Background— Despite growing interest in stent-graft implantation for type-B aortic dissection, there are no established recommendations to prepare and perform an implantation procedure. Methods and Results— We directly compared angiography (ANGIO), transesophageal echocardiography (TEE), and intravascular ultrasound (IVUS) intraprocedually before and after placement of 48 stent grafts in 42 consecutive patients (12 women, 61±11 years of age) with acute and chronic type-B aortic dissection for both usefulness and capability to guide aortic stent-graft implantation. Both IVUS and TEE are superior to ANGIO to identify multiple entries (52 and 43 versus 34; P <0.005 each), to diagnose false-lumen slow flow after stent-graft implantation (32 and 31 versus 24; P <0.005 each) and to detect incomplete stent apposition (18 and 16 versus 8; P <0.005 each). In comparison with ANGIO, guide wire position over the entire length of the aorta was documented more frequently by TEE and IVUS (40 and 42 versus 25; P <0.001 each). In 4 patients with abdominal extension of the dissection, only IVUS was able to accurately identify the false lumen over the entire length of the diseased aorta. TEE was superior to IVUS and ANGIO in the detection of endoleaks (5 versus 0 and 1; P <0.05 each). Intraprocedural ANGIO, TEE, and IVUS had been performed without complications in all patients. Conclusions— TEE in conjunction with ANGIO appears to be advantageous and adds incremental information to safely guide stent-graft placement in type-B aortic dissection. Additional use of IVUS was found to be helpful in patients with complex anatomy and abdominal extension of the dissection.

PURPOSETo optimize the examination protocols of multislice CT (MSCT) of the pelvis for dose reduction with regard to image quality.MATERIALS AND METHODSMSCT of the pelvis was performed on 5 cadaver specimens with stepwise reduction of the tube current at 140 kV (250, 200, 150, 100, 75, 50, 35, 25 mAs) and 120 kV (50, 27 mAs). The remaining scan parameters like collimation (4 x 1 mm) and table speed of 4 mm per rotation remained unchanged. Axial sections and coronal reconstructions were used to evaluate cortex, trabecular structures, subjective image quality, image noise and detail detectability (pelvis and SI joint), with evaluation performed independently by four blinded experienced radiologists on a 5-point scale. Kappa coefficient, accuracy of the observers to sort the films with regard to dose reduction and mean scores of image evaluation were determined for statistical analysis.RESULTSThe deterioration of the image quality was most pronounced for all criteria between 75 mAs and 50 mAs at 140 kV. Good results with adequate image quality were obtained for detail detectability at 50 mAs and 140 kV (effective dose [E]: 3.3 mSv) and for the remaining four criteria at 75 mAs (E: 4.9 mSv). There was a moderate agreement between the four observers (kappa coefficient: 0.27). All observers were excellent in arranging the images according to the increasing dose reduction.CONCLUSIONSImage quality of MSCT of the pelvis appears to be acceptable at 75 mAs and 140 kV with the dose reduced to 46% of the average value of the nation-wide survey of the German Roentgen Society in 1999 for this type of examination.

PURPOSE: We sought to assess the diagnostic accuracy of routine chest radiography for the acute aortic syndrome (dissection, intramural hematoma, penetrating ulcer, or nondissecting aneurysm).METHODS: During a 6-year period, 216 patients (143 men, 73 women; mean [+/- SD] age, 58 +/- 17 years) underwent chest radiography for suspected acute aortic syndrome. Chest films were re-evaluated blindly for aortic disease, based on an overall impression using standard criteria such as widening of the aortic contour and mediastinal shadow. Findings were matched to tomographic images, anatomical inspection, or both, as the criterion standard; aortic disease was confirmed in 109 (50%) of the patients.RESULTS: Chest radiography had a sensitivity of 64% (70/109) and a specificity of 86% (92/107) for aortic disease. Sensitivity was 67% (38/57) for overt aortic dissection, 61% (22/36) for nondissecting aneurysm, and 63% (10/16) for intramural hemorrhage or penetrating ulcer. However, sensitivity was lower for pathology confined to the proximal aorta (47% [21/45]) than for disease involving distal aortic segments (77% [49/64]). A receiver operating characteristic curve analysis of aortic diameters failed to identify a threshold for the diagnosis of aortic disease.CONCLUSION: Chest radiography is of limited value for diagnosing the acute aortic syndrome, particularly for conditions confined to the ascending aorta. Since a definitive diagnosis is required in any patient with clinically suspected acute aortic syndrome, routine chest radiography should be replaced by tomographic aortic imaging. (C) 2004 by Excerpta Medica Inc.

