Percutaneous ethanol sclerotherapy is a promising treatment for recalcitrant angiolymphoid hyperplasia with eosinophilia

Angiolymphoid hyperplasia with eosinophilia (ALHE) is a rare benign vascular proliferation, which manifests as characteristic red nodules and papules, mostly located on the scalp and periauricular regions. Patients seek treatment for both aesthetic and functional reasons, as lesions may ulcerate, bleed and itch. Many therapeutic approaches have been reported, with variable success, and relapse remains a troublesome issue. The aim of this study was to report our experience treating ALHE using percutaneous ethanol sclerotherapy (PES). We present a retrospective case series of three patients treated with PES (1-2 treatment sessions each). All patients had tried and failed other treatments prior to this intervention, but following PES treatment, all patients demonstrated significant improvement, which was sustained at follow-up (range 8-17 months after first treatment). Adverse effects were tolerable and transient. This case series demonstrates PES as a promising treatment for recalcitrant ALHE.

CT imaging features of symptomatic and asymptomatic floating aortic thrombus

AIM

To present the computed tomography (CT) imaging features of floating aortic thrombus with emphasis on clinical and radiographic predictors for systemic shower emboli.

MATERIALS AND METHODS

A retrospective computerised search for patients with protruding thoracic aortic thrombus on CT was conducted. Clinical and demographic characteristics were retrieved from medical files. Patients were divided into two groups: symptomatic and asymptomatic, based on the presence or absence of documented systemic emboli at the time of diagnosis or during follow-up. CT imaging features were analysed: location and extent of systemic emboli, presence or absence of thrombus insertion calcification, percentage of thrombus circumference that is attached to the aortic wall and thrombus volume. Clinical and demographic variables and CT imaging features were analysed as potentially associated with symptomatic emboli.

RESULTS

The symptomatic group included 6/15 (40%) patients and the asymptomatic group included 9/15 (60%) patients. Patients in the symptomatic group were significantly younger (symptomatic: 53.3±11.7 years, asymptomatic: 76.9±8.4 years, p=0.003). All the symptomatic patients were women (100%), while 2/9 (22.2%) of the asymptomatic patients were women, (p=0.007). A non-calcified insertion site was more frequent in the symptomatic group (symptomatic 4/6 [66.7%] versus asymptomatic group 1/9 [11.1%], p=0.011). The percentage of thrombus circumference attached to the aortic wall was significantly smaller in symptomatic patients (symptomatic: 31.8±8.4%, asymptomatic: 43.7±5%, p=0.003).

CONCLUSION

The imaging features of symptomatic floating thrombus include a narrow base of attachment and lack of insertion calcification. Free-floating thrombus should be actively sought and diagnosed or excluded when performing CT andiography for emboli.

The CIRSE Retrievable IVC Filter Registry: Retrieval Success Rates in Practice

CIRSE established a registry of retrievable filter use with the primary aim of determining the success of IVC Filter retrieval and associated complications. Secondary endpoints included filter indications, imaging strategies before retrieval, filter dwell times, and anticoagulation status. A web-based electronic registry was hosted between 01/12/2010 and 30/06/2012. Data entry occurred at the date of IVC filter retrieval and included items such as filter type, indication for filter insertion, access route, dwell time, retrieval success, complications, reasons for failed retrieval, and anticoagulation status. 671 filter retrievals were entered (male:female 333:295, mean age 55, median 57). Retrieval data were not entered in 43/671 leaving 628 patients for analysis. The 4 commonest retrievable filters used were the Celect in 182 patients, the OPTEASE in 161, ALN in 120, and Gunther Tulip in 98. Filters were inserted for absolute indications 40%, relative indications in 31%, and prophylactic in 24%, with 5% missing. Mean filter dwell time was 90 days. Filters were successfully retrieved in 576/628 patients (92%). The mean dwell time for successful retrievals was 85 days versus 145 days for unsuccessful retrievals (p = 0.001). Major complications occurred in 2 patients (0.03%). In summary, the CIRSE retrievable filter registry demonstrates a retrieval rate of 92% across a range of filter types, with a low major complication rate, reflecting current practice. There is an increase in trend of retrievable filter use for relative and prophylactic indications.

