Objectives Vessel wall enhancement (VWE) may be commonly seen on MRI images of asymptomatic subjects. This study aimed to characterize the VWE of the proximal internal carotid (ICA) and vertebral arteries (VA) in a non-vasculitic elderly patient cohort. Methods Cranial MRI scans at 3 Tesla were performed in 43 patients (aged ≥ 50 years) with known malignancy for exclusion of cerebral metastases. For vessel wall imaging (VWI), a high-resolution compressed-sensing black-blood 3D T1-weighted fast (turbo) spin echo sequence (T1 CS-SPACE prototype) was applied post gadolinium with an isotropic resolution of 0.55 mm. Bilateral proximal intradural ICA and VA segments were evaluated for presence, morphology, and longitudinal extension of VWE. Results Concentric VWE of the proximal intradural ICA was found in 13 (30%) patients, and of the proximal intradural VA in 39 (91%) patients. Mean longitudinal extension of VWE after dural entry was 13 mm in the VA and 2 mm in the ICA. In 14 of 39 patients (36%) with proximal intradural VWE, morphology of VWE was suggestive of the mere presence of vasa vasorum. In 25 patients (64 %), morphology indicated atherosclerotic lesions in addition to vasa vasorum. Conclusions Vasa vasorum may account for concentric VWE within the proximal 2 mm of the ICA and 13 mm of the VA after dural entry in elderly subjects. Concentric VWE in these locations should not be confused with large artery vasculitis. Distal to these segments, VWE may be more likely related to pathologic conditions such as vasculitis. Key Points • Vasa vasorum may account for concentric VWE within the proximal 2 mm of the ICA and 13 mm of the VA after dural entry in non-vasculitic elderly people. • Concentric enhancement within the proximal 2 mm of the intradural ICA and within the proximal 13 mm of the intradural VA portions should not be misinterpreted as vasculitis. • Distal of this, VWE is likely related to pathologic conditions, in case of concentric VWE suggestive of vasculitis.
Summary: Background: Arterioureteral fistulas (AUFs) are severe pathologies of different origin and with increasing incidence frequently appear in patients with underlying extensive malignancy and after pelvic surgery. AUF therapy is challenging since symptoms are frequently non-specific and patients are often unsuitable surgical candidates due to comorbidities. Since experiences with endovascular treatment strategies are limited, the feasibility, effectiveness, and safety were evaluated in a consecutive case series. Patients and methods: A retrospective analysis of five patients with endovascular AUF exclusion was performed. Probable predisposing factors for an AUF included history of pelvic malignancy with oncologic surgery in four patients, radiotherapy in four patients, and indwelling ureteral stents in four patients. Clinical presentation, diagnostic management, and site of fistula were assessed. Furthermore, technical and clinical success as well as complications were evaluated. Results: All patients presented with gross haematuria. In four patients, haematuria occurred during endoscopic ureteral stent manipulation. Affected vessels were the internal pudendal artery in one, intrarenal segmental artery and external iliac artery in two, and internal iliac artery in another two patients. Treatment included coil embolisation (n = 2), plug embolisation (n = 3), particulate embolisation (n = 1), and covered stent implantation (n = 2). Technical success was achieved in all procedures. In two cases, re-intervention was necessary due to AUF recurrence, resulting in a clinical success rate of 60.0%. One major complication class D was documented. Conclusions: AUFs can be treated effectively and safely using endovascular techniques. Diagnostic and therapeutic management of this rare entity requires a high level of awareness for potential risk factors as well as an optimal multidisciplinary coordination.
Purpose To determine radiation exposure associated with adrenal vein sampling and its reduction by implementing the rapid cortisol assay and modification of the sampling protocol. Materials and Methods A single-center retrospective study of adrenal vein sampling performed between August 2009 and March 2020 revealed data from 151 procedures. Three subgroups were determined. In group I, a sampling protocol including sampling from the renal veins without the rapid cortisol assay was applied. In group II, blood was sampled using the same protocol but applying the rapid cortisol assay. In group III, a modified sampling protocol was used, in which the additional sampling from the renal veins was dispensed with, while the rapid cortisol assay was retained. Primary endpoints were radiation exposure parameters with dose area product, fluoroscopy time, and effective dose. As secondary endpoints, procedural data including technical success, lateralization, the correlation between patient BMI and radiation exposure, and concordance of lateralization with cross-sectional imaging were investigated. Furthermore, the correlation of aldosterone-cortisol ratios between the adrenal and ipsilateral renal vein was calculated to assess the benefit of sampling from the renal veins. Results For all procedures performed in the study collective, the median dose area product was 60.01 Gy*cm2 (5.71–789.31), the median fluoroscopy time was 14.90 min (3.27–80.90), and the calculated median effective dose was 12.60 mSv (1.20–165.76). Significant differences in radiation exposure parameters between the study subgroups could be revealed. Dose area product resulted in reductions of 57.94 % after implementation of the rapid cortisol assay and a further 40.44 % after revision of the sampling protocol. Fluoroscopy time was reduced by 40.48 % after integration of the rapid cortisol assay and a further 40.47 % after protocol refinement. Radiation doses were increased in cases of resampling (dose area product 51.31 vs. 118.11 Gy*cm2, fluoroscopy time of 12.48 vs. 28.70 min). A strong correlation between patient BMI and procedural dose area product could be found. After the introduction of the rapid cortisol assay, successive improvement of the technical success rate could be found (33.33 % in group I, 90.22 % in group II and 92.11 % in group III). The correlation of aldosterone-cortisol ratios between adrenal and renal veins was poor. Conclusion The introduction of the rapid cortisol assay significantly decreased the radiation exposure and increased the technical success rate. Renal vein sampling did not provide further benefit in the evaluation of primary aldosteronism subtype and its omission resulted in a further reduction of radiation dose. Key Points: Citation Format
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