Subxiphoid access to normal pericardium with micropuncture set: technical feasibility study in pigs

This study was performed with approval from the ethics committee for animal research of the local government. The purpose of the study was to evaluate the technical feasibility of a technique for subxiphoid access to the normal pericardial space with a micropuncture set in 10 large white pigs. With fluoroscopic guidance, a fine needle was inserted through a subxiphoid approach into the anterior mediastinal space to puncture the pericardium, and a micropuncture set was placed in the pericardial space successfully in all animals without complications. Necropsy at 24 hours did not reveal hemomediastinum, hemopericardium, or laceration of the pericardium. Results of the experiments in animals indicated that the technique was feasible and safe.     

An autopsy case of aortitis resulting in sudden death due to a rupture of aneurysm of the aortic sinus

An autopsy case of spontaneous rupture of a clinically undiagnosed inflammatory aneurysm of the aortic sinus is presented. A 34-year-old man consulted a physician complaining of anterior chest pain and heartburn persisting for 2 days. Diagnoses of common cold and gastritis were made, but 3h later his condition deteriorated, leading to death. Autopsy revealed hemopericardium due to rupture of a saccular aneurysm of the aortic sinus. Histological examination of the aortic sinus disclosed aortitis characterized by fragmentation and loss of elastic tissues with fibrous thickening of the intima. Lymphocytes along with polymorphonuclear leucocytes and plasma cells infiltrated the adventitia and media at severely affected areas. These changes were limited to the aortic sinus, and other portions of the aorta and its main branches were essentially intact. An eccentric intimal thickening with medial degeneration was found within the anterior descending branch of the left coronary artery, and occasional collection of lymphocytes was noted in the epicardium. This case would be a rare and illustrative case for differentiation of aortitis, although we could not pinpoint the etiology of the aortitis because of non-specific histological findings and negative serological results for exogenous pathogens.     

Suicide with a signal pen gun

A man committed suicide with a modified signal pen gun and a .22 lr HV HP bullet. The contact shot to the left chest led to a conventional entrance wound. The projectile from the unconventional weapon caused a penetrating wound and was not deformed instead of the expected perforation and deformation. The smooth-bore barrel did not leave characteristic firing marks on the bullet.     

Evaluation of diseased coronary arterial branches by polar representations of thallium-201 rotational myocardial imaging

The perfusion territories in polar representations of stress Tl-201 rotational myocardial imaging in patients with angina pectoris who had one diseased coronary segment were analyzed. The lesions proximal or distal to the first major septal perforator in left anterior descending arteries were detected by the presence or absence of defects at the base of the anterior septum. Right coronary artery lesions were detected by the presence of defects at the basal posterior septum, in contrast to the preservation of myocardial uptake at this portion in lesions of the left circumflex artery. The specific defect patterns were detected in cases with lesions at the first diagonal, obtuse marginal, and posterolateral branches. Recognition of these defects in the polar maps allows detailed detection of diseased coronary arterial branches.     

Central retinal and posterior ciliary artery occlusion after intralesional injection of sclerosant to glabellar subcutaneous hemangioma

The aim of this study is to describe vision loss caused by central retinal artery and posterior ciliary artery occlusion as a consequence of sclerotherapy with a polidocanol injection to a glabellar hemangioma. An 18-year-old man underwent direct injection with a 23-gauge needle of 1 mL of a polidocanol-carbon dioxide emulsion into the glabellar subcutaneous hemangioma under ultrasound visualization of the needle tip by radiologists. He developed lid swelling the next day, and 3 days later at referral, the visual acuity in the left eye was no light perception. Funduscopy revealed central retinal artery occlusion and fluorescein angiography disclosed no perfusion at all in the left fundus, indicating concurrent posterior ciliary artery occlusion. The patient also showed mydriasis, blepharoptosis, and total external ophthalmoplegia on the left side. Magnetic resonance imaging demonstrated the swollen medial rectus muscle. In a month, blepharoptosis and ophthalmoplegia resolved but the visual acuity remained no light perception. Sclerosing therapy for facial hemangioma may develop a severe complication such as permanent visual loss.     

