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Competing Interests: Disclosure The authors report no conflicts of interest in this work.

The sixth part of the Guidelines on Interventional Ultrasound produced under the auspices of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) assesses the evidence for ultrasound guidance and assistance in vascular interventions. Based on convincing data, real-time sonographic guidance for central venous access is strongly recommended as a key safety measure. Systematic analysis of scientific literature shows that in difficult situations and special circumstances US guidance may also improve the efficacy and safety of peripheral venous and arterial access and endovascular interventions. Moreover, the recommendations of this guideline endorse the use of ultrasound to detect complications of vascular access and US-guided interventional treatment of arterial pseudoaneurysms., (© Georg Thieme Verlag KG Stuttgart · New York.)

This is the first part of the Guidelines on Interventional Ultrasound of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) and covers all general aspects of ultrasound-guided procedures (short version; the long version is published online)., (© Georg Thieme Verlag KG Stuttgart · New York.)

This is the first part of the Guidelines on Interventional Ultrasound of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) and covers all general aspects of ultrasound-guided procedures (long version)., (© Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: The aim of this prospective study was to assess the dynamics of potential common bile duct (CBD) dilatation and to find the best predictors in patients after laparoscopic cholecystectomy due to gallstones., Materials and Methods: Fifty patients (36 women, 14 men) with gallstones scheduled for laparoscopic cholecystectomy underwent preoperative sonography one day prior to surgery and again within 24 hours of cholecystectomy. In all patients, the diameter of the CBD was measured again on the 7 (th), 90 (th) and 180 (th) day after cholecystectomy. The luminal diameter was measured just below the bifurcation of hepatic ducts, at the level of intersection with the hepatic artery and at the level of the pancreatic head. The control group consisted of 50 healthy individuals (35 women and 15 men) with normal biochemistry and sonography, and without a history of hepatobiliary disease, clinical symptoms or surgery., Results: The mean preoperative CBD diameter at three locations was 2.27 ± 0.18, 3.49 ± 0.23 and 4.31 ± 0.30, respectively. The mean diameter of the common bile duct measured within 24 hours of surgery and on the seventh postoperative day did not significantly change with respect to the preoperative measurement. Three months after cholecystectomy, the CBD was statistically wider at all three locations (p < 0.05). Six months after cholecystectomy, the CBD remained significantly wider at the proximal and distal part when compared to the preoperative measurements., Conclusion: The CBD showed an overall trend towards a slight, but significant, dilatation after cholecystectomy. The common bile duct dilates significantly 3 months after cholecystectomy. Familiarity with these patterns prevents ultrasound misdiagnosis when examining patients within 6 months of cholecystectomy., (© Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: To evaluate acoustic radiation force impulse imaging (ARFI) of the liver and spleen as a new method for the noninvasive assessment of liver fibrosis (LF)., Materials and Methods: Three groups of 58 examinees were studied: (A) 20 healthy volunteers; (B) 18 patients with chronic viral hepatitis (CVH) B or C having liver fibrosis stages F 1 - 4 (assessed by liver biopsy; Ishak classification); and (C) 20 patients with liver cirrhosis (LC). All participants were examined using the Siemens ACUSON S 2000 Ultrasound Virtual Touch Tissue Quantification system. Ten measurements were performed on both liver lobes and three measurements on the spleen, and the obtained mean values (shear wave velocities [SWV] expressed in m/s) were compared between the groups. In 20 patients the splenic artery pulsatility index (SAPI) was also measured and correlated to the liver and splenic ARFI and histological stage of LF., Results: Hepatic ARFI measurements demonstrated a significant correlation to LB results (Spearman's ρ = 0.766; ρ < 0.001) and SWV cut-off values of 1.3 (AUC 0.96) and 1.86 (AUC 0.99) could reliably differentiate between healthy (A) and non-cirrhotic CVH (B), as well as between non-cirrhotic CVH (B) and LC (C). Splenic SWV cut-off value of 2.73 (AUC 0.82) could differentiate between the patients with LC and non-cirrhotic CVH. A significant correlation was also observed between the SAPI and liver ARFI results (ρ = 0.56; p = 0.013)., Conclusion: The hepatic and splenic SWV measured by ARFI increase with the LF stage, and the hepatic SWV correlate well with SAPI. This new technology enables simultaneous morphological, Doppler and elastometric examinations and might improve the accuracy of noninvasive liver fibrosis assessment., (© Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: Radiofrequency ablation (RFA) is a promising minimal invasive modality to treat small breast cancer (BCA). In most studies cancers were surgically excised shortly after RFA. We present six patients inoperable when diagnosed with BCA, and performed RFA instead of surgery., Materials and Methods: Ultrasound-guided bipolar RFA was performed under local anesthesia in six women aged 63 - 85 years. They had core-biopsy proven T 1 - 2N0 M0, grade I or II, 1.0 - 2.7 cm sized invasive ductal cancers, with positive estrogen receptor status. Four tumors measured > 2 cm, and three 1.0 - 1.2 cm in diameter. Patients were at high-risk for general anesthesia and surgery because of severely impaired cardiac function, advanced age, or associated diseases (acute myeloid leukaemia (AML), diabetes, hypertension, depression) and/or refused surgery., Results: Six tumors in five patients were completely ablated, without recurrence during follow-up (range: 9 - 49 months). One superficially located cancer was partially ablated; the patient died two months later from myocardial infarction. The Patient with AML and BCA had an infection of the treated breast after 4 months and postponed mastectomy to an AML remission status. There were no signs of malignancy in histopathology; the patient finally died of leukemia 42 months after RFA. The remaining four patients are well, without complications., Conclusion: Ultrasound-guided percutaneous RFA under local anesthesia is an effective alternative to surgery for BCA < 3 cm in patients with a high-risk for surgery., (Georg Thieme Verlag KG Stuttgart . New York.)

