Role of echo-colour Doppler in the diagnostic work-up and surgical timing of chronic venous insufficiency

Chronic venous insufficiency affects about 10-12% to 35-50% of the population in industrialised countries. We analyse the role of echo-colour Doppler in the diagnostic-therapeutic work-up for this pathology in the light of their own experience. We report the results of the study of 158 legs in 79 patients, classifying the severity of chronic venous insufficiency using the Widmer classification, and private circulations using the Franceschi shunt classification. The mean duration of the examination was about 30 minutes (range: 22-46). A reflux time > 0.5 sec. was considered pathological. The patients with chronic venous insufficiency were divided into three groups on the basis of type of treatment: medical treatment and elastic compression (group 1,12 patients), sclerotherapy and elastic compression (group II, 20 patients), surgical treatment and sclerotherapy (group III, 36 patients). The echo-colour Doppler results were confirmed in the operating theatre in 34 patients. Echo-colour Doppler enabled us to identify patients who needed less invasive treatment than stripping; in group III, echo-colour Doppler allowed precise mapping and identification of communicant veins and collaterals, with 95% accuracy.     

Defining the limitations of measurements from Doppler spectral recordings

Purpose:The purpose of this study was to determine whether Doppler measurements of peak velocity and four other quantitative measures of spectral shape are affected significantly by the site of the Doppler recording in relation to the location of the maximum stenosis.Method: Continuous-wave and pulsed Doppler recordings were made distal to a 70% (area reduction or 45% diameter reduction) asymmetric stenosis in an in vitro flow model under steady and pulsatile flow conditions. Recordings were taken at six different locations proximal and distal to the stenosis. A photochromic dye technique was used to visualize the actual flow field in the model.Results: Distal to the stenosis, the flow visualization results demonstrated a strong radial and axial variation of the velocity field and thus explained why the Doppler measurements of peak frequency and spectral broadening were strongly dependent on the recording site. The peak frequency was maximum within the throat of the stenosis and returned to the prestenotic value five tube diameters distal to the stenosis. Other measurements of spectral broadening and spectral shape varied greatly depending on the location of the recording site in the poststenotic region. Higher order spectral moments such as the coefficient of kurtosis were found to exhibit large temporal variability, which makes them inappropriate as diagnostic indicators.Conclusions: Because of the complex nature of the poststenotic flow field, these results clearly demonstrate that no single Doppler measurement can accurately quantify the severity of a stenosis. Of the Doppler measurements only peak velocity is related to the severity of stenosis. Reproducible peak velocity measurements are obtained only if the Doppler sample volume is positioned at or very near the throat of the stenosis and at an appropriate radial site that may not necessarily be at the center of the vessel. (J Vasc Surg 1996;24:34-45.)     

Effect of varicocele on testicular artery blood flow in men--color Doppler investigation

OBJECTIVE: Varicocele can be defined as an abnormal tortuosity and dilatation of the veins of the pampiniform plexus. Contradictory results have been obtained from experimental animal models and a few clinical human studies on testicular arterial blood flow in varicocele. The purpose of this study was to determine the changes in testicular arterial blood flow parameters in patients with varicocele. MATERIAL AND METHODS: A total of 62 patients with a clinical diagnosis of left varicocele and a scrotal vein with a diameter of > or = 3 mm on color Doppler ultrasonography were included in the study. A total of 44 fertile normal male volunteers served as controls. RESULTS: Median testicular arterial blood flow and median flow rate in milliliters per minute per 100 g of testicular tissue were found to be significantly decreased in the patient group compared to the control group: blood flow, 1.42 and 2.00 ml/min; flow rate, 9.63 and 12.35 ml/min/100 g, respectively (p < 0.05). Positive correlations were found between sperm concentration and left testicular artery blood flow (p < 0.05) and between left testicular volume and testicular artery blood flow (p < 0.05). CONCLUSIONS: Testicular arterial blood flow was found to be significantly decreased in men with varicocele. This may be a reflection of the impaired microcirculation. Following decreased testicular arterial blood flow, impaired spermatogenesis may result from defective energy metabolism in the microcirculatory bed.     

