Penetrating wounds to the torso: evaluation with triple-contrast multidetector CT

Penetrating injuries account for a large percentage of visits to emergency departments and trauma centers worldwide. Emergency laparotomy is the accepted standard of care in patients with a penetrating torso injury who are not hemodynamically stable and have a clinical indication for exploratory laparotomy, such as evisceration or gastrointestinal bleeding. Continuous advances in technology have made computed tomography (CT) an indispensable tool in the evaluation of many patients who are hemodynamically stable, have no clinical indication for exploratory laparotomy, and are candidates for conservative treatment. Multidetector CT may depict the trajectory of a penetrating injury and help determine what type of intervention is necessary on the basis of findings such as active arterial extravasation and major vascular, hollow viscus, or diaphragmatic injuries. Because multidetector CT plays an increasing role in the evaluation of patients with penetrating wounds to the torso, the radiologists who interpret these studies should be familiar with the CT findings that mandate intervention.

Hybrid treatment of a case of obliterative hepatocavopathy (Budd-Chiari syndrome)

Progressive obliteration of the intrahepatic course of a inferior vena cava is an insidious disease that may lead to portal hypertension with progressive liver engorgement and ultimately to liver cirrhosis. Early diagnosis is extremely important so that therapeutic modalities can be offered that can favorably change the natural course of the disease. We present the case of a young woman whose obliterated vena cava could be successfully recanalized by a combined surgical and interventional technique.

Catheter-directed thrombolytic therapy combined with angioplasty for hepatic vein obstruction in Budd-Chiari syndrome complicated by thrombosis

The aim of this study was to assess the efficacy and safety of catheter-directed thrombolysis combined with angioplasty in the treatment of hepatic vein obstruction in Budd-Chiari syndrome (BCS) complicated by thrombosis. In 14 cases of BCS, the patients with hepatic vein obstruction complicated by thrombosis who underwent catheter-directed urokinase thrombolysis, balloon dilatation and/or stent placement were followed up with an ultrasound examination of the liver. Among the 13 cases of successful treatment, one hepatic vein was recanalized in 12 patients (right hepatic vein, seven cases; left hepatic vein, three cases; middle hepatic vein, one case and accessory hepatic vein, one case) and two hepatic veins (right and left) were recanalized in one patient without serious complications, such as bleeding and pulmonary embolism. There was one patient in whom the treatment was unsuccessful. During an average follow-up period of 24.8±19.6 months, hepatic vein restenosis was observed in one patient in the sixth month after opperation; however, a successful result was obtained following a second balloon dilatation. The remaining 12 patients did not demonstrate any recurrence of restenosis or thrombosis. Catheter-directed thrombolysis combined with angioplasty was observed to be an effective and safe method for the treatment of hepatic vein obstruction in BCS complicated by thrombosis.

Magnetic resonance imaging identifies unsuspected liver abnormalities in patients after the Fontan procedure

OBJECTIVE

To determine whether abdominal magnetic resonance imaging (MRI) detects hepatic abnormalities before clinical or biochemical perturbations in patients after the Fontan procedure.

STUDY DESIGN

Thirty-nine children and adolescents who underwent the Fontan procedure and were referred to a pediatric hepatologist by cardiology services between 2011 and 2012 were reviewed retrospectively. Physical examination findings, routine laboratory tests of liver function, evaluation for chronic liver disease, and abdominal MRI findings were recorded. MRI findings were evaluated relative to time elapsed since surgery by 2 radiologists (blinded).

RESULTS

Assessment for coexisting chronic liver disease was negative in all patients. All patients had a normal serum albumin level and International Normalized Ratio. Twenty-six of the 39 patients (67%) underwent abdominal MRI, 4 had MRI-incompatible hardware, and 9 did not undergo MRI because of insurance denial. All MRI scans demonstrated morphologic liver changes with varying degrees of reticular contrast enhancement compatible with fibrosis and congestion. Reticular contrast enhancement was often nonuniform, and 9 patients (35%) had multifocal arterially enhancing lesions.

CONCLUSION

MRI can identify hepatic abnormalities in patients after Fontan surgery that go undetected by standard clinical and laboratory assessments. These abnormalities are not uniformly distributed throughout the liver, and thus assessment by liver biopsy analysis is subject to sampling error.

Successful recanalization of occluded intrahepatic inferior vena cava in post-liver transplant Budd-Chiari syndrome

Budd-Chiari syndrome following a liver transplant is an uncommon phenomenon. We present a case of endovascular management of a focal circumferential inferior vena cava (IVC) occlusion at the anastomosis that developed 10 years after orthotopic liver transplantation. It was successfully recanalized using the stiff end of the guidewire and percutaneous transluminal angioplasty with a high-pressure balloon. During a 14-month follow up, the IVC remained patent and did not require further intervention.

