Ultrasound Guided Compression Versus Ultrasound Guided Thrombin Injection for the Treatment of Post-Catheterization Femoral Pseudoaneurysms: Systematic Review and Meta-Analysis of Comparative Studies.

OBJECTIVE: To compare results of ultrasound based techniques (ultrasound guided compression-(UGC) versus ultrasound guided thrombin injection (UGTI)) to treat iatrogenic post-catheterization femoral pseudoaneurysms. METHODS: The study design involved a systematic review of the literature and meta-analysis of comparative studies. The MEDLINE, CENTRAL, and OpenGray databases were searched up to October 2015. Primary outcome measure was efficacy, while other outcomes examined were safety (complication rate), duration of the procedure, length of hospitalization, and cost of methods. The random effects model was used to calculate combined overall effect sizes of pooled data. Data are presented as the odds ratio (OR) or mean difference (MD) with 95% confidence intervals (CI). RESULTS: Two randomized control trials and 11 observational studies were included in the analysis. Overall, 786 and 318 subjects underwent UGC and UGTI respectively. The latter modality resulted in a significantly higher success rate (97.4% vs. 69.3%, OR 0.06, 95% CI 0.03-0.11) while the complication rate for both techniques was very low (0.69% vs. 0.78%, OR 1.77, 95% CI 0.40-7.88). Data regarding procedural duration and length of hospitalization were very scarce, favoring UGTI (procedural time: MD 35.53 min, 9.11-63.95, length of hospitalization MD 1.99 days, -0.31-4.29). Scarcity of data did not allow proper cost analysis, but two studies suggested that UGTI may offer reduced treatment costs. CONCLUSION: Available evidence suggests that UGTI is superior in terms of efficacy and as safe as UGC and thus should be used as the primary modality for the treatment of post-catheterization femoral pseudoaneurysms.

Peak wall stress does not necessarily predict the location of rupture in abdominal aortic aneurysms.

UNLABELLED: Using finite element analysis, we evaluated if the site of an aortic bleb, known to be prone to rupture, coincides with the location of peak wall stress (PWS) in a patient-specific abdominal aortic aneurysm (AAA) model. REPORT: PWS was not located at the bleb site, even when stress values were estimated for different bleb wall thicknesses (0.5-2.0 mm) while the rest of the AAA wall was considered constant (2 mm). DISCUSSION: The sites of PWS in AAAs should not always be considered as the sites most prone to rupture since other factors, such as wall strength, may play a role in rupture-risk prediction, depicting the need for further investigation of these parameters.

Sustained improvement of vascular endothelial function during anti-TNFalpha treatment in rheumatoid arthritis patients.

OBJECTIVES: Vascular endothelial function and common carotid artery intima-medial thickness (CCA-IMT) are well-established surrogate markers for early atherosclerotic disease, which accounts for 30-40% of excess mortality in rheumatoid arthritis (RA) patients. Our aim was to investigate whether long-term treatment with anti-tumour necrosis factor (TNF)alpha agents can modulate endothelial function and CCA-IMT. METHODS: Twelve patients with RA (mean age 54.8+/-15 years) on anti-TNFalpha treatment (seven adalimumab, five infliximab) due to uncontrolled disease activity, with mean Disease Activity Score (DAS28) 5.7 (range 4.6-6.9) despite disease-modifying anti-rheumatic drugs (DMARDs), were studied prospectively. Patients were assessed at baseline and after 3 and 18 months for endothelial-dependent vasodilatation, assessed by flow-mediated vasodilatation (FMD), endothelial-independent vasodilatation and CCA-IMT. RA disease activity and response to therapy were assessed by the DAS28 index. RESULTS: After 18 months of treatment, 67% of the patients were responders according to European League Against Rheumatism (EULAR) response criteria. Anti-TNFalpha treatment improved FMD (from 7+/-4.3% to 11.1+/-3.8%, p = 0.026) whereas CCA-IMT did not change significantly [from 0.67 (0.4-1) to 0.68 (0.39-1.2) mm; mean change 0.01 (-0.06 to 0.08) mm]. Endothelial-independent vasodilatation remained stable (20.4+/-7.3% to 22.9+/-6.5%, p = 0.4). CONCLUSIONS: In this small cohort of patients with RA and no clinically overt cardiovascular disease (CVD), after 18 months of treatment with anti-TNFalpha agents, endothelial function improved significantly while CCA-IMT remained stable. Longitudinal studies using more patients are needed to determine the clinical significance of these findings in relation to the risk of atherosclerosis.

