Nonsurgical fluoroscopically guided dacryocystoplasty of common canalicular obstructions

PURPOSE

To assess dacryocystoplasty in the treatment of epiphora due to obstructions of the common canaliculus.

METHODS

Twenty patients with severe epiphora due to partial (n = 16) or complete (n = 4) obstruction of the common canaliculus underwent fluoroscopically guided dacryocystoplasty. In all cases of incomplete obstruction balloon dilation was performed. Stent implantation was attempted in cases with complete obstruction. Dacryocystography and clinical follow-up was performed at intervals of 1 week, and 3, 6, 12, and 18 months after the procedure. The mean follow-up was 6 months (range 3-18 months).

RESULTS

Balloon dilation was technically successfully performed in all patients with incomplete obstructions (n = 16). In three of four patients with complete obstruction stent implantation was performed successfully. Subsequent to failure of stent implantation in one of these patients balloon dilation was performed instead. The long-term primary patency rate in patients with incomplete obstructions was 88% (n = 14/16). In three of four cases with complete obstruction long-term patency was achieved during follow-up. Severe complications, infections, or punctal splitting were not observed.

CONCLUSION

Fluoroscopically guided balloon dacryocystoplasty is a feasible nonsurgical therapy in canalicular obstructions with good clinical results that may be used as an alternative to surgical procedures. In patients with complete obstructions stent placement is possible but further investigations are needed to assess the procedural and long-term results.

[Transjugular liver biopsy with a modified Tru-Cut system: a retrospective study of its successes and complications]

PURPOSE

Evaluation of success and complications in transjugular liver biopsy with a semiautomatic device.

METHODS

A retrospective analysis of 27 transjugular liver biopsies with a modified Tru-Cut system was performed on 25 patients between 3/95 and 12/97.

RESULTS

In 26 of 27 biopsies (96.4%) histopathologically useful liver parenchyma could be obtained. In only one case unspecific connective tissue was found. There were no clinically evident complications, only one parenchymal hematoma was observed by ultrasound (1/27 = 3.6%).

CONCLUSION

The tested device was highly successful in obtaining liver biopsies on patients suffering from coagulopathies with a low complication rate and a simple use.

I-131-Lipiodol therapy in liver neoplasms

Twelve patients with liver neoplasms [10 HCC, 1 CCC, 1 multiple breast cancer metastases (BCM)] were treated by transarterial I-131-Lipiodol. Computed tomography (CT) and single photon emission CT (SPECT) showed pronounced I-131-Lipiodol accumulation in the tumor tissue in all cases. In three patients with HCC a reduction of tumor size was achieved after the first treatment. The remaining patients had big tumor masses; 5 of these (4 HCC, 1 CCC) had stable disease after the first treatment, and 2 HCC were progressive. One patient died immediately after therapy due to other reasons. The BCM proved significant reduction in number and size. Eighteen-FDG-PET (positron emission tomography with fluor-18-deoxy-glucose) and CT controls showed in part different results with pretherapeutic PET proving high interindividual variability in tumor activity. Side effects were tolerable. In summary, the therapy procedure with transarterial I-131-Lipiodol is safe and effective in tumors with moderate tumor mass.

[Variants of the hepatic artery: detection with color--coded sonography pre and post levovist injection]

PURPOSE

Detection of hepatic artery variants is of great clinical importance, for instance, pre liver transplantation, pre intraarterial chemotherapy or for measurement of the Doppler perfusion index. We therefore investigated how accurate variants of the hepatic artery can be detected using color-coded sonography pre and post Levovist injection.

MATERIALS AND METHODS

52 patients (21-78 years) were examined using color-coded sonography pre and post Levovist injection. After the sonographic examination, intraarterial digital subtraction angiography was performed and the results were compared.

RESULTS

Using angiography 14 variants of the hepatic artery were detected in 13 patients. The most common variant in 10 patients were hepatic arteries originating from the superior mesenteric artery. This could be detected with unenhanced color-coded sonography in 8 and with enhanced sonography in 9 patients. In one patient in addition, a hepatogastric trunk was noted by angiography, this was not recognized by sonography. In 2 patients with a hepatogastric trunk, this variant was sonographically seen after Levovist injection in both but with unenhanced sonography in only 1 patient.

CONCLUSION

Most variants of the arterial hepatic blood supply can be diagnosed using conventional color-coded sonography. In some cases enhanced sonography provides additional information, but even with these techniques all variations cannot be detected.

[Visualization of renal arteries and value of color-coded duplex sonography in renal artery stenoses using an ultrasound signal enhancing agent]

PURPOSE

To assess whether the use of an echo-enhancing agent reliably allows the diagnosis of renal artery stenosis with colour-coded Doppler sonography.

