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BACKGROUND: Venous malformations tend to retain their slow-flow behavior, even in progressive disease or regression following therapy. OBJECTIVE: The aim of this study is to analyze the development of acquired hemodynamic relevant arterio-venous fistulae in patients with slow-flow malformations. METHODS: This study is a retrospective analysis based on a consecutive local registry at a tertiary care Interdisciplinary Center for Vascular Anomalies. Patients with venous malformations and development of secondary arterio-venous fistulae were included. Indications for therapy of the vascular malformation were based on patients’ symptoms and complications. The following endpoints were of clinical interest and were assessed: origin of development of arteriovenous fistula, development of secondary comorbidities as a result of the vascular malformation. For analysis we focused on descriptive statistics. RESULTS: Out of 1213 consecutive patients with vascular malformations, in 6 patients perfusion changed from slow flow to arterio-venous fast-flow patterns. Four patients developed the fistula after local trauma in the area of the malformation, the other 2 patients developed the fistula due to progression of the disease and recurrent thrombophlebitis. These 2 patients had no trauma or interventions at the time of arterio-venous fistula development. CONCLUSIONS: Acquired arterio-venous fast-flow fistula in patients with slow flow vascular malformation is very rare and might be a result of local trauma or the progression of the disease with recurrent thrombophlebitis. Specific evidence-based treatment options for these patients do not exist.

The marginal vein (MV) is a congenital, predominantly venous vascular malformation, which is based on a lack of regression of the embryonic venous system in the lower extremities and is associated with a variety of complications. So far, no uniform treatment regimens have been described in the literature.What are the treatment strategies and outcomes in patients with a MV?In the period from 1 January 2008 to 31 December 2020, all patients treated at the University Hospital Augsburg with MV were retrospectively reviewed.The median age at the time of diagnosis was 14.8 years (3-42 years). Out of 16 patients 12 had a leg length difference, 75% of patients (12/16) already had chronic venous insufficiency (CVI) at the time of diagnosis of MV. Open surgical removal of MV was performed as first-line treatment in 31.3% (5/16) patients. The MV was primarily closed by endovenous laser therapy (EVLT) in 1/16 patients, 15/16 patients were treated with redo procedures and 2.6 ± 2.4 (mean±SD) redo procedures were performed per patient in follow-up. The mean follow-up was 8.1 years.In order to prevent/avoid progression of CVI and thrombosis prophylaxis, the MV should be closed/removed promptly after diagnosis. The use of conventional surgical techniques for the removal of MV seems to have an advantage over treatment with minimally invasive procedures in terms of the number of secondary interventions required.HINTERGRUND: Die Marginalvene (MV) ist eine angeborene, vorwiegend venöse Gefäßmalformation, die auf einer fehlenden Rückbildung des embryonalen Venensystems an den unteren Extremitäten beruht. Sie geht mit einer Vielzahl an Komplikationen einher. Bisher werden in der Literatur keine einheitlichen Therapieregime beschrieben.Welche Behandlungsstrategien und Ergebnisse gibt es bei Patienten mit MV?Im Zeitraum 01.01.2008 bis 31.12.2020 wurden alle am Universitätsklinikum Augsburg behandelten Patienten mit Marginalvene retrospektiv aufgearbeitet.Das mediane Alter zum Diagnosezeitpunkt lag bei 14,8 Jahren (3–42 Jahre). 12/16 Patienten hatten eine Beinlängendifferenz. 75 % der Patienten (12/16) hatten bereits zur Diagnosestellung MV eine chronisch-venöse Insuffizienz (CVI). Im untersuchten Kollektiv wurden 62,5 % (10/16) der Patienten zum Zeitpunkt der Diagnosestellung mittels Kompression konservativ behandelt. Bei weiteren 31,3 % (5/16) der Patienten erfolgte primär eine offen-chirurgische Entfernung der MV und bei 1/16 Patienten wurde die MV primär mittels endovenöser Lasertherapie (EVLT) verschlossen; 15/16 Patienten wurden sekundär therapiert. 2,6 ± 2,4 (MW ± SD) Sekundärprozeduren wurden pro Patient im Follow up durchgeführt. Das mittlere Follow-up lag bei 8,1 Jahren.Zur Prävention/Vermeidung einer Progression einer CVI und Thrombembolieprophylaxe sollte nach Diagnosestellung die MV zeitnah verschlossen/entfernt werden. Die Anwendung chirurgisch-konventioneller Techniken zur Entfernung der MV scheint gegenüber der Behandlung mit minimal-invasiven Prozeduren hinsichtlich der Anzahl der erforderlichen Sekundäreingriffe von Vorteil.

Zusammenfassung Hintergrund Die Marginalvene (MV) ist eine angeborene, vorwiegend venöse Gefäßmalformation, die auf einer fehlenden Rückbildung des embryonalen Venensystems an den unteren Extremitäten beruht. Sie geht mit einer Vielzahl an Komplikationen einher. Bisher werden in der Literatur keine einheitlichen Therapieregime beschrieben. Fragestellung Welche Behandlungsstrategien und Ergebnisse gibt es bei Patienten mit MV? Material und Methoden Im Zeitraum 01.01.2008 bis 31.12.2020 wurden alle am Universitätsklinikum Augsburg behandelten Patienten mit Marginalvene retrospektiv aufgearbeitet. Ergebnisse Das mediane Alter zum Diagnosezeitpunkt lag bei 14,8 Jahren (3–42 Jahre). 12/16 Patienten hatten eine Beinlängendifferenz. 75 % der Patienten (12/16) hatten bereits zur Diagnosestellung MV eine chronisch-venöse Insuffizienz (CVI). Im untersuchten Kollektiv wurden 62,5 % (10/16) der Patienten zum Zeitpunkt der Diagnosestellung mittels Kompression konservativ behandelt. Bei weiteren 31,3 % (5/16) der Patienten erfolgte primär eine offen-chirurgische Entfernung der MV und bei 1/16 Patienten wurde die MV primär mittels endovenöser Lasertherapie (EVLT) verschlossen; 15/16 Patienten wurden sekundär therapiert. 2,6 ± 2,4 (MW ± SD) Sekundärprozeduren wurden pro Patient im Follow up durchgeführt. Das mittlere Follow-up lag bei 8,1 Jahren. Diskussion Zur Prävention/Vermeidung einer Progression einer CVI und Thrombembolieprophylaxe sollte nach Diagnosestellung die MV zeitnah verschlossen/entfernt werden. Die Anwendung chirurgisch-konventioneller Techniken zur Entfernung der MV scheint gegenüber der Behandlung mit minimal-invasiven Prozeduren hinsichtlich der Anzahl der erforderlichen Sekundäreingriffe von Vorteil.

