Comparison of Technical and Clinical Outcome of Transjugular Portosystemic Shunt Placement Between a Bare Metal Stent and a PTFE-Stentgraft Device

Purpose

To analyse technical and clinical success of transjugular intrahepatic portosystemic shunt (TIPS) in patients with portal hypertension and compare a stent and a stentgraft with regard to clinical and technical outcome and associated costs.

Materials and Methods

170 patients (56 ± 12 years, 32.9 % females) treated with TIPS due to portal hypertension were reviewed. 80 patients received a stent (group 1) and 83 a stentgraft (group 2), and seven interventions were unsuccessful. Technical data, periprocedural imaging, follow-up ultrasound and clinical data were analysed with focus on technical success, patency, clinical outcome and group differences. Cost analysis was performed.

Results

Portal hypertension was mainly caused by ethyltoxic liver cirrhosis with ascites as dominant symptom (80 %). Technical success was 93.5 % with mean portosystemic gradient decrease from 16.1 ± 4.8 to 5.1 ± 2.1 mmHg. No significant differences in technical success and portosystemic gradient decrease between the groups were observed. Kaplan–Meier analysis yielded significant differences in primary patency after 14 days, 6 months and 2 years in favour of the stentgraft. Both groups showed good clinical results without significant difference in 1-year survival and hepatic encephalopathy rate. Costs to establish TIPS and to manage 2-year follow-up with constant patency and clinical success were 8876 € (group 1) and 9394 € (group 2).

Conclusion

TIPS is a safe and effective procedure to manage portal hypertension. Stent and stentgraft enabled good technical and clinical results with a low complication rate. Primary patency rates are clearly in favour of the stentgraft, whereas the stent was more cost effective with similar clinical results in both groups.

     

Are iatrogenic renal artery pseudoaneurysms more challenging to embolize when associated with an arteriovenous fistula?

Background

Iatrogenic injuries of the renal artery include pseudoaneurysms (PSA) and pseudoaneurysms with arteriovenous fistula (PSA?+?AVF). They can cause hematuria, anemization and flank pain. Endovascular treatment is recommended due to its effectiveness.

Objective

To assess the potential difference between the embolization of iatrogenic renal PSA and iatrogenic renal PSA?+?AVF, in terms of technical and clinical success rate, procedure complexity and impact on the renal function.

Methods

We retrospectively reviewed 30 embolization procedures of iatrogenic renal PSA and renal PSA?+?AVF in 27 patients in two centers between December 2006 and February 2017, comparing technical and clinical success rate, total procedural time, creatinine before and after the procedure and parenchymal ischemic area after the procedure. All patients underwent CT before embolization procedure and different embolization materials were used.

Results

We identified 15 iatrogenic renal PSA and 15 iatrogenic renal PSA?+?AVF (causes: 23 nephron-sparing surgery, 2 nephrostomies, 1 lithotripsy, 1 ureteroscopic pyelolithotomy, 1 renal biopsy). Microcoils were used in 21 cases, microcoils and Spongostan in 3 cases, microcoils and controlled-release microcoils in 4 cases and controlled-release microcoils in 1 case. No significant statistical differences were found in the comparison of technical and clinical success rate, total procedural time, creatinine and parenchymal ischemic area after the procedure.

Conclusions

Transarterial embolization can be considered as the first-line treatment for renal artery iatrogenic lesions, considering its effectiveness. No statistical significant differences were found in the comparison of the embolization procedures of iatrogenic renal PSA and PSA?+?AVF.

     

Arterial Embolization in the Management of Mesenteric Bleeding Secondary to Blunt Abdominal Trauma

Introduction

Mesenteric bleeding is a rare but potentially life-threatening complication of blunt abdominal trauma. It can induce active hemorrhage and a compressive hematoma leading to bowel ischemia. Emergency laparotomy remains the gold standard treatment. We aimed to study the effectiveness and complications of embolization in patients with post-traumatic mesenteric bleeding.

Materials and Methods

The medical records of 7 consecutive patients with active mesenteric bleeding treated by embolization in a level-one trauma center from 2007 to 2014 were retrospectively reviewed. All patients presented with active mesenteric bleeding on CT scans without major signs of intestinal ischemia. We focused on technical success, clinical success, and the complications of embolization.