MATERIALS AND METHODS

We examined the main, segmental, and, if present, the accessory renal arteries of 31 patients before and after intravenous injection of Levovist using colour-coded Doppler sonography and compared the results with digital subtraction angiography. A rise in peak systolic velocity in the main renal artery and a reduction of the acceleration index in segmental arteries were used as parameters to detect renal artery stenosis.

RESULTS

After i.v. administration of Levovist the main stem of the renal arteries could be well delineated in 36 of 62 cases (58%) during colour-coded Doppler sonography against 31 cases without Levovist. Taking only the visible cases in account the sensitivity of native as well as of enhanced colour-coded Doppler sonography of the renal main stem was 100%, the specificity was 96% and 94%, respectively. Only one of 11 accessory renal arteries was identified after echo enhancement. The segmental arteries were seen only after echo enhancement in 12 cases so that 60 of the total of 62 renal arteries (95%) could be evaluated. The sensitivity and specificity of the native examination were 67% and 70%. After echo enhancement sensitivity was 75% and specificity was 81%.

CONCLUSION

Using an echo-enhancing agent the sensitivity and specificity for detection of relevant renal artery stenosis could only be slightly improved compared to the native examination.

[Diagnosis and therapy of Budd-Chiari syndrome]

PURPOSE

Budd-Chiari syndrome is a fairly uncommon disease in Europe. This often leads to its late diagnosis. The syndrome is characterised by portal hypertension and splanchnic congestion due to obstruction of hepatic venous outflow. This paper describes the treatment of three patients with Budd-Chiari syndrome by interventional therapeutic techniques and discusses alternative treatment modalities.

PATIENTS AND METHODS

The first patient presented with veno-occlusive disease and was treated by the placement of a transjugular intrahepatic portosystemic stent-shunt. The second patient showed an occlusion of the major hepatic veins. After percutaneous recanalisation, a stent was placed in the right hepatic vein which remained patient. The third patient had a membranous obstruction of the right hepatic vein which was treated by percutaneous balloon dilatation.

RESULTS

In all patients the clinical symptoms resolved completely after treatment and no complications were encountered.

CONCLUSIONS

The authors conclude that interventional therapeutic techniques offer a wide variety of possibilities for the treatment of patients with Budd-Chiari syndrome and are safe, effective and relatively inexpensive. However, further studies are required to assess the long-term results and survival rates of these patients.

[Native and signal-enhanced power Doppler sonography for characterization of liver lesions]

PURPOSE

To evaluate the characterisation of liver lesions using power Doppler sonography before and after intravenous injection of the ultrasound contrast agent Levovist.

MATERIALS AND METHODS

39 patients with 41 liver lesions (10 haemangiomas, 2 focal nodular hyperplasias (FNH), 2 focal fatty infiltrations, 1 echinococcal lesion, 11 hepatocellular carcinomas, 14 metastases and one cholangiocarcinoma) were evaluated prospectively. Power Doppler images before and after intravenous injection of the ultrasound contrast agent Levovist were analysed by two radiologists and one gastroeterologist, who subjectively classified the distribution (peripheral, central, diffuse) and amount (none, minimal, moderate and strong) of flow pattern in each sonographic examination. Histological verification was obtained in all liver lesions, except in haemangiomas, where MR imaging and in one FNH where scintigraphy was regarded as sufficient proof.

RESULTS

On the whole, power Doppler sonography after contrast injection was superior to unenhanced power Doppler-sonography in 20 liver lesions and equal in 7. After contrast injection, previously visible flow was enhanced in 14 patients, in 6 lesions flow was detected, which was not seen before in the power mode. Moderate or strong flow signals were detected before contrast injection in 8/26, post contrast injection in 18/26 malignant tumours. Contrawise, 13/15 benign lesions did show any or only minimal flow signals before and 10/15 after contrast injection.

CONCLUSION

Intratumoural flow signals favour a malignant tumour. The absence of flow signals is a frequent finding in benign lesions but does not rule out malignancy.

[TIPSS: technical and clinical results after 4 years]

PURPOSE

Retrospective analysis of the technical and clinical results after transjugular portosystemic stent shunt (TIPSS) procedure.

METHOD

Between 1992 and 1996 we tried to establish a TIPSS in 90 patients. The indications were: recurrent variceal haemorrhage (n = 74), refractory ascites (n = 12), hepatorenal syndrome (HRS) (n = 4). Due to advanced liver cirrhosis 16 patients suffered of severe renal dysfunction (HRS). 57 patients had ascites.

RESULTS

TIPSS implantation was technically successful in 96.7% (1992-1994: 5.1%, 1995-1996: 100%) of the patients. Complications occurred in 14.9% (1992-1994: 25.6%, 1995-1996: 6.3%). TIPSS-associated mortality was 2.3% (1992-1994: 5.1%, 1995-1996: 0%). 76.1% of the patients required reinterventions. 85.3% of reinterventions were necessary in the first year after TIPSS placement. The survival rate without reintervention was 28%, 21% and 9% for Child A, B, and C patients, respectively. Recurrent variceal haemorrhage occurred in 12.7%. De novo hepatic encephalopathy developed in 13.8%. Ascites improved in 79.2% and renal function in 75% of the patients.