Comparison of efficacy of side to side versus end to side arteriovenous fistulae formation in chronic renal failure as a permanent hemodialysis access

Background

In candidate patients for permanent hemodialysis or dialysis on a regular basis, an appropriate vascular access has great importance. The best permanent access is AVF (arterio venous fistula). Use of a technique to create AVF with better patency seems to be logical.

Objectives

The present study aimed to compare the efficacy rate of AVFs using two different anastomosis methods; Side to Side (STS) versus End to Side (ETS) and to determine whether the different approaches render any preferences or complications.

Patients and Methods

Sixty end stage renal disease (ESRD) patients were included in this clinical trial in two assigned groups of 30 patients. In one group end to side method to create AVF was used while in the other group Side to Side technique was applied for access in surgery. Both groups were followed for duration of 6 months to assess patency. For evaluating the quantitive variables, t-test was used while qualitative variables were measured using the chi-square and Fisher`s exact tests.

Results

In the 6 months duration, 6 patients (20%) in the STS (side to side) group and 5 patients (16.6%) in the ETS (end to side) group experienced a non-functional AVF. In the ETS group the failure was generally a result of thrombosed access while in the STS group, 4 out of 6 patients with complications, experienced thrombosis while the other 2 patients had venous hypertension. The total failure rate was 18.3% and during the 6 months of follow up no significant difference was detected in the efficacy rate. Nevertheless, in case of longer follow ups, different outcomes could be seen.

Conclusions

This study demonstrated that there was no significant statistical difference between the functional patency rates of fistulae placed by STS or ETS methods.

The role of radical surgery in the management of acquired uterine arteriovenous malformation

BACKGROUND

Acquired arteriovenous malformations (AVMs) can develop after uterine instrumentation. The increased risks of vascular changes, including abnormal placentation, after repeated cesarean sections are well studied. Herein, we describe a patient with delayed hemorrhage from a uterine AVM, following dilation and curettage for a cesarean scar pregnancy.

CASE

A 32-year-old G3P2 presented with a cesarean scar ectopic pregnancy managed with dilation and curettage, which incurred a 1,500-ml blood loss. Within 6 weeks, she returned with 2 episodes of vaginal bleeding. Initial angiography demonstrated a high-flow arteriovenous fistula, which was coiled. Vaginal hemorrhage recurred; repeat angiography demonstrated a large AVM. Gelfoam embolization of the bilateral internal iliac arteries reduced the vascularity of the AVM. The AVM's location, starting at the left lateral apex of the cesarean scar and extending into the parametrium, necessitated a radical hysterectomy. Pathologic examination revealed a placenta percreta extending into the parametrium.

CONCLUSION

The prevalence of uterine AVMs has increased with the rise in surgical obstetrics. In patients with a failed prior interventional procedure, surgical management is necessary to prevent life-threatening hemorrhage. The location of the AVM within the abnormal uterine scar tissue requires familiarity with radical pelvic surgical techniques that are normally used in cancer surgery in order to definitively treat this delayed obstetrical complication.

Asymptomatic renal pseudoaneurysm after percutaneous renal biopsy

A 37-year-old man was referred to Division of Nephrology for a new renal cystic lesion that was found on ultrasonography. Four years prior to presentation, a percutaneous renal biopsy had been performed. Computed tomography scan showed a 4.4-cm-sized renal artery pseudoaneurysm in the left kidney. Selective renal angiography revealed a pseudoaneurysm in the left lower pole of the kidney. The renal pseudoaneurysm was successfully embolized with coil. Follow-up Doppler ultrasonography showed no internal blood flow into the aneurysmal sac. His renal function remained stable after coil embolization.

A case of ruptured renal cortical arteriovenous malformation of the right testicular vein in hemorrhagic fever with renal syndrome

Hemorrhagic fever with renal syndrome (HFRS) is an acute viral disease characterized by fever, hemorrhage, and renal failure. Among the various hemorrhagic complications of HFRS, the spontaneous rupture of an arteriovenous malformation of the testicular vessels with a retroperitoneal hematoma is a rare finding. Here, we report a case of HFRS complicated by a massive retroperitoneal hematoma that was treated with transcatheter arterial embolization.

The role of transarterial embolization in the management of hematuria secondary to congenital renal arteriovenous malformations

OBJECTIVE

To evaluate the efficacy and safety of transarterial embolization (TAE) in the management of hematuria secondary to congenital renal arteriovenous malformations (AVM).

PATIENTS AND METHODS

Between May 2007 and February 2012, 6 patients with congenital AVM treated with TAE were analyzed retrospectively, followed by a brief review of TAE in the treatment of congenital AVM. Clinical records with respect to general conditions, location, embolic materials, complications and overall outcome were collected from the original hospital charts and outpatient medical records.

RESULTS

Three patients with AVM were confirmed by contrast-enhanced CT scans, and the other 3 patients were detected by renal angiography. TAE was performed with steel coils in 2 patients and n-butyl-2-cyanoacrylate (NBCA) in 4 patients. After a mean follow-up of 22 months, no serious adverse effects were observed in all patients. There were no complaints of hematuria at the end of the follow-up period.

