effects of complex spectrum of fat.

PURPOSE: To investigate R2* mapping robustness in the presence of fat using in-phase echoes, without and with spectral modeling of fat (single-peak and multipeak models, respectively), using varying numbers of echoes. MATERIALS AND METHODS: Data from 88 volunteers (men/women: 52/36, ages: 55.4 ± 12.2) were randomly chosen according to magnetic resonance imaging (MRI) liver fat-fraction (%), and classified into six fat-fraction groups (1: 20 cases, 0%-<10%; 2: 20 cases, 10%-<20%; 3: 20 cases, 20%-<30%; 4: 20 cases, 30%-<40%; 5: 8 cases >40% liver fat; 6: subcutaneous fat from all cases). R2* maps obtained from five in-phase echoes (echo times: 4.8-23.8 msec) were retrospectively reconstructed using single-peak and multipeak fat modeling. R2* maps were also calculated using different numbers (2-5) of echoes. RESULTS: Multipeak fat corrected R2* mapping is feasible from in-phase echoes, with noise performance comparable to single-peak R2* when using ≥ 4 echoes. Single-peak R2* showed poor robustness to varying echo time combinations in the presence of fat, where using few echoes resulted in large errors. These errors can be reduced using more echoes, or fully corrected using multipeak fat modeling. The mean R2* increased significantly with increasing fat-fraction when using single-peak R2* for any TE combination (P < 0.001), but did not vary when using multipeak R2* for any TE combination (P ≥ 0.158). CONCLUSION: R2* mapping uncorrected for spectral complexity of fat contains protocol and fat-dependent errors (lack of robustness) in tissues with high fat content. Accounting for complex fat spectrum improves robustness and accuracy of signal fitting, with modest noise performance loss.

Psychosocial consequences and severity of disclosed incidental findings from whole-body MRI in a general population study.

OBJECTIVES: Little is known about the psychosocial impact and subjective interpretation of communicated incide ntal findings from whole-body magnetic resonance imaging (wb-MRI). This was addressed with this general population study. METHODS: Data was based on the Study of Health in Pomerania (SHIP), Germany. SHIP comprised a 1.5-T wb-MRI examination. A postal survey was conducted among the first 471 participants, aged 23-84 years, who received a notification about incidental findings (response 86.0 %, n = 405). The severity of incidental findings was assessed from the participants' and radiologists' perspective. RESULTS: In total, 394 participants (97.3 %) wanted to learn about their health by undergoing wb-MRI. Strong distress while waiting for a potential notification of an incidental finding was reported by 40 participants (9.9 %), whereas 116 (28.6 %) reported moderate to severe psychological distress thereafter. Strong disagreement was noted between the subjective and radiological evaluation of the findings' severity (kappa = 0.02). Almost all participants (n = 389, 96.0 %) were very satisfied with their examination. CONCLUSIONS: Despite the high satisfaction of most participants, there were numerous adverse consequences concerning the communication of incidental findings and false expectations about the likely potential benefits of whole-body-MRI. KEY POINTS: • Disclosed incidental findings from MRI may lead to substantial psychosocial distress. • Subjective and radiological evaluations of incidental findings' severity differ strongly. • Disclosing incidental findings is strongly endorsed by study volunteers. • Study volunteers tend to have false expectations about potential benefits from MRI. • Minimizing stress in study volunteers should be a key aim in MRI research.

Potentially relevant incidental findings on research whole-body MRI in the general adult population: frequencies and management.

