Traumatic injury of the thoracic aorta treated with stent-graft: is long-term CT angiography follow-up justified?

AIM: To report the results of long-term (>5 years) computed tomography (CT) angiography follow-up after thoracic endovascular aortic repair in patients with traumatic thoracic aortic injury. MATERIALS AND METHODS: All follow-up CT angiographies performed in patients with traumatic thoracic aorta injury treated by endovascular stent-graft between 2002 and 2008 were reviewed. Of the 14 patients treated, seven patients had CT angiography follow-up examinations for more than 5 years. All patients were men with a mean age of 26 years. The Talent device was used in four patients and Gore TAG device in three patients. The mean device diameter and length were 24.6 mm and 103 mm, respectively. Follow-up included annual outpatient clinic surveillance and CT angiography examinations, which were reviewed for any device-related complications. The radiation effective dose was calculated from the CT dose report. RESULTS: Thirty-three CT examinations performed 64-110 months (mean 76) after stent-graft implementation were reviewed. The mean follow-up number of examinations per patient was 4.7 (range 2-8). Intra-graft circular mural tissue at the distal part of the stent-graft was seen in one patient. Stable lack of proximal device apposition was seen in all patients. No other radiological complications (e.g., aortic infection, dilatation, aneurysm or pseudoaneurysm, device struts breakage, migration, collapse, endoleak) were detected. None of the patients developed hypertension. The average effective dose was 77.01 mSv (range 34.11-128.84 mSv). CONCLUSION: CT angiography did not reveal any complications developing throughout the long-term follow-up. These results suggest that long-term CT angiography follow-up may not be required.

Appendicitis in adults with incidental midgut malrotation: CT findings.

AIM: To report the computed tomography (CT) findings of acute and complicated appendicitis in adults with incidental midgut malrotation. MATERIALS AND METHODS: The medical records and CT studies of eight patients with appendicitis and incidental midgut malrotation who presented to two medical centres between 1998 and 2009 were reviewed. RESULTS: All patients presented with 1-5 days of acute abdominal pain, which was diffuse in two, left-sided in two, lower abdominal in two, and in the right lower quadrant in two patients. The inflamed appendix was right-sided in three, left-sided in three, and in the midline in two patients. Three cases were complicated by a peri-appendicular abscess, and one patient also had a small bowel obstruction. All patients had a complete non-rotation with right-sided duodenum and jejunum, and left-sided colon. All eight patients had an abnormal superior mesenteric artery-superior mesenteric vein (SMA/SMV) relationship and a dysplastic uncinate process of the pancreas. Urgent surgery was performed in six patients and the remaining two were treated conservatively. CONCLUSION: Altered anatomy in malrotation affects the typical clinical and CT findings of acute appendicitis, therefore delaying diagnosis. When CT shows focal inflammation anywhere within the abdomen, along with an abnormal SMA/SMV relationship, the position of the caecum should be ascertained and acute appendicitis ruled out.

Changes in spleen volume after resection of hepatic colorectal metastases.

AIM: To identify and describe changes in spleen volume occurring in patients with colorectal metastases to the liver after partial hepatectomy. MATERIALS AND METHODS: Forty-one consecutive patients (20 men, 21 women) with histopathology-proven colorectal liver metastases who underwent partial hepatectomy between August 2007 and April 2011 were included. Liver and spleen volumes were measured by computed tomography (CT) volumetry on the most recent CT prior to surgery and on all CTs obtained within a year after partial hepatectomy. Patients were carefully evaluated for and excluded if they had co-morbid conditions known to cause splenomegaly or risk factors for portal hypertension such as underlying liver disease and portal vein thrombosis. RESULTS: Thirty-two (78%) patients demonstrated an increase in spleen volume on the first post-operative CT, with more than a double increase in volume amongst five patients. Spleen volume increased by an average of 43% within 3 months of partial hepatectomy (p < 0.0001) and remained increased through 6 months after surgery, returning to near baseline thereafter. In the remaining nine (22%) patients, the spleen was observed to decrease an average of 11% in volume on first postoperative CT (p < 0.005). CONCLUSIONS: Splenic enlargement after partial hepatectomy of colorectal metastases is a common finding on CT. Increased familiarity amongst radiologists of this phenomenon as likely reflecting physiological changes is important in order to avoid unnecessary evaluation for underlying conditions causing interval enlargement of the spleen.