Data and methods to estimate fetal dose from fluoroscopically guided prophylactic hypogastric artery balloon occlusion.

PURPOSE: To provide data for estimation of fetal radiation dose (DF) from prophylactic hypogastric artery balloon occlusion (HABO) procedures. METHODS: The Monte-Carlo-N-particle (MCNP) transport code and mathematical phantoms representing a pregnant patient at the ninth month of gestation were employed. PA, RAO 20° and LAO 20° fluoroscopy projections of left and right internal iliac arteries were simulated. Projection-specific normalized fetal dose (NFD) data were produced for various beam qualities. The effects of projection angle, x-ray field location relative to the fetus, field size, maternal body size, and fetal size on NFD were investigated. Presented NFD values were compared to corresponding values derived using a physical anthropomorphic phantom simulating pregnancy at the third trimester and thermoluminescence dosimeters. RESULTS: NFD did not considerably vary when projection angle was altered by ±5°, whereas it was found to markedly depend on tube voltage, filtration, x-ray field location and size, and maternal body size. Differences in NFD < 7.5% were observed for naturally expected variations in fetal size. A difference of less than 13.5% was observed between NFD values estimated by MCNP and direct measurements. CONCLUSIONS: Data and methods provided allow for reliable estimation of radiation burden to the fetus from HABO.

Triplet combination with irinotecan plus oxaliplatin plus continuous-infusion fluorouracil and leucovorin as first-line treatment in metastatic colorectal cancer: a multicenter phase II trial.

PURPOSE: To evaluate the efficacy and tolerance of irinotecan (CPT-11) in combination with oxaliplatin (L-OHP) plus fluorouracil (5-FU)/leucovorin (LV) (de Gramont regimen) as first-line treatment of metastatic colorectal cancer (MCC). PATIENTS AND METHODS: Thirty-one patients with MCC who had not received prior therapy for metastatic disease were enrolled. Their median age was 60 years; performance status (World Health Organization) was 0 in 12, 1 in 14, and 2 in five patients; 19 patients (61%) had prior surgery, and 14 (45%) had adjuvant chemotherapy. CPT-11 was administered on day 1 at 150 mg/m(2) as a 90-minute intravenous (IV) infusion; L-OHP was administered on day 2 at 65 mg/m(2) as a 2-hour IV infusion; and on days 2 and 3, LV 200 mg/m(2) preceded 5-FU administration of 400 mg/m(2)/d initial IV bolus dose followed by 600 mg/m(2)/d 22-hour IV continuous infusion. The regimen was repeated every 2 weeks. RESULTS: All patients were assessable for toxicity and 30 for response to treatment. Complete response was achieved in two patients (6.5%) and partial response in 16 (51.6%) (overall response rate, 58.1%; 95% confidence interval, 40.7% to 75.4%); eight patients (25.8%) had stable disease, and five (16.1%) had disease progression. The median duration of response was 9 months, and the median time to disease progression was 13 months. Neutropenia grade 3 to 4 occurred in 14 patients (45%) and febrile neutropenia in two (6%). Diarrhea grade 3 to 4 was observed in 10 patients (32%), neurotoxicity grade 3 to 4 in three (9%), and asthenia grade 3 in two (10%). No treatment-related death has occurred. CONCLUSION: The triplet combination of 5-FU/LV + CPT-11 + L-OHP is a highly active regimen with manageable toxicity as front-line treatment in MCC.

Focal aorto-iliac atherosclerosis amenable to endovascular interventions though considered benign carry a significant risk of cardiovascular mortality: clinical investigation.

