Caesarean-section scar endometriosis (CSSE): clinical and imaging fundamentals of an underestimated entity

Caesarean-section scar endometriosis (CSSE) is a form of extra-pelvic endometriosis developing through endometrial cell implantation anywhere along the route of a previous caesarean section (CS) surgery, including the skin, subcutaneous tissue, abdominal wall muscles, intraperitoneally, and the uterine scar itself. Synchronous intra-abdominal endometriosis is not a prerequisite. Given the rising prevalence of CS, CSSE may be underrepresented in the literature and occur more frequently than previously thought. Locating a painful soft-tissue mass-like lesion along the path of a previous CS scar is the most indicative sign that should initially alarm physicians towards suggesting CSSE, especially if symptoms are typical (cyclically reoccurring with menstruation). The detection of hyperintense (haemorrhagic) foci on T1 fat-saturated sequences will strongly support the diagnosis on magnetic resonance imaging (MRI), the most sensitive imaging method for CSSE assessment. A non-specific, contrast-enhancing, hypodense nodule with spiculate edges may be suggestive if the lesion was originally detected on computed tomography (CT). Although ultrasound is frequently the first imaging method used, the findings are non-specific; therefore, making it more useful for ruling out other differentials and for image-guided biopsy. In any case, histopathology provides the definitive diagnosis. Surgical excision is the mainstay of treatment; however, minimally invasive, percutaneous techniques have also been implemented successfully.

Percutaneous computed tomography-guided radiofrequency ablation of a spinal osteoid osteoma abutting the dura: a case report and review of the literature

PURPOSE

Osteoid osteomas in the spine constitute a challenging group for both surgical and percutaneous approaches. Purpose of the present study is to report a case report of a spinal osteoid osteoma in a challenging spinal location and review literature for safety and efficacy of the technique.

METHODS

We report a case of spinal osteoid osteoma extending in the epidural space and abutting the dura in a pediatric patient treated by percutaneous computed tomography-guided radiofrequency ablation. This is not a systematic review of the literature. A number of separate literature searches were performed. Non-English studies and case reports were excluded from the study. All references of the obtained articles were also evaluated for any additional information.

RESULTS

Although all prophylactic measures were taken (hydrodissection, thermocouples and neurophysiologic monitoring) and the procedure was uneventful, patient within three hours, was unable to raise or bend the unilateral lower extremity below the knee. Pain reduction was significant from the first morning post-ablation and during the follow-up period of 18 months. MR scan was within normal limits. Dexamethasone was iv injected for 24 h and prescribed per os for 7 days. At follow-up 1 week later mobility of the lower extremity had returned to normal.

CONCLUSION

As far as spine ablation is concerned, all prophylactic measures should be taken; neurophysiologic monitoring seems to be more sensitive than temperature measurement. Intravenous and per os corticosteroids are extremely useful in case of nerve damage.

An active approach of pressure waveform matching for stress-based testing of arteries

BACKGROUND

Arterial compliance assists the cardiovascular system with three key roles: (i) storing up to 50% of the stroke volume; (ii) ensuring blood flow during diastole; (iii) dampening pressure oscillations through arterial distension. In mock circulation loops (MCLs), arterial compliance was simulated either with membrane, spring, or Windkessel chambers. Although they have been shown to be suitable for cardiac device testing, their passive behavior can limit stress-based testing of arteries. Here we present an active compliance chamber with a feedback control of variable compliance as part of an MCL designed for biomechanical evaluation of arteries under physiological waveforms.

MATERIALS AND METHODS

The chamber encloses a piston that changes the volume via a cascaded controller when there is a difference between the real-time pressure and the physiological reference pressure with the aim to equilibrate both pressures.

RESULTS

The experimental results showed repeatable physiological waveforms of aortic pressure in health (80-120 mm Hg), systemic hypertension (90-153 mm Hg), and heart failure reduced ejection fraction (78-108 mm Hg). Statistical validation (n = 20) of the function of the chamber is presented against compared raw data.

CONCLUSION

We demonstrate that the active compliance chamber can track the actual pressure of the MCL and balance it in real time (every millisecond) with the reference values in order to shape the given pressure waveform. The active compliance chamber is an advanced tool for MCL applications for biomechanical examination of stented arteries and for preclinical evaluation of vascular implants.

