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Category: Trauma Introduction/Purpose: Postoperative malreduction of syndesmotic disruptions in the rotational ankle fractures can make the poor functional outcome. There were many efforts to evaluate the quality of syndesmotic reduction with computed tomography (CT). However, there were few studies to show the acceptable range of syndesmotic reduction with CT. The aim of this study to investigate the reduction of the distal tibiofibular joint after open reduction and positional pinning with anterolateral approach in rotational ankle injuries and show acceptable range of syndesmotic reduction. Methods: This study included axial CT images of 104 patients (104 ankles) with rotational ankle fractures which were obtained in both ankles including uninjured ankle between 2012 February and 2014 June. At 10 mm proximal to the tibial plafond, anterior, middle, posterior shortest distances (aTFD, mTFD, pTFD) between fibula and tibia were measured and compared with those of uninjured ankles preoperatively, immediate postoperatively and at the followup after removal of syndesmotic fixation. The shortest distance from the anterior border of the fibula to the connecting line between most prominent point of anterior tibia and most prominent point of lateral fibula (ATF) were measured and compared in both ankles preoperatively, immediate postoperatively and at the followup after removal of syndesmotic fixation. The clinical outcomes were evaluated with AOFAS hindfoot score and visual analogue scale for pain. Results: Mean preoperative aTFD, mTFD, pTFD were 3.4±0.5 mm, 6.2±2.4 mm, 10.3±2.9 mm respectively. Mean immediate aTFD, mTFD, pTFD were 1.4±0.3 mm, 2.9±0.5 mm, 5.1±2.0 mm respectively. Mean postoperative aTFD, mTFD, pTFD at the followup after pin removal were 2.4±0.5 mm, 3.6±1.0 mm, 6.3±2.9 mm respectively. Mean ATF were 0.5±0.1 postoperatively. Both aTFD and mTFD significantly improved immediate postoperatively and at the followup after removal of syndesmotic fixation. However mean pTFD was widened compared to uninjured ankle. All postoperative clinical outcomes were improved significantly. Conclusion: Open reduction and positional pinning with anterolateral approach in rotational ankle injuries could show the good clinical outcomes and posterior tibiofibular diastasis could be allowed in terms of syndesmotic reduction if there is no anterior translation of fibula with improved anterior and middle tibiofibular distance at the axial CT images.

To evaluate aortoiliac aneurysms repaired with endovascular stent-grafts complicated by hemodynamically significant graft stenosis.Fifty-four patients (52 men, two women; age range, 41-90 years; mean age, 75 years) with aneurysms of the infrarenal aorta (n = 36) or iliac artery (n = 18) underwent repair by means of placement of an endovascular stent-graft. Technical success was evaluated angiographically during and after placement. At follow-up (range, 12-44 months), all patients underwent sequential duplex ultrasonography, helical computed tomography, and physical examination.Stent-grafts were placed successfully in all cases. Stenosis at the internal iliac arterial origin was identified at angiography in 17 patients (31%). Supplemental intragraft stents were placed in 11 patients, and stent-graft angioplasty alone was performed in one patient. Intragraft stents were placed percutaneously in five patients when stenosis was discovered during follow-up.Supplemental intragraft stents were required in 31% of aortoiliac endovascular stent-grafts to correct stent-graft stenosis and preserve long-term function. Placement of a fully supported stent-graft is necessary to repair an aortoiliac aneurysm.

The purpose of this study was to describe our experience with balloon and self-expanding endovascular grafts for the management of thoracic aortic lesions. Between February 1997 and June 1998, 20 endovascular grafts were implanted in 14 patients for the treatment of thoracic aortic aneurysms and pseudoaneurysms. Endovascular procedures were performed using one of four different devices: (1) Dacron-covered balloon-expandable Palmaztrade mark stent, (2) balloon-expandable Palmaz stent-PTFE graft prosthesis (BE-PS), (3) self-expanding internally supported Nitinol Dacron prosthesis (Vanguardtrade mark SE-V), and (4) self-expanding externally supported Nitinol PTFE prosthesis (Excludertrade mark SE-E). The results show that endovascular grafting represents a potentially important alternative therapy to open repair of the thoracic aorta. Self-expanding devices were, in our experience, easier to use and more accurately deployed.