CONCLUSION

TIPSS is an effective method to treat recurrent variceal haemorrhage, refractory ascites and HRS. Complication and mortality rate depend on the investigator's experience and on the technique used.

[Splenic echinococcosis--a rare differential diagnosis in a cystic lesion of the spleen]

Cystic tumours of the spleen are generally rare and a parasitic origin is relatively improbable. Our case report, however, shows that in case of a splenic cyst, differential diagnosis must always consider the possibility of echinococcosis. We report on a patient suffering from a cystic lesion of the spleen where radiology yielded the final pointer to diagnosing an echinococcosis of the spleen.

[Stent implantation and balloon dilatation in the treatment of stenosis and obstruction of the lacrimal apparatus]

PURPOSE

To evaluate treatment of epiphora caused by obstructions of the nasolacrimal duct system with balloon dilatation and stent implantation.

MATERIAL AND METHODS

28 dacryocystoplasties were performed in 20 patients with complete (n = 7) or incomplete (n = 13) obstruction of the nasolacrimal duct system.

RESULTS

Dacryocystoplasty was technically successful performed in 26 cases (93%). Recanalisation was not achieved in two patients with complete obstructions. 17 patients showed complete or partial resolution of epiphora during follow-up of up to two years (clinical success 85%). Complete reobstruction occurred only in one patient 9 months after balloon dilatation and recanalisation was not possible.

CONCLUSION

With a technical success rate of 93% and a clinical success rate of 85% dacryocystoplasty is a non-operative alternative for treatment of epiphora caused by obstructions of the nasolacrimal duct system.

[CO2 cholangiography]

PURPOSE

Evaluation of the benefit of carbon dioxide (CO2) as contrast medium to reduce intraductal manipulations in biliary drainage.

METHOD

In 8 patients with biliary occlusion demonstrated by cholangiography with iodinated contrast medium, percutaneous CO2 cholangiography was performed by manual injection of 30-50 ml CO2 using the same approach. Capability of CO2 to pass the obstruction and delineate distal parts of the common bile duct was evaluated.

RESULTS

In 5 of 8 patients CO2 visualised additional segments of the occluded bile duct. In 4 patients the poststenotic bile duct was demonstrated with CO2. In one patient 2 cm of the obstructed duct segment was visualised. The intrahepatic duct system could not be examined sufficiently by CO2 administration.

CONCLUSION

Because of its low viscosity, CO2 is a useful contrast medium to visualise the extrahepatic biliary system before performing an external-internal biliary drainage in biliary obstruction. Unnecessary intraductal manipulations may be reduced.

[Hepatic pseudolesion caused by puncture]

We report the diagnosis and differential diagnosis of a hepatic pseudolesion due to percutaneous liver biopsy in a 30-year-old female patient with known chronic hepatitis C and renal insufficiency. In the course of transplant preparation, an abdominal spiral-CT examination pre and post i.v.-contrast injection as well as an angiography with CT-hepaticography and CT-portography were performed. In these examinations a 1 cm, hepatocellular-carcinoma mimicking liver lesion was found; it was hypodense in the CT-portography and showed a marked enhancement in the CT-hepaticography. This "pseudolesion", which was supposed to be due to the liver biopsy, resolved spontaneously.

[The typical radiological findings and course of invasive pulmonary aspergillosis in the immunosuppressed patient]

PURPOSE

This retrospective study was designed to show whether invasive pulmonary aspergillosis, which is often difficult to diagnose by bronchoscopy or serology, can be diagnosed at an early stage by typical radiological findings on conventional radiographs or by CT, specially high resolution CT (HR-CT).

PATIENTS AND METHODS

In 19 Patients with 20 disease episodes, 20 thorax radiographs and eight spiral CT examinations were performed and in four cases HR-CT was also available. The earliest pathological findings and the course of the disease were analysed and the results of the various examinations were compared.

RESULTS

90% of chest examinations, including CT and HR-CT, showed the following lesions as part of the earliest changes: round or wedge-shaped opacities or the so-called "halo" sign. CT or HR-CT always demonstrated more lesions than plain chest radiographs; 75% of lesions appeared typical and thereby contributed to the diagnosis.

CONCLUSION

The typical radiological findings of round or wedge-shaped opacities and the so-called "halo" sign are additional criteria for the diagnosis of invasive pulmonary aspergillosis. The superiority of CT or HR-CT in the demonstration of pathological changes suggests that these should be used early in the investigation of patients who are specially at risk.

