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1343
Letters
Luetic Aneurysm of the Innominate Artery Mimicking a Mass in the Right Side of the Anterior Mediastinum: MR Appearance Luetic aneurysms of the innominate chest radiographs may mimic a mass mediastinum.
We
describe
the
MR
artery are uncommon and on in the right side of the anterior
features
of such
a case.
A 66-year-old man was admitted because of progressive dyspnea. He had a long-standing history of hypertension and emphysema and had been treated for syphilis 20 years before this admission. Posteroanterior
and
opacity
with
lateral
chest
well-defined
mediastinum
(Fig.
radiographs
borders
showed
in the
CT with IV contrast
1A).
right
a 2-cm side
of
masslike
the
anterior
material showed
a partly
enhancing mass at the anterior site of the ascending aorta. On the basis of this study and the patient’s history of syphilis, aneurysm of the ascending aorta was considered as a possible diagnosis. We postulated
that
the
nonenhanced
part
of the
aneurysm
represented
a thrombus within the aneurysm. On angiograms of the aortic root, the aneurysm appeared to be localized at the base of the innominate artery.
Because
the
patient
had
chronic
respiratory
insufficiency,
surgery was not considered. Three months later, MR imaging was performed to study features of the aneurysm and to determine if the size of the mality was increasing. A Philips T5 imager (0.5 T), cardiac and a rnultislice spin-echo sequence with a TE of 1 5 msec effective
TR
of
461
msec
were
aneurysm
2 cm in diameter
innominate
artery
suggesting
the
Aneurysms of
(Fig.
used.
(1].
showed
an
void
was
present
of choice for imaging aneurysm or buckling of this vessel. Angiography should be limited to those cases in which the MR findings are equivocal and further differentiation of an aneurysm from buckling of the
innominate
artery
is needed.
Syphilis
Martin
artery is the
are rare and account most
common
for 3%
etiologic
De Wever
factor
Heerlen,
from
an
aneurysm
of
the
tortuosity of the innominate artery often occur in hypertensive females.
innominate
artery.
Buckling
scans,
we
aneurysms.
When
that
CT
plays
the aneurysm
University
and
mass
think
Hospital
Netherlands
Maastricht,
Hospital
Snoop
Maastricht
The Netherlands
are more frequent entities and These entities may also simulate
in the upper mediastinum [2, 3J. Unlike aneurysms, which may rupture, resulting in death, buckling of the innominate artery is a benign condition [3]. Because of difficulties in differentiating an aneurysm from buckling of the innominate artery on axial CT a right-sided
The
Gabriel
11 1. The diagnosis was not initially considered after CT because it was difficult to differentiate an aneurysm localized in the ascending
aorta
Goei K. T. Tjwa
Reginald
in the aneurysm,
of thrombus.
of the innominate
all aneurysms
images
at the right side of the origin of the
1 B). No flow
presence
Oblique
the MR abnorgating, and an
Fig. 1.-Luetic aneurysm of innominate artery mimicking a mediastinal mass. A, Radiograph shows lesion (arrow) in right side of mediastinum that appeared to be localized in anterior mediastinum on lateral radiograph (not shown). B, Oblique cardiac-gated Ti-weighted spin-echo MR image shows aneurysm (arrow) at origin of innominate artery (arrowhead). Note absence of flow void in aneurysm, indicating formation of thrombus.
a minor
role
in the
imaging
of these
is completely filled with thrombus, the diagnosis may be missed even with CT [4]. MR imaging is noninvasive and can show the longitudinal course of the innominate artery. Consequently, it seems to be the technique
REFERENCES
1 , Gay BB Jr, Walker FJ. Aneurysm of the innominate artery: review of clinical and radiologic findings in 18 cases. Radiology 1953:60:804-813 2. Christensen EE, Landay MJ, Dietz GW, Brinley G. Buckling of the innominate artery simulating a right apical lung mass. AJR 1978:131:119-123 3, Green RA. Enlargement of the innominate and subclavian arteries simulating a mediastinal
4, Tadavarthy
neoplasm.
Am Rev Tuberc
1959:79:790-798
SM, Castaneda-Zuniga WR, Klugman J. Ben Shachar J, Amplatz K. Syphilitic aneurysms of the innominate artery. Radiology 1981: 139:31 -34
1344
LETTERS
December
AJR:159,
1992
A New Technique for Retrieving Catheter Fragments in the Pulmonary Artery A new loop-snare pulmonary
artery
Downloaded from www.ajronline.org by 60.248.135.99 on 10/25/15 from IP address 60.248.135.99. Copyright ARRS. For personal use only; all rights reserved
of a 5-French
system
has
Berman
for retrieving
catheter
devised (Fig.
been
angiographic
1). The
balloon
fragments
system
in the
is composed
catheter
and
a 0.01 8-in.
(0.46 mm) guidewire 260 cm long (Hanako Medical, Chiyoda, Japan). The catheter originally had two sets of three small side holes at the tip; the walls between two
holes
the distal two holes of one set and the proximal
of another
set were
removed,
yielding
two
large
holes,
one
for each set of side holes. A loop snare was formed, with the guidewire inserting through the two large holes. This system, balloon into
catheter
the
with
pulmonary
the wire
loop-snare
had a catheter
had previously An attempt Intravascular
been
made
Retriever
accidentally
into
the
be safely
method
fragment
and
easily
pulmonary
cut
fragment
to retrieve
Set
was
used
in the left pulmonary
had an IV catheter
had
was
can
the
advanced
artery.
The newly devised girl who
loop,
B
long
(Cook,
in the
it by using Bloomington,
in a 6-year-old artery. She
vena
inferior
an 8-French IN).
