[Diagnostics and endovascular treatment of venous diseases]. / Diagnostik und endovaskuläre Therapie venöser Erkrankungen.

In venous disease, acute thromboses and chronic venous insufficiency have the highest health economics relevance. Duplex sonography is the first line diagnostic assessment tool, while cross-sectional imaging is employed as a supplementary method. Due to the availability and examination times computed tomography is preferred in the emergency setting and is supplemented by magnetic resonance imaging (MRI) for specific questions. Endovascular treatment procedures are increasingly becoming available in addition to classical conservative treatment methods.

[Percutaneous access for endovascular therapy of PAOD. Femoral, popliteal and pedal]. / Perkutane Zugänge zur endovaskulären PAVK-Therapie. Femoral, popliteal, pedal.

BACKGROUND: Percutaneous interventions in patients with peripheral arterial occlusive disease (PAOD) are usually performed from an antegrade or retrograde transfemoral arterial access; however, sometimes chronic femoropopliteal and crural occlusions cannot be negotiated via this route with traditional standard methods. OBJECTIVES: Description and evaluation of transfemoral, transpopliteal and transpedal vascular approaches for the treatment of advanced PAOD. MATERIAL AND METHODS: A literature review of available studies on endovascular interventions with distal retrograde access was carried out. RESULTS: Most complex arterial occlusions can be treated by employing modern subintimal procedures and/or additional retrograde approaches. The success rate also depends on the expertise with the appropriate technique and materials used. CONCLUSION: The transfemoral access remains the first choice for the treatment of patients with PAOD. Additional retrograde approaches from a more distal access constitute an alternative after failure of antegrade intervention attempts.

[Young Women - Problematic Patients in Vascular Surgery]. / Junge Frauen - Problempatientinnen in der Gefäßchirurgie.

The treatment of peripheral arterial disease (PAD) in young women between 40 and 60 years of age represents a difficult challenge for the vascular surgeon. Excessive smoking, an early menopause and the unfavourable anatomic proportions of thinner arterial vessels or vein grafts during peripheral bypass-surgery lead to a higher rate of complications or re-occlusion following invasive therapy in comparison to male patients. A special anatomic manifestation appearing nearly only in women around the 6th decade is the so-called aortoiliac hypoplastic syndrome with a high rate of re-occlusion after balloon-dilatation or local thrombendarteriectomy and bypass grafting, respectively. Variabilities in coagulation and the undertreatment of classical risk factors of PAD by medical drugs lead to poorer results in the treatment of PAD in young women. Therefore a conservative therapy - whenever feasible - should be the first choice for treating PAD in young women.

Impact of left atrial appendage morphology on thrombus formation in TAVI patients with atrial fibrillation.

PURPOSE: We aimed to correlate left atrial appendage (LAA) morphology with thrombus formation in patients with severe aortic valve stenosis and atrial fibrillation. METHODS: We analyzed LAA morphology and the prevalence of a thrombus in 231 patients with atrial fibrillation and severe aortic valve stenosis that were referred for pre-interventional CT scan before trans-catheter aortic valve implantation (TAVI) between 2016 and 2018. In addition, we documented neuro-embolic events depending on the presence of LAA thrombus within a follow-up of 18 months. RESULTS: The overall distribution of different LAA morphologies was chicken-wing 25.5%, windsock 51.5%, cactus 15.6% and cauliflower 7.4%. Compared to chicken-wing morphology, patients with non-chicken-wing morphology showed a significantly higher thrombus rate (OR: 2.48, 95%; CI 1.05 to 5.86, p = 0.043). Within the 50 patients with a LAA thrombus, we observed chicken-wing (14.0%), windsock (62.0%), cactus (16.0%) and cauliflower (8.0%) configuration. In patients with LAA thrombus those with chicken-wing configuration have a higher risk (42.9%) to develop neuro-embolic events compared to non-chicken-wing configuration (20.9%). CONCLUSION: We found a lower LAA thrombus rate in patients with chicken-wing morphology compared to patients with non-chicken-wing configuration. However, in the presence of thrombus, those patients with chicken-wing morphology showed a doubled risk for neuro-embolic events compared to patients with non-chicken-wing morphology. These results must be confirmed in larger trials but underline the importance of LAA evaluation in thoracic CT scans and could have an impact on the anticoagulation management.