OBJECTIVES: To report the frequencies of potentially relevant incidental findings in the general adult population and to develop a protocol for their management in whole-body magnetic resonance imaging (wb-MRI). METHODS: A total of 2,500 adult subjects (1,271 women, 1,229 men; mean age 53 years) from the population-based Study of Health in Pomerania underwent standardised wb-MRI. Additionally, 1,129 participants received contrast-enhanced cardiac MRI, 619 men received MR angiography and 544 women received MR mammography. Two independent residents performed first-line reading. A third reader resolved disagreements. An interdisciplinary advisory board decided about disclosure. RESULTS: There were 1,330 incidental findings of potential clinical relevance in 904 subjects (36.2 %). Nine findings (0.4 %) required immediate referral. In total, 1,052 findings (79.1 %) were confirmed by the advisory board and disclosed to 787 participants (31.5 %). The abdominal organs (6.8 %), the urinary tract (6.8 %) and the skeletal system (6.0 %) were affected most often. While 383 findings (36.4 %) were indicated as benign and 62 (5.9 %) as malignant, most abnormalities, 607 (57.7 %), were of an unclear nature. CONCLUSIONS: Potentially relevant incidental findings are very common in wb-MRI research but the nature of these findings remains unclear in most cases. This requires dedicated management to protect subjects' welfare and research integrity.

Effect of multipeak spectral modeling of fat for liver iron and fat quantification: correlation of biopsy with MR imaging results.

PURPOSE: To investigate the effect of the multipeak spectral modeling of fat on R2* values as measures of liver iron and on the quantification of liver fat fraction, with biopsy as the reference standard. MATERIALS AND METHODS: Institutional review board approval and informed consent were obtained. Patients with liver disease (n = 95; 50 men, 45 women; mean age, 57.2 years±14.1 [standard deviation]) underwent a nontargeted liver biopsy, and 97 biopsy samples were reviewed for steatosis and iron grades. MR imaging at 1.5 T was performed 24-72 hours after biopsy by using a three-echo three-dimensional gradient-echo sequence for water and fat separation. Data were reconstructed off-line, correcting for T1 and T2* effects. Fat fraction and R2* maps (1/T2*) were reconstructed and differences in R2* and steatosis grades with and without multipeak modeling of fat were tested by using the Kruskal-Wallis test. Spearman rank correlation coefficient was used to assess fat fractions and steatosis grades. Linear regression analysis was performed to compare the fat fraction for both models. RESULTS: Mean steatosis grade at biopsy ranged from 0% to 95%. Biopsy specimens in 26 of 97 patients (27%) showed liver iron (15 mild, six moderate, and five severe). In all 71 samples without iron, a strong increase in the apparent R2* was observed with increasing steatosis grade when single-peak modeling of fat was used (P=.001). When multipeak modeling was used, there were no differences in the apparent R2* as a function of steatosis grading (P=.645), and R2* values agreed closely with those reported in the literature. Good correlation between fat fraction and steatosis grade was observed (rS=0.85) both without and with spectral modeling. CONCLUSION: In the presence of fat, multipeak spectral modeling of fat improves the agreement between R2* and liver iron. Single-peak modeling of fat leads to underestimation of liver fat.

Contrast enhancement kinetics of normal breast parenchyma in dynamic MR mammography: effects of menopausal status, oral contraceptives, and postmenopausal hormone therapy.

OBJECTIVES: To investigate effects of menopausal status, oral contraceptives (OC), and postmenopausal hormone therapy (HT) on normal breast parenchymal contrast enhancement (CE) and non-mass-like enhancing areas in magnetic resonance mammography (MRM). METHODS: A total of 459 female volunteers (mean age 49.1 ± 12.5 years) underwent T1-weighted 3D MRM 1-5 min after bolus injection of gadobutrol. Quantitative analysis was performed in normal breast parenchyma by manually tracing regions of interest and calculating percentage CE. Semiquantitative analysis was performed in non-mass-like enhancing areas, and signal intensity changes were characterised by five predefined kinetic curve types. The influence of OC (n = 69) and HT (n = 24) on CE was studied using random effects models. RESULTS: Breast parenchymal enhancement was significantly higher in premenopausal than in postmenopausal women (P < 0.001). CE decreased significantly with the use of OC (P = 0.01), while HT had negligible effects (P = 0.52). Prevalence of kinetic curve types of non-mass-like enhancement differed strongly between pre- and postmenopausal women (P < 0.0001), but was similar in OC users and non-OC users (P = 0.61) as well as HT users and non-HT users (P = 0.77). CONCLUSIONS: Normal breast parenchymal enhancement and non-mass-like enhancing areas were strongly affected by menopausal status, while they were not affected by HT use and only moderately by OC use. KEY POINTS: Breast parenchymal enhancement at MR mammography is stronger in premenopausal than postmenopausal women. The prevalence of strong enhancing non-mass-like areas is greater before menopause. Such enhancing non-mass-like areas may impair lesion detection in premenopausal women. Breast parenchymal enhancement is only marginally affected by hormone use. Discontinuation of hormone use before MR mammography may be unnecessary.

