Venous Malformations: Phleboliths Correlate With the Presence of Arteriovenous Microshunts

OBJECTIVE. The objective of this study was to identify differences between venous malformations (VMs) with arteriovenous (AV) microshunts and VMs without AV microshunts. MATERIALS AND METHODS. In this retrospective study, 83 patients with untreated VMs of the extremities underwent a prospectively defined MRI protocol performed at 3 T MR images were reviewed to determine localization and extent of each VM and tissue involvement. The VM volume and the lesion volume relative to body surface were measured. The number of phleboliths within the lesions was determined. Using time-resolved MR angiography, the hemodynamic subtype (VM with AV microshunts versus VM without AV microshunts) was classified, and the interval between the onset of arterial enhancement and lesion enhancement (t(onset)) was measured. Clinical data were reviewed to determine patient demographic characteristics, the onset of symptoms, the frequency of thrombophlebitis, and the pain score. RESULTS. Of the 83 patients, 56 (67%) presented with AV microshunts. The t(onset) (p <= 0.001), absolute and relative lesion volume (p = 0.001), and number of phleboliths (p = 0.038) differed significantly between these two subgroups. With use of a multivariable regression model, the strongest indicator for VM with AV microshunts was the presence of more than two phleboliths (odds ratio, 2.80; p = 0.007). No differences were noted regarding patient demographic characteristics and history or lesion morphologic features or anatomy. CONCLUSION. Occurrence of AV microshunts in untreated VM is a frequent phenomenon. This hemodynamic subtype is significantly associated with phleboliths and large lesions. The subtypes did not differ in terms of history and clinical course

Stereotactic Percutaneous Electrochemotherapy as Primary Approach for Unresectable Large HCC at the Hepatic Hilum

Electrochemotherapy (ECT) is a novel non-thermal ablative technique that combines chemotherapy and the application of electric pulses for reversible cell membrane electroporation. This method was recently performed in the treatment of deep-seated liver tumors during open surgery but experience about percutaneous ECT is rare and further developments like combination of percutaneous ECT with stereotactic navigated devices may be very promising. We report on a case of a 4.7 × 4.5 × 3.5 cm unresectable HCC at the hepatic hilum adjacent to the major vessels and the bile duct that was successfully treated using percutaneous ECT in combination with stereotactic navigation. Follow-up imaging 6 weeks and 6 months after ECT showed complete response

Diagnostik und Behandlung der hereditären hämorrhagischen Teleangiektasie

Zusammenfassung Die hereditare hamorrhagische Teleangiektasie (HHT; Morbus Osler-Weber-Rendu; Morbus Osler) ist mit einer weltweiten Pravalenz von 1:5000-8000 eine seltene Erkrankung der Kapillaren, bei der sich arteriovenose Shunts bilden. Vorwiegend finden sich diese in der Nasenschleimhaut, im Magen-Darm-Trakt, in der Lunge, in der Leber und im zentralen Nervensystem. Leitsymptom der Erkrankung ist die Epistaxis. Die Therapie besteht aus einem mehrstufigen Behandlungskonzept, das neben Nasenpflege und der Lasertherapie in ortlicher Betaubung auch medikamentose Therapien sowie operative Eingriffe in Vollnarkose umfasst. Zusatzlich erfolgt ein Screening zur Erfassung der Beteiligung innerer Organe in enger interdisziplinarer Zusammenarbeit mit den entsprechenden Fachabteilungen. Eine Behandlung der Lasionen im Bereich der (Schleim-) Haut, des Magen-Darm-Trakts und der Leber erfolgt symptomorientiert, wohingegen Gefa ss malformationen der Lunge und des zentralen Nervensystems aufgrund potenzieller und zum Teil bedrohlicher Komplikationen gelegentlich auch ohne subjektive Beschwerden behandlungsbedurftig sind. Abstract Hereditary hemorrhagic telangiectasia (HHT; Osler-Weber-Rendu syndrome; Morbus Osler) represents a syndrome affecting capillary vessels, leading to arteriovenous shunting. With an average worldwide prevalence of 1:5.000-8.000 HHT is considered an orphan disease. Arteriovenous shunts involve predominantly the nasal mucosa, the intestine, lung, liver and central nervous system. Epistaxis is the primary and most bothersome complaint of patients with HHT. A multistage therapeutic concept includes nasal ointment, laser therapy under local anesthesia and surgery under general anesthesia, as well as drug therapies. In addition, screening to determine affection of internal organs is carried out. Lesions that require therapy should be treated in an interdisciplinary setting. Treatment of lesions of the skin, oral and gastrointestinal mucosa and liver is carried out in regard to patients' symptoms, whereas vascular malformations of the lung and brain might need treatment without being symptomatic, due to possible life-threatening complications

