[The thoracodorsal artery perforator flap]

This report presents our experience with the thoracodorsal artery perforator flap. Its use and pitfalls are critically highlighted, especially the application of this flap as an island flap. Only few publications on this recently described flap are available, possibly because of the high level of skill needed in its preparation. In our hospital, this flap was twice used as an island flap, both of which failed, and ten times as a free flap one of which was a failure. Harvesting of this flap is a delicate procedure involving transmuscular vessel preparation, additionally transposition as an island flap is limited in range. Based on our limited experience, we can recommend use of this flap only in carefully selected cases. This procedure has to be performed by experienced microsurgeons, after training on cadavers, and after preoperative color Doppler imaging for determining the precise location of the main perforators. Only in cases, where a long vascular pedicle for an appropriate free tissue transfer is necessary, and where aesthetic appearance as well as minimizing donor-site morbidity are more important than a potentially higher failure rate, utilizing this perforator flap is justified.

Color Doppler sonographic finding of retrograde jugular venous flow as a sign of innominate vein occlusion

Occlusion or stenosis of the superior vena cava, the innominate vein, or both is an important clinical problem that requires prompt diagnosis. To confirm a suspected occlusion, imaging studies revealing the obstruction and the presence of collateral venous routes are needed. Color Doppler sonography (CDUS) is widely used to evaluate suspected venous thrombosis and collateral pathways. We present the CDUS findings in 2 cases of innominate vein occlusion. In case 1, CDUS of the neck and left upper arm, which harbored a permanent hemodialysis access, showed engorged veins in the upper arm, a patent dialysis access, and some collateral veins in the axilla. The subclavian and internal jugular veins were patent, but the flow in the left internal jugular vein was reversed. The left innominate vein was occluded. In case 2, CDUS of the upper arms showed that the veins, the dialysis access in the left upper arm, and the subclavian and jugular veins were patent, but the flow in the left internal jugular vein and in the right subclavian vein was reversed. Collateral veins were seen in the right axillary region. Both innominate veins were occluded. The resulting collateral pathways, ie, retrograde flow in the ipsilateral jugular vein crossing to the contralateral jugular vein through dural sinuses, were confirmed by venography in both cases.

Ureteric jet in renal transplantation patient

We have made a case for an active sphincteric mechanism at the VUJ modifying the ureteric jet Doppler waveform. The transplanted ureter does not have a normal VUJ, but retains inherent peristalsis. This study was to document any difference in the transplanted ureteric jet Doppler pattern. A total of 55 transplant patients and 817 healthy subjects were recruited. The Doppler waveform of the transplanted ureter is distinctly different from that of the healthy adult ureter. There are two major patterns: a short monophasic waveform is the most common (66.1% vs. 2.6% in healthy ureters). Less common is a longer, more phasic, pattern, which, however, does not resemble the patterns of the healthy ureter. This supports the hypothesis that the mode of action at the VUJ is sphincteric, because this is lost with transplantation, and ureteric drainage reverts to a simple unmodified pattern.

Color velocity imaging quantification in the detection of intracranial collateral flow

BACKGROUND AND PURPOSE

The development of intracranial collateral circulation is associated with a lower risk of stroke. A noninvasive technique that can reliably detect the presence of intracranial collaterals would be a valuable factor in the assessment of risk in patients with occlusive cerebrovascular disease.

METHODS

Color velocity imaging quantification was used to measure the blood flow volume of the common carotid and vertebral arteries in 40 patients with carotid occlusive disease. The blood flow volumes in these arteries were correlated with angiographic evidence of collaterals to establish the best cutoffs for detecting intracranial collateral circulation.

RESULTS

A blood flow volume of either > or =370 mL/min in the common carotid artery or > or =120 mL/min in the vertebral artery was indicative of the presence of intracranial collaterals. The sensitivity and specificity for the common carotid artery were 92.3% [95% confidence interval (CI), 62.1 to 99.6] and 92.1% (95% CI, 77.5 to 97.9), respectively. The sensitivity and specificity for the vertebral artery were 75.0% (95% CI, 35.6 to 95.5) and 87.5% (95% CI, 66.5 to 96.7), respectively.

CONCLUSIONS

Color velocity imaging quantification offers a noninvasive, accurate method for detecting the presence of intracranial collateral circulation and quantifying its magnitude. This technique would be a useful adjunct in screening or continuous monitoring of patients with severe carotid occlusive disease.

