Initial Contrast-enhanced Computed Tomography Research Articles

Prognostic value of initial and longitudinal changes in body composition in metastatic pancreatic cancer.

Sarcopenia or visceral adipose tissue has been reported to be related to pancreatic cancer prognosis. However, clinical relevance of the comprehensive analysis of body compositions and their longitudinal changes is lacking. This study analysed the association between body composition changes after chemotherapy and survival in patients with metastatic pancreatic cancer. We retrospectively included 456 patients (mean age±standard deviation, 61.2±10.0years; 272 males and 184 females) with metastatic pancreatic cancer who received palliative chemotherapy from May 2011 to December 2019. Using deep learning-based, fully automated segmentation of contrast-enhanced computed tomography (CT) at the time of diagnosis, cross-sectional areas of muscle, subcutaneous adipose tissue and visceral adipose tissue were extracted from a single axial image of the portal venous phase at L3 level. Skeletal muscle index (SMI), visceral adipose tissue index (VATI), subcutaneous adipose tissue index (SATI) and mean skeletal muscle attenuation (MA) were calculated, and their effect on overall survival (OS) was analysed. Longitudinal changes in body composition and prognostic values were also analysed in a subgroup of patients with 2- and 6-month follow-up CT (n=349). A total of 452 deaths occurred during follow-up in the entire cohort. The survival rate was 49.3% (95% confidence interval [CI], 44.9-54.2) at 1year and 3.7% (95% CI, 2.0-6.8) at 5years. In multivariable analysis, higher MA (≥44.4HU in males and ≥34.8HU in females) at initial CT was significantly associated with better OS in both males and females (adjusted hazard ratio [HR], 0.706; 95% CI, 0.538-0.925; P=0.012 for males, and HR, 0.656; 95% CI, 0.475-0.906; P=0.010 for females), whereas higher SATI (≥42.8cm2/m2 in males and ≥65.8cm2/m2 in females) was significantly associated with better OS in female patients only (adjusted HR, 0.568; 95% CI, 0.388-0.830; P=0.003). In longitudinal analysis, SMI, VATI and SATI significantly decreased between initial and 2-month follow-up CT, whereas mean MA significantly decreased between 2- and 6-month follow-up CT. In multivariable Cox regression analysis of longitudinal changes, which was stratified by disease control state, SATI change was significantly associated with OS in male patients (adjusted HR, 0.513; 95% CI, 0.354-0.745; P<0.001), while other body composition parameters were not. In patients with metastatic pancreatic cancer, body composition mostly changed during the first 2months after starting chemotherapy, and the prognostic factors associated with OS differed between males and females. Initial and longitudinal changes of body composition are associated with OS of metastatic pancreatic cancer.

A pseudo-dilemma: Are we over-diagnosing and over-treating traumatic splenic intraparenchymal pseudoaneurysms?

Splenic embolization for traumatic vascular abnormalities in stable patients is a common practice. We hypothesize that modern contrast-enhanced computed tomography (CT) over diagnoses posttraumatic splenic vascular lesions, such as intraparenchymal pseudoaneurysms (PSA) that may not require embolization. We reviewed the experience at our high-volume center with endovascular management of blunt splenic injuries from January 2016 to December 2021. Multidisciplinary review was used to compared initial CT findings with subsequent angiography, analyzing management and outcomes of identified vascular lesions. Of 853 splenic injuries managed overall during the study period, 255 (29.9%) underwent angiography of the spleen at any point during hospitalization. Vascular lesions were identified on 58% of initial CTs; extravasation (12.2%) and PSA (51.0%). Angiography was performed a mean of 22 hours after admission, with 38% done within 6 hours. Embolization was performed for 90.5% (231) of patients. Among the 130 patients with PSA on initial CT, 36 (27.7%) had no visible lesion on subsequent angiogram. From the 125 individuals who did not have a PSA identified on their initial CT, 67 (54%) had a PSA seen on subsequent angiography. On postembolization CT at 48 hours to 72 hours, persistently perfused splenic PSAs were seen in 41.0% (48/117) of those with and 22.2% (2/9) without embolization. Only one of 24 (4.1%) patients with PSA on angiography observed without embolization required delayed splenectomy, whereas 6.9% (16/231) in the embolized group had splenectomy at a mean of 5.5 ± 4 days after admission. There is a high rate of discordance between CT and angiographic identification of splenic PSAs. Even when identified at angiogram and embolized, close to half will remain perfused on follow-up imaging. These findings question the use of routine angioembolization for all splenic PSAs. Therapeutic/Care Management; Level IV.