AIM: Peripheral arterial disease (PAD) manifested as claudication is surprisingly stable regarding limb deterioration but may indicate increased risk for cardiovascular events and death. We examined whether focal atherosclerotic iliac lesions (TransAtlantic InterSociety Consensus for The Management of Peripheral Arterial Disease-TASC II Type A,B) undergoing endovascular procedures indicate a high risk for limb and life and what is the effect of atherosclerotic risk factors in the rate of adverse outcomes. METHODS: We examined patients undergoing iliac endovascular interventions due to TASC II Type A,B lesions causing disabling claudication during a 10-year period. Outcome in terms of limb condition and total mortality during short and long-term follow-up was evaluated. RESULTS: One-hundred thirty-nine patients and one-hundred seventy limbs were examined. Median follow-up was 4.3 years. There were 100 (58.8%) limbs with Type A and 70 (41.2%) with Type B lesions. Primary patency was 81.2% and secondary patency 92.4%. One-hundred fifteen (67.6%) limbs were improved whereas 42 (24.7%) remained stable and 13 (7.7%) deteriorated during long-term follow-up. Major amputation was performed in 2 and minor amputation in 2 limbs resulting in 2.4% total amputation rate. Overall mortality was 22.6% and 64.5% of all deaths represented cardiovascular events. Statistical analysis revealed significant relations of total mortality with hyperlipidemia and diabetes. CONCLUSION: Endovascular treatment of localized iliac lesions offers good long-term results regarding patency, clinical improvement and limb salvage. Nevertheless, even focal atherosclerosis indicates a significant risk of cardiovascular mortality. Modification of atherosclerotic risk factors early in the course of PAD may be beneficial for these patients.

Endovascular aneurysm repair with the Ovation TriVascular Stent Graft System utilizing a predominantly percutaneous approach under local anaesthesia.

OBJECTIVE: To present our experience with the Ovation Abdominal Stent Graft System (TriVascular Inc., Santa Rosa, CA) during endovascular aneurysm repair (EVAR) and compare results according to the type of anaesthesia. METHODS: We conducted a single-centre retrospective study including patients who underwent EVAR using the Ovation endograft between May 2011 and July 2014. Outcome was evaluated regarding pre-, peri- and immediate postoperative and follow-up measures. Overall results are reported, while additional analysis was performed to compare the outcome between groups of patients undertaking either local or regional/general anaesthesia (LA vs RGA). RESULTS: 66 patients were included. Median follow-up was 13 months (range, 1-39 months). Median age was 72 years and median abdominal aortic aneurysm diameter was 58 mm (range, 54-100 mm). Technical success was 63 (95%), while there were 2 (3%) conversions to open surgery. A total percutaneous approach was used in 50/66 (76%) cases. Overall, 9/66 (14%) subjects suffered from any kind of morbidity. Median hospitalization was 3 days (range, 1-16 days). Immediate and midterm mortality rate was 0%. No endoleak Type I, III, IV or stent migration was observed. There were 8 (13%) Type II endoleaks. Overall, additional endovascular procedures were required in 6 (9%), while surgery was performed in 4 (6%) patients. 44 (67%) patients underwent LA and 22 (23%) RGA. Differences between groups were significant for procedural time (85 vs 107 min; p < 0.001), percutaneous access (91% vs 45%; p < 0.001) and systematic complications (2.3% vs 14%; p = 0.05). CONCLUSION: EVAR with the use of the Ovation endograft shows promising short-term and midterm results regarding safety and effectiveness. Completion of the procedures under LA using a total percutaneous approach seems advantageous and may be used in routine practice. ADVANCES IN KNOWLEDGE: The Ovation Abdominal Stent Graft System is an ultra-low profile stent graft system that allows percutaneous deployment for EVAR and offers excellent overall efficacy and safety. Totally percutaneous EVAR under LA seems advantageous and may be used as a routine with this specific endograft.

Treatment of unresectable malignant abdominal, pelvic and thoracic tumors using abdominal pelvic and thoracic stop-flow chemotherapy.