Sealed rupture of abdominal aortic aneurysms: CT features in 6 patients and a review of the literature.

PURPOSE: To assess the CT features of sealed rupture of abdominal aortic aneurysm. PATIENTS AND METHODS: We reviewed the CT scans of six index cases obtained over a 3 year period with a sealed rupture of an abdominal aortic aneurysm and those reported in the literature over a 21 year period. CT scans were reviewed for aneurysm size, the presence of a draped aorta and adjacent vertebral erosion. A group of consecutive patients with non-ruptured abdominal aortic aneurysm, referred for endovascular aneurysm repair during the same 3 year period constituted the control group. RESULTS: In the study group of 31 patients the mean size of the aneurysm was 6.24 +/- 2.01 cm, compared to 6.01 +/- 0.99 cm in the control group, without statistically significant difference (t = 0.75, df = 97, P = 0.46). A draped aorta was detected in all patients with a sealed rupture. Vertebral erosion was present in all our six, but mentioned in only 14 of the cases reported. CONCLUSION: A sealed rupture of an abdominal aortic aneurysm can occur in relatively small aneurysms. A draped aorta and adjacent vertebral erosion are characteristic CT signs of such a rupture.

The CT findings of abdominal anticoagulant-related hematomas.

Spontaneous bleeding is a serious complication of anticoagulation that should be promptly recognized and treated. The clinical manifestations vary and are related to the site of the hemorrhage. CT, a simple and safe imaging modality, plays an important role in the accurate determination of the presence or absence of an anticoagulant-related bleed, its extent, and its precise location. This pictorial article reviews and demonstrates the CT findings of a variety of anticoagulant-related hematomas at various anatomical locations in the abdomen.

CT findings of latrogenic complications following gastrointestinal endoluminal procedures.

Abdominal CT, a simple and safe imaging modality, plays an important role in evaluating patients suspected of having abdominal complications following nonsurgical gastrointestinal procedures, to accurately determine the presence or absence of such insults. This pictorial article reviews and demonstrates the CT findings of various complications following upper endoscopy, percutaneous endoscopic gastrostomy, endoscopic retrograde cholangiopancreatography, endoscopic US, colonoscopy, and enemas (barium as well as cleansing).

Minimally invasive management of urolithiasis.

The management of urolithiasis has radically changed over the last two decades. Open surgery has been almost completely replaced by minimally invasive procedures, mainly extracorporeal shock wave lithotripsy (ESWL) and ureteroscopy (URS). Although these treatment modalities have been proven to be very safe and effective, serious complications can occur. Prompt diagnosis is often essential and may even be lifesaving. Radiologists play an important role in this setting, since many of these complications can be readily diagnosed by imaging. Awareness of the wide spectrum of complications may be crucial in interpreting imaging studies of patients who have undergone one of these procedures. This article reviews the contemporary management of ureteric stones with ESWL and URS and illustrates the radiological findings of complications of these procedures.

Congenital anomalies of the spleen.

Various congenital anomalies may affect the spleen, starting with common anomalies, such as an accessory spleen, up to rare conditions such as a wandering spleen and polysplenia. Most of these anatomic variants have no clinical significance; they need, however, to be recognized by the radiologist as such. Awareness of these variants is important for the radiologist to interpret the findings correctly and avoid mistaking them for a clinically significant abnormality. In this review we illustrate the spectrum of congenital anomalies of the spleen and stress pitfalls and possible complications resulting from these anomalies.

Congenital internal hernia as a cause of small bowel obstruction: CT findings in 11 adult patients.

