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Zusammenfassung. Angiomyolipome sind die häufigsten benignen Nierentumoren. Die meisten sind spontan aufgetretene Tumoren, mehrheitlich 4,0 cm spontan gefährlich bluten können. Neben spontanem Auftreten gibt es auch Angiomyolipome in Rahmen des tuberösen Sklerosekomplexes (TCS), hier sind die Tumoren öfters grösser, kombiniert mit Nierenzysten und Nierenzellkarzinomen. Die Messung der Echointensität ist für die Diagnose wichtig.

The growing detection of papillary thyroid microcarcinomas (PTMCs) is paralleled by an increase in surgical procedures. Due to the frequent indolent nature, cost, and risk of surgery, active surveillance (AS) and ultrasound-guided minimally invasive treatments (MITs) are in suitable cases of incidental PTMC proposed as alternatives to thyroidectomy. Surgery and radioiodine are the established treatments for relapsing cervical differentiated thyroid carcinoma (DTC) metastases. But radioiodine refractoriness, risk of surgical complications, adverse influence on quality of life, or declining repeat surgery have led to AS and MIT being considered as alternatives for slow-growing DTC nodal metastases. Also, for distant radioiodine-refractory metastases not amenable to surgery, MIT is proposed as part of a multimodality therapeutic approach. The European Thyroid Association and the Cardiovascular and Interventional Radiological Society of Europe commissioned these guidelines for the appropriate use of MIT. Based on a systematic PubMed search, an evidence-based approach was applied, and both knowledge and practical experience of the panelists were incorporated to develop the manuscript and the specific recommendations. We recommend that when weighing between surgery, radioiodine, AS, or MIT for DTC, a multidisciplinary team including members with expertise in interventional radiology assess the demographic, clinical, histological, and imaging characteristics for appropriate selection of patients eligible for MIT. Consider TA in low-risk PTMC patients who are at surgical risk, have short life expectancy, relevant comorbidities, or are unwilling to undergo surgery or AS. As laser ablation, radiofrequency ablation, and microwave ablation are similarly safe and effective thermal ablation (TA) techniques, the choice should be based on the specific competences and resources of the centers. Use of ethanol ablation and high-intensity focused ultrasound is not recommended for PTMC treatment. Consider MIT as an alternative to surgical neck dissection in patients with radioiodine refractory cervical recurrences who are at surgical risk or decline further surgery. Factors that favor MIT are previous neck dissection, presence of surgical complications, small size metastases, and

Abstract. Background: A new stent system was studied in a porcine model to evaluate its feasibility for spot-stenting of the femoropopliteal artery. Materials and methods: In a preliminary study in a single pig, handling and mechanical features of the novel multiple stent delivery system were tested. The Multi-LOC system demonstrated great feasibility regarding its pushability, trackability, and crossability. Excellent visibility of the individual stents allowed exact anatomically controlled implantation. In our main study, four to five short Multi-LOC stents (13 mm long) were implanted into the femoropopliteal arteries of six domestic pigs and long (60 to 100 mm) self-expandable nitinol stents were implanted into the same target vessel contralaterally to allow for intraindividual comparison. After four weeks survival under dual antiplatelet treatment, control angiography was performed. The animals were euthanized, stented vessels were explanted, and histologic sections were examined for the presence of neointimal formation. Results: Multi-LOC stents demonstrated no occlusion of the femoropopliteal axis (0 vs. 1 occlusion distal to a control stent), no stent fractures (0 out of 26 vs. 2 out of 6 control stents), and lower percentage diameter stenosis (0.564 ± 0.056 vs. 0.712 ± 0.089; p = 0.008) and length of stenosis (19.715 ± 5.225 vs. 39.397 ± 11.182; p = 0.007) compared to a standard control stent, which was similar in total length to the multiple stented artery segment. Histological examination confirmed myointimal hyperplasia underlying in-stent stenosis. Conclusions: The multiple stent delivery system was studied in a porcine model, which demonstrated its feasibility. Preclinical experience revealed favourable results concerning stent fracture, restenosis, and patency of spot-stented femoropopliteal arteries.

Treating hepatocellular carcinoma (HCC) remains a challenge; its incidence is increasing worldwide, and the disease is frequently diagnosed in an advanced stage in which curative treatment cannot be provided. According to the Milan criteria and Barcelona Clinic Liver Cancer staging scheme, only a minority of patients are candidates for potentially curative liver transplantation or, in patients without evidence of severe liver cirrhosis, for resection or radiofrequency ablation (1–4). Transarterial chemoembolization (TACE) is accepted as the therapy of choice (1, 2, 5–7) in intermediate disease stages or as a bridging treatment for patients on the waiting list for transplantation. When TACE is contraindicated and in advanced disease, systemic therapy with sorafenib, a multikinase inhibitor, is the only available effective treatment for patients with preserved liver function (8). Depending on patient selection and the embolic agent used, the median survival after TACE ranges from 15.6 to 23.2 months, and the treatment has demonstrated a proven benefit in controlled studies (compared with best supportive care), especially in early intermediate stage patients (5–7, 9–12). In a phase III trial comparing sorafenib with a placebo in advanced-stage HCC in Child A patients, treatment with sorafenib yielded a median survival benefit of 10.7 vs. 7.9 months (8). Through its embolic effect, TACE may induce the release of angiogenic factors, which in turn may promote the outgrowth of surviving tumor cells into tumor recurrence and metastatic spread. Therefore, combining TACE with systemic sorafenib treatment may be an attractive concept (13, 14). Clinical data still remain inconclusive (15–17). Although the toxicity of such a combined regimen (TACE plus sorafenib) does not seem to exceed the toxicity conferred by each of the two modalities alone, the overall toxicity of systemic sorafenib remains high. Common adverse events include diarrhea, hand-foot skin reaction, and fatigue, presenting at grade 3 intensity in approximately 25% of cases (8, 18). These observations have led to the idea of locally administering sorafenib in combination with ethiodized oil to increase the sorafenib concentration in the tumor while reducing the systemic concentration, and thus, toxicity. Recent pilot experiments by Gaba et al. (19) and Chatziioannou et al. (20) revealed transarterial sorafenib chemoembolization to be feasible in non-tumor-bearing rabbits, where favorable pharmacokinetics were observed. The sorafenib concentrations found in the treated lobe were significantly higher than the concentrations reported for systemic therapy, while no immediate histopathologic tissue toxicity was found in animal necropsy (19, 20). In this study, we performed a modified TACE using an emulsion of sorafenib and ethiodized oil (referred to as SORATACE) for the treatment of experimental VX-2 liver tumors in rabbits. Efficacy and safety were measured using contrast-enhanced computed tomography (CT) and histopathologic examinations. Two groups of rabbits receiving either no treatment or oral sorafenib served as controls.

