Conception rates after fluoroscopy-guided fallopian tubal cannulation: an alternative to in vitro fertilization for patients with tubal occlusion

Objective:

Previous studies show good technical success rates for fallopian tube recanalization. Scarce literature exists regarding advance techniques currently used by interventional radiologists during fallopian tube recanalization procedures. This study investigates the level of intervention and tubal patency and its association with technical success and associated pregnancy outcomes.

Methods:

We retrospectively evaluated fallopian tube recanalization procedures performed at a single center in a 24-year period. A total of 160 couples undergoing a basic infertility evaluation were included. Hysterosalpingography with high pressure contrast injection followed by selective contrast, guidewire catheterization at the tubal ostium, and/or microcatheter/microwire recanalization were performed. Comparisons of the tubal fertilization rate by relevant characteristics were tested for statistical significance with t tests for continuous data or with Pearson chi-square tests for categorical data.

Results:

Technical success rate was 94% (319 of 341 tubes). High pressure contrast injection alone (184 of 341, 54%), selective catheterization (40%), and microcatheter/microwire (6%) interventions yielded technical success rates of 98%, 90%, and 73%, respectively. The overall rate of conception was 35% (17 of 48).

Conclusion:

Current techniques of fallopian tube recanalization offer a desirable and safe option with high technical success for patients seeking treatment for infertility due to proximal fallopian tube obstruction.

Role of Stent Grafts and Helical-Woven Bare-Metal Stents in the Superficial Femoral and Popliteal Arteries

Peripheral vascular disease (PVD) is a devastating medical problem that may lead to significant life alterations for patients, from simply limiting their daily activities to potential loss of limbs and eventual demise. Superficial femoral and popliteal arteries are significantly common locations for PVD sequelae to present itself, and owing to their length and mobile nature, treatment of these segments are quite challenging. Indications for PVD treatment include lifestyle-limiting claudication that is not responding to medical management, ischemic rest pain, nonhealing ulcers, and lower extremity gangrene. There is a wide variety of treatment options that include medical management, interventional, and surgical techniques. Interventional techniques include plain old balloon angioplasty, cryoplasty, drug-coated balloon angioplasty, self-expanding bare-nitinol stents, self-expanding covered stents, self-expanding drug-eluding stents, and a number of atherectomy devices (ie, laser, rotational, orbital, and excisional). The scope of this article is to review indications, patient selection, and deployment techniques of Viabahn and Supera self-expanding stents.

Delayed Retrograde Ascending Aortic Dissection After Endovascular Repair of Descending Dissection

We report the case of a 34-year-old woman who developed delayed retrograde ascending aortic dissection after previous endovascular repair of her descending thoracic aorta. Preoperative computed tomography imaging specifically highlights the interaction of endograft springs with the dissection flap and surrounding aortic tissues. Intraoperative findings are presented for comparison and further discussion.

Short-term rebleeding rates for isolated gastric varices managed by transjugular intrahepatic portosystemic shunt versus balloon-occluded retrograde transvenous obliteration

PURPOSE

To assess the short-term rebleeding rate associated with the use of a transjugular intrahepatic portosystemic shunt (TIPS) compared with balloon-occluded retrograde transvenous obliteration (BRTO) for management of gastric varices (GV).

MATERIALS AND METHODS

A single-center retrospective comparison of 50 patients with bleeding from GV treated with a TIPS or BRTO was performed. Of 50 patients, 27 (17 men and 10 women; median age, 55 y; range, 31-79 y) received a TIPS with covered stents, and 23 (12 men and 11 women; median age, 52 y; range, 23-83 y) underwent a BRTO procedure with a foam sclerosant. All study subjects had clinical and endoscopic evidence of isolated bleeding GV and were hemodynamically stable at the time of the procedure. Clinical and endoscopic follow-up was performed. Kaplan-Meier analysis was used to evaluate rebleeding rates from the GV.

RESULTS

The technical success rate was 100% in the TIPS group and 91% in the BRTO group (P = .21). Major complications occurred in 4% of the patients receiving TIPS and 9% of patients the undergoing BRTO (P = .344). Encephalopathy was reported in 4 of 27 (15%) patients in the TIPS group and in none of the patients in the BRTO group (0%; P = .12). At 12 months, the incidence of rebleeding from a GV source was 11% in the TIPS group and 0% in the BRTO group (P = .25).