Consensus Document of the International Union of Angiology (IUA)-2013. Current concept on the management of arterio-venous management

Arterio-venous malformations (AVMs) are congenital vascular malformations (CVMs) that result from birth defects involving the vessels of both arterial and venous origins, resulting in direct communications between the different size vessels or a meshwork of primitive reticular networks of dysplastic minute vessels which have failed to mature to become 'capillary' vessels termed "nidus". These lesions are defined by shunting of high velocity, low resistance flow from the arterial vasculature into the venous system in a variety of fistulous conditions. A systematic classification system developed by various groups of experts (Hamburg classification, ISSVA classification, Schobinger classification, angiographic classification of AVMs,) has resulted in a better understanding of the biology and natural history of these lesions and improved management of CVMs and AVMs. The Hamburg classification, based on the embryological differentiation between extratruncular and truncular type of lesions, allows the determination of the potential of progression and recurrence of these lesions. The majority of all AVMs are extra-truncular lesions with persistent proliferative potential, whereas truncular AVM lesions are exceedingly rare. Regardless of the type, AV shunting may ultimately result in significant anatomical, pathophysiological and hemodynamic consequences. Therefore, despite their relative rarity (10-20% of all CVMs), AVMs remain the most challenging and potentially limb or life-threatening form of vascular anomalies. The initial diagnosis and assessment may be facilitated by non- to minimally invasive investigations such as duplex ultrasound, magnetic resonance imaging (MRI), MR angiography (MRA), computerized tomography (CT) and CT angiography (CTA). Arteriography remains the diagnostic gold standard, and is required for planning subsequent treatment. A multidisciplinary team approach should be utilized to integrate surgical and non-surgical interventions for optimum care. Currently available treatments are associated with significant risk of complications and morbidity. However, an early aggressive approach to elimiate the nidus (if present) may be undertaken if the benefits exceed the risks. Trans-arterial coil embolization or ligation of feeding arteries where the nidus is left intact, are incorrect approaches and may result in proliferation of the lesion. Furthermore, such procedures would prevent future endovascular access to the lesions via the arterial route. Surgically inaccessible, infiltrating, extra-truncular AVMs can be treated with endovascular therapy as an independent modality. Among various embolo-sclerotherapy agents, ethanol sclerotherapy produces the best long term outcomes with minimum recurrence. However, this procedure requires extensive training and sufficient experience to minimize complications and associated morbidity. For the surgically accessible lesions, surgical resection may be the treatment of choice with a chance of optimal control. Preoperative sclerotherapy or embolization may supplement the subsequent surgical excision by reducing the morbidity (e.g. operative bleeding) and defining the lesion borders. Such a combined approach may provide an excellent potential for a curative result. Conclusion. AVMs are high flow congenital vascular malformations that may occur in any part of the body. The clinical presentation depends on the extent and size of the lesion and can range from an asymptomatic birthmark to congestive heart failure. Detailed investigations including duplex ultrasound, MRI/MRA and CT/CTA are required to develop an appropriate treatment plan. Appropriate management is best achieved via a multi-disciplinary approach and interventions should be undertaken by appropriately trained physicians.

CT in the clinical and prognostic evaluation of acute graft-vs-host disease of the gastrointestinal tract

OBJECTIVE

To determine the role of abdominal CT in assessment of severity and prognosis of patients with acute gastrointestinal (GI) graft-vs-host disease (GVHD).

METHODS

During 2000-2004, 41 patients with a clinical diagnosis of acute GI-GVHD were evaluated. CTs were examined for intestinal and extra-intestinal abnormalities, and correlated with clinical staging and outcome.

