Health-related quality of life in children with congenital vascular malformations

A cross-sectional study was performed to evaluate health-related quality of life (HRQOL) in children with congenital vascular malformations (CVM) and to investigate factors associated with an impaired HRQOL. Children (2-17 years) with CVMs who visited the HECOVAN expertise center between 2016-2018 were included. The PedsQL 4.0 Generic Core Scales were used and a score ≥ 1.0 SD below the normative mean was defined as an impaired HRQOL. Factors associated with impairment were investigated using univariate and multivariate logistic regression analysis. The median overall HRQOL was 84.8/100 (n = 207; 41% boys, 59% girls; self-reported IQR 73.9-92.4 and parent-reported IQR 71.4-92.4). Patients aged 13-17 years reported significantly worse physical functioning than those aged 8-12 years (median 84.4, IQR 71.1-93.8 versus median 90.6, IQR 81.3-96.9; p = 0.02). Parents reported a significantly lower overall HRQOL than their children (median 80.4, IQR 70.7-90.8 versus median 85.9, IQR 76.1-92.4; p = 0.001). HRQOL was impaired in 25% of patients. Impairment occurred significantly more often in lower extremity CVMs (38%, p = 0.01) and multifocal CVMs (47%, p = 0.01) compared to CVMs in the head/neck region (13%). Other associated factors included invasive management (31% versus 14%; p = 0.01), age at first treatment ≤ 5 years (48% versus 25%; p = 0.02) and ongoing treatment (38% versus 18%; p = 0.004). After correction for other factors, significance remained for lower extremity CVMs and ongoing invasive treatment.

CONCLUSIONS

Overall median HRQOL was reasonable and not significantly different from the norm sample. Parental ratings were significantly lower than their children's ratings. A quarter of the patients had an impaired HRQOL, which seemed to worsen with age. Independently associated factors included a lower extremity CVM and invasive management.

WHAT IS KNOWN

• Congenital vascular malformations could affect health-related quality of life (HRQOL). • Studies on pediatric patients are limited and either very small or in combination with adult patient series.

WHAT IS NEW

• This study raises awareness of an impaired HRQOL in 25% of pediatric patients with congenital vascular malformations. • Associated factors included a lower extremity CVM and invasive management.

Clinical differences in sirolimus treatment with low target levels between children and adults with vascular malformations - A nationwide trial

The clinical presentation of patients with slow-flow vascular malformations is very heterogeneous. High clinical burden and subsequent reduced health-related quality of life is something they have in common. There is an unmet medical need for these patients for whom regular treatments like surgery and embolization are either insufficient or technically impossible. Sirolimus has been reported to be effective and overall well-tolerated in most patients. However, the main limitation of sirolimus is the reported high toxicity, especially when target levels of 10-15 ng/mL are being used. We report the results of a phase IIB single-arm open-label clinical trial consisting of 68 (67 in the challenge phase and 68 in the rechallenge phase) evaluable patients (children n = 33 and adults n = 35) demonstrating that treatment with low sirolimus target levels (4-10 ng/mL) is effective in 79.1% of the patients. When sirolimus treatment was stopped, the majority of patients experienced a recurrence of symptoms, supporting prolonged or even lifelong treatment requirement. Adults experienced a higher baseline pain score compared with children, having an estimated marginal mean of 6.2 versus 4.1, p < 0.05; however, they showed a similar decrease to children. Furthermore, the pediatric population experienced less often a sirolimus-related grade I-IV adverse event (35.9% vs. 64.1%, p > 0.05) compared with adults. Additionally, response rates were higher in children compared with adults (93.8% vs. 65.7%, p < 0.05), and children responded faster (28 vs. 91 days, p < 0.05). These results suggest benefits of sirolimus in patients with slow-flow vascular malformations and support its initiation as young as possible.

Magnitude and relevance of change in health-related quality of life in patients with vascular malformations treated with sirolimus

Introduction

Vascular malformations are rare congenital anomalies of the vascular system, which can involve the capillaries, veins, arteries, lymphatics, or a combination of vessel types. Patients with vascular malformations experience an impaired health-related quality of life (HRQoL) because of their symptoms (e.g., pain, swelling, and bleeding) and psychosocial distress. Sirolimus is an effective drug used in the medical treatment of these patients; however, relatively little is known about the effect of sirolimus on specific changes in the HRQoL domains and its magnitude.

Methods

The magnitude of change (effect size) following intervention is more informative to clinical practitioners than statistically significant but clinically unimportant changes; therefore, this study aimed to examine the magnitude and meaningfulness of change in the HRQoL of children and adults with vascular malformations following sirolimus treatment using low target levels.

Results

In total, 50 patients with vascular malformations (19 children, 31 adults) were included in this study. These patients experienced a lower HRQoL than the general population, with the adults reporting a significantly lower score in almost all domains. A 6-month sirolimus treatment improved the HRQoL in 29 patients, including 77.8% of the children (Pediatric Quality of Life Inventory score [PedsQL]) and 57.7% of the adults (Short Form 36 [SF-36]). The effect sizes of sirolimus for each SF-36/PedsQL domain ranged from 0.19 to 1.02. The clinically relevant moderate magnitude of changes was seen in the domains of the children's reports: "Physical functioning" and "Social functioning" and in the domains of the parent reports: "Social functioning," "School functioning," and "Psychosocial." A high-magnitude change was seen in the domains "Emotional functioning" and "Psychosocial" in the children's reports and "Physical functioning" in the parent reports. In addition, the moderate magnitude of changes was also seen in the adults SF-36: in all domains except for "Role limitations-physical problems," "Role limitations-emotional problems," and "General health perception."

Conclusion

We believe this is the first study showing the magnitude of change in HRQoL after sirolimus treatment in patients with vascular malformations. Before treatment, these patients experienced an impaired HRQoL compared with the general Dutch population. A 6-month sirolimus treatment with low target levels led to moderate-to-high clinically relevant changes in multiple domains, which significantly improved the HRQoL.

Clinical trial registration

https://clinicaltrials.gov/ct2/show/NCT03987152?cond=Vascular+Malformations&cntry=NL&city=Nijmegen&draw=2&rank=1, identifier: NCT03987152.

Predicting surgical outcome in posterior retroperitoneoscopic adrenalectomy with the aid of a preoperative nomogram

BACKGROUND

Posterior retroperitoneoscopic adrenalectomy (PRA) has several advantages over transperitoneal laparoscopic adrenalectomy (TLA) regarding operative time, blood loss, postoperative pain, and recovery. However, it can be a technically challenging procedure. To improve patient selection for PRA, we developed a preoperative nomogram to predict operative time.

