Best Practice Guideline - DEGUM Recommendations on Breast Ultrasound

For many years, breast ultrasound has been used in addition to mammography as an important method for clarifying breast findings. However, differences in the interpretation of findings continue to be problematic 1 2. These differences decrease the diagnostic accuracy of ultrasound after detection of a finding and complicate interdisciplinary communication and the comparison of scientific studies 3. In 1999, the American College of Radiology (ACR) created a working group (International Expert Working Group) that developed a classification system for ultrasound examinations based on the established BI-RADS classification of mammographic findings under consideration of literature data 4. Due to differences in content, the German Society for Ultrasound in Medicine (DEGUM) published its own BI-RADS-analogue criteria catalog in 2006 3. In addition to the persistence of differences in content, there is also an issue with formal licensing with the current 5th edition of the ACR BI-RADS catalog, even though the content is recognized by the DEGUM as another system for describing and documenting findings. The goal of the Best Practice Guideline of the Breast Ultrasound Working Group of the DEGUM is to provide colleagues specialized in senology with a current catalog of ultrasound criteria and assessment categories as well as best practice recommendations for the various ultrasound modalities.

MR imaging of the neural foramina of the cervical spine: Comparison of 3D-DESS and 3D-FISP sequences

Purpose: To assess whether a single three-dimensional double-echo steady state (3D-DESS) sequence can produce equivalent results when compared to a 3D free induction with steady precession (3D-FISP) sequence for the evaluation of the neural foraminal diameter and structures.

Material and Methods: Five phantoms were imaged on CT with 3-mm axial slices followed by reformatted axial 3D-DESS and 3D-FISP sequences. In addition, 3D-DESS and 3D-FISP sequences of 20 healthy subjects were compared with regard to image quality, differentiation between vertebrae and discs, differentiation between discs and neural foramina, and differentiation between vertebrae and neural foramina.

Results: Compared with CT, 3D-DESS and 3D-FISP sequences consistently underestimated the diameters of the neural foramina. The mean difference values for the 3D-DESS was 12.8%, compared to 9.5% for the 3D-FISP sequence. Concerning the in vivo studies, the 3D-DESS sequence was superior but not statistical significant to the 3D-FISP sequence with regard to image quality, differentiation between vertebrae and discs, differentiation between discs and neural formina, and identification of the nerve roots.

Conclusion: The 3D-DESS sequence is moderately accurate in the evaluation of the neural foraminal size. Compared to the 3D-FISP sequence, the 3D-DESS sequence is compatible concerning the image quality, differentiation between the cervical vertebrae and discs, and between the discs and neural foramina.

Ultrasound Elastography in Breast Cancer Diagnosis

Ultrasound elastography is an established method for characterization of focal lesions in the breast. Different techniques and analyses of the images may be used for the characterization. This article addresses the use of ultrasound elastography in breast cancer diagnosis. In the first part of the article the techniques behind both strain- and shear-wave-elastography are explained and followed by a section on how to obtain adequate elastography images and measurements. In the second part of the article the application of elastography as an adjunct to B-mode ultrasound in clinical practice is described, and the potential diagnostic gains and limitations of elastography are discussed.

ShearWave™ Elastography BE1 multinational breast study: additional SWE™ features support potential to downgrade BI-RADS®-3 lesions

PURPOSE

To determine the benefit of ShearWave™ Elastography (SWE™) in the ultrasound characterization of BI-RADS® 3 breast lesions in a diagnostic population.

MATERIALS AND METHODS

303 BI-RADS® 3 lesions (mean size: 13.2 mm, SD: 7.5 mm) from the multicenter BE1 prospective study population were analyzed: 201 (66%) had cytology or core biopsy, and the remaining 102 had a minimum follow-up of one year; 8 (2.6%) were malignant. 7 SWE features were evaluated with regard to their ability to downgrade benign BI-RADS® 3 masses. The performance of each SWE feature was assessed by evaluating the number of lesions correctly reclassified and the impact on cancer rates within the new BI-RADS® 3' lesion group.