Abstract 12020: Overestimation of the Ischemic Area-at-Risk Despite Partial Resolution of Myocardial Edema Twenty-Four Hours After Myocardial Infarction in Swine

Objective: Accurate delineation of the ischemic area-at-risk (AAR) is essential for precise quantification of tissue salvage following myocardial infarction (MI), but time-dependent changes in tissue composition may influence the AAR when it is measured after reperfusion. Based on evidence that post-MI edema declines 24 hours after reperfusion, we utilized serial contrast-enhanced computed tomography (CT) to determine if this is an optimal timepoint for retrospective assessment of the AAR in swine. Methods: Swine (n=7) were subjected to a 75-minute LAD occlusion, during which an initial CT scan was performed to assess the pre-reperfusion AAR. A second CT scan was performed during re-occlusion of the LAD 24 hours later to determine the post-reperfusion AAR. Echocardiography was performed at baseline as well as 1 hour and 24 hours after reperfusion to assess end-diastolic wall thickness (EDWT) as an index of post-MI edema. Infarct size was quantified via post-mortem TTC staining and expressed relative to pre- vs. post-reperfusion AAR values. Results: Dynamic changes in EDWT were observed throughout the reperfusion period, consistent with marked edema early after reperfusion and a subsequent decline 24 hours later ( Table; top ). Despite partial resolution of edema 24 hours after reperfusion, a significant ~25% increase in the AAR was observed at this timepoint vs. pre-reperfusion values ( Table; bottom ). As a result, infarct size differed significantly if expressed relative to the pre-reperfusion AAR (91.7 ± 9.2 %) vs. the post-reperfusion AAR (70.9 ± 8.3 %, p&lt;0.01). Conclusion: The ischemic AAR is overestimated relative to pre-reperfusion values when measured retrospectively 24 hours after reperfusion, despite partial resolution of myocardial edema at this timepoint. These results illustrate how variability in post-infarction edema may complicate the assessment of relative infarct size and myocardial salvage when the AAR is measured after reperfusion.

Severity of traumatic adrenal injury does not meaningfully affect clinical outcomes.

There are limited data comparing the severity of traumatic adrenal injury (TAI) and the need for interventions, such as transfusions, hospitalization, or incidence of adrenal insufficiency (AI) and other clinical outcomes. The aim of this study was to analyze the relationship between the grade of TAI and the need for subsequent intervention and clinical outcomes following the injury. After obtaining Institutional Review Board approval, our trauma registry was queried for patients with TAI between 2009 and 2017. Contrast-enhanced computed tomography (CT) examinations of the abdomen and pelvis were evaluated by a board-certified radiologist with subspecialty expertise in abdominal and trauma imaging, and adrenal injuries were classified as either low grade (American Association for the Surgery of Trauma (AAST) grade I-III) or high grade (AAST grade IV-V). Patients without initial contrast-enhanced CT imaging and those with indeterminate imaging findings on initial CT were excluded. A total of 129 patients with 149 TAI were included. Eight-six patients demonstrated low-grade injuries and 43 high grade. Age, gender, and Injury Severity Score (ISS) were not statistically different between the groups. There was an increased number of major vascular injuries in the low-grade vs. high-grade group (23% vs. 5%, p < 0.01). No patient required transfusions or laparotomy for control of adrenal hemorrhage. There was no statistical difference in hospital length of stay (LOS), ventilator days, or mortality. Low-grade adrenal injuries were, however, associated with shorter ICU LOS (10days vs. 16days, p = 0.03). The need for interventions and clinical outcomes between the low-grade and high-grade groups was similar. These results suggest that, regardless of the TAI grade, treatment should be based on a holistic clinical assessment and less focused on specific interventions directed at addressing the adrenal injury.