METHODS

All consecutive patients with tumors of ≤ 7 cm and a body mass index (BMI) of < 35 kg/m2 undergoing unilateral PRA between February 2011 and March 2020 were included in the study. The primary outcome was operative time as surrogate endpoint for surgical complexity. Using ten patient variables, an optimal prediction model was created, with a best subsets regression analysis to find the best one-variable up to the best seven-variable model.

RESULTS

In total 215 patients were included, with a mean age of 52 years and mean tumor size of 2.4 cm. After best subsets regression analysis, a four-variable nomogram was selected and calibrated. This model included sex, pheochromocytoma, BMI, and perinephric fat, which were all individually significant predictors. This model showed an ideal balance between predictive power and applicability, with an R2 of 38.6.

CONCLUSIONS

A four-variable nomogram was developed to predict operative time in PRA, which can aid the surgeon to preoperatively identify suitable patients for PRA. If the nomogram predicts longer operative time and therefore a more complex operation, TLA should be considered as an alternative approach since it provides a larger working space. Also, the nomogram can be used for training purposes to select patients with favorable characteristics when learning this surgical approach.

The lymphatic system throughout history: From hieroglyphic translations to state of the art radiological techniques

A comprehensive lymphatic system is indispensable for a well-functioning body; it is integral to the immune system and is also interrelated with the digestive system and fluid homeostasis. The main difficulty in examining the lymphatic system is its fine-meshed structure. This remains a challenge, leaving patients with uninterpreted symptoms and a dearth of potential therapies. We review the history of the lymphatic system up to the present with the aim of improving current knowledge. Several findings described throughout history have made fundamental contributions to elucidating the lymphatic system. The first contributions were made by the ancient Egyptians and the ancient Greeks. Vesalius obtained new insights by dissecting corpses. Thereafter, Ruysch (1638-1731) gained an understanding of lymphatic flow. In 1784, Mascagni published his illustration of the whole lymphatic network. The introduction of radiological lymphography revolutionized knowledge of the lymphatic system. Pedal lymphangiography was first described by Monteiro (1931) and Kinmonth (1952). Lymphoscintigraphy (nuclear medicine), magnetic resonance imaging, and near-infrared fluorescence lymphography further improved visualization of the lymphatic system. The innovative dynamic contrast-enhanced magnetic resonance lymphangiography (DCMRL) transformed understanding of the central lymphatic system, enabling central lymphatic flow disorders in patients to be diagnosed and even allowing for therapeutic planning. From the perspective of the history of lymph visualization, DCMRL has ample potential for identifying specific causes of debilitating symptoms in patients with central lymphatic system abnormalities and even allows for therapeutic planning.

[Disorders of the central lymphatic system]

The central lymphatic system consists of the thoracic duct, cisterna chyli and the retroperitoneal lymphatics through which lymph and chyle flows. Disorders of the central lymphatic system can for instance lead to leakage (chylothorax), accumulation of fluid (lymphedema) and retrograde flow (protein losing enteropathy). Abnormalities in the central lymphatic system were overlooked for years, followed by lack of diagnostic and therapeutic options. This has changed, as the technique of intranodal contrast injection in inguinal lymph nodes brought renewed interest in the central lymphatic system. In this article, the importance of intranodal contrast injection in diagnosis and treatment of disorders of the central lymphatic system will be presented through 3 clinical cases.

Semantic modelling of common data elements for rare disease registries, and a prototype workflow for their deployment over registry data

BACKGROUND

The European Platform on Rare Disease Registration (EU RD Platform) aims to address the fragmentation of European rare disease (RD) patient data, scattered among hundreds of independent and non-coordinating registries, by establishing standards for integration and interoperability. The first practical output of this effort was a set of 16 Common Data Elements (CDEs) that should be implemented by all RD registries. Interoperability, however, requires decisions beyond data elements - including data models, formats, and semantics. Within the European Joint Programme on Rare Diseases (EJP RD), we aim to further the goals of the EU RD Platform by generating reusable RD semantic model templates that follow the FAIR Data Principles.

RESULTS

Through a team-based iterative approach, we created semantically grounded models to represent each of the CDEs, using the SemanticScience Integrated Ontology as the core framework for representing the entities and their relationships. Within that framework, we mapped the concepts represented in the CDEs, and their possible values, into domain ontologies such as the Orphanet Rare Disease Ontology, Human Phenotype Ontology and National Cancer Institute Thesaurus. Finally, we created an exemplar, reusable ETL pipeline that we will be deploying over these non-coordinating data repositories to assist them in creating model-compliant FAIR data without requiring site-specific coding nor expertise in Linked Data or FAIR.

CONCLUSIONS

Within the EJP RD project, we determined that creating reusable, expert-designed templates reduced or eliminated the requirement for our participating biomedical domain experts and rare disease data hosts to understand OWL semantics. This enabled them to publish highly expressive FAIR data using tools and approaches that were already familiar to them.

Effective low dose sirolimus regimen for kaposiform hemangioendothelioma with Kasabach-Merrit Phenomenon in young infants

AIM

Management of kaposiform hemangioendotheliomas (KHE) with Kasabach-Merrit phenomenon is challenging in young infants who are subjected to developmental pharmacokinetic changes. Sirolimus, sometimes combined with corticosteroids, can be used as an effective treatment of KHE. Simultaneously, toxicities like interstitial pneumonitis related to the use of sirolimus may be fatal. As infants have a very low CYP3-enzyme expression at birth, which rises during ageing, we hypothesize, that a reduced metabolization of sirolimus might lead to high sirolimus serum levels and low dose may be sufficient without the side effects.

METHODS

A case series of five infants with kaposiform hemangioendothelioma with Kasabach-Merrit phenomenon was analysed retrospectively. All infants were treated with sirolimus - 0.2 mg/m2 every 24 or 48 hours according to their age. Prednisone was added to the therapy for additional effect in four patients.

RESULTS

In all patients low dose of sirolimus led to therapeutic sirolimus levels (4-6 ng/mL). All infants (aged 4 days - 7 months) had a complete haematological response, without serious adverse events. In all patients, the Kasabach-Merrit phenomenon resolved, the coagulation profile normalized and tumour size reduction was seen.

CONCLUSION

Low dose sirolimus treatment is safe for infants with kaposiform hemangioendothelioma and Kasabach-Merit phenomenon. Essential is to realize that during the first months of life, metabolism is still developing and enzymes necessary to metabolise drugs like sirolimus still have to mature. To avoid toxic levels, the sirolimus dosage should be based on age and the associated pharmacological developments.

