Forensic pathologists have to deal with post-mortem changes of the human body. Those post-mortem phenomena are familiar and largely described in thanatology. However, knowledge about the influence of post-mortem phenomena on the vascular system is more limited, except for the apparition and development of cadaveric lividity. The introduction of multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI) in the forensic field and the expansion of their usage in medico-legal routine, allow for exploring the inside of corpses differently and may play a part in the understanding of thanatological processes. This study aimed to describe post-mortem changes in the vascular system by investigating the presence of gas and collapsed vessels.We investigated post-mortem MDCT data of 118 human bodies. Cases with internal/external bleeding or corporal lesion allowing contamination with external air were excluded. Major vessels and heart cavities were systematically explored and a trained radiologist semi-quantitatively assessed the presence of gas.Collapsed veins were observed in 61.9% of cases (CI95% 52.5 to 70.6) and arteries in 33.1% (CI95% 24.7 to 42.3). Vessels most often affected were for arteries: common iliac (16.1%), abdominal aorta (15.3%), external iliac (13.6%), and for veins: infra-renal vena cava (45.8%), common iliac (22.0%), renal (16.9%), external iliac (16.1%), and supra-renal vena cava (13.6%). Cerebral arteries and veins, coronary arteries, and subclavian vein were unaffected. The presence of collapsed vessels was associated with a minor degree of cadaveric alteration. We observed that arteries and veins follow the same pattern of gas apparition for both the quantity and the location.In post-mortem radiology, collapsed vessels and intravascular gas are frequently visualized and as a result of all post-mortem changes, the assessment of the distribution of blood can be confusing. Therefore, knowledge of thanatological phenomena is crucial to prevent post-mortem radiological misapprehensions and possible false diagnoses.

To reduce inferior vena cava filter (IVCF) related complications, retrieval is recommended whenever possible. Nevertheless, IVCF retrieval rates remain lower than expected, likely due to insufficient follow-up after placement. We evaluated the value of a structured program designed to follow patients by the interventional radiology team up to 5 months after IVCF placement. We prospectively enrolled 366 consecutive patients (mean age 64 ± 17 years; 201 men and 165 women) who benefited from IVCF between March 2015 and February 2020. The program consisted of advising the patient and clinicians to consider IVCF retrieval as soon as possible (standard workflow) and systematically planning an additional follow-up visit at 5-month. Clinical and technical eligibility, as well as technical success for retrieval (TSR) were evaluated. At 5-months, 38 (10.4%) patients were lost to follow-up, and 47 (12.8%) had died. Among survivors, the overall retrieval rate was 58%. The retrieval rates were 83% and 97% for the clinically eligible and technically eligible patients for retrieval, respectively. The 5-month visit enabled 89 additional retrievals (47.8%) compared to the standard workflow. No significant difference was seen in TSR before and after 5 months (p = 0.95). Improved patient tracking with a dedicated IVCF program results in an effective process to identify suitable patients for retrieval and drastically improves retrieval rates in eligible patients. Involving interventionalists in the process improved IVCF patient management.

Purpose: To evaluate the safety and feasibility of peripheral percutaneous endovascular procedures in a large group of outpatients with peripheral arterial disease (PAD). Materials and methods: We retrospectively evaluated all consecutive patients who underwent peripheral transluminal angioplasty (PTA) for PAD of the lower extremities as "Out-Patient Admission Protocol'' (OPAP) from January 2005 until December 2015. A total of 498 consecutive patients (305 men and 193 women) with mean age of 66 +/- 10 (SD) years (range: 37-90 years) were evaluated. By protocol, patients were expected to be discharged 6 hours after the procedure. Clinical profile, procedure details and technical success were reviewed. Complications, conversion rate, readmission rate and long-term follow-up were evaluated. Results: Ninety one percent of patients (454/498) suffered from claudication. Unilateral femoral access was performed in 75.4% (493/654) of procedures with a 6-French sheath in 80.7% (528/654) of procedures. Balloon PTA alone was performed in 17.3% (148/857) and stent placement in 82.7% (709/857) of treated segments. Technical success of lesion treatment was 98.2% (857/873). Closure devices were used in 55.4% (362/654) of procedures. Conversion and readmission rates were 1.8% (12/654) and 0.6% (4/654), respectively. Long-term follow-up was obtained in 386 target lesions, 5-year restenosis of lesion was 20.5% (79/386). Conclusion: As designed, the OPAP was feasible, safe and effective with very low conversion and complications rates. These results strongly support a larger use of such approaches as routine practice. (C) 2018 Published by Elsevier Masson SAS on behalf of Societe francaise de radiologie.

