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An infrarenal duplication of the inferior vena cava with both channels lying on the right side of the aorta was fortuitously found during an abdominal Computed Tomography performed on a 52 year-old woman. Only two same cases seem to be reported in the literature. This very uncommon abnormality probably results from persistence of the infra-renal part of the right subcardinal vein. Radiologists have to be aware of this right-sided ipsilateral duplication for it may be a trap in abdominal imaging as well as "classical" inferior vena cava duplication located on both sides of the abdominal aorta.

The authors report three cases of persistence of the stapedial artery, discovered by computed tomography examination. For two cases, a clinical symptomatology was present but probably related to the association with an aberrant carotid artery in the middle ear; the only case of isolated persistence of the stapedial artery was asymptomatic. Direct visualisation of the abnormal artery was possible on the C. T. scans in two cases and a collateral sign as a larger tympanic part of the facial canal was found in the third case inducing a MRI. The incidence of this anomaly is 0.48 per cent from 1,045 dissections of temporal bones but it is generally clinically unrecognized. The hyoïdo-stapedial artery appears and develops at the 7-18 mm embryonic stages. Partial or complete persistence have been described associated with no regression or no division of the ventral pharyngeal artery.

Background and Purpose: To replace digital subtraction angiography (DSA) in carotid stenosis evaluation, noninvasive imaging techniques have to reach a high concordance rate. Our purpose is to compare the concordance rates of contrast-enhanced MR angiography (CEMRA) and CT angiography (CTA) with Doppler ultrasound (DUS) in clinical routine practice., Methods: We evaluated prospectively with DUS, CEMRA, and CTA 150 patients suspected of carotid stenosis. The overall concordance rates of the 3 techniques were calculated for symptomatic stenosis > or =50% and > or =70%, for asymptomatic stenosis > or =60%, and for occlusion. For the carotid arteries treated by surgery (n=97), the results of each method and combined techniques were recorded, and misclassification rates were evaluated from surgical reports., Results: The overall concordance rates of DUS-CEMRA, DUS-CTA, and CEMRA-CTA were not statistically different. However, the concordance rate of DUS-CEMRA (92.53%) was significantly higher than that for DUS-CTA (79.10%) in the surgical asymptomatic stenosis group (P=0.0258). CTA considered alone would misclassify the stenosis in a significant number of cases (11 of 64) in the surgical asymptomatic group compared with CEMRA (3 of 67) and DUS (1 of 66) (P=0.0186 versus MRA, P=0.0020 versus DUS)., Conclusions: With the techniques as utilized in our study, the overall concordance rates of combined noninvasive methods are similar for measuring carotid stenosis in clinical routine practice, but in asymptomatic carotid stenosis, the decision making for surgery is significantly altered if DUS and CTA are considered in place of DUS and CEMRA.

Objective: To evaluate the diagnostic performance of transthoracic sonography of the lung in view of an acute suspicion of pulmonary embolism., Methods: The diagnosis of pulmonary embolism was made within 48 hours of admission with the use of a validated strategy that combined a lung scan, lower limb sonography, helical computed tomography, and pulmonary angiography in 74 consecutive patients. All patients had a 3-month follow-up. Transthoracic sonography of the lung and pleura was performed in a blinded fashion by investigators unaware of the diagnostic process. It was interpreted as suggestive or not suggestive of pulmonary embolism on the basis of previously published descriptions. The results were kept apart from the patient files until the end of the study., Results: Pulmonary embolism was confirmed in 31 (42%) of the 74 patients. None of the patients classified as pulmonary embolism-negative had a thromboembolic event during the 3-month follow-up. The diagnostic performance of transthoracic sonography was as follows: sensitivity, 71% (95% confidence interval, 52%-85%); specificity, 77% (95% confidence interval, 61%-88%); positive predictive value, 69% (95% confidence interval, 50%-83%); and negative predictive value, 79% (95% confidence interval, 63%-89%). The finding of an isolated pleural infarction was significantly more frequent in pulmonary embolism-positive patients compared with pulmonary embolism-negative patients (P = .0001)., Conclusions: The results from this study suggest that transthoracic sonography of the lung does not fulfill satisfactory performance criteria in view of a clinical suspicion of pulmonary embolism.