Purpose Computed tomography (CT) or magnetic resonance imaging (MRI) guided brachytherapy provides high tumor control rates in hepatocellular carcinoma (HCC) and colorectal liver metastases. In contrast to thermal ablation methods such as radiofrequency ablation (RFA), much less restrictions apply with respect to tumor location or size. In this study, we determined the efficacy and safety of CT- or MRI-guided brachytherapy in metastatic melanoma. Material and methods Fifty-two metastases of malignant melanoma in 14 patients were included in this retrospective study. Local tumor control and safety were evaluated as primary and secondary endpoints. Furthermore, we evaluated overall survival and progression free survival. Tumor locations were liver (n = 31), lung (n = 15), adrenal (n = 3), lymph nodes (n = 2), and kidney (n = 1). Treatment planning was performed using three-dimensional CT or MRI data acquired after percutaneous applicator positioning under CT or open MRI guidance. Subsequently, single fraction high-dose-rate (HDR) brachytherapy was applied using a (192)Iridium source. Clinical and cross-sectional follow-up were performed every 3 months post intervention. Results The median diameter of treated lesions was 1.5 cm (range: 0.7-10 cm). Doses between 15 and 20 Gy were applied (median dose: 19.9 Gy). The mean irradiation time ranged between 7-45 minutes. After treatment, there was one patient with a cholangitis. After a median follow up of five months, the median local tumor control was 90%. The median overall survival of the patients was 8 months. The median progression free survival of the patients was 6 months. Conclusions Image-guided HDR brachytherapy is a safe and effective treatment procedure in metastatic malignant melanoma.

Background Myxoid liposarcomas represent a heterogeneous group of soft tissue tumors in which prognosis is dependent on differentiation. Purpose To identify magnetic resonance imaging (MRI) criteria to distinguish low-grade from high-grade myxoid liposarcomas. Material and Methods MR images of 30 histologically proven myxoid liposarcomas were retrospectively reviewed. Tumors were evaluated according to size, localization, tumor border, and structure as well as tumor composition. These imaging criteria were correlated with histopathological findings. Results Nineteen myxoid liposarcomas were histologically classified as low-grade myxoid liposarcomas, whereas 11 were considered high-grade myxoid liposarcomas. Mean tumor volume of low-grade myxoid liposarcomas (710.1 ± 960.1 ccm) was significantly smaller as compared to high-grade myxoid liposarcomas (2737.0 ± 3423.7 ccm; P = 0.04). In addition to necrotic areas, three tumor components – fatty, myxoid, as well as contrast-enhancing non-fatty, non-myxoid – could be identified. The mean fraction of fatty tumor areas in low-grade myxoid liposarcomas was 10 ± 11% as compared to 6 ± 4% for high-grade myxoid liposarcomas ( P = 0.66). Myxoid components accounted for 88 ± 16% in low-grade myxoid liposarcomas, but only for 45 ± 25% in high-grade myxoid liposarcomas ( P 5% of this tumor fraction was found to be a precise unique predictor for high-grade myxoid liposarcomas with a sensitivity of 100% and a specificity of 95%. Conclusion Tumor components with contrast-enhancing non-fatty, non-myxoid imaging features were predominantly found in high-grade myxoid liposarcomas, which may histologically resemble round cell clusters.

Purpose: An extensive analysis of the value of computed tomography (CT) parameters as potential predictors of the clinical outcome of type 2 endoleaks after endovascular aortic aneurysm repair (EVAR). Materials and Methods: Initial CT scans of 130 patients with abdominal aortic aneurysms (AAAs) were retrospectively reviewed. On the basis of postoperative CT scans and angiographies, patients were stratified into a low-risk group (LRG; without or transient type 2 endoleak; n = 80) and a high-risk group (HRG, persistent type 2 endoleak or need for reintervention; n = 50). Statistical analysis comprised a univariate and multivariate analysis. Results: Anatomical, thrombus-specific, as well as aortic side branch parameters were assessed on the initial CT scan. Of all anatomical parameters, the diameter of the immediate infrarenal aorta was significantly different in the univariate analysis (LRG 22.4 ± 3.8 mm; HRG 23.6 ± 2.5 mm; p = 0.03). The investigation of the thrombus-specific parameters showed a trend towards statistical significance for the relative thrombus load (LRG 31.7 ± 18.0 %; HRG 25.3 ± 17.5 %; p = 0.09). Assessment of aortic side branches revealed only for the univariate analysis significant differences in the patency of the inferior mesenteric artery (LRG 71.3 %; HRG 92.0 %; p = 0.003) and their diameter (LRG 3.3 ± 0.7 mm; HRG 3.8 ± 0.9 mm; p = 0.004). In contrast, the number of lumbar arteries (LAs; LRG 2.7 ± 1.4; HRG 3.6 ± 1.2; univariate: p = 0.01; multivariate: p = 0.006) as well as their diameter (LRG 2.1 ± 0.4 mm; HRG 2.4 ± 0.4 mm; univariate: p Conclusion: The most important predictive factors for the development of high-risk type 2 endoleaks were mainly the number and the diameter of the LAs which perfused the AAA. Key Points: • This study is a very detailed and comprehensive analysis of the value of various CT parameters as potential predictors of the clinical outcome of type 2 endoleaks after EVAR. • Anatomical as well as thrombus-specific parameters were unsuitable as predictors. • The most important predictive factors were mainly the number and the diameter of the LAs which perfused the AAA. Citation Format: • Lowenthal D., Herzog L., Rogits B. et al. Identification of Predictive CT Angiographic Factors in the Development of High-Risk Type 2 Endoleaks after Endovascular Aneurysm Repair in Patients with Infrarenal Aortic Aneurysms. Fortschr Rontgenstr 2015; 187: 49 – 55

This study was designed to identify parameters on CT angiography (CTA) of type II endoleaks following endovascular aortic aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA), which can be used to predict the subsequent need for reinterventions.We retrospectively identified 62 patients with type II endoleak who underwent early CTA in mean 3.7 ± 1.9 days after EVAR. On the basis of follow-up examinations (mean follow-up period 911 days; range, 373-1,987 days), patients were stratified into two groups: those who did (n = 18) and those who did not (n = 44) require reintervention. CTA characteristics, such as AAA, endoleak, as well as nidus dimensions, patency of the inferior mesenteric artery, number of aortic branch vessels, and the pattern of endoleak appearance, were recorded and correlated with the clinical outcome.Univariate and receiver operating characteristic curve regression analyses revealed significant differences between the two groups for the endoleak volume (surveillance group: 1391.6 ± 1427.9 mm(3); reintervention group: 3227.7 ± 2693.8 mm(3); cutoff value of 2,386 mm(3); p = 0.002), the endoleak diameter (13.6 ± 4.3 mm compared with 25.9 ± 9.6 mm; cutoff value of 19 mm; p0.0001), the number of aortic branch vessels (2.9 ± 1.2 compared with 4.2 ± 1.4 vessels; p = 0.001), as well as a "complex type" endoleak pattern (13.6 %, n = 6 compared with 44.4 %, n = 8; p = 0.02).Early CTA can predict the future need for reintervention in patients with type II endoleak. Therefore, treatment decision should be based not only on aneurysm enlargement alone but also on other imaging characteristics.