Time-resolved magnetic resonance angiography (MRA) at 3.0 Tesla for evaluation of hemodynamic characteristics of vascular malformations: description of distinct subgroups

Quantitative evaluation of hemodynamic characteristics of arteriovenous and venous malformations using time-resolved magnetic resonance angiography (MRA) at 3.0 Tesla. Time-resolved MRA with interleaved stochastic trajectories (TWIST) at 3.0 Tesla was studied in 83 consecutive patients with venous malformations (VM) and arteriovenous malformations (AVM). Enhancement characteristics were calculated as percentage increase of signal intensity above baseline over time. Maximum percentage signal intensity increase (signal(max)), time intervals between onset of arterial enhancement and lesion enhancement (t(onset)), and time intervals between beginning of lesion enhancement and maximum percentage of lesion enhancement (t(max)) were analyzed. All AVMs showed a high-flow hemodynamic pattern. Two significantly different (p < 0.001) types of venous malformations emerged: VMs with arteriovenous fistulas (AVF) (median signal(max) 737 %, IQR [interquartile range] = 511 - 1182 %; median t(onset) 5 s, IQR = 5 - 10 s; median t(max) 35 s, IQR = 26 - 40 s) and without AVFs (median signal(max) 284 %, IQR = 177-432 %; median t(onset) 23 s, IQR = 15 - 30 s; median t(max) 60 s, IQR = 55 - 75 s). Quantitative evaluation of time-resolved MRA at 3.0 Tesla provides hemodynamic characterization of vascular malformations. VMs can be subclassified into two hemodynamic subgroups due to presence or absence of AVFs. aEuro cent Time-resolved MRA at 3.0 Tesla provides quantitative hemodynamic characterization of vascular malformations. aEuro cent Malformations significantly differ in time courses of enhancement and signal intensity increase. aEuro cent AVMs show a distinctive high-flow hemodynamic pattern. aEuro cent Two significantly different types of VMs emerged: VMs with and without AVFs

Ethanolgel sclerotherapy of venous malformations improves health-related quality-of-life in adults and children – results of a prospective study

To assess the treatment-induced changes of health-related quality-of-life (HRQoL) in patients with venous malformations (VM) who underwent ethanol gel sclerotherapy. The prospective study in children and adults was approved by the local ethics committee. 31 patients (mean age 23.42 years, range 6.6 - 46.5; 26 female, 5 male) with VM were included. Patients' self-assessed HRQoL was measured before and after treatment using psychometrically validated questionnaires for adults and children. Differences were analysed with a paired t test. 58 sclerotherapy sessions were performed. The Physical Component Summary (PCS) at baseline was 43.69 and increased significantly (p = 0.01122) to 48.95 after treatment. The bodily pain (BP) scale increased significantly from 37.94 to 48.56 (p = 0.00002), the general health (GH) scale increased significantly from 46.69 to 52.17 (p = 0.00609). Baseline Physical Summary Score (PHS) in children increased significantly after treatment (p < 0.00001) from 25.25 to 45.89. The baseline Psychosocial Summary Score (PSS) in children was 51.08 and increased significantly (p = 0.00031) after treatment to 58.84. Paediatric and adult patients with VM suffer from bodily pain with overall reduced physical functioning. After sclerotherapy, these restrictions are successfully returning to normal levels with a positive effect on mental and psychosocial domains. aEuro cent Sclerotherapy in venous malformation patients has an unknown effect on health-related quality-of-life aEuro cent Prospective study showed improvements in bodily pain and general health in adults aEuro cent Children and adults improved from treatment with ethanol gel aEuro cent Sclerotherapy is an appropriate therapy