Unlabelled: AN IMPORTANT SUBJECT: The thromboembolic disease still prevails in the context of surgery, despite the progression in prophylaxis. Particular attention must be paid to the possibility of delayed events, often occurring within the three months following a surgical procedure. Although many general studies, assessing supplementary examination or diagnostic strategies are available, the proportion of patients concerned by a post-operative context varies., In Practice: The Doppler is the diagnostic examination of choice in the case of suspected deep vein thrombosis, but it is not recommended in a strategy of screening for asymptomatic thrombosis in surgery. A suspected embolism can be confirmed or eliminated using noninvasive examinations, but it requires that invasive tests be performed more often than in a medical context. The indication for a helical computed tomography, presently more readily available than a pulmonary angiography, would appear legitimate, so long as a Doppler of the lower limbs is systematically associated. RESERVATIONS IN THE POST-OPERATIVE PERIOD: The results of this strategy, most satisfactory in the majority of patients, do not appear as interesting post-operatively. The studies targeting the management of suspected post-operative pulmonary embolism are rare and warrant further encouragement.

Purpose: To evaluate the midterm results of limited embolization of the uterine arteries in the management of symptomatic uterine fibroids and to evaluate the efficacy and safety of limited uterine artery embolization (UAE) with use of calibrated tris-acryl gelatin microspheres in the management of symptomatic uterine fibroids., Materials and Methods: Twenty women (mean age, 43 years) with symptomatic uterine fibroids underwent bilateral embolization of the uterine arteries with use of calibrated microspheres. Devascularization of the fibroids was achieved and the main uterine artery was left patent in all women. Embolization was offered as an alternative to surgery in all women who had been treated unsuccessfully with medical therapy., Results: All procedures were technically successful. Microspheres 700-900 micro m in diameter were used in 14 women (70%). After a mean follow-up duration of 30.2 months (range, 24-48 mo), all women reported improvement in their symptoms, with 85% reporting complete resolution of menorrhagia at the most recent follow-up. One woman with multiple fibroids required a second embolization procedure because of persisting symptoms at 6 months. She is currently symptom-free after 48 months. In two women with submucosal fibroids, expulsion of necrotic fibroids occurred 2 and 7 months after the procedure, respectively. All women resumed normal menstruation after the procedure. One woman had a successful full-term pregnancy after embolization., Conclusion: Early experience with UAE with use of calibrated tris-acryl gelatin microspheres indicates that it is safe and efficacious in controlling menorrhagia.

The prevention of venous thromboembolism in medical patients remains questioned. All consecutive outpatients admitted in our medical unit were considered for inclusion in this study which aimed to estimate the prevalence of asymptomatic venous thrombosis on admission and the incidence during hospital stay. Exclusion criteria were: age <18 years, suspicion of venous thromboembolism, stay <4 days, ongoing anticoagulant therapy. Venous compression ultrasonography of the lower limbs was performed within 48 h. 234 patients were included. The prevalence of asymptomatic deep vein thrombosis on admission and the incidence during hospital follow-up were respectively 5.5% (95% confidence interval, 3.1 to 9.5%) and 2.6 per 1,000 person-days (95% confidence interval, 0.0 to 5.2). The prevalence and the incidence reached respectively 17.8% (95% confidence interval, 8.5 to 32.6%) and 6.0 per 1,000 person-days (95% confidence interval, 0.0 to 12.7) among patients over 80 years. A high prevalence of asymptomatic deep vein thrombosis on admission was suggested particularly among elderly medical patients.

Aim of the Study: The aim of this retrospective study was to find a link between vascularization failure and fistula in esophageal surgery. The originality of this study was to be based on hyperselective arteriogaphy of the artery vascularizing the gastric plasty, showing all vascular network of the plasty., Patients and Methods: Hyperselective arteriography was carried out in 14 patients operated for esophagus cancer with a gastric plasty replacement. All these patients had a postoperative leakage or a bad vascularization of the gastric plasty during the operation., Results: The vascularization of the gastric plasty was organized from the gastro-epiploic artery by anastomotic transversal network, depending on the left gastro-epiploic artery and left gastric artery. For the 14 patients, a constant link between leakage and vascularization failure could be proved., Conclusion: Esophageal surgery is dependent on the vascular status of the patient. The type of gastric plasty with large or narrow tubulization does not interfere with the quality of vascularization at the top of the plasty due to the preservation of a corporeal low branch.