CONCLUSIONS

BRTO appears to be equivalent to TIPS in the short-term for management of bleeding GV. Further comparative studies are warranted to determine optimal management strategies in individual patients.

The Effect of Balloon-Occluded Transvenous Obliteration of Gastric Varices and Gastrorenal Shunts on the Hepatic Synthetic Function

Purpose:

To evaluate the effect of balloon-occluded transvenous obliteration (BRTO) on the model for end-stage liver disease (MELD) and the Child-Pugh (C-P) score and their individual components.

Methods:

A retrospective review of patients undergoing only BRTO without transjugular intrahepatic portosystemic shunt was performed (08, 2007 to 06, 2010). Pre- and post-BRTO MELD and C-P scores were calculated. The post-BRTO MELD and C-P score samplings were categorized as (1) immediate (within 14 days), (2) early (14-90 days), and (3) delayed (90-180 days) post-BRTO. The C-P and MELD scores and their individual components before and after (various sample intervals) were compared.

Results:

A total of 29 consecutive successful BRTO procedures were found and assessed. In all, 26 had immediate post-BRTO sampling (average 1.8 days after BRTO), 13 (57%) had an early post-BRTO sampling (average 47 days from BRTO), and 10 (38%) had a delayed post-BRTO sampling (average 121 days from BRTO). The bilirubin rises significantly ( P = .007) within days after BRTO, but synthetic function improves significantly between 1.5 and 4.0 months post-BRTO (international normalized ration: P = .02, bilirubin: P = .027, and albumin: P = .012). However, 31% (N = 8/ 26) of the patients had worsening ascites with or without hydrothorax. The MELD score significantly improved circa 4 months post-BRTO (from 14.1 to 10.7, P = .0008). However, the C-P score did not change significantly (from 7.6 to 6.7, P = .063).

Conclusion:

The BRTO has a positive effect on the hepatic synthetic function. However, there is a high incidence of post-BRTO ascites (31% of the patients). As a result, the MELD score appears to be a more sensitive gauge for hepatic synthetic function compared to the C-P score for patients undergoing BRTO.

Prosthetic vascular graft infection imaging

PURPOSE

We are reporting our experience with imaging of vascular graft infections using computed tomography angiography (CTA), white blood cell (WBC) scintigraphy and software-based fusion imaging.

MATERIAL AND METHODS

Institutional review board approval was obtained. We performed a retrospective review of patients who had clinical signs and symptoms of vascular graft infection in whom both WBC single photon emission computed tomography (SPECT) and CTA was performed between 2005 and 2010. We performed fusion imaging with available data using software coregistration technique and analyzed outcome of the patients.

RESULTS

We had 20 patients; 11 had grafts of the aorta, five had peripheral vascular grafts, three had aortic and peripheral vascular grafts, and one had a thoracic aortic graft. WBC imaging was positive in 10 patients, negative in six patients and indeterminate in 4 patients. CTA was positive in six patients, negative in four patients and indeterminate in 10 patients. Sensitivity, specificity, accuracy, positive predictive value and negative predictive value (NPV) for WBC, CTA and WBC SPECT/CTA fusion were 75/100/80/100/50%, 88/50/80/88/50% and 94/50/85/88/67% respectively.

CONCLUSION

The use of CTA, WBC scintigraphy, and image co-registration influenced the diagnostic confidence of graft infection and the outcome of the patients. Software-based fusion imaging of both modalities resulted in improved sensitivity, accuracy, and NPV.

Endovascular management of fusiform renal artery aneurysm in a patient with refractory hypertension using hydrocoils and embospheres

We are reporting endovascular management of a renal artery aneurysm causing renal hypertension. The aneurysm by mass effect compressed the adjacent artery resulting in a hemodynamically significant stenosis. Endovascular management included embosphere embolization of the renal parenchyma distal to the stenosed segment and hydrocoil embolization of the aneurysm itself.

Quantifying increased hepatic arterial flow with test balloon occlusion of the splenic artery in liver transplant recipients with suspected splenic steal syndrome: quantitative digitally subtracted angiography correlation with arterial Doppler parameters

PURPOSE

The purpose of this study is to quantify hepatic arterial flow (HAF) in liver transplants with splenic steal syndrome (SSS) pre- and post-test balloon occlusion of the splenic artery utilizing Doppler ultrasound (DUS) and quantitative digitally subtracted angiography (Q-DSA).