RESULTS

No malignancies were found with an E-color "black to dark blue", which allowed the downgrading of 110/303 benign masses (p < 0.0001), with a non-significant increase in BI-RADS® 3' malignancy rate from 2.6% to 4.1%. E-max ≤ 20 kPa (2.6 m/s) was able to downgrade 48/303 (p < 0.0001) lesions with a lower increase in BI-RADS® 3' malignancy rate (3.1%). No other SWE features were useful for reclassifying benign BI-RADS® 3 lesions.

CONCLUSION

Applying simple reclassification rules, SWE assessment of the maximum stiffness of lesions allowed the downgrading of a sub-group of benign BI-RADS® 3 lesions. This was accompanied by a non-significant increase in the malignancy rate in the new BI-RADS® 3 class.

Shear-wave elastography improves the specificity of breast US: the BE1 multinational study of 939 masses

PURPOSE

To determine whether adding shear-wave (SW) elastographic features could improve accuracy of ultrasonographic (US) assessment of breast masses.

MATERIALS AND METHODS

From September 2008 to September 2010, 958 women consented to repeat standard breast US supplemented by quantitative SW elastographic examination in this prospective multicenter institutional review board-approved, HIPAA-compliant protocol. B-mode Breast Imaging Reporting and Data System (BI-RADS) features and assessments were recorded. SW elastographic evaluation (mean, maximum, and minimum elasticity of stiffest portion of mass and surrounding tissue; lesion-to-fat elasticity ratio; ratio of SW elastographic-to-B-mode lesion diameter or area; SW elastographic lesion shape and homogeneity) was performed. Qualitative color SW elastographic stiffness was assessed independently. Nine hundred thirty-nine masses were analyzable; 102 BI-RADS category 2 masses were assumed to be benign; reference standard was available for 837 category 3 or higher lesions. Considering BI-RADS category 4a or higher as test positive for malignancy, effect of SW elastographic features on area under the receiver operating characteristic curve (AUC), sensitivity, and specificity after reclassifying category 3 and 4a masses was determined.

RESULTS

Median participant age was 50 years; 289 of 939 (30.8%) masses were malignant (median mass size, 12 mm). B-mode BI-RADS AUC was 0.950; eight of 303 (2.6%) BI-RADS category 3 masses, 18 of 193 (9.3%) category 4a lesions, 41 of 97 (42%) category 4b lesions, 42 of 57 (74%) category 4c lesions, and 180 of 187 (96.3%) category 5 lesions were malignant. By using visual color stiffness to selectively upgrade category 3 and lack of stiffness to downgrade category 4a masses, specificity improved from 61.1% (397 of 650) to 78.5% (510 of 650) (P<.001); AUC increased to 0.962 (P=.005). Oval shape on SW elastographic images and quantitative maximum elasticity of 80 kPa (5.2 m/sec) or less improved specificity (69.4% [451 of 650] and 77.4% [503 of 650], P<.001 for both), without significant improvement in sensitivity or AUC.

CONCLUSION

Adding SW elastographic features to BI-RADS feature analysis improved specificity of breast US mass assessment without loss of sensitivity.

Calcification of articular cartilage in human osteoarthritis

OBJECTIVE

Hypertrophic chondrocyte differentiation is a key step in endochondral ossification that produces basic calcium phosphates (BCPs). Although chondrocyte hypertrophy has been associated with osteoarthritis (OA), chondrocalcinosis has been considered an irregular event and linked mainly to calcium pyrophosphate dihydrate (CPPD) deposition. The aim of this study was to determine the prevalence and composition of calcium crystals in human OA and analyze their relationship to disease severity and markers of chondrocyte hypertrophy.

METHODS

One hundred twenty patients with end-stage OA undergoing total knee replacement were prospectively evaluated. Cartilage calcification was studied by conventional x-ray radiography, digital-contact radiography (DCR), field-emission scanning electron microscopy (FE-SEM), and synovial fluid analysis. Cartilage calcification findings were correlated with scores of knee function as well as histologic changes and chondrocyte hypertrophy as analyzed in vitro.