Purpose: Assessment of radiologist’s hand dose in CT-guided interventions and determination of influencing factors. Materials and Methods: The following CT-guided interventions were included: Core biopsy, drainage, periradicular therapy, and celiac plexus neurolysis. The hand dose was measured with an immediately readable dosimeter, the EDD-30 (Unfors, Sweden). The default parameters for CT fluoroscopy were 120 kV, 90 mA and a 4 mm slice thickness. All interventions were performed on a 16-slice CT unit (Aquilion 16 Toshiba, Japan). The tumor size, degree of difficulty (1 – 3), level of experience and device parameters (mAs, dose-length product, scan time) were documented. Results: 138 CT-guided interventions (biopsy n = 99, drainage n = 23, pain therapy n = 16) at different locations (lung n = 41, retroperitoneum n = 53, liver n = 25, spine n = 19) were included. The lesion size was 4 – 240 mm (median: 23 mm). The fluoroscopy time per intervention was 4.6 – 140.2 s (median: 24.2 s). The measured hand dose ranged from 0.001 – 3.02 mSv (median: 0.22 mSv). The median hand dose for lung puncture (n = 41) was slightly higher (median: 0.32 mSv, p = 0.01) compared to that for the liver, retroperitoneum and other. Besides physical influencing factors, the degree of difficulty (p = 0.001) and summed puncture depth (p = 0.004) correlated significantly with the hand dose. Conclusion: The median hand dose for different CT-guided interventions was 0.22 mSv. Therefore, the annual hand dose limit would normally only be reached with about 2000 interventions. Key Points: Citation Format

To evaluate the effectiveness of proximal embolization of the gastroduodenal artery (GDA) using the Amplatzer Vascular Plug 4 (AVP 4) compared with pushable coils to avoid hepaticoenteric collaterals of the GDA stump, which may serve as pathways for nontarget embolization. One hundred thirty-four patients scheduled for 90-yttrium radioembolization (Y-90 RE) using either plugs (n = 67) or standard coils (n = 67) for GDA occlusion were retrospectively analyzed. Parameters recorded were length of the perfused GDA stump, distance device to the GDA origin, perfused proximal side branches after embolization, and durability of vessel occlusion at Y-90 RE. Length of the residually perfused GDA stump was 3.89 ± 2.86 mm for the AVP 4, which was significantly shorter compared with 5.78 ± 3.85 mm for coils (p = 0.005). Distance of the plug to the GDA origin was 1.41 ± 2.60 mm, which was also significantly shorter than 4.73 ± 3.44 mm for coils (p

Die Mehrzahl der abdominalen infrarenalen Aortenaneurysmen wird mittlerweile endovaskular mittels Stentgraft behandelt. Hierbei kann es in bis zu 50 % der Falle zu einer persistierenden, postinterventionellen Perfusion des Aneurysmasacks als sog. Endoleak kommen, welches potenziell die Gefahr einer Zunahme des Aneurysmadurchmessers und somit der Aneurysmaruptur birgt. Aktuell werden insgesamt 5 verschiedene Endoleaktypen unterschieden. Das bildgebende Standardverfahren zur Detektion und Klassifikation ist die Mehrphasencomputertomographie, eine alternative Methode die kontrastmittelgestutzte Sonographie. Je nach Typ des Endoleaks ergeben sich sehr unterschiedliche therapeutische Konsequenzen. Direkte Endoleaks (Typ I und III) ubertragen direkt den systemischen Blutdruck auf die Aneurysmawand und haben ein hohes Rupturrisiko. Eine unverzugliche Intervention ist in der Regel indiziert. Indirekte Endoleaks (Typ II, IV, V) nehmen einen benigneren Verlauf und sollten in der Mehrzahl nur bei Nachweis einer weiteren Expansion des Aneurysmas behandelt werden.

90Y radioembolization is a promising therapy for patients with primary and secondary liver malignancies. Pretherapeutic assessment consists of hepatic angiography and 99mTc-macroaggregated albumin (99mTc-MAA) perfusion scintigraphy to estimate the liver-to-lung shunt and exclude extrahepatic 99mTc-MAA deposition. However, the predictive value of intratumoral 99mTc-MAA uptake remains unclear. Methods: One hundred four patients with chemotherapy-refractory liver-dominant metastatic colorectal cancer were treated with 90Y radioembolization between December 2006 and December 2010. All of the patients underwent angiographic assessment and perfusion scintigraphy with 99mTc-MAA before lobar 90Y radioembolization. For inclusion, patients must have undergone pretherapeutic and follow-up MR imaging (6 wk and 3 mo after radioembolization, respectively). The degree of intratumoral 99mTc-MAA uptake was rated, and liver metastases were classified according to changes in tumor diameter on both an individual and a patient basis using Response Evaluation Criteria in Solid Tumors (RECIST) 1.1. Response at both time points, MAA uptake, and catheter position were then statistically analyzed in a linear and generalized linear mixed model at a significance level of 0.05 (P value). Results: Sixty-six patients with a total of 435 colorectal liver metastases (mean number of lesions ± SD, 6.6 ± 2.8; mean lesion size ± SD, 33.8 ± 21.2 mm; lesion size range, 10–154 mm) were included in this analysis. According to the patient-based analysis, 3 patients had partial response, 49 stable disease, and 6 progressive disease after 6 wk. After 3 mo, 5 patients showed partial response, 26 stable disease, and 17 progressive disease. There was no association of patient-based tumor response with overall 99mTc-MAA uptake (P = 0.172) or with catheter position (P = 0.6456). Furthermore, an interaction effect of 99mTc-MAA uptake and catheter position in relation to tumor response was not found (P = 0.512). Moreover, in lesion-based analysis according to RECIST 1.1 there was no association of tumor response with degree of 99mTc-MAA uptake, catheter position, or interaction of 99mTc-MAA uptake and catheter position (P = 0.339, 0.593, and 0.658, respectively). Conclusion: Response to 90Y radioembolization was found to be independent of the degree of 99mTc-MAA uptake. Therefore, therapy should not be withheld from patients with colorectal liver metastases lacking intratumoral 99mTc-MAA accumulation.

