Computed tomographic angiographic imaging of abdominal aortic aneurysms: implications for transfemoral endovascular aneurysm management

Guinea pig pancreatic segments were superfused during 10 min with physiological saline solutions containing 10(-6) M acetylcholine (ACh) or histamine (10(-3)-10(-6) M) and the potassium concentration in the effluent [K+]o) was measured by flame photometry. Histamine evoked a transient increase in [K/]o. The removal of calcium from the superfusing solution and addition of 10(-4) M EGTA caused a significant reduction in the histamine-evoked potassium outflow. Replacement of chloride (Cl-) in the physiological salt solution by nitrate (NO3-) caused a significant reduction in the histamine-evoked potassium release. However, when Cl- was replaced by bromide (Br-) the response to histamine was unaffected. Pre-treatment of pancreatic segments with furosemide (10(-4 M) or ouabain (10(-3) M) caused a marked reduction in the histamine-induced potassium release. The results suggest that ionic requirements in histamine-evoked potassium release are the same as those in acetylcholine-evoked potassium efflux.     

AneuRx stent graft versus open surgical repair of abdominal aortic aneurysms: multicenter prospective clinical trial

The results of a prospective, nonrandomized, multicenter clinical trial that compared endovascular stent graft exclusion of abdominal aortic aneurysms with open surgical repair are presented. During an 18-month period, 250 patients with infrarenal aneurysms underwent treatment at 12 study sites-190 patients underwent endovascular repair using the Medtronic AneuRx stent graft (Sunnyvale, Calif), and 60 underwent open surgical repair. There was no significant difference in operative mortality rates between the groups. The patients who underwent stent grafting had significant reductions in blood loss, time to extubation, and days in the intensive care unit and in the hospital, with an earlier return to function. The major morbidity rate was reduced from 23% in the surgery group to 12% (P <. 05) in the stent graft group. There was no difference in the combined morbidity/mortality rates between the two groups. Primary technical success at the time of discharge for the patients with stent grafts was 77%, largely as a result of a 21% endoleak rate. At 1 month, the endoleak rate had decreased to 9%. There was no difference in the primary or secondary procedure success rates at 30 days between the surgery and stent graft groups. The primary graft patency rate at 6 months was 98% in the surgery group and 97% in the stent graft group. The aneurysm exclusion rate at 1 month and 6 months was 100% in patients who underwent surgery and 91% in patients who underwent stent grafting. Stent graft migration occurred in three patients and resulted in late endoleaks; each endoleak was corrected by means of endovascular placement of a stent graft extender cuff. There have been no aneurysm ruptures and no surgical conversions to open repair in the stent graft group. Stent graft repair compares favorably with open surgical repair, with a reduced morbidity rate, shortened hospital stays, and satisfactory short term outcomes.     

Co-existing abdominal aortic aneurysm and intra-abdominal malignancy: reflections on the order of treatment

BACKGROUND: The management of simultaneously occurring abdominal aortic aneurysm and intra-abdominal malignancy is controversial. It is unclear whether to treat the aneurysm first or the malignancy, or both simultaneously. If the malignancy is resected first there is a risk of postoperative rupture of the aneurysm. If simultaneous surgery is performed there is a risk of prosthetic graft infection from contamination by gastrointestinal or urinary tract contents. METHODS: Relevant papers from 1960 to 1996, identified from Medline and manual searching, were reviewed. RESULTS AND CONCLUSION: The literature supports the conclusion that the lesion of greater priority is that posing the greater threat to the patient; this is usually the aneurysm, especially if it is over 6 cm in diameter. For renal malignancies simultaneous surgery is the treatment of choice, but for bladder cancer the best management is unclear. Large aneurysms should usually be resected in preference to colorectal cancer unless the cancer is locally advanced, perforated or likely to result in early intestinal obstruction. If both lesions are complicated there may be a case for simultaneous treatment.     

Radiotherapy in the management of thyroid orbitopathy. Computed tomography and clinical outcomes

OBJECTIVE: We investigated the long-term outcome of patients with thyroid orbitopathy treated with orbital radiotherapy using quantitative clinical measurements and orbital computed tomographic morphometric changes. DESIGN: Patients who had undergone orbital radiotherapy for thyroid orbitopathy at least 1 year previously were retrospectively recalled for follow-up examination and computed tomography. Controls were patients with similar disease activity but who had not undergone radiotherapy. SETTING: Subspecialty clinic in a university teaching hospital. PATIENTS: Twenty-one patients (42 orbits) who underwent radiotherapy and six clinically comparable patients who had not undergone radiotherapy (12 orbits). INTERVENTION: Standardized, super-voltage, orbital radiotherapy. MEASUREMENTS: Five clinical indexes of orbitopathy and six computed tomographic indexes were examined for interval changes. RESULTS: The orbital computed tomographic muscle-diameter index enlargement ratio did not change in either group (radiotherapy group, 1.54 to 1.51, not significant; nonradiotherapy group, 1.37 to 1.36, not significant). The mean (+/- SEM) number of muscles with low-density areas increased in both groups (radiotherapy group, 1.1 [+/- 1.9] muscles per orbit; P < .001). Soft-tissue signs improved significantly with lesser improvements in extraocular muscle function in both groups. Proptosis, visual acuity, and intraocular pressure rise on upgaze did not improve significantly in either group. CONCLUSIONS: No changes in muscle size measured with computed tomography were found in either patients undergoing radiotherapy or patients not undergoing radiotherapy after long-term follow-up. Clinical indexes of thyroid orbitopathy, especially soft-tissue signs, improved on follow-up, but this was not influenced by the method of treatment.     