BACKGROUND Vascular malformations of the genitalia often go undetected in clinical examination. These vascular malformations can cause a variety of clinical symptoms such as swelling, pain and bleeding. AIM To characterize the distribution patterns of genital vascular malformations using magnetic resonance imaging (MRI) and to correlate these patterns with clinical findings in order to guide diagnostic decisions. METHODS A retrospective analysis of MRIs of the pelvis and legs in 370 patients with vascular malformation was performed to determine the involvement of the internal and external genitalia. RESULTS In 71 patients (19%), genital involvement could be identified by MRI. Of these, 11.3% (8 of 71) presented with internal involvement, 36.6% (26 of 71) with external involvement and 52.1% (37 of 71) with both internal and external involvement. Over half (57.1%) of the 49 patients with visible external genital signs detected during a clinical examination had additional internal genital involvement. CONCLUSIONS Genital involvement is a common finding in patients with vascular malformation of the legs and/or pelvis. Based on our data, we recommend MRI of the legs and pelvic region in patients with externally visible signs of a vascular malformation of the external genitalia in order to exclude additional internal involvement.

Gefasanomalien sind insgesamt sehr selten, konnen aber sowohl bei Kindern als auch bei Erwachsenen in fast jeder Korperregion auftreten. Aufgrund der Komplexitat dieser vielgestaltigen Erkrankungen ist der Weg zur Diagnosestellung oft sehr schwierig und Bedarf haufig eines interdisziplinaren Teamworks mit engen Absprachen zwischen den einzelnen Behandlungspartnern. Ebenso empfiehlt sich auch fur die Therapieplanung und Durchfuhrung ein Austausch zwischen den einzelnen Disziplinen. Dieser Artikel liefert eine Ubersicht der verschiedenen Haupttypen der Gefasmalformationen aus klinischer, bildgebender und histologischer Sicht in Anlehnung an die aktuelle Klassifikation der Internationalen Gesellschaft zum Studium vaskularer Anomalien (ISSVA).

Study Purpose The DRAGON 1 trial aims to assess training, implementation, safety and feasibility of combined portal- and hepatic-vein embolization (PVE/HVE) to accelerate future liver remnant (FLR) hypertrophy in patients with borderline resectable colorectal cancer liver metastases. Methods The DRAGON 1 trial is a worldwide multicenter prospective single arm trial. The primary endpoint is a composite of the safety of PVE/HVE, 90-day mortality, and one year accrual monitoring of each participating center. Secondary endpoints include: feasibility of resection, the used PVE and HVE techniques, FLR-hypertrophy, liver function (subset of centers), overall survival, and disease-free survival. All complications after the PVE/HVE procedure are documented. Liver volumes will be measured at week 1 and if applicable at week 3 and 6 after PVE/HVE and follow-up visits will be held at 1, 3, 6, and 12 months after the resection. Results Not applicable. Conclusion DRAGON 1 is a prospective trial to assess the safety and feasibility of PVE/HVE. Participating study centers will be trained, and procedures standardized using Work Instructions (WI) to prepare for the DRAGON 2 randomized controlled trial. Outcomes should reveal the accrual potential of centers, safety profile of combined PVE/HVE and the effect of FLR-hypertrophy induction by PVE/HVE in patients with CRLM and a small FLR. Trial Registration Clinicaltrials.gov: NCT04272931 (February 17, 2020). Toestingonline.nl: NL71535.068.19 (September 20, 2019).

Background Intrahepatic arterial pseudoaneurysms are a rare, life-threatening complication after pediatric liver transplantation. Treatment of choice represents interventional radiological management with endovascular embolization of the segmental artery proximal and distal to the aneurysm. However, this technique results in loss of arterial perfusion distal to the aneurysm with subsegment arterial ischemia. Case presentation We report a case of a 1-year-old girl with a pseudoaneurysm in the split-liver graft. Direct percutaneous, transhepatic access to the pseudoaneurysm was performed followed by super selective coil application into the aneurysm. Conclusion Super selective percutaneous, transhepatic coil application is feasible even in pediatric patients after liver transplantation and results in preservation of the entire course of the liver artery.

Die venose Malformation gehort zu den haufigsten angeborenen Gefasmalformationen. Das klinische Erscheinungsbild ist sehr variabel und die Abgrenzung zu anderen Gefasanomalien ist therapieentscheidend. Genaue Kenntnisse uber anerkannte Klassifikationssysteme sind daher erforderlich. Der folgende Artikel befasst sich mit den Starken und Schwachen gangiger Klassifikationssysteme fur Gefasmalformationen und im Speziellen mit der Klassifikation von venosen Malformationen (VM).

