Complex Catheter-Based Structural Heart Reconstruction in a Patient With Tricuspid Atresia and Björk Palliative Conduit

Björk conduit failure is a common reason for reintervention after a Björk modification of the Fontan procedure. We describe a first performed in human percutaneous procedure for the treatment of a failing Björk circuit in an adult with congenital heart disease and complex anatomic features. (Level of Difficulty: Advanced.)

Retrievable Inferior Vena Cava Filters: Indications, Indwelling Time, Removal, Success and Complication Rates

BACKGROUND

Various vena cava filters (VCF) are designed with the ability to be retrieved percutaneously. Yet, despite this option most of them remain in the inferior vena cava (IVC).

OBJECTIVES

To report our experience in the placement and retrieval of three different types of VCFs, and to compare the indications for their insertion and retrieval as reported in the literature.

METHODS

During a 5 year period three types of retrievable VCF (ALN, OptEase, and Celect) were inserted in 306 patients at the Rabin Medical Center (Beilinson and Hasharon hospitals). Indications, retrieval rates, median time to retrieval, success and complication rates were viewed and assessed in the three groups of filter types and were compared with the data of similar studies in the literature.

RESULTS

Of the 306 VCFs inserted, 31 (10.1%) were retrieved with equal distribution in the three groups. In most patients the reason for filter insertion was venous thromboembolic events (VTE) and contraindications to anticoagulant therapy. Mean age was 68.38 ± 17.5 years (range 18-99) and was noted to be significantly higher compared to similar studies (53-56 years) (P < 0.0001). Multi-trauma patients were significantly older (71.11 ± 14.99 years) than post-pulmonary embolism patients (48.03 ± 20.98 years, P < 0.0001) and patients with preventive indication (26.00 ± 11.31, P < 0.0001). The mean indwelling time was 100.6 ± 103.399 days. Our results are comparable with the results of other studies, and there was no difference in percentage of retrieval or complications between patients in each of the three groups.

CONCLUSIONS

In 1 of 10 patients filters should be removed after an average of 3.5 months. All three IVC filter types used are safe to insert and retrieve.

Bronchial artery embolization for massive hemoptysis: Long-term follow-up

Aim

Bronchial artery angiography with embolization has become a mainstay in the treatment of massive hemoptysis. Whereas the immediate success rate is high, the reported long-term success rate varies widely among different groups. We aimed to explore the long-term outcome and clinical predictors associated with recurrent bleeding following bronchial artery embolization.

Methods

We reviewed the clinical characteristics, underlying etiologies, procedure details, and outcome of bronchial artery embolization performed for massive hemoptysis between 1999 and 2012.

Results

All 52 consecutive patients treated by bronchial artery embolization during the study period were included. The major etiologies of massive hemoptysis were bronchiectasis (mostly post-infectious) in 53.8%, and primary and metastatic lung cancer in 30.8%. The immediate success rate was high (48/52; 92%). Of 45 patients who survived more than 24 hours following bronchial artery embolization, recurrent bleeding did not occur in 19 (42.2%) during a median follow-up period of 60 months (range 6–130 months). Bleeding recurred in 26 (57.7%); within 30 days in 15 (33.3%) and after 1 month in the other 11 (24.4%). The average time to onset of early and late repeat bleeding was 2 and 506 days, respectively. Idiopathic bronchiectasis and lung cancer were associated with a high likelihood of late bleeding recurrence.

Conclusions

Bronchial artery embolization is an effective immediate treatment for massive hemoptysis. Because the bleeding recurrence rate is high in patients with lung cancer or idiopathic bronchiectasis, surgery should be considered in these patients following initial stabilization by bronchial artery embolization. For other underlying etiologies, the long-term outcome is excellent.

Transarterial embolization for acute head and neck bleeding: eight-year experience with emphasis on rebleeding risk in cancer patients

OBJECTIVES/HYPOTHESIS

To present our 8-year experience with transarterial embolization for head and neck bleeding, with an emphasis on the need for repeated procedures in patients treated for head and neck cancer.

STUDY DESIGN

Retrospective case series.

METHODS

Tertiary university-affiliated medical center. The cohort included 49 patients who underwent transarterial embolization for acute head and neck bleeding in 2004 to 2012. Outcome measures included procedural success, recurrence, complications, and outcome.

RESULTS

Mean patient age was 60.3 years. Indications for transarterial embolization were bleeding from a tumor (42%), nasal bleeding (36%), bleeding related to neck trauma (8%), tracheal stomal bleeding (8%), and other (4%). Twelve of 21 patients with tumors had been treated by chemoradiation. At least one repeated procedure was required in 11 patients, of whom nine had a history of chemoradiation and surgery for cancer; four of them required a stent for exclusion of pseudoaneurysm, and in six the recurrence presented late after the initial procedure (1 month to 5 years). Major complications included cerebrovascular accident in one patient and death due to major bleeding in two cases. Twenty-one patients died during follow-up, including nine patients with cancer. Eleven deaths occurred up to 4 years after embolization.

CONCLUSIONS

Transarterial embolization is an important tool for the control of head and neck bleeding. Special attention should be given to patients after chemoradiation for cancer. Every effort should be made to control the bleeding because some patients may gain a reasonable lifespan and improved quality of life.

LEVEL OF EVIDENCE

4.

The evaluation of a novel technique to treat saphenous vein incompetence: preclinical animal study to examine safety and efficacy of a new vein occlusion device

Objectives

We tested a novel technique to treat great saphenous vein (GSV) incompetence in an animal model.

Methods

V-block (VVT Medical Ltd, Kfar Saba, Israel), an occlusion device composed of a nitinol frame and anchoring hooks, was percutaneously deployed at the saphenofemoral junction in 12 sheep. Four of the 12 sheep were treated with adjunctive liquid sclerotherapy. Animals underwent duplex ultrasound, venography and histopathological evaluation immediately postimplantation at 30, 60 and 90 days.

Results

V-block was successfully deployed in all animals without adverse events. There was no device migration at follow-up. Histopathological analysis demonstrated V-block to be lodged within the GSV and surrounded by fibrous tissue in all samples. Obliteration of the GSV lumen, widespread intimal loss and multifocal medial smooth muscle loss was noted.

Conclusions

In this animal study V-block was deployed without complications, remained in stable position and led to GSV occlusion. This device has promise for future use in humans.