METHODS

A total of 193 liver transplants were evaluated retrospectively. Hepatic arterial velocity (HAV) and HAF were calculated utilizing DUS and Q-DSA (i-flow prototype, Siemens) pre- and post-splenic artery balloon occlusion. The rate of HAF increase, total HAF, and peak contrast density (PKD) by Q-DSA were compared with HAF by DUS.

RESULTS

Of all, 4 suspected SSS cases underwent test-balloon occlusion with DUS and Q-DSA. Using DUS, HAV and HAF increased by 1.6- to 1.8-fold and 1.7- to 2.6-fold, respectively. Using Q-DSA, the HAF rate, total HAF, and PKD increased by 1.1 to 12.8, 1.5 to 7.6, and 1.3 to 5.3, respectively.

CONCLUSION

Occlusion of the splenic artery in liver transplants with SSS doubles the HAF (+1.7- to 2.6-fold). The Q-DSA parameters correlate qualitatively but overestimate the resultant increased HAF.

Endovascular management of vascular complications in pancreatic transplants

Vascular complications after pancreatic transplantation carry a high rate of graft loss. Endovascular management of these complications is confined to stent placement for iliac artery inflow disease and embolization for arteriovenous fistulae (AVFs), pseudoaneurysms, or active bleeding. The current study describes the endovascular management of pancreatic transplant venous thrombosis (N = 1), arterial stenosis (N = 5), thrombosis (N = 3), pseudoaneurysms (N = 1), and AVF (N = 2). In addition, embolization of nonfunctioning grafts is described as an endovascular alternative to pancreatectomy.

Current status of percutaneous endografting

Significant advances in the technology and techniques in the field of endovascular thoracic and abdominal aortic aneurysm repair have been made since its introduction in the early 1990s. The low incidence of periprocedural complications combined with comparable early outcomes to open surgery have made the endovascular treatment option the first choice of therapy in patients whose aortic anatomy is suitable for endografting. All currently available endografts for aortic aneurysm repair have delivery systems at least 21-French in outer diameter and have traditionally been inserted via surgical cutdowns. More recently, attempts to validate a totally percutaneous approach to the placement of these devices have been introduced by utilizing suture-mediated closure devices. This article will provide an overview of suture-mediated closure devices, our experience with the off-label application of suture-mediated devices for percutaneous closure of arterial access sites during endovascular aneurysm repair, and a review of the literature on this topic.

Embolization therapy for traumatic splenic lacerations

PURPOSE

This study was designed to evaluate the clinical success, complications, and transfusion requirements based on the location of and agents used for splenic artery embolization in patients with splenic trauma.

METHODS

A retrospective study was performed of patients with splenic trauma who underwent angiography and embolization from September 2000 to January 2010 at a level I trauma center. Electronic medical records were reviewed for demographics, imaging data, technical aspects of the procedure, and clinical outcomes.

RESULTS

Fifty patients were identified (34 men and 16 women), with an average age of 48 (range, 16-80) years. Extravasation was seen on initial angiography in 27 (54%) and was absent in 23 (46%). All 27 patients with extravasation were embolized, and 18 of 23 (78.2%) without extravasation were embolized empirically. Primary clinical success was similar (>75%) across all embolization locations, embolic agents, and grades of laceration treated. Of 45 patients treated, 9 patients (20%) were embolized in the main splenic artery, 34 (75.6%) in the splenic hilum, and 2 (4.4%) were embolized in both locations. Partial splenic infarctions developed in 47.3% treated in the splenic hilum compared with 12.5% treated in the main splenic artery. There were four (8.9%) mortalities: two occurred in patients with multiple critical injuries and two from nonbleeding etiologies.

CONCLUSIONS

Embolization of traumatic splenic artery injuries is safe and effective, regardless of the location of treatment. Embolization in splenic hilar branches may have a higher incidence of infarction. The grade of laceration and agents used for embolotherapy did not impact the outcomes.

Endovascular therapy for hepatic artery stenosis and thrombosis following liver transplantation

PURPOSE

To evaluate the effectiveness of endovascular management of steno-oclusive disease in liver transplants.