Recent studies have indicated that multiphase postmortem computed tomography angiography (MPMCTA) allows detection of a pathological enhancement of the myocardium in regions that correlate with the localization of the infarction at histology. The aim of this study was to verify this hypothesis by examining MPMCTA images in cases of myocardial infarction. Therefore, we investigated 10 autopsy cases where death was attributed to myocardial infarction or which showed cardiovascular pathology. As a control group, we selected 10 cases of non-natural (namely, not cardiac) death. The MPMCTA was performed in both groups to ascertain whether a pathological enhancement could be observed. We detected a myocardial enhancement in all cardiac death cases, in the same region that showed infarction at histology. No enhancement was observed in control cases. These results have important implications in the routine management of sudden cardiac death cases. In fact, MPMCTA can not only orient about the cause of death before autopsy, but can especially help to identify affected regions for guiding and improving the sampling for microscopic examination.

Superior vena cava (SVC) syndrome is a group of clinical signs caused by the obstruction or compression of SVC and characterized by edema of the head, neck, and upper extremities, shortness of breath, and headaches. The syndrome may be caused by benign causes but most of the cases are caused by lung or mediastinal malignant tumors. Stenting of SVC has become widely accepted as the palliative treatment for this condition in malignant diseases, as it offers rapid relief of symptoms and improves the quality of life. Preserving previously placed central venous catheters (CVCs) is a major issue in this population. We report the case of a patient with SVC syndrome caused by tumoral obstruction due to central small-cell lung cancer who had right subclavian implanted CVC and a preferential head and neck venous drainage through the left internal jugular and brachiocephalic vein (BCV). We describe a complex procedure of SVC reconstruction with two different objectives: left recanalization and stent placement to ensure head and neck venous drainage and right BCV stenting for CVC repositioning and subsequent replacement. We also review published cases of SVC obstructions stenting with catheter repositioning. The patient experienced quick relief of symptoms after treatment. Chemotherapy was rapidly delivered through the preserved implanted CVC access. A 3-month follow-up computed tomography showed stents patency.

Introduction Postmortem CT angiography is the method of choice for the postmortem imaging investigations of the cardiovascular (CV) system. However, autopsy still remains the gold standard for CV measurement. Nevertheless, there are not any studies on CV measurements on the multi-phase postmortem angiography (MPMCTA) which includes comparisons with autopsy. Therefore, the aim of this study is to compare CV measurements between the native CT scan and the three phases of the MPMCTA to find out which of these modalities correlate the best with autopsy measurements. Methods For this study, we selected retrospectively 50 postmortem cases that underwent both MPMCTA and autopsy. A comparison was carried out between the CV measurements obtained with imaging ( aorta ; heart cavities and cardiac wall thicknesses ; maximum cardiac diameter and cardiothoracic ratio ) and at the autopsy ( aorta ; cardiac valves , ventricular thicknesses , and weight ). Results Our results show that the dynamic phase displays an advantage for the measurement of the aortas. However, the MPMCTA is not accurate to measure the cardiac wall thicknesses. The measurements of the heart cavities show no correlation with the heart valves. The cardiothoracic ratio measured by the MPMCTA shows no correlation with the heart weight. Nevertheless, the maximum cardiac diameter exhibits a correlation with the latter on the venous and dynamic phase. Conclusions These results show that only few CV parameters measured with imaging correlate with measurement obtained at the autopsy. These results indicate that in order to better estimate values obtained at the autopsy, we need to define new reference values for the CV measurement on MPMCTA.

To report our experience using a multilevel patient management algorithm to direct transarterial embolization (TAE) in managing spontaneous intramuscular hematoma (SIMH).