Low-voltage 96 dB snapshot CMOS image sensor with 4.5 nW power dissipation per pixel

Modern “smart” CMOS sensors have penetrated into various applications, such as surveillance systems, bio-medical applications, digital cameras, cellular phones and many others. Reducing the power of these sensors continuously challenges designers. In this paper, a low power global shutter CMOS image sensor with Wide Dynamic Range (WDR) ability is presented. This sensor features several power reduction techniques, including a dual voltage supply, a selective power down, transistors with different threshold voltages, a non-rationed logic, and a low voltage static memory. A combination of all these approaches has enabled the design of the low voltage “smart” image sensor, which is capable of reaching a remarkable dynamic range, while consuming very low power. The proposed power-saving solutions have allowed the maintenance of the standard architecture of the sensor, reducing both the time and the cost of the design. In order to maintain the image quality, a relation between the sensor performance and power has been analyzed and a mathematical model, describing the sensor Signal to Noise Ratio (SNR) and Dynamic Range (DR) as a function of the power supplies, is proposed. The described sensor was implemented in a 0.18 um CMOS process and successfully tested in the laboratory. An SNR of 48 dB and DR of 96 dB were achieved with a power dissipation of 4.5 nW per pixel.

Percutaneous trans-papillary elimination of common bile duct stones using an existing gallbladder drain for access

BACKGROUND

The presence of stones in the common bile duct (CBD) may cause complications such as obstructing jaundice or ascending cholangitis, and the stones should be removed.

OBJECTIVES

To assess the efficacy of percutaneous elimination of CBD stones from the gallbladder through the papilla.

METHODS

During a 4 year period, six patients (five men and one woman, mean age 71.5 years) who had CBD stones and an existing gallbladder drain underwent percutaneous stone push into the duodenum after balloon dilatation of the papilla, with a diameter equal to that of the largest stone. Access into the CBD was from the gallbladder, using an already existing percutaneous gallbladder drain (cholecystostomy tube).

RESULTS

Each patient had one to three CBD stones measuring 7-14 mm. Successful CBD stone elimination into the duodenum was achieved in five of the six patients. The single failure occurred in a patient with choledochal diverticulum, who was operated successfully. There were no major or minor complications during or after the procedures.

CONCLUSIONS

Trans-cholecystic CBD stone elimination is a safe and feasible percutaneous technique that utilizes existing tracts, thus obviating the need to create new percutaneous access. This procedure can replace endoscopic or surgical CBD exploration.

Hyponatremic hypertensive syndrome in pediatric patients: is it really so rare?

BACKGROUND

Hyponatremic hypertensive syndrome (HHS) is characterized by unilateral renal artery stenosis with secondary hypertension and glomerular and tubular dysfunction due to hyperfiltration and activation of the renin-angiotensin system (RAS).

CASE-DIAGNOSIS/TREATMENT

We describe four children with HHS. All presented with polyuria and polydipsia, electrolyte disturbances, metabolic alkalosis, variable tubular dysfunction, and nephrotic range proteinuria along with hypertension. Interestingly, in one patient, glomerular and tubular abnormalities preceded the development of hypertension. All symptoms resolved after the underlying renal ischemia was corrected by percutaneous angioplasty.

CONCLUSION

Hyponatremic hypertensive syndrome may be more common in children than previously thought. Clinicians should be alert of the signs and symptoms because cure is possible with timely diagnosis and treatment.

Infrapopliteal stenting with silicon carbide-coated stents in critical limb ischemia: a 12 month follow-up study

BACKGROUND

Critical limb ischemia is an increasingly common condition that has high surgical morbidity and limited non-surgical options.

OBJECTIVES

To evaluate the use of silicon carbide-coated Motion stents, as compared to reported data for bare metal stents, in elderly patients with infrapopliteal artery stenoses causing critical limb ischemia after failed or complicated percutaneous transluminal angioplasty.

METHODS

Between January 2003 and March 2004, 41 stents were inserted into 17 consecutive patients (11 males, 6 females, mean age 82 years, range 75-93) following unsuccessful or complicated PTA. Seven patients had one-vessel run-off, six had two-vessel and four had three vessel run-off. All patients suffered from CLI, had up to three lesions and more than one co-morbid condition, and were considered at high surgical risk. Silicon carbide-coated Motion coronary stents, 2.5-4 mm diameterand 25 and 30 mm length, were used. Pre-intervention assessment included clinical condition, ankle brachial index, Doppler ultrasound and digital subtracted angiography. Postintervention evaluation included clinical condition, ABI and Doppler ultrasound at 3, 6 and 12 months.

RESULTS

The technical success rate per lesion was 100% (41/41). Two patients died of unrelated causes after 2 and 8 months respectively. Primary patency rates with duplex ultrasound were 68.7% (11/16) at 3 months, 43.7% (7/16) at 6 months and 40% (6/15) after 12 months. Nine patients developed complete occlusion in 13 stents; three of these patients underwent a below-knee amputation and two patients a partial foot amputation. Re-intervention (PTA only) was performed in 7 patients (43.7%). Secondary patency rate was 81.2% (13/16) at 6 months and 60% (9/15) at one year. Mean ABI index had improved at 6 months from 0.32 to 0.67, and to 0.53 at one year. Clinical improvement was evident in 87.5% (14/16) at 6 months and in 66.6% (10/15) at one year.

CONCLUSIONS

Silicon carbide-coated stents are comparable to bare metal stents after 6 and 12 months in infrapopliteal interventions in CLI when stenting is indicated.

Stent graft closure of a high flow splenorenal shunt after liver transplantation

We describe a patient after liver transplantation with a preexisting surgical splenorenal shunt close to the confluence of the splenic and superior mesenteric veins and a wide, short communication between the splenic and renal veins. To close the shunt, an inferior vena cava filter was inserted in the shunt and a vascular plug was placed in the splenic vein inside the filter. When this failed to stop the flow through the shunt, a covered stent was deployed at the superior mesenteric vein-portal vein junction.

Intraoperative ultrasound in colorectal surgery

PURPOSE

To assess the accuracy of intraoperative ultrasound (IOUS) as a localizing technique for colorectal resections, and its impact on surgical management.

METHODS

Twenty-five patients (15 men and 10 women; mean age, 74.4 years) with early cancers (p T1), or polyps, not amenable to endoscopic removal were selected. IOUS was used as a sole method of intraoperative localization. Its performance was evaluated through review of preoperative colonoscopy reports, intraoperative findings, histopathology reports, and clinical follow-up.