Isolated premature pubarche: ultrasonographic and color Doppler analysis--a longitudinal study

Twenty-seven girls with premature pubarche were studied by ultrasonographic and color Doppler analyses to determine the incidence of polycystic ovaries (PCO), to longitudinally assess their evolution, and to search for any hormonal correlation. The girls were submitted to auxological, clinical, and hormonal evaluation, and 21-hydroxylase deficiency was ruled out by an ACTH test. Furthermore, the girls underwent ultrasonographic and color Doppler ovarian and uterine analyses. Among girls with premature pubarche, the prevalence of PCO was 41%. Advanced skeletal maturation, tall stature, and increased hair distribution were constant in these patients. In patients with ultrasonographic and color Doppler evidence of PCO, the ovarian volume, the number of small-sized subcapsular follicles, the stromal echogenicity, and the ovarian stromal vascularization progressively increased during the study. In the whole studied population, ovarian volume correlated with the number of small-sized follicles (r = 0.719; P < 0.0001). Furthermore, a slight and inverse correlation has been found between ovarian volume and ovarian stromal artery pulsatility index (r = -536; P = 0.048). In conclusion, we affirm that PCO are greatly represented among girls with premature pubarche and progressively evolve.

Abdominal lymphoma: differentiation from pancreatic carcinoma with Doppler US

BACKGROUND

Marked lymphadenopathy around the pancreas due to lymphoma (abdominal lymphoma) occasionally can mimic a total pancreatic carcinoma on ultrasonography (US). We investigated whether US and color Doppler US allowed differentiation between those pathologies.

METHODS

We analyzed the US and color Doppler results of 12 cases of abdominal peripancreatic lymphoma and 21 cases of total pancreatic carcinoma.

RESULTS

With regard to shape, echogenicity of the lesion, and mode of vascular involvement, there was no difference between groups. With regard to maximal velocities and resistive indices of the involved vessels, there was no difference between groups. However, the presence of turbulent flows in the involved vessels was seen exclusively in the pancreatic carcinoma group.

CONCLUSION

The presence or absence of turbulent flow in the involved vessels is a very important finding for differentiating abdominal lymphomas from total pancreatic carcinomas.

Inferior mesenteric arteriovenous fistula eight years after sigmoidectomy

We report a 69-year-old woman with liver cirrhosis due to chronic hepatitis C virus (HCV) infection in whom iatrogenic arteriovenous fistula (AVF) developed after sigmoidectomy. A soft mass with bruit led to the diagnosis of inferior mesenteric AVF. Most mesenteric AVF cases have portal hypertension, but this patients showed none of the usual symptoms of portal hypertension; however, she had a splenomegaly that became worse after sigmoidectomy. Clinicians should be aware of the possibility of AVF in patients with a history of abdominal surgery.

The frequency of deep venous thrombosis and pulmonary embolus in acute exacerbation of chronic obstructive pulmonary disease

Infection, pulmonary embolism caused by mostly deep venous thrombosis (DVT), hypoxaemia and drugs, used in the treatment of chronic obstructive pulmonary disease (COPD), related arrhythmia, aspiration are mostly responsible for acute exacerbations of COPD. The incidences of DVT and pulmonary embolus were investigated in 56 hospitalised cases with acute exacerbation of COPD. DVT was diagnosed in six (10.7%) cases with coloured doppler ultrasonography (CDU) and in two cases whose examinations were not sufficient enough to diagnose or refuse DVT. Diagnosis of pulmonary embolus was investigated with ventilation/perfusion scintigraphy in eight cases of clinically medium--high-probable pulmonary embolus. Pulmonary embolus was determined in five cases (8.9%). Age, weight, height, disease course, pulmonary function tests, arterial blood gases and haematocrit values of the cases did not predict the diagnosis of DVT and pulmonary embolus in our cases.

Prenatal diagnosis of ventriculocoronary arterial fistula in a fetus with hypoplastic left heart syndrome and aortic atresia

In a fetus with a hypoplastic left heart syndrome detected at 26 weeks' gestation, a communication between the left ventricular cavity and the left coronary artery was detected using color Doppler. Bidirectional flow was demonstrated and the ventricle was shown to be filled via the fistula during diastole. After premature birth at 31 weeks and neonatal death, autopsy confirmed the findings. Because the association of a heart defect with ventriculocoronary communications worsens the neonatal prognosis, it should be ruled out in fetuses with hypoplastic left heart syndrome before parents are counseled.

Carotid plaque ultrasonic heterogeneity and severity of stenosis

BACKGROUND AND PURPOSE

Several studies have reported on the correlation of ultrasonic carotid plaque morphology, cerebrovascular symptoms, and intraplaque hemorrhage. This study correlates ultrasonic carotid plaque morphology with the degree of carotid stenosis.