Direct Effective Dose Calculations in Pediatric Fluoroscopy-Guided Abdominal Interventions with Rando-Alderson Phantoms – Optimization of Preset Parameter Settings

Objective The aim of the study was to calculate the effective dose during fluoroscopy-guided pediatric interventional procedures of the liver in a phantom model before and after adjustment of preset parameters. Methods Organ doses were measured in three anthropomorphic Rando-Alderson phantoms representing children at various age and body weight (newborn 3.5kg, toddler 10kg, child 19kg). Collimation was performed focusing on the upper abdomen representing mock interventional radiology procedures such as percutaneous transhepatic cholangiography and drainage placement (PTCD). Fluoroscopy and digital subtraction angiography (DSA) acquisitions were performed in a posterior-anterior geometry using a state of the art flat-panel detector. Effective dose was directly measured from multiple incorporated thermoluminescent dosimeters (TLDs) using two different parameter settings. Results Effective dose values for each pediatric phantom were below 0.1mSv per minute fluoroscopy, and below 1mSv for a 1 minute DSA acquisition with a frame rate of 2 f/s. Lowering the values for the detector entrance dose enabled a reduction of the applied effective dose from 12 to 27% for fluoroscopy and 22 to 63% for DSA acquisitions. Similarly, organ doses of radiosensitive organs could be reduced by over 50%, especially when close to the primary x-ray beam. Conclusion Modification of preset parameter settings enabled to decrease the effective dose for pediatric interventional procedures, as determined by effective dose calculations using dedicated pediatric Rando-Alderson phantoms

Evaluation of treatment options for postoperative and spontaneous chylothorax in adults

OBJECTIVES: Both postoperative and spontaneous chylothorax remain therapeutic challenges without recommendations for a standardized treatment approach. Regardless of its aetiology, patients with chylothorax experience prolonged hospitalization and suffer from the associated complications or the invasive therapy administered. METHODS: We conducted a retrospective, observational review of adult patients with chylothorax treated between January 2010 and September 2019. The primary end point was successful management with sustained cessation and/or controlled chylous output. Therapy duration, inpatient stay and the incidence of complications were evaluated as secondary end points. RESULTS: Of the 36 patients included (22 men; median age 63 years), 24 patients (67%) suffered from a postoperative accumulation of chylous fluid in the pleural space; in the remaining 12 (33%) patients, chylothoraces occurred spontaneously. Initial conservative treatment was successful in 42% (n = 15); in the other 20 cases (56%) additional invasive therapeutic strategies were followed. A complicated course requiring more than 1 treatment was seen in 54% (n = 13) of the postoperative and in 58% (n = 7) of the spontaneous cases. The median length of hospitalization was significantly longer in the postoperative group (37.5 vs 15.5 days; P= 0.016). Serious complications were observed only in the postoperative group (P = 0.28). There were no in-hospital deaths. CONCLUSIONS: Basic treatment of both postoperative and spontaneous chylothorax should include dietary measures in all patients. Additional sclerosing radiotherapy and interventional or surgical therapy are often necessary. The choice of therapeutic approach should be indicated, depending on the aetiology and development of the chylothorax. Early, multimodal treatment is recommended

Sequential CT arterioportography-arteriosplenography depicts individual haemodynamic changes in children with portal hypertension without cirrhosis