RESULTS

DCR revealed mineralization in all cartilage specimens. Its extent correlated significantly with the Hospital for Special Surgery knee score but not with age. FE-SEM analysis showed that BCPs, rather than CPPD, were the prominent minerals. On histologic analysis, it was observed that mineralization correlated with the expression of type X collagen, a marker of chondrocyte hypertrophy. Moreover, there was a strong correlation between the extent of mineralization in vivo and the ability of chondrocytes to produce BCPs in vitro. The induction of hypertrophy in healthy human chondrocytes resulted in a prominent mineralization of the extracellular matrix.

CONCLUSION

These results indicate that mineralization of articular cartilage by BCP is an indissociable process of OA and does not characterize a specific subset of the disease, which has important consequences in the development of therapeutic strategies for patients with OA.

Interobserver-variability of lung nodule volumetry considering different segmentation algorithms and observer training levels

OBJECTIVE

The aim of this study was to investigate the interobserver variability of CT based diameter and volumetric measurements of artificial pulmonary nodules. A special interest was the consideration of different measurement methods, observer experience and training levels.

MATERIALS AND METHODS

For this purpose 46 artificial small solid nodules were examined in a dedicated ex-vivo chest phantom with multislice-spiral CT (20 mAs, 120 kV, collimation 16 mm x 0.75 mm, table feed 15 mm, reconstructed slice thickness 1mm, reconstruction increment 0.7 mm, intermediate reconstruction kernel). Two observer groups of different radiologic experience (0 and more than 5 years of training, 3 observers each) analysed all lesions with digital callipers and 2 volumetry software packages (click-point depending and robust volumetry) in a semi-automatic and manually corrected mode. For data analysis the variation coefficient (VC) was calculated in per cent for each group and a Wilcoxon test was used for analytic statistics.

RESULTS

Click-point robust volumetry showed with a VC of <0.01% in both groups the smallest interobserver variability. Between experienced and un-experienced observers interobserver variability was significantly different for diameter measurements (p=0.023) but not for semi-automatic and manual corrected volumetry. A significant training effect was revealed for diameter measurements (p=0.003) and semi-automatic measurements of click-point depending volumetry (p=0.007) in the un-experienced observer group.

CONCLUSIONS

Compared to diameter measurements volumetry achieves a significantly smaller interobserver variance and advanced volumetry algorithms are independent of observer experience.

False-negative results after stereotactically guided vacuum biopsy

The purpose of this study was to determine the false negative rate of stereotactically guided vacuum biopsy (VB). Data of patients with benign lesions in VB were evaluated retrospectively during a median follow-up period of 21 months. A total of 404 VB were considered benign and representative and were recommended for follow-up. Of these 404 lesions, 195 were completely removed radiologically. Follow-up data were available for 354/404 patients (87.6%), with intervals ranging from 3 to 66 months (median 21, mean 22.4). Reintervention or surgery was necessary in 13/354 (3.7%) cases. Of these cases, 5/354 (1.4%) turned out to be false negatives. Four of these cases showed large areas of microcalcifications or several clusters, and only partial removal was possible due to the size of the lesions. Although VB is an accurate procedure for diagnosing nonpalpable breast lesions with a low cancer miss rate, we consider the exclusion of malignancy in cases of disseminated microcalcifications or several clusters as a limitation. The radiologic-pathologic correlation in these cases is a challenge, particularly in terms of the residuals. Strict follow-up of benign lesions is essential to avoid delayed cancer diagnosis.

Bildwandlergestützte Vermeidung einer Torsionsabweichung zur Gegenseite bei der Oberschenkelmarknagelung

BACKGROUND

The problem of preventing malrotation after closed intramedullary nailing of femoral shaft fractures has not been solved yet. As clinical tests and radiologic criteria for intraoperative use provide little accuracy, the theoretical basis for a C-arm-based measurement of the femoral antetorsion was analysed.

METHODS

The directions of femoral neck axis and condylar axis can be identified by the radiologic views "knee joint, lateral view" and "hip joint, axial view". The rotation of the C-arm in relation to a horizontal axis to achieve these views can be measured in degrees. Theoretically, the difference between these rotation angles could be used to calculate the antetorsion. Intact plastic femora (Sawbone) and a femoral shaft fracture model were used to research optical and geometrical phenomena that influence a direct measuring technique.