[Castleman lymphoma: isolated abdominal involvement with an 8-year course in a child]

This article describes a child with isolated, abdominally localized Castleman's disease and 8-years follow-up. Six years after surgical resection of an adrenal tumour, a multifocal disease with liver, spleen and lymph node involvement developed, which has improved for now 2 years after steroid medication.

[Carbon dioxide (CO2) as contrast medium for the new installation and follow-up of a TIPS]

PURPOSE

To determine the efficacy of CO2 as negative contrast medium compared with iodinated contrast medium in creation and control of TIPS.

MATERIAL AND METHODS

CO2 was used during TIPS procedures in 33 patients. In 21 patients a wedged hepatic venography was obtained for planning the shunt tract. Additional TIPS-control DSA was performed in 42 cases by direct portal venography to verify the TIPS function and patency. In all cases CO2 gas was used in addition to iodinated contrast medium.

RESULTS

CO2 produced excellent wedged hepatic venographies in all patients. Visualisation of the portal veins and collaterals was superior to iodinated contrast medium. The TIPS-control DSA performed with CO2 were comparable to those performed with iodinated contrast medium. Complications were not observed in our study.

CONCLUSION

CO2 is an effective contrast medium for TIPS procedures. In particular the visualisation of portal veins performed by CO2-wedged hepatic venography is superior to iodinated contrast medium.

[MRI diagnosis and follow-up of bilateral necrosis of the humeral head as a complication after chemotherapy]

A 14-year old female patient was treated with chemotherapy including cortisone for malignant T-cell lymphoma. After chemotherapy she complained of pain in both hips and shoulders. Bone scintigraphy and conventional radiography failed to show any abnormality. However, bilateral femoral and humeral head necrosis was seen with MR imaging, which was also useful for follow up.

[The diagnosis of intra-abdominal hemorrhages with CO2 as the contrast medium]

PURPOSE

Evaluation of carbon dioxide (CO2) as contrast medium for detection of intraabdominal haemorrhage.

METHOD

We performed in 5 patients 7 DSA examinations (one with upper and three with lower gastrointestinal bleeding, one traumatic spleen rupture) using an iodinated contrast-medium and CO2 for the localisation of haemorrhage.

RESULTS

With iodinated contrast medium it was possible to localise the haemorrhage in three of 5 patients. With CO2 the localisation was possible in all cases. There were no side effects.

CONCLUSION

CO2 is useful for detection of intraabdominal bleeding. Even in cases with negative angiographic results with iodinated contrast medium, CO2 may enable localisation of the bleeding vessel. Because of this, we use CO2 and iodinated contrast media in all cases of intraabdominal haemorrhage. Further studies are required.

[Temporary vena cave filter: critical comments]

PURPOSE

Retrospective evaluation of the reasons for complications caused by the placement of temporary vena cava filters.

METHOD

Retrospective analysis of 9 complications in 6 implanted temporary (2 anthéor TC-, 4 Filcard RF 02-Filter) and 6 retrievable vena cava filters (1 Dil-, 5 FCP 2002-Filter).

RESULTS

We observed 7 filter thromboses and two severe infections. 5 filter thromboses occurred in temporary filters, two filter thromboses and two infections occurred in facultative temporary filters.

CONCLUSION

The main complications of temporary vena cava filters, like filter thrombosis and infection, were associated with the fixation mechanism of the filter. Our results indicate that facultative temporary vena cava filters without a permanent percutaneous retrieval system seem to be the safer system.

[Percutaneous removal of displaced metal stents in TIPS]

PURPOSE

Basing on our experience with three dislocated or displaced stents (one Wallstent, two Plamaz stents) during or after TIPS-procedure, we describe our technique to reposition or remove the stents.

METHOD

The stents were moved back into the inferior vena cava by means of a balloon catheter, an alligator forceps, or an Amplatz gooseneck snare. They were secured against further dislocation by a central guidewire. After insertion of a balloon catheter into each dislocated stent, they were coaxially grasped with an Amplatz gooseneck snare. Stent diameter was reduced by forceful closure of the snare, and then the stent was either relocated or removed.

CONCLUSION

To prevent further stent migration it is necessary to remove the stent via a guidewire. By using a balloon catheter and a coaxially inserted Amplatz gooseneck snare, reduction of the outer stent diameter is possible even in Plamaz stents, facilitating their relocation or removal.

[Malignant desmoplastic tumor with divergent differentiation]

Malignant desmoplastic tumor with divergent differentiation is an extremely rare, but well-defined tumor entity. The case of a 15-year-old boy with this tumor and the differential diagnosis are discussed in the present article.

[Stent implantation for the palliative therapy of upper inflow obstruction in bronchial carcinoma]

AIM OF STUDY

To analyse results obtained in the palliative treatment of obstruction of the upper inflow veins by stent implantation in patients with bronchial carcinoma.

