High-flow Type Research Articles

A novel subtype classification and corresponding surgical strategies for spinal dural cysts –a report of 104 cases

BACKGROUNDThe nomenclature, classification, and surgical approaches for spinal dural cysts (SDCs) remain a subject of controversy. PURPOSEThe present study proposes a novel subtype classification system and corresponding surgical strategies, with the aim of enhancing comprehension of this entity and standardizing surgical treatment. STUDY DESIGNA retrospective review. PATIENT SAMPLEA total of 104 patients with SDCs underwent novel subtype classification and corresponding surgical strategies from January 2015 to December 2021. Fifty-four patients who underwent conventional surgery from January 2012 to December 2014 as the control group for preliminary validation. OUTCOME MEASURESThe outcomes are categorized into 4 levels: excellent, good, unchanged, and deteriorated, based on neurological improvement and pain relief. Grades of excellent and good were identified as improvements. Follow-up magnetic resonance imaging and complications were also evaluated. METHODSBased on the shared pathogenic factor of dural defects, the dural-associated cysts in the spinal canal are uniformly referred to as SDCs. They are further classified into Type 1 (no nerve roots) and Type 2 (containing nerve roots), with 4 additional subtypes based on the shape of the leak and the flow of leakage. The fissure-shaped leak of Type 1a SDCs is directly sutured, whereas the aperture-shaped leak of Type 1b is repaired using a patch. Low-flow leakage of Type 2a is directly sealed using a combination of adipose tissue and fibrin glue, whereas high-flow Type 2b necessitates suturing at the end of the leak to attenuate cerebrospinal fluid flow prior to sealing. RESULTSThe follow-up period averaged 23.8 months. Excellent or good outcomes were achieved in 100%, 88.9%, 100%, and 97.3% for the 4 subtypes respectively. The overall improvement rate of SDCs was 97.1%, which was significantly higher than that of the conventional surgery group (85.2%, p=.008). MRI follow-up showed a significant reduction in cyst size of 100%, 100%, 97.8%, and 97.3% for the 4 subtypes, respectively. The primary complications included pseudomeningocele in 4 cases (3.8%) and delayed wound healing in 5 cases (4.8%). The complication rate was also significantly lower than that of the control group (8.7% vs 24.1%, p=.008). CONCLUSIONSSubtyping SDCs based on the variation of leaks and leakage can enable more targeted surgical strategies, which are helpful for improving treatment effectiveness and reducing complications.

Synoptic Analysis of Flood-Causing Rainfall and Flood Characteristics in the Source Area of the Yellow River

The source area of the Yellow River (SAYR) in China is an important water yield and water-conservation area in the Yellow River. Understanding the variability in rainfall and flood over the SAYR region and the related mechanism of flood-causing rainfall is of great importance for the utilization of flood water resources through the optimal operation of cascade reservoirs over the upper Yellow River such as Longyangxia and Liujiaxia, and even for the prevention of flood and drought disasters for the entire Yellow River. Based on the flow data of Tangnaihai hydrological station, the rainfall data of the SAYR region and NCEP-NCAR reanalysis data from 1961 to 2020, three meteorological conceptual models of flood-causing rainfall—namely westerly trough type, low vortex shear type, and subtropical high southwest flow type—are established by using the weather-type method. The mechanism of flood-causing rainfall and the corresponding flood characteristics of each weather type were investigated. The results show that during the process of flood-causing rainfall, in the westerly trough type, the mid- and high-latitude circulation is flat and fluctuating. In the low vortex shear type, the high pressures over the Ural Mountains and the Okhotsk Sea are stronger compared to other types in the same period, and a low vortex shear line is formed in the west of the SAYR region at the low level. The rain is formed during the eastward movement of the shear line. In the subtropical high southwest flow type, the low trough of Lake Balkhash and the subtropical high are stronger compared to other types in the same period. Flood-causing rainfall generally occurs in areas with low-level convergence, high-level negative vorticity, low-level positive vorticity, convergence of water vapor flux, a certain amount of atmospheric precipitable water, and low-level cold advection. In terms of flood peak increment and the maximum accumulated flood volume, the westerly trough type has a long duration and small flood volume, and the low vortex shear type and the subtropical high southwest flow type have a short duration and large flood volume.