METHODS

Carotid arteries (n=2460) were examined by using color duplex ultrasound during a 1-year period. Carotid stenoses were classified into <50%, 50% to <60%, 60% to <70%, and >70% to 99%. Ultrasonic plaque morphology was characterized as either heterogeneous (mixed hyperechoic, hypoechoic, and isoechoic) or homogeneous.

RESULTS

Heterogeneous plaques were noted in 138 of 794 arteries with <50% stenosis, in 191 of 564 arteries with 50% to <60% stenosis, in 301 of 487 arteries with 60% to <70% stenosis, and in 496 of 615 arteries with 70% to 99% stenosis. The higher the degree of stenosis, the more likely it is to be associated with heterogeneous plaques. Heterogeneous plaques were present in 59% of the arteries with > or =50% stenoses versus 17% of the arteries with <50% stenoses, in 72% of the arteries with > or =60% stenoses versus 24% of the arteries with <60% stenosis, and in 80% of the arteries with > or =70% stenoses versus 34% of the arteries with <70% stenoses (P<0.0001 and odds ratios of 6.9, 8.1, and 8.0, respectively). Heterogeneous plaques were associated with an incidence of symptoms that was higher than that for homogeneous plaques for all grades of stenoses; percentages were, respectively, as follows: 68% versus 16% for <50% stenosis; 76% versus 21% for 50% to <60% stenosis; 79% versus 23% for 60% to <70% stenosis, and 86% versus 31% for > or =70% to 99% stenosis (P<0.0001 and odds ratios of 8.9, 11.9, 12.6, and 13.7, respectively). Heterogeneity of plaques was more positively correlated with symptoms than with any degree of stenosis (regardless of plaque structure). Eighty percent of all heterogeneous plaques were symptomatic versus 58% for all stenoses > or =50%, 68% for all stenoses > or =60%, and 75% for all stenoses > or =70% (P<0.0001, P<0.0001, and P=0.02, respectively).

CONCLUSIONS

The higher the degree of carotid stenosis, the more likely it is to be associated with ultrasonic heterogeneous plaque and cerebrovascular symptoms. Heterogeneity of the plaque was more positively correlated with symptoms than with any degree of stenosis. These findings suggest that plaque heterogeneity should be considered in selecting patients for carotid endarterectomy.

Doppler waveform of the ureteric jet in pregnancy

We have shown that the function of the bladder vesicoureteric junction (VUJ) can be studied by the Doppler waveform of the ureteric jet, and this reflects the active sphincteric mechanism of the VUJ. We wished to investigate if the hormonal changes of pregnancy cause any alteration of VUJ function. A total of 107 pregnant women and 375 nonpregnant women were recruited. Three scans, 20 and 32 weeks of gestational age and 3 months postpartum, were done. The occurrence of a monophasic waveform in the nonpregnant group was 1.9%. In the pregnancy group, this was 18.7%, 41.1% and 1.6% at 20, 32 weeks of gestational age and 3 months postpartum, respectively. The difference in occurrence of the monophasic waveforms was statistically significant (both p = 0.0005 at 20 and 32 weeks). This suggests an adverse hormonal effect on the vesicoureteric junction during pregnancy, and may be a factor in the increased risk of UTI in pregnancy.

Sonography of soft tissue masses of the neck

In many clinical conditions, high-resolution sonography and color (power) Doppler sonography can be used as the first-line modality for evaluating cervical soft tissue masses. Cervical cysts, lipomas, paragangliomas, neurogenic tumors, hemangiomas, and lymphangiomas often exhibit characteristic sonographic appearances. Sonography can be used for lymph node assessment, and most salivary gland diseases can be diagnosed sonographically. Sonography can be used to guide needle biopsy of soft tissue neoplasms and lymph nodes. In addition, the relationship between a cervical mass and the great vessels can be evaluated.

Thyroid vascularity is increased in patients with active acromegaly

OBJECTIVE

To determine whether acromegalic patients have increased thyroidal vascularity and blood flow on colour flow Doppler sonography (CFDS).

DESIGN

Prospective study of consecutive patients.

PATIENTS

Twenty-four acromegalic patients (11 men, 13 women, age 49 +/- 9 years); 38 patients with nontoxic goitre (NTG; 12 men, 26 women, age 50 +/- 7 years); 36 normal subjects (controls; 16 men, 20 women, age 46 +/- 9 years). Among acromegalic patients, 10 had active, untreated disease (Acro-U), seven were in remission after surgery (Acro-R), seven had active disease under treatment with somatostatin analogues (SMSa) (Acro-SA) (Sandostatin LAR, 20 mg, every 28 days).