PATIENTS AND METHODS

Stents were implanted in 14 patients with upper venous obstruction due to bronchial carcinoma (three women, eleven men: mean age 64 [48-74] years), 4 of the superior vena cava (SVC), 6 of the SVC and brachiocephalic vein, 4 of the SVC and subclavian vein. To prevent thromboembolic phenomena all patients received heparin in therapeutic doses for 1-3 days from the time of stents implantation.

RESULTS

Treatment was successful (regression of the clinical signs) in 12 of the 14 patients. Six patients died, without recurrence of the clinical signs, an average of 141 (10-420) days after the procedure. Mean survival time of the six patients who remained without symptoms was 3 months (longest interval 9 months). In one patient thrombotic occlusion of the SVC occurred 6 days after stent implantation. However, local thrombolysis successfully re-opened the vessel. Renewed upper vein obstruction occurred in two patients during follow-up. None of the stent filaments fractured and there was no stent dislocation.

CONCLUSION

With a success rate of 86% stent implantation proved to be a sparing procedure in the palliative treatment of upper inflow vein obstruction, especially in patients with extensive malignant disease.

[Stent implantation as a palliative therapeutic measure in tumor-induced stenoses of the large veins of the body]

PURPOSE

Self-expandable metallic stents were used to treat patients with malignant venous obstructions to determine their effectiveness in producing symptomatic palliation.

METHODS

20 patients with a total of 28 tumour-induced obstructions of the superior vena cava (n = 13), the inferior vena cava (n = 4), the subclavian (n = 4), the innominate (n = 5) and the iliac veins (n = 2) were treated with self-expandable metallic stents. 38 Gianturco stents and 21 Wallstents were applied. Patients were heparinised during the procedure and up to three days afterwards.

RESULTS

In all patients correct positioning of the stents was achieved. In 16 patients stent placement resulted in relief of their symptoms. In 8 patients the symptoms completely disappeared without recurrence until death as a result of tumour progression. The follow-up ranged from 10 days to 14 months. In 8 still living patients no re-obstruction occurred (follow-up average three months). In one patient thrombotic stent occlusion occurred 6 days after the procedure; the v. cava superior was reopened again by local urokinase therapy. Three patients finally developed re-occlusion due to tumour progression. In one patient stent placement was complicated by migration of the Gianturco stent one day after stent implantation and reocclusion of the subclavian vein.

CONCLUSION

The application of self-expandable metallic stents in patients with malignant venous obstruction is a useful palliative therapy.

[Duplex ultrasonographic diagnosis of renal artery stenosis by intrarenal acceleration determination and recognition of the tardus-parvus phenomenon with special regard to multiple renal arteries]

PURPOSE

Use of the "tardus and parvus" abnormalities for the exclusion of significant renal artery stenosis, including multiple renal arteries.

METHOD

The lobar and interlobar renal arteries of 50 hypertensive patients were examined by colour duplex sonography at three different levels. Analysis included determination of the early systolic acceleration time and evaluation of the early diastolic complexes. In all patients, intra-arterial catheter angiography was performed on the following day.

RESULTS

48 out of the 50 colour duplex examinations could be properly evaluated. Angiography showed that 21 patients (42%) had multiple renal arteries, in 13 there was a haemodynamically significant renal artery stenosis and amongst these 4 patients had bilateral renal artery stenoses. The sensitivity and specificity of the early systolic acceleration time at > or = 0.120 sec. was 77 and 46% respectively. Amongst the 17 haemodynamically significant stenoses shown by angiography, 10 demonstrated changes in the early systolic peaks of the Doppler spectrum, a sensitivity of 69% and specificity of 90%.

CONCLUSION

Use of acceleration time and of the early systolic complexes cannot be recommended as sole methods during a screening procedure.

[The value of fine needle puncture in adrenal gland tumors]

The value of fine needle biopsy (FNB) in adrenal masses was investigated in 33 patients presenting with such masses. Representative material was obtained 18 times from 19 patients with a history of tumour. 4 of them were diagnosed to be genuinely benign and 14 to be genuinely malignant. Further representative material was obtained 13 times from 14 patients with incidental findings of adrenal masses. The material gained by puncturing was classified correctly as benign in 9 cases, and twice it was considered benign although the tumours later proved malignant. In one case a clinically not suspected malignant lesion was detected by FNB, while in another case a malignant lesion was suspected by FNB, whereas a benign tumour was proven by means of surgery. The share of malignant diagnoses corresponded with the size of tumour, ascertained by the application of ultrasound or CT. The rate of malignant adrenal masses, which were found incidentally, increased from 7 cm onwards; however, the rate of malignant adrenal masses obtained from patients with a history of tumour increased distinctively already from 4 cm onwards. From 11 patients out of 33, adrenal tissue was obtained and classified as benign lesion (adenoma), although, by means of FNB and the conditions for reasons of method, a well differentiated carcinoma cannot be excluded.