Anomalous origin of the left main coronary artery from the main pulmonary artery in an elderly patient

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) syndrome is an extremely rare diagnosis in elderly patients. We describe a 73-year-old female with ALCAPA who underwent successful repair of this coronary anomaly.     

Anomalous right coronary artery originating from the left main coronary artery

A 54-year-old man with no cardiac history presented with exertional angina. Cardiac catheterization revealed an anomalous right coronary artery originating from the left main coronary artery with external compression during its course between the aorta and the pulmonary artery. He was successfully managed with surgical reimplantation of the right coronary artery into the aorta.     

Isolated anomalous origin of right coronary artery from the main pulmonary artery

The anomalous origin of the right coronary artery (ARCA) from the main pulmonary artery (MPA) is a rare congenital cardiac malformation and usually associated with other cardiac anomalies. Most patients with isolated ARCA from MPA remain asymptomatic, but they may develop myocardial ischemia and even sudden death. We reported an asymptomatic 7-year-old boy referred for evaluation of a heart murmur. Isolation of ARCA from MPA was diagnosed by echocardiography and then confirmed by cardiac catheterization and angiography. The right coronary artery was re-implanted into the ascending aorta. A preoperative thallium-201 myocardial perfusion showed a myocardial ischemia pattern in the anterolateral septal area after a dipyridamole stress test; the ischemia was completely resolved after surgery.     

Doppler sonography in testicular and scrotal imaging

The primary role of Doppler ultrasound of the acute testicle and scrotum is for the diagnosis of spermatic cord torsion or epididymitis. The utility of Doppler in other conditions such as testicular neoplasm is limited, and in general does not increase diagnostic specificity. The application of color Doppler imaging and power Doppler imaging increases sensitivity for the detection of orchitis and testicular neoplasms in which the gray scale findings may be subtle. Power Doppler imaging is more sensitive for the identification of slowly flowing blood than color Doppler imaging. As a result, power Doppler imaging may be particularly helpful for the diagnosis or exclusion of spermatic cord torsion as a cause of acute scrotal pain in the prepubescent male.     

Angioplasty of the left main coronary artery for isolated left main coronary artery disease

Operative technique and results of angioplasty of the left main coronary artery (LMCA) for isolated LMCA disease are reported. Nine consecutive patients, six men and three women, were operated upon. Their ages varied from 46 to 69 years, mean 51 years. All had 50% to 90% stenosis of the LMCA and Class III angina. Cardiopulmonary bypass and a cold cardioplegic solution were used for all operations. There were no operative deaths or infarctions. Follow-up ranged from 0.5 to 4 years, mean 1.9 years. Except for the first patient, who has new stenosis of the proximal anterior descending artery, all patients are free of angina. Repeat angiography in five patients showed a widely patent LMCA with excellent runoff. Our preliminary results suggest that angioplasty of the LMCA can be carried out with low operative risks. The technique appears to be a promising alternative to coronary artery bypass grafting in isolated LMCA disease.     

Spermatogenesis in the contralateral testis of patients with testicular germ cell cancer: histological evaluation of testicular biopsies and a comparison with healthy males

OBJECTIVE: To assess histologically signs of testicular dysgenesis (TD) in the contralateral testes of patients with testicular germ cell tumours (GCTs) and to compare these findings with the spermatogenetic quality in healthy men, as the contralateral testis is considered to be involved with dysgenetic features such as poor sperm production, and accordingly, GCTs are hypothesized to be part of the 'TD syndrome' (TDS). One testicular biopsy is thought to represent spermatogenesis in the entire testis. We evaluated this view by using testicular two-site biopsies. PATIENTS AND METHODS: 2318 patients with testicular GCT had a contralateral testicular two-site biopsy. Testicular biopsies taken on forensic autopsy from 1388 presumably healthy men served as controls. Spermatogenesis was rated histologically according to a modified Johnsen score. Clinical factors were recorded to explore associations with reduced spermatogenesis. Differences in spermatogenesis scoring results among two-site biopsies were noted. Statistical analysis involved Wilcoxon-Mann-Whitney and Jonckheere-Terpstra tests for comparing patients and controls, and for studying associations with clinical factors. Classification and regression-tree analysis was used to explore multivariate associations. RESULTS: Histologically, patients had significantly poorer spermatogenesis than healthy men. Clinically, hypospermatogenesis was significantly associated with testicular atrophy, undescended testes, male infertility, and advanced clinical stage; 5.4% of cases (95% confidence interval 4.43-6.27) had discordant findings of >2 points on double biopsy and 9.8% had differences of 1 point. Discordance was significantly associated with poor spermatogenesis and testicular atrophy. CONCLUSIONS: We confirmed histologically that there is markedly reduced spermatogenesis in the contralateral testes of patients with GCT. This result lends credence to the view that GCT is part of the so-called TDS. But as hypospermatogenesis is associated with advanced clinical stage, impairment of sperm production might at least partly be acquired secondary to the endocrine activity of GCT. There were clinically relevant discordant results on double biopsy in 5.4%, predominantly in infertile patients and in atrophic testes. Thus the histological evaluation of male infertility is best done by multiple biopsies.     