As there is currently no superior hepatocellular carcinoma (HCC) model with percutaneous vascular access for transarterial treatments available, the VX2 rabbit model is frequently used for in vivo investigations on liver carcinoma. However, the VX2 cell line was derived from a virus-induced skin papilloma that can form carcinosarcoma in liver of rabbits and the transferability of obtained results to HCC treatment remains open. Here we compared the most frequently investigated human HCC model cell line, HepG2, with VX2 cells in vitro in terms of sensitivity towards the broad specificity kinase inhibitor sorafenib and responsiveness to the addition of platelet-derived growth factor AB (PDGF-AB), vascular endothelial growth factor (VEGF) and hepatic growth factor (HGF), as well as insulin and interleukin-1β (IL1β). Phosphorylation of protein kinase B (AKT) the mitogen-activated protein kinases (MAPKs) p38 and p42/44 (extracellular signal-regulated kinase, ERK1/2) and inhibitor of kappa light chain gene enhancer alpha (IĸBα) was determined by western blotting as these events are associated with early signaling cascades. Additionally, the inhibition of phosphorylation under sorafenib treatment was investigated. Sorafenib was equally toxic to both cell lines, but only in HepG2 was activation of caspase 3/7 activity, as a sign of apoptosis, observed. VX2 cells exhibited generally more intense phosphorylation signals in response to the growth factors and also serum. In contrast to VX2, HepG2 cells showed no response to PDGF-AB or VEGF as determined by kinase phosphorylation. In both cell lines, sorafenib inhibited growth factor-induced phosphorylation of ERK and p38-MAPK. AKT phosphorylation was only inhibited in VX2 cells and IĸBα phosphorylation was not influenced by this kinase inhibitor in either cell type. Taken together, the two cellular models for HCC share several features related to sorafenib application, but differed in their responsiveness towards growth factors. Therefore, results obtained with the VX2 model cannot be extended to human HCC without appropriate caution.

Zusammenfassung Die intraarterielle Selektive Interne Radiotherapie (SIRT) mit 90 Y-markierten Mikrospharen ist mittlerweile eine wichtige lokal-ablative Therapieoption fur die Behandlung onkologischer Patienten geworden. Die SIRT stellt gegenwartig einen palliativen Therapieansatz fur die Behandlung von Lebermalignomen dar. Infolge der Art des 90 Y-Zerfalls als β - -Strahler ohne eine begleitende Gammaemission, bedarf es zur Validierung der erzielten Verteilung des Radioembolisates einer Bremsstrahlungsbildgebung. Dieser Artikel demonstriert durch eine Phantommessung diese Art der Bildgebung und zeigt anhand einer Patientenstudie die Vorteile einer posttherapeutischen Schnittbildgebung. Es werden Ansatzpunkte fur weitere Optimierungen der Bremsstrahlungsbildgebung aufgezeigt.

To evaluate the efficacy of a workflow consisting of repeat assessment in patients planned for yttrium-90 ((90)Y) radioembolization in case of nontarget visceral technetium-99m ((99m)Tc)-macroaggregated albumin (MAA) accumulation despite initial prophylactic coil embolization of nonhepatic arteries.In 341 patients with primary and secondary liver cancer, pretreatment hepatic angiograms, as well as single-photon emission computed tomography coregistered with magnetic resonance imaging scans, were obtained. Extrahepatic tracer deposition was identified in 33 patients (9.7%) necessitating repeat assessment. Images were reviewed to correlate the site of MAA accumulation with causative gastrointestinal vessels, and repeat angiograms served as reference standard.At repeat angiography, the source of extrahepatic flow was identified and eliminated in 31 of 33 patients (93.9%). In 20 patients (60.6%), successful embolization of nontarget vessels was achieved, in 13 patients (39.4%), MAA was administered more distally. Afterward, extrahepatic MAA deposition was eliminated in 30 patients (90.9%).The algorithm of repeat assessment in case of extrahepatic MAA accumulation has proven highly effective to eliminate extrahepatic shunting, thus decreasing the risk of postradioembolization complications due to inadvertent visceral microsphere deposition.

This study was designed to evaluate overall survival after radioembolization or best supportive care (BSC) in patients with chemotherapy-refractory liver-dominant metastatic colorectal cancer (mCRC). This was a matched-pair comparison of patients who received radioembolization plus BSC or BSC alone for extensive liver disease. Twenty-nine patients who received radioembolization were retrospectively matched with a contemporary cohort of >500 patients who received BSC from 3 centers in Germany. Using clinical databases, patients were initially matched for prior treatments and tumor burden and then 29 patients were consecutively identified with two or more of four matching criteria: synchronous/metachronous metastases, tumor burden, increased ALP, and/or CEA >200 U/ml. Survival was calculated from date of progression before radioembolization or BSC by using Kaplan–Meier analysis. Of 29 patients in each study arm, 16 pairs (55.2%) matched for all four criteria, and 11 pairs (37.9%) matched three criteria. Patients in both groups had a similar performance status (Karnofsky index, median 80% [range, 60–100%]). Compared with BSC alone, radioembolization prolonged survival (median, 8.3 vs. 3.5 months; P

Primary and secondary liver tumors resemble some of the most common causes of cancer and represent a major clinical problem owing to the poor prognosis. First-line therapeutic concepts are mainly based on surgical resection and/or systemic chemotherapy (SCT). However, many patients are not suitable for surgery or have failed SCT, although the total tumor load is still limited, which makes a regional therapy approach appealing.This review focuses on different types of transarterial instillation of chemotherapy, which encompasses conventional and drug-eluting transarterial chemoembolization (TACE), hepatic arterial infusion (HAI) chemotherapy and isolated hepatic perfusion (ILP).TACE can be regarded as the treatment of choice in patients with multinodular hepatocellular carcinoma, but it should still be performed as a lipiodol-based regimen, while the value of doxorubicin-eluting beads needs to be exploited in further randomized controlled trials (RCTs). For patients with colorectal liver metastases, HAI chemotherapy has been challenged by the advent of more effective SCT, but encouraging results have been observed for the combination of the most recent, active drugs given by means of HAI with SCT. Nevertheless, data from RCTs comparing SCT with this transarterial regional therapy approach, as well as with TACE and ILP, are urgently needed.

Summary Background Transjugular intrahepatic portosystemic shunt (TIPS) in patients with portal hypertension may be considered as a rescue therapy in case of recurrent variceal bleeding or failure of endoscopic management. Case Reports We present a case of a patient with massive gastroesophageal variceal bleeding refractory to numerous endoscopic treatments in which TIPS was considered in an attempt to decrease the risk of potentially fatal rebleeding. Standard TIPS procedure was not feasible due to altered anatomy of the liver resulting from right hemidiaphragmatic paresis. Computed Tomography (CT) fluoroscopic guidance was utilized for direct percutaneous puncture of the left hepatic and left portal vein with subsequent guidewire snaring to perform portosystemic shunting via femoral access. Since the procedure, no recurrent variceal bleeding was reported and the shunt remained patent at a 3-year follow-up. Although stent fracture with fragment migration was observed. Conclusions Significant variation in liver anatomy does not preclude the creation of nonsurgical portosystemic shunt. In these cases, combined percutaneous and endovascular technique may be utilized.

