Follow-up Ultrasound Examinations Research Articles

Clinical Features and Outcomes of Gallbladder Polyps in Children.

Background:Gallbladder polyps are rare lesions protruding into the gallbladder lumen with variable clinical presentation. No standard treatment algorithm has been developed for pediatric gallbladders, and the malignant potential of the gallbladder is not clear in children. Therefore, a retrospective study was performed to evaluate the clinical features and treatment options of gallbladder polyps in children.Methods:Between 2014 and 2020, children diagnosed with gallbladder polyps were evaluated for age, gender, clinical features, results of follow-up with ultrasound findings, and treatment options retrospectively.Results:The records of 15 patients with a mean age of 13.2 years (2-20 years) were included. The male: female ratio was 7 : 8. Gallbladder polyps was detected incidentally in 73.3% (n = 11) of the patients. Four (20%) of the patients were symptomatic (26.7%) and complained about abdominal pain. Laboratory tests were normal except in 3 patients who showed slightly increased liver function tests. Two of the patients had 3 polyps on admission. The polyps were 2-10 mm in size. The size of the polyp increased in 5 patients (33.3%) and disappeared in 4 patients (26.6%) in follow-up ultrasound examinations. Five of the patients underwent cholecystectomy and 1 of them was scheduled for surgery. Five of the asymptomatic patients who have polyps less than 10 mm in size are still on follow-up. In patients with cholecystectomy, the histopathology of gallbladders revealed cholesterol polyps (n = 2) and hyperplastic polyps (n = 2). One of the patients with cholecystectomy showed no polyps in histopathological evaluation.Conclusion: Despite the lack of a standardized algorithm, our data suggested that multiple polyps, polyps with increased in size or greater than 10 mm, and the presence of symptoms might require cholecystectomy in children. Asymptomatic patients with small-sized polyps can be identified using ultrasound, and the polyps may disappear during the subsequent follow-up.

Surgical Resection of a Recurrent Hepatocellular Carcinoma with Portal Vein Thrombosis: Is It a Good Treatment Option? A Case Report and Systematic Review of the Literature.

Background: Hepatocellular carcinoma (HCC) is the sixth most frequent diagnosed tumor worldwide and the third leading cause of cancer related death. According to the EASL Guidelines, HCC with portal vein tumor thrombosis (PVTT) is classified as an advanced stage (BCLC stage C) and the only curative option is represented by systemic therapy. Therefore, treatment of HCC patients with PVTT remains controversial and debated. In this paper, we describe the case of a 66-year-old man with a recurrent HCC with PVTT who underwent surgical resection. A systematic review of the literature, comparing surgical resection with other choices of treatment in HCC patients with PVTT, is reported. Methods: A systematic review of the literature regarding all prospective and retrospective studies comparing the survival outcomes of HCC patients with PVTT treated with surgical resections (SRs) or other non-surgical treatments (n-SRs) has been conducted. Case presentation: A 66-year-old Caucasian man with a history of Hepatitis C Virus (HCV) related liver cirrhosis and previous hepatocellular carcinoma of the VI segment treated with percutaneous ethanol infusion (PEI) seven years before presented to our clinics. A new nodular hypoechoic lesion in the VI hepatic segment was demonstrated on follow-up ultrasound examination. A hepatospecific magnetic resonance imaging (MRI) scan confirmed also the presence of a 18 × 13 mm nodular lesion in the V hepatic segment with satellite micronodules associated with V–VIII sectoral portal branch thrombosis. The case was then discussed at the multidisciplinary team meeting, and it was decided to perform a right hepatectomy. The postoperative course was regular and uneventful, and the discharge occurred seven days after the surgery. At eight-month follow-up, there was no clinical nor radiological evidence of neoplastic recurrence, with well-preserved liver function (Child-Pugh A5). Results: Nine studies were included in the review. Median Overall Survaival (OS) ranged from 8.2 to 30 months for SRs patients and from 7 to 13.3 for n-SRs patients. In SR patients, one-year survival ranged from 22.7% to 100%, two-year survival from 9.8% to 100%, and three-year survival from 0% to 71%. In n-SRs patients, one-year survival ranged from 11.8% to 77.6%, two-year survival from 0% to 47.8%, and three-year survival from 0% to 20.9%. Conclusion: The present systematic literature review and the case presented demonstrated the efficacy of surgery as a first-line treatment in well-selected HCC patients with PVTT limited or more distal to the right and left portal branches. However, further studies, particularly randomized trials, need to be conducted in future to better define the surgical indications.