The authors report the case of a 39-year-old man with a common origin of three arteries-the celiac, superior mesenteric, and inferior mesenteric arteries-that has not been described previously in the literature, to their knowledge. This variant, which they call the celiac-bimesenteric trunk, is documented with a selective angiogram, and an embryologic explanation is offered.

We assessed the accuracy of venous compression ultrasonography (CUS) for the detection of asymptomatic deep vein thrombosis in 122 consecutive patients, with a mean age of 69 years, who were hospitalised in an internal medicine unit. All included patients had CUS within 48 h of admission. Twelve out of 17 patients with a positive CUS underwent phlebography, as the others withdrew their consent, whereas the remaining 105 patients with a negative serial CUS testing were clinically followed-up at 3 months. We found that CUS had a sensitivity and a specificity of respectively 1 (95% CI, 0.73 to 1) and 1 (95% CI, 0.96 to 1) for the detection of asymptomatic deep vein thrombosis. Kappa-coefficients for intra-observer and inter-observer agreements were respectively 0.88 and 0.56. We concluded that venous compression ultrasonography, performed as described, fulfils requirements of a screening test that could be available for prophylactic clinical trials or epidemiological researches.

Among spinal arteriovenous malformations (AVMs), dural arteriovenous fistulas (DAVFs) should be distinguished from intradural AVMs. The authors report the unusual and well-documented case of a 49-year-old man who suffered from a rapidly progressive myelopathy. Two concurrent spinal AVMs (one DAVF and one intradural direct AVF [Anson-Spetzler Type IV-B AVM]) were found located in the midthoracic region and in the conus medullaris, respectively. Both AVMs were successfully treated by surgery. To the authors' knowledge, the association of these two pathological entities has not been previously described. Clinically, if the patient fails to improve or deteriorates after the treatment of a spinal AVM, the presence of another AVM should be investigated by repeated angiography, especially if a complete spinal angiography study was not initially performed.

Purpose: The authors report the first results of a new 6-F symmetrically designed permanent nitinol inferior vena cava (IVC) filter, the Cordis TrapEase, evaluated in a multicenter prospective study with 6-months of follow-up., Materials and Methods: A total of 65 patients (29 men, 36 women) who ranged in age from 37 to 96 years (mean age, 68 years) and who were at high risk of pulmonary embolism (PE) were enrolled in 12 centers in Europe and Canada. The study was approved by the institutional review boards at all centers. Study objectives were to evaluate filter effectiveness, filter stability, and caval occlusion. Indications for filter placement were deep vein thrombosis with recurrent thromboembolism and/or free-floating thrombus with contraindication to anticoagulation in 37 patients, and complications in achieving adequate anticoagulation in 28 patients. Follow-up included clinical examination, plain film, Doppler ultrasound, CT scan, and nuclear medicine., Results: The analysis of the data revealed a technical success of 95.4% (three filter-system related implantations not at the intended site, no events of filter tilting) and a clinical success of 100% at 6 months (no cases of symptomatic PE), the study primary endpoint. There were no cases (0%) of filter migration, insertion site thrombosis, filter fracture, or vessel wall perforation. During the study period, there were two cases of filter thrombosis: one case of early symptomatic thrombosis that was successfully treated in the hospital, and one case of nonsymptomatic filter thrombosis detected at 1-month follow-up, with spontaneous recanalization at 3 months. In the latter patient, some residual thrombus was still detected at 6 months. Of the study population of 65 patients, there were 23 deaths. These deaths were not related to the device or the implantation procedure but to the underlying disease process., Conclusion: This study demonstrates the new nitinol permanent IVC filter to be a safe and an effective device, with a low overall complication rate, for use in patients with thromboembolic disease at high risk of PE.

Congenital anomalies of the gallbladder (GB) correspond to the ultimate manifestation of the wide range of anatomical variations that may affect the GB. Anomalies may be numerical: duplication, accessory GB, and, rarely, agenesis. Anomalies of position are more common: ectopic GB, floating or wandering GB. Morphological anomalies (septations) are the most common GB anomalies. Most of these anomalies may result in pitfalls at US imaging.