A Clinical Feasibility Study to Image Angiogenesis in Patients with Arteriovenous Malformations Using 68Ga-RGD PET/CT

Arteriovenous malformations (AVMs) have an inherent capacity to form new blood vessels, resulting in excessive lesion growth, and this process is further triggered by the release of angiogenic factors. ⁶⁸Ga-labeled arginine-glycine-aspartate tripeptide sequence (RGD) PET/CT imaging may provide insight into the angiogenic status and treatment response of AVMs. This clinical feasibility study was performed to demonstrate that ⁶⁸Ga-RGD PET/CT imaging can be used to quantitatively assess angiogenesis in peripheral AVMs. Methods: Ten patients with a peripheral AVM (mean age, 40 y; 4 men and 6 women) and scheduled for endovascular embolization treatment were prospectively included. All patients underwent ⁶⁸Ga-RGD PET/CT imaging 60 min after injection (mean dose, 207 ± 5 MBq). Uptake in the AVM, blood pool, and muscle was quantified as SUV_max and SUV_peak, and a descriptive analysis of the PET/CT images was performed. Furthermore, immunohistochemical analysis was performed on surgical biopsy sections of peripheral AVMs to investigate the expression pattern of integrin α_vβ₃ Results: ⁶⁸Ga-RGD PET/CT imaging showed enhanced uptake in all AVM lesions (mean SUV_max, 3.0 ± 1.1; mean SUV_peak, 2.2 ± 0.9). Lesion-to-blood and lesion-to-muscle ratios were 3.5 ± 2.2 and 4.6 ± 2.8, respectively. Uptake in blood and muscle was significantly higher in AVMs than in background tissue (P = 0.0006 and P = 0.0014, respectively). Initial observations included uptake in multifocal AVM lesions and enhanced uptake in intraosseous components in those AVM cases affecting bone integrity. Immunohistochemical analysis revealed cytoplasmatic and membranous integrin α_vβ₃ expression in the endothelial cells of AVMs. Conclusion: This feasibility study showed increased uptake in AVMs with angiogenic activity, compared with surrounding tissue without angiogenic activity, suggesting that ⁶⁸Ga-RGD PET/CT imaging can be used as a tool to quantitatively determine angiogenesis in AVMs. Further studies will be conducted to explore the potential of ⁶⁸Ga-RGD PET/CT imaging for guiding current treatment decisions and for assessing response to antiangiogenic treatment.

Comprehensive molecular and clinicopathological analysis of vascular malformations: A study of 319 cases

Vascular malformations are part of overgrowth syndromes characterized by somatic mosaic mutations or rarely by germline mutations. Due to their similarities and diversity, clinicopathological classification can be challenging. A comprehensive targeted Next Generation Sequencing screen using Unique Molecular Identifiers with a technical sensitivity of 1% mutant alleles was performed for frequently mutated positions in ≥21 genes on 319 formalin‐fixed paraffin‐embedded samples. In 132 out of 319 cases pathogenic mosaic mutations were detected affecting genes previously linked to vascular malformations e.g. PIK3CA (n=80), TEK (TIE2) (n=11), AKT1 (n=1), GNAQ (n=7), GNA11 (n=4), IDH1 (n=3), KRAS (n=9), and NRAS (n=1). Six cases harbored a combination of mutations in PIK3CA and in GNA11 (n=2), GNAQ (n=2), or IDH1 (n=2). Aberrations in PTEN and RASA1 with a variant allele frequency approaching 50% suggestive of germline origin were identified in six out of 102 cases tested; four contained a potential second hit at a lower allele frequency. Ninety‐one of the total 142 pathogenic mutations were present at a variant allele frequency <10% illustrating the importance of sensitive molecular analysis. Clinicopathological characteristics showed a broad spectrum and overlap when correlated with molecular data. Sensitive screening of recurrently mutated genes in vascular malformations may help to confirm the diagnosis and reveals potential therapeutic options with a significant contribution of PIK3CA/mTOR and RAS‐MAPK pathway mutations. The co‐existence of two activating pathogenic mutations in parallel pathways illustrates potential treatment challenges and underlines the importance of multigene testing. Detected germline mutations have major clinical impact.

Innate glycosidic activity in metallic implants for localized synthesis of antibacterial drugs

The unexpected discovery presented herein is that industrialized metallic wires can perform conversion of the glucuronide prodrugs with ensuing antibacterial effects.

Self-expandable tubular collagen implants

Collagen has been extensively used as a biomaterial, yet for tubular organ repair, synthetic polymers or metals (e.g., stents) are typically used. In this study, we report a novel type of tubular implant solely consisting of type I collagen, suitable to self-expand in case of minimal invasive implantation. Potential benefits of this collagen scaffold over conventional materials include improved endothelialization, biodegradation over time, and possibilities to add bioactive components to the scaffold, such as anticoagulants. Implants were prepared by compression of porous scaffolds consisting of fibrillar type I collagen (1.0-2.0% (w/v)). By applying carbodiimide cross-linking to the compressed scaffolds in their opened position, entropy-driven shape memory was induced. The scaffolds were subsequently crimped and dried around a guidewire. Upon exposure to water, crimped scaffolds deployed within 15-60 s (depending on the collagen concentration used), thereby returning to the original opened form. The scaffolds were cytocompatible as assessed by cell culture with human primary vascular endothelial and smooth muscle cells. Compression force required to compress the open scaffolds increased with collagen content from 16 to 32 mN for 1.0% to 2.0% (w/v) collagen scaffolds. In conclusion, we report the first self-expandable tubular implant consisting of solely type I collagen that may have potential as a biological vascular implant.

Enzyme Prodrug Therapy Achieves Site-Specific, Personalized Physiological Responses to the Locally Produced Nitric Oxide

Nitric oxide (NO) is a highly potent but short-lived endogenous radical with a wide spectrum of physiological activities. In this work, we developed an enzymatic approach to the site-specific synthesis of NO mediated by biocatalytic surface coatings. Multilayered polyelectrolyte films were optimized as host compartments for the immobilized β-galactosidase (β-Gal) enzyme through a screen of eight polycations and eight polyanions. The lead composition was used to achieve localized production of NO through the addition of β-Gal-NONOate, a prodrug that releases NO following enzymatic bioconversion. The resulting coatings afforded physiologically relevant flux of NO matching that of the healthy human endothelium. The antiproliferative effect due to the synthesized NO in cell culture was site-specific: within a multiwell dish with freely shared media and nutrients, a 10-fold inhibition of cell growth was achieved on top of the biocatalytic coatings compared to the immediately adjacent enzyme-free microwells. The physiological effect of NO produced via the enzyme prodrug therapy was validated ex vivo in isolated arteries through the measurement of vasodilation. Biocatalytic coatings were deposited on wires produced using alloys used in clinical practice and successfully mediated a NONOate concentration-dependent vasodilation in the small arteries of rats. The results of this study present an exciting opportunity to manufacture implantable biomaterials with physiological responses controlled to the desired level for personalized treatment.