RESULTS

The lesions were situated in the cecum (n = 5), ascending colon (n = 3), transverse colon (n = 4), descending colon (n = 7), and rectum (n = 6). IOUS technique allowed correct localization in 24 of 25 patients, visualization of the bowel wall, and its penetration by malignant tumors. In rectal lesions, IOUS showed clearly the tumor and its margin, which facilitated performance sphincter-sparing procedure.

CONCLUSION

In patients with small polyps and early cancers of colon and rectum, IOUS may be effectively used as a sole method of intraoperative localization and provide additional information that may alter decision making with regard to surgical technique.

Crossing chronic total occlusions with a new 0.014'' CiTop guidewire: proof of concept

OBJECTIVE

To evaluate the feasibility of a new 0.014'' CiTop guidewire to cross total occlusions within normal and diseased blood vessels; proof of concept.

BACKGROUND

Despite recent advances, chronic arterial occlusions remain the main obstacle of coronary and peripheral interventions.

METHODS

The OVALUM CiTop 0.014'' guidewire is an over-the-wire catheter designed to penetrate through chronic total occlusions (CTO) and allow for further PCI interventions. The CiTop guidewire was tested in normal peripheral and coronary arteries of swine (n = 7) and in totally occluded arterial lesions within human amputations (n = 10).

RESULTS

The CiTop 0.014'' guidewire was operated successfully in seven peripheral blood vessels and 12 coronary arteries without angiographic or histological evidence of damage to the arterial wall. The CiTop crossed 9 of the 10 occluded segments within the human amputation with no angiographic or histological evidence of arterial damage (90% success rate). Average time to cross the occlusion was 4.6 +/- 5.6 min. In one artery (10%), angiographic evidence of perforation was noted and there was histological evidence for arterial wall damage.

CONCLUSION

Our data show that the new 0.014'' CiTop guidewire can be well operated within normal peripheral and coronary arteries of swine, and with minimal complications within totally occluded blood vessels from human amputations while effectively penetrating and crossing total arterial occlusions.

Endovascular diagnosis and intervention in patients with isolated hyperammonemia, with or without ascites, after liver transplantation

Hyperammonemia with or without ascites with normal synthetic liver functions after liver transplantation might indicate the presence of anastomotic stenosis of the portal or hepatic vein or the existence of a patent portosystemic shunt. The authors describe six patients, three children after split-liver transplantation and three adults after cadaver liver transplantation, who presented with hyperammonemia. Three patients had ascites. All lesions were successfully treated percutaneously; stents were placed in patients with anastomotic stenoses and coil embolization was performed in patients with patent portosystemic shunts--with either transhepatic or transjugular approaches according to the site of the abnormality. Ammonia levels returned to normal, and ascites had regressed completely for at least 3 months.

Prevalence of myocardial bridging detected with 64-slice multidetector coronary computed tomography angiography in asymptomatic adults

OBJECTIVE

Myocardial bridging is a congenital condition in which a segment of an epicardial artery has an intramural course within the myocardium. The aim of the present study was to evaluate the prevalence of myocardial bridging and the ability of 64-slice coronary computed tomography angiography to identify myocardial bridging in asymptomatic adults.

METHODS

One hundred sixty-nine consecutive asymptomatic subjects underwent 64-row multidetector computed tomography (MDCT) of the coronary arteries. Two experienced CT radiologists identified myocardial bridging >1 mm in thickness, by consensus. We examined the frequency of myocardial bridging and evaluated the length, thickness, and coronary wall lesions.

RESULTS

Myocardial bridges were found in 28 (17%) of 165 subjects. Twenty-one subjects (75%) had 1 bridge and 7 subjects (25%) had 2, for a total of 35 myocardial bridges. Twenty-one bridges (60%) were located in the left anterior descending, 8.5% in the diagonal branch, and 2.8% in the circumflex arteries. The segment beneath the myocardial bridge was always free of coronary wall plaques, but the arterial segment proximal to it had significant coronary wall plaques in 24 cases (68.6%).

CONCLUSION

We found that the incidence of myocardial bridging in asymptomatic adults is 7%, which is in agreement with some pathologic studies in the literature. Our study shows that MDCT of the coronary arteries is a reliable and noninvasive technique, which can accurately locate the site of myocardial bridging, and measure its thickness, course, and length.

Use of a collagen-based device for closure of low brachial artery punctures

PURPOSE

To report our experience with the Angioseal vascular closure device for hemostasis of distal brachial artery puncture.

METHODS

Between September 2003 and August 2005, 64 Angioseal vascular closure devices were inserted in 64 patients (40 men, 24 women; mean age 65 years) immediately after diagnostic or therapeutic arterial angiographies performed through a 5 Fr to 7 Fr sheath via the distal brachial artery. Ultrasound examination of the brachial artery preceded the angiography in all cases and only arteries wider than 4 mm were closed by the Angioseal. In cases of a sonographically evident thin subcutaneous space of the cubital fossa, tissue tumescence, using 1% Lidocaine, was performed prior to the arterial closure.

RESULTS

The deployment success rate was 100%. No major complications were encountered; only 2 patients developed puncture site hematoma, and these were followed conservatively.

CONCLUSIONS

Closure of low brachial artery punctures with the Angioseal is simple and safe. No additional manual compression is required. We recommend its use after brachial artery access interventions, through appropriately wide arteries, to improve early patient ambulation and potentially reduce possible puncture site complications.

Peripheral cutting balloon in the management of resistant benign ureteral and biliary strictures: long-term results

PURPOSE

To report the long-term follow-up results of peripheral cutting balloon incision and dilatation (PCBID) after failed high-pressure balloon dilatation in patients with benign ureteral and biliary strictures.

MATERIALS AND METHODS

The study included 9 patients (5 males and 4 females) who underwent successful PCBID procedures. Of these, 4 patients had biliary strictures; 2 of them had choledocho-choledochal anastomosis after liver transplantation, one at the choledocho-jejunal anastomosis, and the other at the papilla of Vater after failed endoscopic papillotomy. Of the 5 patients with ureteral strictures, 2 occurred following kidney transplantation, one after local radiation, and 2 had pelvic metastases compressing the urinary tract. The duration of follow-up, both clinical and radiological, was 24 months.