CONCLUSION

For unexplained massive hematuria, congenital renal AVM needs to be considered as a differential diagnosis. Selective renal angiography and embolization should be recommended as the first choice to treat massive hematuria secondary to congenital renal AVM.

Uterine arteriovenous malformation formed in a large uterine cervical myoma

Arteriovenous malformation (AVM) can arise in various organs, particularly the brain, but it is rare in the uterus. Uterine AVM is potentially lethal and is generally associated with uterine trauma, such as dilatation and curettage, therapeutic abortion or uterine surgery. On the other hand, uterine myoma is the most common benign gynecological tumor, but uterine cervical myoma is rare and grows in the extraperitoneal space, with development of complex capillary networks within the tumor. Cervical myoma surgery is therefore a difficult operation with a risk of massive bleeding. We report herein a patient with uterine AVM formed within a large cervical myoma in a postmenopausal woman. The patient was a 55-year-old Japanese woman who complained of lower abdominal distension. Ultrasonography, computed tomography and magnetic resonance imaging showed an 18 × 20-cm uterine cervical tumor with dilatation of numerous vessels. Pelvic angiography was scheduled to provide accurate diagnosis and to minimize intraoperative blood loss. In fact, preoperative pelvic angiography allowed us to identify the true feeding artery and drainage veins. Occlusion of the feeding artery with a balloon device is effective in decreasing intraoperative bleeding. Abdominal total hysterectomy was performed as the surgical management of this uterine AVM. Prophylactic endovascular balloon occlusion of the ipsilateral internal iliac artery reduced the amount of hemorrhage during surgery, although blood transfusion was needed in our patient. In conclusion, preoperative embolosclerotherapy should be considered as a treatment option in patients with AVM present in a large uterine cervical myoma.

Uterine arteriovenous malformation

Uterine arteriovenous vascular malformations (UAVM) are uncommon vascular diseases, occurring during reproductive age. Patients affected by UAMVs usually present with recurrent pregnancy loss or menorrhagia. Initial evaluation of UAVMs is made with ultrasonography (US) and US-Doppler. Magnetic resonance is used when a UAMV is suspected at US. Treatment can be surgical (hysterectomy or surgical removal of AVM), or with selective uterine arterial embolization. We report a case of UAMV, from its clinical signs to diagnostic confirmation and subsequent treatment.

Arteriovenous malformations and other vascular malformation syndromes

Vascular malformations are a disruption of the normal vascular pattern in which it is expected that a capillary network of microscopic vessels lies interposed between high-pressure arteries that deliver blood and thin-walled veins that collect low-pressure blood for return to the heart. In the case of arteriovenous malformations, arteries or arterioles connect directly to the venous collection system, bypassing any capillary bed. Clinical consequences result from rupture and hemorrhage, from dramatically increased blood flow, or from the loss of capillary functions such as nutrient exchange and filtering function. These malformations can occur sporadically or as a component of inherited vascular malformation syndromes. In these and other hereditary vascular malformation syndromes, genetic studies have identified proteins and pathways involved in vascular morphogenesis and development. A common theme observed is that vascular malformations result from disruption in pathways involved in vascular stability. Here we review the vascular malformations and pathways involved in hereditary hemorrhagic telangiectasia, capillary malformation-arteriovenous malformation, cerebral cavernous malformations, and mucocutaneous venous malformations.

Treatment of Budd-Chiari syndrome with a focus on transjugular intrahepatic portosystemic shunt

AIM

To evaluate long-term complications and survival in patients with Budd-Chiari syndrome (BCS) referred to a Danish transjugular intrahepatic portosystemic shunt (TIPS) centre.

METHODS

Twenty-one consecutive patients from 1997-2008 were retrospectively included [15 women and 6 men, median age 40 years (range 17-66 years)]. Eighteen Danish patients came from the 1.8 million catchment population of Aarhus University Hospital and three patients were referred from Scandinavian hospitals. Management consisted of tests for underlying haematological, endocrinological, or hypercoagulative disorders parallel to initiation of specific treatment of BCS.

RESULTS

BCS was mainly caused by thrombophilic (33%) or myeloproliferative (19%) disorders. Forty-three percents had symptoms for less than one week with ascites as the most prevalent finding. Fourteen (67%) were treated with TIPS and 7 (33%) were manageable with treatment of the underlying condition and diuretics. The median follow-up time for the TIPS-treated patients was 50 mo (range 15-117 mo), and none required subsequent liver transplantation. Ascites control was achieved in all TIPS patients with a marked reduction in the dose of diuretics. A total of 14 TIPS revisions were needed, mostly of uncovered stents. Two died during follow-up: One non-TIPS patient worsened after 6 mo and died in relation to transplantation, and one TIPS patient died 4 years after the TIPS-procedure, unrelated to BCS.