METHODS

Retrospective review of liver transplant recipients with hepatic artery stenosis (HAS) or thrombosis (HAT) was performed. The HAS group was treated with balloon angioplasty with selective stent placement. The HAT group was treated with catheter-directed thrombolysis. Primary, unassisted, and assisted patency and graft survival rates were calculated.

RESULTS

In all, 31 patients were identified (21 males; mean age, 51 years). A total of 25 of 31 (81%) patients had HAS and 6 of 31 (19%) had HAT. Collectively, a total of 35 endovascular procedures were performed to treat HAS in 25 patients. Overall technical success rate was 91%, with 11% major complication rate. Primary-assisted patency rate and graft survival at 6 and 12 months were 87% and 81%, and 76% and 72%, respectively. Only 1 successful thrombolysis of HAT was achieved.

CONCLUSION

Endovascular management is effective for HAS but not for HAT.

Percutaneous occlusion of the left subclavian and celiac arteries before or during endograft repair of thoracic and thoracoabdominal aortic aneurysms with detachable nitinol vascular plugs

PURPOSE

To review an experience with the Amplatzer vascular plug (AVP) for prevention of type II endoleaks during endovascular aneurysm repair (EVAR) of thoracic and thoracoabdominal aneurysms.

MATERIALS AND METHODS

Retrospective review was undertaken of 14 patients undergoing transcatheter occlusion of the left subclavian (n = 12) or celiac artery (n = 2) with the AVP as part of EVAR of thoracic and thoracoabdominal aneurysms at a single institution. Procedural criteria evaluated were success at target vessel occlusion, the number of AVPs used, use of adjunctive embolization devices, and embolization-related ischemic end-organ events. Follow-up imaging criteria included evaluation of persistent target vessel occlusion, evidence of device migration, and the presence and characterization of endoleak secondary to AVP failure.

RESULTS

Complete target vessel occlusion was documented for all cases. In six cases, more than one AVP was placed, with an average of 1.5 devices per patient. In two cases, adjunctive coils were placed. Computed tomographic or magnetic resonance angiography follow-up was available for all patients (mean follow-up, 419 days; range 28-930 d). No case showed evidence of device migration or type II endoleak resulting from AVP failure. There was a single instance of left subclavian artery recanalization without type II endoleak. There were no embolization-related ischemic end-organ events.

CONCLUSIONS

Transcatheter arterial occlusion of the subclavian and celiac arteries with the AVP is a valuable adjunct to endografting in cases in which side branch embolization is necessary to extend the landing zone.

Effect of transjugular intrahepatic portosystemic shunt placement on renal function: a 7-year, single-center experience

PURPOSE

Transjugular intrahepatic portosystemic shunt (TIPS) creation has been shown to improve renal function in small series of patients with hepatorenal syndrome. The present study examined the effect of TIPS creation on renal function in a large series of patients undergoing TIPS creation who had varying degrees of baseline renal function.

MATERIALS AND METHODS

All de novo TIPS creations during a 7-year period at a single institution were retrospectively reviewed regardless of indication. Pre- and postprocedural laboratory values were obtained and used to calculate Model for End-Stage Liver Disease (MELD) scores and glomerular filtration rates. Subanalysis was performed based on degree of renal insufficiency and indication for the procedure.

RESULTS

A total of 201 successful conventional TIPS procedures were identified. Of those, 72 patients were excluded for lack of follow-up, death during the same hospitalization, lack of TIPS function, or end-stage renal failure requiring dialysis before TIPS creation, leaving 129 procedures. Patients with preprocedural creatinine levels of 1.2-1.9 mg/dL (n = 45) showed an improvement in mean creatinine from 1.5 to 1.1 mg/dL (P < 10(-12)) and patients with preprocedure creatinine levels greater than 2.0 mg/dL (n = 21) showed an improvement from 2.8 to 1.5 mg/dL (P < 10(-5)). MELD scores decreased in patients with creatinine levels greater than 2.0 mg/dL from 22.1 to 19.2 (P < 0.005) but increased in all other patient groups. Amount of iodinated contrast medium administered did not affect creatinine level changes.

CONCLUSIONS

TIPS creation improves renal dysfunction in chronic liver disease. Patients with poorer renal function benefit the most from TIPS creation.

Outcomes of covered kissing stent placement compared with bare metal stent placement in the treatment of atherosclerotic occlusive disease at the aortic bifurcation

PURPOSE

To review the outcomes with the use of balloon-expandable covered iliac kissing stents as compared with bare metal stents in the treatment of atherosclerotic disease at the aortic bifurcation.