Shear wave elastography for the evaluation of testicular salvage after testicular torsion.

The aim of this study was to assess the utility of shear wave elastography in the follow-up of testicular detorsion, evaluate long-term outcomes, and explore its relationship with parameters such as tissue stiffness values, pain duration, and torsion type. Elastography examinations were independently performed by two radiologists to evaluate patients who presented to our hospital for follow-up after being diagnosed with testicular torsion and age-matched controls. Inter-observer variability of the mean testicular tissue elasticity was excellent (Intraclass correlation coefficient: 0.939, p < 0.001). Median time between testicular detorsion and follow-up ultrasound examination was 18 months (range, 11-36 months). Torsion side, torsion degree, and pain duration were recorded, and testicular volumes were calculated. The study population comprised 24 patients (48 testes) with a mean age of 21.1 ± 7.8 years. The mean testicular volume was measured as 12.3 ± 5.4ml for the testicular salvage group, 13.9 ± 3.8ml for the contralateral testes, and 13.7 ± 2.7ml for the control group (p=0.553). The mean testicular speed mode values were higher in the testicular salvage group (1.34 ± 1.21 m/s) compared with the contralateral testes group (1.00 ± 0.08 m/s), and the control group (1.01 ± 0.06 m/s), however there was no statistically significant difference between the three groups (p=0.861). While testicular atrophy was detected in three patients, an intraparenchymal wedge-shaped focal hypoechoic area developed after torsion in a further three patients. The elastography examination for focal hypoechoic areas revealed an increase or decrease in tissue stiffness compared to the normal parenchyma. The tissue stiffness values of the testicular salvage group were higher in complete torsion compared to incomplete torsion. The elastography method contributes to other imaging methods in distinguishing focal lesion areas that can be seen after testicular torsion from malignant conditions. Elastography presents as a feasible and practical complementary modality for the follow-up of testicular salvage after torsion.

Time for Resolution of COVID-19 Vaccine-Related Axillary Lymphadenopathy and Associated Factors.

BACKGROUND. The variable clinical course of subclinical lymphadenopathy detected on breast imaging after COVID-19 vaccination creates management challenges and has led to evolving practice recommendations. OBJECTIVE. The purpose of this study was to assess the duration of axillary lymphadenopathy ipsilateral to COVID-19 vaccination detected by breast imaging and to assess factors associated with the time until resolution. METHODS. This retrospective single-center study included 111 patients (mean age, 52 ± 12 years) with unilateral axillary lymphadenopathy ipsilateral to mRNA COVID-19 vaccine administration performed within the prior 8 weeks that was detected on breast ultrasound performed between January 1, 2021, and October 1, 2021, and who underwent follow-up ultrasound examinations at 4- to 12-week intervals until resolution of the lymphadenopathy. Patient information was extracted from medical records. Cortical thickness of the largest axillary lymph node on ultrasound was retrospectively measured and was considered enlarged when greater than 3 mm. Multivariable linear regression analysis was used to identify independent predictors of time until resolution. RESULTS. The mean cortical thickness at the initial ultrasound examination was 4.7 ± 1.2 mm. The lymphadenopathy resolved a mean of 97 ± 44 days after the initial ultrasound examination, 127 ± 43 days after the first vaccine dose, and 2.4 ± 0.6 follow-up ultrasound examinations. A significant independent predictor of shorter time to resolution was Pfizer-BioNTech (rather than Moderna) vaccination (β = -18.0 [95% CI, -34.3 to -1.7]; p = .03]. Significant independent predictors of longer time to resolution were receipt of the second dose after the initial ultrasound examination (β = 19.2 [95% CI, 3.1-35.2]; p = .02) and greater cortical thickness at the initial ultrasound examination (β = 8.0 [95% CI, 1.5-14.5]; p = .02). Patient age, history of breast cancer, and axillary symptoms were not significantly associated with time to resolution (all p > .05). CONCLUSION. Axillary lymphadenopathy detected with breast ultrasound after COVID-19 mRNA vaccination lasts longer than reported in initial vaccine clinical trials. CLINICAL IMPACT. The prolonged time to resolution supports not delaying screening mammography because of recent COVID-19 vaccination. It also supports the professional society recommendation of a follow-up interval of at least 12 weeks when vaccine-related lymphadenopathy is suspected.