Patch Technique for Primary Treatment of Type A Carotid Cavernous Fistula: A Case Series and Technical Notes.

The utilization of flow diverters (FDs) in the treatment of high-flow Type A carotid cavernous fistulas (CCFs) has been described before mainly as an adjunct to the traditional endovascular techniques and rarely as a stand-alone treatment. In this study, we retrospectively evaluated our experience with FDs as the solo nonadjunctive treatment of Type A CCF with severe cortical venous reflux (CVR). A retrospective review was performed of patients with Type A CCFs who were treated using FDs' patch technique (PT). Patients' demographics, clinical data, and preoperative and postoperative ocular examination were recorded. The procedure technique, pipeline embolization device (PED) diameters, and immediate and late procedure outcomes were described. Three patients were included in this case series. All patients had history of trauma and presented with decreased visual acuity, cranial nerve II deficit, limited extraocular muscles' movement, and increased intraocular pressure (IOP). Diagnostic angiography was performed, which confirmed high-flow Type A CCF. Endovascular treatment was performed through distal radial access in 2 patients and femoral access in 1 patient by deploying 4 sequentially enlarging PEDs with immediate resolution of the ocular symptoms. Follow-up angiography confirmed complete resolution of CCF in 2 patients. One patient was lost to follow-up; however, angiogram at 4 months demonstrated residual small CCF with significant improvement from postprocedure angiogram. The patch technique using sequentially enlarging FDs is a reasonable alternative solo technique for the treatment of direct CCF symptoms and results in immediate resolution of CVR while preserving the cavernous sinus anatomy.

Interventional treatment of traumatic carotid-cavernous fistula: A case report.

Patients with traumatic carotid-cavernous fistula (TCCF) usually go to the ophthalmology department first because of the symptoms such as protrusion of eyes, edema and congestion of combined membrane, vision loss and so on. It is easy to be misdiagnosed and missed. We report a case of left eye swelling and vision loss caused by TCCF after head injury due to traffic accident, which failed to respond to ophthalmic treatment for many times. The similar situation is very likely to cause panic among patients. Cerebral angiography revealed left internal carotid-cavernous fistula (high flow type). Left internal carotid artery covered stent implantation was performed. The fistulas and the original venous mass were completely covered by the covered stent, and the development of the vascular mass disappeared. The patient's eye symptoms basically disappeared 14 days after the operation. Interventional treatment of TCCF is effective.

Microsurgical resection of high-flow cerebral arteriovenous malformations after recurrent stroke

Arteriovenous malformations (AVMs) are tangled lesions that may digress the blood flow particularly the high flow ones and microsurgical resection is challenging. The natural history of AVM is not completely understood and its management is controversial. Microsurgical resection of cerebral arteriovenous malformation is a challenging procedure, particularly for high-flow type. Embolization, microsurgery, or radiotherapy are treatment options. Preoperative planning to control the feeders, arachnoid dissection around the AVM for identification and control of all arterial feeders around the AVM surfaces, lastly control of draining vein is the principal of microsurgery. The goal of surgery is to remove the AVM completely to eliminate the risk of bleeding avoiding neurological deterioration. In this paper, we reviewed a case of high-flow cerebral AVM in recurrent bleeding with successful microsurgical resection.The patient in this case report significantly improved his neurological condition and demonstrated a good quality of life during long-term follow-up. The results of this study showed that the microsurgical removal of AVMs represents an efficient treatment with good clinical outcomes. In the future, more investigations of the factors that lead to AVM rupture are required for the advancement of effective medical procedures.