We evaluated sequential computed tomography (CT) arterioportography-arteriosplenography for the assessment of venous pathways in children with portal hypertension without cirrhosis. Institutional Review Board approval was obtained for this retrospective, single-centre study. CT was performed after contrast application via catheters placed in the superior mesenteric artery (CT arterioportography) and the splenic artery (CT arteriosplenography) consecutively. Venous pathways in 22 children were evaluated. In all patients, the detailed haemodynamic consequences of portal hypertension could be characterised. The supply of varices at different locations could be assigned to the superior mesenteric vein or splenic vein system. Retrograde blood flow through the splenic vein and inferior mesenteric vein, portosystemic shunting, and patency of splanchnic veins were determined. CT arterioportography-arteriosplenography allowed a complete evaluation of individual haemodynamic pathways in children with portal hypertension

Update on Percutaneous Local Ablative Procedures for the Treatment of Hepatocellular Carcinoma

Background Hepatocellular carcinoma (HCC) is the fifth most common tumor worldwide. Because many hepatocellular carcinomas are already unresectable at the time of initial diagnosis, percutaneous tumor ablation has become established in recent decades as a curative therapeutic approach for very early (BCLC 0) and early (BCLC A) HCC. The aim of this paper is to provide a concise overview of the percutaneous local ablative procedures currently in use, based on their technical characteristics as well as clinical relevance, taking into account the current body of studies. Materials and Methods The literature search included all original papers, reviews, and meta-analyses available via MEDLINE and Pubmed on the respective percutaneous ablation procedures; the primary focus was on randomized controlled trials and publications from the last 10 years. Results and Conclusions Radiofrequency ablation (RFA) and microwave ablation (MWA) are well-established procedures that are considered equal to surgical resection in the treatment of stage BCLC 0 and A HCC with a diameter up to 3 cm due to their strong evidence in international and national guidelines. For tumors with a diameter between 3 and 5 cm, the current S3 guidelines recommend a combination of transarterial chemoembolization (TACE) and thermal ablation using RFA or MWA as combination therapy is superior to thermal ablation alone in tumors of this size and shows comparable results to surgical resection in terms of overall survival. Alternative, less frequently employed thermal procedures include cryotherapy (CT) and laser ablation (LA). Non-thermal procedures include irreversible electroporation (IRE), interstitial brachytherapy (IBT), and most recently, electrochemotherapy (ECT). Due to insufficient evidence, these have only been used in individual cases and within the framework of studies. However, the nonthermal methods are a reasonable alternative for ablation of tumors adjacent to large blood vessels and bile ducts because they cause significantly less damage to these structures than thermal ablation methods. With advances in the technology of the respective procedures, increasingly good evidence, and advancements in supportive techniques such as navigation devices and fusion imaging, percutaneous ablation procedures may expand their indications for the treatment of larger and more advanced tumors in the coming years. Citation Format Luerken L, Haimerl M, Doppler M et al. Update on Percutaneous Local Ablative Procedures for the Treatment of Hepatocellular Carcinoma. Fortschr Rontgenstr 2022; DOI: 10.1055/a-1768-0954 Background Hepatocellular carcinoma (HCC) is the fifth most common tumor worldwide. Because many hepatocellular carcinomas are already unresectable at the time of initial diagnosis, percutaneous tumor ablation has become established in recent decades as a curative therapeutic approach for very early (BCLC 0) and early (BCLC A) HCC. The aim of this paper is to provide a concise overview of the percutaneous local ablative procedures currently in use, based on their technical characteristics as well as clinical relevance, taking into account the current body of studies. Materials and Methods The literature search included all original papers, reviews, and meta-analyses available via MEDLINE and Pubmed on the respective percutaneous ablation procedures; the primary focus was on randomized controlled trials and publications from the last 10 years. Results and Conclusions Radiofrequency ablation (RFA) and microwave ablation (MWA) are well-established procedures that are considered equal to surgical resection in the treatment of stage BCLC 0 and A HCC with a diameter up to 3 cm due to their strong evidence in international and national guidelines. For tumors with a diameter between 3 and 5 cm, the current S3 guidelines recommend a combination of transarterial chemoembolization (TACE) and thermal ablation using RFA or MWA as combination therapy is superior to thermal ablation alone in tumors of this size and shows comparable results to surgical resection in terms of overall survival. Alternative, less frequently employed thermal procedures include cryotherapy (CT) and laser ablation (LA). Non-thermal procedures include irreversible electroporation (IRE), interstitial brachytherapy (IBT), and most recently, electrochemotherapy (ECT). Due to insufficient evidence, these have only been used in individual cases and within the framework of studies. However, the nonthermal methods are a reasonable alternative for ablation of tumors adjacent to large blood vessels and bile ducts because they cause significantly less damage to these structures than thermal ablation methods. With advances in the technology of the respective procedures, increasingly good evidence, and advancements in supportive techniques such as navigation devices and fusion imaging, percutaneous ablation procedures may expand their indications for the treatment of larger and more advanced tumors in the coming years. Citation Format Luerken L, Haimerl M, Doppler M et al. Update on Percutaneous Local Ablative Procedures for the Treatment of Hepatocellular Carcinoma. Fortschr Rontgenstr 2022; DOI: 10.1055/a-1768-095

