Management of patients with "ex vacuo" pneumothorax after thoracentesis

RATIONALE AND OBJECTIVES: To determine clinical outcome in patients who developed "ex vacuo" pneumothorax following thoracentesis and to assess the benefit of chest tube placement for this complication. MATERIALS AND METHODS: We retrospectively reviewed records of 282 patients who underwent 437 thoracenteses at a single institution during a 6-year period. We identified 34 patients (12.1%) who developed a pneumothorax following 39 thoracenteses (8.8%) and then identified a subset of patients with pneumothorax "ex vacuo" defined as a moderate to large hydropneumothorax or small pneumothorax persisting for more than 3 days. Patient charts were reviewed to document the treatment strategy employed and subsequent clinical outcome, which included length of hospital stay, resolution of pneumothorax, reaccumulation of pleural effusion, and overall survival. RESULTS: Ten patients developed "ex vacuo" pneumothroax following thoracentesis. None complained of significant worsening of symptoms following thoracentesis. Seven patients were treated by observation alone and 3 patients underwent tube thorocostomy. A decrease in size of the pneumothorax was observed in only 3 patients, none of whom had a chest tube placed. Effusion completely reaccumulated in 7 patients. All 10 patients died during the follow-up period; the mean survival was 157 days (range: 13-402 days). Survival among patients treated by observation was 191.4 days versus 71.7 days for patients receiving chest tubes. CONCLUSION: Life expectancy for most patients who develop "ex vacuo" pneumothorax following therapeutic thoracentesis is short (<6 months). Chest tube placement is not necessary in asymptomatic patients and is unlikely to provide clinical benefit.     

Image fusion analysis of 99mTc-HYNIC-Tyr3-octreotide SPECT and diagnostic CT using an immobilisation device with external markers in patients with endocrine tumours

Purpose The aim of this study was to assess the value of multimodality imaging using a novel repositioning device with external markers for fusion of single-photon emission computed tomography (SPECT) and computed tomography (CT) images. The additional benefit derived from this methodological approach was analysed in comparison with SPECT and diagnostic CT alone in terms of detection rate, reliability and anatomical assignment of abnormal findings with SPECT.Methods Fifty-three patients (30 males, 23 females) with known or suspected endocrine tumours were studied. Clinical indications for somatostatin receptor (SSTR) scintigraphy (SPECT/CT image fusion) included staging of newly diagnosed tumours (n=14) and detection of unknown primary tumour in the presence of clinical and/or biochemical suspicion of neuroendocrine malignancy (n=20). Follow-up studies after therapy were performed in 19 patients. A mean activity of 400 MBq of ^99mTc-EDDA/HYNIC-Tyr³-octreotide was given intravenously. SPECT using a dual-detector scintillation camera and diagnostic multi-detector CT were sequentially performed. To ensure reproducible positioning, patients were fixed in an individualised vacuum mattress with modality-specific external markers for co-registration. SPECT and CT data were initially interpreted separately and the fused images were interpreted jointly in consensus by nuclear medicine and diagnostic radiology physicians.Results SPECT was true-positive (TP) in 18 patients, true-negative (TN) in 16, false-negative (FN) in ten and false-positive (FP) in nine; CT was TP in 18 patients, TN in 21, FP in ten and FN in four. With image fusion (SPECT and CT), the scan result was TP in 27 patients (50.9%), TN in 25 patients (47.2%) and FN in one patient, this FN result being caused by multiple small liver metastases; sensitivity was 95% and specificity, 100%. The difference between SPECT and SPECT/CT was statistically as significant as the difference between CT and SPECT/CT image fusion (P<0.001). Twenty-seven abnormal SPECT findings in 17 patients could not be initially assigned to organs, but were clearly delineated after image fusion. In 21 patients (40%), clinically relevant information was obtained by image fusion as compared with SPECT alone.Conclusion Co-registration of SPECT and diagnostic CT using a cost-effective immobilisation device provides excellent accuracy for tumour detection of endocrine malignancies and is superior to SPECT and CT alone. Image fusion reduces false positive results and can detect additional lesions. Anatomical information provided by CT enables precise localisation of abnormalities observed in SPECT.     