CONCLUSION

FNB is indicated for non-functioning tumours examined in patients with a history of tumour, furthermore, for incidental findings of the size between 4-6 cm. A diagnostic approach to adrenal masses is suggested.

[The measurement of vascular diameter to determine stent and balloon size in percutaneous procedures in the pelvic circulation]

AIM

Should the sizes of balloons and stents used in the pelvic circulation be determined by the size of the ipsilateral or contralateral vessel?

STUDY DESIGN

The angiographic findings in 31 patients were analysed; in 10 an occlusion and in 21 a high grade stenosis (greater than 75%) of the common iliac artery had been treated by stenting (26) or simple PTA (5).

RESULTS

In 26 of the 31 patients there was marked reduction in the lumen distal to the lesion up to 40%. In 17 patients this was reversed immediately after the procedure and in five others the lumen increased but a difference between the two sides remained. The changes on the two sides following treatment were statistically significant (external iliac artery: p = 0.00013).

CONCLUSION

The results indicate that the "normal" contralateral measurements should be used rather than the distal ipsilateral vessel diameter.

[Computerized tomography in diagnosis of lung metastases: improvement with the spiral technique]

Computed tomography is the imaging modality of choice for detection or exclusion of pulmonary metastases. In most cases these are spheric, multiple, bilateral, and located in the peripheral areas of the middle and lower fields of the lungs. Differential diagnosis of solitary pulmonary nodules is difficult. Evaluating whether they are malignant or benign is insufficient despite the application of multiple CT criteria. Spiral computed tomography acquiring an imaging volume in a breathhold has led to significant improvement in the sensitivity of detecting pulmonary nodules. Imaging protocols are presented, and the influence of the different parameters is discussed. Although not all pulmonary metastases may be detected with spiral computed tomography, it is the most important examination when considering pulmonary metastasectomy. Computed tomography is the imaging modality of choice when monitoring pulmonary metastases during systemic therapeutic regimens by measuring all nodules or "indicator lesions."

[Computerized tomography of kidney tumors]

Among 220 renal tumors which we detected by computed tomography, there were 168 renal cell carcinomas, 24 tumor of the renal pelvis, 16 angiomyolipomas, 6 Wilms tumors, 3 oncocytomas, one liposarcoma, one mesenchymal tumor, and one rhabdomyosarcoma. Computed tomography had the highest accuracy of the diagnostic procedures with a sensitivity of 99.5% and a specificity of 98%. 83% of the renal cell carcinomas showed signs of malignancy in computed tomography; the staging of the renal tumors by computed tomography was correct in 67% of the cases. The diagnostic value of other diagnostic tools (sonography, urography, angiography, cavography) of renal tumors is discussed in terms of our own results.

[Gadolinium-DTPA (Magnevist) as contrast medium for arterial DSA]

16 DSA investigations using intra-arterial Gd-DTPA were performed on 12 patients. The contrast medium was administered either as a 0.5 molar gadolinium solution (commercially available) or diluted with distilled water to a 0.2-0.4 molar gadolinium solution. The injection was made either by pressure injector or by hand. The aortic arch, abdominal aorta and pelvic and lower limb arteries were examined. 14 of the 16 procedures were diagnostically adequate, but compared with iodinated contrast materials, contrast was less marked. There were no cardiovascular, neurological or allergic side effects. Three patients suffered a feeling of heat and one patient had mild pain during the injection. Even large volumes rapidly injected (up to 20 ml/s of the commercially available solution) were well tolerated. DSA with intra-arterial Gd-DTPA seems to be a suitable alternative for vascular imaging if iodine-containing contrast materials are contraindicated.

[The safety belt: effects on injury patterns of automobile passengers]

Since 1984 the law concerning safety belts has been implemented; this paper deals with the findings in 386 victims of motor accidents who were x-rayed between 1981 and 1989. Minor injuries have been ignored. The number of passengers wearing belts increased by 30% after 1984. The number of passenger injuries did not decrease. Injuries directly caused by the belts included a small number of fractures of clavicles, the sternum and ribs and one pelvic fracture, one serious abdominal injury with tearing of the mesenteric artery and one ruptured spleen. An indirect result of wearing seat belts was a marked increase in cervical whiplash injuries and some increase in thoracic vertebral fractures. None of the belt induced injuries proved fatal. Amongst those using seat belts there was a significantly lower fatality rate and injuries causing prolonged disability. In particular, using seat belts, serious injuries to the skull and brain were reduced by 80%. Similarly injuries to the abdomen, the odontoid, pelvis and hip joint were greatly reduced. The advantages of wearing a seat belt greatly outweigh the disadvantages.