Thermal ablation of unresectable liver tumors: factors associated with partial ablation and the impact on long-term survival.

BACKGROUND: Thermal ablation procedures, including radiofrequency ablation (RFA) or laser-induced interstitial thermotherapy (LITT), are now well established in the treatment of malignant unresectable hepatic tumors. But the impact of partial ablation (PA) on long-term survival following computed tomography (CT)-guided radiofrequency ablation and laser- induced interstitial thermotherapy of unresectable malignant liver lesions and the associated risk factors of PA remain partially unknown. MATERIAL/METHODS: This study included 254 liver tumors in 91 consecutive patients (66 men and 25 women; age 60.9 ± 10.4 years; mean tumor size 25 ± 14 mm [range 5-70 mm]) who underwent thermal ablation (RFA or LITT) between January 2000 and December 2007. Mean follow-up period was 21.1 month (range 1-69 months). Survival rate and local progression-free survival (PFS) were calculated for patients with complete ablation (CA) vs. patients with partial ablation (PA) to assess the impact on long-term survival. RESULTS: Median survival after CA was 47 months compared to 25 months after PA (P=0.04). The corresponding 5-year survival rates were 44% vs. 20%. Median PFS for CA was 11 months compared to 7 months for PA (P=0.118). The sole statistically significant risk factor for PA was tumor size (>30 mm; P=0.0003). Sustained complete ablation was achieved in 71% of lesions ≤ 30 mm vs. 47% of lesions >30 mm. CONCLUSIONS: We conclude that achievement of complete ablation is a highly important predictor of long-term survival and that tumor size is by far the most important predictor of the likelihood of achieving complete ablation.

The role of the vagus nerve: modulation of the inflammatory reaction in murine polymicrobial sepsis.

The particular importance of the vagus nerve for the pathophysiology of peritonitis becomes more and more apparent. In this work we provide evidence for the vagal modulation of inflammation in the murine model of colon ascendens stent peritonitis (CASP). Vagotomy significantly increases mortality in polymicrobial sepsis. This effect is not accounted for by the dilatation of gastric volume following vagotomy. As the stimulation of cholinergic receptors by nicotine has no therapeutic effect, the lack of nicotine is also not the reason for the reduced survival rate. In fact, increased septic mortality is a consequence of the absent modulating influence of the vagus nerve on the immune system: we detected significantly elevated serum corticosterone levels in vagotomised mice 24 h following CASP and a decreased ex vivo TNF-alpha secretion of Kupffer cells upon stimulation with LPS. In conclusion, the vagus nerve has a modulating influence in polymicrobial sepsis by attenuating the immune dysregulation.

In vivo imaging of pancreatic tumours and liver metastases using 7 Tesla MRI in a murine orthotopic pancreatic cancer model and a liver metastases model.