Computed-tomography-guided transforaminal intrathecal nusinersen injection in adults with spinal muscular atrophy type 2 and severe spinal deformity. Feasibility, safety and radiation exposure considerations

BACKGROUND AND PURPOSE

The purpose was to investigate our centre's experience on computed-tomography-guided (CT-guided), transforaminal, intrathecal administration of nusinersen in adult subjects with spinal muscular atrophy (SMA) type 2 and severe spinal deformity.

METHOD

This is a retrospective, single-centre study investigating the feasibility and safety of CT-guided, transforaminal, lumbar puncture for the intrathecal administration of nusinersen (Spinranza®; Biogen; Cambridge, MA, USA) in a cohort of adult subjects with SMA type 2, severe neuromuscular scoliosis and previous spinal surgery. Between January 2019 and October 2019, five male, adult, SMA type 2 subjects were eligible to be treated in our centre with nusinersen. The mean age of the patients was 31 ± 9 years (range 19-43 years). The study's outcome measures were technical success, adverse events and radiation exposure.

RESULTS

In total, four patients completed the four loading doses, whilst the fifth patient received only one loading dose; two patients also received their first maintenance doses. Overall, 20 consecutive transforaminal, intrathecal treatments were analysed. Technical success was 100% (20/20 intrathecal infusions). No adverse events were documented following the procedures. Mean dose-length product (DLP) value per injection was 665.4 ± 715.5 mGy*cm. Estimated mean effective dose per injection was 12.7 ± 12.9 mSv. Subgroup analysis between the chronologically first 10 versus subsequent 10 procedures demonstrated a clear trend towards less radiation exposure in the latter, although this difference did not reach statistical significance (DLP: 984.7 ± 903.3 vs. 436.7 ± 321.5 mGy*cm, P = 0.165; respectively).

CONCLUSIONS

In this retrospective series, CT-guided transforaminal access for intrathecal injection of nusinersen was proven feasible and safe. A decrease in radiation dose over time was noted. Protocols to minimize radiation exposure are essential.

Haematocrit and haemoglobin decrease following image-guided percutaneous core needle biopsies

AIM

To determine the clinical significance of variation in haematocrit (Ht) and haemoglobin (Hb) values before and after image-guided percutaneous core needle biopsies (PCNBs) and evaluate its clinical significance.

MATERIALS AND METHODS

This single-centre, retrospective study included all the patients who underwent image-guided PCNBs between November 2012 and September 2018. In total, 105 cases (56 male; 53.3%; mean age 72±8 years) were available for analysis. Biopsies included lesions of the liver, lung, kidney, bone, paravertebral and soft-tissue masses, peritoneal implantations, and retroperitoneal neoplasms. The study's primary outcome was to compare the pre- and post-procedural Ht and Hb values and to evaluate their clinical significance.

RESULTS

A significant decrease of the mean Hb and Ht values was detected post-biopsy (12.79±1.85 g/dl versus 12.03±1.72 g/dl and 38.75±4.93% versus 36.49±4.73%; p<0.0001). A decrease in the Ht and/or Hb level was noted in 93/105 (88.6%) and 94/105 (89.5%) of the patients; respectively. Four minor bleeding complications were noted (4/105; 3.8%), which resolved without any further treatment. An >4% decrease in Ht value was noted in 17/105 cases (16.2%) and an Hb decrease of ≥1.5 mg/dl was noted in 10/105 cases (9.5%), all without any haemodynamic compromise.

CONCLUSIONS

A moderate post-PCNB decrease in Ht and Hb values compared to baseline should be expected, but should not raise concerns regarding an ongoing bleeding event, if not correlated with haemodynamic and clinical signs of haemorrhage.

Detection of myocardial ischemia due to clinically asymptomatic coronary artery stenosis at rest using supervised artificial intelligence-enabled vectorcardiography - A five-fold cross validation of accuracy

BACKGROUND

Coronary artery disease (CAD) is a leading cause of death and disability. Conventional non-invasive diagnostic modalities for the detection of stable CAD at rest are subject to significant limitations: low sensitivity, and personal expertise. We aimed to develop a reliable and time-cost efficient screening tool for the detection of coronary ischemia using machine learning.