Results

Six endovascular procedures were successful in controlling hemorrhage but 1 patient had surgery to stop associated arterial and venous bleeding. One patient suffered from bowel ischemia, a major complication of embolization, which was confirmed by surgery. No acute renal failure was noted after angiography. For 1 patient we performed combined management as the endovascular approach allowed an easier surgical exploration.

Conclusion

In mesenteric trauma with active bleeding, embolization is a valuable alternative to surgery and should be considered, taking into account the risk of bowel ischemia.

     

Microfracture is more cost-effective than autologous chondrocyte implantation: a review of level 1 and level 2 studies with 5 year follow-up

Purpose

Focal cartilage defects in the knee may have devastating effect on the knee joint, where two of the main surgical treatment options are microfracture and autologous chondrocyte implantation. Comparative studies have failed to establish which method yields the best clinical results. A cost-effectiveness analysis of microfracture and autologous chondrocyte implantation would contribute to the clinical decision process.

Methods

A PubMed search identifying level I and level II studies with 5 year follow-up was performed. With the data from these studies, decision trees with associated service provision and costs connected to the two different techniques were designed. In addition to hospital costs, we included costs connected to physiotherapy following surgery. To paint a broader cost picture, we also included indirect costs to the society due to productivity loss caused by work absence.

Results

Four high-quality studies, with a follow-up of 5 years, met the inclusion criteria. A total of 319 patients were included, 170 undergoing microfracture and 149 autologous chondrocyte implantation. The re-operation rate was 23 (13.5%) following microfracture, and 18 (12.1%) for autologous chondrocyte implantation. Both groups achieved substantially better clinical scores at 5 years compared to baseline. Microfracture was more cost-effective when comparing all clinical scores.

Conclusion

Microfracture is associated with both lower costs and lower cost per point increase in patient reported outcome measures. There is a need of well-designed, high-quality randomized controlled trials before reliable conclusions regarding cost-effectiveness in the long run is possible.

Level of evidence

III.

     

Potential mechanisms of cerebellar hypoplasia in prematurity

Introduction

The cerebellum undergoes dramatic growth and maturation over the neonatal period after preterm birth and is thus particularly sensitive to impaired development due to various clinical factors.

Methods

Impairments in growth can occur independent of cerebellar parenchymal damage, such as from local hemorrhage, resulting from reduced expression of sonic hedgehog signaling to trigger the appropriate expansion of the granule precursor cells.

Results

The primary risk factors for impaired cerebellar development include postnatal glucocorticoid exposure, which has direct effects on the sonic hedgehog pathway, and supratentorial brain injury, including intraventricular hemorrhage and white matter injury, which may result in crossed cerebellar diaschisis and local toxic effects of blood products on the external granular layer. Other cardiorespiratory and nutritional factors may also exist. Impaired cerebellar development is associated with adverse outcomes in motor and cognitive development.

Conclusion

New approaches to care to counteract these risk factors may help improve long-term outcome after preterm birth.

     

Percutaneous Treatment of Intrahepatic Biliary Leak: A Modified Occlusion Balloon Technique

Purpose

To report a novel modified occlusion balloon technique to treat biliary leaks.

Methods

A 22-year-old female patient underwent liver transplantation with biliary-enteric anastomosis. She developed thrombosis of the common hepatic artery and extensive ischemia in the left hepatic lobe. Resection of segments II and III was performed and a biliary-cutaneous leak originating at the resection plane was identified in the early postoperative period. Initial treatment with percutaneous transhepatic drainage was unsuccessful. Therefore, an angioplasty balloon was coaxially inserted within the biliary drain and positioned close to the leak.

Results

The fistula output abruptly decreased after the procedure and stopped on the 7th day. At the 3-week follow-up, cholangiography revealed complete resolution of the leakage.

Conclusion

This novel modified occlusion balloon technique was effective and safe. However, greater experience and more cases are necessary to validate the technique.

     

Cardiac computed tomography as a viable alternative to echocardiography to detect vegetations and perivalvular complications in patients with infective endocarditis

Purpose

We considered cardiac computed tomography (CT) as a possible alternative modality to echocardiography in the assessment of infective endocarditis (IE). We evaluated the diagnostic capability of preoperative CT.