PURPOSE To assess the feasibility of performing uterine artery embolization as an outpatient treatment for symptomatic uterine fibroids. MATERIALS AND METHODS Forty-nine consecutive patients (mean age, 44.5 years; range, 28–54 years) underwent uterine artery embolization during a 12-month period. Embolization was performed with 350–500 μm polyvinyl alcohol particles (44 of 49) or Gelfoam pledgets (five of 49). At discharge, patients were given instructions regarding the constitutional symptoms to expect after embolization. A specific medication regimen consisting of prochlorperazine, ketorolac, meperidine, and hydrocodone was prescribed for relief of these symptoms. All patients were telephoned within 24 hours of discharge. During long-term follow-up, a questionnaire was administered to all patients to evaluate the periprocedural experience. Three-month clinical follow-up was available in 26 patients and 6-month imaging follow-up was available in 16 patients. RESULTS Fourteen patients presented with menorrhagia, six had bulk-related symptoms (abdominal distension, stress incontinence, pelvic pain), and 29 had both. Technical success for bilateral embolization was 98%. Forty-seven of 49 patients were discharged to home 6–8 hours after the procedure; two patients required overnight observation in an ambulatory unit (one because of postprocedure hypertension and one because of a late procedure completion time). At the first follow-up phone call, reported symptoms included pelvic pain/cramping in 83.7% (41 of 49), fatigue in 75.5% (37 of 49), nausea/vomiting in 46.9% (23 of 49), and a nonpurulent vaginal discharge in 18.4% (nine of 49). These symptoms were satisfactorily controlled with discharge medications in 48 of 49 patients. No patients returned to the hospital or visited an emergency room during the first 48 hours after discharge. Forty-six of 49 patients were satisfied with the decision for home discharge. The average uterine volume reduction in 16 patients with 6-month imaging follow-up was 47.5%; 88.5%, of patients (23 of 26) with 3-month clinical follow-up reported improvement or elimination of symptoms. CONCLUSIONS With defined telephone follow-up, staff availability, and a protocol designed to alleviate the postprocedure constitutional symptoms, uterine artery embolization is both safe and effective when performed as an outpatient procedure.

To compare the prevalence of hepatic arterial complications in patients who underwent hepatic arterial chemoembolization for hepatocellular carcinomas before orthotopic liver transplantation with the prevalence of hepatic arterial complications in the total population of liver transplant recipients.Forty-seven patients underwent selective hepatic arterial chemoinfusion with mitomycin C, doxorubicin hydrochloride, and cisplatin combined with embolization. The prevalence rates for hepatic arterial complications, including pseudoaneurysm, stenosis, anastomotic disruption, and thrombosis, were tabulated and compared with results in 1,154 patients who underwent orthotopic liver transplantation but not chemoembolization.Of the 47 patients who had undergone preoperative hepatic arterial chemotherapy, 13% developed hepatic arterial complications within a mean of 7 days after transplantation; an 8% prevalence of hepatic arterial thrombosis was observed. Of the 1,154 patients who underwent orthotopic liver transplantation but not chemotherapy, 6% developed hepatic arterial complications; a 5% prevalence of hepatic arterial thrombosis was observed. There was no statistically significant difference in the prevalence rates for thrombosis and complications between the patients who underwent chemoembolization before orthotopic liver transplantation and those who did not. The mean interval between chemotherapy and orthotopic liver transplantation was 111 days (range, 3-428 days).Patients who undergo hepatic arterial chemotherapy are not at an increased risk of developing hepatic arterial thrombosis or other hepatic arterial complications after orthotopic liver transplantation.

Background. Sickle cell intrahepatic cholestasis is a potentially catastrophic complication of sickle cell anemia. Once acute liver failure develops, transplantation is the only option. We describe a patient with sickle cell intrahepatic cholestasis who underwent liver transplantation. Methods. Data were obtained from the chart. Serial hemoglobin S levels were monitored, and measures were taken to maintain hemoglobin S

Percutaneous transluminal angioplasty is a commonly performed procedure. The clinical success of such a procedure is determined by the combination of the post-procedure angiographic appearance and the pressure gradient across the lesion. This case demonstrates the importance of recognizing the anatomical variation if proper pressure measurements are to be obtained.

Purpose: Successful endovascular repair of an abdominal aortic aneurysm (AAA) requires the creation of a hemostatic seal between the endograft and the underlying aortic wall. A short infrarenal aortic neck may be responsible for incomplete aneurysm exclusion and procedural failure. Sixteen patients who had an endograft positioned completely below the lowest renal artery and 37 patients in whom a porous portion of an endograft attachment system was deliberately placed across the renal arteries were studied to identify if endograft positioning could impact on the occurrence of incomplete aneurysm exclusion. Methods: Fifty-three patients underwent aortic grafting constructed from a Palmaz balloon expandable stent and an expandable polytetrafluoroethylene (ePTFE) graft implanted in an aorto-ilio-femoral, femoral-femoral configuration. Arteriography, duplex ultrasonography and spiral CT scans were performed in each patient before and after endografting to evaluate for technical success, the presence of endoleaks, and renal artery perfusion. Results: There was no statistically significant difference in patient demography, AAA size, or aortic neck length or diameter between patients who had their endografts placed below or across the renal arteries. However, significantly more proximal aortic endoleaks occurred in those patients with infrarenal endografts (P ≤.05). Median serum creatinine level before and after endografting was not significantly different between the 2 patient subgroups, with the exception of 2 patients who had inadvertent coverage of a single renal orifice by the endograft. Median blood pressure and the requirement for antihypertensive therapy remained the same after transrenal aortic stent grafting. Significant renal artery compromise did not occur after appropriately positioned transrenal stents as shown by means of angiography, CT scanning, and duplex ultrasound scan. Mean follow-up time was 10.3 months (range, 3 to 18 months). Patients who had significant renal artery stenosis (≥50%) before aortic endografting did not show progression of renal artery stenosis after trans-renal endografting. Two patients with transrenal aortic stent grafts had inadvertent coverage of 1 renal artery by the endograft because of device malpositioning, which resulted in nondialysis dependent renal insufficiency. In addition, evidence of segmental renal artery infarction (