RESULTS

20 patients had GVHD clinical Stage I-II and 21 had Stage III-IV. 39 (95%) had abnormal CT appearances. The most consistent finding was bowel wall thickening: small (n=14, 34%) or large (n=5, 12%) bowel, or both (n=20, 49%). Other manifestations included bowel dilatation (n=7, 17%), mucosal enhancement (n=6, 15%) and gastric wall thickening (n=9, 38%). Extra-intestinal findings included mesenteric stranding (n=25, 61%), ascites (n=17, 41%), biliary abnormalities (n=12, 29%) and urinary excretion of orally administered gastrografin (n=12, 44%). Diffuse small-bowel thickening and any involvement of the large bowel were associated with severe clinical presentation. Diffuse small-bowel disease correlated with poor prognosis. 8 of 21 patients responded to therapy, compared with 15 of 20 patients with other patterns (p=0.02), and the cumulative incidence of GVHD-related death was 62% and 24%, respectively (p=0.01). Overall survival was not significantly different between patients with diffuse small-bowel disease and patients with other patterns (p=0.31). Colonic disease correlated with severity of GVHD (p=0.04), but not with response to therapy or prognosis (p=0.45).

CONCLUSION

GVHD often presented with abdominal CT abnormalities. Diffuse small-bowel disease was associated with poor therapeutic response. CT may play a role in supporting clinical diagnosis of GI GVHD and determining prognosis.

Large renal angiomyolipomas: digital subtraction angiographic grading and presentation with bleeding

AIM

To investigate whether a grading system of renal AMLs based on digital subtraction angiography (DSA) and computerized tomography (CT), could help to select patients for embolization.

MATERIALS AND METHODS

Thirty patients with 35 renal angiomyolipomas (size range 4-20 cm, mean 9.9 cm) underwent both digital subtraction angiography (DSA) and computed tomography (CT). Based on the DSA appearance the tumours were graded into three grades: grade I, minimal vascularity; grade II, moderate vascularity; grade III, marked vascularity.

RESULTS

There were seven grade I (mean 9.3 cm, range 4.5-20 cm), 18 grade II (mean 8.9 cm, range 5-18 cm) and 10 grade III tumours (mean 12.1 cm, range 4-20 cm). Five grade I tumours did not cause symptoms (71%) and two caused flank pain and haematuria, respectively (14.3% each). Nine of the grade II tumours were asymptomatic (50%), seven caused bleeding (39%) and two caused flank pain (11%). Four grade III tumours were asymptomatic (40%), five caused bleeding (50%) and one pain (10%).

CONCLUSIONS

According to our criteria, large angiomyolipomas with minimal vascularity are less likely to bleed, and do not need prophylactic treatment. This needs to be confirmed in larger studies.

Ethanol sclerotherapy of peripheral venous malformations

BACKGROUND

Venous malformations are congenital lesions that can cause pain, decreased range of movement, compression on adjacent structures, bleeding, consumptive coagulopathy and cosmetic deformity. Sclerotherapy alone or combined with surgical excision is the accepted treatment in symptomatic malformations after failed treatment attempts with tailored compression garments.

OBJECTIVES

To report our experience with percutaneous sclerotherapy of peripheral venous malformations with ethanol 96%.

PATIENTS AND METHODS

41 sclerotherapy sessions were performed on 21 patients, aged 4-46 years, 15 females and 6 males. Fourteen patients were treated for painful extremity lesions, while five others with face and neck lesions and two with giant chest malformations had treatment for esthetic reasons. All patients had a pre-procedure magnetic resonance imaging (MRI) study. In all patients, 96% ethanol was used as the sclerosant by direct injection using general anesthesia. A minimum of 1-year clinical follow-up was performed. Follow-up imaging studies were performed if clinically indicated.