Die periphere arterielle Verschlusskrankheit (PAVK) ist grundsatzlich mit einer erheblichen Einschrankung der gesundheitsbezogenen Lebensqualitat verbunden. Aufgrund der Haufigkeit der Erkrankung ist eine Optimierung der Therapiestrategien wichtig. Die Messung der gesundheitsbezogenen Lebensqualitat ist dabei ein wichtiges Instrument in der Entscheidungsfindung und Differenzialindikation. Es konnte gezeigt werden, dass endovaskulare Verfahren die Lebensqualitat von PAVK-Patienten vor allem kurz- und mittelfristig verbessern. Fur die Erzielung von positiven Langzeiteffekten ist eine Kombination von endovaskularen Techniken und strukturierten Trainingsprogrammen anzustreben.

Vascular anomalies are very rare, but can occur in children and adults in almost every region of the body. Due to the complexity of this disease, the path to a definitive diagnosis is often difficult. It requires interdisciplinary teamwork with close exchange of information between the individual treatment partners to reach the correct diagnosis and then to start the best therapy. This article provides an overview of the main types of vascular malformations from a clinical, imaging, and histological point of view, following the current classification of the International Society for the Study of Vascular Anomalies (ISSVA).

Abdominal lymphatic malformations (LM) are relatively rare findings in the differential diagnosis of focal abdominal lesions; however, they represent a challenge especially in younger patients. The aim of this review article is to provide up-to-date information about the different kinds of LM manifestations. In addition, related syndromes and typical imaging features to facilitate the diagnosis are discussed.The clinical presentation of abdominal LM is unspecific, whereby most are asymptomatic and comprise incidental findings of thin-walled cystic masses anywhere in the abdomen. The fluid in the cystic masses may be proteinaceous, contain blood, or be infected. Radiological imaging features overlap with other cystic diseases; hallmark in LM is a lack of a solid component and exclusive enhancement of the walls and septae.In cystic abdominal masses in early childhood or young adults, abdominal LM must be taken into account by the radiologist. Newly defined entities in this spectrum of diseases are central conducting lymphatic anomaly (CCLA) and generalized lymphatic anomaly (GLA).

Objectives To evaluate initial treatment and risk factors for amputation-free survival in patients with critical limb ischaemia (CLI). Design Prospective clinical cohort study at a single vascular surgical centre in Germany. Methods Data on 104 consecutive patients (115 ischaemic limbs) presenting with their first episode of CLI were collected prospectively over a 3-year period. Initial treatment was classified as conservative therapy, intervention, surgery, or major amputation. Patient co-morbidities were assessed by uni- and multivariate analysis to determine risk factors for limb salvage, survival and amputation-free survival. Results Indications for treatment were rest pain in 27 (23.5%) and tissue loss in 88 (76.5%) limbs. Revascularisation was attempted in 65% of all limbs: 45% by intervention and 55% by surgery. In 9% primary amputation was necessary and 22% received conservative therapy. Median follow-up was 28 months (1–42). The 3-year limb salvage, patient survival, and amputation-free survival rates were 73%, 41%, and 31%, respectively. Diabetes, cardiac disease and renal insufficiency were associated with poor survival. Combined cardiac and renal disease adversely affected amputation-free survival (HR, 3.68; 95% CI, 1.51–8.94; P Conclusions At least two third of all patients presenting with CLI can be offered some type of direct revascularisation. In patients with major cardiac disease and renal insufficiency, a poor outcome in terms of amputation-free survival is to be anticipated.

PURPOSE: Restenosis remains a major problem in percutaneous transluminal angioplasty (PTA) of peripheral arteries. The aim of this feasibility study was to evaluate the technical feasibility and safety of a new endovascular brachytherapy (EVBT) device with Rhenium-188 in restenosis prophylaxis of infrainguinal arteries. MATERIALS AND METHODS: From March 2006 to April 2009, 52 patients with 71 infrainguinal arterial lesions were treated with Re-188 to prevent restenosis after PTA. 40 patients with 53 lesions (24 de-novo lesions and 29 restenoses) were reexamined (clinic, color-coded duplex ultrasound) after a mean follow-up period of 12.7 months (2.6 to 25.1 months). The liquid beta-emitter Re-188 was introduced to the target lesion via an EVBT certified PTA balloon and a tungsten applicator. After the calculated irradiation time, Re-188 was aspirated back into the tungsten applicator. A dose of 13 Gy was applied at a depth of 2 mm into the vessel wall. RESULTS: After a mean follow-up of 12.7 months, the overall restenosis rate after Re-PTA was 15.1 % (8 / 53 lesions). The restenosis rate for de-novo lesions was 20.8 % (5 / 24) and 10.3 % for restenoses (3 / 29). In 4 patients reintervention was necessary (3 PTAs and 2 major amputations). No periprocedural complications were observed. No elevated radiation dose for the patient or the interventionalist was measured. CONCLUSION: EVBT with a Re-188 filled balloon catheter was technically feasible and safe after PTA of infrainguinal arterial lesions with restenosis rates lower than expected compared to published results. Treatment of restenoses seems to be more effective than de-novo lesions.

The understanding of hereditary vascular anomalies was hampered for a long time by unclear und unspecific terminology. Today, the classification of the International Society for the Study of Vascular Anomalies (ISSVA) differentiates between vascular tumours (mostly infantile haemangioma) with active endothelial proliferation and regression and vascular malformations (VM), which are defects of the vascular morphogenesis and are distinguished in predominantly venous, arterial, capillary, lymphatic, arteriovenous or combined VM. Symptoms are pain, swelling and restricted movement, accompanied by skin signs like dys-plastic veins and capillary VM (naevus flammeus). Thrombophlebitis and chronic venous insufficiency are related to venous VM. Arteriovenous VM are progressive and can cause ischaemic necroses, in rare cases even a high-output cardiac fail-ure. Lymphatic VM lead to localised swelling, in the long run often to recurrent erysipelas and lymphorroea. Primary imaging is provided by -ul-trasound including flow measurements. Mor-phol-ogy and organ involvement is best delineated by magnetic resonance imaging. Phlebography is used to image deep venous system anomalies and is always accompanied by varicography of the dysplastic parts of the venous VM. Digital subtraction angiography is performed to demon-strate the flow pattern in feeding arteries, the nidus and the drainage veins of arteriovenous VM. Besides size and localisation the prognosis of the patients is determined by the pressure (the high-er the pressure, the poorer the prognosis) and the flow rate (the higher the flow rate, the poorer the prognosis) in the VM. Diagnosis and treatment of these rare diseases are best performed in special-ised, interdisciplinary centres.