Periorbital Inner Canthal Arteriovenous Malformations: Percutaneous Glue Embolization in Three Cases

AbstractInner canthal or palpebral arteriovenous malformations (AVMs) are uncommon and difficult lesions to treat if they are of high-flow type. Though they may present with mainly cosmetic reasons, they derive feeders from the ophthalmic artery and are associated with dangerous anastomoses. Percutaneous liquid embolic agent has been used to treat various head and neck vascular malformations and tumors and, if done in meticulous attention to detail, can offer cure or control before surgical excision. We report three adults who presented with medial canthal swelling and on imaging diagnosed to have high-flow AVMs. They underwent percutaneous n-butyl cyanoacrylate (glue) embolization and subsequently operated to excise the embolized malformation without any blood loss or complications.

Intraoperative contrast-enhanced ultrasound for early diagnosis of endoleaks during endovascular abdominal aortic aneurysm repair

BackgroundThe aim of this study was to evaluate the feasibility and utility of intraoperative contrast-enhanced ultrasound (CEUS) for early detection of endoleaks (ELs) during endovascular abdominal aortic aneurysm repair (EVAR) compared with completion digital subtraction angiography. MethodsPatients undergoing elective EVAR from January 2017 to April 2018 were consecutively enrolled in this prospective study. After endograft deployment, two-digital subtraction angiography (2DSA) with orthogonal C-arm angulations (anteroposterior and sagittal view) were routinely performed. After the endovascular treatment of clear, high-flow type I/III ELs detected by 2DSA, intraoperative CEUS was carried out in sterile conditions on the surgical field before guidewire removal. Presence and type of EL were evaluated with 2DSA and CEUS. CEUS was performed with the vascular surgeon blinded to the 2DSA findings. The primary end point was the level of agreement between 2DSA and CEUS to detect any type of EL and type II EL. Agreement between two diagnostic methods was calculated using Cohen's kappa. The secondary end point was utility of CEUS for intraoperative adjunctive procedure guidance. ResultsSixty patients were enrolled (mean age, 78 ± 6 years; 90% male). 2DSA revealed 11 ELs (18%; 1 type IA, 10 type II), and CEUS 25 ELs (42%; 2 type IA, 23 type II). 2DSA and CEUS were in agreement in 39 cases (65%; 32 no ELs, 7 type II ELs). CEUS detected 17 ELs not identified by 2DSA (28%; 2 type IA, 15 type II); 2DSA detected three ELs not identified by CEUS (5%; 3 type II). In one case, 2DSA and CEUS detected type II and type IA ELs, respectively. For EL and type II EL detection, Cohen's kappa was 0.255 and 0.250, respectively (both “fair agreement”). Intraoperative adjunctive sac embolization was performed under CEUS control in 4 cases and technical success was 100%. ConclusionsIntraoperative CEUS during EVAR is feasible and can detect a greater number of ELs than 2DSA, in particular type II ELs. Further studies are necessary to assess the reliability of this intraoperative diagnostic examination. In type II ELs, CEUS may represent an additional, useful tool for intraoperative sac embolization guidance.

Angioarchitecture and hemodynamics of microvascular arterio-venous malformations.

IntroductionArteriovenous malformations (AVMs) are characterized by pathological high flow, low resistance connections between arteries and veins. Treatment is critically dependent on correct interpretation of angioarchitectural features. However, some microfistular AVMs do not match the characteristics described in current AVM classification systems. Therefore, we propose a new subgroup of microfistular AVMs, composed of enlarged, fistulous paths on the venous half of capillaries and/or dilated draining venules (hyperdynamic, capillary-venulous malformation [CV-AVM]). CV-AVMs still ensure arterial flow to the periphery and fistulous venous drainage is less pronounced than in classical AVMs such that these lesions are often misinterpreted as venous malformations.Materials and methodsWe developed a computational model to study the effects of microvascular anomalies on local hemodynamics, as well as their impact on angiographic contrast propagation. Flow rates and pressures were computed with a lumped parameter description, while contrast propagation was determined by solving the 1D advection-diffusion equation.Results and conclusionsFor the newly proposed CV-AVM angioarchitecture, the computational model predicts increased arterio-venous contrast agent transit times and highly dispersive transport characteristics, compared to microfistular, interstitial type IV AVMs and high flow type II and III AVMs. We related these findings to time-contrast intensity curves sampled from clinical angiographies and found that there is strong evidence for the existence of CV-AVM.