X-ray findings on the testicular artery in varicocele

X-ray findings on the internal testicular artery following abdominal aortography are described. A group of 32 patients with left-sided varicocele were examined. The course of internal testicular artery was visualized in 27 patients. In 5 sterile patients prolonged filling of the left internal testicular artery up to the venous phase of the abdominal aortography has been observed. The non-physiological courses of the artery are described.     

Surgical treatment of the left main trunk and left main equivalent coronary artery disease

The comparative studies on operative and hemodynamic results following aorto-coronary bypass grafting were performed in 9 patients with left main trunk (LMT) stenosis and 20 with left main equivalent (LME). One of 20 LME had bypass grafts occluded on the postoperative angiogram. There were two operative deaths, one in LMT, another in LME, and one late death. Following results were obtained in 8 LMT (Group I) and 15 LME (Group II) whose all bypass grafts were patent. There were significantly higher operative mortality rate and the incidence of perioperative myocardial infarction in Group I (11.1% versus 5.0%). Cardiac index and left ventricular ejection fraction significantly increased postoperatively in both groups. Mean Vcf and PLVSP/LVESV significantly increased postoperatively in Group II, but not in Group I. Left ventricular anterior segmental wall motion significantly increased in both groups and apical in Group I, whereas it did not in the postero-inferior segment. The completely revascularized patients had a better postoperative left ventricular function comparing with the incompletely revascularized patients. Angina disappeared postoperatively in all patients in Group I and 12 (75%) in Group II. In both groups, NYHA classification was improved from class III or IV preoperatively to class I or II postoperatively. Postoperative 8 years actuarial survival rate was 88.2% in Group I and 84.6% in Group II. In conclusion, it was suggested that much more strict perioperative management and complete revascularization were needed in the patient with LMT.     

Two cases of testicular torsion diagnosed by the ultrasonic Doppler method

Two cases of testicular torsion diagnosed with ultrasonic Doppler method are reported. Case 1. A 17-year-old male noticed pain and swelling of the right intrascrotal contents during sleeping and visited our clinic. A Doppler signal was obtained from the normal testicle, but not from the affected one. Bilateral orchiopexy was therefore done under the diagnosis of right testicular torsion. Case 2. A 20-year-old male visited our clinic with complaints of pain and swelling of the right intrascrotal contents. The ultrasonic Doppler method revealed no blood flow to the right testicle. After manual detorsion, pain improved and Doppler sound was audible. Bilateral prophylactic orchiopexy was performed later.     

Left testicular artery arching over the ipsilateral renal vein

Aim:To report two cases of the left testicular artery arching over the left renal vein(LRV)before running downwardto the testis.Methods:The subjects were obtained from two Japanese cadavers.During the student course ofgross-anatomical dissection,the anatomical relationship between the testicular vessels and the renal vein was specifi-cally observed.Results:The arching left testicular artery arose from the aorta below the LRV and made a looparound the LRV,which appeared to be mildly compressed between the arching artery and the psoas major muscle.Conclusion:Clinically,compression of the LRV between the abdominal aorta and the superior mesenteric arteryoccasionally induces LRV hypertension,resulting in varicocele,orthostatic protenuria and hematuria.Consideringthat the incidence of a left arching testicular artery is higher than that of a right one,an arching left artery could be anadditional cause of LRV hypertension.(Asian J Androl 2006 Jan;8:107-110)