CONCLUSION

In our BCS cohort TIPS-treated patients have near-complete survival, reduced need for diuretics and compared to historical data a reduced need for liver transplantation.

Congestive hepatopathy secondary to large renal arteriovenous malformation

A 75-year-old woman presented with acute onset dyspnoea, and was found to have signs of pulmonary congestion on clinical examination. Imaging revealed cardiomegaly and coincident congestive hepatopathy, secondary to a left renal arteriovenous malformation. The presence of a high flow vascular shunt in the left kidney was possibly the causative factor behind both the high-output cardiac failure and congestive hepatopathy.

Budd-Chiari syndrome

OBJECTIVE

Budd-Chiari syndrome (BCS) is an uncommon condition characterized by obstruction of the hepatic venous outflow tract. Presentation may vary from a completely asymptomatic condition to fulminant liver failure. BCS is an example of postsinusoidal portal hypertension. The management can be divided into three main categories: medical, surgical, and endovascular. The purpose of this article is to present an overall perspective of the problem, diagnosis, and management.

CONCLUSION

BCS requires accurate, prompt diagnosis and aggressive therapy. Treatment will vary depending on the clinical presentation, cause, and anatomic location of the problem. Patients with BCS are probably best treated in tertiary care centers where liver transplantation is available.

Hypertension, secondary to a renal artery aneurysm, treated by ex vivo aneurysm repair and autotransplantation

Hypertension is becoming a more common problem in childhood and adolescence. About 5-10% of paediatric patients with hypertension have underlying renovascular disease. Although renal artery aneurysms (RAAs) are an uncommon cause of disease of the renal vessels, they are recognised as a cause of hypertension. We describe a 15-year-old man with symptomatic hypertension who after extensive investigation was found to have a right RAA. Our patient responded to conservative management with two antihypertensive agents, but as a young sports enthusiast, he was keen to pursue more definitive options. Complex anatomy of the aneurysm precluded the use of endovascular treatment. Surgical options were explored, and after counselling, our patient underwent a nephrectomy, ex vivo aneurysm repair and autotransplantation with which his hypertension resolved. Our case highlights the difficulty of diagnosing RAAs in hypertensive patients and that, in carefully selected patients, invasive surgical intervention of RAAs is a viable treatment option.

Is primary pulmonary meningioma a giant form of a meningothelial-like nodule? A case report and review of the literature

Minute pulmonary meningothelial-like nodules (PMNs) are asymptomatic, small nodules that are occasionally detected in surgical or autopsy specimens. Recent improvements in tumor imaging and the increased use of computed tomography (CT) scans of the chest have led to the early detection of these pulmonary nodules in various clinical settings, often before surgery or health examinations. However, large PMNs have rarely been observed. In this study, we report a patient with a large PMN, which was almost identical to so-called ‘primary pulmonary meningioma’. A CT scan of his chest revealed a small, well-circumscribed nodule. Immunohistochemical analysis of the tumor revealed that the tumor cells were positive for CD56, epithelial membrane antigen, and progesterone receptor. Given the similarity of these results to the staining pattern of minute PMNs in previous reports, we suggest that the primary pulmonary meningiomas reported to date are, in fact, a giant form of PMN.

Imaging of systemic lupus erythematosus. Part II: gastrointestinal, renal, and musculoskeletal manifestations

Systemic lupus erythematosus (SLE) is a chronic, multisystem autoimmune disease that has a relapsing and remitting course. It has a wide range of presentations with various organ manifestations. In this review, we have compiled the radiological findings of gastrointestinal, renal, and musculoskeletal manifestations of SLE.

Cumulative radiation dose from medical imaging in kidney transplant patients

BACKGROUND

Although many patients undergoing kidney transplant are exposed to multiple examinations that increase cumulative effective doses (CEDs) of ionizing radiation, no data are available characterizing their total longitudinal radiation burden and relating radiation burden with risk factors for more exposure.

METHODS

We did a retrospective cohort study of 92 patients (mean age 52 years; range: 20-75 years) who underwent kidney transplant at University Hospital, Novara, Italy, that evaluated all following medical imaging procedures involving ionizing radiation undergone beginning June 2007, and all subsequent procedures through August 2011, at the centre.

RESULTS

The mean and median annual CED were 17.2 and 4.9 millisieverts (mSv) per patient-year. The mean and median total CED per patient over the study period were 46.1 and 17.3 mSv, respectively. Twenty-eight and 12% of patients had total CED >50 and 100 mSv, values which are associated with a good or strong evidence of an increased cancer mortality risk, respectively. Computed tomography scanning accounted for 73% of the total CED. The annual CED was significantly higher in incident patients and in patients with ischaemic heart disease and cancer.

CONCLUSION

In this institution, multiple testing of kidney transplant patients was common in many patients associated with high cumulative estimated doses of ionizing radiation.

