Erectile dysfunction: role of computed tomography cavernosography in the diagnosis and treatment planning of venous leak.

BACKGROUND Venous leak appears to be the most common cause of vasculogenic erectile dysfunction (ED), which can be treated with venous embolization. Traditionally, conventional cavernosography was used for the diagnosis and treatment planning of venous leak. Recently, computed tomography (CT) cavernosography was introduced as a novel cross-sectional imaging method proposed to be advantageous over conventional cavernosography. We created a novel management algorithm for diagnosing venous leak including CT cavernosography as an imaging modality. In order to provide a broader basis for our management algorithm, a systematic literature review was conducted. MAIN BODY In this article we systematically review relevant literature on using CT cavernosography for the diagnosis and treatment planning in ED patients with venous leak following the PRISMA selection process. Nine full-text articles were included in the review and assigned a level of evidence grade (all grade II). Two studies (2/9) compared the results of conventional cavernosography with those of CT cavernosography which was superior for site-specific venous leak identification (19.4% vs. 100%, respectively). CT cavernosography is a more detailed imaging method that is faster to perform, exposes the patient to less radiation, and requires less contrast material. In one study (1/9), CT cavernosography was used for diagnostic purposes only. Eight studies (8/9) cover both, diagnostic imaging and treatment planning including embolization (1/9) and sclerotherapy (2/9) of venous leak in patients with venogenic ED. Three studies (3/9) describe anatomical venous leak classifications that were established based on CT cavernosography findings for accurate mapping of superficial and/or deep venous leak and identification of mixed or more complex forms of venous leak present in up to 84% of patients. In addition to treatment planning, one study (1/9) used CT cavernosography also for follow-up imaging post treatment. CONCLUSION CT cavernosography is superior to conventional cavernosography for diagnosis and treatment planning in patients with ED caused by venous leak (grade II levels of evidence). Consequently, CT cavernosography should be included in management algorithms for ED patients with suspected venous leak

Endoluminal stent-graft relining of visceral artery bypass grafts to treat perigraft seroma

PURPOSE: To describe the endovascular treatment of intra-abdominal perigraft seromas associated with small-caliber expanded polytetrafluoroethylene (ePTFE) grafts. CASE REPORTS: Two patients who underwent hybrid repair of thoracoabdominal aortic aneurysms in which renovisceral bypass grafts were implanted presented with large, symptomatic perigraft seromas. The 5- to 8-mm-diameter ePTFE bypass grafts believed to be involved in the seromas were successfully relined with self-expanding Viabahn stent-grafts in percutaneous procedures. The patients' symptoms were relieved, and imaging follow-up (18 and 10 months, respectively) has shown near complete resorption of the seromas. CONCLUSION: It is expected that this minimally invasive technique could be very valuable in treating aortic, renovisceral, and peripheral perigraft seroma

Comparing percutaneous primary and secondary biliary stenting for malignant biliary obstruction: A retrospective clinical analysis

Purpose: Percutaneous transhepatic primary biliary stenting (PS) is an alternative to the widely used staged procedure (secondary biliary stenting, SS) for treating obstructive jaundice in cancer patients. To evaluate the efficacy and safety of PS and SS, a retrospective analysis was carried out. Materials and Methods: The percutaneous biliary stenting procedures performed between January 2000 and December 2007 at one hepatobiliary center were retrospectively analyzed, comparing the technical success rates, complications, and length of hospitalization of the two procedures. Of 61 patients (mean age 65.5 ± 13.1 years; range 31.1-92.7 years) suffering from obstructive jaundice caused by primary or metastatic tumors, 30 received PS and 31 received SS. The groups were comparable in the anatomical level of the obstruction, stent configuration, or the concurrent presence of cholangitis. Placement of metallic stents required one session for patients in the PS group and an average of 2.6 ± 1.1 sessions for patients in the SS group. Results: The overall technical success rate was 98.4% with 1 (1/61) failed approach to transcend the occlusion in the SS group. The rate of minor complications was 10% in the PS group and 6.5% in the SS group. The corresponding rates of major complications were 23.3% and 54.8%, respectively. SS patients had a higher rate of complications in general ( P < 0.05), as well as a higher rate of severe complications in particular ( P < 0.05). Procedural mortality was 0% for both the groups. The mean overall length of hospitalization was 7.7 ± 9.6 days for PS and 20.6 ± 19.6 days for SS ( P < 0.001). Conclusion: Primary percutaneous biliary stenting of malignant biliary obstructions is as efficacious and safer than a staged procedure with secondary stenting. By virtue of requiring shorter hospital stays, primary stenting is likely to be more cost-effective

How accurate is unenhanced multidetector-row CT (MDCT) for localization of renal calculi?