ObjectivesTo assess health-related quality of life (HRQoL) up to 24 months after successful infrageniculate bypass surgery for limb-threatening ischaemia.Methods89 patients with infrageniculate bypass surgery for limb-salvage were studied. HRQoL was assessed using the Short Form (SF)-36v1 questionnaire before, 6, 12, and 24 months after revascularisation.Results47 patients (53%) with intact limb and functioning graft were assessed after 24 months, 27 patients (30%) died, further 7 required secondary amputation, 3 suffered irremediable graft occlusion, and 4 were lost to follow-up. The 24-months HRQoL-values were significantly improved in 4 domains: physical functioning (p

This report presents a review of the literature on endovascular brachytherapy (EVBT) after percutaneous transluminal angioplasty (PTA) in the femoropopliteal segment. We summarize the pathophysiological changes induced by PTA and EVBT within the vessel wall, technical considerations regarding various radiation sources and their application, the impact of stents on the radial dose profile, recommendations for dosimetry of beta and gamma sources, results of experimental and clinical trials, and the medication required before, during, and after EVBT. We aim to help to identify patients who are eligible for EVBT, to choose an appropriate technical approach, and to initiate adequate antiplatelet and anticoagulant therapy.

PURPOSE To test the "Questionnaire for Life Quality in Patients with Peripheral Arterial Occlusive Disease at the Stage of Critical Ischemia" (FLeQKI) in a prospective study with respect to responsiveness and practicability. PATIENTS AND METHODS The responsiveness of the FLeQKI for therapy-induced changes of health related quality of life was prospectively determined in 65 consecutive patients with peripheral occlusive arterial disease at the stage of critical ischemia prior to percutaneous transluminal angioplasty (PTA) or bypass operation, and 1 month and 6 months after. 40 healthy individuals who were matched for age and questioned with the FLeQKI twice within 6 months served as the control. Additionally, all patients and healthy volunteers were questioned with the "Medical Outcomes Study Group Short Form" (SF-36). In all patients, the ankle/brachial index (ABI) was measured along with each of the three interviews. To validate practicability, we measured the time needed to fill out the questionnaires and asked the patients to indicate on a visual analog scale (VAS) graduated from 0 - 10 how strenuous they found the questionnaires to be. For statistical analysis, two-sided paired t-tests were used. RESULTS The treatment group consisted of 35 men and 30 women with an age of 75.1+/-7.0 years, and the control group was comprised of 21 men and 19 women with an age of 73.4+/-7.8 years. In the control group, none of the FLeQKI scales showed significant changes over time (p>0.05). In the pAVK group, all scales improved between the interviews before and 6 months after therapy. Changes were either significant (comorbidity, p 0.05) as non-strenuous. CONCLUSION Regarding responsiveness and practicability, the FLeQKI is well suited for determining the specific impairments of life quality in patients with peripheral arterial occlusive disease in the stage of critical ischemia. Compared with the SF-36, the FLeQKI reached similar or better psychometric values.

PURPOSE To develop a disease-specific measuring instrument for quality of life in German-speaking patients with peripheral arterial occlusive disease in the stage of critical ischemia and to test it in a prospective study for validity and reliability. MATERIALS AND METHODS We developed a questionnaire compiling items representing subjective disease relevant health states. With 35 of these items, we designed the scales comorbidity (KO), physical pain (SZ), physical functioning (KF), physical state (KS), social functioning (SB), mental health (PB), and therapy-induced limitations (TE). Each item was to be valued as never, seldom, often or always. The scales were standardized with a control group of 40 individuals without peripheral arterial occlusive disease who were interviewed twice in an interval of 6 months using both the FLeQKI and the Medical Outcomes Study Group Short Form 36 (SF-36). Convergent and discriminative validity was determined in 65 consecutive in-patients with peripheral occlusive arterial disease in the stage of critical ischemia who were interviewed with FLeQKI and SF-36 prior to percutaneous transluminal angioplasty (PTA) or bypass operation and 1 month and 6 months after. The internal consistency and test-retest reliability of the FLeQKI were determined in the control group. For statistical analysis, Cronbach's alpha Test and Pearsons Product Moment Correlation were used. RESULTS The control group consisted of 21 men and 19 women with an age of 73.4+/-7.8, and the treatment group was comprised of 35 men and 30 women with an age of 75.1+/-7.0. In the treatment group, convergent validity reached high values in the scales SB, KF, PB, and SZ (r=0.41-0.70). With their discriminative validity (r=-0.04-0.30), TE and KS were independent, specific dimensions of life quality. The control group showed good values for internal consistency (Cronbach's alpha=0.54-0.93) and for test-retest reliability (r=0.44-0.96). CONCLUSION The FLeQKI is well suited for determining the specific impairments of life quality in patients with peripheral arterial occlusive disease at the stage of critical ischemia. Its psychometric scores for validity and reliability corresponded to those of the SF-36.