Haemosuccus pancreaticus: a diagnostic challenge and its management through interventional radiology

BackgroundHaemosuccus pancreaticus (HP), also known as pseudohaemobilia, is defined as upper gastrointestinal tract hemorrhage originating from the pancreatic duct into the duodenum via the ampulla of Vater or major pancreatic papilla. Pseudoaneurysm formation from the splenic artery is a common complication of pancreatitis; however, upper gastrointestinal bleed resulting from rupture of splenic artery pseudoaneurysm into the pancreatic duct is unusual and challenging to diagnose.Case presentationA 26-year-old patient presented with multiple episodes of hematemesis, melena, and intermittent abdominal pain. A contrast-enhanced computed tomography (CECT) scan was performed that demonstrated chronic calcific pancreatitis with a pseudoaneurysm in the splenic artery in close relation to the main pancreatic duct. The patient was immediately shifted for endovascular management, and the pseudoaneurysm was successfully embolized. Post embolization, the patient developed splenic abscess, which was managed by percutaneous catheter drainage.ConclusionDue to its rarity and being challenging to diagnose, the mortality rate of HP is high. A high level of expertise is required to diagnose HP, and it should be considered in all upper gastrointestinal bleed patients associated with acute or chronic pancreatitis. Rapid initial CECT and angiography should be performed to confirm the diagnosis, followed by embolization of the bleeding pseudoaneurysm to eliminate the need for surgery. This case report highlights the challenges in the diagnosis and management of HP.

S3070 Severity of Biliary Pancreatitis in Hispanics vs Non-Hispanics: Are There Any Differences?

INTRODUCTION: Biliary pancreatitis manifests as pancreatic inflammation due to ductal obstruction by a stone at the sphincter of Oddi. Often presenting as acute-onset abdominal pain with elevated biochemical markers, it can be a life-threatening disease requiring urgent evaluation. Contrast-enhanced computed tomography (CT) identifies the presence and extent of pancreatitis necrosis, and the CT Severity Index (CTSI) is a reliable predictor of severity and mortality of acute biliary pancreatitis. Mortality due to biliary pancreatitis ranges from 3% in patients with interstitial edematous pancreatitis to 17% in those who develop pancreatic necrosis, demonstrating the need for early identification and intervention. This study compared the severity of disease in Hispanic and non-Hispanic patients based on the CTSI as well as the Revised Atlanta Classification for Acute Pancreatitis. METHODS: A retrospective analysis of 303 biliary pancreatitis cases in patients aged 18-80 years from 2012 to 2019 were reviewed. Initial CT findings were standardized by a single reader. Patients were excluded if they did not have a diagnosis of biliary pancreatitis or an initial CT scan on admission. Data was analyzed with R, using univariate and multivariable logistic regression and Fisher’s exact test. RESULTS: 185 patients (average age 53.5 years) were Hispanic, and 118 (average age 49 years) were non-Hispanic. 21/185 (11.4%) patients in the Hispanic group presented with a fluid collection on initial CT versus 19/118 (16.1%) non-Hispanic patients (P = 0.309). 9/185 (4.9%) Hispanics had an acute necrotic collection (ANC), compared to 6/118 (5.1%) non-Hispanics (P = 0.44). 8/185 (4.3%) Hispanics had an acute peripancreatic fluid collection (APFC) associated with interstitial edematous pancreatitis, compared to 10/118 (8.5%) non-Hispanics. 5 total patients presented with a pancreatic pseudocyst, of which 4 were Hispanic. The average CTSI score was 2.14 +/- 1.96 for non-Hispanics and 1.82 +/- 1.76 (P = 0.132) for Hispanics. CONCLUSION: No statistical differences were noted in severity of biliary pancreatitis based on imaging evaluation among the two groups. The absolute difference of patients with pancreatic pseudocyst suggests that Hispanics may have stayed home longer between the onset of symptoms and hospital admission. This is the first study to classify ethnic differences in severity based on CT imaging. Larger cohort population studies are necessary to determine if statistically significant differences are present or not.Table 1.: Patient DemographicsTable 2.: Presence/Type of Fluid Collection on CT Scan and CTSI in Hispanics versus Non-Hispanics

Does contrast-enhanced ultrasound have a role in evaluation and management of pediatric renal trauma? A preliminary experience