Objective: Primary aldosteronism (PA) is one of the most common forms of secondary hypertension, which can be cured by surgical removal of an adrenal gland if aldosterone secretion is lateralized. Adrenal vein sampling (AVS) is the gold standard method to assess lateralization of aldosterone secretion in PA. Recently, the use of free metanephrine (fMN) instead of cortisol has been proposed to determine correct positioning of the catheter during AVS (selectivity). As almost all fMN is released by the adrenal glands to be sulphate-conjugated peripherally. We hypothesized that free/total metanephrine ratio (FTMR) measured in each adrenal vein would be non inferior to fMN to assess selectivity. The objective of the study was to compare the FTMR to fMN and cortisol to assess selectivity. Design and method: cortisol, free and total metanephrines were measured in the distal and proximal veina cava and in the right and left adrenal veins in patients with PA referred for sequential, non cosyntropin-stimulated AVS. Correct placement of the tip the catheter was assessed by computed tomography angiography (CTA). Receiver operating characteristic (ROC) curves were used to assess the performance of each marker independently of cut-off choices. Results: 76 patients (37 women) were included in the study. Mean age (±SD) was 51.3 ± 9.7 years. Of those, 56 had a successful positioning of the tip of the catheter ascertained in both adrenal veins. ROC curve analyses on the left adrenal vein established an area under the curve (AUC) of 1.0 ± 0 for both free metanephrine and the FTMR compared to an AUC 0.966 ± 0.015 for cortisol. In the right adrenal vein, AUC were respectively 0.967 ± 0.020, 0.968 ± 0.20, and 0.824 ± 0.044 for FTMR, free metanephrine and cortisol. Cut-offs values for the selectivity index determined by ROC for FTMR, fMT and cortisol were respectively 0.41, 10.0 and 2.63 on the left and 0.30, 9.9 and 2.5 on the right. Conclusions: The use of the FTMR performs similarly to fMN to assess the selectivity of the adrenal vein catheterization. Its use could limit the number of blood samples and time of the procedure as only blood from the adrenal veins is necessary.

Implanted venous access device (IVAD) late dysfunction is commonly caused by fibrin sheath formation. The standard method of endovascular fibrin sheath removal is performed via the femoral vein. However, it is not always technically feasible and sometimes contraindicated. Moreover, approximately 4-6 h of bed rest is necessary after the procedure. In this article, we describe an alternative method of fibrin sheath removal using the brachial vein approach in a young woman receiving chemotherapy for breast cancer. The right basilic vein was punctured, and a long 6 degrees F introducer sheath was advanced into the right subclavian vein. Endovascular maneuvers consisted on advancing Atrieve(TM) Vascular Snare 15-9 mm after catheter insertion in the superior vena cava through a 5.2 degrees F Judkins left catheter. IVAD patency was restored without any complication, and the patient was discharged immediately after the procedure. In conclusion, fibrin sheath removal from an obstructed IVAD could be performed via the right brachial vein. Further research is necessary in order to prove efficacy of this technique.

In clinical practice, the cardiothoracic ratio (CTR) was first utilized on plain chest radiography, and subsequently with computed tomography (CT) to diagnose cardiomegaly with a threshold of 0.5. Using CTR in forensic practice could help to detect cardiomegaly on post-mortem CT (PMCT) prior to the autopsy. However, an adaption of the threshold could be necessary because of post-mortem changes. Our retrospective study aimed to measure the CTR on PMCT and test the possible influence of variables. We selected 109 autopsy cases in which the heart weight was within normal limits. A forensic pathologist and a radiologist measured separately the CTR on axial and scout views on PMCT. We tested the statistical concordance between the two readers and between the axial and scout view and identified factors that could be associated with a modification of the CTR. The CTR measurements revealed an overestimation of the measurements made on scout compared to axial view. The inter-reader correlation was very high for both views. Among the different variables statistically tested, heart dilatation and body mass index (BMI) were the only two factors statistically associated with an augmentation of the CTR. The CTR can be useful in the diagnosis of cardiomegaly on PMCT. However, dilatation of the cardiac chambers caused by acute heart failure may be misinterpreted radiographically as cardiomegaly. Inter-observer reliability in our study was very high. CTR may be overestimated when measured on the scout view. Further investigations with larger cohorts, including cases with cardiac hypertrophy, are necessary to better understand the relationship between radiological CTR and the morphology of the heart.

We present the case of a 75-year-old patient with asymptomatic gastro-duodenal artery aneurism (GAA) that was coiled through the left femoral artery. The gastro-duodenal artery (GDA) was then embolized. Following the intervention, the patient'™s left foot became cold. A sub-acute ischemia caused by a stenotic effect in the left external iliac artery and by lower limb embolic phenomena caused by the introductor, was diagnosed. A thromboembolectomy of the popliteal, anterior and posterior tibial and peroneal arteries was performed with a Fogarty catheter with good results. Aneurisms of the GDA are rare. Rupture is a severe and unpredictable complication that complicates management and darkens prognosis. Though endovascular treatment for splanchnic aneurisms are used more and more often and offers numerous advantages compared to surgery, it is not without risk. A multidisciplinary approach with careful collaboration between the surgeon and the radiologist is recommended. Abbreviattions: GAA: gastro-duodenal artery aneurism, GDA: gastro-duodenal artery.