BACKGROUND: Stop-flow perfusion (SFP) has been recently used to enhance the effects of chemotherapy in patients with locally advanced tumors. PATIENTS AND METHODS: Over a 2-year period we performed abdominal, pelvic and thoracic SFP in 12 patients with unresectable or metastatic tumors, using balloon catheters inserted into the abdominal aorta and inferior vena cava. Blood flow was occluded and hypoxic extracorporeal perfusion or SFP was performed for advanced diseases. The chemotherapeutic agents were directly administered into the aorta and/or inferior vena cava for thoracic SFP. The procedure was repeated in each patient, with one-month interval between sessions. Haemofiltration was also applied in two patients with generalized abdominal disease in order to reduce systemic toxicity. RESULTS: At post-operative CT or MRI follow-up, tumor shrinkage of more than 50% was observed in six patients, while post-SFP chemotherapy surgical resection of the tumors became feasible in four cases. The relief of pain, wherever present, was dramatic in the immediate post-operative period. Overall clinical improvement was achieved in all 12 patients. Post-operative recovery was uneventful in all but two patients, who developed minor systemic toxicity. CONCLUSION: SFP appears to be a safe technique with low morbidity which improves the quality of life of cancer patients and allows satisfactory control of locally advanced tumors and metastatic carcinomatosis.

First-line intra-arterial chemotherapy (IAC) with epirubicin and mitoxantrone in locally advanced breast cancer.

BACKGROUND: Approximately 20% of patients with breast cancer present with locally advanced disease without distant metastases. This phase II double-center trial aimed at investigating the activity of epirubicin (Farmorubicin)--mitoxantrone (Onkotrone/Novantrone) combination as first-line intra-arterial chemotherapy (IAC) in locally advanced breast cancer patients. PATIENTS AND METHODS: Thirty-six patients with locally advanced disease and no prior exposure to anthracyclines received the following regimen: epirubicin (Farmorubicin) 30 mg/mq and mitoxantrone (Onkotrone/Novantrone) 10 mg/mq by IAC short infusion on day 1, every 3 weeks for up to six cycles. Prior to IAC an arteriogram of subclavian, internal mammary and lateral thoracic arteries was obtained in all patients, followed by infusion of a blue dye solution into the arteries to determine the most appropriate vessel that supplies the tumor area. RESULTS: Objective responses, confirmed at least 4 weeks after the first documentation, were observed in 25 patients (70%; 95%CI, 62% to 80%): 3 CR, 22 PR. Although three of the patients showed complete tumor regression, operative removal or toilet mastectomy became feasible in 25 patients since tumor shrinkage ranged over 75%. A total of 25 mastectomies were carried out for 36 patients. Four patients had bulky tumors (> 13 cm tumor diameter), while 8 patients had ulcerated tumors, two of which presented with complete infiltration of normal breast tissue. The median time to progression and median overall survival were 11 and 27 months, respectively. The time to local response was 3 weeks and time to mastectomy was 9 weeks. Transient neurological disorders developed in six patients and skin chemical burns with painful inflammatory reactions were encountered in ten patients. No systemic toxicity was observed in terms of bone marrow depression and hair loss. No cardiotoxicity was observed. In all specimens necrosis was reported (complete 3 cases, partial 16 and minimal 6). CONCLUSION: A combination of epirubicin (Farmorubicin) and mitoxantrone (Onkotrone/Novantrone) as IAC appears to be a safe and well tolerated treatment for locally advanced breast cancer without clinical evidence of distant metastases. When combined with surgery it offers interesting results in terms of local control and allows a high rate of mastectomies in otherwise inoperable cases.

The role of infrapopliteal angioplasty.