The purpose of this study was to assess the safety and feasibility of MR-guided percutaneous nephrostomy (PCN) using a 1.0 Tesla open MR-scanner with fast dynamic imaging. Twenty-five patients with failed ultrasonographic insertion due to various reasons, such as nondilated pelvic systems, obesity, and parapelvic cysts, were investigated. In summary, 35 nephrostomy procedures were performed; 15 patients received monolateral and 10 patients bilateral placement. For guidance and monitoring, fast T2w single-shot-TSE imaging in a fluoroscopic mode in two orthogonal planes was used to guide the insertion of the needle into a predetermined calyx in freehand technique. Nephrostomy was inserted via Seldinger-technique. The procedure was regarded as technically successful if the placement of the catheter provided adequate drainage of the collecting system. Demonstration of an intrapelvic position of the catheter was verified by antegrade pyelography using T1w GRE imaging after injection of diluted Gd-DTPA into the collecting system. Under the experimental conditions of the study, the time for the complete procedure was 30 (range, 23–39) min. Puncture and placement of the nephrostomy was performed in 5 (range, 3–10) min on average. Our results demonstrated a pinpoint puncture of the pelvic system in a reasonable timeframe even in patients with difficult conditions, suggesting that MR-guided PCN using the open 1 Tesla system can be assessed as a reliable, fast, and safe method applicable in the clinical routine setting.

To assess postprocedural angiograms, the ankle–brachial index (ABI), and transcutaneous oxygen tension (TcPO2) to predict outcome after infrageniculate angioplasty (PTA) in diabetic patients with critical limb ischemia (CLI) scheduled for amputation. PTA was performed in 28 diabetic patients with CLI confined to infrapopliteal vessels. We recorded patency of crural vessels, including the vascular supply of the foot as well as the ABI and TcPO2 of the foot. Technical success rate was 92.9% (n = 26), and limb-salvage rate at 12 months was 60.7% (n = 17). The number of patent straight vessels above and below the level of the malleoli increased significantly in patients avoiding amputation. Amputation was unnecessary in 88.2% (n = 15) patients when patency of at least one tibial artery was achieved. In 72.7% (n = 8) of patients, patency of the peroneal artery alone was not sufficient for limb salvage. ABI was of no predictive value for limb salvage. TcPO2 values increased significantly only in patients not requiring amputation (P = 0.015). In patients with only one tibial artery supplying the foot or only a patent peroneal artery in postprocedural angiograms, TcPO2 was capable of reliably predicting the outcome. Below-the-knee PTA as an isolated part of therapy was effective to prevent major amputation in more than a half of diabetic patients with CLI. TcPO2 was a valid predictor for limb salvage, even when angiographic outcome criteria failed.

Irreversible electroporation (IRE) is a newly developed nonthermal tissue-ablation technique in which high-voltage electrical pulses of microsecond duration are applied to induce irreversible permeabilisation of the cell membrane, presumably through nanoscale defects in the lipid bilayer, leading to apoptosis. The purpose of this study was to assess the feasibility and safety of ablating renal cell carcinoma (RCC) tissue by IRE. Six patients scheduled for curative resection of RCC were included. IRE was performed during anaesthesia immediately before the resection with electrographic synchronisation. Central haemodynamics were recorded before and 5 min after electroporation. Five-channel electrocardiography (ECG) was used for detailed analysis of ST waveforms. Blood sampling and 12-lead ECG were performed before, during, and at scheduled intervals after the intervention. Analysis of ST waveforms and axis deviations showed no relevant changes during the entire study period. No changes in central haemodynamics were seen 5 min after IRE. Similarly, haematological, serum biochemical, and ECG variables showed no relevant differences during the investigation period. No changes in cardiac function after IRE therapy were found. One case of supraventricular extrasystole was encountered. Initial histopathologic examination showed no immediate adverse effects of IRE (observation of delayed effects will require a different study design). IRE seems to offer a feasible and safe technique by which to treat patients with kidney tumours and could offer some potential advantages over current thermal ablative techniques.

Standard treatment for upper urinary tract urothelial carcinoma (UUTUC) implies the radical removal of all urothelium-lined tissue, which requires nephroureterectomy with bladder cuff removal. We report on a patient with a rare coincidence of UUTUC and horseshoe kidney in whom a preoperative angiography helped to identify and subsequently embolize an abberant isthmic feeding artery, which was located in between both collecting systems. Ischemic discoloration of the isthmus area facilitated resection and no major blood loss occurred. Preoperative superselective embolization of the isthmus as the renal split area can be an effective tool to facilitate nephroureterectomy in the case of a horseshoe kidney.

PURPOSE: The aim of this prospective study was to examine two port systems for intravenous chemotherapy, authorized for high pressure injection, with respect to implantation, complications, implementation, and patency. MATERIALS AND METHODS: 40 high pressure port systems of the two available models (20 × Power Port [Bard], 20 × T-Port-Contrast [PFM]) and 20 standard port systems (X-Port [BARD]) as the control group were implanted. Both high pressure systems are authorized for injection with a maximum pressure of 300 PSI. The patient population was comprised of patients with different malignomas and liver metastases. At regular intervals following the protocol of the chemotherapy, multiphasic CT for tumor staging was carried out. RESULTS: The intravenous port systems were implanted without complications under sonographic guidance with transjugular access. The mean implantation time was 30 min (range: 22 - 40 min). After a median follow-up time of 6 months, the port patency was 100 %. No port infections and no complications during high pressure injection of contrast agent occurred during this period. The level of contrast measured in the aorta was equivalent to the level of contrast in the vessels when contrast agent is administered over a large peripheral intravenous access. CONCLUSION: The intravenous high pressure port systems are equivalent to standard systems with regard to implantation and implementation. Intravenous chemotherapy can be performed as usual. The advantage is the possibility of multiphasic CT with authorized flow rates of up to 5 ml/sec.