MEASUREMENTS

CFDS pattern and intrathyroidal peak systolic velocity (PSV) were determined by a colour Doppler system with a 7.5-MHz linear transducer. PSV measurements were made at the level of the intrathyroidal arteries (normal values 3.8 +/- 1.0 cm/s). Thyroid volume was calculated by the ellipsoidal model. Assays included measurements of serum GH, IGF-I, free T4, free T3, TSH, antithyroglobulin (anti-Tg) and antithyroperoxidase (anti-TPO) antibodies, TSH-receptor antibodies (TRAb).

RESULTS

Serum GH (+/- SD) and IGF-I (+/- SD) levels were: Acro-U: GH 26 +/- 31 microg/l, IGF-I 783 +/- 299 microg/l; Acro-SA: GH 15 +/- 25 microg/l, IGF-I 366 +/- 212 microg/l; Acro-R: GH 1.3 +/- 1.0 microg/l, IGF-I 241 +/- 99 microg/l. To convert values for serum GH to mU/l multiply by 2.6; to convert values for serum IGF-I to nmol/l multiply by 0.13075. All controls had CFDS pattern 0 (absent vascularity or minimal spots); among NTG patients, 36 had pattern 0 and two had pattern I (parenchymal blood flow with patchy uneven distribution). Five patients with acromegaly had pattern 0, 12 had pattern I and seven pattern II (mild increase of colour flow Doppler signal with patchy distribution). Among the five acromegalic patients with pattern 0, three were Acro-R and two were Acro-SA. Among patients with pattern I, six were Acro-U, two were Acro-SA and four were Acro-R. Among patients with pattern II, four were Acro-U and three Acro-SA; two patients of the latter group had elevated serum IGF-I under SMSa treatment. Intrathyroidal PSV was 3.8 +/- 1.0 cm/s in controls, 4.0 +/- 1.1 cm/s in NTG, 7.4 +/- 0.8 cm/s in Acro-U, 4.9 +/- 1.3 cm/s in Acro-SA treatment and 4.5 +/- 1.0 in Acro-R. (Acro-U vs. Acro-SA, P = 0.0003; vs. Acro-R, Controls, or NTG, P < 0.0001). PSV values in Acro-SA were higher than those observed in NTG or controls (P = 0.05, P = 0.01, respectively); PSV values in Acro-R did not differ from those in NTG or controls. Intrathyroidal PSV values were correlated with serum IGF-I (r = 0.73, P < 0.0001) and, although less strongly, GH levels (r = 0.54, P = 0.01). Goitre was present in 19 of 24 patients; diffuse in three and nodular in 16. Thyroid function was normal in all subgroups of acromegalic patients. Anti-Tg, anti-TPO antibodies and TRAb were negative in all subjects.

CONCLUSIONS

Patients with active acromegaly have increased intrathyroidal blood flow (colour flow Doppler sonography pattern II, increased peak systolic velocity values); this was not observed in the large majority of patients under treatment with somatostatin analogues and in any patient in remission. Accordingly, colour flow Doppler sonography and peak systolic velocity measurements may be considered an additional useful peripheral parameter for rapid assessment of the activity of acromegaly.

The role of radiological imaging in the diagnosis of acute appendicitis

Several strategies have been employed to improve the accuracy of the diagnosis of appendicitis and to reduce the associated perforation rate. Because clinical algorithms have been disappointing, many physicians resort to radiological modalities. Plain abdominal x-rays are nonspecific, barium enema examination has relatively low accuracy, scintigraphy scans require considerable time and are difficult to interpret, and magnetic resonance imaging is relatively unstudied. The most promising modalities are graded compression sonography and computed tomography. In expert hands, these techniques can achieve a high degree of accuracy. Nevertheless, most published studies have been marred by methodological difficulties. Moreover, ultrasound is more useful in detecting than in ruling out appendicitis. The radiological criteria for acute appendicitis, the accuracy of various imaging modalities and the limitations of the available research are described.

Prospective study of color duplex ultrasonography compared with contrast venography in patients suspected of having deep venous thrombosis of the upper extremities

BACKGROUND

The optimal strategy for diagnosis of deep venous thrombosis (DVT) is less well established for the upper extremities than for the lower extremities. Duplex color ultrasonography can be difficult to perform in the upper extremities because of their anatomy, and contrast venography is often indicated. Moreover, limited data exist on the use of duplex color ultrasonography in this setting.

OBJECTIVE

To determine the accuracy of duplex ultrasonography for diagnosis of DVT of the upper extremities.

DESIGN

Prospective study of duplex ultrasonography compared with venography.

SETTING

A teaching hospital in Amsterdam, the Netherlands.