Polyvinyl alcohol terminal chemoembolization for hepatocellular carcinoma with hepatic arteriovenous shunts: Safety, efficacy, and prognostic factors

PurposeTo evaluate the safety and efficacy of polyvinyl alcohol (PVA) terminal chemoembolization and to identify the prognostic factors associated with survival in hepatocellular carcinoma (HCC) patients with hepatic arteriovenous shunts (HAVS). Materials and methodsOf 133 patients’ managements were retrospectively analyzed. HAVS was classified into three types: slow-flow, intermediate-flow and high-flow. The size of the PVA used was determined following the scheme: slow-flow HAVS: 300–500μm PVA; intermediate-flow HAVS: 500–710μm PVA; high-flow HAVS: 710–1000μm PVA. The HCCs with slow-flow and intermediate-flow HAVS were embolized by PVA plus chemotherapeutic agents lipiodol emulsion, while the high-flow HAVS were treated by PVA with chemotherapeutic agents. Survival curves were calculated by Kaplan-Meier method and compared by log-rank test. The influence of possible prognostic factors on survival were analyzed by multivariate Cox proportional-hazards method. ResultsThe median overall survival (OS) of 133 patients was 9.1 months. The median OS of the slow-flow type, intermediate-flow type and high-flow type patients were 10.8, 9.1 and 7.3 months, respectively. There was no statistically significant difference among different HAVS types (P=0.239). The 30-day mortality was 3.8%. Cox multivariate survival analysis revealed that initial preoperative AFP value≥400ng/ml (HR=2.105, P=0.006) was an independent risk factor. While multiple embolization (HR=0.482, P=0.011), tumor remission (HR=0.431, P=0.041) and multimodality therapy (HR=0.416, P=0.004) were independent protection factors. ConclusionIt is safe and effective for HCCs with HAVS treated by terminal chemoembolization therapy with PVA plus chemotherapeutic agents lipiodol emulsion (or PVA plus chemotherapeutic agents). The HCCs with HAVS achieves good prognosis with multiple embolization, tumor remission and multimodality therapy, while achieves poor prognosis with inital preoperative high AFP value (≥400ng/ml).

Diagnosis and management of priapism

Priapism is defined as an erection for more than 4 h without sexual stimulation. The most common form with nearly 95% is the ischemic or low-flow form, which is very painful. The other 5% are comprised of nonischemic high-flow type usually caused by a blunt perineal trauma and the recurrent or intermittent so-called stuttering priapism. Anamnesis as well as physical and laboratory examination are important during the diagnostic workup. Patients who suffer from sickle cell anemia are predestined to develop priapism. Priapism constitutes a urological emergency because especially the low-flow type has to be treated immediately to prevent a long-lasting fibrosis of the corpus cavernosa and a consecutive erectile dysfunction. The first step is the puncture and aspiration of blood from the corpus cavernosa if necessary combined with the injection of α-agonists. In case detumescence is not achieved, an operative shunt should be placed after an MRI. If there is a complete fibrosis of the corpus cavernosa possibly combined with penis deviation the implantation of a penile prosthesis is an option. The therapy of high-flow priapism is not as urgent as that of low-flow priapism because there is no risk of ischemia. If conservative therapeutic options fail, the superselective embolization of the fistula is the treatment of choice. In recurrent or intermittent priapism, the goal is to avoid new episodes with drug treatment. Because of the low incidence of priapism, it is very difficult to recommend and favor one therapeutic procedure.