Infrapopliteal percutaneous transluminal angioplasty (PTA) is currently indicated in patients with critical limb ischaemia (CLI). It may be performed after femoral angioplasty or bypass surgery, to improve outflow and hence patency of the proximally treated segment. Patients with CLI are typically elderly with multiple co-morbidities and limited life expectancy and therefore, a procedure, which is minimally invasive with reduced morbidity and mortality but lesser long-term patency, may be more appropriate than a more invasive procedure with better long-term patency. Clinical success is superior to angiographic patency, because once healing has occurred, should the artery restenose or occlude, collateral flow can be sufficient to preserve tissue integrity if there is no further injury. Although no prospective randomized trials have been performed, the reported limb-salvage rates of PTA are comparable with surgery. As PTA carries a lower morbidity and mortality, shorter hospital stay and does not preclude surgery, it is ideal for this group of patients who are high-risk surgical candidates. Improvements in guide-wire and catheter technology and recanalization techniques mean that very long stenoses or occlusions, and multiple lesions can be treated successfully. At the current time, PTA is the treatment of choice for infrapopliteal occlusive disease; experience with the use of stents in this territory is increasing but currently insufficient to justify their primary use.

Case report: CT and MRI demonstration of hypothalamic and infundibular relapse in childhood acute lymphoblastic leukaemia.

The central nervous system is affected in up to 10% of patients with acute lymphoblastic leukaemia, usually in the form of leptomeningeal infiltration. Parenchymal spread is rare. We report a case in which CT and MRI demonstrated hypothalamic and infundibular relapse.

Occult aorto-iliac disease in patients with symptomatic coronary artery disease.

BACKGROUND: Atherosclerosis may affect the entire cardiovascular system despite absence of symptoms. Early changes in the wall of the carotid artery have been related to a higher morbidity and mortality from coronary artery disease (CAD). This study was conducted to investigate the relationship between the presence of occult aorto-iliac disease (OAID) and certain risk factors with the severity of CAD. METHODS: Two hundred and eighty-four consecutive patients subjected to coronary angiography (CA) were studied. Additional images of the aorto-iliac arterial segment were taken. Patients with negative CA or symptomatic lower limb arterial disease (LLAD) were excluded from further analysis. In the remaining patients, the risk factors (age, smoking, diabetes mellitus, hypertension, hyperlipidemia and positive family history for atherosclerosis) and the severity of coronary artery disease (CAD) were analyzed in relation to the presence or absence of OAID. RESULTS: Twelve patients with impaired renal function were excluded from the study. Negative CA was found in 12% (32/272) and symptomatic LLAD was present in 14% (37/272). Eligible for further analysis were 203 patients with positive CA and no LLAD. A hundred and ten of them had a positive CA and the presence of OAID whereas the remaining 93 patients had only a positive CA. The patients with OAID had more severe CAD on CA (p=0.003). There was no difference between the two groups concerning age and gender. The most common risk factors in both groups were hypercholesterolemia and a positive family history but with a significantly higher prevalence in the patients with OAID (p=0.008 and p<0.001, respectively). CONCLUSIONS: The presence of OAID in coronary patients was associated with more severe CAD and with a significantly higher prevalence of hypercholesterolemia and positive family history for atherosclerosis. This subset of patients may represent those with more aggressive atherosclerosis.

Patterns of venous reflux in limbs with venous ulcers. Implications for treatment.

AIM: To investigate the anatomic distribution of vein reflux in limbs with healed or active ulcers (CEAP V and VI). METHODS: Sixty limbs (58 patients) belonging to CEAP classes V and VI were identified from 798 limbs (519 patients) with ultrasonically proven chronic venous insufficiency (CVI). Age, gender, duration of the venous ulcer, and history of deep venous thrombosis were correlated to the anatomic distribution of the venous reflux. RESULTS: The prevalence of active or healed ulcers in limbs with CVI was 7.5%. Among 60 limbs with ulcers, primary CVI was present in 34 (56.7%) and post-thrombotic CVI in 26 limbs (43.3%). No difference in age and gender was found between the 2 groups (p=0.2 and p=0.8, respectively). However, the duration of the ulcer was longer in limbs with post-thrombotic CVI (p<0.05). The prevalence of perforator reflux was 41.2% (14/34) in limbs with primary CVI and 38.5% (10/26) in limbs with post-thrombotic CVI (p=0.8). Superficial venous insufficiency, with or without perforating vein reflux, was the commonest pattern in limbs with primary CVI; it was rare in limbs with post-thrombotic CVI (22/34 or 64.7% vs 2/26 or 7.7%, p<0.01). Deep vein insufficiency was present in 35.3% (12/34) of the limbs with primary CVI and in 92.3% (24/26) of the limbs with post-thrombotic CVI (p<0.01). CONCLUSION: Superficial venous insufficiency, with or without perforating vein reflux, was the commonest pattern in limbs with primary CVI, whereas, deep venous insufficiency was present in most of the limbs with post-thrombotic CVI. The prevalence of perforating vein reflux was comparable in both settings. Thus, elimination of superficial reflux is expected to result in ulcer healing of most limbs with primary CVI, whereas, the value of such treatment in post-thrombotic limbs is not clear.