Coronary, ventricular, and pulmonary abnormalities associated with rupture of the interventricular septum complicating myocardial infarction.

Left ventricular wall motion abnormalities, the extent and location of coronary artery stenoses, and the radiographic evidence of pulmonary venous hypertension were analyzed in a retrospective study of 40 patients who had surgically proven rupture of the interventricular septum after myocardial infarction. In 33 patients in whom chest films were available, interstitial or alveolar pulmonary edema was present in 78%, while left ventricular enlargement was present in 82%. Of 26 patients who had coronary angiography, complete occlusion of the right coronary artery, left anterior descending artery, or left circumflex artery was present in 92%, with few, if any, collateral vessels around the occlusion. The location of the rupture in the muscular septum was always in the region of akinesis or dyskinesis. Posterior defects were associated with posterobasal and diaphragmatic akinesis, and anterior defects with apical akinesis. Left ventricular aneurysms were adjacent to the septal rupture in 68%, and 74% had mitral regurgitation. The right ventricular diaphragmatic wall in posterior rupture was always akinetic, indicating right ventricular infarction. Thus ventricular septal defect after myocardial infarction (1) tends to occur with multiple coronary occlusions about which little collateral flow develops; (2) can accurately be localized anteriorly or posteriorly in the muscular septum by the location of the akinetic left ventricular wall segment; and (3) has an associated right ventricular infarct when rupture is posterior.     

左冠状动脉瘘的影像诊断与介入治疗

目的 :探讨左冠状动脉瘘的影像诊断和介入治疗价值。方法 :2 7例均行X线平片和彩色多普勒检查 ;行升主动脉造影者 4例 ,选择性冠状动脉造影者 2 3例 ;3例行介入治疗 ,16例于体外循环下行冠状动脉瘘修复术。结果 :5例X线平片和 15例彩色多普勒检查基本上能提示诊断 ,血管造影均能明确诊断 ,血管造影显示左冠状动脉瘘通过左前降支和左回旋支形成较粗大的瘘口者 16例 (5 9.3% ) ,左冠状动脉细小分支瘘者 11例 (40 .7% ) ,其中发生于左冠状动脉前降支的细小分支者 6例、发生于左回旋支的细小分支者 4例、同时源于左前降支和左回旋支的细小分支者 1例。在这 2 7例中 ,瘘入右心室 13例 (48.2 % ) ,瘘入肺动脉者 7例 (2 5 .9% ) ,瘘入左心室 5例 (18.3% ) ,瘘入左房者 2例 (7.4 % )。 3例患者行介入治疗 ,经 6个月随访观察 ,未见异常改变。结论 :选择性冠状动脉造影是诊断冠状动脉瘘的最佳方法 ,在治疗方面目前除手术治疗外 ,介入治疗亦是一种较好的手段     

Unusual origin and course of the first septal branch of the left coronary artery: Angiographic recognition

The anatomical variants of the origin and course of the first septal branch (S1) of the left coronary artery system have received little attention in the literature dealing with coronary angiography. We describe here the angiographic features of the ectopic origin of S1 from epicardial branches of the left coronary artery other than the left anterior descending artery as observed in 8 cases from a series of 700 consecutive patients (1.1%). The S1 originated from the left main coronary artery in 1 case, from a diagonal branch in 4, and from an intermediate branch in 3 cases. Previous reported cases are reviewed. Because the S1 may supply up to 15% of the blood to the myocardium, the recognition of this variable origin may have clinical implications and has to be considered as a part of the complete evaluation of coronary arteriograms of patients referred for coronary artery revascularization.     

双源CT冠状动脉成像在老年冠心病临床诊断中的应用分析

目的 探讨在老年冠心病临床诊断中双源CT冠状动脉成像的应用价值.方法 2019年12月至2020年7月期间,从我院选取140例老年冠心病患者根据随机数字表法分为对照组和观察组,每组患者均为70例.对照组行常规冠状动脉造影方法诊断,观察组行双源CT冠脉成像方法诊断.对比2组患者检查结果,冠状动脉分支诊断效果和冠状动脉节段...     

