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OBJECTIVE/BACKGROUND: The objective was to assess the technical success, patency, and clinical outcome after stent placement for chronic obstruction of the inferior vena cava (IVC). METHODS: A retrospective analysis was carried out of patients with chronic IVC obstruction verified with computed tomography and/or magnetic resonance venography, accepted for stent placement at the Norwegian National Unit for Reconstructive Deep Venous Surgery from March 2010 to September 2015. Clinical status was categorized according to the CEAP classification and symptom severity was assessed using venous clinical severity score (VCSS). Stent patency was evaluated by colour duplex ultrasound. Large -diameter Wallstents were placed in the IVC and concurrent iliac and femoral obstructions via right internal jugular and femoral vein access. Sixteen patients presented with symptoms of chronic venous disease. Four patients had symptoms assumed to be related to a reduced cardiac preload. Twelve patients had IVC occlusion and eight had stenosis. Median follow-up was 25 months (range 3-70 months). RESULTS: Stent placement in the IVC was successful in 19 of 20 patients. Primary patency after 24 months was 67% and secondary patency 83%. Fifteen of 19 patients had open stents at final follow-up. Re-interventions were performed in four patients and included catheter directed thrombolysis in all and adjunctive stenting in three. Thirteen of 19 patients (68%) reported a sustained and significant clinical improvement. Mean VCSS improved from 8.5 (range 3-25) at baseline to 7 (range 2-23) at final follow-up (p = .007). There were no peri-procedural or long-term complications. CONCLUSION: The endovascular approach with stent placement for chronic IVC obstruction is a safe treatment option that should be offered to patients who otherwise have little opportunity for sustained clinical improvement.

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BACKGROUND: Postprandial discomfort following intake of poorly absorbable, but fermentable carbohydrates is a common complaint in patients with irritable bowel syndrome (IBS). We used lactulose as a model substance for this group of symptom triggering carbohydrates, aiming to visualize the intestinal response in IBS patients compared to healthy controls. METHODS: Patients with IBS according to Rome III criteria (n = 52) and healthy controls (n = 16) underwent a lactulose challenge test. By using magnetic resonance imaging, we measured small bowel water content (SBWC), and distension (diameter) of the distal ileum and the colon, both in fasting state and 1 h after ingestion of 10 g lactulose. We recorded symptoms after lactulose ingestion. KEY RESULTS: Lactulose provoked significantly more symptoms in IBS patients than in healthy controls (p < 0.0001). SBWC increased more in the patient group compared to the control group (p = 0.0005). The postprandial diameter of the terminal ileum was larger in patients with IBS and the postprandial diameter of the ascending colon was smaller in patients with diarrhea-predominant phenotype (IBS-D). Symptoms were not correlated with change in SBWC (r = 0.05; p = 0.11), nor to the diameters of the terminal ileum or the colon. CONCLUSIONS & INFERENCES: Compared to healthy controls, IBS patients developed more symptoms and had an abnormal accumulation of fluid in the small bowel in response to ingestion of the unabsorbable carbohydrate lactulose. This may be due to impaired motor activity of the small intestine or impaired function of the ileocecal segment.

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BACKGROUND: Additional treatment with catheter-directed thrombolysis (CDT) has recently been shown to reduce post-thrombotic syndrome (PTS). OBJECTIVES: To estimate the cost effectiveness of additional CDT compared with standard treatment alone. METHODS: Using a Markov decision model, we compared the two treatment strategies in patients with a high proximal deep vein thrombosis (DVT) and a low risk of bleeding. The model captured the development of PTS, recurrent venous thromboembolism and treatment-related adverse events within a lifetime horizon and the perspective of a third-party payer. Uncertainty was assessed with one-way and probabilistic sensitivity analyzes. Model inputs from the CaVenT study included PTS development, major bleeding from CDT and utilities for post DVT states including PTS. The remaining clinical inputs were obtained from the literature. Costs obtained from the CaVenT study, hospital accounts and the literature are expressed in US dollars ($); effects in quality adjusted life years (QALY). RESULTS: In base case analyzes, additional CDT accumulated 32.31 QALYs compared with 31.68 QALYs after standard treatment alone. Direct medical costs were $64,709 for additional CDT and $51,866 for standard treatment. The incremental cost-effectiveness ratio (ICER) was $20,429/QALY gained. One-way sensitivity analysis showed model sensitivity to the clinical efficacy of both strategies, but the ICER remained < $55,000/QALY over the full range of all parameters. The probability that CDT is cost effective was 82% at a willingness to pay threshold of $50,000/QALY gained. CONCLUSIONS: Additional CDT is likely to be a cost-effective alternative to the standard treatment for patients with a high proximal DVT and a low risk of bleeding.