Arthroscopic findings of the hip in new onset hip pain in adolescents with previous Legg-Calve-Perthes disease

Nine adolescent patients with new onset hip pain and previous Legg-Calve-Perthes disease (LCPD) were evaluated by hip arthroscopy. Eight of the nine patients had previous hip surgery for their LCPD and a pain-free interval averaging over 5 years. Hip arthroscopy was performed in the supine position on a fracture table using a distention distraction technique. Eight of the nine hips had intra-articular abnormalities including; four tears of the ligamentum teres, three femoral head osteochondritis dissecans, two labral tears, two hips with significant synovitis and three hips with other femoral head abnormalities. Seven of the eight hips improved following their arthroscopic treatment and the patients returned to their before-pain activities including sports. Three patients have required subsequent surgery. The abnormal mechanics from residual femoral head deformity may increase the risk of developing a variety of painful lesions. Hip arthroscopy is a safe way to evaluate and treat these intra-articular abnormalities.     

Fenestrated endovascular grafting: The renal side of the story

BACKGROUND: Fenestrated endovascular aneurysm repair uses the visceral aortic segment, in the setting of a suboptimal proximal neck, for sealing and fixation. This technique requires the placement of visceral stents and might be hampered by the deleterious effects of such interventions. This study was performed to define outcomes related to renal events. MATERIALS AND METHODS: Consecutive clinical records and radiographic studies of patients treated primarily with an endovascular approach with a fenestrated endograft were reviewed. The population was divided into groups with and without baseline renal dysfunction based on the National Kidney Foundation definition of chronic kidney disease. Morphologic measurements and the detection of postoperative renal events such as renal artery stenosis or occlusion, need for dialysis, deterioration of renal function by using estimated glomerular filtration rate (GFR), and secondary interventions related to the renal arteries were assessed. Preoperative and postprocedural factors predictive for the development of renal dysfunction were assessed by using a Fisher exact test, t test, and logistic regression. RESULTS: A total of 72 patients were treated between 2001 and 2004 with a mean age, aneurysm size, and follow-up of 75 years, 6.2 cm, and 6 months (range, 1 to 24 months), respectively. No ruptures and five deaths (two procedure-related) were observed. There were 23 patients with baseline renal insufficiency and 49 patients without insufficiency. Twenty-four patients had deterioration in GFR >30% during the follow-up period, and 17 patients experienced 19 renal-related events (more common in patients with baseline insufficiency, 39% vs 16.3%; P = .04; relative risk, 2.4). Four patients required dialysis (two permanent), and all had preoperative renal dysfunction ( P = .002); similarly, death was also more common in this group (17.4% vs 2%; P = .02; relative risk, 8.52). Renal events in most patients occurred within the first postoperative month (59%). However, mean GFR stabilized after 6 months. CONCLUSION: Aneurysm repair with fenestrated endovascular grafts is associated with a significant risk for adverse renal events (16% in those without renal dysfunction, although none developed a creatinine >2 mg/dL, and 39% for patients with preoperative renal dysfunction). These patients must be meticulously followed, particularly within the first month after such a procedure. When renal artery restenosis is suspected or diagnosed, aggressive approach might be warranted to limit the extent of late renal dysfunction.     

Endovascular repair of thoracic aortic lesions with the Zenith TX1 and TX2 thoracic grafts: intermediate-term results