To compare local tumor control after percutaneous tumor ablation by interstitial laser therapy (ILT) or CT-guided brachytherapy (CTGB). In a matched pair analysis including 18 patients with 36 liver metastases of colorectal primary, both ILT and CTGB were performed in different lesions. The following matching factors were considered: (i) tumor size ≤ 5 cm, and (ii) execution of chemotherapy after tumor ablation. Primary endpoint was local tumor control. Treated lesions were identical in terms of tumor size and all matching criteria were fulfilled in all patients except for the performance of adjuvant chemotherapy. Median follow-up was 14 months (3–24 months) for both groups. Only five of 18 patients (28%) demonstrated local tumor progression after CTGB, whereas in ten of 18 patients (56%) tumor progression was found after ILT. Differences encountered were significant for all patients (p = 0.04), whereas in those who fulfilled all matching criteria (n = 14) the level of statistical significance was not reached (p = 0.23). CTGB demonstrated superior local tumor control compared to ILT in long-term follow-up.

Case report.To present a rare anomaly of the inferior vena cava associated with radicular pain and to illustrate its imaging characteristics.Irritation of the trigeminal nerve by vascular anomalies, resulting in neuralgia is a well-recognized entity. Recently, compression of peripheral nerve roots due to enlarged epidural venous plexus has been described as a possible cause of back and radicular pain, too.A 26-year-old man presented with acute exacerbation of lower back pain associated with radiculopathy down his left thigh. On radiologic workup, a prolapse of a lumbar intervertebral disc was ruled out, but agenesis of the infrarenal segment of the inferior vena cava was found, which has caused bilateral deep venous thrombosis. Venous flow was redirected mainly via enlarged lumbar epidural, ascending lumbar, and paravertebral veins.No associated congenital heart or abdominal organ defects were found and screening for thrombophilia was negative. The patient was successfully treated with anticoagulation under which symptoms gradually resolved.The authors believe that epidural venous enlargements should be considered as a cause of radicular and/or back pain in patients with anomalies of the inferior vena cava, because pathologic processes compressing nervous structures can cause pain.

Most cholangiocarcinomas (CCA) are locally advanced and unresectable at the time of diagnosis. Currently, chemotherapy combining gemcitabine with a platinum agent is the recommended first-line treatment regimen for advanced biliary tract cancer. However, median overall survival is only approximately 1 year. As the hepatic tumor burden is the limiting factor for the prognosis of these patients, local tumor control is essential.We present and discuss the current evidence for such therapy options for patients with CCA.Local and locoregional therapies have been shown to be well tolerated and can contribute to tumor control in the context of a comprehensive oncologic treatment strategy, and may prolong survival of patients with advanced CCA. Unfortunately, only few high-quality clinical trials are available.Randomized prospective clinical trials enrolling larger numbers of patients need to be carried out to elucidate the precise value of these treatments alone as well as in combination with systemic chemotherapy.Das cholangiozelluläre Karzinom (CCA) ist zum Zeitpunkt der Diagnose meist lokal fortgeschritten und damit inoperabel. Derzeit ist die Kombination von Gemcitabin mit einem platinhaltigen Agens das empfohlene Erstlinienbehandlungsschema für das fortgeschrittene CCA. Dennoch beträgt das mediane Gesamtüberleben damit nur etwa 1 Jahr. Da die Lebertumorlast der limitierende Faktor für die Prognose dieser Patienten darstellt, ist eine lokale Tumorkontrolle essenziell.Wir präsentieren und diskutieren die aktuelle Datenlage solcher Behandlungsoptionen für Patienten mit CCA.Lokale und lokoregionale Therapien haben eine gute Verträglichkeit und können zur Tumorkontrolle im Rahmen einer umfassenden onkologischen Behandlungsstrategie beitragen, die das Überleben von Patienten mit fortgeschrittenem CCA verlängern kann. Leider stehen derzeit nur wenige qualitativ hochwertige klinische Studien zur Verfügung.Um die genaue Wertigkeit solcher Behandlungen alleine sowie in Kombination mit systemischen Therapien beurteilen zu können, bedarf es der Durchführung prospektiv randomisierter klinischer Studien mit großen Patientenzahlen.

Iodine-containing polyvinyl alcohol polymer (I-PVAL) is a novel precipitating liquid embolic that allows for artifact-free evaluation of CT angiography (CTA). As accurate aneurysm volumetry can be performed with multidetector CTA, we determined volumes of experimental aneurysms before, immediately after, and 4 weeks after embolization of 14 porcine experimental carotid sidewall aneurysms with this liquid embolic. An automated three-dimensional software measurement tool was used for volumetric analysis of volume-rendering CTA data. Furthermore, intra-aneurysmal pressure changes during liquid embolization were measured in four silicone aneurysms and potential polymer volume changes within 4 weeks were assessed in vitro. Liquid embolic injection was performed during temporary balloon occlusion of the aneurysm neck, resulting in a mean occlusion rate of 98.3%. Aneurysms enlarged significantly during embolization by 61.1 +/- 28.9%, whereas a significant shrinkage of 5.6 +/- 2.7% was observed within the follow-up period. Histologic analysis revealed an inflammatory foreign body reaction with partial polymer degradation. In silicone aneurysm models, intra-aneurysmal pressure remained unchanged during liquid embolic injection, whereas balloon inflation resulted in a mean pressure increase of 31.2 +/- 0.7%. No polymer shrinkage was observed in vitro. The aneurysm enlargement noted was presumably due to pressure elevation after balloon inflation, which resulted in dilatation of the weak venous wall of the newly constructed aneurysm--another shortcoming of this experimental aneurysm model. The volume decrease after 4 weeks expressed partial polymer degradation.

Object To evaluate iodine-containing polyvinyl alcohol (I-PVA) as a precipitating liquid embolic agent, implant characteristics—including radiopacity, setting behavior, and biocompatibility—were studied in an aneurysm model in swine. Methods Twelve broad-based carotid artery (CA) sidewall aneurysms were surgically constructed in six pigs. Iodine-containing polyvinyl alcohol dissolved in dimethyl sulfoxide (DMSO) was injected during temporary balloon occlusion bridging the aneurysm neck. Control angiography as well as multidetector row computerized tomography (CT) angiography was performed after 4 weeks. Harvested aneurysms were investigated histopathologically and by 3-tesla high-field magnetic resonance (MR) imaging. The mean degree of aneurysm occlusion achieved was 96%. In two aneurysms a minimal protrusion of I-PVA into the CA lumen was observed. During one embolization, leakage of the liquid embolic agent due to DMSO-induced damage of the microcatheter resulted in CA occlusion. Aneurysms embolized with I-PVA could be discriminated clearly from the parent artery on CT angiograms because there was no beam-hardening artifact. High-field MR imaging allowed a detailed depiction of the liquid embolic distribution within the aneurysm. Histologically, a mild to moderate inflammatory response was found in successfully embolized aneurysms, and the polymer mass was frequently covered by a membrane of fibroblasts and endothelial cells. Conclusions Iodine-containing polyvinyl alcohol is a ready-to-use liquid embolic agent clearly visible under fluoroscopy; additives are not required. The setting behavior allows for controlled delivery in aneurysm cavities. Histological studies performed 4 weeks after embolization revealed no sign of toxic tissue response to the liquid embolic agent. Overall, I-PVA exhibits interesting implant characteristics in that radiopaque admixtures are not necessary, thus allowing for artifact-free evaluation of treated aneurysms by using CT and MR angiography.