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PURPOSE: The aim of this study was to compare the diagnostic performance of contrast-enhanced ultrasound (CEUS) to computed tomography (CT) in trauma patients after splenic embolization. MATERIALS AND METHODS: 22 patients (17 male and 5 female) with a mean age of 32 (15 - 57 years) were studied with ultrasound (US), CEUS and CT in 23 early follow-up examinations 5 days (range: 0 - 12 days) after intervention and 17 late follow-up examinations 69 days (range: 52 - 189 days) after intervention. Perisplenic fluid, hematoma, laceration, infarction, scars and injury grade were evaluated. US and CEUS readings were performed independently by two radiologist, blinded to the CT results. RESULTS: The sensitivity and specificity for CEUS at early follow-up were 85 % and 70 % for perisplenic fluid, 80 % and 94 % for subcapsular hematomas, 83 % and 73 % or lacerations and 75 % and 87 % for infarctions, respectively. The sensitivity and specificity at late follow-up were 60 % and 100 % for subcapsular hematomas, 91 % and 67 % for intrasplenic hematomas, 100 % and 93 % for lacerations and 89 % and 100 % for scars, respectively. The overall sensitivity and specificity for all lesions were 87 % and 88 % at early follow-up (n = 138) and 85 % and 95 % at late follow-up (n = 102), respectively. Compared to CT, CEUS underestimated the injury grade in 2 / 40 cases and overestimated the injury grade in 3/40 cases. CONCLUSION: CEUS is a useful tool for the detection of post-traumatic lesions. It is comparable to CT in follow-up after splenic embolization and may replace CT in follow-up studies.

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A variety of conditions other than acute myocardial infarction may cause ST-elevation. Our objective was to evaluate the impact of cardiac magnetic resonance (CMR) on differential diagnosis from a prospective series of patients with suspected ST-elevation myocardial infarction (STEMI) and completely normal coronary arteries. Among 1,145 patients with suspected STEMI, 49 patients had completely normal coronary arteries and entered a prospective registry. CMR was done within 24 h, if possible, and included function analyses, T2-weighted imaging (T2 ratio), T1-weighted imaging before and after gadolineum administration (global relative enhancement; gRE), and late gadolineum enhancement (LGE). All patients were asked for a follow-up CMR after approximately 3 months. The incidence of patients with suspected STEMI and normal coronary arteries was 4.3% and mean age was 45 ± 14 years (STEMI group 64 ± 13 years; P<0.001). 55% had a recent history of infection. Cardiac biomarkers showed a moderate elevation on admission. There was a significant change from baseline to follow-up for LV end-diastolic volumes (EDV) (P<0.001), LV mass (P<0.05), mean T2 ratio (P<0.05), and LGE volume (P<0.05). Major diagnostic groups were myocarditis (29%), pericarditis (27%), and takotsubo cardiomyopathy (10%). 18% were regarded as non-diagnostic. The study showed an incidence of 4.3% of patients with suspected STEMI and completely normal coronary arteries. Early CMR was valuable in the evaluation of the differential diagnoses and to exclude myocardial abnormalities in patients with uncertain aetiology. Further studies are needed for the assessment of long-term outcome.