METHODS

We developed a supervised artificial intelligence algorithm combined with a five lead vectorcardiography (VCG) approach (i.e. Cardisiography, CSG) for the diagnosis of CAD. Using vectorcardiography, the excitation process of the heart can be described as a three-dimensional signal. A diagnosis can be received, by first, calculating specific physical parameters from the signal, and subsequently, analyzing them with a machine learning algorithm containing neuronal networks. In this multi-center analysis, the primary evaluated outcome was the accuracy of the CSG Diagnosis System, validated by a five-fold nested cross-validation in comparison to angiographic findings as the gold standard. Individuals with 1, 2, or 3- vessel disease were defined as being affected.

RESULTS

Of the 595 patients, 62·0% (n = 369) had 1, 2 or 3- vessel disease identified by coronary angiography. CSG identified a CAD at rest with a sensitivity of 90·2 ± 4·2% for female patients (male: 97·2 ± 3·1%), specificity of 74·4 ± 9·8% (male: 76·1 ± 8·5%), and overall accuracy of 82·5 ± 6·4% (male: 90·7 ± 3·3%).

CONCLUSION

These findings demonstrate that supervised artificial intelligence-enabled vectorcardiography can overcome limitations of conventional non-invasive diagnostic modalities for the detection of coronary ischemia at rest and is capable as a highly valid screening tool.

Current state of total artificial heart therapy and introduction of the most important total artificial heart systems

Due to the declining instances of organ donation, total artificial heart (TAH) therapy is of increasing importance for the management of end-stage biventricular heart failure. We introduce the currently most important established and novel TAH systems (SynCardia, CARMAT, ReinHeart, BiVACOR), report clinical outcomes and discuss technical requirements for the successful implementation of TAH therapy as an alternative to cardiac transplantation.

Should heart failure patients be left to fate? Temporary implementation of veno-arterial extracorporeal membrane oxygenation for haemodynamic support during excision of rectal carcinoma in an end-stage biventricular heart failure patient

Management of end-stage heart failure patients requiring major general surgery is not well defined. Due to poor cardiorespiratory reserve, perioperative morbidity and mortality are excessively high. We report a case of temporary implementation of veno-arterial extracorporeal membrane oxygenation for haemodynamic support during excision of rectal carcinoma in an end-stage heart failure patient and describe perioperative management.

FD-OCT and IVUS intravascular imaging modalities in peripheral vasculature

Intra-Vascular Ultra-Sound (IVUS) and Frequency Domain-Optical Coherence Tomography (FD-OCT), in vivo, intra-vascular, imaging modalities, widely used in the field of coronary disease, have been recently implemented in peripheral endovascular procedures, for procedural assessment, plaque characterization and determination of predictors of treatment outcomes. Their unique characteristics have also been used in order to provide additional features and improve the performance of re-entry devices and atherotomes. Areas covered: Present review focuses on available literature regarding these two promising imaging technologies in the peripheral vasculature, highlighting the added value produced by their use in endovascular therapy, their limitations and their utilization in new endovascular devices. Authors also provide their future perspective and the possible benefits in understanding vascular behavior and lesion characterization in peripheral endovascular interventions. Expert commentary: By providing both quantitative but also qualitative data on vessel and lesion morphology, intravascular imaging modalities offer a valid solution for endovascular treatment evaluation and outcome presentation homogeneity.

Liver failure in total artificial heart therapy

BACKGROUND

Congestive hepatopathy (CH) and acute liver failure (ALF) are common among biventricular heart failure patients. We sought to evaluate the impact of total artificial heart (TAH) therapy on hepatic function and associated clinical outcomes.

METHODS

A total of 31 patients received a Syncardia Total Artificial Heart. Preoperatively 17 patients exhibited normal liver function or mild hepatic derangements that were clinically insignificant and did not qualify as acute or chronic liver failure, 5 patients exhibited ALF and 9 various hepatic derangements owing to CH. Liver associated mortality and postoperative course of liver values were prospectively documented and retrospectively analyzed.

RESULTS

Liver associated mortality in normal liver function, ALF and CH cases was 0%, 20% (P=0.03) and 44.4% (P=0.0008) respectively. 1/17 (5.8%) patients with a normal liver function developed an ALF, 4/5 (80%) patients with an ALF experienced a markedly improvement of hepatic function and 6/9 (66.6%) patients with CH a significant deterioration.

CONCLUSIONS

TAH therapy results in recovery of hepatic function in ALF cases. Patients with CH prior to surgery form a high risk group with increased liver associated mortality.