Materials and methods

We retrospectively evaluated the depiction of vegetations and perivalvular complications in preoperative cardiac CT images of 14 patients diagnosed with IE who required surgical intervention, who were seen at our institution from May 30, 2008 to February 3, 2017. We compared the CT findings with those of TTE and TEE assessments, and intraoperative findings.

Results

Cardiac CT correctly identified intraoperatively proven vegetations in 12 out of 13 (92.3%) patients and demonstrated 100% sensitivity and positive predictive value in depicting vegetations in the aortic valve and 100% sensitivity, specificity, positive predictive value, and negative predictive value in depicting pseudoaneurysm as perivalvular complications. CT offered superior identification of pseudoaneurysm to that with echocardiography and detected vegetations as small as 6 mm in maximal length. Vegetation size correlated well between TEE and CT.

Conclusion

Favorable comparison of CT and echocardiography in detecting vegetations and perivalvular complications in patients diagnosed with IE suggested potential for expansion in the use of CT for evaluating organic lesions in patients suspected or diagnosed with IE.

     

Heparin-bonded stent graft treatment for major visceral arterial injury after upper abdominal surgery

Purpose

To analyse technical success, complications, and short- and intermediate-term outcomes after heparin-bonded stent graft implantation for the treatment of major abdominal vessel injury after upper abdominal surgery.

Methods

This retrospective, IRB-approved analysis included 29 consecutive patients (female: n = 6, male: n = 23, mean age 65.9 ± 11.2 years). All patients underwent angiography and attempted heparin-bonded stent-graft implantation because of a major visceral arterial injury after upper abdominal surgery. Electronic clinical records, angiographic reports and imaging datasets were reviewed to assess technical success and complications. Telephone interviews were performed to obtain follow-up information and to estimate short- (> 30 days) and intermediate-term (> 90 days) outcomes.

Results

Successful stent graft placement was achieved in 82.8% (24/29). Peri-interventional complications were observed in 20.7% (6/29) and delayed, angiography-associated complications were observed in 34.5% (10/29) of the patients. Symptomatic re-bleeding occurred in 24.1% (7/29). Short-term survival (> 30 days) was 72.4% (21/29). Intermediate survival (> 90 days) was 37.9% (11/29).

Conclusion

Treatment of major vascular injuries with heparin-bonded stent grafts is feasible with a high technical success rate. However, survival depends on the underlying surgical condition, making interdisciplinary patient management mandatory.

Key Points

? Stent graft implantation is challenging, but has a high technical success rate. ? Complications are frequent but surgical conversion is rarely necessary. ? Survival depends on the underlying surgical condition causing the vascular injury. ? Interdisciplinary management is crucial for the survival of these patients.

     

Non-contrast-enhanced magnetic resonance angiography: a reliable clinical tool for evaluating transplant renal artery stenosis

Purpose

To evaluate image quality of non-contrast-enhanced magnetic resonance angiography (MRA) and compare transplant renal artery stenosis (TRAS) seen by non-contrast-enhanced MRA with digital subtraction angiography (DSA) as the gold standard.

Materials and methods

330 patients receiving 369 non-contrast-enhanced MRA examinations from July 2014 to June 2017 were included. Thirty patients received at least two MRA examinations. Image quality was independently assessed by two radiologists. Inter-observer agreement was analyzed. Transplant renal artery anatomy and complications were evaluated and compared with DSA. If possible, accuracy was calculated on a per-artery basis.

Results

Good or excellent image quality was found in 95.4 % (352/369) of examinations with good inter-observer agreement (K=0.760). Twenty-two patients with DSA had 28 non-contrast-enhanced MRA examinations within a 2-month period. Of these, 19 patients had TRAS, two patients had pseudoaneurysms, and one patient had a normal transplant renal artery but an occluded external iliac artery. Non-contrast-enhanced MRA correctly detected 19 TRAS and nine normal arteries, giving 96.6 % accuracy on a per-artery basis.

Conclusions

Non-contrast-enhanced MRA demonstrates a good depiction of the transplanted renal artery and shows good correlation with DSA in cases where there was TRAS.

Key Points

? Good or excellent image quality was found in 95.4 % of examinations. ? Non-contrast-enhanced MRA can clearly map transplant renal artery anatomy. ? Non-contrast-enhanced MRA is a reliable tool to detect TRAS.