Clinical presentation and anatomic distribution of chronic venous insufficiency of the lower limb in a typical Mediterranean population.

BACKGROUND: The aim of this study was to demonstrate the characteristics of lower limb chronic venous insufficiency (CVI) in a homogeneous Mediterranean population. METHODS: Investigation of 694 patients with uni- or bilateral symptoms and signs of lower limb CVI using colour duplex scanning. Limbs with previous venous surgery were excluded. The limbs were classified according to history and ultrasonic findings into those with post-thrombotic and those with primary CVI. The clinical presentation according to the CEAP classification was correlated to the anatomic distribution of venous reflux. RESULTS: Most of the symptomatic limbs (537/656, 81.5%) with primary CVI belonged to classes 1 to 3. In these limbs reflux confined to superficial veins was very common (64.5%, 424/656) whereas the prevalence of deep and perforator vein reflux was 18.5 and 25.5%, respectively. In contrast most of the limbs (69.5%) with post-thrombotic CVI belonged to classes 4 to 6, had a complex pattern of reflux, and involvement of deep and perforator veins was common (86.5 and 48%, respectively). In about a quarter (24%) of patients with suspected primary CVI no reflux was found in either limb on duplex scanning. Most of them (48%) had telangiectasis. Bilateral reflux was found in 71% of the patients with primary CVI. CONCLUSIONS: The clinical presentation was worse in limbs with post-thrombotic CVI than in those with a primary disease. Post-thrombotic CVI was associated with a complex pattern of reflux, affecting mostly the deep and perforator veins, whereas superficial reflux was the most common pattern in limbs with primary CVI. Therefore, surgery aiming to eliminate superficial reflux would confer only a minimal benefit in limbs with post-thrombotic CVI but would treat the majority of the limbs with the primary CVI. The high prevalence of bilateral reflux found in patients with primary CVI suggests a bilateral predisposition, which supports the hypothesis of the existence of a generalised venous disease.

Systemic thrombolysis with the use of tenecteplase for segmental acute renal in-farction potentially associated with multiple thrombophilic gene polymorphisms.

BACKGROUND/AIM: The potential association of acute renal infarction with multiple thrombophilic gene polymorphisms and the experience of treatment with tenecteplase are described for the first time in the international literature. DESCRIPTION OF THE CASE: The case of a 50-year old male with segmental acute renal infarction potentially associated with multiple thrombophilic gene polymorphisms is presented. He was thrombolysed with a single intravenous bolus of tenecteplase in a weight-adjusted dose (0.53mg/Kg bodyweight). Within 30 minutes after drug administration, the patient's symptoms were completely relieved. Patient's clinical course was uneventful with an acceptable renal function outcome eight weeks post-treatment. The following gene polymorphisms were identified: G455A (b-fibrinogen); C677T; A1298C (methylenetetrahydropholate reductase); T196C (platelet glycoprotein IIIa); 4G/5G (plasminogen activator inhibitor-1). CONCLUSION: Tenecteplase is a safe and simple to use thrombolytic, with favourable pharmacokinetic profile, which might be useful if administered early, especially when local thrombolysis is impossible or unavailable and therefore warrants further investigation in clinical trials. Hippokratia 2014; 18 (1): 67-70.