Efficacy and safety of embolization in iatrogenic traumatic uterine vascular malformations

AIM

To retrospectively evaluate the efficacy of embolotherapy in patients with iatrogenic traumatic uterine arteriovenous malformations (AVMs).

MATERIALS AND METHODS

A retrospective review of all patients who underwent uterine arterial embolization in Peking Union Medical College Hospital between January 2000 and December 2010 was performed. Forty-two patients were diagnosed with a uterine vascular malformation. All patients had obstetric manipulations before. Serial beta-human chorionic gonadotropin (β-HCG) levels were measured to exclude gestational trophoblastic neoplasia. All patients underwent transcatheter embolization of bilateral uterine arteries. The complications, control of haemorrhage, and outcome of subsequent pregnancies were assessed.

RESULTS

A total of 49 embolization procedures were performed in 42 patients. Seven patients required repeated embolizations for recurrence of bleeding. The technical success rate of embolization was 100%. Bleeding was controlled in 35 of 42 patients (83%) after the first embolization procedures, and bleeding was controlled in another two patients who underwent repeat embolization at a median follow-up of 29 months (range 3 months to 5 years). The overall clinical success rate was 88% (37/42). Thirteen patients subsequently became pregnant and eight of 13 patients had uneventful intrauterine pregnancies carried to term. Seven patients had post-embolization syndrome and no other complication occurred.

CONCLUSION

Percutaneous embolotherapy is a safe and effective treatment for traumatic AVMs. Future pregnancy is still possible after embolization.

Surgical treatment of a ruptured giant renal artery aneurysm--case report and literature review

Renal artery aneurysms are the second most common visceral artery aneurysms after splenic artery aneurysms, and before hepatic artery aneurysms. The study presented a case of a ruptured giant right renal artery aneurysm in a female patient. The presented case is worth mentioning, due to the giant size of the lesion. The diameter of the aneurysm exceeded 10 cm. Available literature data mentioned single reports of such large aneurysms located in the renal arteries. In spite of the fact that renal artery aneurysms are the second most common visceral artery aneurysms, their management is accompanied by some controversy. Literature data mentioned the dominance of endovascular techniques. However, surgical treatment remains to be the most effective and radical method.

Retroperitoneal hematoma — a rare complication after cervical conization because of cervicoisthmic arteriovenous malformation: a case report

A rare case is presented concerning retroperitoneal hemorrhage in a 28-year-old patient after a cold knife conization and cervical suture reconstruction. Arteriovenous cervicoisthmic malformation is a risk factor that was identified in a hysterectomy sample.

[Delayed bleeding after partial nephrectomy. Management with selective embolization]

INTRODUCTION

Bleeding after partial nephrectomy can be immediate or delayed and may have severe consequences. The incidence of this complication is low. The most frequent cause of delayed bleeding is arterial pseudoaneurysm. Superselective embolization is a feasible therapeutic option that has shown good results.

OBJECTIVE

To evaluate treatment and outcomes of delayed bleeding in our series of patients with partial nephrectomy.

MATERIAL AND METHODS

We performed a retrospective study of our database of partial nephrectomies. Patients who developed delayed bleeding (after discharge) were identified. Clinical histories were reviewed and data on presentation, diagnosis, treatment and outcomes were analyzed.

RESULTS

Among our series of patients undergoing partial nephrectomy, three developed delayed bleeding (1.3%). Symptom onset occurred 17 to 25 days after surgery and consisted of hematuria or lumbar pain. Diagnosis was provided through ultrasound, abdominal computed tomography and renal angiography. In all three patients, a complicated pseudoaneurysm was diagnosed and all patients underwent renal artery catheterization with selective renal artery embolization. In all patients, immediate control of bleeding was achieved. Outcome after a follow-up of 61 to 92 months was favorable.

CONCLUSIONS

Selective vascular embolization is the treatment of choice of renal pseudoaneurysm after partial nephrectomy in hemodynamically stable patients.

Thrombosed Aneurysm of a Segmental Renal Artery Branch. Diagnostic and Therapeutic Approach

Introduction

We present the case of a 37-year-old man with a thrombosed aneurysm of a segmental branch of the left renal artery, which was diagnosed after a radiological investigation for colic-like pain, and treated conservatively with endovascular approach.