Morphologic perfusion patterns and PI-RADSv2.1 in transition zone prostate cancer.

PURPOSE: To evaluate morphologic perfusion patterns in transition zone prostate cancer in multiparametric MRI controlled by in-bore MRI-guided prostate biopsy. METHODS: Two experienced radiologists evaluated MRI perfusion patterns in consensus from 321 biopsy cores from the transition zone in 141 patients. Transition zone cancer was present in 77 cores in 36 patients. Single early-phase perfusion images were evaluated separately for the presence of a transition zone prostate cancer (consensus tumor early perfusion). The proposed criteria for the perfusion pattern (asymmetry, signal strength, and homogeneity) were rated in consensus for each biopsy position in the presence of the T2w images including the markers of the biopsy trace. We analyzed receiver operating characteristic curves for the PI-RADSv2.1 score and the proposed perfusion pattern. RESULTS: A logistic regression model with PI-RADSv2.1 and perfusion patterns in early perfusion imaging improved the model fit significantly compared to a model containing only PI-RADSv2.1 (Likelihood Ratio Test, LR = 14.5, p < .001). The AUC was 0.96 for the multiple regression model compared to 0.92 for the PI-RADSv2.1 alone. The evaluation of homogeneity in single early-enhancement images is not inferior compared to the conventional DCE parameter of PI-RADSv2.1 (AUC 0.84 versus 0.83). CONCLUSION: Morphologic perfusion patterns significantly improve the diagnostic performance of PI-RADSv2.1 in TZ prostate cancer.

Quality indicators for the development and didactics of ultrasound courses in continuing medical education.

PURPOSE: Based on evaluation data from participant feedback, a concept was to be developed for introductory abdominal ultrasound courses lasting several days. This approach was to be developed incrementally with the intent of maximizing the learning effect per time. MATERIALS AND METHODS: This concept has been modified annually over several years based on the findings of educational research and the scores on final examinations in OSCE format. It has been modified with the aid of detailed questionnaires completed by approximately 2000 participating physicians and has thus undergone incremental optimization. RESULTS: Analysis of the most recent 1005 questionnaires has shown that participants recommend a modular course design with only brief lectures on theory (average optimal duration of 20 min., SD 9.6 min.). These should alternate with longer practical "hands-on" ultrasound exercises (60 - 90 min., accounting for at least 50 - 60 % of the course time), consolidating drawing exercises, and breaks. 51 % of the physicians specified 5 participants as the ideal group size for practical exercises, while 43 % specified only 4. The discussion presents 10 specific quality indicators for efficient ultrasound courses. It elucidates the feasibility and logistical prerequisites of this model, and compares it with other basic course concepts. Furthermore, this article presents a model for an evaluation covering the course concept and tutors as well as discussing a training program for tutors including a cost analysis. CONCLUSION: In summary, the participants estimate the course design to represent a mature concept that has demonstrated its feasibility and broad acceptance among physicians in CME.

Associated findings and complications of retroperitoneal fibrosis in 204 patients: results of a urological registry.