PURPOSE:To compare the performance of helical computed tomography (CT) and endoscopic ultrasonography (US) in the preoperative staging of gastric cancer.MATERIALS AND METHODS:Fifty-one consecutive patients with a primary malignant gastric tumor (stage T2-T4) were preoperatively evaluated with both helical CT and endoscopic US within 3 days. Each tumor was staged according to the TNM classification system with both modalities. All patients subsequently underwent surgery. Results of CT and endoscopic US were compared with histologic staging of tumor invasion depth and regional lymph node metastasis. For comparison of CT and endoscopic US data, the marginal homogeneity test was used, and a P value of less than.05 was determined to indicate statistical significance.RESULTS:In comparison with histologic results, CT achieved correct T staging in 39 patients (76%) and correct N staging in 35 patients (70%). The corresponding results for endoscopic US achieved correct T staging in 44 patients (86%) and correct N staging in 45 patients (90%). There was no significant difference between T staging (P =.55) and N staging (P >.99). Because of challenging detection of wall layers, correct T staging was difficult for CT and endoscopic US in the differentiation of T2 and T3 lesions.CONCLUSION:Compared with endoscopic US, helical CT focused on the stomach provides valuable results regarding T and N staging in patients with gastric cancer.

Purpose: Detection of malignant liver lesions with gadolinium-enhanced volumetric interpolated breath-hold examination (VIBE) in comparison with SPIO-enhanced MRT (four different SPIO-enhanced T2w sequences) and histological and imaging follow-up in non-cirrhotic livers at 1.5 T. Patients and Methods: Twenty-two patients with suspected focal liver lesions prospectively underwent a gadolinium-enhanced 3D VIBE. Four T2w sequences (HASTE sequence, fast spin-echo-sequence with and without fat-saturation, FLASH 2D gradient echo-sequence) after administration of superparamagnetic iron oxide (SPIO) served as gold standard combined with histological work-up in 17 patients and histological and imaging follow-up in five patients. The image quality was evaluated and the detectability of intrahepatic lesions was rated by the alternative free-response receiver operating characteristic (AFROC) analysis. In addition, the contrast-to-noise ratio was compared. Results: Altogether 49 malignant and 35 benign liver lesions were found. Concerning the image quality, VIBE turned out to be of slightly poorer image quality than the SPIO-enhanced examination with HASTE sequence (4.95 vs. 5.0). The fast spin-echo-sequence without fat-saturation demonstrated the highest contrast-to-noise ratio. All sequences showed a comparable certainty in detecting lesion (area under the curve 0.68-0.73) and identifying malignant liver lesions. Conclusion: Despite the small number of patients, VIBE seems to be a comparable, inexpensive and fast method in diagnosing malignant liver lesions.