Analysis of a New Ultrasound Classification System following Ablation of the Great Saphenous Vein

Ablation of truncal vein reflux, whether by thermal or nonthermal techniques, may be associated with thrombus extension into the deep system and deep venous thrombosis (DVT) in a small number of patients. To assess for this, most patients undergo a follow-up ultrasound examination within 24 to 72 hours after the procedure. Two prior classification systems for describing thrombus extension and managing postprocedure anticoagulation therapy have been widely used. Recently, a new classification system, arteriovenous fistula (AVF) consensus, was published that combined the two in an effort to establish one universal system. In this study, our objective was to use all three classifications in a cohort of patients to determine the impact of consolidating systems in the management of patients with different levels of great saphenous vein (GSV) closure. We performed a retrospective cohort review of consecutive patients who underwent GSV ablation with mechanochemical or thermal techniques at two associated medical centers during years 2015-2017 and 2018-2019. Only patients who underwent postprocedure duplex ultrasound at 24 to 72 hours were included. Ultrasounds were independently assigned to each of the classification systems based on the level of closure (Table). Patient charts were also reviewed to identify treatment. A total of 223 patients were analyzed (150 underwent radiofrequency ablation and 73 ClariVein ablation). The mean age was 58.5 with 49% females and 51% males. Of the patients, 52% underwent concomitant phlebectomies. Two patients required anticoagulation post treatment. Another two underwent a follow-up ultrasound examination with one patient who had unchanged findings and one with improvement of the level of closure. The rest did not require any further follow-up. This was consistent with recommendations by all three classifications. GSV ablation at a level that requires anticoagulation or repeat ultrasound examination is rare, occurring in <1% of patients. The previous systems and AVF consensus system are similar enough that applying either one for the purpose of postprocedure management results in no change in treatment. Based on this data, the AVF classification system may be applied when clinically indicated in the postablation period, to standardize the reporting of this infrequent but important complication.TableNumber of patients by level of closureKabnick class (n = 223)Lawrence class (n = 223)AVF consensus class (n = 223)I (210)I (195)Ia (195)II (12)II (5)Ib (15)III (0)III (10)II (12)Iv (1)IV (11)III (0)V (1)IV (1)VI (1) Open table in a new tab

Extracranial ultrasound following mechanical thrombectomy in patients with acute stroke

Mechanical thrombectomy (MT) is standard care for patients suffering from an ischemic stroke due to a large vessel occlusion. Immediate and follow-up transcranial ultrasound examinations after MT were shown to have a diagnostic benefit. However, it is unclear whether repeated extracranial ultrasound after MT has an additional diagnostic yield, that is, depicts new findings. Retrospectively, from our prospective database we identified all patients after MT who presented for a follow-up examination between January 2017 and March 2020 and who had received an ultrasound examination after MT and at follow-up. Clinical data were extracted from our database. Ultrasound images of all patients were revisited to identify new findings at follow-up compared to examination after MT. Ninety-one patients were identified appropriate for further analysis, with a mean age of 67.8±16 years. Median National Institute of Health Stroke Scale at admission was 11±8.5 points. At baseline ultrasound, 18 patients (19.8%) had no atherosclerotic alterations and 73 patients (82.2%) had a plaque burden of ≥1 plaque. During follow-up, in 5 patients (5.5%) a pathological finding presented in first examination evolved dynamically, that is, normalized. Vessel status of all other patients was stable, especially, in no patient a new relevant pathological finding occurred. Although sonographic normalization of pathologic findings was observed, pathologic new findings were not detected during follow-up. This study provides first data for a discussion of the role of ultrasound in a structured stroke care after MT. However, larger studies are required to improve the understanding.