PURPOSE: We studied the frequency of associated findings and complications of retroperitoneal fibrosis in a large clinical collective of urological patients. MATERIALS AND METHODS: All urology departments in Germany were invited to participate in a registry of patients with retroperitoneal fibrosis, for which a data sheet with more than 200 questions was developed. RESULTS: As of March 2010 a total of 204 patients were registered. The male-to-female ratio was 2.1:1 and the average age at onset was 55.6 years. In 123 cases (60.3%) the diagnosis was confirmed by histopathology. Coexisting autoimmune diseases were found in 9.8% of patients, consisting mainly of thyroid disorders. Coexisting fibrosis was detected in 3.4% of the patients and 73.9% of those queried were active smokers. Of 176 patients for whom data on therapy were available 123 received monotherapy and 41 received combination therapy for a mean of 12.1 months (12 received none), while 87 underwent a total of 103 operative procedures. Hydronephrosis was the most frequent complication in 95.6% of patients. Atrophic kidney from undetected hydronephrosis appeared in 46 patients (22.5%) and in 4 bilateral damage necessitated dialysis. Complications from vascular obstruction were observed in 27.5% of patients. Large bowel obstruction requiring colostomy occurred in 4 patients (2.0%). CONCLUSIONS: Patients with retroperitoneal fibrosis often first present to urology departments upon referral for hydronephrosis. In this series at least 1 kidney appeared to be irreversibly damaged in more than 20% of patients. Urologists should be mindful of the role of smoking role as a risk factor, complications arising from vascular and large bowel obstructions, and the possible association of retroperitoneal fibrosis with autoimmune disease.

Evaluation of an OSCE assessment tool for abdominal ultrasound courses.

PURPOSE: The purpose of this study was the conception and evaluation of a standardized and reliable assessment tool in the OSCE format to measure the performance and practical skills of abdominal ultrasound users in PGME. MATERIALS AND METHODS: The design, logistics, pacing and the choice of tested competencies of a rotating OSCE parcours, as well as the options for quality control using detailed checklists versus global rating scales and different approaches to the training of the involved raters are described. Over the last 15 years the parcours has undergone incremental improvement and has been used in final examinations of abdominal ultrasound courses with approximately 5000 medical students and 2000 residents and fellows. For evaluation, all item difficulties and discrimination coefficients of the individual stations and the reliability (Cronbach's alpha) were calculated for the last 626 assessments. RESULTS: All 14 hands-on stations showed discrimination coefficients from 0.31 to 0.65 (mean 0.48; SD 0.09). The 13 diagram stations showed mean values of 0.50 (SD 0.16). Data analysis revealed mean homogeneous item difficulties of 0.78 (SD 0.02) and 0.62 (SD 0.04), respectively. Cronbach's alpha was 0.69 with five stations and reached values above 0.8 when more than 8 stations are combined in one parcours. CONCLUSION: The homogeneous distribution of item difficulties provides an opportunity for designing different OSCE versions with different levels of reliability. Several options to adjust the cut-off values, the choice of the examined contents and factors that influence the examinees' acceptance of this assessment tool for PGME or CME ultrasound courses are discussed. Overall, the values of reliability and accuracy of this assessment tool are high enough to be used also for high-stakes examinations in the field of abdominal ultrasound.

[Venous interventions--part 1: techniques and lower torso thromboses]. / Venöse Interventionen--Teil 1: Interventionstechniken und Thrombosen der Bein- und Beckenvenen.

Venous thrombosis is one of the most common vascular diseases. Without treatment, pulmonary embolism is a potentially life-threatening complication. Long-term complications are chronic venous insufficiency and post-thrombotic syndrome. Medical anticoagulation is currently the standard therapy, since it prevents appositional thrombus growth although it usually can not prevent the development of post-thrombotic syndrome. The structure of the thrombotic material often leads to partial recanalisation with residual stenosis. Early and sufficient systemic thrombolysis with adequate concentration may achieve disintegration of the thrombus and preservation of venous valve function. Supplementary to conservative therapy, local catheter thrombolysis is possible even in cases with contraindications for a systemic thrombolysis therapy. Additional interventional techniques reduce the required concentration of the thrombolytic. Venous stenosis can be treated by balloon angioplasty and stent implantation. This article reviews the different percutaneous treatment options as well as their application and usefulness in thrombosis of the lower torso.