Differential hemodynamic characteristics of high-resistance vs. high-flow type of pulmonary artery hypertension revealed by phase-contrast MRI

Results As compared to Group 1, MPA of Group 2 and 3 showed larger cross-sectional area (P<0.001), decreased distensibility (P=0.001), slower flow velocity (P<0.001), faster PWV (p=0.005), with more (P<0.001) and longer duration (P=0.030) of vortex and higher PVR (P<0.001). (Table). Compared to Group 2, Group 3 had lower flow rate (P=0.002), shorter accelerative time (P=0.003) and higher PVR (P=0.018).(Table). With multiple linear regression model, we found that vortex (number and duration) and PWV of MPA predicted well of meanPAP in Group 3 (R=0.821), while only moderately in Group 2 (R=0.625). With adding the distensibility of MPA, the prediction of mean PAP improved significantly (R=0.625 to 0.978) in Group 2, while only marginally in Group 3 (R=0.821 to 0.873). Conclusions

Kupffer-Phase Findings of Hepatic Hemangiomas in Contrast-Enhanced Ultrasound with Sonazoid

The aim of this study was to assess quantitatively the Kupffer-phase enhancement patterns of hepatic hemangiomas in contrast-enhanced ultrasound (CEUS) with Sonazoid. A total of 46 patients with 46 hepatic hemangiomas (17.1 ± 6.2 mm in diameter, 34 typical type and 12 high-flow type) underwent CEUS in the Kupffer phase. The lesion-to-liver contrast ratio in the Kupffer phase was quantitatively assessed for both types of hemangioma. Most of the hepatic hemangiomas, whether or not they were the high-flow type, were iso- to hypo-echoic relative to the surrounding liver parenchyma. The contrast ratio was –5.33 ± 6.70 dB for the high-flow hemangiomas and −4.54 ± 6.28 dB for the typical hemangiomas. There was no significant difference in contrast ratio between the two types of lesions (p = 0.73). All of the hemangiomas, whether of typical or high-flow type, are iso- to hypo-echoic relative to the surrounding liver parenchyma on Kupffer-phase imaging.

Post traumatic temporalis muscle hemangioma

Hemangioma accounts for 7% of total tumors of soft tissue in which 0.8% is intramuscular. Only 17% of the intramuscular hemangioma are posttraumatic at any site. There are only 23 case reports of temporalis muscle hemangioma and among these there is only one case report of posttraumatic hemangioma of the temporalis muscle in the available literature. Here we report a second case of posttraumatic temporalis muscle hemangioma in a 30-year-old female who presented with 4-year long history of progressive enlarging and painful swelling on the left temporal region following blunt injury in the same region. The mass was completely removed and histopathological examination showed cavernous hemangioma, so it should always be considered in the differential diagnosis of unexplained pain and swelling of muscle. Magnetic resonance imaging (MRI) is investigation of choice but computed tomography (CT) carotid angiography is superior choice with high flow type as it not only gives detail of a lesion but also shows arterial feeder and draining veins, which help in surgical planning as in our case.

Giant High-Flow Type Pulmonary Arteriovenous Malformation: Coil Embolization with Flow Control by Balloon Occlusion and an Anchored Detachable Coil

Pulmonary arteriovenous malformations (PAVMs) are often treated by pushable fibered or non-fibered microcoils, using an anchor or scaffold technique or with an Amplatzer plug through a guiding sheath. When performing percutaneous transcatheter microcoil embolization, there is a risk of coil migration, particularly with high-flow type PAVMs. The authors report on a unique treatment in a patient with a giant high-flow PAVM whose nidus had a maximum diameter of 6 cm. A detachable coil, not detached from a delivery wire (an anchored detachable coil), was first placed in the feeding artery under flow control by balloon occlusion, and then multiple microcoils were packed proximally to the anchored detachable coil. After confirming the stability of the microcoils during a gradual deflation of the balloon, we finally released the first detachable coil. The nidus was reduced in size to 15 mm at one year postoperatively.