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BACKGROUND: Approximately one in four patients with acute proximal deep vein thrombosis (DVT) given anticoagulation and compression therapy develop post-thrombotic syndrome (PTS). Accelerated removal of thrombus by thrombolytic agents may increase patency and prevent PTS. OBJECTIVES: To assess short-term efficacy of additional catheter-directed thrombolysis (CDT) compared with standard treatment alone. PATIENTS AND METHODS: Open, multicenter, randomized, controlled trial. Patients (18-75 years) with iliofemoral DVT and symptoms < 21 days were randomized to receive additional CDT or standard treatment alone. After 6 months, iliofemoral patency was investigated using duplex ultrasound and air-plethysmography assessed by an investigator blinded to previous treatment. RESULTS: One hundred and three patients (64 men, mean age 52 years) were allocated additional CDT (n = 50) or standard treatment alone (n = 53). After CDT, grade III (complete) lysis was achieved in 24 and grade II (50%-90%) lysis in 20 patients. One patient suffered major bleeding and two had clinically relevant bleeding related to the CDT procedure. After 6 months, iliofemoral patency was found in 32 (64.0%) in the CDT group vs. 19 (35.8%) controls, corresponding to an absolute risk reduction (RR) of 28.2% (95% CI: 9.7%-46.7%; P = 0.004). Venous obstruction was found in 10 (20.0%) in the CDT group vs. 26 (49.1%) controls; absolute RR 29.1% (95% CI: 20.0%-38.0%; P = 0.004). Femoral venous insufficiency did not differ between the two groups. CONCLUSIONS: After 6 months, additional CDT increased iliofemoral patency from 36% to 64%. The ongoing long-term follow-up of this study will document whether patency is related to improved functional outcome.

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BACKGROUND: Magnetic resonance enteroclysis (MRE) is suggested to become the preferred radiological method in small-bowel Crohn's disease (CD). However, the performance of inexperienced readers may influence the diagnostic value of the method and has not been previously investigated. PURPOSE: To compare readings of MRE in small-bowel CD performed by experienced and inexperienced readers before and after training. MATERIAL AND METHODS: One experienced radiologist (observer 1) and two trainees (observers 2 and 3) reviewed 60 MRE examinations. A second reading was performed after training. Bowel wall thickness (BWT), ulcers (BWU), stenosis (BWS), fistulas (FIS), and abscesses (ABS) were evaluated. A reference standard based on clinical records was established. RESULTS: BWT in the terminal ileum was evaluated with high diagnostic performance (sensitivity: observer 1, 83%; observer 2, 72%; observer 3, 78%). Only BWU was diagnosed with a higher sensitivity by observer 1 (78% vs. 33% and 39%, respectively; P=0.02). False-positive findings for BWT in the jejunum (observer 2: 7; observer 3: 4) and fistulas and abscesses (observer 2: 11/5; observer 3: 5/4) were made by the trainees. Interobserver agreement in the jejunum was poor (observer 1/observer 2: kappa=0.23; observer 1/observer 3: kappa=-0.03) and in the ileum good (observer 1/observer 2: kappa=0.78; observer 1/observer 3: kappa=0.73). After training, evaluation of BWU (observer 2: 56%, P=0.22; observer 3: 44%, P=0.03), BWT (observer 2: 2; observer 3: 2), and interobserver agreement in the jejunum improved (observer 1/observer 2: kappa=0.66; observer 1/observer 3: kappa=0.66). However, the number of diagnosed fistulas and abscesses remained high. CONCLUSION: Before training, most findings of Crohn's disease in the terminal ileum were evaluated with high diagnostic performance by all readers. However, the inexperienced readers evaluated BWU with a low sensitivity and overestimated the number of FIS, number of ABS, and increased BWT in the jejunum. After training, evaluation by inexperienced readers of BWU and increased BWT in the jejunum improved.

