Aortic Bulge: A Possible Predictive Sign of Impending Aortoenteric Fistula.

PURPOSE: The purpose of this study is to introduce the aortic bulge sign, a finding observed retrospectively on computed tomography prior to the acute presentation of aortoenteric fistula, and to determine its interobserver reliability. METHODS: Following research ethics board approval, all cases of aortoenteric fistula at our institution occurring from 2011-2015 were identified retrospectively. All previous computed tomography images of patients who eventually developed aortoenteric fistula were reviewed by a single observer for the presence of a potentially predictive finding of fistulization, the aortic bulge sign. These previous images were then combined with age and sex matched controls into a case bank. Eight radiology residents and staff were instructed in observing the aortic bulge sign. These observers then reviewed the case bank in a blinded analysis to determine the interobserver reliability of this finding. RESULTS: Fourteen cases of aortoenteric were identified. The average patient age was 70.71 years with a male-to-female ratio of 11:3. Eleven patients had previous computed tomography images available for review. With blinded analysis by multiple observers, the aortic bulge sign was identified with greater than 80% agreement in six of 11 cases (66.67%). Fleiss' kappa was calculated at k = 0.60 (95% confidence interval 0.50-0.69), corresponding to moderate-to-substantial interobserver agreement. CONCLUSIONS: The aortic bulge sign has been retrospectively identified as a promising computed tomography finding of eventual aortoenteric fistula prior to acute presentation. Further study is required to determine the diagnostic value of this sign.

Subintimal recanalization of peripheral chronic occlusive arterial disease with modified transseptal needle.

PURPOSE: To report an alternative technique of subintimal recanalization of chronically occluded lower-extremity arteries using a modified transseptal needle (MTSN) to reenter the true lumen. MATERIALS AND METHODS: From December 2008 to December 2010, 98 patients with chronic arterial occlusions were treated with endovascular techniques. True lumen reentry with conventional subintimal techniques failed in 23 of these patients (24%). Retrospective review of medical records and procedure data was performed, and clinical presentation, lesion location, Trans-Atlantic Inter-Society Consensus II classification, amount of calcification, procedure time, recanalization time with conventional subintimal technique, recanalization time with the MTSN, and complications were recorded. During the 24-month period, 11 common iliac arteries (CIAs), three external iliac arteries (EIAs), one combined CIA/EIA, six superficial femoral arteries (SFAs), and two combined SFA/popliteal arteries were treated with MTSNs. RESULTS: Successful recanalization with the MTSN was obtained in 21 patients (91%). There was one complication of pseudoaneurysm formation in the EIA. The average occlusion length of the CIA was 6.7 cm; that of the SFA was 15.9 cm. The average procedure time was 73 minutes, with 20 minutes used to attempt to reenter the true lumen and 6.3 minutes used to reenter the true lumen with the MTSN. CONCLUSIONS: The MTSN technique is safe and effective and offers another approach to reenter the true lumen of chronic total arterial occlusions during subintimal recanalization in difficult cases.

Hemorrhage From Left Hepatic Artery Pseudoaneurysm as a Complication of Acute Pancreatitis in a Patient With Fibromuscular Dysplasia.

Hepatic artery pseudoaneurysms are a rare complication of pancreatitis, and their rupture and bleeding cause high mortality. We present the case of a 76-year-old woman with fibromuscular dysplasia who developed a new left hepatic artery pseudoaneurysm within a week of her first episode of acute pancreatitis and later suffered an acute pseudoaneurysm bleed successfully treated with transcatheter coil embolization. To the best of our knowledge, this is the first case reported of a patient with fibromuscular dysplasia with pancreatitis-related pseudoaneurysm formation. One must consider pseudoaneurysms and associated bleeding as complications of acute pancreatitis because prompt recognition can lead to timely management.

Aortosternal Venous Compression: A Review of Two Cases.

Aortosternal venous compression (AVC) is a rare venous compression syndrome that involves brachiocephalic venous compression due to its positioning between the sternum and the aorta. One of the features of AVC involves compression of the left innominate vein with variability in luminal caliber on inspiration and expiration. Imaging modalities such as computed tomography (CT) examination can aid in initial diagnosis; however, venography can be utilized for confirmatory diagnosis due to its higher specificity during the inspiratory and expiratory phases. Through findings demonstrated during venography, we herein present two cases of confirmed AVC secondary to an aberrant right subclavian artery. Characteristic imaging features in the diagnosis of AVC and its etiology are discussed.

Laparoscopy, dorsal lumbotomy and flank incision live donor nephrectomy: comparison of donor outcomes.

BACKGROUND: Flank incision (FL), dorsal lumbotomy (DL) and laparoscopic surgery have been effective approaches to donor nephrectomy. While laparoscopic donor nephrectomy (LDN) has become increasingly popular, there has yet to be a direct comparison of the three modalities. METHODS: We performed a retrospective chart review of FL, DL and LDN operations between 2002 and 2010 within a single institution. Donor and recipient characteristics, as well as surgical outcomes, were assessed. RESULTS: There were 496 donor nephrectomy operations available for analyses. Patients in the LDN group had the lowest estimated blood loss, compared to the DL and FL groups (p < 0.001), lowest rate of complications (p < 0.01), and shortest hospital stay (p < 0.0001). Donors who underwent DL used an average of 60.12 ± 5.0 mg of morphine, which was significantly less than that used by patients in the LDN (93.2 mg, p < 0.0001) and FL (111.82 mg, p < 0.001) groups. Mean serum creatinine of recipients at day 1 post-op was the highest in the FL group (p < 0.0001 FL vs. LDN, p < 0.001 FL vs. DL), but there were no significant differences between the three groups at 2 weeks, 6, 12, 18, and 24 months post-operation (p > 0.45). CONCLUSIONS: Although a lower pain experience of LDN was not indicated, the use of LDN should be favoured over DL and FL as it is associated with fewer complications, and shorter length of stay. Of note, DL appears to be associated with higher complications and is likely not a preferred option for donor nephrectomy.