Left bundle branch block and coronary artery disease: Accuracy of dipyridamole thallium-201 single-photon emission computed tomography in patients with exercise anteroseptal perfusion defects

Background  Reduced septal or anteroseptal uptake of thallium-201 during exercise is frequently observed in patients with left bundle branch block (LBBB) even in the absence of left anterior descending (LAD) coronary artery disease. The purpose of this study was to evaluate prospectively the accuracy of dipyridamole²⁰¹TI single-photon emission computed tomography (SPECT) in detecting LAD coronary artery disease in patients with LBBB and septal or anteroseptal perfusion defects on exercise²⁰¹TI SPECT. Methods and Results  Twelve consecutive patients (10 men and two women) with complete LBBB and septal or anteroseptal perfusion defects on exercise²⁰¹TI SPECT underwent dipyridamole²⁰¹TI SPECT. The delay between dipyridamole and exercise was 2 to 30 days. Coronary angiography was performed during this period in all patients. Six (50%) of 12 patients with exercise perfusion defects showed normal perfusion after dipyridamole; all had normal coronary angiograms. The remaining six patients also had positive results of dipyridamole studies, two with moderate and four with severe septal or anteroseptal perfusion defects. Coronary angiography showed significant (>50%) LAD coronary artery stenosis in three patients; three patients with severe septal or anteroseptal perfusion defects after dipyridamole had normal coronary angiograms. Neither the evaluation of apical involvement nor the presence of dilated ventricles, decreased left ventricular ejection fraction, or wall motion abnormalities could help to identify (or explain) false-positive results. Conclusion  This study confirms that dipyridamole is more accurate than exercise in excluding LAD coronary artery disease. However, there are still false-positive results and the severity of the septal or anteroseptal perfusion defect does not add additional information to identify LAD coronary artery disease. Coronary angiography is thus necessary for positive dipyridamole study results to identify coronary artery disease as a major prognostic factor in patients with LBBB.     

Lateral C1-2 puncture for myelography: posterior approach.

The lateral C1-2 puncture approach for myelography is a modification of the technique for percutaneous radiofrequency cervical cordotomy. Positioning of the needle in the posterior, rather than anterior, one third of the canal avoids injury to anomalous vertebral artery branches which lie in the anterior half of the neural canal at this level.     

The normal distribution of thoracoabdominal aorta small branch artery ostia

The purpose of this study was to determine the normal distribution of aortic branch artery ostia. CT scans of 100 subjects were retrospectively reviewed. The angular distributions of the aorta with respect to the center of the T3 to L4 vertebral bodies, and of branch artery origins with respect to the center of the aorta were measured. At each vertebral body level the distribution of intercostal/lumbar arteries and other branch arteries were calculated. The proximal descending aorta is posteriorly placed becoming a midline structure, at the thoracolumbar junction, and remains anterior to the vertebral bodies within the abdomen. The intercostal and lumbar artery ostia have a distinct distribution. At each vertebral level from T3 caudally, one intercostal artery originates from the posterior wall of the aorta throughout the thoracic aorta, while the other intercostal artery originates from the medial wall of the descending thoracic aorta high in the chest, posteromedially from the mid-thoracic aorta, and from the posterior wall of the aorta low in the chest. Mediastinal branches of the thoracic aorta originate from the medial and anterior wall. Lumbar branches originate only from the posterior wall of the abdominal aorta. Aortic branch artery origins arise with a bimodal distribution and have a characteristic location. Mediastinal branches of the thoracic aorta originate from the medial and anterior wall. Knowing the location of aortic branch artery ostia may help distinguish branch artery pseudoaneurysms from penetrating ulcers.     