The aim of this investigation was to compare two current non-invasive modalities, single photon emission tomography (SPECT) using 123-iodine-alpha-methyl tyrosine (123I-IMT) and single-voxel proton magnetic resonance spectroscopy (1H-MRS) at 3.0 T, with regard to their ability to differentiate between residual/ recurrent tumors and treatment-related changes in patients pretreated for glioma. The patient population comprised 25 patients in whom recurrent glioma was suspected based on MR imaging. SPECT imaging started 10 min after iv. injection of 300-370 MBq 123I-IMT and was performed using a triple-head system. The IMT uptake was calculated semiquantitatively using regions-of-interest. 1H-MRS was performed at 3.0 T using the single-volume point-resolved spectroscopy (PRESS) technique. Guided by MR imaging volumes-of-interest for spectroscopy were placed into the suspected lesions. Signal intensities of choline-containing compounds (Cho), creatine and phosphocreatine (Cr), and N-acetylaspartate (NAA) were obtained. When using the cut-off of 1.62 for 123I-IMT uptake, the sensitivity, specificity, and accuracy of the 123I-IMT SPECT were 95, 100 and 96%, respectively. For 1H-MRS, the sensitivity, specificity and accuracy were 89, 83 and 88%, respectively, based both on the metabolic ratios of Cho/Cr and Cho/NAA as tumor criterion with cut-off values of 1.11 and 1.17, respectively. In conclusion, 123I-IMT SPECT yielded more favorable results compared to 1H-MRS at distinguishing recurrent and/or residual glioma from post-therapeutic changes and may be particularly valuable when the evaluation of tumor extent is necessary.

Dynamic CT perfusion was performed in two patients with newly developed fixed dilated pupils and similar CT findings of multiple intracranial haematomas and impending transtentorial herniation. CT perfusion in case 1 showed severely reduced supratentorial and mesencephalic haemodynamic parameters. The patient died at the same day. CT perfusion in case 2 revealed physiologic perfusion parameters. Emergency bifrontal decompressive craniectomy was performed through which intracranial pressure was successfully lowered. This patient took a satisfactory clinical course. These results demonstrate that besides stroke as its main field of application, dynamic CT perfusion can also be performed in patients with critically raised intracranial pressure to obtain quick information's about tissue viability.

Using a prospectively collected database of patients undergoing diagnostic or therapeutic angiography via transfemoral access, we sought to determine those patients who may benefit from ultrasound-guided puncture of the femoral artery. One-hundred-twelve patients with normal anticoagulation parameters were randomized in two groups. Fifty-six patients received ultrasound-guided puncture of the femoral artery, 56 patients underwent traditional palpation-guided vessel cannulation. Parameters assessed included procedure-time, number of attempts for successful puncture, intensity of the arterial pulse, previous ipsilateral punctures, history and risk factors of arteriosclerosis and leg circumference at the site of puncture. The data was analyzed by using outcome measures according to evidence-based medicine criteria. Only in patients with weak arterial pulse and thoses with a leg circumference of 60 cm or greater ultrasound guidance significantly decreased the number of attempts needed as well as the time for successful arterial puncture. In both patient subgroups, the number needed to treat (NNT) was 2, the absolute benefit increase (ABI) was 50 and 57%, respectively. In contrast, time for vessel cannulation was increased in patients with strong arterial pulse using ultrasound guidance. No significant differences were found with respect to diminished complications neither comparing both patient groups nor comparing risk subgroups. In conclusion ultrasound guidance for femoral artery access is recommended only in patients with a weak or absent arterial pulse and obese patients.

Developmental venous anomalies (DVAs) are common abnormalities of intracranial venous drainage, which may occur in conjunction with other cerebral vascular malformations and are known for their benign natural history. The authors present the case of a 16-year-old boy who experienced a spontaneous brainstem hemorrhage due to a cavernoma. Preoperative angiography findings revealed a large DVA draining the right cerebellar hemisphere. The patient underwent suboccipital surgery for cavernoma resection and recovered completely from his neurological symptoms. Fourteen months later he returned with progressive symptoms. Repeated angiography demonstrated a complex dural arteriovenous fistula (DAVF) of the transverse sinus, which had developed next to the DVA. Several transarterial and transvenous embolizations were ineffective. Common causes of acquired DAVFs and the potential role of the DVA in the development of the DAVF in this case are discussed on the basis of the pertinent literature.

Fragestellung. Welche Vorteile bringen die Fortschritte der Mehrzeilen-Spiral-CT-(MZCT-)Technologie sowie der Bildnachbearbeitung in der Diagnostik und Darstellung intrakranieller Aneurysmen mittels CT-Angiographie (CTA)? Methodik. Patienten mit vermuteten intrakraniellen Aneurysmen wurden mittels CTA der 4- und 8-Zeilen-Spiral-CT-Generation untersucht. Die Bildrekonstruktion erfolgte mit “Maximum intensity projection” (MIP), “Volume rendering” (VR) und bei Aneurysmen im Bereich des Karotissiphons zudem mit angepassten multiplanaren Rekontruktionen (MPR). Die Ergebnisse wurden mit denen der digitalen Subtraktionsangiographie (DSA) verglichen. Ergebnisse. Bei insgesamt 19 Patienten konnten 21 von 22 Aneurysmen mittels CTA erfasst werden.Es gelang eine hochauflosende dreidimensionale Darstellung der Morphologie der Aneurysmen im raumlichen Bezug zu den umgebenden Strukturen. Bildnachbearbeitungstechniken gestatteten zusatzliche Informationen durch eine Innenansicht des Aneurysmalumens, eine virtuelle vaskulare 3D-Endoskopie sowie eine virtuelle 3D-Kraniotomie. Schlussfolgerungen. Im Vergleich zur DAS stellt die MZ-CTA ein sinnvolles erganzendes und im Einzelfall auch alternatives Verfahren bei der Diagnostik mit deutlichen Vorteilen in der Darstellung intrakranieller Aneurysmen dar.