Peripheral low intensity sign in hepatic hemangioma: Diagnostic pitfall in hepatobiliary phase of Gd‐EOB‐DTPA‐enhanced MRI of the liver

To describe the presence of "peripheral low intensity sign" in hepatic hemangioma in the hepatobiliary phase (HP) of gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance imaging (MRI) and to compare the frequency of this sign between hepatic hemangiomas and hepatic metastases. The Institutional Review Board approved this study and waived the requirement for informed consent. Sixty-four patients with 51 hepatic hemangiomas (n = 31 patients) and with 58 hepatic metastases (n = 33 patients) underwent Gd-EOB-DTPA-enhanced MRI. In all hepatic hemangiomas, 41 lesions were the typical type and 10 were the high flow type. HP images were qualitatively evaluated for the frequency of peripheral low intensity sign in hepatic hemangiomas and hepatic metastases using a four-point scale. Statistical evaluations were performed with a Mann-Whitney U-test. Peripheral low intensity signs were demonstrated in 24 (47%) of 51 hepatic hemangiomas, while they were seen in 27 (47%) of 58 hepatic metastases. There was no significant difference in the mean visual score of peripheral low intensity sign between all hepatic hemangiomas (0.84 ± 1.03) and hepatic metastases (0.76 ± 0.92). The mean visual score of peripheral low intensity sign in typical hemangiomas (1.02 ± 1.06) was significantly higher than that in high flow hemangiomas (0.10 ± 0.32) (P = 0.008). Peripheral low intensity sign is not specific for malignant tumors, and can be seen even in hepatic hemangiomas on HP of Gd-EOB-DTPA-enhanced MRI.

Proptosis, Congestion, and Secondary Glaucoma Due to Carotid-Cavernous Fistula After Embolization

Carotid-cavernous fistulas (CCFs) are traumatic or spontaneously occurring communications between the carotid artery and the cavernous sinus. Carotid-cavernous fistulas can be due to a direct connection or indirect connections between the carotid artery system and the cavernous sinus. According to the etiologic classification, they may be of traumatic or spontaneous origin, and according to the angiography classification, they may be of direct or dural. Most CCFs are of spontaneous origin, and these are reported as frequently self-healing lesions. Spontaneous CCFs are mostly secondary to arteriosclerotic changes, which explains the increased ratio of elderly patients. Traumatic CCFs are usually of high-flow type and need intervention. The symptoms are various usually correlated to the size and type of venous drainage. The most frequent symptoms on presentation are proptosis, conjunctivitis, and chemosis; however, this picture may be complicated by optic nerve edema, cranial nerve palsies, and intracranial hemorrhage. We report a case with right low-flow dural CCF, which has worsened after angiography and recovered totally soon after endovascular embolization process.

Hepatic Hemangiomas: Evaluation of Enhancement Patterns at Dynamic MRI With Gadoxetate Disodium

The aim of this retrospective study was to assess the enhancement patterns of hepatic hemangiomas on gadoxetate disodium. A total of 22 patients with 32 hepatic hemangiomas (23 typical type and nine high-flow type) in normal liver underwent gadoxetate disodium-enhanced MRI. Contrast-enhanced images were obtained before and after contrast injection, including arterial phase, portal phase, equilibrium phase, and three hepatobiliary phases (10, 15 and 20 minutes). Signal-to-phantom ratios of hemangiomas and the portal vein as well as lesion-to-liver contrast-to-phantom ratios were assessed. Mean signal-to-phantom ratios of all 32 hemangiomas showed the highest value on the arterial phase and subsequently decreased over time (p = 0.029 to p < 0.001). Mean lesion-to-liver contrast-to-phantom ratios of all 32 hemangiomas showed a positive value during the arterial phase and increasingly negative values at later time points (p = 0.001 to p < 0.001). The enhancement pattern of hemangiomas was equal to that of the portal vein at all time points. There was no significant difference in signal-to-phantom ratio between typical hemangiomas and high-flow hemangiomas at any time point. Most hepatic hemangiomas showed hypointensity relative to surrounding liver parenchyma during the equilibrium phase and the hepatobiliary phase. In addition, hepatic hemangiomas showed a signal intensity matching the portal vein at all phases, a finding we believe may be characteristic for hepatic hemangiomas on gadoxetate disodium-enhanced MR images.