MATERIALS AND METHODS

A review of consecutive patients from a single institution with atherosclerotic occlusive disease at the aortic bifurcation treated with balloon-expandable kissing stents was performed between January 1, 2002, and September 1, 2007. Fifty-four patients were identified and divided into two groups: those with bare metal stents and those with covered stents. Technical and clinical success (Fontaine classification), complications, and patency at follow-up were documented.

RESULTS

Twenty-six patients (17 men, nine women; mean age, 61 years; age range, 39-79 years) received covered stents and 28 patients (15 men, 13 women; mean age, 61 years; age range, 38-82 years) received bare metal stents. Technical success was achieved in 100% of patients in both groups. Major complications occurred in three of the 26 (11%) with covered stents (P = .66) and two of the 28 patients (7%) with bare metal stents. The median follow-up was 21 months (20 months for covered stents vs 25 months for bare metal stents; range, 1-62 months). Twenty-two of the 26 patients (85%) with covered stents had sustained improvement in clinical symptoms during the follow-up period compared with 15 of the 28 patients (54%) with bare metal stents (P = .02). Primary patency rates at 1 and 2 years were 92% and 92%, respectively, for covered stents and 78% and 62% for bare metal stents (P = .023).

CONCLUSIONS

The use of covered balloon-expandable kissing stents for atherosclerotic aortic bifurcation occlusive disease provides superior patency at 2 years as compared with bare metal balloon-expandable stents.

Transcatheter renal artery embolization: clinical applications and techniques

Renal artery embolization is a minimally invasive procedure that is increasingly being used for treatment of a wide range of conditions. The main indications for renal artery embolization include (1) prenephrectomy and preradiofrequency ablation infarction of renal tumors, (2) management of renal angiomyolipomas, (3) palliations of unresectable renal malignancy, (4) renal hemorrhage (life-threatening or chronic debilitating hematuria), (5) arteriovenous fistulas, (6) vascular malformations, (7) renal artery aneurysms and pseudoaneurysms, and other less common indications, such as severe hydronephrosis and hypertension. A variety of embolic materials are available, such as metal coils, sclerosants (glue, Onyx, absolute ethanol, lipiodol), and particulate embolic agents (polyvinyl alcohol particles and embospheres). Selection of the appropriate agent depends on the clinical application, technical and clinical endpoints, as well as the pathology lesion(s) targeted. Renal artery embolization can be performed alone or in combination with remodeling techniques, stent-grafting, and balloon- or stent-assisted coiling in more complicated cases. The procedure is generally regarded as safe and effective for diverse applications and is considered as an evolving area in the field of endoluminal therapy.

Endovascular therapy for patients with renal angiomyolipoma presenting with retroperitoneal haemorrhage

We report our experience treating four patients with acutely bleeding angiomyolipoma (AML) of sizes between 4 and 12 cm who were managed with endovascular embolisation with a mean follow-up of 10 months. In our case series, we demonstrate that endovascular embolisation in the acute setting for bleeding AMLs is a viable treatment option. AML should be in the differential diagnosis of acutely bleeding renal masses, even when there is no fat assessed by computed tomography (CT) imaging in the renal mass.

SAFE ZONE FOR C1 LATERAL MASS SCREWS

OBJECTIVE

To evaluate the possible complications of overpenetrated C1 lateral mass screws and to identify and define a “safe zone” area anterior to the C1 vertebra.

METHODS

The study was performed on 10 cadavers and 50 random patients who had undergone computed tomographic scanning with contrast medium of the neck for other purposes. Atlas lateral mass screw trajectories were plotted, and the safe zone for screw placement anterior to the atlas vertebra was determined for each trajectory.

RESULTS

The trajectory of the internal carotid artery was measured from its medial wall. The trajectory of the internal carotid artery according to the ideal entrance point of the screw was 11.55 ± 4.55 degrees (range, 2–22 degrees) in the cadavers and 9.78 ± 4.55 degrees (range, −5 to 22 degrees) bilaterally in the patients. At 15 degrees (ideal screw trajectory), the thickness of the rectus capitis anterior muscle and longus capitis muscle was 6.69 ± 0.83 mm (range, 5.32–7.92 mm) in the cadavers and 7.29 ± 1.90 mm (range, 0.50–13.63 mm) bilaterally in the patients. The smallest distance from the internal carotid artery to the anterior cortex of the C1 vertebra was calculated as 4.33 ± 2.03 mm (range, 1.15–8.40 mm) bilaterally in the cadavers and 5.07 ± 1.72 mm (range, 2.15–8.91 mm) bilaterally in radiological specimens.