Re-Evaluation of Fetal Anatomy During Third Trimester Follow-Up Ultrasound Examination.

Re-Evaluation of Fetal Anatomy During Third Trimester Follow-Up Ultrasound Examination.

Prognostic Significance of Ultrasound Findings of Acute Acalculous Cholecystitis for Elderly Long-Term Bedridden Patients.

Background: Acute acalculous cholecystitis (AAC) is characterized by the development of cholecystitis in the gallbladder without gallstones or with small gallstones unrelated to inflammatory diseases. This disease is not rare in the elderly bedridden patients with co-morbidities and prone to develop life-threatening gangrene or perforation of gallbladder. Early imaging is essential for detecting and effectively treating AAC. This study aimed to evaluate the use of ultrasound diagnostic criteria for the diagnosis and prognosis of elderly long-term bedridden patients with suspected AAC.Methods: We retrospectively studied 374 elderly bedridden patients with clinical manifestations of AC at the acute stage of the disease. Gallbladder anomalies were found in 92 patients by ultrasound examination, which correlated with the duration time of clinical manifestations, complications, as well as therapeutic prognosis. The major and minor ultrasound criteria of AAC were made according to the Tokyo Guidelines 2018. Ultrasound results were thought to be AAC positive when they met two major criteria or one major and two minor criteria.Results: Forty-three (46.7%) of the 92 patients presented with AAC (+) test results based on the ultrasound criteria, with a higher incidence of complications (27.9%) than AAC (–) patients (0%; P < 0.001). The median length of symptoms (8 vs. 4 days, P < 0.001) and duration of antibiotic therapy (13 vs. 5 days, P < 0.001) were longer in the AAC (+) group.Conclusions: The ultrasound-based AAC (+) group often had a worse prognosis than the AAC (–) group. Therefore, patients from the AAC (+) group should receive a follow-up ultrasound examination to detect disease progression early.

VP46.19: Volumetric assessment of cervical cerclage indemnity using the Omniview technique

Ultrasound evaluation of the indemnity of uterine cerclage. A prospective clinical study, in Santo Domingo, Dominican Republic, was conducted that included five singleton pregnancies, between 16–36 weeks of gestation, diagnosed with cervical insufficiency and treated with cervical cerclage. Ultrasound follow-up examination was performed using the 3D volumetric technique Omniview, with a single line tracing the sagittal plane of the cervix, crossing both ultrasound reference points of the cerclage, with a thickness of 2 mm. Subsequently, tissue rendering was used, with a 50/50% mixture, 3D Contrast: 60, and 3D brightness: 57. The entire uterine cerclage suture was visualised, including its knot, using the 3D transvaginal ultrasound rendered and captured with the Omniview technique at 16, 28, 34, and 36 weeks of gestation. The volumetric 3D transvaginal ultrasound Omniview technique allows for the evaluation of the integrity of the suture and cerclage knot on different gestational ages. This allows the physician to suggest the use of alternative pharmacological therapies for the prevention of preterm labour if rupture or dehiscence of the cerclage is evidenced. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

The growth rates of solitary gallbladder polyps compared to multi-polyps: A quantitative analysis.