PURPOSE: To investigate the correlation between unenhanced MDCT and intraoperative findings with regard to the exact anatomical location of renal calculi. DESIGN, SETTING, AND PARTICIPANTS: Fifty-nine patients who underwent unenhanced MDCT for suspected urinary stone disease, and who underwent subsequent flexible ureterorenoscopy (URS) as treatment of nephrolithiasis were included in this retrospective study. All MDCT data sets were independently reviewed by three observers with different degrees of experience in reading CT. Each observer was asked to indicate presence and exact anatomical location of any calcification within pyelocaliceal system, renal papilla or renal cortex. Results were compared to intraoperative findings which have been defined as standard of reference. Calculi not described at surgery, but present on MDCT data were counted as renal cortex calcifications. RESULTS: Overall 166 calculi in 59 kidneys have been detected on MDCT, 100 (60.2%) were located in the pyelocaliceal system and 66 (39.8%) in the renal parenchyma. Of the 100 pyelocaliceal calculi, 84 (84%) were correctly located on CT data sets by observer 1, 62 (62%) by observer 2, and 71 (71%) by observer 3. Sensitivity/specificity was 90-94% and 50-100% if only pyelocaliceal calculi measuring >4 mm in size were considered. For pyelocaliceal calculi≤4 mm in size diagnostic performance of MDCT was inferior. CONCLUSION: Compared to flexible URS, unenhanced MDCT is accurate for distinction between pyelocaliceal calculi and renal parenchyma calcifications if renal calculi are >4 mm in size. For smaller renal calculi, unenhanced MDCT is less accurate and distinction between a pyelocaliceal calculus and renal parenchyma calcification is difficult

Outcome of endovascular revascularisation in patients with acute obstructive mesenteric ischaemia - a single-centre experience

BACKGROUND Acute embolic or thrombotic mesenteric ischaemia (AMI) is a rare but life-threatening clinical condition. Despite diagnostic and therapeutic advances, the mortality rate remains high, between 60 % and 90 %. Over the last years revascularisation was increasingly performed by endovascular techniques. The aim of this study was to retrospectively analyse the clinical outcome of catheter-directed thrombolysis (CDT) and aspiration thrombectomy (AT) in patients with AMI with regard to technical success, intervention-related complication rate, need for secondary abdominal surgery, clinical course and 30-day mortality rate. PATIENTS AND METHODS Thirteen patients (4 men, 9 women; mean age 74.5 ± 17 years) with 12 embolic and one thrombotic occlusion of the superior mesenteric artery (SMA) underwent emergent endovascular revascularisation of SMA. Clinical data including all imaging reports, laboratory analysis and follow-up data were derived from the electronic patient file and images were reviewed on a Picture Archiving and Communication System. RESULTS Eleven patients (n = 11; 84.6 %) underwent CDT and AT, and two patients (n = 2; 15.4 %) had AT alone. Technical success with complete restoration of SMA perfusion was achieved in 38.5 % (n = 5). Adjunctive angioplasty ± stenting was mandatory in 2 patients. Overall, the intervention-related complication rate was 38.5 %. In total, 46.2 % (n = 6) clinically improved following the intervention, while 38.5 % required explorative laparotomy after the intervention, with 2 colectomies and 2 small bowel resections. Overall, the 30-day mortality rate was 30.8 %. CONCLUSIONS Endovascular revascularisation with CDT in combination with AT is feasible, with a technical success rate of 38.5 % (n = 5). Endovascular revascularisation was beneficial for 46.2 % (n = 6) of the patients, who clinically improved following the intervention. The need for secondary explorative laparotomy was rather low, with 38.5 % (n = 5) of the patients. The 30-day-mortality remains high with 30.8 %

Chimney and periscope grafts to facilitate endovascular treatment of aortic transection in a patient with aberrant right subclavian artery

PURPOSE: To report the use of parallel grafts to extend the proximal landing zone for stent-graft repair of aortic transection involving an aberrant right subclavian artery (ARSA). CASE REPORT: A 28-year-old patient was referred for treatment of traumatic aortic transection with contained rupture at the level of an ARSA. Immediate thoracic endovascular aortic repair (TEVAR) was planned because of hemodynamic instability. To achieve rapid sealing and maintain perfusion to both subclavian arteries, a chimney stent to the left subclavian artery (LSA) and a periscope stent-graft to the ARSA were deployed successfully. After surgical repair of all fractures, the patient was discharged 1 month after the initial injury in good condition. Imaging follow-up at 10 months showed a stable repair, patent parallel grafts, and no complications. CONCLUSION: TEVAR with chimney and periscope grafts proved to be a safe and quick treatment for a patient requiring ARSA repair in acute aortic transection. This technique maintained blood flow to the ARSA and LSA in a totally endovascular approach, which could be very valuable in transection cases where bypass surgery to supra-aortic branches is compromised or deemed challenging due to thoracic wall and/or neck trauma. Parallel grafting can be a valuable tool to address any acute aortic pathology as it can be performed with off-the-shelf devices