RESULTS

The 9 patients who underwent successful PCBID procedures represented 82% of the original group treated by PCBID, which we reported in a previous publication. There were no periprocedural complications. The rate of primary patency, which was confirmed clinically and ultrasonographically at the end of follow- up, was 55% (5/9), and the secondary patency rate was 78% (7/9). Choledocho-choledochal restenosis occurred in 2 patients, 5 and 9 months after liver transplantation, who were treated percutaneously; one by balloon angioplasty (secondary patency for 19 months) and the other by PCBID (patency for 15 months). The remaining 2 patients (both with pelvic metastases) had restenosis 5 and 6 months postprocedure and were successfully treated by the insertion of double-J ureteral stents.

CONCLUSION

PCBID is a simple and safe option for the treatment of ureteral and biliary strictures after failed high-pressure balloon dilatation, which demonstrated a two-year primary patency rate of 55% and a secondary patency rate of 78%.

MR Angiography for Abdominal and Thoracic Aortic Aneurysms: Assessment Before Endovascular Repair in Patients with Impaired Renal Function

OBJECTIVE

The aim of the study was to establish the feasibility of using MR angiography as the sole imaging technique before endovascular repair of abdominal or thoracic aortic aneurysms and to compare preprocedural measurements by MR angiography and digital subtraction angiography in patients with impaired renal function.

CONCLUSION

MR angiography appears to be effective and reliable for use as the sole imaging method before endovascular repair of aortic aneurysms in patients with renal impairment.

Intraoperative ultrasonography: a tool for localizing small colonic polyps

BACKGROUND AND AIMS

Small colonic polyps are difficult to palpate and thus difficult to localize during surgery. Preoperative injection of dyes and "on-the-table colonoscopy" are some of the methods used to allow the surgeon to find the polyps. The aim of the present study was to evaluate the value of intraoperative ultrasound as a tool that may allow detection of small colonic polyps during surgery.

RESULTS

The study population consisted of nine consecutive patients referred to surgery for polyps of the large bowel that were not amenable to endoscopic removal. At surgery, the colon was filled with saline and than scanned by linear ultrasound probe. In 8 out of 9 patients, intraoperative ultrasound successfully detected all polyps, even those smaller than 0.5 cm. In one patient with two polyps, one in the right colon was easily localized, but a second flat, 0.4-cm tubular adenoma at the splenic flexure was missed. In three patients, intraoperative ultrasound showed penetration into the muscular coat. These polyps were found on pathology to be invasive cancer.

CONCLUSION

Intraoperative ultrasound makes it possible for surgeons to easily localize small nonpalpable polyps of the large bowel. Furthermore, it can determine the aggressive potential of these lesions with great accuracy.

Epidermoid cyst and teratoma of the testis: sonographic and histologic similarities

OBJECTIVE

The classic sonographic description of an epidermoid cyst is a mass with a target or onion ring appearance of alternating rings of hyperechogenicity and hypoechogenicity. This study presents a pathologic-sonographic assessment of classic and nonclassic appearances of an epidermoid cyst of the testis and reports the possible similarity between a classic epidermoid cyst and a teratoma on sonography.

METHODS

We reviewed the sonographic and histologic features of 8 testicular tumors that either had a classic onion ring pattern or were found at pathologic examination to be epidermoid cysts but did not have the classic sonographic pattern.

RESULTS

Three epidermoid cysts had a typical onion ring appearance. Histologic sections of these tumors revealed a squamous epithelial layer lining the cyst and multiple concentric laminated layers of keratin. Two tumors did not have a typical sonographic appearance of epidermoid cysts but were found to be epidermoid cysts at pathologic examination. One was homogeneously hypoechoic, and the other had irregular cystic and solid components, but neither had a target or onion ring appearance. Histologically, both of these tumors consisted of cystic cavities lined by squamous epithelium and contained desquamated keratinized epithelium. Notably, 3 other tumors pathologically diagnosed as teratomas had a sonographic appearance of classic epidermoid cysts. These tumors contained layers of keratin, but the cyst was lined by both squamous cells (ectodermal origin) and cylindrical epithelium (endodermal origin), thereby precluding the diagnosis of epidermoid cysts.

CONCLUSIONS

There is considerable overlapping of the sonographic appearances of teratomas and epidermoid cysts of the testis. Although the onion ring appearance of an intratesticular tumor is suggestive of an epidermoid cyst, this appearance may also be found in cases of a teratoma. Whereas the former condition can be treated by local enucleation, the latter requires radical orchiectomy.

Percutaneous transluminal angioplasty of an occluded surgical splenorenal shunt in a 4-year-old child after liver transplantation

Percutaneous transluminal angioplasty is increasingly used in children. We present a case of successful balloon angioplasty of an occluded surgical splenorenal shunt in a 4-year-old child who underwent liver transplantation because of biliary atresia. Percutaneous reopening of the shunt is a relatively safe procedure that may spare patients of surgical intervention.

Use of peripheral cutting balloon in the management of resistant benign ureteral and biliary strictures

PURPOSE

To report the initial and midterm results of percutaneous cutting balloon incision and dilation (PCBID) for the treatment of benign ureteral and biliary strictures in patients after failed high-pressure balloon dilation.

MATERIALS AND METHODS

The study sample consisted of 11 patients: three with ureteric strictures after renal transplantation, three with biliary anastomotic strictures after liver transplantation, three with pelvic metastatic disease compressing the ureter, one after a failed endoscopic papilla of Vater sphincterotomy, and one with tight stenosis at the choledochojejunal anastomosis. All strictures were resistant to high-pressure balloon dilation. Four patients underwent PCBID immediately after failed high-pressure balloon dilation in the same session, and seven underwent the procedure in a separate session within the subsequent week. The width of the peripheral cutting balloons did not exceed the diameter of the normal lumen (7-8 mm).

RESULTS

PCBID was successful in nine patients (82%). One failure occurred in a transplanted ureter and one occurred in a transplanted liver with a choledochocholedochal anastomosis. In both cases, PBCID was performed in the same session as failed high-pressure balloon dilation. There were no periprocedural complications. Patency was confirmed at the 3- and 6-month clinical and ultrasonographic follow-up.

CONCLUSION

PCBID is a simple minimally invasive method for the treatment of benign ureteric and biliary strictures. The success rate is high and no complications occurred.