16层螺旋CT冠状动脉血管成像技术临床应用

目的:探讨16层螺旋CT冠状动脉成像技术临床应用价值。方法:对45例临床诊断或可疑冠心病的住院患者行16层螺旋CT冠状动脉回顾性心电门控平扫及增强扫描。将增强扫描图像传送到Wizard图像工作站进行最大密度投影(MIP)、多平面重组(MPR)、曲面重组(CPR)、容积再现技术(VRT)及平带多平面重组(RMPR)。并将VRT及MIP重组像为参照,用平扫图像对冠状动脉各支段进行钙化积分。结果:左冠状动脉主干(LM)、左前降支近中段(LAD1、LAD2)、第一对角支(D1)、左回旋支(LCX)及右冠状动脉近段(RCA1)显示均45例(100%),左前降支远段(LAD3)23例(51%),第二对角支(D2)30例(67%),第三对角支(D3)24例(53%),第一左缘支(M1)36例(80%),第二缘支(M2)28例(62%),右冠状动脉中段(RCA2)41例(91%),右冠状动脉远段(RCA3)43例(96%)及后降支(PDA)34例(76%)。左冠状动脉主干钙化12例(27%),左前降支近中段钙化有29例(64%),左回旋支钙化例数22例(49%),右冠状动脉近中段钙化有24例(53%)。结论:16层螺旋CT可对冠状动脉进行钙化积分并准确显影,是冠状动脉粥样硬化疾病筛选和诊断的首选方法。     

334例选择性冠状动脉造影分析

目的:探讨冠心病病人冠状动脉病变范围、程度、评估冠脉造影价值及其局限性。方法:用Judkins法行选择性左、右冠脉造影334例,观察并记录冠脉病变范围和程度。结果:334例冠脉造影有病理性改变212例(63.4%),其中单支病变97例(45.7%),双支病变66例(31.1%)三支病变45例(21.2%),四支病变4例(1.9%)。共累及417支血管,分别为前降支207支(49.6%),右冠119支(28.5%),回旋支85支(20.3%)左主干6支(1.4%)。心肌梗塞组(A组)阳性率88.9%,心绞痛组(B组)80%,胸痛组(C组)11.7%。结论:选择性冠状动脉造影仍然是诊断冠心病的金标准,它具有其他无创性检查无法替代的作用。     

Single Coronary Artery with Aortic Regurgitation

An isolated single coronary artery can be associated with normal life expectancy; however, patients are at an increased risk of sudden death. A case is reported of a 54-year-old man with several months of chest pressure with activity. On exercise Sestamibi stress testing, the patient developed a hypotensive response with no symptoms and minimal electrocardiographic changes. Nuclear scanning demonstrated reversible septal and lateral perfusion defects consistent with severe ischemia. Coronary angiography revealed a single coronary artery with the right coronary artery arising from the left main. There were high-grade stenotic lesions in the left anterior descending and circumflex arteries with only moderate atherosclerotic disease in the right coronary artery. An aortogram showed 2–3+ aortic regurgitation, with an ejection fraction of 45% on ventriculography. The patient underwent four-vessel revascularization and aortic valve replacement and did well postoperatively.     

CT diagnosis of cardiac and pericardial injuries

The purpose of this retrospective study was to determine the CT findings diagnostic of cardiac and pericardial injury, including signs of pericardial tamponade, in patients suffering from blunt and penetrating trauma. A search of the CT radiology database at a level I trauma center was performed to identify cases in which injury to the heart or pericardium was diagnosed, as well as to identify cases of pericardial tamponade. All cases were reviewed to ascertain the specific CT findings, and medical records were reviewed to assess the influence of CT findings on management and to assess for clinical evidence of pericardial tamponade. Eighteen patients had direct CT evidence of cardiac or pericardial injury, including nine cases of pneumopericardium, eight cases of hemopericardium, and one case of intrapericardial gastric herniation. Four of these patients were found to have direct cardiac injuries. Three additional cases with CT evidence of pericardial tamponade were identified, two secondary to cardiac compression by an anterior mediastinal hematoma and one following repair of left ventricular rupture. Of 11 patients with CT evidence of tamponade, only three were suspected clinically. Cardiac and pericardial injuries are usually diagnosed surgically and are often clinically unsuspected, particularly in blunt trauma. As CT is increasingly utilized as a general screening test for thoracic/abdominal trauma, these injuries may be first suspected on the basis of CT findings, and knowledge of the CT findings of cardiac injury or tamponade is crucial.     