RESULTS

17 patients showed complete or partial symptomatic improvement after one to nine therapeutic sessions. Four patients with lower extremity lesions continue to suffer from pain and they are considered as a treatment failure. Complications were encountered in five patients, including acute pulmonary hypertension with cardiovascular collapse, pulmonary embolus, skin ulcers (two) and skin blisters. All patients fully recovered.

CONCLUSION

Sclerotherapy with 96% ethanol for venous malformations was found to be effective for symptomatic improvement, but serious complications can occur.

Laparoscopic splenectomy for torsion of wandering spleen associated with celiac axis occlusion

BACKGROUND

Wandering spleen is a spleen lacking its normal ligamentous attachments, and thus subjected to free movement in the abdominal cavity, and even torsion around its pedicle. Surgical treatment includes either fixation (splenopexy) or resection (splenectomy). Both procedures can now be accomplished using the laparoscopic approach.

METHODS AND RESULTS

We describe a case of a torsion of a wandering spleen, leading to recurrent episodes of abdominal pain, and eventually to splenic ischemia, necessitating splenectomy. The diagnosis was complicated by associated angiographic findings of celiac axis occlusion, possibly by median arcuate ligament compression. Laparoscopic splenectomy was successful, and led to complete resolution of symptoms.

CONCLUSIONS

Although a rare condition, wandering spleen can be diagnosed accurately by imaging studies, mainly CT scan and angiography. Nowadays, the laparoscopic approach is preferred and enables the surgeon to perform either splenopexy or splenectomy, depending on the vascular status of the spleen.

Fatal liver infarction after transjugular intrahepatic portosystemic shunt procedure

Hepatic infarction is a rare disease. We describe here a cirrhotic patient with end-stage renal failure and recurrent tense ascites with fatal hepatic infarction after transjugular intrahepatic portosystemic shunt (TIPS) procedure. Abdominal ultrasound, radionuclide liver scan, abdominal computed tomography scan, and finally liver biopsy established the diagnosis. The mechanism causing the infarct is not clear. However, as the infarct appeared after the patient had an episode of shock and disseminated intravascular coagulation, it could well be that the concomitant hepatic arterial insufficiency contributed to the infarct. Physicians should be aware of this possible catastrophic complication.

Abciximab in carotid stenting for postsurgical carotid restenosis: intermediate results

PURPOSE

To report intermediate results of a pilot study in which the glycoprotein IIb/IIIa receptor antagonist abciximab was given to patients during percutaneous carotid stenting for recurrent internal carotid artery (ICA) stenosis. The objective was to prevent procedure-related cerebral embolic events and decrease the incidence of recurrent stenosis.

METHODS

Sixteen patients (9 women; mean age 66.5 years, range 39-78) with severe ICA recurrent stenosis (>80%) underwent balloon angioplasty and stenting. Before the procedure, abciximab was administered intravenously as a bolus (0.25 mg/kg) followed by a 12-hour continuous infusion (10 microg/min).

RESULTS

Fifteen patients received stents (14 Wallstent and 1 Strecker); 1 vessel was dilated with only 50% improvement in luminal diameter. Two stented arteries had residual stenosis (<30%) but satisfactory luminal diameter was achieved in the remaining 13 (81%) arteries. There were no neurological ischemic events during or following the procedure, nor were there any bleeding or peripheral vascular complications. Duplex surveillance studies up to 12 months revealed no significant recurrent stenosis in the treated vessels.

CONCLUSIONS

The administration of abciximab in conjunction with percutaneous revascularization procedures for postsurgical carotid artery stenosis may reduce cerebral ischemic episodes. It may also attenuate restenosis in the treated artery.

Diverticula of the male urethra: a review of 61 cases

Sixty-one cases of diverticulum of the male urethra were reviewed. This group included 10 patients with congenital and 51 with acquired diverticula. The etiology of the acquired variety, the radiological findings, and the frequency of appearance in both congenital and acquired diverticula of the urethra during a 30-year period are described.