The aim of this study is to report the CT findings in patients proved to have congenital internal hernia (CIH) as a cause of small bowel obstruction (SBO). The CT scans of 11 patients (9 men and 2 women, with ages ranging from 20 years to 95 years (mean 60.7 years), presenting with clinical symptoms and signs of SBO without previous abdominal surgery or trauma, were retrospectively reviewed. In all patients features of SBO were seen. In addition, in nine of them a saclike mass, containing dilated small bowel loops with mesenteric vessels converging toward its orifice was demonstrated and a pre-operative diagnosis of an incarcerated internal hernia was suggested. In the other two, a closed loop obstruction was seen without an identifiable cause. Mural thickening of the entrapped loops within the hernial sac was seen in five patients, with hypoperfusion in four of them, blurring of the mesenteric vessels with localized mesenteric fluid was demonstrated in seven and free peritoneal fluid in 10. All patients were operated on following the CT and an incarcerated CIH was confirmed. Gangrenous bowel was present at exploration in seven cases. One patient died. In conclusion, in patients with intact abdomen and SBO, CT may be the first imaging modality to discover a clinically unsuspected CIH, which requires prompt surgical intervention. Radiologists should be aware of the CT features suggestive of a SBO caused by CIH, i.e. a saclike mass of dilated small bowel loops, as a correct diagnosis will influence patient management and prognosis.

Abdominal CT findings in nephropathic amyloidosis of familial Mediterranean fever.

To evaluate the abdominal CT features of reactive amyloidosis, abdominal CT scans of 20 patients with amyloidosis of familial Mediterranean fever (FMF) were reviewed and compared with abdominal CT scans of 2 control groups: 22 patients with chronic renal failure (CRF) due to non-amyloidotic kidney diseases and 40 patients with normal kidney function. The kidney size of patients with amyloidosis of FMF were found to vary during the course of the disease from normal or slightly larger than normal at the proteinuric phase, to smaller than normal and comparable to kidney size in CRF, at the uremic stage. Compared to kidney disease of other causes, more patients with FMF-amyloidosis had dense kidneys with coarse parenchymal calcification and calcification in other abdominal organs. Patients with FMF-amyloidosis had fewer aortic calcifications than patients with non-amyloidotic kidney disease. These findings suggest that kidney disease of reactive amyloidosis may have abdominal CT findings distinguishing it from other types of kidney diseases.

Laparoscopic splenectomy for torsion of wandering spleen associated with celiac axis occlusion.

BACKGROUND: Wandering spleen is a spleen lacking its normal ligamentous attachments, and thus subjected to free movement in the abdominal cavity, and even torsion around its pedicle. Surgical treatment includes either fixation (splenopexy) or resection (splenectomy). Both procedures can now be accomplished using the laparoscopic approach. METHODS AND RESULTS: We describe a case of a torsion of a wandering spleen, leading to recurrent episodes of abdominal pain, and eventually to splenic ischemia, necessitating splenectomy. The diagnosis was complicated by associated angiographic findings of celiac axis occlusion, possibly by median arcuate ligament compression. Laparoscopic splenectomy was successful, and led to complete resolution of symptoms. CONCLUSIONS: Although a rare condition, wandering spleen can be diagnosed accurately by imaging studies, mainly CT scan and angiography. Nowadays, the laparoscopic approach is preferred and enables the surgeon to perform either splenopexy or splenectomy, depending on the vascular status of the spleen.

Paraffin oil bezoar impacted in the small bowel: CT findings.

A case of a paraffin oil bezoar impacted in the small bowel, resulting from the prolonged use of paraffin oil as treatment for increasing constipation in a patient with metastatic ovarian carcinoma, is described. Although pharmacobezoars are reported in the literature, we could not find a description of the CT findings of a paraffin oil bezoar.

Pictorial review. CT of duodenal pathology.

This pictorial review presents the CT findings in different pathological entities of the duodenum. The aim of the article is to demonstrate the contribution of a common imaging modality, i.e. abdominal CT, in the diagnosis of various duodenal disorders.

Pictorial review: adult intussusception--a CT diagnosis.