BackgroundTo report our initial experience using intravenous contrast-enhanced ultrasound (CEUS) in pediatric renal trauma with the potential for substantial radiation reduction. MethodsA retrospective review of all patients who underwent intravenous CEUS at our institution between May 2015 and January 2018 for the suspicion of blunt renal trauma. CEUS was obtained either as an immediate or short-term comparison to contrast-enhanced computed tomography (CECT), or in outpatient follow-up. ResultsCEUS was performed on 7 patients (9 kidneys) with age range 2 months to 16 years old. CEUS was utilized as a comparison to CECT in 4 of 7 patients for initial evaluation, clinical change, or short-term follow-up. CEUS alone was used in one patient with low suspicion for renal injury. In the remaining two patients, CEUS was obtained as a follow-up study weeks after the initial CECT, following conservative management. All patients with confirmed renal injury by CECT (n = 5) underwent a follow-up CEUS at 1–2 months. ConclusionsIn an era of conservative management for renal trauma in which operative intervention is dictated more often by the clinical course than radiographic findings, it is reasonable to consider alternative imaging methods such as CEUS in stable patients to decrease radiation exposure. Level of Evidence RatingIV

New Risk Factors for Infected Pancreatic Necrosis Secondary to Severe Acute Pancreatitis: The Role of Initial Contrast-Enhanced Computed Tomography.

Pancreatic necrosis is a risk factor for poor prognosis of acute pancreatitis (AP). However, the associations between the findings on initial contrast-enhanced computed tomography (CT) of the pancreas and infected pancreatic necrosis (IPN) are unclear. This was a retrospective cohort study. Patients with severe AP (SAP) from January 2014 to December 2016 at the First Affiliated Hospital of Nanchang University were enrolled and assigned to an IPN group and a non-IPN group. Univariate and multivariate logistic regression analyses were sequentially performed to assess the associations between the variables and IPN development. A receiver operating characteristic (ROC) curve was generated for the qualified independent risk factor. Forty-two patients with IPN were compared with 100 patients without IPN. Contrast-enhanced CT was performed 7 (range 3-10) days after AP onset. Multivariate stepwise logistic regression analyses showed that the number of acute peripancreatic fluid collections (APFCs) (OR 1.328, P = 0.006), presence of peripancreatic and pancreatic parenchymal necrosis (OR 4.001, P = 0.001), and gastrointestinal wall thickening (OR 3.353, P = 0.006) were independent risk factors for IPN secondary to SAP. The area under an ROC curve for the number of APFCs was 0.714, the sensitivity was 78.60%, and the specificity was 57.30% at a cutoff value of 4.5. The number of APFCs, presence of peripancreatic and pancreatic parenchymal necrosis, and gastrointestinal wall thickening were independent risk factors associated with IPN. As initial contrast-enhanced CT (about 7days from AP onset) plays an important role in predicting IPN, it is important for clinicians to consider initial imaging of the pancreas.

Clinical importance of minimal enhancement of type B intramural hematoma of the aorta on computed tomography imaging

ObjectiveTo investigate the instability, morphology, natural course, and prognostic value of enhancement of the thrombosed false lumen on contrast-enhanced computed tomography (CT) scans in patients with type B intramural hematoma of the aorta (IMH). MethodsA total of 65 patients (42 men; mean age, 75 years) with type B IMH were evaluated retrospectively. On initial CT scans, attenuation of the false lumen (AFL) was determined before enhancement and in the early and delayed phases of contrast enhancement. Then enhancement of the false lumen (EFL) was calculated (AFL in the delayed image − AFL in the precontrast image). The Cox proportional hazards model was employed to estimate the risk of IMH-related events, including death or surgical repair. ResultsThe mean AFL for precontrast CT, arterial phase enhanced CT, and delayed phase enhanced CT was 56.3 ± 10.5, 59.9 ± 10.8, and 63.7 ± 11.1 Hounsfield units, respectively, whereas the mean EFL was 7.4 ± 9.0 Hounsfield units. EFL was the only independent predictor of IMH-related events (n = 23; hazard ratio, 1.008; 95% confidence interval, 1.03-1.15; P = .0044) and IMH-related death/surgical repair (n = 10; hazard ratio, 1.111; 95% confidence interval, 1.017-1.213; P = .0197). ConclusionsIn patients with IMH, EFL is the most powerful predictor of IMH-related events, as well as IMH-related death or surgical repair.

