Early hemodynamic characteristics of eversion and patch carotid endarterectomies

Abstract

Objective

Carotid endarterectomy (CEA) is currently the gold standard in the operative management of carotid artery stenosis. While eversion and patch CEAs vary greatly in technique, various studies have determined equivalence with regard to clinical outcomes. However, the hemodynamic differences following each procedure are not known. This study aimed to investigate any early hemodynamic differences between eversion and patch CEAs.

Methods

All CEAs performed at our institution from March 2012 to June 2018 were aggregated in a retrospective database by querying the 35301 CPT code from the electronic medical record system. Variables collected included gender, age, laterality of CEA, type of procedure, and pre- and post-operative duplex ultrasound (DUS) date and quantitative findings. Exclusion criteria included any procedure with incomplete data, a post-operative DUS > 90 days following the procedure, CEAs with concomitant bypass(es), isolated external carotid artery (ECA) endarterectomies, and re-do CEAs.

Results

One hundred and seventy-one CEAs were performed in 161 unique patients. There were 101 males and 60 females, with an average age of 69.7 (38-96; ± 9.36). 63 CEAs were excluded from analysis: 51 due to incomplete data, eight with a > 90 day post-operative DUS, 2 isolated ECA endarterectomies, 1 CEA with a carotid–subclavian bypass, and 1 re-do CEA secondary to an infected patch. Twenty-seven eversion and 81 patch CEAs were included in analysis. There was no difference in procedure laterality or gender between the two cohorts (p > 0.05); however, patients who received an eversion CEA were older on average (73.3 vs 67.5; p = 0.002). Pre-operative peak systolic velocities (PSV) of the proximal internal carotid artery (ICA), distal ICA, and distal common artery (CCA) were all similar (p > 0.05). Post-operative DUS was performed at 17.0 and 12.9 days in the eversion and patch CEA cohorts, respectively (p = 0.12). Post-operative PSV and change in PSV were similar for all three aforementioned segments (p > 0.05).

Conclusion

Although eversion and patch CEAs vary greatly in technique and post-procedure anatomy, there was no significant difference in post-operative PSV or change in PSV at or around the carotid bifurcation.

A comparative evaluation of cataract classifications based on shear-wave elastography and B-mode ultrasound findings

Abstract

In this study, a comparison is made of the findings of B-mode ultrasound and ultrasound elastography with the Lens Opacities Classification (LOCS) grade in patients with senile cataracts. A total of 74 patients with cataracts and 32 age-matched healthy volunteers as the control group were evaluated in the departments of ophthalmology and radiology between 2016 and 2017. In the patient group, cataracts were graded according to LOCS, and B-mode sonographic appearance and elasticity measurements were recorded, after which the cataract grade and sonoelastography/B-mode ultrasound findings were compared using statistical methods. Among the 74 patients with cataracts, 38 were females (51.4%) and 36 were males (48.6%), and the mean age was 62.05 ± 7.95 (43–78) years. A Chi-square test revealed a significant relationship between ultrasound echogenicity of cataract and grade of cataract (p < 0.005). The ultrasound elastography revealed a mean shear-wave velocity of 2.90 m/s ± 0.371 (2.13–3.53) among patients with grade 3 cataracts, 3.1 m/s ± 0.45 (2.26–3.98) among patients with grade 4, 3 m/s ± 0.58 (2.35–4.60) among patients with grade 5 and 3 m/s ± 0.528 (2.31–4.50) among patients with grade 6 cataracts, and 3 m/s ± 0.258 (2.36–3.58) among the normal subjects. No statistically significant difference was noted in the analysis of variance (p > 0.005). While cataract grade and B mode echogenicity were directly proportional, there was no significant difference in lens elasticity.

Extended-FAST plus MDCT in pneumothorax diagnosis of major trauma: time to revisit ATLS imaging approach?

Abstract

Background and objective

Pneumothorax (PNX) detection is of the utmost clinical relevance because it may quickly progress to cause hemodynamic instability as a consequence of invasive ventilation. Radiography is characterized by a low sensitivity to detect this disease; in recent years, chest ultrasound (US) has gained increased visibility in the diagnosis of acute respiratory emergencies including PNX. The aim of this retrospective study was to evaluate the clinical impact of extended focused assessment with sonography in trauma (E-FAST) during the past 6 years of experience with this technique in our Level I trauma center.