[Venous interventions. Part 2: Thromboses of the upper torso and mesenteric veins]. / Venöse Interventionen. Teil 2: Thrombosen der oberen Körperhälfte und der mesenterialen Venen.

This article focuses on the percutaneous treatment options of venous thromboses and occlusions. Interventional therapy modalities for mediastinal, brachial, axillar, cerebral, and mesenteric thromboses are reviewed. Stenoses of the superior vena cava are most often caused by mediastinal malignomas. Balloon angioplasty together with stent implantation is an effective method for revascularisation in cases of upper venous congestion. Benign central venous stenoses are common in dialysis patients for whom interventional therapy using balloon angioplasty has proven excellent results. In the treatment of insufficient dialysis access, percutaneous techniques represent the first-choice option. Regarding cerebral and mesenteric thrombosis, interventional therapy is restricted to selected individual cases.

Radiological central vein treatment in vascular access.

In the last decades, the percutaneous interventional approach for the treatment of central venous obstructions (CVO) has become increasingly popular as the treatment of first choice because of its minimal invasiveness and reported success rates. CVOs are caused by a diverse spectrum of diseases which can be broadly categorized into two principal eliciting genera, either benign or malignant obstructions. The large group of benign venous obstructions includes the increasing number of end-stage renal disease patients with vascular access related complications. Due to the invasiveness and complexity of thoracic surgery for benign CVOs, the less invasive percutaneous interventional therapy can generally be considered the preferred treatment option. Initially, the radiological intervention consisted of balloon angioplasty alone, subsequently additional stent placement was applied. This was advocated as either primary placement or secondary in cases of elastic recoil or residual stenosis after percutaneous transluminal angioplasty (PTA). The efficacy of angioplasty of CVO in patients with vascular accesses, either with or without stenting, has been addressed by various studies. Overall, reports indicate an initial technical and clinical success rate above 95% and satisfactory patency rates. However, systematic follow-up and frequent re-interventions are necessary to maintain vascular patency to achieve long-term success.

Diffusion-weighted MRI and PET-CT in the follow up of chronic periaortitis.

Aim of the present study is to compare magnetic resonance imaging (MRI) and positron emission tomography (PET) parameters in the follow up of chronic periaortitis (CP), with a focus on changes in the apparent diffusion coefficient (ADC) and standardized uptake values (SUV). 127 patients with CP were treated in our urology between 2007 and 2017. We identified 14 patients with parallel abdominal MRI and PET-CT examinations before therapy and in the follow up resulting in a total of 56 examinations. Relative contrast uptake and diffusion-weighted MRI parameters were compared to SUV in the corresponding PET-CT examinationsand laboratory infection markers. All examined MRI and PET-CT parameters showed significant changes between basis and follow-up examinations. Median ADC values increased significantly (p < 0.001) in the follow up. SUVmax and the other MR parameter (contrast uptake, DWI-signal) declined significantly. We observed a strong negative correlation between ADC and SUVmax (rho: - 0.61; p < 0.001). In addition, we found an inverse correlation of ADC with the inflammation markers ESR (rho: - 0.64; p < 0.001) and CRP (rho: - 0.54; p = 0.001). MRI and PET-CT showed comparable results in the individual follow up of CP and compared to laboratory inflammation markers. Our data support MRI as first imaging modality due to absent radiation and the necessity of repetitive follow-up examinations in patients with CP.

Proximal culprit lesion and coronary artery occlusion independently predict the risk of microvascular obstruction in acute myocardial infarction.