Embolization of transected vertebral arteries in unstable trauma patients

The aim of this paper is to report our experience with coil embolization for the treatment of vertebral artery transection in unstable trauma patients. The course of four patients admitted to our units between 1998 and 2003 with traumatic injuries of the upper thorax or neck is described. All had unstable hemodynamic parameters at presentation. Emergent arteriogram revealed vertebral artery transection, which was managed by immediate coil embolization proximal to the injury site. Initial technical success was achieved in all four patients, with hemodynamic improvement. No further treatment or surgery to control the vessel injury was needed. There were no immediate or late complications of the procedure and no neurological sequelae. Emergency coil embolization is an effective endovascular technique for use in unstable patients with angiography findings of a transected vertebral artery.

Evaluation of the analytical performance characteristics of the Bayer ACS:180® B-type natriuretic peptide (BNP) assay

BACKGROUND

B-type natriuretic peptide (BNP) is a cardiac hormone that regulates hemodynamic equilibrium and alleviates ventricular stress. In patients with chronic heart failure, BNP levels increase in proportion to the severity of clinical symptoms and degree of decreased left ventricular ejection fraction. BNP has clinical utility in the evaluation, management, and prognosis of patients with heart failure.

METHODS

We evaluated the analytical performance characteristics of the BNP immunochemiluminometric assay in the ACS:180 instrument at three hospital laboratory sites. The analytical performance characteristics evaluated included imprecision, sensitivity (minimum detectable concentration, MDC), analytical measurement range (AMR), dilution linearity/recovery, lot-to-lot reagent variation, high-dose hook effect, and comparison against ADVIA Centaur BNP results on patients' EDTA-plasma samples.

RESULTS

Total imprecision was <10% coefficient of variation at BNP concentrations of 43-1830 pg/ml; MDC was 6.9 pg/ml; AMR was 6.9-5000 pg/ml; overall recovery of BNP in samples diluted up to 1:10 was 98%; there was no lot-to-lot reagent variation in BNP results and no high-dose hook effect at BNP concentrations up to 100,000 pg/ml; and, ACS:180 results were highly correlated (r=0.996) with Centaur BNP results.

CONCLUSIONS

The ACS:180 BNP assay demonstrated excellent analytical performance characteristics and agreement with BNP results obtained using the Centaur instrument.

Uterine artery embolization: A pilot study in a rabbit model

Eight female adult ex-breeder New Zealand white rabbits underwent bilateral, unilateral, or superselective unilateral uterine artery embolization. The histopathologic changes after embolization in New Zealand white rabbits resemble those in humans, making rabbits an appropriate model for experimental uterine artery embolization.

Sonographic diagnosis of right segmental omental infarction

PURPOSE

The purpose of this study was to identify the characteristic features of omental infarction so that this entity can be differentiated from other acute conditions in the right lower quadrant of the abdomen.

METHODS

A retrospective review was undertaken. We searched our hospital medical records and found 6 patients with the diagnosis of omental infarction in the last 3 years. Clinical, sonographic, and CT findings at the time of hospital admission and at follow-up were studied.

RESULTS

In 5 of the 6 patients (83%) sonography demonstrated a moderately hyperechoic, noncompressible ovoid mass located in the omental fat between the umbilicus and the right colon corresponding to the point of maximal tenderness or to the site of a palpable lesion on physical examination. In 1 patient, sonography revealed no abnormalities. In all patients, the diagnosis of omental infarction was confirmed by CT. One patient underwent laparoscopy because of intractable pain; laparoscopy revealed a necrotic segment in the omentum, and pathologic analysis confirmed the original diagnosis.

CONCLUSIONS

Omental infarction is a benign self-limited disease that can mimic acute abdomen. The diagnosis can be established preoperatively with sonography and CT, which may avoid unnecessary laparotomy.

Balloon angioplasty of popliteal and crural arteries in elderly with critical chronic limb ischemia

OBJECTIVE

Elderly patients with extensive infrainguinal peripheral vascular disease and critical chronic limb ischemia (CCLI) are poor surgical candidates. Our purpose was to evaluate angiographic and clinical results of popliteal, infrapopliteal, and multi-level disease percutaneous transluminal angioplasty (PTA) in such patients.

DESIGN

Retrospective study of angiographic and clinical files in selected group.

MATERIALS AND METHODS

Between 1996 and 2002, 38 elderly patients aged 80-94 years old (mean age 83.3) with critical leg ischemia were treated with PTA. All patients were at high surgical risk. 31/38 (81.5%) patients had chronic non-healing wounds, and 14/38 (37%) had multi-level disease of superficial femoral, popliteal and crural arteries. One hundred and two lesions were treated by angioplasty. Immediate angiographic and 1 year clinical results were retrospectively analyzed.

RESULTS

The overall procedural success rate was 32/38 (84.2%). There were three major complications (7.9%), but no deaths, and three technical failures, all were of infrapopliteal lesions. After 1 year, 27 patients could be followed, five patients died during the first year of unrelated causes. Twenty-three patients (85.2%), were clinically re-occluded within 1 year, but complete and partial wound healing was achieved in 80% (16/20) and rest pain improvement in 57% (4/7), so that overall limb salvage was 74% (20/27).

CONCLUSIONS

Elderly patients with multi-level CCLI have a short patency term following angioplasty of 14.8% after 1 year. Nevertheless, this temporary vascular patency enables wound healing or improvement in 74% of these patients, thus such endovascular interventions are recommended in this age group.

Physical examination may miss the diagnosis of bilateral varicocele: a comparative study of 4 diagnostic modalities

PURPOSE

We evaluated the sensitivity of 3 noninvasive methods for detecting left and right varicoceles.

MATERIALS AND METHODS

Three noninvasive methods for the detection of varicocele in the left and right internal spermatic veins were evaluated in 214 infertile men, namely, physical examination, scrotal contact thermography and ultrasound Doppler. Venography was used as the reference diagnosis.

RESULTS

Varicocele was detected in 195 patients (91.1%), on the left side in 37 (19%), on the right side in 3 (1.5%) and bilaterally in 155 (79.5%). Scrotal contact thermography using varicoscreen proved to be the most accurate method. Sensitivity, specificity, accuracy and positive predictive value were 98.9%, 66.6%, 98.5% and 100%, respectively, for left varicocele, and 95.6%, 91.6%, 94.9% and 98%, respectively, for right varicocele. Doppler sonography was associated with the highest number of false-positive results. Accuracy in evaluating retrograde flow was lowest for both sides for physical examination and highest for the combination of Doppler sonography and contact thermography, with a sensitivity, specificity, accuracy and positive predictive value of 100%, 33.3%, 99.0% and 98.9%, respectively, for the left side, and 97.4%, 58.3%, 90.3% and 91.1%, respectively, for the right side. In 165 (85%) of the 195 patients who underwent internal spermatic vein embolization sperm parameters were improved.