1297 FLUORODEOXYGLUCOSE POSITRON EMISSION TOMOGRAPHY/COMPUTED TOMOGRAPHY FOR PREOPERATIVE STAGING AND POSTOPERATIVE FOLLOW-UP OF UROTHELIAL CARCINOMA

You have accessJournal of UrologyBladder Cancer: Detection & Screening1 Apr 20131297 FLUORODEOXYGLUCOSE POSITRON EMISSION TOMOGRAPHY/COMPUTED TOMOGRAPHY FOR PREOPERATIVE STAGING AND POSTOPERATIVE FOLLOW-UP OF UROTHELIAL CARCINOMA Anwar Alesawi, Andre Caron, Alain Bergeron, Helene Hovington, Vincent Fradet, Louis Lacombe, and Yves Fradet Anwar AlesawiAnwar Alesawi Quebec, Canada More articles by this author , Andre CaronAndre Caron Quebec, Canada More articles by this author , Alain BergeronAlain Bergeron Quebec, Canada More articles by this author , Helene HovingtonHelene Hovington Quebec, Canada More articles by this author , Vincent FradetVincent Fradet Quebec, Canada More articles by this author , Louis LacombeLouis Lacombe Quebec, Canada More articles by this author , and Yves FradetYves Fradet Quebec, Canada More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.2651AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The treatment and prognosis of bladder cancer depends on lymph node involvement in addition to other factors, but the accuracy of conventional imaging modalities for the prediction of nodal involvement or even detection of recurrence in early stage is limited. This study retrospectively investigated the value of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) in the staging and follow up of urothelial carcinoma in comparison to contrast-enhanced computed tomography (CT). METHODS We reviewed 148 files of urothelial carcinoma patients. Of these, 134 had initial and 80 had follow-up PET/CT scans while 103 patients had initial and 82 had follow-up CT scans. Initial CT and PET/CT results were correlated with histopathology data (grade, stage and lymph node status). Follow-up CT and PET/CT results were confirmed by repeated imaging studies. RESULTS The sensitivity for detecting lymph node metastasis before surgery was 43.39% vs 43.58% while the specificity was 100% vs 95.23% for PET/CT scan vs CT scan, respectively. PET/CT scan had higher specificity in detecting recurrence (97.87% vs 90.19%) with higher positive predictive value (96.97% vs 85.7%). There was a significant association between recurrence discovered by PET/CT scan and the nodal status as 86.7% of patients who developed recurrence had positive lymph node whereas 13.3% had negative lymph node at surgery (p<0.0001, chi square). In addition, stage status at surgery was significantly associated with PET/CT scan discovered recurrence as 86.7% of patients who developed recurrence were ≥pT3 while 13.3% were ≤pT2 (p<0.005, chi square). CONCLUSIONS PET/CT scan is not inferior to CT scan in detecting positive lymph nodes before surgery of urothelial cancers while it is superior to CT scan in detecting recurrence after surgery. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e530 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Anwar Alesawi Quebec, Canada More articles by this author Andre Caron Quebec, Canada More articles by this author Alain Bergeron Quebec, Canada More articles by this author Helene Hovington Quebec, Canada More articles by this author Vincent Fradet Quebec, Canada More articles by this author Louis Lacombe Quebec, Canada More articles by this author Yves Fradet Quebec, Canada More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Descending aortic aneurysmal changes following surgery for acute DeBakey type I aortic dissection