PURPOSE To determine the current incidence of major amputations, bypass procedures and percutaneous transluminal angioplasties (PTA) in a study population of patients with peripheral arterial occlusive disease in a German referral center. MATERIALS AND METHODS In a retrospective study, we recruited patients with peripheral arterial occlusive disease who underwent an amputation, bypass procedure, or PTA in the region of the pelvis or lower limbs between 1996 and 2003 at the Augsburg Medical Center. Patients were identified via the hospital database. This was performed with the help of the International Classification of Diseases (ICD 9 and 10), the operation code (OPS), and appropriate invoices. The incidence of PTAs was further estimated with 200 charts. RESULTS Of 5379 patients, 627 underwent amputation, 1832 a bypass procedure, and 2920 a PTA. The incidence of PTAs increased during the study period from 51.3/100 000/year to 64.4/100 000/year (p < 0.01), while the number of amputations and bypass procedures remained stable. The incidence of PTAs was exceeded by that of bypass procedures only in patients older than 85 years. The age of the amputees decreased during the study period from 72.2 to 70.5 years (p < 0.01). The age of patients who underwent a bypass procedure increased from 67.2 to 69.4 years, and the age of patients who underwent PTA increased from 66.3 to 69.8 years (p < 0.01). Bypass procedures and PTAs were performed in men 6.3 years earlier than in women (p < 0.01). CONCLUSION The result is a population-corrected need of 8.4/100 000/year major amputations, 23/100 000/year bypass procedures and 64.4/100 000/year PTAs for patients with peripheral arterial occlusive disease within the referral area of our hospital. The performance of major amputations and bypass procedures stagnates, while the incidence of PTAs is increasing.

PURPOSE: To test whether contrast-enhanced low mechanical index (low MI) sonography is superior to non enhanced B-Mode sonography in differentiating synovitis and joint effusion. MATERIAL AND METHODS: In a retrospective study, 22 patients with proven rheumatoid arthritis underwent B-Mode sonography and low-MI sonography of 25 symptomatic joints of the upper and lower limbs. For low-MI sonography, 5 ml Sonovue (Bracco Altana Pharma GmbH, Konstanz) were injected as an intravenous bolus followed by 10 ml of 0.9 % saline solution. Magnetic resonance imaging (MRI) was obtained additionally in 3 joints. With non-enhanced sonography, we diagnosed a synovitis in case of an echogenic and a joint effusion in case of an anechoic mass. With contrast-enhanced sonography, we diagnosed a synovitis in case of enhancement and a joint effusion in the absence of enhancement of the intraarticular mass. RESULTS: In 13 joints, synovitis and joint effusion were differentiated by both non-enhanced and enhanced sonography. In 12 joints, this differentiation was only possible with contrast-enhanced sonography. In 3 patients diagnosed by sonography as having a synovitis, this diagnosis was proven by MRI. CONCLUSION: Contrast-enhanced low-MI sonography is superior to non-enhanced B-Mode sonography in differentiating synovitis and joint effusion.

Endovascular radiotherapy is the first effective prophylaxis of restenosis after percutaneous transluminal angioplasty (PTA) and stenting. The FDA recently approved two devices for the delivery of intracoronary radiation following coronary artery stenting. Published multicenter, double-blind, randomized trials of intracoronary radiation therapy report good results for preventing in-stent restenosis, while the data for the peripheral circulation are still inconclusive. Beta-emitters are easier applicable and probably also safer, whereas gamma-emitters have been more extensively evaluated clinically so far. Primary indication for endovascular brachytherapy are patients at high risk for restenosis, such as previous restenoses, in-stent hyperplasia, long stented segment, long PTA lesion, narrow residual vascular lumen and diabetes. Data from coronary circulation suggest a safety margin of at least 4 to 10 mm at both ends of the angioplastic segment to avoid edge restenosis. To prevent late thrombosis of the treated coronary segment, antiplatelet therapy with clopidogrel and aspirin are recommended for at least 6 months after PTA and for 12 months after a newly implanted stent. An established medication regimen after radiotherapy of peripheral arteries is still lacking.

The Medical Outcome Short Form 36 is commonly used as a generic quality of life measure in the assessment of vascular disease. The Claudication Scale CLAU-S, the PAVK-86 Fragebogen, and the Walking Impairment Questionnaire WIQ are validated disease-specific questionnaires for intermittent claudication. A disease specific tool for critical ischaemia is lacking. Quality of life of patients with peripheral arterial occlusive disease is not only impaired in the physical functioning domains (mobility, self care, activities of daily living), but moreover in their social and emotional wellbeing. This situation worsens under conservative treatment. Angioplasty and operation produce similar improvements in all dimensions of hrQOL. As radiological interventional procedures just aim to improve hrQOL and do not bring a definite cure for the underlying disease, patients perception of their quality of life should be taken into account both in the indication for angioplasty and for the scientific evaluation of new treatment modalities.

Radiological interventional therapy is described in seven patients with a distinct clinical syndrome of exercise-induced neurogenic intermittent claudication due to a reversible ischaemia of the lumbosacral plexus during walking accompanied by transient neurologic deficits. This condition was presumably caused by a reversible vascular steal phenomenon during exertion. The underlying vascular conditions were stenoses of the internal and/or common iliac arteries. All patients underwent percutaneous transluminal angioplasty (PTA) during the period from 1988 to 2001; an additional stent was placed in two patients. After a mean follow-up period of 18 months, four patients were asymptomatic, two had an improvement in walking-distance of 300 m and 800 m, respectively, and one patient developed a peripheral intermittent claudication without neurological complaints. In four patients, however, a further intervention was required. In patients with intermittent claudication due to exercise induced ischaemia of the lumbosacral plexus, a successful treatment is possible by means of PTA. Repeat intervention is justified if symptoms recur.

Background and Objective To evaluate the efficacy of a new temperature-controlled Diode laser to generate in vivo tissue coagulations with laser-induced interstitial thermotherapy (LITT) in pig liver and MRI-correlation of these necroses. Study Design/Materials and Methods Each of four animal subjects received eight treatments at four different constant temperatures (70, 80, 90, and 100°C) and at two out of three different intervals (3, 6, 9 minutes), resulting in a total of 32 lesions. After sacrificing, the liver was examined in an open MRI (0.35T). Tissue necrosis was measured macroscopically and compared with the size measured by MRI. Results The size of the necrosis was energy dependent with the largest extent at 100°C at 9 minutes (2.1 cm). The correlation between macroscopic lesion size and MRI findings was significant (P > 0.036). Histological workup excluded carbonization in every case. Conclusions LITT carried out with the Diode laser provides reproducible necroses of pig liver in vivo. MR-imaging results compared favorably with those obtained by pathologic specimens. Lasers Surg. Med. 29:374–378, 2001. © 2001 Wiley-Liss, Inc.