     

Komplikationen beim kathetergestützten Aortenklappenersatz nach transfemoralem Zugang

Background

Catheter-assisted aortic valve replacement or transcatheter aortic valve implantation (TAVI) has been carried out for over 10 years. Even in the initial phases typical complications after a transfemoral approach became apparent.

Aim

This article describes how the indications for TAVI and the avoidance of complications must be checked as exemplified by four autopsy cases.

Material and methods

In the first case the iliac vessels in an 86-year-old female patient ruptured during an attempt to reposition the implanted valve. In the second case a laceration of the aorta occurred close to the original aortic valve and the 82-year-old female patient died due to pericardial tamponade. In the third case an 89-year-old woman suffered a covered laceration of the aorta and the patient died during an attempt to replace the vessel. In a further case of an 83-year-old woman during transfemoral valve replacement the positioning of the valve was unsuccessful and a second valve had to be implanted due to embolization of the unfolded valve.

Results

In all four cases the indications for TAVI in the multimorbid patients were justified. The complications were very different and in two cases assessment of the original vascular lacerations could no longer be carried out due the fact that surgery had already begun.

Conclusion

Most patients undergoing TAVI are multimorbid hence the treatment of complications becomes extremely difficult and bears a great risk of causing further complications.

     

Post-operative deformation and extrusion of the discoid lateral meniscus following a partial meniscectomy with repair

Purpose

The purpose of this study was to investigate the morphology of the discoid lateral meniscus sequentially following a partial meniscectomy with repair using magnetic resonance imaging (MRI).

Methods

Nine patients with a symptomatic discoid lateral meniscus with a peripheral tear were enrolled in this study, and a partial meniscectomy with repair was performed arthroscopically. An MRI examination was performed 2 weeks after surgery (before weight bearing was permitted) and again 6 months after surgery (when sporting activities could resume). The width, height and distance of the discoid lateral meniscus were measured. The distance was defined as the distance between the edges of the discoid lateral meniscus and the tibia.

Results

The width of the anterior, middle and posterior segments significantly decreased from 2 weeks to 6 months after surgery. The height of the middle and posterior segments significantly increased from 2 weeks to 6 months after surgery, whereas the height of the anterior segment did not significantly change. The distance of the anterior, middle and posterior segments significantly decreased from 2 weeks to 6 months after surgery.

Conclusion

The discoid lateral meniscus exhibited deformation and extrusion from 2 weeks to 6 months after a partial meniscectomy with repair. Therefore, the function of load transmission might not be maintained appropriately after surgery.

Level of evidence

IV.

     

History of shoulder instability surgery

Purpose

The surgical management of shoulder instability is an expanding and increasingly complex area of study within orthopaedics. This article describes the history and evolution of shoulder instability surgery, examining the development of its key principles, the currently accepted concepts and available surgical interventions.

Methods

A comprehensive review of the available literature was performed using PubMed. The reference lists of reviewed articles were also scrutinised to ensure relevant information was included.

Results

The various types of shoulder instability including anterior, posterior and multidirectional instability are discussed, focussing on the history of surgical management of these topics, the current concepts and the results of available surgical interventions.

Conclusions

The last century has seen important advancements in the understanding and treatment of shoulder instability. The transition from open to arthroscopic surgery has allowed the discovery of previously unrecognised pathologic entities and facilitated techniques to treat these. Nevertheless, open surgery still produces comparable results in the treatment of many instability-related conditions and is often required in complex or revision cases, particularly in the presence of bone loss. More high-quality research is required to better understand and characterise this spectrum of conditions so that successful evidence-based management algorithms can be developed.

Level of evidence

IV.

     

Navigation-based tibial rotation at 90° of flexion is associated with better range of motion in navigated total knee arthroplasty

Purpose

In clinical practice, people with better femorotibial rotation in the flexed position often achieve a favourable postoperative maximum flexion angle (MFA). However, no objective data have been reported to support this clinical observation. In the present study, we aimed to investigate the correlation between the amount of intraoperative rotation and the pre- and postoperative flexion angles.