The aim of the study was to determine the risk factors for descending aortic aneurysmal changes following surgery for acute DeBakey type I aortic dissection. A total of 129 patients who underwent surgery for acute type I aortic dissection between 2000 and 2010 were evaluated by contrast-enhanced computed tomography (CT) at least 6 months later (median follow-up 29.5 months, interquartile range 16.3-49.3 months). The study endpoint was the development of aortic aneurysms (diameter >55 mm). Risk factors for aortic aneurysms were determined by Cox regression analysis. Aortic dilatation occurred in 23 of the 129 (17.8%) patients. Aortic aneurysms were observed at the proximal descending in 19 (14.7%) patients, the mid descending in 12 (9.3%) patients, the distal descending in seven (5.4%) patients and at the abdominal aorta in one (0.8%) patient. Multivariate analysis showed that the luminal diameter of the proximal descending aorta on initial CT was the only significant and independent factor predicting aneurysm formation (hazard ratio 1.12, 95% confidence interval [CI] 1.02-1.22, P = 0.014). Receiver operating curves assessing the ability of preoperative proximal descending aorta diameter to predict aortic aneurysms showed an area under the curve of 0.72 (95% CI 0.60-0.84, P = 0.001), with a greatest accuracy at 40.95 mm (sensitivity 65.2%, specificity 78.3%). The 5-year freedom from aortic aneurysm rates in patients with proximal descending diameters ≤ 40 and >40 mm were 84.4 ± 6.6 and 55.6 ± 11.1%, respectively (P = 0.001). The proximal descending aorta was the major site of aneurysm formation following surgery for acute type I aortic dissection. The large proximal descending aortic diameter on initial CT predicted the late aneurysm, suggesting that adjunctive procedures combined with aortic replacement are needed to prevent the late aneurysm.

Diagnostic usefulness of 18F-FDG PET/CT in the differentiation of pulmonary artery sarcoma and pulmonary embolism

The purpose of this study was to evaluate the usefulness of 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) in differentiating pulmonary artery sarcoma from pulmonary embolism. We evaluated three patients with pulmonary artery sarcoma and 10 patients with proximal pulmonary embolism (6 men and 7 women, ranging in age from 35 to 94 years). All the patients had evidence of perfusion defects in their proximal pulmonary arteries on contrast-enhanced computed tomography (CT) scans performed prior to PET/CT. The maximum standardized uptake value (SUV(max)) of FDG uptake in all the lesions was measured using PET/CT. The location of lesions, background uptake or thrombi in the legs were evaluated in both groups as basic characteristics. The mean SUV(max) of the pulmonary artery sarcomas (7.63 +/- 2.21, n = 3) and the pulmonary embolisms (2.31 +/- 0.41, n = 10) were significantly different (P < 0.05). The mean times between the initial contrast-enhanced CT scan and PET/CT scan were similar in both groups (P = 0.7804). The differences in the locations in lesions between the three groups (right, left and bilateral) or background uptakes were not significant. FDG PET/CT could distinguish pulmonary artery sarcoma from pulmonary embolism based on the SUV(max) value.

Value of contrast-enhanced CT for managing mesenteric injuries after blunt trauma: review of five-year experience.

The purpose of this retrospective study was to determine the value of contrast-enhanced computed tomography (CT) in the detection and management of mesenteric injuries after blunt trauma. Between June 1995 and December 2000, 1,619 consecutive abdominal CT examinations were performed in the setting of major blunt trauma. Findings at CT were evaluated before patients were classified as having grade 1 or grade 2 lesions or none. Grade 1 represented the presence of minor injuries: mesenteric haziness, confined fluid, and/or small hematomas (<30 mm) within the mesenteric folds and abdominal injuries; grade 2 was appropriate to evidence of major injuries: moderate to large hematomas (>30 mm), active bleeding, hemoperitoneum, and further abdominal injuries. On the basis of the CT findings, 161 (9.9%) of 1,619 patients were classified as having grade 1 and 25 (1.5%) of 1,619 patients as having grade 2 injuries. Of the 161 (77.6%) patients with grade 1 injuries, 125 were managed conservatively, while 36 (22.4%) underwent surgery. Of the 25 (84%) patients with grade 2 injuries, 21 were treated surgically and 1 (4%) patient was followed medically. Three (12%) of the 25 patients underwent laparotomy after 24 h close clinical observation and monitoring. Initial CT findings in 1,433 (88%) of the 1,619 patients were negative for mesenteric injuries, and in 1,430 of these cases no delayed mesenteric hemorrhage was observed. Contrast-enhanced CT has a critical role in the identification and exclusion of mesenteric injuries. Persistent, active extravasation of contrast material, in isolation or associated with further abdominal lesions, is a sign of a high likelihood of injury requiring urgent laparotomy. Haziness, isolated confined clotted mesenteric hemorrhage, and small hematomas within the mesentery are nonspecific findings and should be considered in the appropriate clinical context. Close clinical observation, monitoring, and surgical expertise are mandatory for appropriate management.