CONCLUSION

The internal carotid artery trajectory is lateral to the ideal entrance point of C1 lateral mass screws. The medial angulation of a screw placed in the lateral mass of C1 seemed to increase the margin of safety for the internal carotid artery. The rectus capitis anterior and longus capitis muscles may be thought of as a safe zone area for C1 lateral mass screws. At more than 25 degrees of medial angulation, the risk of perforation of the oropharyngeal wall increases.

In vitro assessment of aortic stent-graft integrity following exposure to Onyx liquid embolic agent

PURPOSE

Endovascular stent-grafts are increasingly being used for treatment of abdominal and thoracic aortic aneurysms. Postprocedural complications include development of endoleaks. Recently, an embolic agent known as Onyx has been employed to treat type II endoleaks. Onyx is a biocompatible copolymer dissolved in dimethyl sulfoxide (DMSO). Although DMSO is known to damage some angiographic catheters, little is known concerning whether this compound damages stent-graft material. The current study was undertaken to directly explore this issue.

MATERIALS AND METHODS

Four stent-grafts were evaluated: the Excluder, Zenith, AneuRx, and Talent. Stent-grafts were incubated for 24 hours at 37 degrees C under each of the following conditions: DMSO alone, 50/50 mixture of DMSO/Onyx, mixture of 1 part 50/50 DMSO/Onyx and 9 parts whole blood, and untreated control. Stent-grafts were microdissected into 15-mm sections, after which they were evaluated with scanning electron microscopy.

RESULTS

No appreciable differences between stent-grafts exposed to DMSO and untreated controls were seen. Although liquid embolic agent was seen coating stent-grafts exposed to a 50/50 mixture of DMSO and Onyx, no evidence of fiber breakdown was noted. Stent-grafts exposed to DMSO/Onyx/whole blood demonstrated a thin coating of clot and Onyx without visual evidence of fiber compromise.

CONCLUSIONS

The current study provides compelling evidence that short-term exposure of endograft material to DMSO, DMSO/Onyx, or DMSO/Onyx/whole blood is not associated with acute structural compromise of four commonly used aortic endografts. Future in vivo studies will help to further establish the safety of this agent.

Mediastinal thymoma invading the superior vena cava and the right atrium

An 86-year-old male patient presented with a large mediastinal tumor. A needle biopsy was performed and revealed a diagnosis of invasive thymoma. Multidetector computed tomography (MDCT) angiography was performed in order to assess operability of the tumor. This showed a heterogeneously enhancing anterior mediastinal mass. The tumor had invaded the left brachiocephalic vein, presumably via the inferior thymic veins, which is a known feature of these tumors. The thymoma grew then endovenously through the superior vena cava into the right atrium. A pacemaker lead was completely encased by tumor tissue. The patient was deemed inoperable and underwent radiation therapy.

Novel technique for evaluating complex pelvic arteriovenous malformations with catheter-directed subtracted MR angiography

Residual or recurrent arteriovenous malformation (AVM) nidal filling is not uncommon after embolization of complex peripheral AVMs. The major reason for this is incomplete embolization of the nidus owing to failure to detect all feeder vessels other than the dominant one. Herein, the authors describe a novel "intravenous minus intraarterial" subtraction magnetic resonance (MR) angiography technique that enabled the delineation of additional feeding branches not clearly identifiable at intravenous contrast-enhanced MR angiography or nonselective pelvic angiography. This technique may be particularly useful in the evaluation of complex AVMs and their subsequent management with embolization.