Percutaneous penile venoablation for treatment of impotence

Percutaneous penile venoablation with sclerosing agents and coils was performed in 58 patients. Of 104 ablations attempted, 44 of 51 (86%) transpenile, and 46 of 53 (86.7%) retrograde interventions were technically successful. In 40 patients (69%) erectile function improved (intercourse was possible in 21 without additional measures). Initially improved erectile function deteriorated in 24 patients during follow-up (in an average of 6 months); in 15 of these, intercourse was still possible with injection of vasoactive drugs. In 7 patients, repeat venoablation improved erectile function again. Hot contrast medium was slightly superior to sodium morrhuate as a sclerosing agent. In successfully treated patients, the average decrease in venous leakage was 30 ml/min vs 13 ml/min in treatment failures, with considerable overlap between both groups. Only minor complications were observed. We conclude that percutaneous penile venoablation is technically feasible, and safe. Whether the procedure will have a definite role in the treatment of venogenic impotence, however, still has to be determined.

Percutaneous ultrasonic angioplasty: initial results of an in-vitro study on normal and atherosclerotic human vessel segments

The aim of the present study was to assess the efficacy and safety of a new ultrasound catheter system in vitro before employing it in humans. Ultrasound energy was applied to 141 normal and atherosclerotic human vessel segments, obtained at autopsy. Macroscopical and histological examination of the treated vessel segments revealed that ultrasound energy is atraumatic to the normal vessel wall. In atherosclerotic vessel segments, there was macroscopically significant reduction in the size of plaques. In 7/10 completely occluded femoral arterial segments, recanalization could be achieved. The resulting lumen approximated the diameter of the wire probe. Therefore, ultrasound energy is an appealing form of energy for recanalization of completely obstructed atherosclerotic vessels and for disintegration of atherosclerotic plaques. Clinically, ultrasonic angioplasty may become an adjunctive modality to balloon angioplasty.

[Carbon dioxide--contrast medium for digital subtraction angiography]

Fundamental considerations: Despite appreciable improvements in conventional iodine-containing contrast media, vascular studies involving patients with renal insufficiency, hyperthyroidism or known allergic reaction to conventional contrast media continue to pose a problem. Own study: Testing the investigation of the possibility of visualizing vessels using carbon dioxide as a gaseous contrast medium. In 30 patients, angiography of the pelvis and legs (DSA) employing conventional iodine-containing media and/or CO2 were carried out simultaneously. RESULTS, handling and toleration were compared. In two further patients, percutaneous transluminal angioplasty and stent implantation, respectively, were successfully performed under CO2 control.

RESULTS

All the findings obtained with "normal" DSA were also obtainable with CO2. The CO2 examination, however, was often plagued by incomplete contrasting of the blood vessels, with interruption of the contrast medium column, which made assessment more difficult. In two of the 30 patients undergoing angiography of the pelvis and legs, the investigation had to be abandoned on account of persistent intensive lower abdominal pain under CO2 injection.

[Retrograde venous occlusion--therapy of impotence of venous origin]

Retrograde occlusion of penile drainage veins can produce improvement in patients with impotence due to venous leaks. We performed 50 transfemoral and three transjugular procedures; 46 (86%) were technically successful. Clinical improvement was found in 24 out of the 46 procedures (52%). In 20 patients spontaneous intercourse became possible, in four this occurred after intracavernous injection of vaso-active substances. In eleven patients there was deterioration after one to twenty months; in seven this was treated by repeated venous occlusion. In 13 patients improvement has been maintained over a period of one to thirty months (average 10.5 months). There were no complications.

[Injuries of the thoracic skeleton]

Injuries of the thoracic skeleton are an important indicator of other, relevant traumatic changes after a polytrauma. Most fractures occur in the ribs, followed by fractures of the clavicle, the scapula and the sternum. Because of their high kinetic energy, car accidents are the main reason for thoracic fractures. The basic radiologic tool is the a.p. projection of the thorax in supine position; in addition, other conventional x-ray examinations or computed tomography are performed. Most thoracic fractures are treated conservatively, only in few cases (instability of the thorax, risk of pseudoarthrosis, incongruence of joint surfaces) surgical procedures are used.

[Selective blood sampling from the sinus petrosus inferior: a comparison of CRF and TRH stimulation]

In 10 patients with hypophyseal Cushing microadenomas, selective bilateral sampling from the inferior petrosal sinuses was performed and the effect of stimulation by iv TRH and CRF was compared. On the side of the microadenoma. ACTH concentration rose from 650 +/- 242 pg/ml to 2712 +/- 843 pg/ml following injection of CRF and 2025 +/- 242 pg/ml after TRH. Contralateral values were 165 +/- 79 pg/ml, 490 +/- 200 pg/ml and 165 +/- 72 pg/ml respectively. Prolactin concentration on the side of the adenoma was 98 +/- 49 ng/ml before stimulation, 236 +/- 62 ng/ml after CRF and 747 +/- 168 ng/ml after TRH. Contralateral concentration was 22 +/- 10 ng/ml, 64 +/- 19 ng/ml respectively. Sampling localised all adenomas correctly, whereas contrast-enhanced MRT diagnosed only four adenomas.