Background. Endovascular stent-graft placement is a new concept for the treatment of aortic dissection and aneurysm. Intravascular ultrasound (IVUS) with established diagnostic features may be instrumental in guiding endovascular procedures. Methods: We performed IVUS and digital angiography before, during, and after implantation of 47 stent grafts in 40 patients with Stanford type B dissection (26 patients, 28 stent grafts), thoracic aneurysm (9 patients, 11 stent grafts), and abdominal aneurysm (5 patients, 8 stent grafts). Results: IVUS could clearly identify the aortic anatomy and differentiate between true and false lumen in all cases of dissection. In four patients with type B dissection extending from the thoracic to the abdominal aorta the true lumen was exclusively identified by IVUS, and thus, essential for safe execution of the procedure. In another patient stent-graft placement in the aorta was optimized by covering a second entry detected by IVUS, but undetected by angiography. The site of stent implantation, the true and false lumen, as well as entry and reentry were always identified in both thoracic and abdominal aorta. In comparison with angiography, IVUS information led to additional balloon molding due to incomplete stent apposition in seven cases. Conclusions: As an adjunctive imaging modality IVUS is likely to improve stent-graft placement in aortic type B dissection, especially in patients with abdominal extension.

PURPOSE:Evaluation of angiography in the diagnosis and treatment of acute and chronic gastrointestinal bleeding.MATERIALS AND METHODS:Thirty-seven consecutive patients with clinically suspected gastrointestinal bleeding underwent selective angiography of the visceral arteries. If technically possible, patients with radiologically proven hemorrhage underwent selective embolization with microcoils. Not all angiographically detected bleeding vessels were embolized. Clinical outcome was determined from a review of the medical records.RESULTS:37 patients underwent 43 angiographies, which demonstrated 25 bleedings considered acute and 18 considered chronic. Seventeen patients had previous intestinal surgery. In 9 of the 37 patients, 12 of the 43 (sensitivity: 28 %) hemorrhages were detected. A postoperative bleeding was found in 6 patients. With one exception, all angiographically positive cases were clinically considered to be acute. Transcatheter embolization of the bleeding vessels with microcoils was performed in 6 patients, with 3 patients having the bleeding stopped permanently and 3 patients requiring further surgical treatment. In 3 patients, embolization was not possible for technical reasons. No complications attributable to angiography were seen.CONCLUSION:Angiography should be performed in patients with spontaneous and postoperative gastrointestinal bleeding. Transcatheter embolization is an effective and safe therapeutical option in both clinical settings.

: Marfan syndrome is a genetic disorder with autosomal dominant inheritance. It is caused by mutations in the fibrillin-1 gene and leads to different disease manifestations. Seventy-five percent of the affected individuals develop an aneurysm of the ascending aorta, 41 % suffer from aortic dissections, and 93 % die of cardiovascular diseases. Skeletal changes occur in two-thirds of the patients, and lens dislocation is observed in 60 to 80 %. Without treatment, the life expectancy is 32 +/- 16 years. However, Marfan patients can live up to 60 years if they receive optimal therapy. Early diagnosis of the disease and it 's life-threatening sequelae is the prerequisite for early therapy. Radiologic diagnostic techniques are of pivotal importance in this context as they allow the identification of major and minor disease manifestations and the detection of severe dilatations and aortic dissections at an early stage. This overview describes the radiologically detectable multiple changes seen in Marfan syndrome and explains the diagnostic value of various imaging techniques in the diagnosis and therapy of Marfan syndrome.

Marfan syndrome is a genetic disorder with autosomal dominant inheritance. It is caused by mutations in the fibrillin-1 gene and leads to different disease manifestations. Seventy-five percent of the affected individuals develop an aneurysm of the ascending aorta, 41 % suffer from aortic dissections, and 93 % die of cardiovascular diseases. Skeletal changes occur in two-thirds of the patients, and lens dislocation is observed in 60 to 80 %. Without treatment, the life expectancy is 32 +/- 16 years. However, Marfan patients can live up to 60 years if they receive optimal therapy. Early diagnosis of the disease and it 's life-threatening sequelae is the prerequisite for early therapy. Radiologic diagnostic techniques are of pivotal importance in this context as they allow the identification of major and minor disease manifestations and the detection of severe dilatations and aortic dissections at an early stage. This overview describes the radiologically detectable multiple changes seen in Marfan syndrome and explains the diagnostic value of various imaging techniques in the diagnosis and therapy of Marfan syndrome.