CONTEXTE: L'incision du flanc, la lombotomie dorsale et la laparoscopie sont des techniques efficaces pour une néphrectomie chez un donneur vivant. Même si la laparoscopie a connu une montée en popularité, aucune comparaison directe entre les trois modalités n'a été effectuée. MÉTHODOLOGIE: Nous avons procédé à un examen rétrospectif des dossiers de patients ayant subi une néphrectomie par incision du flanc, par lombotomie dorsale et par laparoscopie entre 2002 et 2010 dans un même établissement. Les caractéristiques des donneurs et des receveurs ainsi que les résultats de la chirurgie ont été évalués. RÉSULTATS: Les analyses ont porté sur 496 néphrectomies. En comparaison avec les donneurs ayant subi une incision du flanc ou une lombotomie dorsale, les donneurs ayant subi une laparoscopie présentaient la perte sanguine estimée la plus faible (p < 0,001), le taux le plus bas de complications (p < 0,01) et la plus courte durée du séjour en hôpital (p < 0,0001). Les donneurs qui ont subi une lombotomie dorsale ont utilisé en moyenne 60,12 ± 5,0 mg de morphine, soit une valeur significativement plus faible que celle notée chez les patients ayant subi une laparoscopie (93,2 mg, p < 0,0001) et une incision du flanc (111,82 mg, p < 0,001). Le taux moyen de créatinine sérique le lendemain de l'intervention était le plus élevé chez les patients ayant subi une incision du flanc p ( < 0,0001 incision du flanc vs laparoscopie, p < 0,001 incision du flanc vs lombotomie dorsale), mais les différences entre les trois groupes n'étaient pas significatives 2 semaines, 6, 12, 18 et 24 mois après l'opération (p > 0,45). CONCLUSIONS: Même si aucune réduction de la douleur n'a été observée avec la laparoscopie, il faut tout de même favoriser le recours à cette technique plutôt qu'à une lombotomie dorsale ou une incision du flanc, car elle est associée à moins de complications et à un séjour plus court en hôpital. Il est à noter que la lombotomie dorsale semble associée à un taux plus élevé de complications et n'est probablement pas une option à privilégier pour une néphrectomie chez un donneur.

Decrease in donor heart injury by recombinant clusterin protein in cold preservation with University of Wisconsin solution.

BACKGROUND: Donor organ injury during cold preservation before transplantation negatively impacts graft survival. Clusterin (CLU) is a chaperonic protein, and its expression confers donor hearts resistance to cold ischemic injury. This study was conducted to evaluate if the supplement of recombinant CLU protein (rCLU) protects donor organs from injury during cold storage with University of Wisconsin (UW) solution. METHODS: Human endothelial cell cultures were used as an in vitro model. Heart transplantation in mice was used as an in vivo model. Cell membrane disruption or death was indicated by the release of lactate dehydrogenase (LDH). Donor injury was determined by its functional recovery, and histologic and biochemical analyses. RESULTS: Supplement of rCLU to UW solution protected cultured human endothelial cells from cold-induced cell necrosis, as evidenced by a decrease in both release of LDH and the number of ethidium bromide-stained necrotic cells. The protective activity of rCLU was associated with enhanced membrane fluidity at cold temperature. During cold storage of heart organs in UW solution, supplemental rCLU significantly decreased LDH release from heart tissue. In a preclinical model of transplantation, heart grafts after cold preservation with rCLU-containing UW solution had better functional recovery and decreased perivascular inflammation, neutrophil infiltration, and cardiac cell death, including apoptosis and necrosis, that correlated with lower levels of serum creatine kinase and LDH in recipients. CONCLUSION: Our data suggest that supplement of CLU protein in a cold preservation solution may have potential in improving cold preservation of donor organs in transplantation.

Cricoid pressure displaces the esophagus: an observational study using magnetic resonance imaging.

BACKGROUND: Cricoid pressure (CP) is often used during general anesthesia induction to prevent passive regurgitation of gastric contents. The authors used magnetic resonance imaging to determine the anatomic relationship between the esophagus and the cricoid cartilage ("cricoid") with and without CP. METHODS: Magnetic resonance images of the necks of 22 healthy volunteers were reviewed with and without CP. Esophageal and airway dimensions, distance between the midline of the vertebral body and the midline of the esophagus, and distance between the lateral border of the cricoid or vertebral body and the lateral border of the esophagus were measured. RESULTS: The esophagus was displaced laterally relative to the cricoid in 52.6% of necks without CP and 90.5% with CP. CP shifted the esophagus relative to its initial position to the left in 68.4% of subjects and to the right in 21.1% of subjects. Unopposed esophagus was seen in 47.4% of necks without CP and 71.4% with CP. Lateral laryngeal displacement and airway compression were demonstrated in 66.7% and 81.0% of necks, respectively, as a result of CP. CONCLUSION: In the absence of CP, the esophagus was lateral to the cricoid in more than 50% of the sample. CP further displaced both the esophagus and the larynx laterally.