CONCLUSIONS

The present study yielded 2 major findings. Thermography is more sensitive and accurate for the detection of varicocele than Doppler ultrasound and physical examination, and it can be used for screening as a single modality in infertile men. Doppler ultrasound and thermography are complementary and their combined use yields the highest sensitivity and accuracy.

Elevation of serum testosterone and free testosterone after embolization of the internal spermatic vein for the treatment of varicocele in infertile men

BACKGROUND

To evaluate the effect of internal spermatic vein (ISV) embolization on levels of serum testosterone and free testosterone and on spermatogenesis.

METHODS

The files of 83 infertile men treated for varicocele were reviewed for changes in serum testosterone, free testosterone and spermatogenesis after ISV embolization.

RESULTS

Mean serum testosterone concentration rose after embolization by 43%, from 12.07 +/- 6.07 nmol/l to 17.22 +/- 8.43 nmol/l (P<0.001). Mean serum free testosterone concentration rose by 72%, from 5.93 +/- 2.44 nmol/l to 10.21 +/- 7.69 nmol/l (P<0.001). Mean sperm concentration increased from 7.49 +/- 1.73 x 10(6)/ml to 18.14 +/- 2.36 x 10(6)/ml (P<0.001); mean sperm motility increased from 21.74 +/- 2.47 to 34.47 +/- 2.27% (P<0.001); and mean sperm morphology increased from 6.63 +/- 1.07 to 13.08 +/- 1.44% (P<0.001).

CONCLUSIONS

ISV embolization apparently induces an increase in both serum testosterone and free testosterone concentrations and in sperm parameters in infertile patient with varicocele, regardless of the size of the varicocele.

Incidental testicular tumors in infertile men

OBJECTIVE

To characterize the population of infertile men with an incidental finding of testicular tumor diagnosed during infertility work-up and to describe their unique presentation and pathological findings.

DESIGN

Retrospective study of 11 men in whom a testicular tumor was incidentally diagnosed during evaluation for infertility out of 150 patients who underwent orchiectomy over a 10-year period (1992 to 2002).

SETTING

University-affiliated urologic referral center.

PATIENT(S)

Infertile men with an incidental testicular mass who underwent radical orchiectomy.

INTERVENTION(S)

Description of patient characteristics: age at diagnosis, presentation, history of undescended testis, and type of infertility.

MAIN OUTCOME MEASURE(S)

Tumor size and location and pathological diagnosis.

RESULT(S)

Eleven patients met the study's inclusion criteria, 11 tumors were identified and characterized. The tumors were usually small, centrally located and nonpalpable. Histologically, six were malignant germ-cell tumors and three were Leydig-cell tumors; two patients had no histologic evidence of tumor. All patients with a history of undescended testis had malignant germ-cell tumors.

CONCLUSION(S)

The use of trans-scrotal sonography enables early diagnosis of small nonpalpable tumors. A history of an undescended testis may necessitate a more aggressive approach, as these patients are at increased risk for testis cancer. Further studies are warranted to establish the yield of routine sonographic screening of infertile men and their specific management.

Leydig cell tumors of the testis: gray scale and color Doppler sonographic appearance

OBJECTIVE

To determine the gray scale and color Doppler sonographic features of Leydig cell tumors of the testis in a series of patients.

METHODS

We retrospectively analyzed the sonographic appearance of 10 proven Leydig cell tumors in 9 patients aged 26 to 47 years. Sonographic features that were reviewed included the size and echogenicity of the tumors, presence of cystic areas or calcifications, and distribution pattern of detectable blood flow on color or power Doppler imaging.

RESULTS

The tumors ranged from 0.4 to 3.0 cm in diameter, but most were less than 1.0 cm in diameter. In 1 testis, 2 discrete Leydig cell tumors were found. Nine (90%) of the 10 tumors were homogeneously hypoechoic. Only 1 tumor was isoechoic with the testis. None of the tumors contained calcifications. Of 8 tumors with color Doppler imaging, 7 (88%) showed a characteristic pattern of increased peripheral blood flow, which was either circumferential or punctate. Only 1 tumor was found with internal hypervascularity.

CONCLUSIONS

Peripheral hypervascularity in a hypoechoic testicular tumor that has little or no internal color Doppler flow should suggest the possibility of a Leydig cell tumor, and consideration should be given to testicle-sparing surgery.

External-internal nephro-uretero-ileal stents in patients with an ileal conduit: long-term results

OBJECTIVES

To describe an improved technique for upper urinary tract drainage in patients with ureteroileal anastomotic stricture after radical cystectomy and urinary diversion to an ileal conduit, and to review our experience and long-term results.

METHODS

From 1995 to 2002, 16 patients (18 renal units) with ureteroileal anastomotic stricture after radical cystectomy and urinary diversion to an ileal conduit underwent external-internal nephro-uretero-ileal stent placement. The procedure consisted of three stages: insertion of a percutaneous nephrostomy tube; retrograde external-internal stent placement with the help of an antegrade-inserted wire, leaving the stent's port in the stoma bag; and periodic retrograde stent exchange. The median duration of follow-up was 26.6 months.

RESULTS

The overall success rate was 94.7%. No serious complications occurred during the procedure or during follow-up. Patient compliance was fairly good. In 75% of the patients, the stent served as the definitive treatment, avoiding the need for surgical revision.

CONCLUSIONS

External-internal nephro-uretero-ileal stent placement can be used successfully and safely as a definitive treatment for anastomosis-related complications in patients after radical cystectomy and urinary diversion to an ileal conduit.

Percutaneous balloon dilatation for the treatment of early and late ureteral strictures after renal transplantation: long-term follow-up

We report our experience with percutaneous balloon dilatation (PBD) for the treatment of ureteral strictures in patients with renal allografts. Of the 422 consecutive patients after renal transplantation in our center 10 patients had ureteral strictures. An additional 11 patients were referred from other centers. The 21 patients included 15 men and 6 women aged 16 to 67 years. Strictures were confirmed by sonography and scintigraphy in all cases. Patients underwent 2 to 4 PBDs at 7-10-day intervals. Clinical success was defined as resolution of the stenosis and hydronephrosis on sequential ultrasound and normalization of creatinine levels. Patients were divided into two groups: those who underwent transplantation more than 3 months previously and those who underwent transplantation less than 3 months previously. PBD was successful in 13 of the 21 patients (62%). There was no statistically significant difference in success rate between the patients with early (n = 12) and those with late (n = 9) obstruction: 58.4% and 66%, respectively. No major complications were documented. PBD is a safe and simple tool for treating ureteral strictures and procedure-related morbidity is low. It can serve as an initial treatment in patients with early or late ureteral strictures after renal transplantation.