Inferior Vena Cava Stent-Graft Placement to Treat Endoleak Associated With an Aortocaval Fistula

To report a case in which a persistent high-flow type II endoleak after endovascular aneurysm repair (EVAR) of a leaking abdominal aortic aneurysm (AAA) complicated by an aortocaval fistula was repaired with a stent-graft in the inferior vena cava (IVC). A 76-year-old man underwent emergent EVAR with an aortomonoiliac device to exclude a leaking 9-cm AAA. The 30-day computed tomography (CT) scan showed 2-mm sac expansion and a type II endoleak arising from a lumbar artery; the outflow vessel was the inferior vena cava (IVC) via a fistula that was not depicted on the non-contrast preoperative CT or the intraoperative angiogram. No intervention was deemed necessary at the time. Six months after EVAR, the AAA had not expanded further, but the fistula between the sac and the IVC was larger in diameter. A tubular stent-graft was implanted in the IVC to seal the defect. No complications have been noted up to 36 months after the IVC stent-graft procedure. Aortocaval fistulae should be excluded in the case of persistent type II endoleaks after EVAR for ruptured AAAs. IVC endografting is a minimally invasive alternative to treat such a complication, with promising midterm results in this patient.

Endovascular Repair of Abdominal Aortic Aneurysms with Aortocaval Fistula

ObjectivesTo examine the risk of high-flow type II endoleak following endovascular repair of abdominal aortic aneurysm with aortocaval fistula. DesignCase reports. SubjectsTwo patients with abdominal aortic aneurysms with aortocaval fistula. MethodsBoth patients had an endovascular repair of their aortic aneurysms. ResultsThe aneurysms were successfully treated in both patients, without any endoleak on completion angiography. Apart from a transient type II lumbar endoleak in one of the patients, no endoleak was found after 3 and 12 month follow-up. Seven other cases have been published, reporting one type II and one type Ic endoleak. ConclusionWe found no evidence that endovascular repair of abdominal aortic aneurysm with aortocaval fistula is associated with a higher incidence of persistent endoleak.

Diagnosis and treatment of priapism: experience with 5 cases

Objectives. Priapism is a rare disease, but needs early intervention and appropriate management. We present 5 cases, 2 of nonischemic high-flow priapism and 3 of ischemic low-flow priapism.Methods. Focusing on the differential diagnosis of priapism between the nonischemic high-flow type and the ischemic low-flow type, we reviewed the medical records of 5 patients.Results. Of the examinations carried out, cavernosography, blood gas analysis of cavernosal blood, color Doppler ultrasound, and internal pudendal arteriography were useful in differentiating the type of priapism. Complete detumescence of the penis in 2 cases of high-flow priapism and 3 cases of low-flow priapism was achieved by selective embolization with gelform and by glandular-cavernosal shunting, respectively. No recurrence was observed in any patient, and postoperative erectile function was preserved in 4 patients and is unknown in 1.Conclusions. These results indicate that angiographic studies provide the most reliable information for the differentiation of the type of priapism. However, color flow Doppler ultrasound and cavernosal blood gas determination can obviate the need for angiographic studies and are noninvasive. Although conservative treatment or even expectant management may be feasible with high-flow priapism, aggressive treatment should be carried out for low-flow priapism immediately after initial treatment fails to achieve detumescence of the penis. Selective embolization of the internal pudendal artery may be the treatment of choice for patients with high-flow priapism.