Several studies suggest solitary gallbladder polyps (GBPs) have an increased malignancy risk compared to multi-polyps. Furthermore, some malignant GBPs possessed faster growth rates compared to benign GBPs. To our knowledge, no study has established a relationship between GBP number and growth rates. Hence, this study aims to: (i) determine whether there is a statistical significance in growth rates between solitary GBPs versus multi-polyps; (ii) determine, in a four-year period, the proportion of GBPs in this study's total cohort that exhibit growth compared to previous studies. A retrospective, quantitative, cohort study was implemented utilising 100 consecutive patient records from three private radiology clinics. These were assessed against the eligibility criteria and allocated into the solitary or multi-polyp study group, depending on number of GBPs detected on initial and follow-up ultrasound examinations conducted 6-48 months later. Patient age, GBP sizes, time interval between initial and follow-up ultrasound examinations and GBP growth rates were compared between the study groups utilising Student's t tests. No statistically significant difference was found between the study groups according to gender, age, GBP size and time between ultrasound examinations. Furthermore, there was no statistically significant difference between the growth rates of solitary and multi-polyp groups (P = 0.77). Most GBPs [92/100 (92%)] grew <2 mm in maximal diameter, while 8/100 (8%) of GBPs grew ≥2 mm in maximal diameter at follow-up. The large majority of GBPs maintained size stability at follow-up. On average, solitary GBPs did not grow faster than multi-polyps, although further research is recommended to reinforce this.

Renal pelvic dilation

Renal pelvic dilation

Hydroureter

Hydroureter

Ectopic ureterocele

Ectopic ureterocele

Retained Placenta Creta After Selective Fetal Reduction in Twin Pregnancy: A Case Report

Abstract Placenta accreta spectrum (PAS) disorders are severe obstetric complications and can cause life-threatening hemorrhage, hysterectomy, or even death. PAS disorders in one of dichorionic diamniotic twins are rare to be seen in clinical practice and lack of standard management strategies. We reported a case of retained placenta creta after selective fetal reduction in one of dichorionic diamniotic twins. A 32-year-old woman with a history of cesarean section was diagnosed with placenta increta in one of dichorionic diamniotic twins at 16 weeks of gestation. After discussion, the couple required to be hospitalized for selective fetal reduction. She received selective termination by ultrasound-guided single fetal intracardiac injection of potassium chloride. The follow-up prenatal ultrasound examinations detected the placenta of the reduced fetus did not stop invade the myometrium of the uterus but developed from placenta increta to placenta percreta. The patient was diagnosed with placental percreta by prenatal ultrasound signs and surgical findings. The patient underwent scheduled cesarean delivery at 34+5 gestational weeks. The outcome of maternal and fetal was satisfactory for our elaborate operation and optimal management. PAS disorders are severe obstetric complications with an increasing incidence. Combined with twin pregnancy makes PAS disorders more intractable. We should learn that selective fetal reduction probably cannot solve it thoroughly. Intensive and standard management is essential to promote maternal and fetal outcomes.

ХИРУРГИЧЕСКАЯ ТАКТИКА ПРИ ПОЛИПАХ ЖЕЛЧНОГО ПУЗЫРЯ

Background. Due to the use of modern diagnostic technique the detection rate of gallbladder polyps constitutes 3-6%, and the number of cholecystectomies for polyps reaches up to 10% of all operations on this organ. Objective. To evaluate diagnosis and treatment outcomes in patients with gallbladder polyps and to define specific indications for surgical treatment (on the basis of a large number of observations). Material and methods. The article evaluates diagnosis and treatment outcomes in 237 patients with gallbladder polyps. Results. 235 (99,2%) patients underwent laparoscopic cholecystectomy. 2 (0,8%) patients with concomitant postoperative ventral hernia underwent herniolaparotomy, open cholecystectomy, anterior abdominal wall repair using a polypropylene mesh. Conclusions. Patients with small polyps (up to 5 mm) undergo follow-up ultrasound examination every 6 months; in case of doubtful findings CT or MRI of the gallbladder should be performed. The patients with medium polyps (5-10 mm) undergo laparoscopic cholecystectomy provided the polyps are multiple or with a broad base, otherwise such patients are followed-up. Laparoscopic cholecystectomy should be performed in case of large polyps or in patients with gallstone disease regardless of polyp size.