Embolization of the Geniculate Arteries Is an Effective Treatment of Recurrent Hemarthrosis Following Total Knee Arthroplasty That Can Be Safely Repeated

BACKGROUND

Recurrent hemarthrosis is a late complication in up to 1.6% of patients following total knee arthroplasty (TKA). In the absence of intrinsic coagulopathy, one etiology is bleeding of hypertrophic vascular synovium. The aim of this study is to evaluate the clinical outcome of patients referred to our center for angiographic embolization of geniculate arteries for recurrent hemarthrosis following TKA.

METHODS

We retrospectively studied a cohort of patients who were referred for geniculate artery embolization following TKA between August 2011 and September 2016.

RESULTS

A total of 24 embolization procedures were performed on 14 patients. Seven (50%) of these 14 patients underwent one embolization procedure. Due to symptom recurrence, 4 patients underwent a repeated procedure and 3 patients a third procedure. All embolization procedures were technically successful at the time of the procedure. Two patients reported an inguinal hematoma that healed without further treatment. At follow-up of mean 26.8 months, clinical success was achieved in 12 of the 14 patients (86%).

CONCLUSION

Embolization of the geniculate arteries in our study was a safe and effective treatment of recurrent spontaneous hemarthrosis following TKA. Although we have performed a substantial number of reinterventions, results of this study show that this procedure can be safely repeated without adverse events. Our results indicate that embolization could possibly be the treatment of choice when conservative measures fail and can be repeated in the event of recurrent or persistent symptoms.

Noninvasive diagnostic tools for pelvic congestion syndrome: a systematic review

Introduction

In the work‐up of patients with suspected pelvic congestion syndrome, venography is currently the gold standard. Yet if non‐invasive diagnostic tools are found to be accurate, invasive venography might no longer be indicated as necessary.

Material and methods

A literature search in Pubmed and EMBASE was performed from inception until 6 May 2017. Studies comparing non‐invasive diagnostic tools to a reference standard in the work‐up of patients with (suspected) pelvic congestion syndrome were included. Relevant data were extracted and methodological quality of individual included studies was assessed by the Quality Assessment of Diagnostic Accuracy Studies (QUADAS‐2) tool.

Results

Nine studies matched our inclusion criteria. Six studies compared ultrasonography to venography and three studies described a magnetic resonance imaging technique. In using transvaginal ultrasonography, the occurrence of a vein greater than five mm crossing the uterine body had a specificity of 91% (95% CI; 77–98%) and occurrence of pelvic varicoceles a sensitivity and specificity of 100% (95% CI; 89–100%) and 83–100% (95% CI; 66–93%), respectively. In transabdominal ultrasonography, reversed caudal flow in the ovarian vein accounted for a sensitivity of 100% (95% CI; 84–100%). Detection of pelvic congestion syndrome with magnetic resonance imaging techniques resulted in a sensitivity varying from 88 to 100%.

Conclusions

The sensitivity of ultrasonography and magnetic resonance imaging seem to be adequate, which indicates a role for both tests in an early stage of the diagnostic workup. However, due to methodological flaws and diversity in outcome parameters, more high standard research is necessary to establish a clear advice for clinical practice.

Pasireotide does not improve efficacy of aspiration sclerotherapy in patients with large hepatic cysts, a randomized controlled trial

OBJECTIVES

We tested whether complementary use of the somatostatin analogue pasireotide would augment efficacy of aspiration sclerotherapy of hepatic cysts.

METHODS

We conducted a double-blind, placebo-controlled trial in patients who underwent aspiration sclerotherapy of a large (>5 cm) symptomatic hepatic cyst. Patients were randomized to either intramuscular injections of pasireotide 60 mg long-acting release (n = 17) or placebo (sodium chloride 0.9 %, n = 17). Injections were administered 2 weeks before and 2 weeks after aspiration sclerotherapy. The primary endpoint was proportional cyst diameter reduction (%) from baseline to 6 weeks. Secondary outcomes included long-term cyst reduction at 26 weeks, patient-reported outcomes including the polycystic liver disease-questionnaire (PLD-Q) and safety.

RESULTS

Thirty-four patients (32 females; 53.6 ± 7.8 years) were randomized between pasireotide or placebo. Pasireotide did not improve efficacy of aspiration sclerotherapy at 6 weeks compared to controls (23.6 % [IQR 12.6-30.0] vs. 21.8 % [9.6-31.8]; p = 0.96). Long-term cyst diameter reduction was similar in both groups (49.1 % [27.0-73.6] and 45.6 % [29.6-59.6]; p = 0.90). Mean PLD-Q scores improved significantly in both groups (p < 0.01) without differences between arms (p = 0.92).

CONCLUSIONS

In patients with large symptomatic hepatic cysts, complementary pasireotide to aspiration sclerotherapy did not improve cyst reduction or clinical response.

KEY POINTS

• Complementary pasireotide treatment does not improve efficacy of aspiration sclerotherapy. • Cyst fluid reaccumulation after aspiration sclerotherapy is a transient phenomenon. • Aspiration sclerotherapy strongly reduces symptoms and normalizes quality of life.

Continuously Grooved Stent Struts for Enhanced Endothelial Cell Seeding

Purpose

Implantation of pre-endothelialized stents could enhance cellular recovery of a damaged vessel wall provided attached cells remain viable, functional and are present in sufficient numbers after deployment. The purpose of this study was to evaluate the feasibility of grooved stainless steel (SS) stents as a primary endothelial cell (EC) carrier with potentially enhanced EC protection upon stent deployment.

Materials and Methods

Attachment and behavior of enzymatically harvested human adult venous ECs seeded onto gelatin-coated vascular stents were evaluated in an in vitro setting. Smooth and grooved SS stents and smooth nitinol stents were studied.

Results

All cells expressed EC markers vWF and CD31. Using rotational seeding for a period of 16–24 h, ECs attached firmly to the stents with sufficient coverage to form a confluent EC monolayer. The grooved SS wire design was found to enable attachment of three times the number of cells compared to smooth wires. This also resulted in an increased number of cells remaining on the stent after deployment and after pulsatile flow of 180 ml/min for 24 h, which did not result in additional EC detachment.