Computed tomography, ultrasound and lymphography in the diagnosis of malignant lymphoma

Lymphographic findings were compared with the results at histopathology in 42 laparotomized patients with malignant lymphoma. Of 12 patients with lymphographically suggested lesions in normal-sized lymph nodes, only one had pathologic changes at histologic examination. Computed tomography gave a better idea of the extent of the disease than lymphography. Moreover, CT had an equal diagnostic accuracy as lymphography for demonstrating enlarged para-aortic lymph nodes. CT should therefore be able to replace lymphography in examination of malignant lymphoma. Ultrasound had the same diagnostic accuracy as CT regarding the upper and middle abdomen but not in the lower abdomen. Ultrasound is of special value in thin patients and when guided needle biopsy is required.     

Computed tomography as a guide in the diagnosis and follow-up of brain abscesses

The diagnosis and follow-up of 20 cases of intracranial abscess are analyzed, with particular attention to the role of computed tomography (CT). the differential diagnosis of the CT appearance is presented, and the value of clinical and laboratory findings is discussed. Of special interest is the potential effect of steroids on CT findings as well as the frequent observation of a residual enhancing focus seen on the scan obtained at hospital discharge.     

Radionuclide angiography as an adjunct in diagnosis of ruptured aortic aneurysm: case report

Radionuclide angiography is a rapid, safe, and reliable method of imaging aneurysms of the abdominal aorta in patients who are too ill to undergo contrast angiography or when time is a critical factor.     

Computed tomography analysis of resected small adenocarcinomas of the lung less than 15 mm in diameter--correlation of radiologic and histologic characteristics

To analyze the radiographic characteristics of small adenocarcinomas of the lung that can be detected by computed tomography (CT), 46 resected small peripheral adenocarcinomas measuring less than 15 mm in diameter were retrospectively reviewed, and the marginal and internal findings and surrounding vessels of the tumors as shown on thin-section CT images were correlated with six histologic classifications (types A-F) as defined by Noguchi et al. The adenocarcinoma CT images were classified into two patterns: a solid-density type (n = 21) and an air-containing type (n = 25). The lesions of the air-containing type were further divided into two different growth patterns: a complete air-containing type (n = 12) and an incomplete air-containing type (n = 13). The solid-density adenocarcinomas shown in the CT images fell mainly into the C, D, F and Noguchi classifications. Although one sample in the complete air-containing category was type C, the rest were type A. The incomplete air-containing category included 4 type As and 9 type Bs. The CT findings for the 24 adenocarcinomas in the air-containing category (96%) showed an opaque ground-glass internal texture. Plural vascular involvement was observed in all 46 adenocarcinomas examined. Our results suggest that thin-section CT findings can play an important role in differentiating lung cancer and increasing our knowledge of the radiologic and pathologic correlations.     

Sepsis outcomes in infants and children with central venous catheters: percutaneous versus surgical insertion

OBJECTIVE: To review the literature on central venous catheters (CVCs) in infants and children. DATA SOURCES: Published surgical, medical, nursing, and nutritional studies from 1968 to the present. STUDY SELECTION: More than 250 studies were reviewed; selection criteria for the 64 studies chosen included age, percutaneous CVC (PCVC) or surgical CVC (SCVC) use, and defined rate of sepsis. DATA EXTRACTION: Included study purpose, sample size and age, indications for total parenteral nutrition, insertion method and sites, number of CVCs, and sepsis outcomes. DATA SYNTHESIS: Yielded weighted mean sepsis rates that were 3.5 times higher for SCVC use in neonatal and/or pediatric populations; subanalyses of homogeneous groups of studies yielded rates that were 2.5 to 3.8 times higher. CONCLUSIONS: Percutaneous CVC insertion should be given primary consideration for neonatal and pediatric intensive-care patients.     