Sphygmomanometer-induced hemostasis following iatrogenic guidewire perforation during lower extremity angioplasty.

Iatrogenic guidewire perforation is a well-known complication of lower extremity angioplasty that is often benign or can be easily treated with endovascular techniques. However, perforations that occur in arterial side branches may be more challenging to manage. If bleeding persists, open surgery and fasciotomy may be required to evacuate the resulting hematoma and prevent compartment syndrome. These subsequent procedures increase morbidity and, if the angioplasty was performed in the outpatient setting, necessitate patient transfer to a hospital. To address these challenges, we describe a non-invasive hemostasis technique involving serial sphygmomanometer cuff inflations over the affected site in a series of five patients who experienced this complication at our office. We retrospectively reviewed the medical records of consecutive patients undergoing lower extremity angioplasty that were found to have an arterial guidewire perforation on completion angiogram at our outpatient center between February 2012 and February 2017. Patients found to have iatrogenic guidewire perforations were administered intravenous protamine sulfate and were transferred to the surgical recovery room. Patients received ibuprofen or acetaminophen for pain management. A blood pressure cuff was placed around the site of perforation, and patients received serial cuff inflation cycles with repeated examinations of both limbs until patients reported cessation of pain and there were no signs of a developing hematoma. Patients were observed for two hours before they were discharged home. A follow-up duplex ultrasound examination was completed within one week of the intervention. Over the course of five years, 536 angioplasties were performed at our outpatient office. Five of these patients experienced iatrogenic guidewire perforation (0.93%). Perforations occurred in branches of the anterior or posterior tibial artery. All of these patients were successfully managed with the aforementioned hemostasis technique. None of these patients required transfer to a hospital for further management, and no complications were reported at follow-up. Complications of iatrogenic guidewire perforations in lower extremity arterial side branches can be safely and effectively managed by applying external compression around the affected site with an automatic blood pressure cuff.

Using Z-score to optimize population-specific DDH screening: a retrospective study in Hangzhou, China

BackgroundDDH (Developmental Dysplasia of the Hip) screening can potentially avert many morbidities and reduce costs. The debate about universal vs. selective DDH ultrasonography screening in different countries revolves to a large extent around effectiveness, cost, and the possibility of overdiagnosis and overtreatment. In this study, we proposed and evaluated a Z-score enhanced Graf method to optimize population-specific DDH screening.MethodsA total of 39,710 history ultrasonography hip examinations were collected to establish a sex, side specific and age-based Z-scores model using the local regression method. The correlation between Z-scores and classic Graf types was analyzed. Four thousand two hundred twenty-nine cases with follow-up ultrasonographic examinations and 5284 cases with follow-up X-ray examinations were used to evaluate the false positive rate of the first examination based on the subsequent examinations. The results using classic Graf types and the Z-score enhanced types were compared.ResultsThe Z-score enhanced Graf types were highly correlated with the classic Graf’s classification (R = 0.67, p < 0.001). Using the Z-scores ≥2 as a threshold could reduce by 86.56 and 80.44% the false positives in the left and right hips based on the follow-up ultrasonographic examinations, and reduce by 78.99% false-positive cases based on the follow-up X-ray examinations, respectively.ConclusionsUsing an age, sex and side specific Z-scores enhanced Graf’s method can better control the false positive rate in DDH screening among different populations.

OHVIRA-syndrome in a newborn

OHVIRA-Syndrome (Obstructed hemivagina with ipsilateral renal anomaly) is a rare congenital malformation. Diagnosis of this malformation is usually made during adolescence. Delayed diagnosis may result in serious complications with potential future obstetric problems. We report on a newborn girl presenting with an interlabial mass formation, a vaginal introitus on the right lateral aspect and an orthotopic urethral meatus on primary inspection. Ultrasound examination revealed left sided renal agenesis and a hydrocolpos posterior to the bladder. OHVIRA-Syndrome was assumed and a surgical incision of the obstructed left hemivagina for drainage of the hydrocolpos was performed. Further examination confirmed anatomical conditions corresponding to OHVIRA-Syndrome. Aside from routine clinical follow-up and regular ultrasound examination, further interventions were postponed until puberty. In this case report we aim to share our experience of a newborn girl with OHVIRA-Syndrome. We discuss appropriate medical decision-making regarding surgical management of patients with this malformation during each stage of development with a corresponding literature review.