PURPOSE: This prospective study was designed to assess the technical success and outcome after patients with thoracic aortic pathology at high risk for conventional therapy were treated with the Zenith TX1 and TX2 endovascular graft. METHODS: Between 2001 and 2004, patients at high risk for conventional surgical therapy presenting with chronic aortic dissections, thoracic aneurysms, or aortobronchial or aortoesophageal fistulas were treated with a single- or multiple-piece endovascular grafts. Surgical modification of proximal or distal fixation sites was performed when necessary to establish adequate regions for device landing zones. Follow-up studies included radiographic evaluation before discharge and at 1, 6, 12, and 24 months. Aortic morphologic characteristics were determined by using three-dimensional imaging studies and centerline of flow measurements. Statistical analyses were performed with Kaplan Meier analysis to assess survival, factors predictive of poor outcome, and morphologic changes, including sac shrinkage. RESULTS: A total of 100 patients (42% women) were treated, including 81 aneurysms, 15 aortic dissections (with aneurysms), 2 patients with fistulous connections (1 aortobronchial and 1 aortoesophageal), 1 subclavian artery aneurysm, and 1 aortic rupture. Mean follow-up and aneurysm size were 14 months and 62 mm, respectively. Most patients (55%) had undergone prior aortic aneurysm repair. Surgical modifications were required to create adequate implantation sites in 29% patients, including 14 elephant trunk/arch reconstructions, 18 carotid-subclavian bypasses, and 4 visceral vessel bypasses. Iliac conduits were required in 19 patients. Overall mortality was 17%, and aneurysm-related mortality was 14% at 1 year. Sac regression (>5 mm maximum diameter decrease) was observed in 52% and 56% at 12 and 24 months. Growth was noted in one patient (1.6%) at 12 months. Endoleaks were detected in eight patients (8.5%) at 30 days and three patients (6%) at 12 months. Secondary interventions were required in 15 patients. Migration (>10 mm) of the proximal or distal stent was noted in three patients (6%) (two proximal and one distal), none of which required treatment or resulted in an adverse event. CONCLUSIONS: Acceptable intermediate-term outcomes have been achieved in the treatment of high-risk patients in the setting of both favorable and challenging anatomic situations with these devices. The complexity of the patient population, in contrast to endovascular infrarenal repair, attests to the differences in the pathophysiology aortic disease in the anatomic beds.     

Traumatic fibular tendon dislocation combined with medial malleolar fracture: a very uncommon association in ankle trauma

We report two unusual cases of ankle injury involving dislocation of the fibular tendon and fracture of the medial malleolus. Only one case has been reported previously in the literature. We discuss the pathogenic mechanisms and the clinical and radiological aspects of this unusual ankle injury. The importance of early surgical treatment is emphasized.     

Cerebral monitoring with transcranial Doppler ultrasonography improves neurologic outcome during repairs of acute type A aortic dissection

OBJECTIVE: Neurologic complications after repair of acute type A aortic dissection remain significant. The use of power M-mode transcranial Doppler monitoring to verify cerebral blood flow during these repairs might decrease cerebral ischemia by correcting malperfusion. The purpose of this study was to analyze the use of power M-mode transcranial Doppler monitoring during repairs of acute type A dissection with regard to neurologic outcome. METHODS: We performed a prospective study of patients undergoing repairs of acute type A aortic dissection. Repairs included profound hypothermic circulatory arrest and retrograde cerebral perfusion. Patients in whom transcranial Doppler monitoring was used to monitor cerebral blood flow and modify operative technique during repair (study group) were compared with those without monitoring and modification (control group). RESULTS: Between September 2001 and October 2003, we repaired 56 cases of acute type A dissection. Power M-mode transcranial Doppler monitoring was used in 50% (28/56) of cases. Power M-mode transcranial Doppler monitoring altered operative cannulation and guided retrograde cerebral perfusion flow in 28.5% (8/28) and 78.6% (22/28) of cases, respectively. Two patients presented with preoperative stroke, one in each group. One operative death occurred in each group. In-hospital mortality and the occurrence of new stroke were not significantly different between the 2 groups. Temporary neurologic dysfunction occurred less often in the study group (14.8% [4/27] vs 51.8% [14/27], P = .008). CONCLUSIONS: Identification of cerebral malperfusion requires cerebral monitoring. By ensuring cerebral blood flow by using power M-mode transcranial Doppler monitoring and correcting cerebral malperfusion by modifying operative technique, neurologic outcome was improved during repairs of acute type A aortic dissection.