BACKGROUND: Pancreatic cancer is the fourth leading cause of tumour death in the western world. However, appropriate tumour models are scarce. Here we present a syngeneic murine pancreatic cancer model using 7 Tesla MRI and evaluate its clinical relevance and applicability. METHODS: 6606PDA murine pancreatic cancer cells were orthotopically injected into the pancreatic head. Liver metastases were induced through splenic injection. Animals were analyzed by MRI three and five weeks following injection. Tumours were detected using T2-weighted high resolution sequences. Tumour volumes were determined by callipers and MRI. Liver metastases were analyzed using gadolinium-EOB-DTPA and T1-weighted 3D-Flash sequences. Tumour blood flow was measured using low molecular gadobutrol and high molecular gadolinium-DTPA. RESULTS: MRI handling and applicability was similar to human systems, resolution as low as 0.1 mm. After 5 weeks tumour volumes differed significantly (p < 0.01) when comparing calliper measurments (n = 5, mean 1065 mm3+/-243 mm3) with MRI (mean 918 mm3+/-193 mm3) with MRI being more precise. Histology (n = 5) confirmed MRI tumour measurements (mean size MRI 38.5 mm2+/-22.8 mm2 versus 32.6 mm2+/-22.6 mm2 (histology), p < 0,0004) with differences due to fixation and processing of specimens. After splenic injection all mice developed liver metastases with a mean of 8 metastases and a mean volume of 173.8 mm3+/-56.7 mm3 after 5 weeks. Lymphnodes were also easily identified. Tumour accumulation of gadobutrol was significantly (p < 0.05) higher than gadolinium-DTPA. All imaging experiments could be done repeatedly to comply with the 3R-principle thus reducing the number of experimental animals. CONCLUSIONS: This model permits monitoring of tumour growth and metastasis formation in longitudinal non-invasive high-resolution MR studies including using contrast agents comparable to human pancreatic cancer. This multidisciplinary environment enables radiologists, surgeons and physicians to further improve translational research and therapies of pancreatic cancer.

Intraarterial recombinant tissue plasminogen activator thrombolysis of acute and semiacute lower limb arterial occlusion: quality assurance, complication management, and 12-month follow-up reinterventions.

OBJECTIVE: The purpose of this study is to assess the efficacy of intraarterial thrombolysis in acute and semiacute occlusions of the lower limb. MATERIALS AND METHODS: A total of 77 native arteries and 52 bypass grafts were investigated in 129 patients (mean [± SD] age, 64.6 ± 11.1 years) with acute (i.e., symptoms for ≤ 14 days) or semiacute (i.e., symptoms for > 14 days) peripheral arterial occlusions of the lower limb treated by catheter-directed recombinant tissue plasminogen activator (rt-PA) thrombolysis. Therapeutic success was retrospectively analyzed according to vessel type and duration of occlusion. Morbidity and mortality rates associated with thrombolytic treatment were calculated. The hospitalization period after primary intervention was recorded. Reinterventions and amputations were assessed at 12-month follow-up. RESULTS: Recanalization was accomplished by rt-PA thrombolysis in 73.6% of all cases. There was no difference in primary therapeutic success between native arteries and bypass grafts (p = 0.601). Thrombolysis was more effective in acute peripheral occlusions, and hospital stays were shorter than those for patients with semiacute occlusion (p = 0.001). The morbidity rate was 31% (minor complications, 20.2%; major complications, 10.9%), and the mortality rate was 2.3%. Within 12 months, radiologic and surgical interventions were necessary for 27 patients. The limb salvage rate after primarily successful recanalization was 89.5%. CONCLUSION: Intraarterial rt-PA thrombolysis is an effective and reasonable method for treating acute peripheral arterial occlusion. The method is less effective in semiacute occlusions, leading to extended hospitalization. Within 12 months, a quarter of the patients required reinterventions, and amputations were necessary in 10% of the cases.

Endovascular retrieval of a dislocated pushable coil in the common hepatic artery using a cerebral stent retriever.

BACKGROUND: This is case of removing a dislocated pushable coil from the common hepatic artery (CHA) as a possible complication of using pushable coils in the embolization of an upper gastrointestinal bleeding (UGIB) from the gastroduodenal artery (GDA) by using a pRESET stent retriever (Phenox, Bochum, Germany) which is utilized mainly for treatment of endovascular stroke. CASE PRESENTATION: An 88-year-old female patient was referred to our hospital to get an emergency embolization of the GDA causing an UGIB with a relevant drop of the hemoglobin level. During the routine embolization of the GDA using pushable coils, a complete dislocation of the last coil into the CHA took place leading to a relevant slowing down of the arterial blood flow to the liver. A decision was thereby made to remove the dislocated coil to avoid further possible complications which was successfully achieved. CONCLUSIONS: Various stent retrievers have been proven to be effective in removing dislocated coils during intracerebral coiling of different pathologies. This case report is to our knowledge the first case report proving the high efficacy and safety of using yet another stent retriever, namely a pRESET stent retriever in removing a fully dislocated coil in the abdominal vessels, namely in this case the CHA.