RESULTS

Several geometrical phenomena were observed, making direct measurement with arithmetic corrective factors not recommendable. For practical reasons, a data table was created, correlating the difference between the two C-arm angles with true antetorsion. In an interobserver trial with 18 trauma surgeons, the method proved to achieve high accuracy with a maximum interobserver variation of 5 degrees.

CONCLUSIONS

The method is easily reproducible, reliable and can be recommended to every surgeon. Due to the wide range of physiological antetorsion angles in different individuals, fair results can be expected controlling the rotation with standard value tables, and excellent results can be expected using bilateral measurement.

Value of fat-suppressed proton-density-weighted turbo spin-echo sequences in detecting meniscal lesions: comparison with arthroscopy

PURPOSE

To evaluate fat-suppressed (FS) proton-density-weighted (PDw) turbo spin-echo (TSE) magnetic resonance imaging (MRI) compared to arthroscopy in the detection of meniscal lesions.

MATERIAL AND METHODS

In a prospective study, 31 knee joints were imaged on a 1.5T MR scanner before arthroscopy using the following sequences: (a) coronal and sagittal FS-PDw TSE (TR/TE: 4009/15 ms); (b) coronal T1w SE (TR/TE: 722/20 ms), and sagittal PDw TSE (TR/TE: 3800/15 ms). Other imaging parameters were: slice thickness 3 mm, FOV 160 mm, matrix 256 x 256. A total of 186 meniscal regions (62 menisci; anterior horn, body, posterior horn) were evaluated. Standard of reference was arthroscopy. Sensitivity, specificity, negative predictive value (npv), positive predictive value (ppv), and accuracy were calculated.

RESULTS

Arthroscopically, meniscal lesions were detected in 55/186 segments (35 medial and 20 lateral meniscal lesions). Sensitivity, specificity, npv, ppv, and accuracy for combination of coronal and sagittal FS PDw TSE were 91.4%, 98.3%, 95%, 97%, and 93.5% for the medial meniscus, and 90%, 98.6%, 97.3%, 94.7%, and 96.8% for the lateral. The results were comparable to the combination of coronal T1w SE and sagittal PDw TSE for the medial (88.6%, 98.3%, 93.4%, 96.9%, 91.4%) and the lateral (90%, 95.9%, 97.2%, 85.7%, 92.5%) meniscus.

CONCLUSION

FS PDw TSE-MR sequences are an excellent alternative for the detection of meniscal lesions in comparison with diagnostic arthroscopy.

2005 Dr. Gary J. Becker Young Investigator Award: Periprocedural Oral Administration of the Leflunomide Analogue FK778 Inhibits Neointima Formation in a Double-injury Rat Model of Restenosis

PURPOSE

To test the efficacy of limited oral administration of the new leflunomide analogue FK778 for suppression of neointima proliferation in a double-injury restenosis model in the rat.

MATERIALS AND METHODS

For induction of aortic lesions, silicon cuffs were placed operatively around the infrarenal aortas of Lewis rats. After 21 days, the aortic cuffs were removed and the lesions were dilated with 2-F Fogarty catheters inserted via the left common carotid artery. The novel immunosuppressant FK778 was administered at a dose of 5 mg/kg body weight (group 1) or 15 mg/kg body weight (group 2) in a total of 38 animals. For both doses, three different periinterventional time periods, each with a 5-day course of oral FK778, were defined as follows: (i) days -2 to 2, (ii) days 1-5, and (iii) days 7-11, with six or seven rats in each group. After 3 weeks, intima/media ratios were assessed morphometrically and immunohistochemistry for quantification of intimal alpha-actin expression was performed.

RESULTS

In both dose groups, there was a trend toward inhibition of neointima formation when the 5-day course of FK778 was started before or 1 day after the intervention. However, in the lower-dose group, inhibition of neointima was not statistically significant regardless of the time frame of treatment (groups 1a-c). With the higher dose, suppression of intimal hyperplasia was significant when FK778 was administered between days 1 and 5 after angioplasty (group 2b; P<.01). Expression of alpha-actin in the intima of FK778-treated rats was significantly reduced when the drug was started 2 days before angioplasty in group 1a (P<.05) or 1 day after angioplasty in both dosage groups (group 1b, P<.01; group 2b, P<.05).