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BACKGROUND: Magnetic resonance cholangiopancreaticography (MRCP) is commonly used to evaluate the pancreatic (PD) and common bile duct (CBD), and the addition of secretin is used to obtain functional information (S-MRCP). Neither method gives any information on flow velocities within the ducts. PURPOSE: To evaluate a new, MRI diffusion-based, slow-flow-sensitive sequence for the detection of slow flow changes in the PD and CBD. MATERIAL AND METHODS: Seven healthy volunteers were examined. A modified single-shot turbo spin-echo sequence was used to detect slow flow changes. Three b factors (0, 6, and 12 s/mm(2)) were used. The flow sensitivity was applied in two directions, vertically and horizontally. Scanning was performed before and after glucagon was given, and again after an intravenous injection of secretin. The sequence gives signal loss from a duct when flow increases, and such changes were recorded. RESULTS: All images showed the PD with b = 0 (no flow sensitization). After administration of glucagon, artifacts from bowel movements were reduced and visibility of the PD was improved at both b = 6 and b = 12. Significant reduction of the visibility of the PD, indicating increased flow, was recorded both at b = 6 and b = 12 after the administration of secretin. There were no changes in the visibility of the CBD. CONCLUSION: This study shows that MRI-based detection of slow flow changes inside the PD is possible. Due to the sequence's high sensitivity to any motion, further studies are required before adopting the method for clinical use.

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PURPOSE: To evaluate the diagnostic accuracy and inter- and intra-observer agreement of magnetic resonance enteroclysis (MRE) in patients with or without Crohn's disease of the small intestine. MATERIAL AND METHODS: 60 consecutive patients with or without Crohn's disease examined with MRE were included. Two observers independently reviewed the MRE examinations, searching for 12 pathological signs. The reference standard was ileoscopy or surgery of the terminal ileum performed in 41 patients. RESULTS: Crohn's disease of the small intestine was found in 24 (40%) patients. MRE findings of increased intestinal wall thickness, intestinal wall enhancement, intestinal wall ulcer, and inflammatory activity of the terminal ileum showed high sensitivity, specificity, and positive and negative predictive values. Intestinal stenosis had sensitivities ranging from 43% to 100%, depending on the cut-off value. Inter- and intra-observer agreement was good or excellent for most pathological signs. However, observer agreement of intestinal wall edema was only fair and moderate. CONCLUSION: MRE evaluated Crohn's disease with a high diagnostic accuracy in the terminal ileum. Most MRE variables were evaluated with good or excellent observer agreement, indicating that the method was highly reproducible. Our study supports the notion that MRE is an appropriate method for diagnosing Crohn's disease.

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AIMS: To study the long-term survival after out-of-hospital cardiac arrest and successful cardiopulmonary resuscitation (CPR) in patients with acute ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI). MATERIAL AND METHODS: In-hospital and 2-year survival of 40 patients treated with primary PCI after out-of-hospital cardiac arrest and STEMI was compared with that of a reference group of 325 STEMI patients, without cardiac arrest, also treated with primary PCI in the same period. RESULTS: In the group with out-of-hospital cardiac arrest, both in-hospital and 2-year mortality was 27.5%. In the reference group, in-hospital and 2-year mortality was 4.9 and 7.1%, respectively. After discharge from hospital there was no significant difference in mortality between the groups. CONCLUSION: Long-term prognosis is good in selected patients after successful out-of-hospital CPR and STEMI treated with primary PCI.

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PURPOSE: To study the safety of giving protamin after coronary angioplasty to reverse heparin for immediate removal of the femoral sheath. MATERIAL AND METHODS: After successful angioplasty, 100 patients were randomized to receive protamin and immediate sheath removal or to the control group with sheath removal after 3 h. Patients were followed for 30 days so that groin complications and coronary events could be compared. After 6 months, target vessel revascularization and death were recorded. RESULTS: The time to mobilization was significantly shorter in the protamin group compared to the control group; 6 versus 19 h. The protamin patients were more satisfied than the control patients, in particular during bed rest after compression. Puncture site complications were one (2%) and two (4%) pseudoaneurysms in the protamin group and the control group, respectively. Early angina and restenosis/reocclusion before 30 days were seen in 4 patients in the protamin group and in 1 in the control group. Adverse incidents between 30 days and 6 months were the same for both groups. CONCLUSION: Protamin reversal improved patient comfort and reduced immobilization time. The cardiac safety concern observed requires the antiplatelet agent clopidogrel to be given before the procedure.