Background— Aortic intramural hematoma (IMH) is a variant of overt aortic dissection. The predictors of progression of IMH to dissection and rupture are still unknown, and strategies for management are not established. Methods and Results— A multicenter study was conducted comprising 66 patients with IMH and hospital admission ≤48 hours after onset of initial symptoms. Among these, progression to aortic dissection or rupture occurred in 30 (45%) and death occurred in 13 (20%) patients within 30 days. Late progression was noted in 14 (21%) and death in 11 (17%) patients, yielding a 1-, 2-, and 5-year survival of 76%, 73%, and 43%, respectively. In a set of 9 variables, multivariate analysis identified IMH location in the ascending aorta (type A; P =0.02) and moderately ectatic aortic diameters (49±13 mm with progression versus 57±16 mm without progression; P =0.03) as independent predictors of early progression. In type A IMH, early mortality was 8% with swift surgery versus 55% without surgery ( P =0.004). The risk of late progression of IMH was independently associated with age at index diagnosis ( P =0.01) and absence of β-blocker therapy during follow-up ( P =0.03). Kaplan-Meier analysis confirmed improved 1-year survival of IMH with β-blocker therapy (95% versus 67% without β-blockers; P =0.004). Conclusions— Regardless of aortic diameter, IMH of the ascending aorta (type A) is at high risk for early progression, and, thus, undelayed surgical repair should be performed. Moreover, oral β-blocker therapy may improve long-term prognosis of IMH independent of anatomical location.

Zusammenfassung Während bei Erwachsenen vorwiegend die untere HWS von einem Trauma betroffen ist, überwiegen bei jüngeren Kindern Verletzungen im Bereich C1/C2. Dabei kann es in seltenen Fällen auch zu Bandverletzungen in diesem Bereich kommen. Die diagnostische Abklärung solcher Verletzungen erweist sich in der Praxis als äußerst schwierig. Ebenso existieren in der Literatur kaum Daten hinsichtlich Behandlungsregime und Prognose. Wir berichten über 2 Kinder mit einer isolierten Ruptur der Ligg. alaria. Die Diagnose wurde in beiden Fällen durch MRT gesichert, welche wir zum Ausschluss von ligamentären Verletzungen der oberen HWS bei Kindern als Mittel der Wahl empfehlen. Trotz widersprüchlicher Datenlage zur biomechanischen Bedeutung der Ligg. alaria halten wir ein konservatives Vorgehen für vertretbar. Maßgeblich bleibt jedoch die umgehende Abklärung, um eine mögliche Gefährdung des Patienten zu vermeiden.

Background. This retrospective study was performed to evaluate the diagnostic power of combined transthoracic echocardiography and conventional contrast-enhanced computed tomography to distinguish different aortic pathologies presenting with acute aortic syndrome. Methods and Results. Transthoracic echocardiography and conventional contrast-enhanced computed tomography of 78 patients with independently confirmed aortic disease and clinical signs of acute aortic syndrome were blindly re-evaluated. Acute aortic disease was demonstrated by combined transthoracic echocardiography and conventional contrast-enhanced computed tomography in all cases, with the diagnosis of aortic dissection in 39 cases (92% sensitivity), intramural hemorrhage or penetrating aortic ulcer in four cases (100% sensitivity) and nondissecting aortic aneurysm in 35 cases (97% sensitivity). In 58 cases (74%) signs of aortic instability comprising sidebranch involvement, aortic regurgitation, pericardial effusion and/or mediastinal hematoma were demonstrated by combined transthoracic echocardiography and conventional contrast-enhanced computed tomography. Conclusions. Combined transthoracic echocardiography and conventional contrast-enhanced computed tomography are highly useful for corroborating acute aortic syndrome and signs of aortic instability. Moreover, with the use of stringent diagnostic criteria different aortic pathologies presenting with acute aortic syndrome may be detected with higher accuracy.