Transhepatic balloon dilatation of early biliary strictures in pediatric liver transplantation: successful initial and mid-term outcome

PURPOSE

To evaluate the initial and mid-term outcomes of transhepatic balloon dilatation for the treatment of early biliary strictures in lateral left-segment liver transplants in young children.

METHODS

Between April 1997 and May 2001, seven children aged 9 months to 6 years with nine benign strictures in left-segment liver grafts were treated percutaneously. Sessions of two or three dilations were performed three or four times at average intervals of 10-20 days. In each session, the biliary stenoses were gradually dilated using balloons of 3-7 mm. Follow-up ranged from 12 to 54 months (mean 27 months, median 12 months). Clinical success was defined as resolution of the stenosis, normalization of liver enzymes and lack of clinical symptoms

RESULTS

Technical success was achieved in all nine strictures. Hemobilia occurred in one patient and was successfully treated. On follow-up, all patients had complete clinical recovery with normalization of liver function and imaging of patent bile ducts.

CONCLUSION

Balloon dilatation is an effective and relatively safe method for the treatment of early biliary strictures in left-segment liver transplantation in young children. We recommend this approach as the initial treatment for early strictures. Metal stents or surgery should be reserved for patients with late appearance of strictures or failure of balloon dilatation.

Varicocele: a bilateral disease

OBJECTIVE

To evaluate the prevalence of varicocele in the left and right spermatic veins in infertile men by several methods of examination.

DESIGN

Prospective study.

SETTING

Andrology unit of a department of obstetrics and gynecology, and interventional radiology unit of the radiology department at a tertiary care facility.

PATIENT(S)

Two hundred eighty-six infertile men evaluated for varicocele.

INTERVENTION(S)

Patients underwent evaluation for infertility. Physical examination was followed by contact thermography, Doppler sonography, and venography of both testes.

MAIN OUTCOME MEASURE(S)

We measured the prevalence of varicocele in the left and right spermatic veins in infertile men, and the response of semen parameters after embolization of internal spermatic vein.

RESULT(S)

Varicocele was detected by one of the noninvasive methods and confirmed by venography in 255 patients (89.2%): the left site in 45 (17.6%), the right side in 4 (1.5%), and bilaterally in 206 (80.8%). All patients were treated by embolization. Mean sperm concentration increased from 6.12 +/- 1.02 to 21.3 +/- 1.69 million/mL; mean sperm motility from 16.81 +/- 1.51 to 35.90 +/- 1.41%; and mean sperm morphology from 9.75 +/- 0.85 to 16.92 +/- 1.17%. Pregnancy rate was 43.5%.

CONCLUSION(S)

The present study finds that what was traditionally considered a predominantly unilateral anatomical abnormality apparently has a strikingly high bilateral prevalence (80.7%). This may suggest that we should consider varicocele a bilateral disease. The second finding is the high rate of varicocele detected by venography, thermography, and sonography when compared with physical examination results. Our study may have important implications for treatment, indicating that patients with clinical evidence of unilateral left varicocele should be carefully evaluated for bilateral varicocele.

The effect of class-specific protease inhibitors on the stabilization of B-type natriuretic peptide in human plasma

BACKGROUND

B-type natriuretic peptide (BNP) is a cardiac hormone that regulates hemodynamic equilibrium. In the circulation, its activity is controlled by proteolytic factors. Accurate measurement of BNP in a patient's plasma may be affected by degradation due to proteolysis.

OBJECTIVE

We report on the identification and performance of classes of protease inhibitors that stabilize BNP in plasma.

DESIGN AND METHODS

Using the Bayer ADVIA Centaur BNP assay, we measured the effect of arginine, serine and/or specific kallikrein protease inhibitors (PIs) on exogenous spiked or endogenous BNP in patient plasma.

RESULTS

Compared to controls without inhibitor, all PIs were capable, to varying degrees, of retarding the rate of proteolytic degradation. The kallikrein-specific inhibitor, D-Phe-Phe-Arg-chloromethylketone (PPACK II) was most effective as a single constituent and was able to eliminate BNP degradation in patient samples for up to 6-10 days when stored at 2-8 degrees C.

CONCLUSIONS

The stability of BNP was markedly increased in the presence of kallikrein-specific PPACK II and a broad spectrum of serine PIs. Use of these compounds offers a simple method of extending sample handling and storage of plasma samples containing BNP.

Initial experience with ovarian vein embolization for the treatment of chronic pelvic pain syndrome

BACKGROUND

Ovarian vein embolization was recently suggested as the preferred treatment for chronic pelvic pain syndrome.

OBJECTIVE

To evaluate the technical feasibility, complications and early clinical and radiographic results of ovarian vein embolization in women with pelvic pain syndrome.

METHODS

Percutaneous transcatheter ovarian vein embolization with coils was performed in six patients aged 27-53 years who presented with pelvic pain syndrome. All had lower abdominal pain, and pelvic varicosities were found on Doppler ultrasound and retrograde ovarian vein venography. Embolization was done unilaterally in three patients (on the left side) and bilaterally in three. Mean follow-up by telephone questionnaire was 7.3 months.

RESULTS

The procedure was technically successful in all patients. Two patients reported partial relief of symptoms (33.3%) and three had complete relief (50%), for a total of 5 patients (83.3%) with some measure of improvement. There were no complications following the procedure.

CONCLUSIONS

Percutaneous transcatheter ovarian vein embolization seems to be safe and feasible for the treatment of pelvic pain syndrome. The procedure is performed on an outpatient basis and is well tolerated by patients.

Detrusor resistive index evaluated by doppler ultrasonography as a potential indicator of bladder outlet obstruction

OBJECTIVES

To appraise detrusor blood flow by Doppler ultrasonography in men with suspected bladder outlet obstruction (BOO) to determine whether this imaging technique provides useful information for the assessment of BOO. Experimental studies have shown that BOO is associated with reduced blood flow to the detrusor.