Endovascular aneurysm repair in high-risk patients

Purpose: The purpose of this study was to evaluate the role of endovascular aneurysm repair in high-risk patients. Methods: The elective endovascular repair of infrarenal aortic aneurysm was performed in 116 high-risk patients with either custom-made or commercial stent grafts. The routine follow-up examination included contrast-enhanced computed tomography (CT) before discharge, at 3, 6, and 12 months, and annually thereafter. Patients with endoleak on the initial CT underwent re-evaluation at 2 weeks. Those patients with positive CT results at 2 weeks underwent endovascular treatment. Results: Endovascular repair was considered feasible in 67% of the patients. The mean age was 75 years, and the mean aneurysm diameter was 6.3 cm. The American Society of Anesthesiologists grade was II in 3.4%, III in 65.5%, IV in 30.1%, and V in 0.9%. There were no conversions to open repair. Custom-made aortomonoiliac stent grafts were implanted in 77.6% of the cases, custom-made aortoaotic stent grafts in 11.2%, and commercial bifurcated stent grafts in 11.2%. The 30-day rates of mortality, major morbidity, and minor morbidity were 3.4%, 20.7%, and 12%, respectively, in the first 58 patients and 0%, 3.4%, and 3.4%, respectively, in the last 58. The late complications included five cases of stent graft kinking, two cases of femorofemoral graft occlusion, and three cases of proximal stent migration, one of which led to aneurysm rupture. At 2 weeks after repair, endoleak was present in 10.3% of the cases. All the type I (direct perigraft) endoleaks underwent successful endovascular treatment, whereas only one type II (collateral) endoleak responded to treatment. The technical success rate at 2 weeks was 86.2%, and the clinical success rate was 96.6%. The continuing success rate was 87.9%. Seventeen patients died late, unrelated deaths. Conclusion: Endovascular aneurysm repair is safe and effective in patients at high risk, for whom it may be the preferred method of treatment. (J Vasc Surg 2000;31:122-33.)

Stab wounds to the back and flank in the hemodynamically stable patient: A decision algorithm based on contrast-enhanced computed tomography with colonic opacification

The authors wanted to determine whether contrast-enhanced computed tomography (CE-CT) with colonic opacification is an accurate tool to triage hemodynamically stable victims of stab wounds to the flank and back. One hundred forty-five consecutive patients were categorized as low-risk ( penetration superficial to the deep fascia) or high-risk (penetration beyond the deep fascia) based on CE-CT findings. There were no significant differences in admission vital signs, Glasgow Coma Scale, or complete blood counts between low- and high-risk groups. None of the 92 low-risk patients required surgery or had sequelae. Six of the 53 high-risk patients underwent surgery, 2 based on initial CE-CT, 4 due to evolving clinical signs. The CE-CT correctly predicted surgical findings in all cases. Hemodynamically stable patients with stab wounds to the back and/or flank can be successfully triaged based on CE-CT findings. Low-risk patients may be discharged immediately. High-risk patients may have a discharge decision implemented at 24 hours.

Extraosseous Ewing's sarcoma computed tomography evaluation before and after chemotherapy

Fourteen patients with extraosseous Ewing's sarcoma were evaluated by computed tomography (CT) and conventional radiography. The sites of involvement were in the lower extremities (six cases), the chest wall (four), pelvis (two), and the paravertebral region (two). In seven cases, the initial contrast-enhanced CT disclosed a necrotic soft tissue mass in four, two of them with peripheral enhancement. In three cases, the mass was homogeneous and did not enhance. CT enabled us to detect the size of the mass, the integrity of adjacent bone and medullary cavity, and to determine the presence or absence of metastases. CT was useful for evaluation of the patients' tumor response to treatment. In three of four patients treated with chemotherapy, CT showed evidence of a dramatic initial response. In one patient who was resistant to chemotherapy, surgical methods were required.