Mortality in abdominal aortic aneurysm surgery--the effect of hospital volume, patient mix and surgeon''s case load

The absence of nosocomial infections control in the hospital Henri-Laborit, specialized in mental medicine, has brought ourselves to answer the question: is the nosocomial infection in psychiatric hospital a myth or a reality? A retrospective study of global nosocomial infections incidence has been realized from ten years of microbiology laboratory data. During this time, 716 patients have contracted one or several nosocomial infections. The incidence rate is 3%, the incidence density rate 0.3/1000. The urinary infections represent half of the infections, followed by the septic wounds. Some infections like septicaemia implicate the patient vital prognosis.     

Whole body computed tomography in the diagnosis of abdominal and thoracic malignancy: review of 600 cases

Whole-body computed tomography (CT) was performed on 600 patients with known or suspected malignancy at the National Institutes of Health. This new diagnostic modality utilizes a finely columnated X-ray source mounted opposite a computer-linked detector bank to generate anatomic cross-sectional images of the body part being scanned. CT proved valuable in defining many pathologic processes and was, at times, deemed the only test short of exploratory surgery that yielded diagnostic information. This latter benefit was most acutely emphasized in lesions affecting the retroperitoneum, adrenal glands, pelvis, liver, and immediate subpleural pulmonary parenchyma.     

Activation of coagulation and fibrinolysis in patients with abdominal true aortic aneurysm associated with disseminated intravascular coagulation

Two cases of abdominal true aortic aneurysm (AAA) associated with disseminated intravascular coagulation (DIC) were reported. Case 1 was an 81-year-old male who was admitted because of hematoma on the left leg and in whom was found by MRI an aortic aneurysm of 14 cm in diameter. Coagulation studies indicated DIC by revealing thrombocytopenia, hypofibrinogenemia and increased level of FDP. DIC was well controlled by surgical repair of the aneurysm after the administration of a small dose of heparin. Case 2 was a 60-year-old male who was admitted because of lumbago and hematoemesis and in whom was found by CT and echography an aortic aneurysm of 5.5 cm in diameter. Coagulation studies indicated DIC by revealing thrombocytopenia and an increased level of FDP. On the 2nd hospital day, he suddenly died due to the rupture of the aortic aneurysm. In most of 9 cases with AAA without DIC, plasma levels of thrombin-antithrombin III complex, plasmin-alpha 2 plasmin inhibitor complex and FDP-D dimer were also elevated. These findings indicate that the coagulation and fibrinolysis systems were generally activated in patients with AAA, and that DIC tends to occur in patients with a giant aortic aneurysm or an impending ruptured aneurysm.     

The spontaneous aortocaval fistula: a complication of the abdominal aortic aneurysm. Case report and review of the literature

AIMS: (i) to compare Helicobacter pylori serology in two 70-year-old cohorts in Gothenburg, Sweden, born 21 years apart, (ii) to study H. pylori serology in a 70-year-old cohort over 20 years. POPULATION AND METHOD: H. pylori serology at the age of 70 was investigated in 98 men and 132 women born in 1901/02 and in 77 men and 113 women born in 1922. In 21 men and 40 women Helicobacter serology was monitored longitudinally with examinations at 70, 81, and 90 years of age. The analyses were performed on frozen samples by use of an in-house enzyme immunoassay with a sensitivity of 0.99, specificity of 1.00 and positive and negative predictive values of 0.96 and 1.00, respectively. Absorbance values <0.500 were interpreted as negative; values of > or = 0.700 were interpreted as positive, and values in between as inconclusive. RESULTS: The 70-year-old cohort, born in 1922, showed a significantly lower proportion of subjects with positive H. pylori serology in both men (57.1% vs 80.6%) and women (48.7% vs 75.8%) compared with 70-year-olds born in 1901/02. There were no significant sex differences in either cohort. No longitudinal increase or decrease could be demonstrated in those who were examined at 70, 81 and 90 years of age. CONCLUSIONS: The difference in H. pylori prevalence between the two cohorts may reflect a rapid change in socio-economic conditions in Sweden during this 20-year period.     

Small polypoid lesions of the gallbladder: differential diagnosis and surgical indications by helical computed tomography

We report the case of a 16-year-old girl who experienced sudden cardiac arrest from ventricular fibrillation, complicating an arrhythmogenic right ventricular dysplasia, a rare heart muscle disorder, occurring typically in young adults, characterized by a fibrofatty replacement of the right ventricular myocardium. Symptomatic ventricular arrhythmias are frequent, and sudden death has been reported. In our case, diagnosis of arrhythmogenic dysplasia was based on the association of one major criterion and two minor criteria as suggested by the relevant task force. In contrast with most other reports, the chest ECG did not display the typical features. An automatic transvenous pectoral cardioverter-defibrillator was implanted. The authors emphasise that juvenile forms are more exposed to ventricular fibrillation and sudden cardiac death, and consequently require the early detection of the disease. Family cases have been described and the occurrence in one individual must lead to investigations in the relatives.     