Methods

Fifty-five patients with varus osteoarthritis undergoing computer-assisted posterior-stabilized total knee arthroplasty (TKA) were enrolled. After registration, rotational stress was applied towards the knee joint, and the rotational angles were recorded by using a navigation system at maximum extension and 90° of flexion. After implantation, rotational stress was applied for a second time, and the angles were recorded once more. The MFA was measured before surgery and 1 month after surgery, and the correlation between the amount of femorotibial rotation during surgery and the MFA was statistically evaluated.

Results

Although the amount of tibial rotation at maximum extension was not correlated with the MFA, the amount of tibial rotation at 90° of flexion after registration was positively correlated with the pre- and postoperative MFA (both p < 0.005). However, no significant relationship was observed between the amount of tibial rotation after implantation and the postoperative MFA (n.s.).

Conclusion

The results showed that better femorotibial rotation at 90° of flexion is associated with a favourable postoperative MFA, suggesting that the flexibility of the surrounding soft tissues is an important factor for obtaining a better MFA, which has important clinical relevance. Hence, further evaluation of navigation-based kinematics during TKA may provide useful information on MFA.

Level of evidence

Diagnostic studies, development of diagnostic criteria in a consecutive series of patients, and a universally applied “gold” standard, Level II.

     

No difference between fixed- and mobile-bearing total knee arthroplasty in activities of daily living and pain: a randomized clinical trial

Purpose

Until now, there are no definitive conclusions regarding functional differences related to middle- and long-term everyday activities and patient pain following implantation of mobile- and fixed-platform tibial prostheses. The aim of this study was to determine whether there are middle-term differences in knee function and pain in patients undergoing fixed- and mobile-bearing total knee arthroplasty (TKA).

Methods

Eligible patients were randomized into two groups: the first group received TKA implantation with a fixed tibial platform (group A); the second group received TKA with a mobile tibial platform (group B). Patients were followed up (2 years), and their symptoms and limitations in daily living activities were evaluated using the Knee Outcome Survey—Activities of Daily Living Scale (ADLS), in addition to pain evaluation assessed using the pain visual analogue scale (VAS).

Results

There were no significant differences in function and symptoms in the ADLS and VAS between the study groups.

Conclusion

The type of platform used in TKA (fixed vs. mobile) does not change the symptoms, function or pain of patients 2 years post-surgery. Although mobile TKAs may have better short-term results, at medium- and long-term follow-up they do not present important clinical differences compared with fixed-platform TKAs. This information is important so that surgeons can choose the most suitable implant for each patient.

Level of evidence

Randomized clinical trial, Level I.

     

The features of intestinal tuberculosis by contrast-enhanced ultrasound

Purpose

To examine the imaging characteristics of intestinal tuberculosis by conventional ultrasound and contrast-enhanced ultrasound (CEUS).

Materials and methods

Characteristics of the conventional and contrast-enhanced ultrasound images of 31 patients with intestinal tuberculosis confirmed by surgery were retrospectively examined. CEUS was used to evaluate the pattern of the bowel wall enhancement.

Results

Of the 31 patients with intestinal tuberculosis (IT), 27 had infections located at the ileocecum and 4 at the hepatic flexure of the colon. Conventional ultrasound showed that the mean thickening of bowel wall was 1.38 cm, ranging from 0.56 to 2.20 cm. Two types of bowel wall enhancement patterns on CEUS were observed. For 13 % of the patients (4/31), the serosa was quickly enhanced first, then the mucosa was enhanced gradually (type 1 enhancement). In the remaining 27 patients, the whole bowel wall was quickly diffusely enhanced (type 2 enhancement). In addition, the enhancement of the thickened bowel wall was homogeneous in 9 patients, while the others showed inhomogeneous enhancement.

Conclusion

CEUS found detailed patterns of bowel wall enhancement of intestinal tuberculosis and had the potential to provide useful information for the diagnosis of suspected patients.

     

Segmental analysis of respiratory liver motion in patients with and without a history of abdominal surgery

Purpose

The purpose of this study was to analyze the respiratory motion of each segment of the liver in patients with or without a history of abdominal surgery using four-dimensional computed tomography.

Materials and methods

In total, 57 patients treated for abdominal tumors using proton beam therapy were enrolled. Eighteen patients had a history of abdominal surgery and 39 did not. The positions of clearly demarcated, high-density regions in the liver were measured as evaluation points with which to quantify the motion of each liver segment according to the Couinaud classification.