Conclusions

The grooved stent provides a potential percutaneous means to deliver sufficient numbers of viable and functional cells to a vessel segment during vascular intervention. The grooves were found to offer a favorable surface for EC attachment and protection during stent deployment in an in vitro setting.

Electronic supplementary material

The online version of this article (doi:10.1007/s00270-017-1659-4) contains supplementary material, which is available to authorized users.

Endovascular versus surgical revascularization in proximal subclavian artery obstruction

BACKGROUND

The aim of this paper was to compare the outcomes of endovascular versus surgical treatment in patients with symptomatic proximal subclavian artery obstruction through a retrospective clinical study. Treatment of symptomatic subclavian artery obstruction can be performed with percutaneous transluminal angioplasty or open surgical reconstruction. Comparative studies are scarce.

METHODS

Technical success, patency and complication rates of 47 endovascular reconstructions in 46 patients were retrospectively compared with those of 19 open surgical reconstructions in 17 patients performed between 1996 and 2012. An additional series of 51 surgical reconstructions performed in the same institution between 1976 and 1993 served as a reference.

RESULTS

The technical success rate was 79% for endovascular and 100% for open surgical reconstructions (P<0.05). Primary patency was 72% and 89% at 1 year or 54% and 55% at 5 years for the endovascular and open surgical groups, respectively (log rank 0.210, P=0.65). Assisted primary patency was 77% and 100% at 1 year or 67% and 67% at 5 years, respectively (log rank 0.528, P=0.47). There was no mortality and major complications were infrequent, occurring equally in both groups (P=0.22).

CONCLUSIONS

Although with its less invasive character endovascular treatment has gained preference over surgical treatment of proximal subclavian obstruction in many cases, extrathoracic surgical reconstruction can be performed with a higher technical success rate, similar patency and a comparable number of complications.

Adrenal vein sampling versus CT scan to determine treatment in primary aldosteronism: an outcome-based randomised diagnostic trial

BACKGROUND

The distinction between unilateral aldosterone-producing adenoma or bilateral adrenal hyperplasia as causes of primary aldosteronism is usually made by adrenal CT or by adrenal vein sampling (AVS). Whether CT or AVS represents the best test for diagnosis remains unknown. We aimed to compare the outcome of CT-based management with AVS-based management for patients with primary aldosteronism.

METHODS

In a randomised controlled trial, we randomly assigned patients with aldosteronism to undergo either adrenal CT or AVS to determine the presence of aldosterone-producing adenoma (with subsequent treatment consisting of adrenalectomy) or bilateral adrenal hyperplasia (subsequent treatment with mineralocorticoid receptor antagonists). The primary endpoint was the intensity of drug treatment for obtaining target blood pressure after 1 year of follow-up, in the intention-to-diagnose population. Intensity of drug treatment was expressed as daily defined doses. Key secondary endpoints included biochemical outcome in patients who received adrenalectomy, health-related quality of life, cost-effectiveness, and adverse events. This trial is registered with ClinicalTrials.gov, number NCT01096654.

FINDINGS

We recruited 200 patients between July 6, 2010, and May 30, 2013. Of the 184 patients that completed follow-up, 92 received CT-based treatment (46 adrenalectomy and 46 mineralocorticoid receptor antagonist) and 92 received AVS-based treatment (46 adrenalectomy and 46 mineralocorticoid receptor antagonist). We found no differences in the intensity of antihypertensive medication required to control blood pressure between patients with CT-based treatment and those with AVS-based treatment (median daily defined doses 3·0 [IQR 1·0-5·0] vs 3·0 [1·1-5·9], p=0·52; median number of drugs 2 [IQR 1-3] vs 2 [1-3], p=0·87). Target blood pressure was reached in 39 (42%) patients and 41 (45%) patients, respectively (p=0·82). On secondary endpoints we found no differences in health-related quality of life (median RAND-36 physical scores 52·7 [IQR 43·9-56·8] vs 53·2 [44·0-56·8], p=0·83; RAND-36 mental scores 49·8 [43·1-54·6] vs 52·7 [44·9-55·5], p=0·17) for CT-based and AVS-based treatment. Biochemically, 37 (80%) of patients with CT-based adrenalectomy and 41 (89%) of those with AVS-based adrenalectomy had resolved hyperaldosteronism (p=0·25). A non-significant mean difference of 0·05 (95% CI -0·04 to 0·13) in quality-adjusted life-years (QALYs) was found to the advantage of the AVS group, associated with a significant increase in mean health-care costs of €2285 per patient (95% CI 1323-3248). At a willingness-to-pay value of €30 000 per QALY, the probability that AVS compared with CT constitutes an efficient use of health-care resources in the diagnostic work-up of patients with primary aldosteronism is less than 0·2. There was no difference in adverse events between groups (159 events of which nine were serious vs 187 events of which 12 were serious) for CT-based and AVS-based treatment.

INTERPRETATION

Treatment of primary aldosteronism based on CT or AVS did not show significant differences in intensity of antihypertensive medication or clinical benefits for patients after 1 year of follow-up. This finding challenges the current recommendation to perform AVS in all patients with primary aldosteronism.

FUNDING

Netherlands Organisation for Health Research and Development-Medical Sciences, Institute of Cardiology, Warsaw.

Endovascular Management of a Gunshot Wound Injury to the Innominate Artery and Brachiocephalic Vein

Surgical repair of penetrating injuries of the thoracic outlet with combined arterial and venous involvement is associated with considerable morbidity and mortality. A 37-year-old man presented to the emergency room with a left-sided penetrating zone I neck injury caused by a close-range handgun shot. This had resulted in an injury to the innominate artery and the origin of the right common carotid artery, with shunting to the brachiocephalic vein. This was managed endovascularly by stenting of the innominate artery and by coiling of the origin of the carotid artery. An endovascular approach to this injury is feasible and has the advantage of appropriate visualization of the vascular lesions with limited blood loss during the repair.

Hypotensive Hemostatis (Permissive Hypotension) for Ruptured Abdominal Aortic Aneurysm: Are We Really in Control?