Intussusception, usually thought of as a childhood condition, may be encountered in adults as well, and is then more often associated with underlying pathology. While the condition is mostly unsuspected clinically, as patients present with non-specific abdominal pain that is often of long duration, CT findings are characteristic. Examples are shown of intussusception both in the small bowel and colon. Awareness of these findings allows the radiologist to make the correct diagnosis.

CT findings in patients with familial Mediterranean fever during an acute abdominal attack.

The aim of this study is to present the abdominal CT findings of patients with familial Mediterranean fever (FMF) examined during an acute abdominal attack. CT scans of 17 patients (10 women and 7 men; age range 11-45 years) were retrospectively reviewed. Attention was directed to mesenteric or peritoneal abnormalities and to the presence of appendiceal pathology. Patients were divided into two groups; group A (n=14) consisted of patients with an acute abdominal attack caused by FMF, and group B (n=3) consisted of patients whose attack proved to be owing to a separate pathology requiring surgery. Characteristic CT findings of acute abdomen in FMF included mesenteric pathology (n=12), mainly of engorged vessels with thickened mesenteric folds, mesenteric lymphadenopathy (n=6) and ascites (n=6). Signs of focal peritonitis were found in four patients. Radiologists should be familiar with such CT findings of peritoneal irritation in patients with FMF during an acute attack, and may suggest this clinical diagnosis in the proper clinical setting in a patient who has not been previously diagnosed. Alternatively, the radiologist should be aware of the possibility of a concurrent acute appendicitis or other acute abdominal pathology in patients with known FMF and should search for it.

CT of a thickened-wall gall bladder.

This pictorial article reviews the various clinical entities that may cause mural thickening of the gall bladder encountered on contrast enhanced CT.

CT findings in congenital anomalies of the spleen.

There is a wide range of congenital anomalies of the spleen. Some are common, such as splenic lobulation and accessory spleen. Other less common conditions, such as wandering spleen and polysplenia, have particular clinical significance. Radiologists need to be aware of the various congenital variants of the spleen in order to recognize clinically important anomalies and to avoid mistaking less significant ones for an abnormality. In this pictorial review, the embryology of congenital anomalies of the spleen as well as their appearance on CT are described, diagnostic pitfalls are identified and complications of the anomalies are discussed.

CT diagnosis of malpositioned chest tubes.

Insertion of a chest tube into the pleural space is standard management for various pleural disorders. Malpositioning of chest tubes in extrathoracic, intraparenchymal and mediastinal locations and in the fissures is common. Malpositioning results not only in inadequate drainage of air and fluid but may also result in increased morbidity and mortality. Diagnosis of a malpositioned tube is sometimes difficult to establish on a chest radiograph. CT, however, has proven to be extremely accurate in evaluating the position of a chest tube and has often provided additional valuable information with significant therapeutic impact.

CT findings in ten patients with failed renal allografts: comparison with findings in functional grafts.

Our aim is to report the computed tomography (CT) features of the long-term failed renal allograft. Ten patients with failed renal transplants in whom the graft was left in situ underwent CT for various unrelated indications. The majority of the failed grafts showed marked shrinkage and coarse punctate diffuse parenchymal calcifications. Small cysts were seen in four grafts. A long-term failed renal transplant appeared on CT as a small rounded soft tissue mass. The graft was almost always heavily calcified. Lack of awareness of the nature of such a mass may mislead the radiologist in interpreting it as a space-occupying lesion.

Postoperative pneumoperitoneum: prevalence, duration, and possible significance.

Free intraperitoneal air after abdominal surgery is a confounding finding with uncertain significance. A diagnostic dilemma often arises as to its origin: does it merely represent residual postoperative pneumoperitoneum (PP), which will need no intervention, or does it indicate a complication such as an anastomotic leak or a perforation of the gastrointestinal tract. Residual PP is usually well tolerated, as it will be absorbed over time and requires no therapy. On the other hand, air escaping through a gastrointestinal tract perforation or leak usually represents an intra-abdominal catastrophe requiring urgent intervention. This intriguing subject has been dealt with quite extensively based on plain film radiography findings in the past 50 years, and has lately also been studied on CT. This review discusses factors influencing the prevalence of PP and its range of duration.