METHODS

Twenty-nine consecutive men with lower urinary tract symptoms were prospectively enrolled. A urodynamic pressure-flow study was performed by the urologist to determine BOO, and Doppler ultrasonography was subsequently performed by the radiologist. The physicians were unaware of the other's results. Scanning was performed on a filled and empty bladder. Arterial blood flow was measured at three distinct sites, the two lateral walls and the trigone, and the resistive index (RI) of each site was calculated (RI = (V(MAX) - V(MIN))/V(MAX)). For each patient, the arithmetic average of the three RIs was defined as the detrusor RI. The findings were compared between patients with and without evidence of BOO. A logistic regression model tested the predictive value of the RI.

RESULTS

According to the pressure-flow study results, 22 (75%) and 7 (25%) of the 29 patients were diagnosed as having or not having BOO, respectively. A statistically significant difference was found between the detrusor RI in the obstructed versus nonobstructed patients in both full (P <0.001) and empty (P <0.03) bladder states (0.79 versus 0.68 and 0.74 versus 0.66, respectively). Our logistic regression model predicted BOO with an overall accuracy of 86%, positive predictive value of 95%, and negative predictive value of 57%.

CONCLUSIONS

The RI of arterial blood flow in the detrusor measured by Doppler ultrasonography provides important predictive information for the presence of BOO. Additional studies are warranted to validate our results and explore the role of Doppler ultrasonography in the management paradigms of patients with suspected BOO.

Effect of aging on the adult extrahepatic bile duct: a sonographic study

OBJECTIVE

To determine whether the size of the extrahepatic bile duct increases with age in adults.

METHODS

We prospectively collected data on 251 patients aged 20 years or older who underwent abdominal sonography. None of the patients had a history of liver, gallbladder, biliary, or pancreatic disease or surgery. The extrahepatic bile duct was measured at 3 locations: in the porta hepatis, in the most distal aspect of the head of the pancreas, and midway between these points. Least squares linear regression was used to correlate patient age and the size of the extrahepatic bile duct.

RESULTS

There were 126 men and 125 women aged 20 to 94 years (mean +/- SD, 52.5 +/- 17.63 years). Twelve percent of the study population were younger than 30 years, and 12% were older than 80 years. The mean diameters of the common bile duct in the 3 locations were as follows: proximal, 3.39 +/- 1.14 mm; middle, 3.72 +/- 1.28 mm; and distal, 4.28 +/- 1.18 mm. The overall mean for all measures was 3.66 +/- 1.15 mm. The width of the common bile duct ranged from 1.0 to 8.6 mm. There was a significant correlation between common bile duct size and age (r = 0.535; P < .001). Mean common bile duct sizes were 3.128 +/- 0.862 mm in the patients younger than 50 years and 4.19 +/- 1.15 mm in the patients older than 50 years (P < .001 by independent t test for equality of means). We have found that the duct gradually dilated 0.04 mm/y.

CONCLUSIONS

This study revealed an age-dependent change in the diameter of the extrahepatic bile duct. We suggest that the upper normal limit of the duct in elderly persons be set at 8.5 mm.

Radiofrequency ablation for the management of liver tumors

BACKGROUND

Radiofrequency ablation has recently become a viable treatment option for unresectable primary or secondary lesions confined to the liver.

OBJECTIVE

To study the local therapeutic efficacy, side effects and complications of radiofrequency ablation for the treatment of hepatocellular carcinoma and liver metastases. This is the first reported experience of radiofrequency ablation for treating malignant hepatic tumors in Israel.

METHODS

Fifteen consecutive patients, aged 53-73 years, with 23 lesions (8 patients with HCC and 7 with secondary liver tumors) underwent radiofrequency ablation under general anesthesia. RITA nine-array 5 cm thermal ablation catheter and the model 1500 generator were used. The mean diameter of all tumors was 4.28 cm (range 1-10 cm). Three lesions were 1-3 cm in diameter (small), 17 lesions measured 3.1-5 cm (medium), and 3 measured 5.1-10 cm (large).

RESULTS

Complete necrosis was found in 8 (66%) of 12 HCCs by computed tomography scan. Of the remainder, diffuse tumor recurrence was demonstrated in three lesions (25%) after lipiodol injection and there was one local tumor recurrence. In the metastases group complete necrosis was found in 5 of 11 lesions (45%). One major complication (peritonitis) was treated with antibiotics and four (26%) minor complications (right pleural effusion, small subcapsular hematoma) were monitored.

CONCLUSIONS

Radiofrequency ablation appears to be an effective, safe and relatively simple procedure for the treatment of liver tumors.

Nonfunctioning renal allograft embolization as an alternative to graft nephrectomy: report on seven years' experience

PURPOSE

Graft nephrectomy is the treatment of choice in patients with graft intolerance syndrome, but it is associated with high morbidity and mortality rates. Renal vascular embolization has been suggested as a possible alternative. The aim of this study was to evaluate the efficacy and safety of arterial embolization of these nonfunctioning transplanted kidneys.

METHODS

Twenty-six transplanted kidneys in 25 patients with irreversible renal graft rejection and graft intolerance who underwent arterial embolization at our center from August 1994 to April 2001 were analyzed for procedural success and long-term outcome. Embolization was performed with absolute alcohol or with polyvinyl alcohol (Ivalon) and coils.

RESULTS

Twenty-four of the 26 (92%) procedures were technically successful, but in one patient only partial occlusion of one of two renal arteries was achieved, and in another the renal artery was already completely occluded. There were two major complications: emphysematous pyelonephritis necessitating nephrectomy and groin abscess that was drained. Follow-up ranged from 8 to 84 months. Clinical success was achieved in 24 of the 26 procedures (92%), and only in one patient did embolization fail to relieve the symptoms, and nephrectomy was performed 3 months later.

CONCLUSION

Renal vascular embolization is a simple, safe and effective technique for the treatment of nonfunctioning renal allografts associated with graft intolerance syndrome. We suggest that it be considered the treatment of choice.

Large vessel aneurysms in Wegener's granulomatosis

Large vessel aneurysm is not a classical finding in Wegener's granulomatosis. We describe a case report of WG complicated by subclavian artery aneurysm and review the literature on large-vessel and medium-vessel aneurysms in WG. The involved arteries included the aorta and the hepatic, renal, and left gastric arteries. In all but one case, abdominal pain was the presenting symptom. Treatment included medical and vascular interventions. In two patients, the involved vessel ruptured, leading to massive hemorrhage and death. We concluded that unexplained abdominal pain or extremity ischemia in patients with WG should alert the physician to the possibility of a large-vessel or medium-vessel aneurysm.