The purpose of this study was to investigate whether a protocol for permissive hypotension was feasible for patients admitted with a ruptured abdominal aortic aneurysm (RAAA). It was aimed to limit prehospital intravenous fluid administration to 500 mL and to maintain systolic blood pressure at a range of 50 to 100 mm Hg following admission, using nitrates when indicated. The diagnosis of RAAA was confirmed with sonography, and all patients with uncontrolled hypovolemic shock immediately underwent open aneurysm repair (OAR). In all other cases, computed tomographic (CT) angiography was performed to determine the eligibility for endovascular aneurysm repair (EVAR). From January 1, 2004, to December 31, 2006, 95 patients with a suspected RAAA were admitted. In 77 patients, the diagnosis of RAAA was confirmed. Twenty-eight cases (36%) underwent OAR for uncontrolled hemodynamic instability. Following CT-angiographic evaluation, 25 of the remaining 49 cases were considered unsuitable for EVAR and subsequently underwent OAR. In 24 of 77 cases (31%), the RAAA was treated with EVAR. Preoperative systolic blood pressure recordings in EVAR patients showed median values (± SD) of 98 (± 34.7) mm Hg in the emergency department and 114 (± 26.2) mm Hg in the operating theater. The desired systolic blood pressure range of 50 to 100 mm Hg was reached in 11 of 24 cases (46%). In 13 of 24 cases (54%), a systolic blood pressure higher than 100 mm Hg was recorded for a period longer than 60 minutes. The 30-day mortality was 32 of 77 (42%), with 6 of 24 (25%) in the EVAR group and 26 of 53 (49%) in the OAR group. This is the first published series of RAAA in which a protocol of permissive hypotension has been adopted. The concept appeared to be feasible in the majority of cases. Protocol violations were sparse ( n = 5). Uncontrolled hypotension occurred in 36% (28 of 77) of all patients, and the desired systolic blood pressure range was achieved in 46% (11 of 24) of the EVAR patients.

The Use of Laser Guidance Reduces Fluoroscopy Time for C-Arm Cone-Beam Computed Tomography-Guided Biopsies

PURPOSE

When using laser guidance for cone-beam computed tomography (CBCT)-guided needle interventions, planned needle paths are visualized to the operator without the need to switch between entry- and progress-view during needle placement. The current study assesses the effect of laser guidance during CBCT-guided biopsies on fluoroscopy and procedure times.

MATERIALS AND METHODS

Prospective data from 15 CBCT-guided biopsies of 8-65 mm thoracic and abdominal lesions assisted by a ceiling-mounted laser guidance technique were compared to retrospective data of 36 performed CBCT-guided biopsies of lesions >20 mm using the freehand technique. Fluoroscopy time, procedure time, and number of CBCT-scans were recorded. All data are presented as median (ranges).

RESULTS

For biopsies using the freehand technique, more fluoroscopy time was necessary to guide the needle onto the target, 165 s (83-333 s) compared to 87 s (44-190 s) for laser guidance (p < 0.001). Procedure times were shorter for freehand-guided biopsies, 24 min versus 30 min for laser guidance (p < 0.001).

CONCLUSION

The use of laser guidance during CBCT-guided biopsies significantly reduces fluoroscopy time.

Preoperative CT-Angiography Predicts Ex Vivo Vein Length for Right Kidneys After Laparoscopic Donor Nephrectomy

BACKGROUND Implantation of a kidney with a short renal vein is technically more challenging and therefore prone for technique-related complications. It remains unclear whether pre-operative computed tomography angiography (CTA), to assess vascular anatomy of the donor kidney, can be used to predict renal vein length. MATERIAL AND METHODS Right and left renal vein lengths of 100 consecutive kidney donors were measured in an oblique-coronal plane multiplanar reconstruction image of 100 consecutive kidney donors in whom ex vivo vein length was measured after recovery. In a second retrospective cohort of 100 consecutive kidney donors donating a right kidney, preoperative CTA vein length measurements were correlated to anastomosis time and early graft outcome. RESULTS Left and right renal vein lengths, measured on CTA, were 43.2 mm and 30.0 mm, respectively. No correlation was found between CTA and ex vivo measurements for the left renal vein (p=.610), whereas a significant correlation was found for the right renal vein (p=.021). In the retrospective cohort, right renal vein length was significantly correlated with the anastomosis time but not with early graft outcome. CONCLUSIONS The length of the right, but not the left, renal vein can be predicted by preoperative CTA, but this does not hold true for the left renal vein.

Aspiration sclerotherapy combined with pasireotide to improve reduction of large symptomatic hepatic cysts (SCLEROCYST): study protocol for a randomized controlled trial

BACKGROUND

Aspiration sclerotherapy is an effective therapeutic option for large symptomatic hepatic cysts. However, incomplete cyst reduction following aspiration sclerotherapy is frequently reported. Strong post-procedural cyst fluid secretion by cholangiocytes, which line the epithelium of the hepatic cyst, seems to be associated with lower reduction rates. Previous studies showed that somatostatin analogues curtail hepatic cyst fluid production. This trial will evaluate the effect of aspiration sclerotherapy combined with the somatostatin analogue pasireotide on cyst reduction. By combining treatment modalities we aim to improve cyst reduction leading to greater symptomatic relief and reduced rates of cyst recurrence.

METHODS/DESIGN

This single center, randomized, double-blind, placebo-controlled clinical trial evaluates the additional effect of pasireotide when combined with aspiration sclerotherapy in patients with a large (>5 cm) symptomatic hepatic cyst. A total of 34 participants will be randomized in a 1:1 ratio. In the active arm, patients will receive pasireotide (long-acting release, 60 mg injection) two weeks prior to and two weeks following aspiration sclerotherapy. Patients in the control arm will receive placebo injections at corresponding intervals. The primary outcome is proportional cyst diameter reduction four weeks after aspiration sclerotherapy compared to baseline measurements, obtained by ultrasonography. As secondary outcomes, proportional volume reduction, recurrence, symptomatic relief and improvement of health-related quality of life will be assessed. Furthermore, safety and tolerability of the combination of pasireotide and aspiration sclerotherapy will be evaluated.

DISCUSSION

This trial aims to improve efficacy of aspiration sclerotherapy by a combined approach of two treatment modalities. We hypothesize that pasireotide will decrease fluid re-accumulation after aspiration sclerotherapy, leading to effective hepatic cyst reduction and symptomatic relief.

TRIALS REGISTRATION

This trial is registered with ClinicalTrials.gov (identifier: NCT02048319 ; registered on 6 January 2014) and EudraCT (identifier: 2013-003168-29; registered on 16 August 2013).

Is there still a place for adrenal venous sampling in the diagnostic localization of pheochromocytoma?