Objective: Primary aldosteronism is a frequent form of secondary hypertension. Adrenal vein sampling (AVS) remains the gold standard technique to evaluate the lateralization of aldosterone secretion. Recently it has been proposed that free metanephrine is potentially a better molecule to assess the selectivity of adrenal vein sampling than cortisol in non stimulated sequential AVS. The objective of this study was to compare cortisol to free metanephrine to assess adrenal vein selectivity using currently proposed cutoffs in non stimulated patients. Design and method: This was a prospective monocentric study. Aldosterone, cortisol and free metanephrine were measured in patients referred for AVS using commercial immunoassays for steroids and LC/MSMS for free metanephrine. Blood samples were taken from peripheral and both adrenal veins. Phi coefficients were measured using two different cutoffs for cortisol. Results: 51 AVS from 49 patients (49% women) were included in the analysis. Mean age was 50.1 ± 9.1 years old and BMI was 28.1 ± 4.7 kg/m2. Office systolic and diastolic blood pressure were respectively 154 ± 17.1 mmHg and 91.7 ± 13.2 Failure and success rate are shown in Table 1.Based on a ratio > 12 for free metanephrine, >3 or >2 for cortisol, the success rate for the right adrenal vein was respectively 85%, 42% and 59%. For the left adrenal vein the success rate was respectively 96 %, 69% and 84%. Phi coefficients were higher when a cortisol ratio > 2 was used, but remained weak. Conclusions: This study shows that, independently, of the method used to assess selectivity, the success rate is lower for the right adrenal vein. Secondly, based on current recommended selectivity indexes for cortisol and free metanephrine, the discordance rate of successful adrenal vein sampling is high. Outcome studies based on blood response after adrenal surgery are necessary to choose the best marker of selectivity.

The vast majority of superior vena cava (SVC) syndromes are of malignant causes, but with growing use of indwelling central catheters and implanted cardiac devices, benign SVC syndromes are becoming more frequent. The main objective of this study is to evaluate long term outcome in patients treated for benign SVC syndrome by endovascular techniques.

The objectives of this study were to define the success rate of adrenal vein sampling, and its clinical determinants, and to compare the accuracy of high-resolution adrenal computed tomography with AVS.

Multi-phase postmortem CT-angiography (MPMCTA) is used routinely for investigating cases of traumatic and natural death at the University Centre of Legal Medicine, Lausanne-Geneva. Here, we report the case of a patient affected by Leriche syndrome, with a history of numerous cardiovascular interventions, including an axillobifemoral bypass. The multiple cardiovascular changes presented by the patient were visualised by this relatively new technique and they were shown not to be related to the cause of death. This case demonstrated the utility of MPMCTA for investigating bodies with suspected vascular pathologies. Moreover, it revealed the advantages of MPMCTA over conventional autopsy to investigate a modified vascular anatomy. This was the first case in which MPMCTA was performed by injecting a contrast-agent mixture into a vascular prosthesis.

The goal of this study was to assess the localization and types of thrombosed plaques in cases of sudden cardiac death attributed to coronary artery disease and to evaluate possible correlations with body mass index (BMI) and increased heart weight. This retrospective study was performed on forensic cases for which the cause of death was attributed to coronary artery disease. A complete autopsy and a multi-phase postmortem computed tomography (CT) angiography (MPMCTA) were performed in all cases. Eighty-five cases were selected (mean age, 55.18 ± 11.04 years; 72 men and 13 women). MPMCTA performed prior to autopsy enabled an evaluation of coronary artery perfusion before dissection of the body and helped therefore to guide sampling for histology. An acute coronary thrombosis was found in 57 cases, which included plaque erosion in 26 cases (mean age, 46.73 ± 8.33 years) and rupture or intra-plaque hemorrhage in 31 cases (mean age, 58.23 ± 10.62 years). Erosions were most frequently found in the left anterior descending artery (61.5 %), while only 35.48 % of ruptures were observed in this artery. Chronic coronary pathology was considered as the main cause of death in 28 cases (mean age, 59.64 ± 9.47 years). Sixty-two of the cases (72.94 %) had a BMI in the overweight category (BMI ≥25), with the highest mean BMI in patients with chronic coronary pathology without acute thrombosis found at autopsy. The heart weight was above the predicted reference values in 52 cases (61.18 %). Our results are in accordance with previously published studies on the spatial distribution of vulnerable plaques. We observed a higher percentage of eroded plaques than previously reported. Patients with coronary erosions were significantly younger than those with plaque rupture or those without an acute coronary thrombosis (p values <0.0001). BMI and heart weight were significantly higher for cases without thrombosis in comparison with those with plaque rupture (p values 0.028 and 0.003, respectively). Our results indicating that increased BMI and overweight hearts are associated with chronic ischemic heart disease are compatible with clinical studies. Performing more postmortem studies on forensic autopsies, including modern radiological examinations with MPMCTA, can enhance the detection of vulnerable plaques in living patients and prevent sudden cardiac death.