Peter Fries

We report on a 6-year-old boy with underlying hypoplastic left heart syndrome and a total cavopulmonary connection (Fontan circulation) with a diagnosis of plastic bronchitis. After an initial good response to therapy, his productive cough became significantly stronger again. Four months later, the patient’s mother brought a preserving jar containing an extensive bronchial cast to the clinic, the size of which is rarely seen in small children. Plastic bronchitis is a rare but dreaded complication in patients with Fontan circulation as well as in infectious or inflammatory diseases; its treatment is challenging.

Objectives: The purpose of this study was to analyze image quality and radiation exposure of thoracic computed tomography angiography (CTA) in children with congenital heart diseases (CHDs) using either manual contrast medium (CM) injection or automated power injectors with bolus tracking. Methods: A total of 137 thoracic CTAs of 120 consecutive pediatric patients were included in this retrospective study. We analyzed the method of CM administration (power injection with bolus tracking (PI) or manual injection (MI)), injection routes, volumes and flow rates of CM. For the evaluation of objective image quality, attenuation values in the heart chambers and great thoracic vessels were determined by region-of-interest (ROI) analysis and signal-to-noise (SNR) and contrast-to-noise (CNR) ratios calculated thereof. Visual image quality was assessed by two blinded readers (four-point Likert-scale) analyzing the presence of artifacts and the depiction of relevant anatomical structures. Effective radiation doses were calculated with dose length products and specific conversion factors. Results: CM administration was performed using PI in 119/137 CTAs, whereas MI was conducted in 18/137. The smallest size of peripheral venous cannulas was 24 gauge in 36/137 (26.3%) cases. Overall mean CM volume was 17 mL ± 16 mL (mean ± SD). In PI, the mean flow rate of CM was 1.52 ± 0.90 mL/s with a range between 0.5 and 5.0 mL/s. When comparing the overall PI population and an age-, size- and weight-matched PI subpopulation (18 cases) with the MI population, attenuation values in Hounsfield units (HU) and CNR values were significantly higher in the PI groups than in the MI group for each relevant cardiac structure (left ventricle, right ventricle, ascending aorta and pulmonary trunk, p = 0.02–0.001). Overall image quality and depiction of cardiac structures were rated significantly better in CTAs with PI (interquartile ranges: “good” to “excellent” (Likert 3–4)) in PI compared with CTAs acquired with MI (interquartile ranges: “fair” to “good” (2–3)) in MI by both readers (p < 0.001). The inter-observer reliability was strong, with a Kendall’s Tau-b correlation coefficient of τ = 0.802 (p < 0.001). The mean effective radiation dose (E) did not differ significantly when comparing the stratified samples (i.e., the matched PI subgroup and the MI group; 0.5 (±0.3) mSv in both, p = 0.76). There were no complications associated with the CM injections for both application approaches. Conclusions: Automated contrast agent applications with power injectors and bolus tracking ensure better image quality in pediatric CTA, even when low volumes and flow rates need to be applied. There is a slight increase in radiation associated with bolus tracking. This approach represents a suitable imaging technique for the work-up of congenital heart disease.

This study aimed to report on complication management in a 58-year-old woman referred for transjugular biopsy for the evaluation of unknown liver disease. After an initial uneventful biopsy procedure, the patient complained of severe upper abdominal pain. Laboratory tests revealed increasing liver enzymes. Imaging studies depicted an iatrogenic pseudoaneurysm associated with an arterio-biliary fistula originating from the right peripheral hepatic artery. Angiography and percutaneous transarterial superselective embolotherapy was performed by means of a microcatheter and microvascular plug. Precise device positioning allowed for successful closure of the bleeding site without compromising the hepatic vasculature.

Background. This paper aimed to prospectively evaluate the safety of embolization therapy of pulmonary arteriovenous malformations (PAVMs) for the detection of cerebral infarctions by pre- and post-interventional MRI. Method One hundred and five patients (male/female = 44/61; mean age 48.6+/−15.8; range 5–86) with pre-diagnosed PAVMs on contrast-enhanced MRA underwent embolization therapy. The number of PAVMs treated in each patient ranged from 1–8 PAVMs. Depending on the size and localization of the feeding arteries, either Nester-Coils or Amplatzer vascular plugs were used for embolization therapy. cMRI was performed immediately before, and at the 4 h and 3-month post-embolization therapy. Detection of peri-interventional cerebral emboli was performed via T2w and DWI sequences using three different b-values, with calculation of ADC maps. Results Embolization did not show any post-/peri-interventional, newly developed ischemic lesions in the brain. Only one patient who underwent re-embolization and was previously treated with tungsten coils that corroded over time showed newly developed, small, diffuse emboli in the post-interventional DWI sequence. This patient already had several episodes of brain emboli before re-treatment due to the corroded coils, and during treatment, when passing the corroded coils, experienced additional small, clinically inconspicuous brain emboli. However, this complication was anticipated but accepted, since the vessel had to be occluded distally. Conclusion Catheter-based embolization of PAVMs is a safe method for treatment and does not result in clinically inconspicuous cerebral ischemia, which was not demonstrated previously.