Microvascular obstruction (MO) and coronary flow have been independently described to have a high prognostic impact after acute myocardial infarction (AMI). Their interdependence has not been precisely elucidated, so far. Aim of this study was to investigate the impact of coronary flow on the occurrence of MO in patients with AMI. 336 patients with revascularized AMI were examined by cardiac magnetic resonance imaging. Patients were categorised into two groups based on the presence of MO. Procedural characteristics and marker of infarct size were analyzed. MO was present in 110 (33 %) and absent in 226 (67 %) patients. Both groups differed significantly regarding pre- and post-interventional thrombolysis in myocardial infarction (TIMI) flow. After multivariable regression analysis pre-interventional TIMI-flow 0, proximal culprit lesion, post-interventional TIMI-flow

Diagnosis and treatment of insufficient dialysis vascular access.

A wide variety of diagnostic and minimally invasive modalities is currently available to radiologists for providing sufficient medical care for dialysis patients. In addition to clinical examination, ultrasound is the first line imaging method in suspected dialysis vascular access dysfunction. The percutaneous approach is the primarily recommended therapeutic option in many cases. This article reviews the current diagnostic and therapeutic methods in dialysis vascular access insufficiency.

Diffusion-weighted MRI in the follow-up of chronic periaortitis.

OBJECTIVE: To evaluate the usefulness of diffusion-weighted MRI (DWI) for the assessment of the intraindividual follow-up in patients with chronic periaortitis (CP) under medication. METHODS: MRI data of 21 consecutive patients with newly diagnosed untreated disease were retrospectively examined before and after medical therapy, with a median follow-up of 16 weeks. DWI parameters [b800 signal, apparent diffusion coefficient (ADC) values] of the CP and psoas muscle were analysed together with the extent and contrast enhancement. Pre- and post-treatment laboratory inflammation markers were acquired parallel to each MR examination. RESULTS: Statistically significant lower b800 signal intensities (p ≤ 0.0001) and higher ADC values (p ≤ 0.0001) were observed after medical treatment within the fibrous periaortic tissue. Extent and contrast enhancement of the CP showed also a statistically significant decrease (p ≤ 0.0001) in the follow-up examinations, while the control parameters within the psoas muscle showed no differences. CONCLUSION: DWI seems to be a useful method for the evaluation of response to treatment without contrast agents. The technique may be helpful in the assessment of disease activity to guide further therapeutic strategies. ADVANCES IN KNOWLEDGE: DWI detects significant differences in the intraindividual follow-up of CP under medical therapy.

Diffusion-weighted MRI in the follow-up of chronic periaortitis.

OBJECTIVE:: To evaluate the usefulness of diffusion-weighted MRI (DWI) for the assessment of the intraindividual follow-up in patients with chronic periaortitis (CP) under medication. METHODS:: MRI data of 21 consecutive patients with newly diagnosed untreated disease were retrospectively examined before and after medical therapy, with a median follow-up of 16 weeks. DWI parameters [b800 signal, apparent diffusion coefficient (ADC) values] of the CP and psoas muscle were analysed together with the extent and contrast enhancement. Pre- and post-treatment laboratory inflammation markers were acquired parallel to each MR examination. RESULTS:: Statistically significant lower b800 signal intensities (p ≤ 0.0001) and higher ADC values (p ≤ 0.0001) were observed after medical treatment within the fibrous periaortic tissue. Extent and contrast enhancement of the CP showed also a statistically significant decrease (p ≤ 0.0001) in the follow-up examinations, while the control parameters within the psoas muscle showed no differences. CONCLUSION:: DWI seems to be a useful method for the evaluation of response to treatment without contrast agents. The technique may be helpful in the assessment of disease activity to guide further therapeutic strategies. ADVANCES IN KNOWLEDGE:: DWI detects significant differences in the intraindividual follow-up of CP under medical therapy.

[Endovascular therapy of an iatrogenic renal-artery-perforation after fenestrated-aortic-repair (fEVAR)]. / Endovaskuläre Therapie einer iatrogenen Nierenarterienperforation nach fenestrierter Aortenprothese (fEVAR).