Carotid artery stenting: Influence of experience and cerebrovascular risk factors on outcome.

AIM: To evaluate technical success, complications and the influence of the learning curve on outcome in carotid artery stenting (CAS) performed in patients not suitable for surgery. PATIENTS AND METHODS: One hundred and nine procedures of protected carotid stenting in 103 high risk patients were performed. All patients presented at least one factor that potentially increased the surgical risk of carotid endoarterectomy (CEA), according to SAPPHIRE criteria. Neurologic complications were quantified by the National Institutes of Health Stroke Scale (NIHSS) and were evaluated by median Rankin Scale (mRS). To evaluate the influence of experience of the operator to perform CAS, we retrospectively analyzed periprocedural and neurological complications of the first 50 procedures compared with that of the following 59 interventions. RESULTS: Technical success rate was 98%. Neurological periprocedural complications were revealed in 4.5% of patients. In-hospital and 30-days neurological complications rate was 7.6 and 2.6% respectively. Periprocedural neurological complications rate was lower in the last procedures performed, according to a higher confidence of the operators. CONCLUSIONS: CAS may be performed as an alternative of CEA for the treatment of severe carotid obstructive disease in patients not suitable for surgery. The learning curve positively influence complications rate.

Quality improvement guidelines for imaging detection and treatment of endoleaks following endovascular aneurysm repair (EVAR).

Major concerns after aortic aneurysm repair are caused by the presence of endoleaks, which are defined as persistent perigraft flow within the aortic aneurysm sac. Diagnosis of endoleaks can be performed with various imaging modalities, and indications for treatment are based on further subclassifications. Early detection and correct classification of endoleaks are crucial for planning patient management. The vast majority of endoleaks can be treated successfully by interventional means. Guidelines for Imaging Detection and Treatment of endoleaks are described in this article.

Accuracy of multislice CT angiography for the assessment of in-stent restenoses in the iliac arteries at reduced dose: a phantom study.

OBJECTIVE: We investigated the potential of low-dose CT angiography for accurate assessment of in-stent restenoses (ISRs) of the iliac artery. METHOD: A Rando anthropomorphic phantom (Alderson Research Labs, Stanford, CA), custom-made wax simulating hyperplastic tissue and a nitinol stent were used to simulate a patient with clinically relevant iliac artery ISRs. The cylindrical lumen was filled with a solution of iodine contrast medium diluted in saline, representing a patient's blood during CT angiography. The phantom was subjected to standard- and low-dose angiographic exposures using a modern multidetector (MD) CT scanner. The percentage of ISR was determined using the profile along a line normal to the lumen axis on reconstructed images of 2 and 5 mm slice thickness. Percentage ISRs derived using the standard- and low-dose protocols were compared. In a preliminary study, seven patients with stents were subjected to standard- and low-dose MDCT angiography during follow-up. The resulting images were assessed and compared by two experienced radiologists. RESULTS: The accuracy in measuring the percentage ISR was found to be better than 12% for all simulated stenoses. The differences between percentage ISRs measured on images obtained at 120 kVp/160 mAs and 80 kVp/80 mAs were below 6%. Patient image sets acquired using low-exposure factors were judged to be of satisfactory diagnostic quality. The assessment of ISR did not differ significantly between image sets acquired using the standard factors and those acquired using the low-exposure factors, although the mean reduction in patient effective dose was 48%. CONCLUSION: A reduction in exposure factors during MDCT angiography of the iliac artery is possible without affecting the accuracy in the determination of ISRs.

External jugular vein aneurysm: a source of thrombotic complications.

Superficial venous aneurysms are rare and usually are uneventful. We present a case in which a 40-year old female presenting with a thrombosed external jugular vein aneurysm which previously caused an undetected pulmonary embolism. The aneurysm was excised and the external jugular vein was ligated under local anesthesia and anticoagulation was initiated. In conclusion aneurysms of the superficial venous system should be considered as a possible source of pulmonary emboli. These sites can safely be excised and ligated under local anesthesia offering long term protection from its possible complications.