Management von Viszeralarterienaneurysmen unter besonderer Berücksichtigung der Organperfusion – Erfahrungen über mehr als 20 Jahre

Background Visceral artery aneurysms (VAA) are rare and often incidental findings. Indications for treatment are symptomatic patients, pseudoaneurysms and a true aneurysm of diameter of >= 2.5 cm for mesenteric arteries and >= 3 cmfor renal artery aneurysms. Pregnancy and liver transplantation play an important role in aneurysm rupture. Technical success after open or endovascular procedure and maintenance of organ perfusion are crucial. The aim of this review is to evaluate our data and experience of more than 20 years and to develop a strategy to deal with visceral artery aneurysm in elective and emergency cases. Patients Between 1995 and 2018, 179 patients (84 males, 95 females, median age 62 [18-87] years) were diagnosed with VAA at the Regensburg University Hospital. The site of aneurysm was the splenic artery in 113 (63%) patients (pts), hepatic and renal arteries in 22 and 21 pts (12% each), and gastropancreaticoduodenal artery in 14 (8%) and superior/inferior mesenteric artery in 9 (5%) cases. Surveillance without intervention occurred in 110 (62%) pts, and 34 (19%) pts underwent open and 35 (19%) endovascular repair. In all patients, preoperative imaging was performed, preferably by computed tomography angiography (CTA). Results A total of 69 patients underwent open or endovascular repair. 51 (74%) pts were treated electively, 18 (26%) pts presented urgently with acute bleeding. 16 emergency pts received endovascular treatment, and in 2 pts open surgery was performed. After emergency treatment, two pts exhibited segmental liver malperfusion without consequences. In one case, segmental bowel resection was necessary. 32/51 (63%) patients were treated electively by open surgery, 19/51 (37%) by endovascular procedures. There were no liver or bowel infarctions. Four splenectomies and one unilateral nephrectomy were necessary in patients with splenic or renal artery aneurysms. Moreover, three partial renal infarctions were noticed postoperatively (overall 8/21 [38%]). After endovascular repair of splenic or renal artery aneurysms, two cases of splenic and three cases of renal segmental infarction were observed. Splenectomy had to be performed twice (overall 7/14 [50%]). Organ perfusion was monitored by CTA, and preferentially by contrast enhanced ultrasound. Conclusion The endovascular approach is the preferred option in an emergency to control bleeding in pseudoaneurysms. Patients for elective splenic or renal artery aneurysm repair have to be evaluated very carefully to achieve technical success with occlusion of the aneurysm and excellent organ perfusion. Imaging techniques such as ultrasound, especially CEUS, are strongly recommended in postoperative follow-up. Partial or complete splenic infarction leads to vaccination