CONCLUSION

In the double-injury rat model presented, balloon-mediated proliferation of smooth muscle cells in the intima with consecutive intimal thickening was influenced by FK778 in a dose-dependent manner. However, long-term studies are needed to exclude a delay of vascular healing in this particular model.

Short-term rapamycin for inhibition of neointima formation after balloon-mediated aortic injury in rats: is there a window of opportunity for systemic prophylaxis of restenosis?

PURPOSE

To evaluate the efficacy of limited short-term systemic administration of rapamycin to prevent neointimal intimal hyperplasia (NIH) in a double-injury rat model of restenosis.

METHODS

Aortic lesions were induced by perivascular placement of silicone cuffs around the aorta of 36 Lewis rats. After 3 weeks, the cuffs were removed, and the vessels were subjected to secondary balloon injury. Rapamycin (sirolimus) was intravenously administered for 5 days in dosages of 0.5 or 2 mg/kg/d beginning at various time points relative to the balloon injury: (1) days -2 to +2, (2) days 1 to 5, or (3) days 7 to 11. For each treatment period, 6 rats received the 5-day course of the lower or higher dose of rapamycin. Eight rats served as controls undergoing 2-stage injury without rapamycin treatment. Morphometry and immunohistochemistry were performed at 21 days after angioplasty.

RESULTS

NIH and intimal alpha-actin expression were inhibited by both dosages when treatment started 2 days before or 1 day after angioplasty. Results were statistically significant for the lower dose when started 1 day after angioplasty (p < 0.01) and for the higher dose when initiated 2 days before the intervention (p < 0.05). Treatment commencing at 7 days did not reduce NIH in either dosage group.

CONCLUSIONS

In a double-injury rat model, NIH can be inhibited by short-term systemic rapamycin, but suppression of early cell migration and proliferation is pivotal. A limited peri-interventional antiproliferative therapy may be of value as an adjunct to control restenosis after balloon angioplasty and/or stenting.

Characterization of a New Double-Injury Restenosis Model in the Rat Aorta

PURPOSE

To characterize a new rat model of restenosis for evaluation of local or systemic drug strategies.

METHODS

Arterial lesions were induced by placement of silicone cuffs around the aorta of Lewis rats. After 21 days, the cuffs were removed, and a subgroup of rat aortas was subjected to secondary balloon injury. Remodeling of wall compartments and cell kinetics were assessed morphometrically at 3, 7, 14, 21, and 28 days after the single and double-injury approaches. Immunohistochemistry was used to assess the distribution of macrophages, smooth muscle cells, and proliferating cells within the layers of the arterial wall in the experimental groups versus sham-operated and untreated controls.

RESULTS

After cuff placement, the adventitia initially undergoes significant enlargement, while the media shows a reduction in relative thickness. Accumulation of cells within the adventitia at 3 and 7 days is followed by a marked decline in cell density at 14 days, with simultaneously increasing cell numbers in the intima. At this time, activated macrophages are detected in the adventitia, indicating chronic inflammation. Following cuff placement, mild intimal hyperplasia develops. In the double-injury model, extensive neointimal hyperplasia forms rapidly, with a peak at 14 days.

CONCLUSIONS

This new double-injury model is technically easy, and multiple experiments can be accrued in short periods of time. It provides an additional platform to identify new targets and strategies for the prophylaxis of postangioplasty restenosis.

Kritische odontogene Infektion mit Mediastinalbeteiligung

BACKGROUND

Occasionally, trivial odontogenic infections may develop into complex diseases. This may even result in an unrestrained phlegmonous spread causing life-threatening complications. These problems have decreased since the introduction of antibiotics and also due to improved oral hygiene and improved diagnostic measures resulting in optimized medical treatment. However, life-threatening forms are still seen, in particular if infections spread along the cervical fascial sheaths down towards to the mediastinum. Over the past decade the number of critical infections has increased in other medical specialties. This is usually explained by the development of multiresistant pathogens in the context of nosocomial infections.