Results

In total, 218 evaluation points were analyzed. Comparison of differences in the motion of individual liver segments showed that among patients without a history of surgery, the maximum was 29.0 (7.2–42.1) mm in S6 and the minimum was 15.1 (10.6–19.3) mm in S4. Among patients with a history of surgery, the maximum was 28.0 (9.0–37.4) mm in S7 and the minimum was 6.3 (4.1–9.3) mm in S3.

Conclusion

The distances and directions of respiratory motion differed for each liver segment, and a history of abdominal surgery reduced the respiratory motion of the liver. It is necessary to selectively use the internal margin setting.

     

Endovascular Management of Native Postcoarctation Thoracic Aortic Aneurysms

Purpose

Postcoarctation thoracic aortic aneurysm formation is one of the most serious complications for coarctation of aorta. Open surgery to repair these aneurysms is associated with high morbidity and mortality. Endovascular therapy is an attractive alternative to open surgery. We have studied the efficacy and safety of endovascular therapy for postcoarctation thoracic aortic aneurysms, and will share our findings and experience through this document.

Methods

The data was retrospectively collected on consecutive patients who were presented with postcoarctation thoracic aortic aneurysms at our medical center.

Results

Between January 2006 and May 2016, 5 patients underwent elective endoluminal therapy for postcoarctation thoracic aortic aneurysms. They were treated with stent graft deployment to exclude aneurysms. All procedures were technically successful and there were no perioperative morbidity nor mortality. The median follow-up was 51.6 months (range 3–116 months). All aneurysms remained excluded and stent grafts were patent.

Conclusion

Endovascular repair is a promising alternative to open surgery for native postcoarctation thoracic aortic aneurysms.

     

Safety and effectiveness of transcatheter embolization in the treatment of internal mammary artery injuries

Purpose

Demonstrate the role of endovascular management in the treatment of internal mammary artery (IMA) injuries using transcatheter embolization reviewing our 7-year experience.

Materials and methods

Our retrospective analysis of cases consists of a total of 12 patients (8 M and 4 F; mean age 52 years) who underwent angiographic studies and transcatheter embolization for IMA injuries. Causes of vascular injury were divided in high-energy trauma (n = 6), iatrogenic (n = 3) and penetrating injuries (n = 3). Type of trauma, associated injury, imaging findings, treatments and complications were assessed. Imaging findings included active haemorrhage, pseudoaneurysm and focal dissection.

Results

Embolization was performed with microcoils in all patients; complete thrombosis was obtained in four patients by additional injection of Spongostan pledgets and in two patients with 300–500 μm particles. The technical success rate was 100%. No patient died as a direct result of vascular injury; one died of myocardial contusion and one for severe multiorgan failure related to high-energy trauma. No major and minor complications were registered. No patient required emergency surgery or subsequent surgical treatment.

Conclusion

Transcatheter embolization offers an effective, efficient and safe alternative to conventional surgical management of IMA injuries.

     

Arterial embolizations with microvascular plug in extracranial and intracranial districts: technical results

Purpose

A new detachable microvascular plug (MVP, Reverse Medical^®, Irvine, CA, USA) has been recently developed; three models are available according to the size (MVP3–MVP5–MVP7). MVP3 and MVP5 are released through a 0.027″ microcatheter, MVP7 through a 4 Fr catheter. This series aims to describe an initial single-center experience examining intraprocedural safety and technical success of MVP.

Materials and methods

Ten patients (mean age 55.1 years) have been treated for arterial embolization using MVP; eight extracranial and two intracranial arterial embolizations have been performed. The embolizations were because of: four bleedings, three aneurysms, two pseudoaneurysms, and one presurgical nephrectomy.

Results

MVP3 was used in five cases, MVP5 in four cases, and MVP 7 once. In all cases, the MVP was successfully released in < 1 min. In six patients, the MVP was the sole embolizing agent employed, while in four subjects, it was positioned complementary after coils. The technical and clinical success was obtained in 100%; hemorrhages were interrupted and aneurysms and pseudoaneurysms did not show recanalization at follow-up.

Conclusions

MVP seems to be a safe embolizing device that interventional radiologists should consider when facing arterial embolization of both body and neuroarterial districts; the main advantage is related to MVP3 and MVP5 models that can be adopted for distal embolization thanks to the precise release through 0.027″ microcatheter.