Applicability of cardiogoniometry as a non-invasive screening tool for the detection of graft vasculopathy in heart transplant recipients

Currently available diagnostic modalities for the detection of graft vasculopathy following orthotopic heart transplantation are subject to various restrictions. We hypothesized that cardiogoniometry, a novel non-invasive diagnostic tool for the detection of atherosclerotic coronary vessel disease, is applicable in the graft vasculopathy setting. Cardiogoniometric results were obtained during routine follow-up in 49 consecutive, unselected heart transplant recipients and then retrospectively correlated blindly by an independent reader to recent angiographic findings. Sensitivity of cardiogoniometry was 100%, specificity 62.3%, positive predictive value 68.75%, negative predictive value 100%, negative likelihood ratio 0 and positive likelihood ratio 2.888. Cardiogoniometry is potentially applicable as an easy-to-perform, non-invasive screening tool predominantly for the exclusion but also for the detection of graft vasculopathy in heart transplant recipients.

Implantation technique of the 50-cm3 SynCardia Total Artificial Heart: does size make a difference?

Despite downsizing, implantation technique of the 50-cm(3) SynCardia Total Artificial Heart and settings of the Companion driver remain unchanged. Owing to the absence of de-airing nipples, de-airing procedure is even more crucial and has to be performed carefully.

Percutaneous dilatational tracheostomy following total artificial heart implantation

Coagulation disorders and an immune-altered state are common among total artificial heart patients. In this context, we sought to evaluate the safety of percutaneous dilatational tracheostomy in cases of prolonged need for mechanical ventilatory support. We retrospectively analysed the charts of 11 total artificial heart patients who received percutaneous dilatational tracheostomy. We focused on early and late complications. We observed no major complications and no procedure-related deaths. Early minor complications included venous oozing (45.4%) and one case of local infection. Late complications, including subglottic stenosis, stomal infection or infections of the lower respiratory tract, were not observed. In conclusion, percutaneous dilatational tracheostomy in total artificial heart patients is safe. Considering the well-known benefits of early tracheotomy over prolonged translaryngeal intubation, we advocate early timing of therapy in cases of prolonged mechanical ventilation.

Antiplatelet therapy in critical limb ischemia: update on clopidogrel and cilostazol

Antiplatelet therapy is essential for critical limb ischemia (CLI) patients, both as primary prevention for ischemic events and as adjuvant pharmacotherapy in order to avoid acute or late thrombo-occlusive events and maintain patency following peripheral endovascular or open surgical limb-salvage revascularization procedures. According to currently updated international guidelines clopidogrel as monotherapy or as part of dual antiplatelet therapy is recommended in CLI patients, while recent evidence delineated the beneficial effect of cilostazol in patients undergoing peripheral endovascular angioplasty or stenting as its administration resulted in a decrease of restenosis and clinically-driven reinterventions, as well as in the enhancement of platelet inhibition. This review aims in discussing recent evidence on the topic of antiplatelet therapy in CLI patients, with a special focus on the use of clopidogrel and cilostazol.

A monitoring and physiological control system for determining aortic valve closing with a ventricular assist device

OBJECTIVES

Real-time monitoring of the aortic valve function and the loading state of the left ventricle (LV) during mechanical circulatory support is essential. Therefore, we developed a system that determines accurately the aortic valve closing moment based on integrals derived from the pump inlet pressure and the pump power [pressure-power area (PPA)].

METHODS

A Deltastream diagonal pump was implanted in 10 healthy Rhoen sheep. Changes in ventricular volume and pressure in different assist levels were measured by a conductance catheter placed in the LV and were correlated with intrinsic pump signals, motor power, voltage and current. Measurements were obtained in the state of normal as well as decreased left ventricular contractility induced by β-blockers.

RESULTS

Complete datasets were obtained in seven animals. The PPA-feedback signal reached its maximum at the speed of aortic valve closing. This was validated by pressure-volume (PV)-catheter measurements both at the baseline and in the state of decreased contractility. In both cases, zero-crossing occurred at the point of aortic valve closing speed.

CONCLUSIONS

With this trial, we deliver the experimental basis for the development of an automatic feedback controller that would allow periodic speed changes in accordance with the loading state of the native ventricle and the opening state of the aortic valve. This would deliver real-time data to treating physicians and enable the establishment of a standard weaning protocol.