Thallium-201 SPECT in coronary artery disease patients with left bundle branch block

Fourteen patients with left bundle branch block (LBBB) underwent immediate postexercise and 3-hr delayed 201Tl single photon emission computed tomography (SPECT) with quantitative analysis using bullseye polar maps. Test performance in detecting individual coronary artery stenosis greater than or equal to 50% demonstrated 100% sensitivity. Specificity was 100% for circumflex stenosis, 78% for right coronary stenosis, but only 10% for left anterior descending coronary stenosis. This very low specificity was due to the fact that 3/4 (75%) patients with left anterior descending stenosis and also 9/10 (90%) patients with normal left anterior descending coronary arteries had immediate septal perfusion defects with redistribution in all cases at 3 hr. Septal abnormalities were most marked in patients who achieved high peak heart rates (greater than 170 bpm). Thus, with LBBB, 201Tl SPECT is indeterminate for left anterior descending coronary disease.     

Endovascular Repair of a Right-Sided Descending Thoracic Aortic Aneurysm Associated with a Right Aortic Arch and a Left Subclavian Artery Arising from a Kommerell’s Diverticulum

This case report describes the endovascular repair of a right-sided descending thoracic aortic aneurysm associated with a right aortic arch and an aberrant left subclavian artery. A 76-year-old male with multiple comorbidities was incidentally found to have a right-sided descending thoracic aortic aneurysm with a maximum diameter of 6.2 cm. Additionally, there was a right aortic arch with a retroesophageal segment and separate arch branches arising in the following order: left common carotid artery, right common carotid artery, right subclavian artery, and left subclavian artery that was aberrant, arising from a Kommerrell’s diverticulum. The aneurysm was successfully excluded by deployment of a Zenith TX1 36 × 32 × 20-mm stent-graft using wire traction technique via the left femoral and right brachial arteries in order to deal with two severe aortic angulations. At 18-month follow-up the patient was doing well, with aneurysm sac shrinkage to 5.9 cm and no signs of endoleak or migration. Endovascular repair of right-sided descending thoracic aortic aneurysms with a right arch and aberrant left subclavian artery is feasible, safe, and effective. In such rare configurations, which demand considerably increased technical dexterity and center experience, endovascular repair emerges as an attractive therapeutic option.     

Shoulder,hip, and knee arthrography needle placement using fluoroscopic guidance: practice patterns of musculoskeletal radiologists in North America

Objective  The aim of this study was to evaluate the range of techniques used by radiologists performing shoulder, hip, and knee arthrography using fluoroscopic guidance. Materials and methods  Questionnaires on shoulder, hip, and knee arthrography were distributed to radiologists at a national radiology meeting. We enquired regarding years of experience, preferred approaches, needle gauge, gadolinium dilution, and volume injected. For each approach, the radiologist was asked their starting and end needle position based on a numbered and lettered grid superimposed on a radiograph. Results  Sixty-eight questionnaires were returned. Sixty-eight radiologists performed shoulder and hip arthrography, and 65 performed knee arthrograms. Mean experience was 13.5 and 12.8 years, respectively. For magnetic resonance arthrography, a gadolinium dilution of 1/200 was used by 69–71%. For shoulder arthrography, an anterior approach was preferred by 65/68 (96%). The most common site of needle end position, for anterior and posterior approaches, was immediately lateral to the humeral cortex. A 22-gauge needle was used by 46/66 (70%). Mean injected volume was 12.7 ml (5–30). For hip arthrography, an anterior approach was preferred by 51/68 (75%). The most common site of needle end position, for anterior and lateral approaches, was along the lateral femoral head/neck junction. A 22-gauge needle was used by 53/68 (78%). Mean injected volume was 11.5 ml (5–20). For knee arthrography, a lateral approach was preferred by 41/64 (64%). The most common site of needle end position, for lateral and medial approaches, was mid-patellofemoral joint level. A 22-gauge needle was used by 36/65 (56%). Mean injected volume was 28.2 ml (5–60). Conclusion  Arthrographic approaches for the shoulder, hip, and knee vary among radiologists over a wide range of experience levels. No grants were received for this study and no conflicts of interest to report.