Endovascular foreign body removal of a MynxGrip polyethylene glycol (PEG) sealant embolus using a cerebral stent retriever.

BACKGROUND: This is a rare case of removing an intra-arterial foreign body represented by MynxGrip polyethylene glycol (PEG) sealant as a rare complication of using the MynxGrip™ Vascular Closure Device (AccessClosure, Inc., Mountain View, CA) using a pRESET stent retriever (Phenox, Bochum, Germany) which is utilized mainly for treatment of endovascular stroke. CASE PRESENTATION: A 60-year-old female patient suffering from intermittent claudication in the right lower limb (stage IIb according to Fontaine) due to a peripheral arterial occlusive disease was presented for an elective revascularization using balloon angioplasty of a short chronic occlusion of the right superficial femoral artery. After a successful revascularization of the right superficial femoral artery using a retrograde femoral access from the left common femoral artery, the patient suffered from an acute limb ischemia in the left foot with distal popliteal embolization with involvement of BTK (below the knee) trifurcation. This is believed to be due to an intra-arterial foreign body embolism of MynxGrip polyethylene glycol sealant as a rare complication of using the MynxGrip™ Vascular Closure Device. CONCLUSIONS: Stent retrievers have been used previously in removing dislocated coils especially in the cerebral vessels. This case report however proves a high efficacy and safety of using stent retrievers in removing different and rather unusual intra-arterial foreign bodies such as MynxGrip polyethylene glycol sealant.

Magnetic resonance-guided upper abdominal biopsies in a high-field wide-bore 3-T MRI system: feasibility, handling, and needle artefacts.

OBJECTIVE: To investigate the feasibility and handling of abdominal MRI-guided biopsies in a 3-T MRI system. METHODS: Over a 1-year period, 50 biopsies were obtained in 47 patients with tumours of the upper abdominal organs guided by 3-T MRI with a large-bore diameter of 70 cm. Lesions in liver (47), spleen (1) and kidney (2) were biopsied with a coaxial technique using a 16-G biopsy needle guided by a T1-weighted three-dimensional gradient recalled echo volumetric interpolated breath-hold examination (T1w-3D-GRE-VIBE) sequence. Sensitivity, specificity, accuracy, complication rate, interventional complexity, room/intervention time and needle artefacts were determined. RESULTS: A sensitivity of 0.93, specificity of 1.0 and accuracy of 0.94 were observed. Three patients required a rebiopsy. There was a minor complications rate of 13.6%, and no major complications were observed. Histopathology revealed 38 malignant lesions, and 3-month follow-up confirmed 9 benign lesions. Mean lesion diameter was 3.4 ± 3.1 cm (50% being smaller than 2 cm). Mean needle tract length was 10.8 ± 3.3 cm. Median room time was 42.0 ± 19.8 min and intervention time 9.3 ± 8.1 min. Needle artefact size was about 9-fold greater for perpendicular access versus access parallel to the main magnetic field. CONCLUSION: Biopsies of the upper abdomen can be performed with great technical success and easy handling because of the large-bore diameter. The MRI-guided biopsy needle had an acceptable susceptibility artefact at 3 T. However future research must aim to reduce the susceptibility effects of the biopsy systems.

Percutaneous biliary drainage in patients with nondilated intrahepatic bile ducts compared with patients with dilated intrahepatic bile ducts.