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PURPOSE: To study the feasibility of placing a polytetrafluoroethylene (PTFE)-covered stent graft into native coronary arteries and assess the complications and the restenosis rate. MATERIAL AND METHODS: Fifty consecutive patients with stable angina pectoris were included and the stent graft was placed into native coronary arteries. Clinical and angiographic follow-up were performed after 6 months. RESULTS: The stent grafts were successfully placed in all patients. The mean reference diameter was 3.3 +/- 0.6 mm. During follow-up the stent grafts occluded in patients after 1, 2 and 2.5 months and one more was occluded at 6 months. Three patients experienced myocardial infarction, 2 Q wave and one non-Q wave. After 6 months 42 (84%) patients had angina NYHA class 0 or 1. Target vessel revascularization was done in 11 cases for restenosis in the graft (n = 4), outside the graft (n = 3) and both (n = 4), giving a restenosis rate of 24%. The total major adverse coronary events at 6 months was 24%. CONCLUSION: The stent graft was deployed with a high success rate. The restenosis rate was not higher than expected for bare stents. However, this study showed that subacute occlusion may occur more frequently and we therefore recommend that ticlopidine or clopidogrel treatment should be prolonged to at least 3 months.

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PURPOSE: To evaluate the use and quality of CT pulmonary angiography in our department, and to relate the findings to clinical parameters and diagnoses. MATERIAL AND METHODS: A retrospective study of 324 consecutive patients referred to CT pulmonary angiography with clinically suspected pulmonary embolism (PE). From the medical records we registered clinical parameters, blood gases, D-dimer, risk factors and the results of other relevant imaging studies. RESULTS: 55 patients (17%) had PE detected on CT. 39 had bilateral PE, and 8 patients had isolated peripheral PE. 87% of the examinations showing PE had satisfactory filling of contrast material including the segmental pulmonary arteries, and 60% of the subsegmental arteries. D-dimer test was performed in 209 patients, 85% were positive. A negative D-dimer ruled out PE detected at CT. Dyspnea and concurrent symptoms or detection of deep vein thrombosis (DVT), contraceptive pills and former venous thromboembolism (VTE) were associated with PE. The presence of only one clinical parameter indicated a negative PE diagnosis (p < 0.017), whereas two or more suggested a positive PE diagnosis (p < 0.002). CT also detected various ancillary findings such as consolidation, pleural effusion, nodule or tumor in nearly half of the patients; however, there was no association with the PE diagnosis. CONCLUSION: The quality of CT pulmonary angiography was satisfactory as a first-line imaging of PE. CT also showed additional pathology of importance in the chest. Our study confirmed that a negative D-dimer ruled out clinically suspected VTE.

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BACKGROUND: There is little information available on long-term follow up of patients treated with primary angioplasty for acute myocardial infarction. MATERIAL AND METHODS: 100 consecutive patients with acute ST-elevation myocardial infarction and symptoms of less than six hours' duration were treated with primary angioplasty. Clinical examination was performed in 97 patients and exercise stress test in 74 patients 11-37 months (mean 20 months) later. Patients were observed for survival up to 48 months. RESULTS: 24 patients had been rehospitalized, 16 because of chest pain. 77 patients were treated with beta blocker, 83 with statins, and 95 with antithrombotic medication. 84 patients were in NYHA (New York's Heart Association's classification's) class I at follow-up examination. Three patients died. 11 patients had a serious event, reinfarction (n = 3) or need for revascularization (n = 8) during the first 13 months. Total cumulative mortality rates after one and three years were 3% (95% CI 1-8) and 11% (95% CI 6-19). INTERPRETATION: The good initial results in primary angioplasty are maintained in long-term follow-up. This is in accordance with reports from centres abroad.

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A rare side effect from metformin is lactic acidosis. There have been much concern about the reported risk when metformin was combined with contrast medium. Almost all reported cases following combination with contrast media occurred when pre-existing poor renal function was present. A recent review of the literature has resulted in new recommendations in Europe and the USA. We suggest new guidelines for Norway with regard to the use of metformin in patients undergoing radiological examination with contrast media.