Repair of left ventricular driveline tear in a SynCardia-total artificial heart patient

We report the case of a 64-year old Caucasian male patient with a tear of the left ventricular driveline just above the driveline-air tube junction. We describe the repair technique and the necessary set of tools.

Image based evaluation of mediastinal constraints for the development of a pulsatile total artificial heart

Background

Good anatomical compatibility is an important aspect in the development of cardiovascular implants. This work analyzes the interaction of the pump unit of an electrically driven pulsatile Total Artificial Heart (TAH) and the mediastinum. For an adequate compliance, both overall dimensions and alignment of inlets and outlets must be matched.

Methods

Cross-sectional medical image data of 27 individuals, including male and female patients suffering from end stage heart failure, was segmented and reconstructed to three dimensional (3D) surface models. Dimensions and orientations of relevant structures were identified and analyzed. The TAH surface model was virtually placed in orthotopic position and aligned with atrioventricular valves and big vessels. Additionally seven conventional cadaver studies were performed to validate different pump chamber designs based on virtual findings. Thereby 3D-coordinates were captured and introduced to the virtual environment to allow quantitative comparison between different individuals.

Results

Spatial parameters varied more in male patients with higher values if heart failure persists. Good correlation of the virtual analysis both to literature data and conventional cadaver studies could be shown. The full data of the 27 individuals as well as the summarized values found in literature are enclosed in the appendix. By superimposing the TAH-volume model to the anatomy, various misalignments were found and the TAH-design was adjusted.

Conclusions

Virtual fitting allows implant design adjustments in realistic anatomy which has not been influenced by thoracotomy. Higher numbers of relevant individuals can be reasonably investigated in the virtual environment and quantitatively correlated. Using this approach, conventional cadaver studies can be significantly reduced but not obviated, due to the unavailable haptic feedback and immobility of potentially compressed structures.

Veno-venous extracorporeal membrane oxygenation with a bicaval dual-lumen catheter in a SynCardia total artificial heart patient

We report the case of a 55 years old caucasian male patient with cardiogenic shock due to an extended myocardial infarction who underwent SynCardia Total Artificial Heart implantation and veno-venous extracorporeal membrane oxygenation with a bicaval dual-lumen cannula for the treatment of adult respiratory distress syndrome.

Fluoroscopically guided balloon dilatation for the treatment of achalasia: long-term outcomes

To report the immediate and long-term outcomes following the fluoroscopically guided balloon dilatations performed in our department for the treatment of achalasia. We reviewed retrospectively all patients that underwent a fluoroscopically guided balloon dilatation because of achalasia in our department between April 2007 and September 2010. The follow-up was performed by interviews and/or investigation of the patient's medical and imaging records. The primary endpoints of the study were technical success, clinical success, major complication rates, and repeat dilatation rates because of recurrence of clinical symptomatology. Secondary endpoints were the rate of minor complications and the dilatation-free interval. Various parameters that could affect the clinical outcome were also analyzed. Thirty-nine consecutive patients (20 female) with a mean age 44 ± 17 years underwent 69 dilatations, while 10/39 (25.6%) patients had a history of a previous laparoscopic myotomy. The most common symptom was dysphagia (64/69, 92.7%), while regurgitation and/or retrosternal pain were present in 12/39 (30.7%) and 9/39 (23%) of the cases, respectively. Technical success was achieved in 98.5% (68/69). There were no procedure-related major complications. The mean balloon diameter used was 30 ± 3.9 mm, and the mean period of follow-up was 27.7 ± 16.0 months. Excellent or good initial responses were noted in 54/66 cases (81.8%). A repeated dilatation to deal with recurrence of symptoms was performed in 69.4% of the cases (25/36). In the majority of the cases, two dilatations were needed in order to achieve long-term relief from symptoms. A dilatation-free interval of 4 years was observed in 26.4%. Clinical success was achieved in 30/36 patients (83.3%). Subgroup analysis did not detect significantly different recurrence rates in patients with and without previous laparoscopic myotomy (50% vs. 69% respectively), those of young age (75% < 21 years vs. 68.8% > 21 years), and male gender (71.4% male vs. 55.0% females). The high redilatation rate was attributed to the utilization of smaller balloons by less experienced operators. Fluoroscopically guided balloon dilatation is a safe and effective method for the treatment of achalasia. Young age and prior Heller's laparoscopic myotomy were not associated with increased rates of recurrence rate or clinical failure.