Our objective is to outline the utility of adrenal venous sampling (AVS) with measurements of metanephrine to normetanephrine ratios for diagnostic localization of phaeochromocytoma in a patient with normal plasma levels of catecholamines. A 53-year-old-woman was referred for evaluation of recurrent pheochromocytoma following a right adrenalectomy 14 years earlier. Diagnosis of recurrent disease was established from elevations in plasma metanephrines with normal levels of catecholamines. Magnetic resonance imaging indicated two 1-2 cm masses in the right surgical bed and another 1-1.5 cm mass in the left adrenal. These masses were negative on (123)I-metaiodobenzylguanidine scintigraphy. There was no evidence of a hereditary syndrome. We, therefore, carried out two investigational approaches to identify the tumor masses. Hybrid positron emission tomography/computed tomography with (68)Ga-DOTATOC ((68)Ga-DOTATOC-PET/CT) confirmed the presence of recurrent disease in the right surgical bed and also suggested additional left adrenal involvement. Normal plasma catecholamines precluded the use of adrenal venous sampling (AVS) with catecholamine measurements. Hence, we performed AVS with measurements of plasma metanephrines, which were 4- to 7-fold higher in the left adrenal vein than in central venous plasma. We observed a reversal of the normally high metanephrine to normetanephrine ratio (mean value ± SD 5.28 ± 1.86; range 3.36-8.84, n = 13) to 0.73, establishing the presence of a left adrenal pheochromocytoma. Surgical pathology confirmed bilateral disease. This case highlights a scenario where a combination of (68)Ga-DOTATOC-PET/CT and AVS with measurement of the metanephrine to normetanephrine ratio was crucial for the preoperative assessment of a patient with bilateral pheochromocytoma.

Automatic segmentation of the wire frame of stent grafts from CT data

Endovascular aortic replacement (EVAR) is an established technique, which uses stent grafts to treat aortic aneurysms in patients at risk of aneurysm rupture. Late stent graft failure is a serious complication in endovascular repair of aortic aneurysms. Better understanding of the motion characteristics of stent grafts will be beneficial for designing future devices. In addition, analysis of stent graft movement in individual patients in vivo can be valuable for predicting stent graft failure in these patients. To be able to gather information on stent graft motion in a quick and robust fashion, we propose an automatic method to segment stent grafts from CT data, consisting of three steps: the detection of seed points, finding the connections between these points to produce a graph, and graph processing to obtain the final geometric model in the form of an undirected graph. Using annotated reference data, the method was optimized and its accuracy was evaluated. The experiments were performed using data containing the AneuRx and Zenith stent grafts. The algorithm is robust for noise and small variations in the used parameter values, does not require much memory according to modern standards, and is fast enough to be used in a clinical setting (65 and 30s for the two stent types, respectively). Further, it is shown that the resulting graphs have a 95% (AneuRx) and 92% (Zenith) correspondence with the annotated data. The geometric model produced by the algorithm allows incorporation of high level information and material properties. This enables us to study the in vivo motions and forces that act on the frame of the stent. We believe that such studies will provide new insights into the behavior of the stent graft in vivo, enables the detection and prediction of stent failure in individual patients, and can help in designing better stent grafts in the future.

Metastatic potential of an aneurysmal bone cyst

Aneurysmal bone cysts (ABCs) are benign bone tumors consisting of blood-filled cavities lined by connective tissue septa. Recently, the hypothesis that ABCs are lesions reactive to local hemodynamics has been challenged after the discovery of specific recurrent chromosomal abnormalities. Multiple cases of malignant transformation of ABC into (osteo)sarcoma have been described, as well as a number of cases of telangiectatic osteosarcoma which had been misdiagnosed as ABC. We herewith document a case of a pelvic ABC metastatic to the lung, liver, and kidneys. Diagnosis was confirmed by the presence of a break in the USP6 gene, which is pathognomonic for ABC, in a pulmonary metastasis of our patient. Sarcomatous transformation as an explanation for this behavior was ruled out by demonstrating diploid DNA content in both the pulmonary lesion and the primary tumor.

Systematic review: diagnostic procedures to differentiate unilateral from bilateral adrenal abnormality in primary aldosteronism

BACKGROUND

Computed tomography (CT), magnetic resonance imaging (MRI), and adrenal vein sampling (AVS) are used to distinguish unilateral from bilateral increased aldosterone secretion as a cause of primary aldosteronism. This distinction is crucial because unilateral primary aldosteronism can be treated surgically, whereas bilateral primary aldosteronism should be treated medically.

PURPOSE

To determine the proportion of patients with primary aldosteronism whose CT or MRI results with regard to unilateral or bilateral adrenal abnormality agreed or did not agree with those of AVS.

DATA SOURCES

PubMed, MEDLINE, EMBASE, and Cochrane Library, 1977 to April 2009.

STUDY SELECTION

Studies describing adults with primary aldosteronism who underwent CT/MRI and AVS were included. Of 472 initially identified studies, 38 met the selection criteria; extractable data were available for 950 patients.

DATA EXTRACTION

The CT/MRI result was considered accurate when AVS showed unilaterally increased aldosterone secretion on the same side as the abnormality seen on CT/MRI or when AVS showed symmetric aldosterone secretion and CT/MRI revealed bilateral or no unilateral abnormality.

DATA SYNTHESIS

In 37.8% of patients (359 of 950), CT/MRI results did not agree with AVS results. If only CT/MRI results had been used to determine lateralization of an adrenal abnormality, inappropriate adrenalectomy would have occurred in 14.6% of patients (where AVS showed a bilateral problem), inappropriate exclusion from adrenalectomy would have occurred in 19.1% (where AVS showed unilateral secretion), and adrenalectomy on the wrong side would have occurred in 3.9% (where AVS showed aldosterone secretion on the opposite side).

LIMITATION

The lack of follow-up data in the included articles made it impossible to confirm that adrenalectomies were performed appropriately.

CONCLUSION

When AVS is used as the criterion standard test for diagnosing laterality of aldosterone secretion in patients with primary aldosteronism, CT/MRI misdiagnosed the cause of primary aldosteronism in 37.8% of patients. Relying only on CT/MRI may lead to inappropriate treatment of patients with primary aldosteronism.

Stent placement in patients with atherosclerotic renal artery stenosis and impaired renal function: a randomized trial

BACKGROUND

Little is known about the efficacy and safety of renal artery stenting in patients with atherosclerotic renal artery stenosis (ARAS) and impaired renal function.

OBJECTIVE

To determine the efficacy and safety of stent placement in patients with ARAS and impaired renal function.

DESIGN

Randomized clinical trial. Randomization was centralized and computer generated, and allocation was assigned by e-mail. Patients, providers, and persons who assessed outcomes were not blinded to treatment assignment.

SETTING

10 European medical centers.

PARTICIPANTS

140 patients with creatinine clearance less than 80 mL/min per 1.73 m(2) and ARAS of 50% or greater.

