Search

Introduction: Percutaneous left ventricular assist devices are an important tool in the management of patients with severe cardiogenic shock. Limited experiences concerning vascular complications after long term implantation of these devices exist. We report on a large arteriovenous fistula after placement of a left ventricular assist device, which has not been described in the literature. The arteriovenous fistula was of clinical relevance because it represented a supplementary cardiac burden in a patient with impaired left ventricular function after a severe myocardial infarction.

OBJECTIVES: Venous pressure measurement using an intravenous catheter is the sole method for the diagnosis of venous hypertension in patients with chronic venous insufficiency. A noninvasive tool to quantify increased venous pressure is essential for studying venous pathophysiology. Aim of the study was to investigate the value of controlled compression ultrasound (CCU) for noninvasive assessment of venous pressure (VP) of the great saphenous vein (GSV) in healthy persons and patients with venous insufficiency to quantify venous hypertension. METHODS: An optimal visible part of the GSV directly above the ankle was marked on the skin and compressed under ultrasound control and pressure needed for complete compression of the vein was recorded using a pressure manometer with a translucent silicone membrane. Complete insufficiency of the GSV (Hach IV) was documented by duplex ultrasound by an independent investigator before start of the study. VP measurement was performed while normal breathing, deep inspiration and expiration and during a standardized Valsalva maneuver. RESULTS: Twenty controls and 19 patients with complete insufficiency of the GSV were included. Valsalva maneuver induced a slight increase in VP in controls (20.1 ± 4.5 vs 25.1 ± 6.6 mbar) but a significant higher increase in patients from 26 to 37 mbar (IQR 18.5-28.0 vs 31.5-43.0; p < 0.001). CONCLUSION: Noninvasive venous pressure measurement of the great saphenous vein using CCU is feasible and documents an increased pressure during Valsalva maneuver in Hach IV patients compared to healthy controls.

Bei der 52-jahrigen Frau wurde bei einer adulten polyzystischen Nierenerkrankung mit terminaler Niereninsuffizienz eine Nierentransplantation durchgefuhrt. Seit der Implantation der Spenderniere in den rechten Unterbauch fiel eine progrediente Beinschwellung rechts auf mit einem deutlichen Spannungsgefuhl in der rechten Wade. Die Patientin wurde zur Duplexsonographie bei Verdacht auf eine tiefe Beinvenenthrombose zugewiesen. Die Kompressionssonographie femoro-popliteal und im Bereich des Unterschenkels ergab keinen Anhalt fur eine Thrombose. Auffallig war die Dopplerspektralanalyse des venosen Flusses in der Vena femoralis communis rechts (A) im Vergleich zur Gegenseite (B). Weiterhin abgebildet ist ein Langsschnitt nahe der Transplantatniere im Bereich der mittleren Vena iliaca externa rechts (C) mit der entsprechenden Dopplerspektralanalyse (D). Die Dopplerspektralanalyse zeigt vier auffallige Befunde auf.

Background: Musical murmurs (MMs) are Doppler phenomena which sound like high-frequency musical sounds. They reflect high and turbulent flow within relevant stenoses and were first described in degenerated bioprosthetic valves and later in intracranial vessels and were associated either with high-grade arterial stenosis, small collateral arteries or carotid cavernous fistulas. Objective of this article is to illustrate the spectrum of imaging of MMs observed in renal, intestinal and peripheral vessels. Patients and methods: Four experienced vascular ultrasound laboratories had been asked to report their cases with documented musical tones in color coded duplex sonography (CCDS) within a two year observational period (2008 and 2009). Documented Doppler findings and corresponding clinical data were analyzed. Results: MMs were found in 18 patients with an incidence of 0.05 % and were observed in high grade stenosis in hemodialysis access (n = 5), in post-biopsy arteriovenous fistulas after renal transplantation (n = 3), in renal transplant artery (n = 1) and vein (n = 3), stenoses in peripheral (n = 2) and intestinal arterial disease (n = 2), and in peripheral veins (n = 2). Conclusions: The so called musical murmurs are a rare but potentially relevant finding in CCDS. They are caused by a variety of underlying pathologies with different clinical implications, however correct interpretation is mandatory since urgent therapy might be necessary.

Ein 42-jahriger Mann stellt sich wegen einer seit mehr als 2 Jahren bestehenden schmerzlosen Schwellung im Bereich der linken Stirn vor (Abb. 1A ). Als moglichen Ausloser des Befundes gibt er ein stumpfes Trauma wahrend einer umfangreichen Renovierung des Hauses an. Im Verlauf war die Grose des Knotens haufig wechselnd, moglicherweise prominenter unter Stresssituationen. Der ansonsten gesunde, sportliche Mann ohne Gefasrisikofaktoren fuhlt sich wegen der asymptomatischen Schwellung auch nicht kosmetisch gestort. Die Sonographie (Abb. 1B bis D und Videosequenz ) zeigt drei pathologische Befunde.