PATIENTS AND METHODS

We reviewed the patients' records of the past 15 years at the Department of Oral and Maxillofacial Surgery of the University Hospital Kiel to assess a possible increase of odontogenic infections with life-threatening complications. From 1990 to 2004, four patients with odontogenic infections exhibiting critical phlegmonous spread were treated in the intensive care unit. Two patients developed bacterial mediastinitis which could be controlled by intravenous antibiotics only. One patient progressed to general septic mediastinitis and eventually died of cardiorespiratory arrest. The last patient also had septic mediastinitis and developed right pleural empyema. Several operations were necessary before the disease could be controlled. This patient's case report is presented in detail.

CONCLUSION

The prognosis of patients with mediastinitis crucially depends on (a) early diagnosis including computed tomography of the neck and thorax, (b) early radical surgical intervention, and (c) optimized pathogen-oriented antibiotic treatment.

Gadobutrol-enhanced moving-table magnetic resonance angiography in patients with peripheral vascular disease: a prospective, multi-centre blinded comparison with digital subtraction angiography

The purpose of this study was to compare moving-table three-dimensional contrast-enhanced magnetic resonance angiography (CE MRA), using 1.0-mol gadobutrol, with intra-arterial digital subtraction angiography (i.a. DSA) for evaluation of pelvic and peripheral arteries in patients with peripheral arterial occlusive disease. A total of 203 patients were examined in a prospective, multi-centre study at 1.0/1.5 T. Ten vessel segments of one leg were evaluated on-site and by three independent blinded reviewers off-site. One hundred eighty-two patients were evaluable in blinded reading. For pelvis and thigh, there was statistically significant diagnostic agreement between CE MRA and i.a. DSA on-site (94%) and off-site (86-88%). Overall, for detection of clinically significant stenoses, 93% sensitivity and 90% specificity were achieved in on-site evaluation, with 71-76 and 87-93% off-site; for detection of occlusion, sensitivity and specificity on-site were 91 and 97%, with 75-82 and 94-98% off-site. Evaluation was more sensitive on-site than off-site for detection of stenoses and occlusion, whereas specificity was similar. The CE MRA with 1.0-mol gadobutrol gave results comparable to those of i.a. DSA for the larger arteries of pelvis and thigh. Results for calf arteries were compromised by spatial resolution and technical limitations.

Bolus-chasing contrast-enhanced 3D MRA of the lower extremity. Comparison with intraarterial DSA

PURPOSE

To evaluate step-table 3D contrast-enhanced (CE) MRA with bolus chasing for the detection and grading of stenoses in patients with peripheral vascular disease (PVD) of the lower extremities.

MATERIAL AND METHODS

Fifty patients were studied by step-table bolus-chasing 3D-CE-MRA and i.a. DSA within 24 h. After determination of the individual circulation time, CE-MRA was performed during power injection of 40 ml of Gd-DTPA. To cover the whole range between the renal arteries and the feet with three slab locations, the scanner table was manually advanced twice for 350 mm. Total imaging time was 1 min 23 s. The degree of stenosis and image quality of the images were evaluated by 2 observers. In addition, a treatment plan was established based on the 3D-CE-MRA and DSA investigations.

RESULTS

In 44 of 50 patients (88%), the visualization of the arterial tree from the renal arteries to the foot was possible. Forty-six of 50 patients (92%) had good or very good image quality. In the calf, 3D-CE-MRA was superior to DSA in 6 patients. For the detection of stenosis >50%, sensitivity was 99.5%, specificity 98.8%, positive predictive value 95.6% and the negative predictive value 99.8%. Cohen's kappa for 3D-CE-MRA vs. DSA was 0.926; for interobserver agreement it was 0.96.

CONCLUSION

Bolus-chasing 3D-CE-MRA with manual table movement is a simple, robust and easy to perform technique which provides high quality angiograms of the lower extremity arterial system and is comparable to, i.a., DSA for the diagnosis of PVD.

Bolus-chasing contrast-enhanced 3D MRA of the lower extremity. Comparison with intraarterial DSA

PURPOSE

To evaluate step-table 3D contrast-enhanced (CE) MRA with bolus chasing for the detection and grading of stenoses in patients with peripheral vascular disease (PVD) of the lower extremities.