Materials and Methods

After repeated episodes of colic-like pain in his left side with normal ultrasound of the urinary tract, A.R. (37 years old) undergoes a CT urogram of the abdomen, which shows a complete thrombosis of the middle third of the left renal artery, which is associated with hypoperfusion of the lower middle third of the kidney with suspected ischemia of the lower pole. In confirmation of the previous clinical scenario, we proceed with a urgent angiography, which identifies a pseudoaneurysm, partially thrombosed, of the segmental branch of the left renal artery at the lower middle pole. During the hospitalization, the clinical picture is complicated by an unstable arterial hypertension associated with headache and nausea. A renal scintigraphy confirms a severe impairment of the renal function mainly at the level of the middle third of the lower left kidney. The total glomerular filtration rate sec. Gates was equal to 64.3 mL/min with a percentage breakdown of the global renal function of 28% to the right and 72% to the left. The location of the vascular defect argues for endovascular intervention in the attempt to preserve the remaining renal parenchyma. We proceed with a standard angiography with selective access to the left renal artery with a catheter via femoral artery Cobra 5Fx80 TERUSMO cm. The tortuosity of the thrombus and the angle of the aneurysm site prevent, despite several attempts, the passage of the guide wire for a possible stenting and fibrinolysis. We opt for the placement of 5 spirals at the aneurysm (Boston Soft GDC-10 SR 360 7mm x 15cm), in order to preserve the residual parenchyma, excluding the aneurysmal artery at risk of rupture and extent of the thrombus.

Results

Immediately after the procedure, the clinical picture remained stable with complete remission of painful symptoms and with a good blood pressure control. At about 6 months, the renal scintigraphy shows a filtered global impairment of 70%, 30% for the left kidney, a slight improvement over the previous controls. The blood pressure remains within the limits with amlodipine 5 mg.

Conclusions

Renal artery aneurysms are uncommon and occur in approximately 0.09% of the general population. The etiopathogenesis at a young age is often dysplastic in nature and the diagnosis is made incidentally or during evaluation of related symptoms, being asymptomatic until they become complicated. Their treatment is proposed to prevent complications such as rupture or thrombosis. Given the extreme variability of presentation, the surgical technique, traditional or endoscopic, is at the surgeon's discretion. In our case, we opted for a conservative approach since the degree of renal parenchyma impairment and the patient's hemodynamic condition allowed to.

Curative treatment of pelvic arteriovenous malformation--an alternative strategy: transvenous intra-operative embolisation

OBJECTIVES

Pelvic arteriovenous malformations (AVMs) are difficult to treat. Arterial embolisation is the most common strategy but often has poor results. We report an alternative surgical approach of controlled intra-operative transvenous embolisation with long-term results in seven cases.

MATERIALS AND METHODS

Between 1980 and 2008, we treated seven patients (four men, three women, mean age 50 years). Indications were rectal bleeding (one case), urinary tract problems (four cases), oedema of lower limb (one case) and high-output cardiac failure (one case). Four of them had previous operations and three had previous attempts for embolisation. Embolisation of the malformation was performed through the internal iliac vein. This was done after clamping of all the feeding and draining vessels. The agent used was cyanocrylate (one case), Ethibloc (one case) and bone wax (five cases).

RESULTS

Mortality was 0%. Complications occurred in two patients (28,5%), one pulmonary embolism and one regressive femoral paresis. Three patients were re-operated for various reasons. The mean follow-up period was 6 years (1-12 years). Symptoms resolved in all patients, while control by computed tomography (CT) angioscan revealed one residual shunt.

CONCLUSION

Complete surgical excision of pelvic AVMs is not always possible. Embolisation does not offer a permanent cure. Intra-operative transvenous embolisation of persisting complex AVMs appears to be an alternative approach with good immediate and long-term results. Ethylene glycol appears to be the most suitable agent.

A case of Budd-Chiari syndrome: Gd-EOB-DTPA-enhanced MR findings

Budd-Chiari syndrome (BCS) is a rare disorder caused by the obstruction of hepatic venous outflow, leading to sinusoidal congestion, ischemic injury to liver cells and portal hypertension. Long-term survival largely depends on whether hepatocellular carcinoma occurs. A recently available liver-specific contrast medium, gadolinium-ethoxybenzyl-diethylenetriamine penta-acetic acid (Gd-EOB-DTPA), reportedly has high diagnostic capability for detection of malignant liver tumors. However, there has been no report of the sue of Gd-EOB-DTPA-enhanced magnetic resonance imaging (MRI) for BCS. We present a case of chronic BCS who underwent both gadopentetate dimeglumine (Gd-DTPA) and Gd-EOB-DTPA-enhanced MRI. Hepatic congestion and edema were seen as slightly hypointense areas on Gd-EOB-DTPA-enhanced hepatobiliary-phase images, although these areas were observed as slightly hyperintense on previously obtained Gd-DTPA-enhanced delayed-phase image. Reduced uptake of Gd-EOB-DTPA by hepatocytes in the region of congestion or edema may account for this difference, which should be recognized in image interpretations.

Hepatobiliary and pancreatic imaging in children-techniques and an overview of non-neoplastic disease entities

Imaging plays a major role in the diagnostic work-up of children with hepatobiliary or pancreatic diseases. It consists mainly of US, CT and MRI, with US and MRI being the preferred imaging modalities because of the lack of ionizing radiation. In this review the technique of US, CT and MRI in children will be addressed, followed by a comprehensive overview of the imaging characteristics of several hepatobiliary and pancreatic disease entities most common in the paediatric age group.