Background and Purpose —Transcranial color-coded sonography (TCCS) via the suboccipital approach allows direct and continuous visualization of the basilar artery (BA). In this study, we intended to evaluate the ability of native TCCS in visualizing the length of the BA by means of a comparison with postmortem measurements. Methods —The BA was prospectively studied by TCCS shortly before death (median 3 days) in 46 moribund neurological patients (mean±SD age 71.1±13.1 years). The length of the BA was determined by measuring the distance between the vertebrobasilar junction and the deepest available flow signal in the top of the BA. During autopsy, photos of the vertebrobasilar system were taken to evaluate the true anatomic length and variations of the course of BA in situ, eg, straight, curved, or S-shaped. Results —Comparison of the in vivo ultrasound measurements of BA length and postmortem data was possible in 44 of 46 cases. In the 2 remaining patients, the BA was occluded. The mean insonation depth of the vertebrobasilar junction was found at 66.9±7.1 mm. The mean BA length was 21.5±6.8 mm by color-coded duplex and 32.9±6 mm anatomically ( P Conclusions —Color duplex imaging enables correct visualization of the proximal two thirds of the BA, but only exceptionally of its distal one third. A tortuous course of the BA leads to an underestimation of its anatomic length.

With technical improvements (higher frequency and extended field-of-view sonography) the ability of ultrasound to detect pathology in the musculoskeletal system has been greatly increased. As in MRI, and unlike conventional radiography, soft tissue lesions in muscles, tendons and occasionally in joints can be shown directly. An advantage is real-time imaging of joints during stress. A disadvantage is limited demonstration of internal structures within joints. This paper provides an overview of various pathologies with emphasis on acute disorders.

To provide follow-up data on endovascular intervention for venous stenoses in the pelvis.Between 1985 and 1995, 35 patients presented with 42 stenoses of the pelvic veins after operative thrombectomy and creation of an arteriovenous fistula, combined with intraoperative venous angioscopy. All patients underwent angioplasty and, if unsuccessful, percutaneous insertion of an endovascular stent (n = 7).Angioplasty with and without endovascular stenting was technically successful in 34 of 35 patients (97%). Average length of the stenoses was 20.6 mm (range 10-90 mm), average diameter before dilation 4.1 mm (range 2-6 mm), and average diameter after dilation 10.1 mm (range 5-18 mm). Intraoperative angioscopy showed pathologic findings (intimal laceration or residual thrombotic material) in 14 patients. After an average follow-up period of 4.13 years, 24 (69%) patients had patent veins. The difference in the primary patency rate between patients with angioscopically abnormal veins (6 of 14 patients, corresponding to a patency rate of 43%) and patients with angioscopically normal veins after thrombectomy (18 of 21 patients, corresponding to a patency rate of 86%) was statistically significant (p0.01, log rank test).Percutaneous transluminal angioplasty and/or stenting are good treatment modalities for pelvic vein stenosis following surgical thrombectomy. Angioscopically abnormal veins have a poorer long-term patency, regardless of the type of intervention.

Zur Vermeidung einer Verletzung bei einer Reoperation wurde der linke A.-mammaria-interna-Bypass (LIMAB) zum R. interventricularis anterior (RIVA) mit Hilfe des PRECLUDE® IMA Sleeve (PIMAS) ummantelt. Ziel der prospektiv durchgefuhrten Untersuchung war die Evaluierung der fruh- und mittelfristigen klinischen Ergebnisse sowie die Aussagekraft der spiral-computertomographischen Angiographie (SCTA) zur Bestimmung der Lokalisation des PIMAS und der Durchgangigkeit des LIMAB. Innerhalb eines Zeitraumes von 18 Monaten wurde im Rahmen der chirurgischen Myokardrevaskularisation bei 75 Patienten (69 Manner und 6 Frauen) mit einem durchschnittlichen Alter von 55 Jahren der LIMAB zum RIVA mit einem PIMAS ummantelt. Die Fruhletalitat lag bei 2,6% und war nicht durch die PIMAS-Verwendung bedingt. Ein perioperativer Myokardinfarkt trat in 2 Fallen (2,6%) auf und war auserhalb des LIMAB-Versorgungsgebietes lokalisiert. Es wurden keine Wundinfektionen beobachtet. Eine ambulante Nachuntersuchung konnte 6 Monate postoperativ bei allen Patienten stattfinden. Zur Evaluierung des mit PIMAS ummantelten LIMAB wurde eine SCTA angewandt. Die Lokalisation und Detailbeschreibung des PIMAS war in allen Fallen problemlos moglich. Bei 4 Patienten (5,3%) bestand der Verdacht auf einen Verschlus des LIMAB, der in 2 Fallen durch eine selektive Angiographie bestatigt wurde. Somit lag der positive pradiktive Wert der SCTA bei 50% (2 verschlossene LIMAB als verschlossen diagnostiziert; 2 offene LIMAB als veschlossen diagnostiziert). Der negative pradiktive Wert betrug 100% (70 offene LIMAB als offen diagnostiziert). Die Ummantelung des LIMAB mittels PIMAS zur Prophylaxe der Bypassverletzung bei einer Reoperation erhoht nicht die Letalitat und Morbiditat nach Myokardrevaskularisation. Die Darstellung des ummantelten LIMAB mit Hilfe der SCTA ermoglicht eine zuverlassige Beurteilung seiner Durchgangigkeit sowie seine Lokalisation und liefert somit wichtige Hinweise zur Vorbereitung der Strategie bei einer Reoperation.