Purpose: Frequency encoded Doppler ultrasound (DUS) imaging has allowed identification of flow in thyroid tumours, but its role in evaluation of thyroid nodules for malignancy has not been accurately defined. We wanted to investigate the possible role of DUS in differentiation of benign and malignant nodules., Materials and Methods: DUS and spectral parameters were analysed in 50 benign and 20 malignant thyroid nodules. The following patterns of vascularity were identified: pattern 0--no visible flow; pattern 1--minimal internal flow without a peripheral ring; pattern 2--peripheral ring of flow but minimal or no internal flow; pattern 3--peripheral ring of flow and a small-to moderate amount of internal flow; pattern 4--extensive internal flow with or without a peripheral ring. Peak systolic velocity (PSV) and end diastolic velocity (EDV) was measured and resistance index (RI) was calculated., Results: Significantly more benign nodules had vascularisation patterns 1.2 and 3. Significantly more malignant nodules had vascularisation patterns 3 and 4, and only pattern 4. EDV was significantly lower in malignant than in benign nodules (6.06 +/- 4 cm/sec vs. 13.01 +/- 8.74 cm/sec). RI was significantly higher in malignant than in benign thyroid nodules (0.75 +/- 0.08 vs. 0.56 +/- 0.09). For RI > or = 0.70: 80% sensitivity, 92% specificity, 80% positive predictive value, 92% negative predictive value, and 88.6 % accuracy, were calculated in characterising malignant thyroid nodules., Conclusion: We believe that internal flow without or with minimal peripheral flow on DUS and RI > or = 0.70 can be used to distinguish between malignant and benign thyroid nodules fairly reliably. Nodules with prevailing peripheral vascularisation and minimal or no internal vascularisation, and RI below 0.70 are probably benign.

Fibrous cortical defects are local disturbances of ossification, most commonly seen in the metaphysis of tubular bones in growing children. These lesions are usually clinically silent, and most of them heal by being replaced with normal bone. Along with typical age, location and absence of clinical symptoms, plain radiographic films allow the diagnosis of fibrous cortical defect to be made. Because of rare but occasionally occurring complications, follow-up examinations are necessary. In a child with fibrous cortical defect the ultrasound examination demonstrated that fibrous cortical defects display a rather typical sonographic image. One finds clearly delineated defects of the bone located in the vicinity of the knee joint, filled with hypo-echogenic soft tissue, also displaying prominent internal vascularisation on colour-Doppler. We followed this patient up with repeated US examinations revealing the lesions to be shrinking in size and becoming shallower. Echogenic foci within the lesions appeared. It could be presumed that these changes represent the healing process and are comparable to the areas of sclerosis seen on CT scans. We believe that ultrasound with all its benefits is a powerful complementary method for the diagnosis and follow-up of fibrous cortical defects in children.