[Spiral CT with three-dimensional (3D) surface reconstruction in assessing solitary pulmonary foci]

Recently it has been thought possible to characterise a pulmonary lesion by its vascular involvement. The complex vascular relationships are difficult to demonstrate by the "normal" technique of transverse CT sections. Spiral CT with 3D-surface reconstruction makes it possible to evaluate the vessels accurately and simulates the appearances one would have by looking into the thorax with a demonstration of all vessels lying within the pulmonary space examined by CT. Venous involvement was shown in every one of 18 malignant lesions but was also found in 4 out of 11 benign lesions, arterial involvement occurred in 14 out of 18 malignant and in 2 benign lesions. CT evidence of vascular involvement is in favour of a malignant tumour but is no absolute proof.

[Long-term observation after percutaneous transluminal angioplasty in the pelvic and leg areas]

In this study 163 patients had long term follow ups after PTA; the value of a test which had previously hardly been used, the "Cox proportional hazards model", for prognostic purposes is stressed. In this test account is taken of the severity of the stenosis before PTA, the extent of re-stenosis following PTA and the distance of the occlusion from the aorta and these are related to the likelihood of success. The use of the Cox proportional hazards model with an accurate description of the clinical material and the use of the Kaplan-Meier method is recommended in order to obtain comparable figures for the results obtained in various centres. In this study patency after six months was 77%, after a year 67%, after three years 46% and after five years 37%.

[The incidence of focal liver lesions in patients with colorectal carcinoma]

The preoperative sonographic findings in 166 patients with confirmed colorectal carcinomas were analysed to determine the frequency of focal liver lesions. In 15 patients liver metastases were found at the first examination and in a further 16 patients they were detected subsequently. Homogeneous high-intensity echoes were found in only one patient. Cysts occurred in 13 and haemangiomas in 11 patients. The latter showed solitary lesions which exceeded 25 mm in only one patient and otherwise measured between 6 mm and 15 mm. Focal abnormalities of fat distribution were found in 12 patients. Even in a tumor patient, the first differential diagnosis of a solitary, homogeneous liver lesion of less than 2 cm is a hemangioma and further investigation is mandatory.

[Ultrasound-proven adrenal gland tumor. References for diagnostic management]

Due to the increasing number of ultrasonographic examinations, tumors of the adrenal glands are being detected more and more often. In the present paper, suggestions for the further diagnostic evaluation are made: in the case of sonographically detected solid tumors of the adrenals, computed tomography is the next procedure of choice. If CT scan also fails to enable an unequivocal diagnosis, the next step must be laboratory investigations. Hormone-producing tumors, irrespective of size, as well as non-hormone-producing tumors larger than 6 cm in diameter or symptomatic neoplasms are all treated by surgery. In the case of an oncological patient with an asymptomatic non-hormone-producing tumor, differential diagnosis via needle aspiration should be attempted in all tumors measuring less than 6 cm in diameter. In the event of an incidental finding, fine needle aspiration is performed only in lesions measuring between 4 and 6 cm; for tumors of less than 4 cm, we consider a wait-and-see approach, with follow-up examinations at 3-month intervals to be justified.

[Distribution of the incidence of sonographically detected focal liver changes in patients with colorectal cancer]

Aim of the following study was to investigate how often liver metastases are detected in oncologic patients as compared to other focal liver lesions. Preoperative sonographic examinations of 209 patients with proven colonic or rectal cancer were studied. In 19 liver metastases were detected, which in only one patient were homogeneous echogenic. Liver cysts were found in 17, hemangiomas in 15 patients, all of whom where solitary lesions and between 6 and 25 mm in diameter. Focal fatty infiltration was diagnosed in 14 patients. In conclusion, a sonographically detected liver lesion, which is homogeneous echogenic and less than 20 mm in size, is most likely to be a hemangioma and should be further investigated, if therapeutically relevant.

[Percutaneous sonographic angioplasty. Initial experimental results]

Aim of the present study was to examine in vitro the effects of a new ultrasound catheter system on atherosclerotic and normal vessels before employing the system in humans. 141 attempts were made on 32 vascular preparations obtained at autopsy. The vessels were opened longitudinally within 24 hours of death, dilated with gelatine and were then "treated" in a waterbath using varying degrees of pressure, angle of incidence, sound intensity and duration of sound. Macroscopic and histological examinations of the preparation showed no morphological change in normal vessels except evidence of pressure by the catheter. In particular, there were no perforations of the vessel wall. In atherosclerotic segments there was significant reduction in the size of plaques following treatment.