PATIENTS

126 consecutive inpatients and outpatients with suspected DVT of the upper extremities.

MEASUREMENTS

Contrast venography was obtained after duplex ultrasonography and was judged independently. A three-step protocol, involving compression ultrasonography, color ultrasonography, and color Doppler ultrasonography, was used. Sensitivity, specificity, and likelihood ratios for ultrasonography as a whole were calculated. The independent value of each step was assessed.

RESULTS

Venography and ultrasonography were not feasible in 23 of 126 patients (18%) and 1 of 126 patients (0.8%), respectively. Results of ultrasonography were inconclusive in 3 patients. Venography demonstrated thrombosis in 44 of 99 patients (44%); in 36 patients (36%), thrombosis was related to intravenous catheters or malignant disease. Sensitivity and specificity of duplex ultrasonography were 82% (95% CI, 70% to 93%) and 82% (CI, 72% to 92%), respectively. Venous incompressibility correlated well with thrombosis, whereas only 50% of isolated flow abnormalities proved to be thrombosis-related.

CONCLUSIONS

Duplex ultrasonography may be the method of choice for initial diagnosis of patients with suspected thrombosis of the upper extremities. However, in patients with isolated flow abnormalities, contrast venography should be performed.

Transvaginal color Doppler sonographic evaluation of the uterus in postmenopausal women on daily raloxifene therapy

OBJECTIVE

To evaluate the effect of raloxifene on the endometrium and the uterus by transvaginal color Doppler sonography.

METHODS

The study group was composed of 34 asymptomatic postmenopausal women. All had been treated with raloxifene 60 mg/day for 6 months. The patients underwent transvaginal color Doppler sonography before starting raloxifene and after treatment. The uterus was scanned by transvaginal ultrasound to evaluate the pulsatility (PI) and resistance (RI) indices of both uterine arteries. The mean values for the uterine arteries were analyzed.

RESULTS

The mean age of the women was 57.56 +/- 4.44 years (range 48-64 years), and mean number of years since the menopause was 8.67 +/- 5.44 (range 1-25 years). The mean endometrial thickness (3.62 +/- 1.13 vs. 3.59 +/- 0.95 mm) and uterine volume (40.67 +/- 18.36 vs. 38.05 +/- 19.47 ml) were not significantly different before starting treatment and after treatment (p > 0.05). The mean values of the PI (3.49 +/- 1.56 vs. 3.90 +/- 1.38) and RI (0.94 +/- 0.11 vs. 0.98 +/- 0.10) of the uterine arteries were not significantly different before starting treatment and after treatment (p > 0.05).

CONCLUSION

Daily therapy with raloxifene did not stimulate the endometrium, the uterus or uterine blood flow.

The limited practical value of color Doppler sonography in the differential diagnosis of men with erectile dysfunction

From the files of the outpatient urology department 44 men with ED had undergone both psychophysiological diagnostic screening (PDS, VSS, VSS+VIB, ICI+VSS+VIB) and color Doppler sonography testing (CDS, including VSS). PDS was carried out by one medical physiologist, CDS by one urologist. The diagnoses reached could be compared. This study revealed that CDS in ED-patients often resulted in an incorrect diagnosis, that is a presumed vascular abnormality while many such patients demonstrated firm erections under PDS-laboratory test conditions. Thus, it was concluded that CDS as a (first) screening test in ED-patients is of limited value. It was further emphasized that PDS, although giving quite relevant information about possible etiology and therapeutic treatment, is not a necessary first screen. Good history taking, preferably of the man and his partner, is still the basic first screen and quite often offers enough information to make a treatment plan with reasonable likelihood of success.

Usefulness of color Doppler sonography for assessing hemodynamics of free flaps for head and neck reconstruction

This report focuses on the monitoring of intraoperative and postoperative hemodynamics of free flaps for repair of head and neck defects by color Doppler sonography (CDS). The study group included 20 patients with head and neck cancer who underwent resection and reconstruction with free flaps. The hemodynamics in the feeding arteries of the flaps were measured during the following six stages: before surgery, immediately after microvascular anastomosis, and on postoperative days 1, 3, 5, and 7. The pulsatility index (PI) was used as the index for measuring changes in hemodynamics over time. Grafts showed the maximal PI immediately after vascular anastomosis. PI decreased over 3 to 7 days. Of the 20 patients, 1 patient in whom the hypopharynx was reconstructed with the radial forearm flap developed venous occlusion. This was diagnosed during the early stage using CDS, allowing the flap to be saved. CDS proved to be very useful for real-time observation of the hemodynamics in free flaps.