Der Verlauf sowie der zugrundeliegende Pathomechanismus eines typischen Syndroms nach Bestrahlung der Cauda equina wird dargestellt. Retrospektiv wurden 7 Patienten mit Strahlenspatschadigung der Cauda equina klinisch und neurophysiologisch im Verlauf untersucht. Nach einer Latenz von durchschnittlich 5 Jahren, 6 Monaten entwickelten alle 7 Patienten eine aufsteigende, schlaffe Paraparese der Bein- und Huftmuskulatur ohne begleitende Schmerzen, die teilweise von sensiblen und vegetativen Ausfallen begleitet wurden. Die neurophysiologischen Befunde mit evozierten Potentialen, Neurographie und Elektromyographie trugen wesentlich zur Differentialdiagnose gegenuber einer Tumorinfiltration bei. Der Verlauf war progredient und nicht wesentlich beeinflusbar. Ursprunglich wurde dem beschriebenen Syndrom ein isolierter Untergang der a-Motoneurone im Myelon zugrundegelegt. Der klinische Verlauf der untersuchten Patienten mit zusatzlichen sensiblen und vegetativen Ausfallen sprechen fur eine direkte, bilaterale Schadigung der lumbosakralen Wurzeln in ihrem intraspinalen Verlauf. Praziser als der bisher gelaufige Terminus der „radiogenen Amyotrophie” ware deshalb die Etikettierung als „radiogenes Cauda-equina-Syndrom”.

Rottach, Klaus G., Vallabh E. Das, Walter Wohlgemuth, Ari Z. Zivotofsky, and R. John Leigh. Properties of horizontal saccades accompanied by blinks. J. Neurophysiol. 79: 2895–2902, 1998. Using the magnetic search coil technique to record eye and lid movements, we investigated the effect of voluntary blinks on horizontal saccades in five normal human subjects. The main goal of the study was to determine whether changes in the dynamics of saccades with blinks could be accounted for by a superposition of the eye movements induced by blinks as subjects fixated a stationary target and saccadic movements made without a blink. First, subjects made voluntary blinks as they fixed on stationary targets located straight ahead or 20° to the right or left. They then made saccades between two continuously visible targets 20 or 40° apart, while either attempting not to blink, or voluntarily blinking, with each saccade. During fixation of a target located straight ahead, blinks induced brief downward and nasalward deflections of eye position. When subjects looked at targets located at right or left 20°, similar initial movements were made by four of the subjects, but the amplitude of the adducted eye was reduced by 65% and was followed by a larger temporalward movement. Blinks caused substantial changes in the dynamic properties of saccades. For 20° saccades made with blinks, peak velocity and peak acceleration were decreased by ∼20% in all subjects compared with saccades made without blinks. Blinks caused the duration of 20° saccades to increase, on average, by 36%. On the other hand, blinks had only small effects on the gain of saccades. Blinks had little influence on the relative velocities of centrifugal versus centripetal saccades, and abducting versus adducting saccades. Three of five subjects showed a significantly increased incidence of dynamic overshoot in saccades accompanied by blinks, especially for 20° movements. Taken with other evidence, this finding suggests that saccadic omnipause neurons are inhibited by blinks, which have longer duration than the saccades that company them. In conclusion, the changes in dynamic properties of saccades brought about by blinks cannot be accounted for simply by a summation of gaze perturbations produced by blinks during fixation and saccadic eye movements made without blinks. Our findings, especially the appearance of dynamic overshoots, suggest that blinks affect the central programming of saccades. These effects of blinks need to be taken into account during studies of the dynamic properties of saccades.

Large saccadic gaze shifts are frequently accompanied by blinking. Using the magnetic search coil technique, we investigated the effect of voluntary blinks on the eye position during fixation and on saccades of five normal subjects and three patients suffering from Niemann-Pick type C disease. Blinks during fixation reproducibly caused downward and nasalward deflections of both eyes. Each participant had to perform 20 and 40 degree vertical or horizontal saccades between two continuously visible targets: at first without blinking and then with a blink together with each saccade. The saccadic accuracy was not affected by blinks in the normal subjects. However, blinks caused considerable changes in the dynamic properties of saccades: for 20 deg saccades the peak velocity was markedly decreased in all subjects (average 19 %) as compared with saccades without blinks. On the other hand, the duration of saccades with blinks was increased by an average of 36 %. The effects of blinks on 40 deg saccades were similar, but the changes were somewhat smaller. In contrast to normal subjects, patients with Niemann-Pick disease were able to increase and speed up their hypometric and slow vertical saccades by blinking. Grosere Blickwendungen gehen haufig mit Lidschlagen einher. Wir untersuchten mit Hilfe der magnetischen Search-Coil-Technik die Auswirkung von Lidschlagen wahrend Fixation und wahrend Sakkaden bei funf Normalpersonen und bei drei Patientinnen mit Niemann-Pick-Erkrankung (Typ C). Wahrend Fixation fuhrten Lidschlage stets zu einer Abwarts- und Nasalwartsbewegung beider Augen. Die Genauigkeit vertikaler und horizontaler Sakkaden von 20°- bzw. 40°-Amplitude wurde durch gleichzeitige Lidschlage im Vergleich zu Sakkaden ohne begleitende Lidschlage nicht beeinflust, die Verlaufsbahn der Sakkaden hingegen wurde durch Lidschlage deutlich verandert. Es kam zu einer deutlichen Anderung der Sakkadendauer und -geschwindigkeit. Die Maximalgeschwindigkeit der 20°-Sakkaden war bei allen Normalpersonen deutlich reduziert (im Durchschnitt 19 %), die Dauer um durchschnittlich 36 % verlangert. Der Einflus von Lidschlagen auf 40°-Sakkaden war vergleichbar, aber etwas weniger ausgepragt. Im Gegensatz dazu waren die Patientinnen mit Niemann-Pick-Erkrankung in der Lage, durch Lidschlage ihre hypometrischen und verlangsamten vertikalen Sakkaden zu vergrosern und zu beschleunigen.