HISTORY AND ADMISSION FINDINGS: A 75-year-old patient was initially hospitalized for therapy-evaluation of a an acquaint infrarenal abdominal-aortic-aneurysm, with a maximum diameter of 5.3 cm. Medical history showed a known contained rupture of the aneurysm. Except for a substituted Hypothyroidism and a COPD Stadium II (GOLD), there were no other previous diseases known. EXAMINATIONS: Laboratory showed a slight normochrome, normocytic anemia (hemoglobin 13 g/dl, MCV and MCH were normal) together with a decreased total amount of erythrocytes of 3.89/pl. TSH value was increased significantly at 7.960 mU/l. Initially creatinine was measured at 1.02 mg/dl. Sonography and CT-scan of the abdominal vessels had shown no new insights other than the aneurysm of the abdominal aorta. A surgical revision was indicated. TREATMENT AND COURSE: After primarily uncomplicated implantation of a fenestrated EVAR, the patient showed a progressive hemoglobin loss concomitant with a considerable increase of renal retention parameters. A "spurium"/false aneurysm of the right renal artery was found, which moreover showed a retroperitoneal bleeding. The patient subsequently underwent successful endovascular therapy in our clinic and was dismissed from the hospital in good condition and without further complications. Follow up controls showed no signs of new pathologies. CONCLUSION: "Direct" post-operative complications after EVAR are a rarity. In our case, the interventional endovascular approach of the bleeding from the right renal artery was a successful and sufficient treatment of the potentially life-threatening complication.

[Subcutaneous mass as initial manifestation of an osteolytic metastasis]. / Subkutane Weichteilschwellung als Erstmanifestation einer osteolytischen Knochenmetastase.

HISTORY AND CLINICAL FINDINGS: A 69-year-old woman was admitted for evaluation of a left occipital subcutaneous tumour which had grown during the preceding eight weeks from 2 × 2 cm to 4 × 4 cm. INVESTIGATIONS: Sonography revealed a pressure-sensitive subcutaneous mass with osteolytic destruction in the occipital bone. Cranial magnetic resonance imaging confirmed the osteolytic lesion. Thoracic computed tomography showed a lesion in the upper left lobe of the lung with metastases in the hilar lymph nodes. DIAGNOSIS, TREATMENT AND COURSE: Transbronchial biopsy revealed a bronchial carcinoma. After resection of the osteolytic lesion its histology was confirmed to be an osseous metastasis of the carcinoma. Palliative chemotherapy and cranial irradiation were initiated. CONCLUSION: Solitary osteolytic lesions of the skull occur in the context of osseous metastases. Other possible causes include solitary plasmocytoma and eosinophilic granuloma.

MR evaluation of retroperitoneal fibrosis.

PURPOSE: Retroperitoneal fibrosis (RPF) is a rare fibrosing process. The relation of contrast enhancement within the fibrosis and the psoas muscle was suggested for the evaluation of disease activity and response to treatment, but no standardized method for the quantification of the disease activity is currently available. We introduce an MR parameter for the evaluation of RPF. MATERIALS AND METHODS: 29 patients with untreated idiopathic RPF were examined before medical therapy and after three months of treatment. MR analyses included quotients of T 1 and T 2-signal intensities between the RPF and the psoas muscle. Furthermore, we examined the dynamic contrast enhancement of the fibrous tissue. The respective data were compared with the extent of the RPF after 3 months. RESULTS: In the follow-up examinations we observed a significant regression in 37.9 % (n = 11) of cases, a mild regression in 48.3 % (n = 14) and a stable extent in 13.8 % (n = 4). Patients with a significantly reduced extent showed the highest mean values for the applied MR quotients in the initial examination. The lowest mean values for the respective parameters were found for the group with a stable extent. Only dynamic enhancement quotients showed statistically significant differences (p = 0.011) between the groups of response. CONCLUSION: We observed a significant reduction in the fibrous tissue after pharmacological treatment in patients with an elevated dynamic enhancement quotient in the initial examination.