Saphenofemoral arteriovenous fistula as hemodialysis access

BACKGROUND

An upper limb arteriovenous (AV) fistula is the access of choice for haemodialysis (HD). There have been few reports of saphenofemoral AV fistulas (SFAVF) over the last 10-20 years because of previous suggestions of poor patencies and needling difficulties. Here, we describe our clinical experience with SFAVF.

METHODS

SFAVFs were evaluated using the following variables: immediate results, early and late complications, intraoperative and postoperative complications (up to day 30), efficiency of the fistula after the onset of needling and complications associated to its use.

RESULTS

Fifty-six SFAVF fistulas were created in 48 patients. Eight patients had two fistulas: 8 patent (16%), 10 transplanted (20%), 12 deaths (24%), 1 low flow (2%) and 20 thrombosis (39%) (first two months of preparation). One patient had severe hypotension during surgery, which caused thrombosis of the fistula, which was successfully thrombectomised, four thrombosed fistulae were successfully thrombectomised and revised on the first postoperative day. After 59 months of follow-up, primary patency was 44%.

CONCLUSION

SFAVF is an adequate alternative for patients without the possibility for other access in the upper limbs, allowing efficient dialysis with good long-term patency with a low complication rate.

Hereditary haemorrhagic telangiectasia: pathophysiology, diagnosis and treatment

Hereditary haemorrhagic telangiectasia, inherited as an autosomal dominant trait, affects approximately 1 in 5000 people. The abnormal vascular structures in HHT result from mutations in genes (most commonly endoglin or ACVRL1) whose protein products influence TGF-ß superfamily signalling in vascular endothelial cells. The cellular mechanisms underlying the generation of HHT telangiectasia and arteriovenous malformations are being unravelled, with recent data focussing on a defective response to angiogenic stimuli in particular settings. For affected individuals, there is often substantial morbidity due to sustained and repeated haemorrhages from telangiectasia in the nose and gut. Particular haematological clinical challenges include the management of severe iron deficiency anaemia; handling the intricate balance of antiplatelet or anticoagulants for HHT patients in whom there are often compelling clinical reasons to use such agents; and evaluation of apparently attractive experimental therapies promoted in high profile publications when guidelines and reviews are quickly superseded. There is also a need for sound screening programmes for silent arteriovenous malformations. These occur commonly in the pulmonary, cerebral, and hepatic circulations, may haemorrhage, but predominantly result in more complex pathophysiology due to consequences of defective endothelium, or shunts that bypass specific capillary beds. This review will focus on the new evidence and concepts in this complex and fascinating condition, placing these in context for both clinicians and scientists, with a particular emphasis on haematological settings.

Achados de imagem e alternativas terapêuticas das malformações vasculares periféricas

As malformações vasculares periféricas compreendem um espectro de lesões que se tornam aparentes no decorrer da vida e podem ser encontradas em praticamente todo o corpo. São pouco comuns e frequentemente confundidas com o hemangioma infantil. Estas doenças são completamente distintas tanto em relação à história clínica como ao prognóstico e às formas de tratamento. Nestas lesões, a história evolutiva e as características do exame físico são de extrema importância para o adequado diagnóstico clinicorradiológico, que guiará a melhor alternativa terapêutica. As classificações mais recentes dividem as malformações vasculares periféricas levando em consideração o fluxo sanguíneo (alto e baixo) e os componentes vasculares envolvidos (arteriais, capilares, linfáticos e venosos). As malformações vasculares periféricas representam um desafio diagnóstico e terapêutico, e exames complementares como tomografia computadorizada, ultrassonografia com Doppler e ressonância magnética, em conjunto com a história clínica, podem trazer informações quanto às características de fluxo e à extensão das lesões. Arteriografia e flebografia confirmam o diagnóstico, avaliam a sua extensão e orientam a decisão terapêutica. Malformações de baixo fluxo geralmente são tratadas por abordagem percutânea e injeção de agente esclerosante, enquanto para as malformações de alto fluxo o acesso é endovascular com uso de agentes embolizantes permanentes líquidos ou sólidos.

Giant coronary artery aneurysms in a Japanese octogenarian - The oldest case of Kawasaki Disease?

Kawasaki disease (KD) is a leading cause of non-atherosclerotic coronary artery aneurysms and, less commonly, peripheral artery aneurysms. We report an 81-year-old Japanese man from Hawaii with a history of an abdominal aortic aneurysm, bilateral iliac aneurysms, and an ambiguous right atrial cystic mass. The patient developed new-onset atrial fibrillation during lithotripsy. Angiography and magnetic resonance imaging revealed giant coronary artery aneurysms of the right coronary artery (RCA) and left anterior descending artery, and a thoracic aortic aneurysm. The RCA aneurysm was greater than 2 inches in diameter at the time of operation. Although we cannot confirm whether the patient had KD during childhood, this is the most likely diagnosis in the absence of a connective tissue disorder, systemic vasculitis, or atherosclerotic risk factors. This patient may represent the oldest case of KD, predating the earliest known case by more than 20 years. This case sheds light on the historical epidemiology of KD and its clinical course, especially regarding late vascular sequelae.