OBJECTIVES The objective of this study was to compare the parameter maps of a new flat-panel detector application for time-resolved perfusion imaging in the angiography room (FD-CTP) with computed tomography perfusion (CTP) in an experimental tumor model. MATERIALS AND METHODS Twenty-four VX2 tumors were implanted into the hind legs of 12 rabbits. Three weeks later, FD-CTP (Artis zeego; Siemens) and CTP (SOMATOM Definition AS +; Siemens) were performed. The parameter maps for the FD-CTP were calculated using a prototype software, and those for the CTP were calculated with VPCT-body software on a dedicated syngo MultiModality Workplace. The parameters were compared using Pearson product-moment correlation coefficient and linear regression analysis. RESULTS The Pearson product-moment correlation coefficient showed good correlation values for both the intratumoral blood volume of 0.848 (P < 0.01) and the blood flow of 0.698 (P < 0.01). The linear regression analysis of the perfusion between FD-CTP and CTP showed for the blood volume a regression equation y = 4.44x + 36.72 (P < 0.01) and for the blood flow y = 0.75x + 14.61 (P < 0.01). CONCLUSIONS This preclinical study provides evidence that FD-CTP allows a time-resolved (dynamic) perfusion imaging of tumors similar to CTP, which provides the basis for clinical applications such as the assessment of tumor response to locoregional therapies directly in the angiography suite.

Prior to radioembolization (RE) of hepatic tumors, many centers prophylactically occlude the cystic artery (CA) during evaluation angiography (EVA) to prevent radiation-induced cholecystitis. There is no conclusive evidence for the protective effect of CA embolization and it bears the risk of inducing ischemic cholecystitis. The aim of this study is to evaluate the justification for CA embolization by comparing clinical and morphologic imaging parameters between patients undergoing coil occlusion of the cystic artery (COCA) and those with uncoiled CA (UCCA). Retrospective comparison of 37 patients with UCCA versus 68 patients with COCA in terms of clinical findings (CRP, leukocyte count, body temperature, upper abdominal pain) and morphologic imaging parameters associated with cholecystitis (gallbladder (GB) wall thickness, free fluid in GB bed, bremsstrahlung SPECT) after EVA, after RE, and at 6-week follow-up. At none of the 3 time points (EVA, RE, 6-week follow-up) was there any significant difference in CRP, leukocyte count, body temperature, or upper abdominal pain between the UCCA and COCA group. There was also no significant difference between the two groups with regard to GB wall thickness, fluid in the GB bed, and bremsstrahlung in SPECT. One patient of the UCCA group and two patients of the COCA developed cholecystitis requiring treatment. Comparison of clinical and imaging findings between patients with and without CA embolization prior to RE identified no predictors of radiogenic or ischemic cholecystitis after RE. Our study provides no evidence for a benefit of prophylactic CA embolization before RE.

To evaluate the efficacy and safety of a novel retrograde transvenous embolization technique of peripheral arteriovenous malformations (AVMs) using Onyx. We conducted a retrospective analysis of all patients who underwent transvenous retrograde Onyx embolization of peripheral AVMs with dominant venous outflow over a 29-month period. The embolization is aimed at retrograde filling of the nidus after building a solid plug in the dominant venous outflow (push-through). Classification, clinical signs, technical aspects, clinical and technical success rates, and complications were recorded. Short-term outcome was assessed. 11 Symptomatic patients (8 female; mean age 31.4 years) were treated at our Vascular Anomalies Center with this method between January 2012 and May 2014. The AVMs were located on the upper extremity (n = 3), pelvis (n = 2), buttock (n = 2), and lower extremity (n = 4). Retrograde embolization was successfully carried out after preparatory transarterial-flow reduction in eight cases (73 %) and venous-flow reduction with Amplatzer Vascular Plugs in four cases (36 %). Complete devascularization (n = 10; 91 %) or 95 % devascularization (n = 1; 9 %) led to complete resolution (n = 8; 73 %) or improvement of clinical symptoms (n = 3; 27 %). One minor complication occurred (pain and swelling). During a mean follow-up time of 8 months, one clinically asymptomatic recurrence of AVM was detected. Initial results suggest that retrograde transvenous Onyx embolization of peripheral AVMs with dominant venous outflow is a safe and effective novel technique with a low complication rate.

To assess the potential of a steerable microcatheter in a comparative preclinical trial. A total of 100 small target vessels of the lower limbs with a maximum diameter of 3 mm were prospectively randomized to catheterize with either the preshaped torqueable Direxion™ (J tip shape; Boston Scientific, Natick, MA) or a similarly steam-shaped Renegade™ microcatheter (Boston Scientific) in a porcine model. Catheterization was first performed in combination with a microguidewire and afterwards without. No significant differences were found for the mean vessel diameter in the Direxion (1.53 ± 0.44 mm; n = 50) or Renegade (1.62 ± 0.43 mm; n = 50; p = 0.35) group. Guidewire-assisted catheterization was successful in all target vessels, whereas access was achieved in most cases with the guidewire alone. However, when it became necessary to steer the Direxion actively, this was regarded as key to obtain vessel access in three of four target vessels (75 %). Vessel catheterization without guidewire was significantly more successful with the Direxion (88 %; n = 44) compared with the Renegade (32 %; n = 16; p

Einleitung: Isolierte Iliacalarterienaneurysmata sind selten, im Falle einer Ruptur jedoch potenziell lebensgefährlich. Material und Methoden: Das Ziel der Studie bestand in der retrospektiven Auswertung systematisch-prospektiv registrierter Daten von konsekutiven Patienten mit isoliertem Iliacalarterienaneurysma[for full text, please go to the a.m. URL], 131. Kongress der Deutschen Gesellschaft für Chirurgie

REPLY: We would like to thank Drs. Lam and Smits for their concerns and comments regarding the methodology in our study ([1][1]). The aim of our study was to answer the frequently occurring clinical question of whether a patient with low or no 99mTc-macroaggregated albumin (99mTc-MAA) uptake in

REPLY: First, we would like to thank Dr. Kao for his elaborate comments regarding our article ([1][1]). It is a matter of common sense that in cases of radioembolization, the determination of dose distribution is a challenging task because of the complexity of quantitative imaging and the limited

We report the case of a 47-year-old patient with autosomal dominant polycystic kidney disease, who became symptomatic owing to a painful metastasis of a renal cell carcinoma. Abdominal sonography, multiphase CT and MRI were performed in order to localise and resect the primary tumour, but its identification was severely hampered owing to multiple renal cysts. In addition to standard MRI protocol, a spin-echo, single-shot echo planar diffusion-weighted imaging sequence was performed. The mean apparent diffusion coefficient (ADC) of renal cysts was 2.66±0.12 × 10(-3) mm(2) s(-1), 1.76±0.19 × 10(-3) mm(2) s(-1) of renal parenchyma in and 1.26±0.18 × 10(-3) mm(2) s(-1) of a suspicious soft-tissue mass at the midsection of the right kidney, indicating an area of higher cellularity. This value was significant lower than the ADC obtained for renal parenchyma (p0.0001). Right-sided nephrectomy was performed and the pathological diagnosis of the suspicious lesion was clear cell renal carcinoma.