INTERVENTION

Stent placement and medical treatment (64 patients) or medical treatment only (76 patients). Medical treatment consisted of antihypertensive treatment, a statin, and aspirin.

MEASUREMENTS

The primary end point was a 20% or greater decrease in creatinine clearance. Secondary end points included safety and cardiovascular morbidity and mortality.

RESULTS

Forty-six of 64 patients assigned to stent placement had the procedure. Ten of the 64 patients (16%) in the stent placement group and 16 patients (22%) in the medication group reached the primary end point (hazard ratio, 0.73 [95% CI, 0.33 to 1.61]). Serious complications occurred in the stent group, including 2 procedure-related deaths (3%), 1 late death secondary to an infected hematoma, and 1 patient who required dialysis secondary to cholesterol embolism. The groups did not differ for other secondary end points.

LIMITATION

Many patients were falsely identified as having renal artery stenosis greater than 50% by noninvasive imaging and did not ultimately require stenting.

CONCLUSION

Stent placement with medical treatment had no clear effect on progression of impaired renal function but led to a small number of significant procedure-related complications. The study findings favor a conservative approach to patients with ARAS, focused on cardiovascular risk factor management and avoiding stenting.

Hemobilia as a late complication after blunt abdominal trauma: a case report and review of the literature

BACKGROUND

Bleeding within the biliary tree, called hemobilia, is a rare complication after blunt hepatic trauma.

OBJECTIVES

To report on a patient who developed hemobilia 1 month after a blunt abdominal injury and to discuss the diagnosis and treatment of hemobilia.

CASE REPORT

A 17-year-old boy presented with upper gastrointestinal bleeding caused by hemobilia 1 month after a blunt liver injury. Angiography revealed a pseudoaneurysm of the right hepatic artery, which was successfully treated with embolization.

CONCLUSIONS

The diagnosis of hemobilia first requires consideration of the diagnosis, particularly in patients with previous abdominal trauma. Hemobilia should be included in the differential diagnosis of upper gastrointestinal bleeding. Investigations of choice include computed tomography scan followed by angiography. During angiography, treatment can be done by endovascular embolization.

Breast MR imaging in women at increased lifetime risk of breast cancer: clinical system for computerized assessment of breast lesions initial results

The authors developed a clinical system for computerized delineation, rating, and classification of breast lesions depicted in contrast material-enhanced magnetic resonance images obtained in women with increased lifetime risk of breast cancer. Initial results showed negative predictive values above 98% at 50% positive predictive value with negligible interoperator differences. The system demonstrated potential to help exclude malignancy with high confidence and reproducibility with a positive predictive value that is acceptable in screening.

Accuracy of internal mammary lymph node localization using lymphoscintigraphy, sonography and CT

BACKGROUND AND PURPOSE

An accurate internal mammary (IM) lymph node localization technique is required for proper irradiation of the IM lymph nodes in breast cancer patients. In this study the measurement accuracy of three techniques for direct or indirect localization of the IM nodes was estimated.

MATERIALS AND METHODS

In 40 patients the IM lymph node depth and lateral distance from the patient midline were measured with lymphoscintigraphy in intercostal spaces 2, 3 and 4. The corresponding position of an IM vessel was measured with sonography and CT in intercostal spaces 1-4. The sonography and CT vessel measurements in the four intercostal spaces were compared to determine the measurement accuracy of sonography. The node and vessel data in intercostal space 2 were inserted into a mathematical model to determine the measurement accuracy of lymphoscintigraphy and CT for node detection.

RESULTS

Vessel depths measured by sonography were systematically too shallow and the lateral vessel position could not be accurately determined. The mathematical model showed that the node depth and lateralization in one intercostal space can be measured directly by lymphoscintigraphy within an accuracy (1 SD) of 5 mm in depth and 6 mm in the lateral direction. The accuracy of CT for indirect node detection was 6 mm in depth and 7 mm in the lateral direction.

CONCLUSIONS

Sonography is not a suitable technique for measuring the IM vessel or node position. Lymphoscintigraphy and CT have measurement accuracies for node detection that are acceptable for radiotherapy.

Reproducibility of mammary gland structure during repeat setups in a supine position

PURPOSE

In breast conserving therapy, complete excision of the tumor with an acceptable cosmetic outcome depends on accurate localization in terms of both the position of the lesion and its extent. We hypothesize that preoperative contrast-enhanced magnetic resonance (MR) imaging of the patient in a supine position may be used for accurate tumor localization and marking of its extent immediately prior to surgery. Our aims in this study are to assess the reproducibility of mammary gland structure during repeat setups in a supine position, to evaluate the effect of a breast immobilization device, and to derive reproducibility margins that take internal tissue shifts into account occurring between repeat setups.

MATERIALS & METHODS

The reproducibility of mammary gland structure during repeat setups in a supine position is estimated by quantification of tissue shifts in the breasts of healthy volunteers between repeat MR setups. For each volunteer fiducials are identified and registered with their counter locations in corresponding MR volumes. The difference in position denotes the shift of breast tissue. The dependence on breast volume and the part of the breast, as well as the effect of a breast immobilization cast are studied.

RESULTS

The tissue shifts are small with a mean standard deviation on the order of 1.5 mm, being slightly larger in large breasts (V> 1000 cm3), and in the posterior part (toward the pectoral muscle) of both small and large breasts. The application of a breast immobilization cast reduces the tissue shifts in large breasts. A reproducibility margin on the order of 5 mm will take the internal tissue shifts into account that occur between repeat setups.

CONCLUSION

The results demonstrate a high reproducibility of mammary gland structure during repeat setups in a supine position.

Delayed pseudoaneurysm after renal artery angioplasty

PURPOSE

To report delayed pseudoaneurysm formation after percutaneous renal artery angioplasty.

CASE REPORTS

A 56-year-old woman succumbed to complications of a ruptured right juxtarenal aortic pseudoaneurysm 2 years after right renal artery stenting for renal impairment. The juxtarenal aorta had been normal on aortography at the time of angioplasty. She gave a history of right-sided back pain that started within 8 months of the angioplasty. A 21-year-old woman with left renal artery stenosis due to fibromuscular dysplasia was treated with balloon angioplasty, after which there was evidence of active extravasation. The completion angiogram, after a period of observation, documented cessation of the leak. Follow-up angiography because of persisting hypertension disclosed a large, asymptomatic, intrarenal pseudoaneurysm that was repaired with bench surgery and autotransplantation.

CONCLUSIONS

We advise that patients with symptoms referable to the site of renal artery intervention and those who have had complicated interventions should have follow-up imaging to exclude pseudoaneurysm formation.