A case of congenital aneurysm of the main pulmonary artery incidentally discovered following blunt chest trauma is reported. This anormaly is rare and the authors will emphasize the plain radiographic and MRI findings. The etiology and evolution of this entity are not well known.

Previous studies have suggested the utility of D-Dimer ELISA assays in eliminating a diagnosis of pulmonary embolism (PE). Our objectives were to evaluate the performance of a new, rapid, quantitative, and automated Liatest D-Dimer Assay in patients with suspected PE. Three hundred eighty-six consecutive patients referred to our institution between March 1992 and December 1996 for clinically suspected PE, with recent clinical signs not exceeding 1 wk, were included in this study. Diagnosis of PE was based on clinical evaluation, radionuclide lung imaging, lower limb examination, and, when required, pulmonary angiography. D-Dimer performances, for both Liatest D-Dimer and standard D-Dimer ELISA (Asserachrom DDi), assays, were assessed at the end of the study. Among the 386 patients tested, 146 (37.8%) were classified as PE-positive. Liatest D-Dimer assay had a 100% sensitivity (95% confidence interval, 97 to 100%) and a negative predictive value of 100% (95% confidence interval, 94 to 100%). A normal result, below the cutoff of 500 ng/ml, occurred in 83 of the 386 (21%) patients. There was a strong agreement between Liatest D-Dimer and Asserachrom DDi analyses. These findings suggest that this rapid, quantitative, and automated D-Dimer assay provides a useful diagnostic tool for the clinician with regard to exclusion of PE.

In previous studies, enzyme-linked immunosorbent assays (ELISA) for plasma D-dimer analysis have demonstrated high sensitivity, suggesting their potential usefulness in excluding deep venous thrombosis (DVT). We evaluated the usefulness of a new D-dimer test (Liatest D-dimer) for suspected DVT in a prospective study of patients admitted to the hospital because of recent (not exceeding 1 week before admission) clinical signs. Contrast venography or compression ultrasonography or both were performed within 24 hours of admission. A new quantitative determination of D-dimer concentration using a suspension of microlatex particles coated with specific antibodies was tested. A standard plasma D-dimer ELISA measurement was also performed. Of 464 patients, 276 had a proven DVT (distal, 74; proximal, 202). For a cutoff level of 400 ng/mL, sensitivity of the Liatest method in the diagnosis of overall DVT was 94.6% (95% confidence interval, 92.0%-97.0%), and the specificity was 35% (95% confidence interval, 28%-42%). The sensitivity and negative predictive value were 98.5% and 95.6%, respectively, in the diagnosis of proximal DVT, but only 83.8% and 84.6%, respectively, in the diagnosis of distal DVT. This new rapid Liatest D-dimer assay seems to be highly sensitive and could replace the ELISA method in excluding patients with proximal DVT. Both methods provide lower sensitivity for distal DVT.

Objective: To compare oral anticoagulant treatment (fluindione) started on either the 1st or the 10th day of a low-molecular-weight heparin (enoxaparin) treatment for deep vein thrombosis confirmed by venography., Design: An open, multicenter, randomized study in two parallel treatment groups., Interventions: All patients received enoxaparin, 1 mg/kg s.c. twice daily, and oral fluindione, 20 mg once daily, either beginning on day 1 or on day 10 of the enoxaparin treatment. Enoxaparin was discontinued once the international normalized ratio under fluindione was stable between 2.0 and 3.0 over 2 days. Fluindione treatment was maintained during a 3-month follow-up period., Outcome Measurements: Specific examinations (venography and/or V/Q lung scanning and/or angiography) were performed only in the event of a clinically suspected recurrence of venous thromboembolism during the 3-month follow-up period. All cases were blindly assessed by an independent Reading Committee., Results: A clinically suspected venous thromboembolism was confirmed by objective tests in 1 of 223 patients (group of delayed introduction of fluindione; n = 111). Equivalence was demonstrated between the two treatment schedules (p < 0.0001) for a maximal difference of 10% (90% confidence interval: -2.42 to 0.58). The mean duration of hospitalization was significantly reduced (p = 0.0001) in the group with early introduction of fluindione. The incidence of hemorrhage was comparable between the two treatment groups., Conclusion: Early and delayed introduction of oral anticoagulant treatment in association with subcutaneous enoxaparin in patients with deep vein thrombosis was shown to be equivalent in preventing the recurrence of venous thromboembolism. In patients with early introduction of oral anticoagulant, hospitalization was significantly reduced.