Methods

Between January 2013 and December 2018, we performed a retrospective case-series study including 3320 consecutive patients admitted to the emergency department of our hospital because of major trauma. Extended-US was always performed and reported immediately after FAST during primary survey and before multidetector computed tomography (MDCT) scans. The presence of PNX was determined using the well-known accepted US criteria. US findings were compared with computed tomography (CT) findings, the reference standard for PNX detection.

Results

Of the 6640 lungs observed with E-FAST, there were 1244 PNX cases, while 1328 PNX cases were detected either on the basis of MDCT or on the basis of the presence of air flush during the thoracic decompression in the emergency room. Among the 84 false negatives, 12 patients had subcutaneous emphysema, 38 had a body mass index higher than 27, 6 had a thoracic wall hematoma, and 4 had chest penetrating trauma. There were 10 false positives in the diagnosis of PNX at US examination, with mild extension and not clinically significant. The overall sensitivity of E-FAST for PNX detection was 93.6% (1244/1328), the specificity of E-FAST was 99.8% (5312/5322), the negative predictive value (NPV) was 98.4% (5312/5396), and the positive predictive value (PPV) was 99.2% (1328/1338).

Conclusion

Our results demonstrate that bedside thoracic US is characterized by a very good accuracy in the diagnostic work-up of major trauma patients, even in difficult conditions, allowing rapid diagnosis of PNX.

Advances in knowledge

The novelty of this research lies in the possibility of diagnosing potential life-threatening conditions in a very short time by means of US, thus proposing a revision of the Advanced Trauma Life Support (ATLS) guidelines in order to incorporate it in the work-up of high-energy injured patients.

Safety and effectiveness of ultrasound-guided percutaneous transhepatic biliary drainage: a multicenter experience

Abstract

Aims

Aim of this study is to describe a multicenter experience on percutaneous transhepatic biliary drainage (PTBD) performed with ultrasound-guidance to access the biliary tree, focusing on safety, effectiveness and radiation dose exposure; differences between right- and left-sided approaches have been also evaluated.

Methods

This is a multicenter prospective single-arm observational study conducted on patients affected by biliary tree stenosis/occlusion with jaundice and endoscopically inaccessible. The procedures have been performed puncturing the biliary system under US guidance and crossing the stenosis/occlusion under fluoroscopy. Beam-on time and X-ray dose have been evaluated.

Results

117 patients affected by biliary tree stenosis/occlusion not manageable with an endoscopic approach have been included in this analysis. The biliary stenosis/occlusion was malignant in 90.8% and benign in 9.2%. Technical success, considered as positioning of a drainage tube into the biliary tree, was 100%. Overall clinical success, considered as decrease in total bilirubin level after a single procedure, was 95.7%. The overall mean number of liver punctures to catheterize the biliary tree was 1.57. The mean total beam-on time was 570.4 s; the mean dose-area product was 37.25 Gy cm². No statistical significant differences were observed in terms of technical and dosimetry results according to right-sided and left-sided procedures. Complications rate recorded up to 30 days follow-up was 10.8%, all of minor grades.

Conclusions

In this series US guidance to access the biliary tree for PTBD was a safe and effective technique with an acceptable low-grade complications rate; the reported radiation dose is low.

Graphic abstract

Ultrasonography of the pediatric spleen: a pictorial essay

Abstract

In infants and children, the spleen is involved in many pathological processes, whether those processes are isolated or related to systemic diseases. Pathology of the pediatric spleen includes congenital anomalies, splenomegaly, trauma, focal lesions, infarction, and tumors. Ultrasonography (US) is a widely available, fast, noninvasive imaging technique to assess the size, shape, and position of the spleen, as well as to define splenic echotexture. US is capable of screening for splenic disorders without the risk of ionizing radiation; it is the initial imaging examination performed to evaluate suspected splenic pathology, providing clinicians with helpful decisional support. US plays an important role in the detection of even very small amounts of hemoperitoneum, a herald of significant abdominal organ injury, in pediatric blunt abdominal trauma. Moreover, contrast-enhanced US may allow early detection of splenic injuries, ideally minimizing children’s risk from radiation exposure. This pictorial essay illustrates the normal ultrasound appearance of the pediatric spleen and the sonographic findings which may guide clinicians to a correct diagnosis of pathologic conditions.

Clinical significance of contrast-enhanced ultrasound in chronic kidney disease: a pilot study

Abstract

Background

Contrast-enhanced ultrasound (CEUS) has the potential to improve the imaging of renal blood flow and renal lesional vascularity in real time with high temporal and spatial resolution.