Zielsetzung: Prospektive Evaluation der Machbarkeit und Sicherheit der perkutanen Vakuum-assistierten Aspirationthrombektomie (VAAT) zur Behandlung der massiven Lungenarterienembolie (mLAE). Material und Methoden: In einer multi-nationalen Kohorte von 12 konsekutiven Patienten (Median 54; Spanne 35 – 80 Jahre) wurde eine klinisch manifeste akute mLAE durch Kontrastmittelverstärkte CT und transthorakale Echokardiografie verifiziert. Nach Eintreten eines kardiopulmonalen Schock wurde eine perkutane VAAT (Penumbra Indigo XTORQ 8F) in Intubationsnarkose bei allen Patienten durchgeführt. Zwei Patienten benötigten eine extrakorporale Membranoxygenierung (EKMO) zur kardiopulmonalen Unterstützung. Es wurde bei den EKMO Patienten eine therapeutische Heparinisierung eingeleitet, bei den übrigen 5.000 I.E. Heparin vor und während der VAAT. Rechtsherzbelastung, mittlerer Pulmonalarteriendruck (mPAP), periphere transkutane Sauerstoffsättigung und Überleben wurden erfasst. Ergebnisse: Die VAAT konnte in allen Patienten angewendet werden. Die mittlere Prozedurzeit war 112+/-47 (55 – 180) Minuten, Kontrastmittel 130+/-19 (100 – 150)ml, Thrombektomievolumen 213+/-55 (150 – 300)ml. Der mPAP verbesserte sich von 58+/-7 (52 – 65) auf 30+/-3 (24 – 34) mmHg (p = 0,0080), die periphere Oxigenierung von Aufnahme 83+/-4 (79 – 90) zu 96+/-2 (96 – 99)% postinterventionell (p = 0,0222), der Rechts-/Linksherzquotient nach 24h von 1,5+/-0,2 (1,24 – 1,7) zu 1,0+/-0,1 (0,86 – 1,2) (p = 0,0031). Die Nachverfolgung bis zu 2 Jahre zeigte keine Prozedurbedingen Komplikationen wie bspw. Blutung oder Tod. Schlussfolgerungen: In einer internationalen Registerstudie mit einer limitierten Patientenzahl konnte die perkutane Vakuumassistierte pulmonale Thrombektomie bei akuter massiver Lungenarterienembolie die potentiell letale Rechtsherzbelastung sicher und effektiv signifikant reduzieren.

Background: The aim of this study was to develop two simple positioning devices for anteroposterior pelvis radiographs and to evaluate their effect on accuracy of the radiographs for assessment of the acetabular orientation compared with non‐instrumented positioning.Methods: The superior anterior iliac spines and the pubic symphysis were used as anatomical landmarks to obtain a horizontal orientation of the pelvis according to the anterior pelvic plane. Anteroposterior pelvis radiographs were taken of 11 human cadaveric pelvic bones with each of the positioning devices and without any device. Defined measurements were carried out to objectify the tilt and rotation of the pelvis and to assess the cross‐over sign as well as the presence of the ischial spine sign. Computed tomography scans were performed as a standard of reference. Bland‐Altman‐Plots were used to compare the continuous measurement values and Cohen’s Kappa was applied for the categorical data. Intra‐ and inter‐observer reliability was determined by the intraclass correlation coefficient and Cohen’s Kappa.Results: The mean values of the measurements showed a high variability. A low correlation of the measurement values was found between the radiographs of the different positioning methods and the computed tomography scans. The intra‐ and inter‐observer reliability was good (Cohen’s Kappa 0.78 and 0.69; intraclass correlation coefficient 0.99 and 0.98).Conclusion: The use of positioning devices did not lead to more accurate anteroposterior pelvis radiographs compared to non‐instrumented positioning. Simple positioning devices do not provide standardized anteroposterior pelvis radiographs for reliable assessment of the acetabular orientation.

Evaluation of diagnostic accuracy of an oscillometry-based device (VascAssist) combining fully automated ankle-brachial index (ABI) and pulse-wave velocity (PWV) assessment for detection of peripheral arterial disease (PAD).