Neuroimaging characteristics in subgroup of GBMs with p53 overexpression

Glioblastoma multiforme (GBM) is a heterogeneous group of tumors, and neuroimaging characteristics have not been well-defined in molecular subgroups. Eighty-five patients with GBM were analyzed regarding imaging characteristics and correlation to p53 expression. The p53 positivity was graded according to percentage of positive cells (Grade 0, for < 10%; Grade 1, for <25%; Grade 2, for 26-50%; Grade 3, for >50% labeled cells). Imaging characteristics evaluated in the preoperative MRI were location and number of lesions, dimensions of enhancing lesion and of surrounding edema, mass effect, tumor borders, enhancement pattern after intravenous contrast administration, and tumor necrosis. Eighteen tumors had p53 expression >50% in immunohistochemical staining. Preoperative MRI of patients harboring those tumors with high p53 positivity revealed typical lesions with ring enhancement pattern and well-defined borders in T1-weighted images with contrast, and they were significantly different from other groups of p53 expression. There was no difference in terms of location and number of the lesions, dimensions of enhancing lesion and surrounding edema, mass effect, and the tumor necrosis between four different groups of p53 expression. A special subgroup of GBMs with p53 overexpression has ring enhancement pattern and well-defined border on MRI that may be influential in preoperative planning and postoperative management of adjunct therapy.

Diagnosis of Aortoenteric Fistulas with CT Angiography

PURPOSE

To describe the diagnostic findings of primary and secondary aortoenteric fistulas (AEFs) at computed tomographic (CT) angiography in a cohort of patients known to have AEF and to correlate those findings with those from endoscopic gastroduodenoscopy (EGD) and surgery.

MATERIALS AND METHODS

CT angiography was performed in nine patients with AEF. There were four men and five women aged 43-85 years (mean age, 67 years). All CT angiograms were retrospectively reviewed for signs of AEF. Reports from EGD, surgery, and pathologic examination were also reviewed.

RESULTS

One patient had a primary AEF, and eight patients had a secondary AEF. Findings at CT angiography were suggestive of the diagnosis in all nine patients. The two definitive CT angiographic findings were identification of the graft within the bowel lumen in two patients (22%) and active extravasation in one patient (11%), allowing the definitive diagnosis in three of the nine patients (33%). Secondary signs, which helped predict the high likelihood of the diagnosis but could also be seen in graft infection or inflammation without AEF, were as follows (in descending order of frequency): effacement of the periaortic or perigraft fat plane and the fat plane between the aorta and bowel (nine patients, 100%), perigraft soft tissue (nine patients, 100%), bowel wall thickening adjacent to the graft (eight patients, 89%), perigraft fluid (seven patients, 78%), perigraft hematoma (six patients, 67%), pseudoaneurysm or aneurysm bulge (six patients, 67%), ectopic gas (five patients, 56%), and dystrophic vascular graft calcification (one patient, 11%). The diagnosis was confirmed surgically in seven patients and with clinical follow-up in two.

CONCLUSION

CT angiography is well suited for helping make or suggesting the diagnosis of AEF and is potentially more accurate than EGD.

Anatomic relationship of the internal jugular vein and the common carotid artery applied to percutaneous transjugular procedures

PURPOSE

To demonstrate the anatomic relationship of the internal jugular vein (IJV) with the common carotid artery (CCA) in order to avoid inadvertent puncture of the CCA during percutaneous central venous access or transjugular interventional procedures.

METHODS

One hundred and eighty-eight consecutive patients requiring either central venous access or interventional procedures via the IJV were included in the analysis. The position of the IJV in relation to the CCA was demonstrated by portable ultrasonography. The IJV location was recorded in a clock-dial system using the carotid as the center of the dial and the angles were measured. Outcomes of the procedure were also recorded.

RESULTS

The IJV was lateral to the CCA in 187 of 188 patients and medial to the CCA in one patient. The left IJV was at the 12 o'clock position in 12 patients (6%), the 11 o'clock position in 17 patients (9%), the 10 o'clock position in 142 patients (75%) and at the 9 o'clock position in 17 patients (9%). The right IJV was at the 12 o'clock position in 8 patients (4%), the 1 o'clock position in 31 patients (16%), the 2 o'clock position in 134 patients (71%) and the 3 o'clock position in 17 patients (9%). In one patient the left IJV was located approximately 60 degrees medial to the left CCA; this was recorded as 2 o'clock on the left since it is opposite to the 10 o'clock position.

CONCLUSION

Knowledge of the IJV anatomy and relationship to the CCA is important information for the operator performing an IJV puncture, to potentially reduce the chance of laceration of the CCA and avoid placement of a large catheter within a critical artery, even when ultrasound guidance is used.