Purpose

This study investigated the clinical significance of real-time CEUS in cases of chronic kidney disease (CKD).

Materials and methods

Included patients were stratified according to their estimated glomerular filtration rate (eGFR): Group I (CKD stage I and II), eGFR ≥ 60 ml/min/1.73 m²; group II (CKD stage III), eGFR of 30 ≤ eGFR < 60 ml/min/1.73 m²; and group III (CKD stage IV and V), eGFR of eGFR < 30 ml/min/1.73 m². Real-time and dynamic imaging of the renal cortex was performed using CEUS. Several bolus model perfusion and laboratory parameters were compared. The differences in perfusion or laboratory parameters among the groups and correlation between perfusion or laboratory parameters and eGFR were assessed.

Results

Of the 24 patients, 4 were classified into group I, 13 into group II, and 7 into group III. No significant differences were found among the three groups in the perfusion parameter analysis. No parameter was significantly positively correlated with eGFR. In the laboratory parameter analysis, significant differences in several parameters (RBC, BUN, SCr, glucose, TCh, phosphorus, TP, p < 0.05) were detected among the three groups. These parameters significantly correlated with eGFR (correlation coefficient, R = − 0.7625 to 0.6026).

Conclusions

Kidney perfusion parameters in CEUS do not correlate with kidney function in this pilot study.

Treatment of a calcific bursitis of the medial collateral ligament: a rare cause of painful knee

Abstract

Medial knee pain is common in clinical practice and can be caused by various conditions. In rare cases, it can even be by calcific bursitis of the medial collateral ligament (MCL). Treatment of calcific bursitis and/or calcification of the MCL classically includes observation, local injections, shockwave therapy and surgical resection. We report a case of nontraumatic medial knee pain poorly responsive to conservative treatments. Ultrasound (US) imaging revealed a massive lobed hyperechoic formation with partial acoustic shadow in the MCL context compatible with calcific bursitis, and magnetic resonance imaging (MRI) confirmed the presence of the bursa’s calcific deposit surrounded by hyperintense signal compatible with pericalcific edema. We performed a double-needle ultrasound-guided percutaneous lavage (UGPL), which is today a fairly common treatment for many musculoskeletal disorders, such as rotator cuff calcific tendinopathy and elbow extensor tendons pathology, but regarding the knee, it is not part of ordinary care. This report shows the clinical and imaging presentation of calcific bursitis of the MCL and describes in detail the technique to perform the UGPL with a system of two needles, two syringes and a double connection to ensure a correct lavage of the calcium deposit without significant intrabursal pressure increase and consequently without pain during the procedure.

Skin cancer: findings and role of high-resolution ultrasound

Abstract

Currently available high-resolution transducers allow a detailed ultrasound (US) assessment of skin tumors. US complements clinical examination, dermoscopy, and biopsy in the initial differential diagnosis, surgical planning, locoregional staging, and follow-up of patients with skin malignancies. It is important for dermatologists, skin surgeons, and US operators to be aware of the US imaging findings and to recognize the clinical scenarios where imaging is indicated in the management of skin cancer. The purpose of this review article is to address the most common indications for US in skin oncology and to provide a comprehensive guide to the gray-scale and color-Doppler findings in cutaneous malignant tumors.

Pediatric musculoskeletal ultrasound: a pictorial essay

Abstract

Ultrasound (US) is the main imaging modality for the evaluation of pediatric patients with musculoskeletal diseases; particularly, it is an appropriate and reliable tool for diagnosis, follow-up and treatment of several musculoskeletal pathologies affecting the pediatric age. High-frequency (10–15 MHz) and high-resolution probes provide very lofty quality images, allowing a detailed study of the pediatric musculoskeletal system. Among the well-known advantages of this technique—such as the absence of ionizing radiations, its low cost and wide availability—US can as well rely on some intrinsic characteristics of the pediatric musculoskeletal system that can improve its diagnostic capability. The unossified portions of the pediatric skeleton and the absence of a thickened adipose tissue allow US to be highly effective and reliable in the study of muscles, tendons and cartilage. Lower-frequency sectoral transducers can be required in the study of some joints such as the shoulder or the hip, as well as in the examination of deep soft-tissue lesions. Furthermore, both color and spectral Doppler play an important role in the examination of soft-tissue lesions and synovial phlogosis. In this pictorial essay the main pathological conditions of pediatric musculoskeletal system will be examined, such as painful hip, evolutionary hip dysplasia, osteochondrosis, trauma-related pathologies and juvenile idiopathic arthritis.