Evaluating the Transvaginal Ultrasound Diagnostic Criteria for Abnormal First-Trimester Pregnancy With Follow-Up Into the Third Trimester and Validation of Results.

To evaluate the current ultrasound diagnostic criteria for non-viable pregnancy in the first trimester. We conducted a retrospective chart review involving 3 tertiary care institutions. Consecutive first-trimester ultrasound reports between January 2013 and June 2016 were reviewed. All first-trimester ultrasound examinations performed to assess pregnancy viability with adequate imaging or clinical follow-up were included. Inclusion criteria based on follow-up were adequate imaging to document ongoing intrauterine pregnancy or clinical follow-up demonstrating viability or non-viability. Data on mean sac diameter (MSD), yolk sac presence/diameter, embryo presence/length, presence of a heartbeat, and heart rate were collected. This was followed by a retrospective validation review of another consecutive cohort. Two hundred and forty-five examinations with a viable-pregnancy outcome and 301 examinations with a non-viable pregnancy outcome were reviewed. The main predictor of non-viable pregnancy was an MSD of ≥20 mm in the absence of a yolk sac (positive predictive value [PPV] 100%; 95% CI 93%-100%), embryo (PPV 100%; 95% CI 90%-100%), or heartbeat (PPV 100%; 95% CI 96%-100%]). Other predictors of non-viability were a measurable embryo without a yolk sac (PPV 100%; 95% CI 91%-100%), yolk sac diameter ≥8 mm (PPV 100%; 95% CI 91%-100%), and absence of heartbeat with an embryo ≥3 mm (PPV 100%; 95% CI 97%-100%). These findings were confirmed in a validation cohort of 45 viable and 53 non-viable pregnancies, with the exception of 1 case of viable pregnancy with no heartbeat and an embryo length 3.3 mm. Based on the median daily growth of 1.2 mm in the viable cohort, 21% of follow-up ultrasound examinations were performed too early for an MSD threshold of 20 mm and 55%, for an MSD threshold of 25 mm. In our cohort, MSD ≥20 mm in the absence of yolk sac or an embryo with heartbeat always predicted a non-viable pregnancy.

Case of endovenectomy and stenting with functioning arteriovenous fistula in extended post-thrombotic occlusion of deep veins

We describe herein a case of surgical treatment of a 32-year-old female patient presenting with multilevel post-thrombotic occlusion of deep veins of the left lower limb. Laboratory study revealed high-risk hereditary thrombophilia (homozygous mutation of PAI-1, MTR, heterozygous mutation of MTHFR, MTRR, ITGA2). The first stage included endovenectomy from the common femoral vein with creation of an arteriovenous fistula between femoral vessels. An attempt of endovascular stenting of iliac veins was initially unsuccessful. After 3 months, the woman was rehospitalized to undergo successful endovascular operation with stenting of the iliac veins and common femoral artery on the background of the functioning arteriovenous fistula. The clinical outcome of the operation was good. Follow-up ultrasonographic examinations (ultrasound duplex scanning) were performed at 3, 6, 10 and 13 months after the second operation. The findings of ultrasound duplex scanning at 13 months showed that the stented segments of deep veins were freely patent, with the arteriovenous fistula functioning well. There were no signs of impairments of central haemodynamics, with significant regression of clinical symptoms. The total score by the Villalta scale as compared with the baseline values decreased from 13 to 5. Given the pattern of deep vein lesions, complexity of open and endovascular operations, and the presence of thrombophilia, we decided to abstain from disuniting the arteriovenous fistula. This case report demonstrates possibility, efficacy and safety of long functioning of an artificial arteriovenous fistula in a particular patient cohort.