Late-appearing brachiocephalic aneurysm: an atypical vascular sequella of Kawasaki disease

Kawasaki disease (KD) is an acute vasculitis that can result in cardiovascular sequelae. One of the most serious consequences of KD is the development of arterial aneurysms that can lead to thrombosis and ischemia. Commonly, these lesions, occurring early in the course of KD, are found in the coronary arteries. However, this location is not exclusive. This report presents a case of KD with atypical findings of a late-appearing brachiocephalic artery aneurysm. The authors suggest that for patients with complicated KD, surveillance should include a careful vascular survey to discover aneurysms distant from the heart.

Renovascular hypertension in children

Renovascular disease is an uncommon but important cause of hypertension in children. It is usually diagnosed after a long delay because blood pressure is infrequently measured in children and high values are generally dismissed as inaccurate. Many children with renovascular disease have abnormalities of other blood vessels (aorta, cerebral, intestinal, or iliac). Individuals suspected of having the disorder can be investigated further with CT, MRI, or renal scintigraphy done before and after administration of an angiotensin-converting-enzyme inhibitor, but angiography is still the gold standard. Most children with renovascular disease will need interventional or surgical treatment. Endovascular treatment with or without stenting will cure or reduce high blood pressure in more than half of all affected children. Surgical intervention, if needed, should be delayed preferably until an age when the child is fully grown. Modern treatment provided by a multidisciplinary team of paediatric nephrologists, interventional radiologists, and vascular surgeons offers good long-term treatment results.

Cutting Balloon Angioplasty in Children with Resistant Renal Artery Stenosis

Children with systemic hypertension resulting from a renovascular stenosis commonly have fibromuscular dysplasia and respond to percutaneous transluminal renal angioplasty (PTRA). There is a subset of children, however, with conditions that appear to be resistant to PTRA (eg, syndromic renal artery stenosis and arteritis). These patients are often treated surgically. The development of the cutting balloon may provide a minimally invasive alternative to surgery in these individuals. Associated adverse events may include recurrent stenosis, arterial occlusion with renal loss, and arterial rupture with extravasation and pseudoaneurysm formation. Some of these adverse events can be successfully treated with percutaneous interventional techniques. The authors present four cases of cutting balloon angioplasty performed at two large metropolitan children's hospitals in children with resistant renal artery stenosis.

Chapter 11 Kawasaki Disease

Kawasaki disease (KD) is an acute febrile systemic vasculitis usually occurring in children younger than five years, and rarely reported in neonates and adults. This chapter discusses the epidemiology, etiology, pathogenesis, clinical manifestations, and treatments of KD. The etiology still remains unknown, although epidemiological and clinical features strongly suggest an infectious cause. Immunological abnormalities in the acute phase of the disease reflect activation of immune system and marked production of cytokines by activated cells. KD has some similarities to toxin-mediated diseases, both from a clinical and an immunological point of view. The role of one or more superantigens competent of stimulating large numbers of T cells produced by certain strains of Staphylococcus or Streptococcus is discussed in the chapter, in the context of the etiology of KD. Atypical cases are those with fever, acute surgical symptoms, or neurological manifestations as presenting signs. Medical history, physical examination, and laboratory tests including elevated white-blood cell (WBC) count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and low hemoglobin, sodium and albumin levels may help to rule out illnesses mimicking KD. Oral or pulsed corticosteroids in children refractory to intravenous immunoglobulins (IVIG) are an alternative and safe treatment.

TSH receptor signaling via cyclic AMP inhibits cell surface degradation and internalization of E-cadherin in pig thyroid epithelium

Incorporation of E-cadherin into the adherens junction is a highly regulated process required to establish firm cell-cell adhesion in most epithelia. Less is known about the mechanisms that govern the clearance of E-cadherin from the cell surface in both normal and pathological states. In this study, we found that the steady-state removal of E-cadherin in primary cultured pig thyroid cell monolayers is slow and involves intracellular degradation. Experimental abrogation of adhesion by a Ca2+ switch induces rapid cell surface proteolysis of E-cadherin. At the same time, endocytosed intact E-cadherin and newly synthesized E-cadherin accumulate in intracellular compartments that largely escape further degradation. Acute stimulation with thyroid-stimulating hormone (TSH) or forskolin prevents all signs of accelerated E-cadherin turnover. The findings indicate that TSH receptor signaling via cyclic AMP stabilizes the assembly and retention of E-cadherin at the cell surface. This suggests a new mechanism by which TSH supports maintenance of thyroid follicular integrity.