A unique method of closure for an aortocaval fistula in association with a ruptured abdominal aortic aneurysm: report of a case

We report herein the case of a 78-year-old man in whom an aortocaval fistula caused by spontaneous rupture of an abdominal aortic aneurysm (AAA) was successfully treated by a unique surgical technique. The aortocaval fistula had been revealed by an aortography after the patient presented with high-output heart failure. During the operation, massive bleeding from the fistula was evident. The fistula measured 2 cm in diameter, and was located between the right posterior wall of the AAA and the inferior vena cava (IVC). Direct suturing of the defect in the IVC failed to close the fistula because the tissue around it would not hold together due to degeneration. However, the bleeding was finally able to be controlled by plugging the fistula with isolated and properly trimmed omentum packed within the excluded aneurysmal sac. Unfortunately, the patient died due to respiratory failure on the 201st postoperative day. A pathological autopsy revealed that the aortocaval fistula had been closed by fibrous tissue and that the IVC was patent. Although such a drastic operative measure to repair an aortocaval fistula has never before been reported, it could be an alternative when direct closure proves unsuccessful.     

Evolution of post-traumatic aortic aneurysm in the subacute phase: magnetic resonance imaging follow-up as a support of the surgical timing

OBJECTIVES: A recent surgical series documented that in traumatic aortic rupture (TAR) a surgical repair postponed to the treatment of associated lesions reduced operative and overall mortality. Nevertheless some isolated cases may develop to free rupture. Until now, no imaging follow-up studies of post-traumatic aortic lesions have been reported in the early stage. The aim of this study is to analyze the behaviour of traumatic aortic ruptures in the subacute phase, in order to detect the morphological characteristics of unstable post-traumatic aneurysms. METHODS: Twenty-five consecutive patients affected by traumatic aortic rupture (one intimal hemorrhage, 19 partial lesions and five circumferential lesions) were admitted to the department of cardiac surgery. Magnetic resonance imaging (MRI) was the imaging method used to confirm the diagnosis. No one was operated on during the acute phase. All patients were treated with beta-blockers and vasodilators as well as limited fluid administration. Delayed surgery was carried out in 18 patients at 243 days (+/-127), after the resolution of associated lesions. A scheduled MRI follow-up was performed at 7, 15 and 30 days and immediately before the operation. The parameters examined were increase of post-traumatic aneurysm, increase of periaortic hematoma and modification of the thoracic associated lesions. RESULTS: At 30 days a 3.0 +/- 3.7 mm median increase of the aneurysm was observed, while in the subsequent period the lesions became substantially stable, resulting in a 4.4 +/- 3.6 mm increment at the end of the follow-up. The circumferential lesions presented a higher increment with respect to the partial lesions. In three cases an augmentation of 6, 7 and 12 mm was detected and surgical repair was anticipated. In 13 cases a periadventitial hematoma surrounding the aortic aneurysm decreased through the time. One case of intimal hemorrhage healed spontaneously, with no aneurysm formation. Thoracic associated lesions (pleural and pericardial effusions, rib fractures, lung focal contusions and two cases of ARDS) resolved at 30-60 days. CONCLUSIONS: Despite common knowledge, considering TAR highly evolutive in the acute and subacute phase, this study demonstrated that this pathological entity is relatively stable if a proper pharmacological treatment is administrated. MRI follow-up is recommended in order to detect isolated cases of unstable aneurysm.     

Cerebrovascular diseases in patients with arteriosclerotic aortic aneurysm and arteriosclerosis obliterans studied by carotid ultrasonography and by computed tomography of the brain

To estimate the incidence of cerebrovascular diseases in arteriosclerotic aortic aneurysm (AA) and arteriosclerosis obliterans (ASO) and their characteristics, 92 patients with AA and 102 patients with ASO were studied with carotid ultrasonography and brain computed tomography (CT), and were compared with 49 patients with hypertension. The mean ages of the patients were 70 to 72 years old and all were male. Hypertension was common in the AA group: diabetes and cigarette smoking were common in the ASO group. Carotid plaque lesions seen on ultrasonography were significantly more common in the AA (66%) and ASO (85%) groups than in the patients with hypertension (39%). The mean carotid diameter was significantly greater in the AA group than in the other two groups. The mean wall thicknesses in the AA and ASO groups were greater than in the patients with hypertension. Computed tomography showed that low-density areas were also common in the AA group (56%) and ASO (53%) groups than in the patients with hypertension (24%). Most of the low-density areas were thought to be lacunae or dilated perivascular spaces in the subinsula and putamen. Moderately and highly severe periventricular lucencies were also common in the AA group. These findings indicate that carotid changes, seen in AA and ASO, reflected the characteristics of arterial lesions, and that arteriolosclerotic lesions were common in patients with AA and ASO. Therefore, cerebrovascular diseases should be taken into account in the management of patients with AA and ASO.