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BACKGROUND: Percutaneous angioplasty is an alternative to thrombolysis to reestablish coronary blood flow in patients with transmural myocardial infarction. At present, this treatment option is not widely accepted in Norway. MATERIAL AND METHODS: From 1996 to 1998, one hundred consecutive patients were treated with angioplasty for acute transmural infarction. The angiography showed one-vessel disease in 55%, two-vessel in 25%, and multivessel in 20%. The infarct related artery was the LAD in 44%, the CX in 14%, the RCA in 41%, and bypass graft in one. 92% had TIMI 0 or 1 flow. Stent was placed in 73%, GPIIb/IIIa was used in 11% and temporary pacemaker placed in 5%. RESULTS: Successful angioplasty was performed in 95%, 3% was not done, and 2% failed. Peripheral stenoses were treated in 15% and stenoses in other arteries in 10%. Complications and events within 24 hours related to the angioplasty were seen in 9%. CONCLUSION: Primary angioplasty for acute myocardial infarction can be done with high primary success, good short-term results and few complications.

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BACKGROUND: Much attention has lately been focused on primary angioplasty in the treatment of acute myocardial infarction. This report describe our results in 100 patients. MATERIAL AND METHODS: 100 consecutive patients with acute ST elevation myocardial infarction and a history of less than six hours were treated with primary angioplasty. The mean time from start of symptoms until establishment of reperfusion of the infarct related artery was 224 minutes; "the door-to-balloon" time was 69 minutes. RESULTS: Angioplasty was successful in 95% of all patients. Mean ejection fraction measured before discharge in 71 patients was 56%. Hospital and 30-days' mortality was 1%. New revascularization was needed in 6%. Average observation period in the coronary care unit was 1.8 days; no patient needed treatment for ventricular arrhythmias after angioplasty. The first 24 hours 24% had symptomatic congestive heart failure, reduced to 11% at hospital discharge on day 6. Acute rehospitalization within the first 30 days was necessary in 7%, but only in 2% for chest pain. INTERPRETATION: Our results are comparable to those of other high volume centres and show well preserved ventricular function and low hospital and 30-days' morbidity and mortality.

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BACKGROUND: Treatment of renal artery stenosis with angioplasty may be performed in patients with renovascular hypertension, ischaemic renal failure, or to preserve renal function. MATERIAL AND METHODS: From 1982 to 1993 Rikshospitalet performed 591 renal angioplasties in 419 patients with significant renal artery stenoses. Clinical and angiographic follow-ups were performed up until 1996. RESULTS: In patients with atherosclerotic disease, the acute success rate was 94%, primary patency 60%, and secondary patency 74%. The results were better for fibromuscular dysplasia. Patients with the highest blood pressure and those with recent onset of hypertension had the largest decrease in blood pressure. Renal angioplasty of bilateral stenosis or stenosis to a single functioning kidney preserved renal function in patients with normal to moderately reduced renal function. There were no overall positive effects on blood pressure and renal function in patients with serum creatinine > 250 mumol/l. CONCLUSION: Renal angioplasty can be done in selected patients with renal artery stenosis. The selection of patients for renal angioplasty is important in order to increase the clinical success rate. Clinical as well as angiographic follow-ups for detection of restenosis are mandatory.

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BACKGROUND: During the last two years the Intervention Centre at the Nation Hospital of Norway and Ullevål Hospital have pursued a research programme in telemedicine aimed at exploring the potential of inter-hospital collaboration. MATERIAL AND METHODS: Both hospitals established a communication network between operating rooms and lecture halls. Sound and video from minimally invasive surgical and radiology procedures were transmitted on a wide bandwidth ATM network (34 Mbits/s) to gain experience with the use of telemedicine for educational purposes and the treatment of patients. RESULTS: Evaluations of technical off-line and clinical line transmissions have given us helpful information about the potential of telemedicine and what it will take to utilise this potential. With the MPEG2 standard, a wide bandwidth network yields sufficient sound and image quality for educational and clinical collaboration. However, multimedia communication requires changes in the organisation to secure quality of service in relation to technical management and telemedical production. INTERPRETATION: Inter-hospital collaboration on telemedicine may be a resource in clinical practice, facilitating professional enhancements, particularly in surgery, radiology and internal medicine. Changes in the organisation are needed, but they are feasible.

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