Duplex ultrasound is widely used to detect vascular dysfunction after kidney transplantation. We describe musical murmurs found in renal allografts. A 29-year-old man with an increase in serum creatinine 1 month after cadaveric kidney transplantation was referred for duplex ultrasound to exclude perfusion dysfunction. Renal arterial and venous circulation was normal. However, during Doppler spectral recording, a loud “seagull cry” was audible (audio file in the online-only Data Supplement). Spectral analysis displayed mirror-image parallel strings and bands of low to moderate frequency (Figure 1A and B). A small arteriovenous fistula, presumably after previous biopsy, was detected as cause of the turbulent flow. Inasmuch as no bleeding complication or pseudoaneurysm formation occurred, a conservative strategy was chosen, and follow-up with duplex ultrasound was recommended. Figure 1. A and B, Renal transplant with …

Purpose: Factors predicting renal function and recurrent stenosis following percutaneous renal revascularization are poorly identified. The predictive value of hemodynamic duplex ultrasound (DUS) parameters was evaluated. Methods: In a prospective observational study patients undergoing stenting of renal artery stenosis (RAS) were included. Renal resistance index (RI) and peak systolic velocity (PSV) were measured at baseline, one day, and six months after intervention. Results: At 6-months follow-up 16 (16.8%) restenosis of 105 treated renal arteries were detected. Baseline RI was 0.69 +/- 0.12 and increased significantly to 0.72 +/- 0.09 after 6 months (p < 0.0001), however, RI did not predict restenosis. PSV at baseline and age were independent predictors for increased RI at 6 months (p = 0.0078 and p = 0.0019). Diabetics had a significant higher RI before revascularization (0.74 +/- 0.08) than non-diabetics (0.68 +/- 0.12, p = 0.04). PSV after stenting was higher in patients with restenosis (1.4 +/- 0.4 m/sec vs. 1.0 +/- 0.3 m/sec, p = 0.002) and was an independent predictor for restenosis. Conclusions: Increased PSV within the stent one day after the procedure is predictive for restenosis. Patients with high grade RAS and older patients have a worse outcome. DUS is recommended to detect patients at risk for restenosis after percutaneous renal revascularization.

BACKGROUND: Limited data exist concerning changes of renal perfusion directly after kidney transplantation. Colour-coded duplex sonography is the accepted method to assess kidney perfusion after transplantation. A widely used, although unspecific, Doppler parameter is the intrarenal resistance index (RI). The aim of this study was to clarify the influence of different patient- and procedure-related factors on RI before and immediately after living kidney transplantation. METHODS: In a prospective study, 80 living kidney transplantation donor-recipient pairs were included. RI was measured in the donor 1 to 3 days before nephrectomy and in the recipient during the first hour after transplantation to examine the influence of age, heart rate, duration of cold and warm ischaemia time and immunosuppressive medications. RESULTS: Mean RI did not differ between donors and recipients. RI correlated with age, both in donors (r = 0.58, P > 0.001) and recipients (r = 0.39, P > 0.001). In recipients, 10 or more years younger than their donors (n = 24), an average decrease of 0.05 in RI compared to the donors' value was observed (P = 0.01). Heart rate, cold and warm ischaemia time and immunosuppressive medications had no influence on the recipient RI. In patients with delayed graft function, a significant increase in RI within 14 days was observed. However, the initial RI was not predictive of graft function. CONCLUSIONS: The transplanted kidney seems to be able to adjust its RI within a short time despite several potential harmful factors that can occur during the transplantation.

Der 55-jahriger Patient stellte sich zu einer duplexsonografischen Verlaufskontrolle bei bekannter mesenterialer Arteriosklerose vor. Der Patient fuhlte sich wohl und verneinte abdominelle Beschwerden. Der sehr schlanke Mann machte den Untersucher bereits vor der Sonografie darauf aufmerksam, dass er „sehr schlecht zu schallen“ sei. Mit 19 Jahren war ein Hodentumor rechts mit Semicastratio, abdominaler Lymphnodektomie und Radiotherapie behandelt worden. DIE DUPLEXSONOGRAFIE ZEIGT 3 PATHOLOGISCHE BEFUNDE.WELCHE SIND DAS?ERLAUBEN DIESE BEFUNDE EINE DIAGNOSE? WENN JA, WELCHE?SIND DIFFERENZIALDIAGNOSEN MoGLICH? WENN JA, WELCHE?Auflosung

Bei dem 33-jahrigen Mann wurde vor 3 Wochen eine transradiale Koronarangiographie durchgefuhrt. Der Patient bemerkte neu ein Vibrieren im Bereich der ansonsten reizlos verheilten Punktionsstelle. Der Puls der Arteria radialis war gut palpabel, ein leichtes Vibrieren im Bereich der Punktionsstelle sowie ein lautes hochfrequentes systo-diastolisches Stromungsgerausch an der Punktionsstelle waren wahrzunehmen. Die Duplexsonographie und Dopplerspektralanalyse zeigen insgesamt vier Befunde.