Ziel unserer Studie war die Bestimmung der diagnostischen Vertigkeit des Magnetisation Transfer Contrast (MTC) bei zerebralen Erkrankungen. 24 konsekutive Patienten erhielten prospektiv nach einem festgelegten Sequenzprotokoll eine MRT des Zerebrums vor und nach Applikation von 0,1 mmol/kg KG Gadoteridol. Hierbei wurden konventionelle Spinechosequenzen und MTC-Sequenzen nativ und nach Kontrastmittelgabe in randomisierter Reihenfolge angewandt. Verschiedene Regions of Interest (ROI) wurden gemessen und anschliesend die diagnostische Aussage bewertet. Nach Applikation des MTC Vorsattigungspulses verminderte sich der Kontrast zwischen weiser und grauer Substanz deutlich. Auch die Morphologie einer Lasion war schlechter beurteilbar. Der Kontrast zwischen Gadolinium aufnehmenden Herden und dem umgebendem Hirngewebe stieg jedoch an. Insgesamt wird in der klinischen Anwendung des MTC in der Bildgebung des Gehirns keine entscheidende Verbesserung gesehen. Die Effekte nach Gadoliniumgabe sind vergleichbar mit einer Erhohung der Kontrastmitteldosis oder einem verlangerten Delay zwischen Injektion und Bildgebung. Einzig bei einer Neuritis der Hirnnerven ergibt der spezifische MT-Effekt einen diagnostischen Vorteil.

Correct clinical and angiographic classification of vascular anomalies, including consideration of their flow pattern (high-flow versus low-flow), is the basis of accurate indications for minimally invasive therapy modalities such as embolization. Technical advancements and miniaturization of catheter materials (including steerable microwires, flow-directed microcatheters and detachable tips) gained access for embolotherapy to lesions anywhere in the body. The aim of embolization, which is mainly indicated for therapy of high-flow arteriovenous malformations, is the complete, permanent occlusion of the lesion nidus. Nowadays, embolotherapy is performed using permanent liquid embolization agents, in multiple staged sessions. This technique reduces complications such as ischemic necrosis and peripheral nerve lesions compared to alcohol embolization. Sole occlusion of the arterial inflow by surgical resection or interventional coil application is considered obsolete. The size of the lesion and the high treatment costs limit the use of embolotherapy.

Infrastructural improvements with a combination of interventional and open surgical procedures.Separate performance of interventional and open surgical procedures.Implementation of hybrid operating rooms.Intraoperative high-quality digital subtraction angiography.Best hygienic conditions Intraoperative improved image quality Improved patient management Increased patient safety Broadening of indicationsMajor improvement from a medical standpoint Different implications from a management perspective Economic aspects challengingExact planning of all aspects and effects is necessary.

Liquid embolic agents are used for permanent occlusion of capillaries but optimal administration properties are lacking.The lack of visualization by fluoroscopy and the risk of serious complications are disadvantages of conventional embolic agents, such as ethanol and Histoacryl.Onyx is a liquid embolic agent consisting of ethylene vinyl alcohol copolymer dissolved in various concentrations of dimethyl sulfoxide (DMSO) and suspended micronized tantalum powder to provide contrast for fluoroscopy.The physicochemical characteristics of Onyx allow controlled application, forming a defined cast and permanent occlusion. Disadvantages are the high costs. Furthermore, the solvent DMSO requires special catheter material and causes pain during Onyx application.Onyx has been primarily used for interventional neuroradiological treatment but peripheral applications are becoming increasingly more common.Currently, Onyx is mainly used for embolotherapy of endoleaks after endovascular aortic aneurysm repair, for treatment of acute arterial bleeding and for treatment of arteriovenous malformations.

The understanding of hereditary vascular anomalies was hampered for a long time by unclear und unspecific terminology. Today, the classification of the International Society for the Study of Vascular Anomalies (ISSVA) differentiates between vascular tumours (mostly infantile haemangioma) with active endothelial proliferation and regression and vascular malformations (VM), which are defects of the vascular morphogenesis and are distinguished in predominantly venous, arterial, capillary, lymphatic, arteriovenous or combined VM. Symptoms are pain, swelling and restricted movement, accompanied by skin signs like dys-plastic veins and capillary VM (naevus flammeus). Thrombophlebitis and chronic venous insufficiency are related to venous VM. Arteriovenous VM are progressive and can cause ischaemic necroses, in rare cases even a high-output cardiac fail-ure. Lymphatic VM lead to localised swelling, in the long run often to recurrent erysipelas and lymphorroea. Primary imaging is provided by -ul-trasound including flow measurements. Mor-phol-ogy and organ involvement is best delineated by magnetic resonance imaging. Phlebography is used to image deep venous system anomalies and is always accompanied by varicography of the dysplastic parts of the venous VM. Digital subtraction angiography is performed to demon-strate the flow pattern in feeding arteries, the nidus and the drainage veins of arteriovenous VM. Besides size and localisation the prognosis of the patients is determined by the pressure (the high-er the pressure, the poorer the prognosis) and the flow rate (the higher the flow rate, the poorer the prognosis) in the VM. Diagnosis and treatment of these rare diseases are best performed in special-ised, interdisciplinary centres.

We present a review of the literature on endovascular brachytherapy (EVBT) after percutaneous transluminal angioplasty (PTA) in the femoropopliteal and tibial arteries. The pathophysiological changes induced by PTA and EVBT within the vessel wall, technical considerations regarding 192Ir and 188Re, the results of clinical trials, and the medication required before, during, and after EVBT are summarized.