MATERIAL AND METHODS

Fifty patients were studied by step-table bolus-chasing 3D-CE-MRA and i.a. DSA within 24 h. After determination of the individual circulation time, CE-MRA was performed during power injection of 40 ml of Gd-DTPA. To cover the whole range between the renal arteries and the feet with three slab locations, the scanner table was manually advanced twice for 350 mm. Total imaging time was 1 min 23 s. The degree of stenosis and image quality of the images were evaluated by 2 observers. In addition, a treatment plan was established based on the 3D-CE-MRA and DSA investigations.

RESULTS

In 44 of 50 patients (88%), the visualization of the arterial tree from the renal arteries to the foot was possible. Forty-six of 50 patients (92%) had good or very good image quality. In the calf, 3D-CE-MRA was superior to DSA in 6 patients. For the detection of stenosis >50%, sensitivity was 99.5%, specificity 98.8%, positive predictive value 95.6% and the negative predictive value 99.8%. Cohen's kappa for 3D-CE-MRA vs. DSA was 0.926; for interobserver agreement it was 0.96.

CONCLUSION

Bolus-chasing 3D-CE-MRA with manual table movement is a simple, robust and easy to perform technique which provides high quality angiograms of the lower extremity arterial system and is comparable to, i.a., DSA for the diagnosis of PVD.

Hemobahn stent-grafts for treatment of femoropopliteal arterial obstructions: midterm results of a prospective trial

PURPOSE

To report a prospective study to evaluate safety, effectiveness, and midterm patency of self-expanding stent-grafts in patients with femoropopliteal occlusive disease.

MATERIALS AND METHODS

Sixty-three Hemobahn stent-grafts were used in 52 patients for treatment of medium- or long-segment (>3 cm) occlusions (82.7%) and stenoses (17.3%) of the femoropopliteal artery. The mean length of vessel segments covered was 10.9 cm +/- 5.13. Follow-up with documentation of clinical symptoms, assessment of Rutherford clinical stage of peripheral vascular disease, and color-coded duplex sonography was performed at discharge, at 1, 3, 6, 12, 18, and 24 months after implantation, and yearly thereafter. Mean follow-up duration was 23.8 months +/- 6.9 (range, 8-36 mo). Follow-up data at 12 and 24 months after treatment were available for 47 of 52 (90.4%) and 31 of 52 patients (59.6%), respectively.

RESULTS

Device implantation was technically successful in all 52 patients, yielding an overall technical success rate of 100%. Procedure-related complications were observed in 12 of 52 patients (23.1%) and consisted of distal embolization (n = 4, 7.7%), minor groin hematoma (n = 7, 13.5%), and arteriovenous fistula (n = 1, 1.9%), but prolonged hospitalization and further medical, interventional, or surgical measures were not required. Stent-graft placement induced an initial improvement of the mean resting ankle-brachial index from 0.54 +/- 0.12 to 0.89 +/- 0.14 (P <.01). Primary patency rates at 12 and 24 months were 78.4% +/- 5.8 and 74.1% +/- 6.2, respectively. Primary assisted patency rates were 82.4% +/- 5.3 at 12 months and 80.3% +/- 5.6 at 24 months. Secondary patency rates at 12 and 24 months were 88.3% +/- 4.5 and 83.2% +/- 5.5, respectively. There was no significant difference (log-rank test, P >.3) between primary patency rates in patients grouped according to lengths of implanted grafts (ie, length of the treated lesions).

CONCLUSION

Endovascular placement of Hemobahn stent-grafts for percutaneous treatment of medium- to long-segment high-grade stenoses and occlusions of the femoropopliteal artery is a safe procedure with excellent initial success rates and promising midterm results.

[Sport injuries of the extensor mechanism of the knee]

Injuries of the extensor mechanism of the knee occur frequently during sport activity. For a successful treatment they must be diagnosed early. Besides osseous structures the patellar tendon, the patella, the quadriceps muscle and tendon, retinacula and bursae can be affected. After initial clinical examination there are different noninvasive imaging modalities available for assessment of bone, cartilage, ligaments, tendons and soft tissue. Conventional radiographs are still the basic imaging tool for the clinician. Additional information about the osseous status is provided by computed tomography, whereas sonography plays an important role concerning diagnosis of soft tissue injuries. For the detection of cartilagenous, ligamentous or tendon lesions MRI is the superior non-invasive imaging modality.