Objective and Importance: Cases of intraorbital arteriovenous malformations are rare, and their management presents a challenge for multidisciplinary teams., Clinical Presentation: A 39-year-old woman developed a pulsating exophathalmos, visual loss, and ocular pain within 1 month, revealing the presence of intraorbital arteriovenous malformations. She underwent only surgical treatment., Intervention: A fronto-orbital approach with removal of the orbital rim was performed. A CO2 laser facilitated all the surgical steps., Conclusion: Full recovery of vision and correction of the proptosis have been achieved, and postoperative magnetic resonance imaging and angiography confirmed the total removal of the malformations. The literature is reviewed regarding the management of such lesions. Surgery remains the treatment of choice. The role of embolization is discussed.

Selective embolization is the best treatment for intrarenal arterial lesions due to trauma or percutaneous procedures with non-controlled or recurrent haematuria. Three male patients, aged 20-70 (mean 49 years), were recently treated in our institution by means of arterial embolization with microcoils. Two patients presented a pseudo-aneurysm and an arterio-venous fistula secondary to percutaneous nephrolithotomy and one patient presented an isolated pseudo-aneurysm due to trauma. In the 3 cases, haematuria (associated with retroperitoneal haemhorrage in one case) was not controlled and required repeated units of blood. Embolization allowed definitive treatment of these lesions. One of our patients with a solitary functional kidney presented rapidly increasing renal failure which completely resolved after arterial embolization. We think that microcoils are the embolic agents of choice to perform endovascular treatment in this indication.

This study was designed to assess the risk of associated pulmonary embolism according to the level of deep venous thrombosis. From March 1992 to March 1994, 328 patients were referred to medical units for suspected deep venous thrombosis, with recent clinical signs, less than a week. Each patient underwent contrast venography and/or duplex ultrasounds of lower extremities, ventilation and perfusion lung scan within 48 hours and angiography in case of low or intermediate pulmonary embolism probability. Diagnosis of deep venous thrombosis was confirmed in 155 patients; location was distal in 41, proximal in 114; an associated pulmonary embolism was found in 66 patients (10 with distal, 56 with proximal deep venous thrombosis); odds ratio was 2.99 (95% Cl: 1.2-3.13). Significantly higher risk of associated pulmonary embolism when deep venous thrombosis involves proximal veins is confirmed, but as many as 10 out of 41 patients with distal thrombosis also had an associated embolism. Management of both distal and proximal deep venous thromboses appears identical.

The authors report a new case of leiomyosarcoma of the duodenum. The exoluminal growth and the volume of this tumor explain the difficulties of the imaging methods diagnostic. Computed tomography, magnetic resonance imaging and angiography were not sufficient to determine the origin of the tumor. Surgical exposure itself was not conclusive and only pathology provided the definitive diagnosis. We think that endoscopic ultrasonography should be indicated in these submucosal tumors of the duodenum to differentiate them from pancreatic neoplasms.

The authors present a case of a retroperitoneal lymphocele following prosthetic reconstruction of the abdominal aorta followed by a discussion about the principal differential diagnosis of a retroperitoneal collection following surgery on abdominal aorta. To date, only ten cases have been reported in this post-operative; it is probably a more frequent complication; the radiologist must play a major role both in the detection and the treatment of such collections.

In 21 cases of acetabulum fractures of 19 patients, the authors compare the findings given by three dimensional reconstructions of axial CT scan cuts with the plain films. The number of CT scan cuts is reasonable for each patient. Working time is about 20 to 30 minutes for the technician. In the cases of complex and displaced fractures, three dimensional imaging brings often decisive informations for the therapeutic management of these patients. Unusual views are often allowed but completely adapted to each type of fracture.