OBJECTIVE: The purpose of this article is to compare the technical success and guidance of percutaneous transhepatic biliary drainage (PTBD) in patients with nondilated and dilated bile duct systems using different techniques to supplement the conventional approach. MATERIALS AND METHODS: Between 2006 and 2008, 71 patients (mean age, 66.6 years) underwent PTBD with 97 interventions. According to sonographic evaluation of bile duct morphology, patients were divided into two groups: 50 patients with dilated and 21 patients with nondilated bile ducts. In a retrospective analysis, both groups were compared for technical success, fluoroscopy time, complications, and medical indications. The use of interventional guidance (deviations from the standard protocol) in patients with nondilated bile ducts was recorded. RESULTS: The technical success rate was 90% in patients with dilated bile ducts versus 81% in patients with nondilated ducts, with no significant difference (p = 0.36). The greater complexity of the intervention in patients with nondilated bile ducts resulted in longer fluoroscopy times (p = 0.04). Complication rates were not different between the two groups. The main indication for PTBD was relief of a compressed biliary system in patients with dilated ducts and postoperative management of complications or prevention of tumor-associated bile duct obstruction in patients with nondilated ducts. T-drainage, additional CT-guided puncture, and temporary gallbladder drainage were performed in 16 of 21 interventions for patients with nondilated bile ducts, resulting in a 100% success rate, versus a success rate of 60% in the five PTBDs of nondilated ducts performed in the conventional manner. CONCLUSION: T-drainage, additional CT-guided puncture, and temporary gallbladder drainage improve the technical success of PTBD when used in patients with nondilated bile ducts. With these measures, technical success and complication rates in patients with nondilated ducts are comparable to those for PTBD of dilated bile ducts.

Assessing early vascular changes and treatment response after laser-induced thermotherapy of pulmonary metastases with perfusion CT: initial experience.

OBJECTIVE: The objective of our study was to use perfusion CT to prospectively monitor early vascular changes in tumor perfusion of pulmonary metastases after laser-induced thermotherapy (LITT) and to determine whether any of the perfusion parameters would predict technical success after therapy. SUBJECTS AND METHODS: Twelve patients with histologically proven pulmonary metastases undergoing LITT were enrolled prospectively in this study. Perfusion CT was performed before treatment, 1 day after treatment, and 4-6 weeks after therapy, and tumor blood flow, tumor blood volume (TBV), mean transit time (MTT), and permeability of the capillary wall surface (capillary permeability-surface product) in 22 pulmonary metastases were calculated. Perfusion parameters at baseline and after LITT were compared. Measurement of tumor diameter on long-term follow-up CT was the gold standard with which perfusion CT results were compared for local control. RESULTS: Median tumor blood flow, TBV, and capillary permeability-surface product had decreased significantly from baseline by 43%, 61%, and 73%, respectively, 1 day after LITT. Perfusion parameters obtained 4-6 weeks after treatment had not changed significantly compared with those obtained 1 day after therapy. There seems to be a good correlation between changes in perfusion CT parameters 1 day after therapy and local outcome, according to the Response Evaluation Criteria in Solid Tumors (RECIST), 1 year after therapy. CONCLUSION: Perfusion CT of pulmonary metastases has potential in the assessment of early vascular changes that result from LITT and predicting technical success immediately after treatment. Tumors with perfusion measurements that had not changed after therapy indicated progressive disease.

Whole-body magnetic resonance imaging for staging of lung cancer.

Accurate staging of lung cancer is requisite to choose the optimal therapeutic strategy and is very important for prognosis. Multimodality diagnostic imaging is currently used for detection, staging, and follow-up. Whole-body FDG PET/CT provides 'anatometabolic' information and improves diagnostic accuracy especially for M-staging. MRI has unrivalled tissue contrast, provides very exact morphological information, and does not involve ionizing radiation compared to PET/CT. MRI is widely used for diagnosing and characterizing pathologies in all regions of the body. The use of multiple receiver channels and parallel imaging enables examination of the whole body with shorter acquisition time while high image quality is maintained. This article gives an overview of initial clinical results obtained with whole-body MRI in staging lung cancer.