The
cava. Dotter
fragment
in two.
One of the two pieces was carried away
artery.
The
newly
devised
loop
snare
was
ad-
vanced into the left pulmonary artery with the balloon inflated, and the tip of the catheter was placed in the artery smoothly and safely. We retrieved the fragment in 1 mm (Fig. 2). Many nonsurgical techniques in the pulmonary artery have
for the retrieval been reported
of catheter fragments [1-3]. They can be
classified into three groups according to the instruments used: loop snare, grasping forceps, and basket retriever. Our new retrieval system is a loop-snare system, but it has some advantages over the
D
C Fig. 2.-A-D,
retrieval
Schematic
drawing catheter
system to remove
shows procedure for using loop-snare fragment from left pulmonary artery.
techniques. Our system is safer, easier, and more reliable than stiff-tipped catheters from the point of view of handling. Because of the balloon at the tip of the catheter, even an inexperi-
conventional
enced
operator
pulmonary than
can
artery
the usual
advance
with
ones
little
the
tip with
difficulty.
because
The
the modified
the
snare
snare side
loop holes
loop
into
the
left
is easier
to open
are large
enough
to accommodate the wire. Furthermore, this system can be made easily from catheters available in any cardiovascular laboratory and is not
expensive.
Masayuki Kiyohiko
Zuguchi Sakamoto
Yoshihiro Takai and colleagues Tohoku
C
University
Sendai
980, Japan
REFERENCES
1 . Uflacker
R, Lima 5, Melicher AC. Intravascular foreign bodies: percutaneous retrieval. Radiology 1986:160:731-735 2. Tanaka M, lyomasa Y. Nonsurgical technique for removal of catheter fragments from the pulmonary artery. Cathet Cardiovasc Diagn 1983:9:
109-112 3, Yedlicka JW, Cerlson JJE, Amplatz DWK, Castaneda-Zuniga WR. Intravascular foreign body removal. In: Wilfrido AC, Tadavarthy SM, eds. Interventiona! radiology, 2nd ed. Baltimore: Williams & Wilkins, 1992: 705-716
H D
Fig.
E
1.-Schematic
F
drawing of procedure for making angiographic balloon catheter
snare device from Berman
modified loopand long thin
guidewire. A, Anglographic balloon catheter. Arrow indicates side hole. B-D, Walls are removed between distal two small side holes on one side and between proximal two on other side, yielding two large side holes, one on each side of catheter. Asterisk = knife, arrowhead = balloon. E and F, Loop snare is formed by inserting long guidewire (open arrow) through two large side holes.
Percutaneous Hepatocellular Recently, bleeding
Chung
hepatocellular
intratumoral
injection
first case
of control
graphically
guided
Ethanol Injection Carcinoma et al. [1]
reported
carcinoma of alcohol
of bleeding percutaneous
in Bleeding
findings who
during
were
laparotomy.
hepatocellular injection
in three
patients
successfully We
carcinoma
of alcohol.
treated describe
with by the
by sono-
AJR:159,
December
Fig. 1.-Sonogram
shows
perito-
Atypical
neal fluid collection (arrowhead) and hyperechogenic tumor nodule (arrow) injected with absolute alcohol in woman with bleeding hepatocellular carcinoma.
Downloaded from www.ajronline.org by 60.248.135.99 on 10/25/15 from IP address 60.248.135.99. Copyright ARRS. For personal use only; all rights reserved
1345
LETTERS
1992
Choledochal
In his review proposes
abdominal
tenderness.
Blood
on pediatric
devised
by
biliary
Alonso-Lej
sonography et al. [2]
[1], for
HaIler
classifying
cysts into three major types: type 1 , concentric dilatation of the common bile duct; type 2, diverticular outpouching of the common bile duct; and type 3, choledochocele. In a previous article in the AJR, Savader et al. [3] proposed a scheme outlined by Todani et al. (cited in [4]) that classifies choledochal cysts into five types and subtypes as follows: type 1 A, cystic dilatation of the common bile duct; type 1 B, focal, segmental, dilatation of the common bile duct; type 1C, fusiform choledochal dilatation; type 2, true choledochal choledochal
and extrahepatic
3, choledochocele; type 4A, multiple intrahepatic cysts; type 4B, multiple extrahepatic cysts; type 5,
Caroli’s
We recently
diverticulum;
A 60-year-old woman with because of sudden abdominal
article
a scheme
Cyst
alcoholic cirrhosis pain and anemia. pressure
and
pulse
was hospitalized She had diffuse rate
were
type
disease.
choledochal
normal.
cyst
that
does
treated not
a patient
conform
to any
who
had an unusual
of these
types.
Relevant laboratory results were as follows: hemoglobin, 6.8 g/dI (68 g/l); hematocrit, 14.2% (0.14); prothrombin time, 52% of control; total serum bilirubin, 52 MmoI/l; serum alkaline phosphatase, 267 lU/I (normal,
1343
Letters
Luetic Aneurysm of the Innominate Artery Mimicking a Mass in the Right Side of the Anterior Mediastinum: MR Appearance Luetic aneurysms of the innominate chest radiographs may mimic a mass mediastinum.
We
describe
the
MR
artery are uncommon and on in the right side of the anterior
features
of such
a case.
A 66-year-old man was admitted because of progressive dyspnea. He had a long-standing history of hypertension and emphysema and had been treated for syphilis 20 years before this admission. Posteroanterior
and
opacity
with
lateral
chest
well-defined
mediastinum
(Fig.
radiographs
borders
showed
in the
CT with IV contrast
1A).
right
a 2-cm side
of
masslike
the
anterior
material showed
a partly
enhancing mass at the anterior site of the ascending aorta. On the basis of this study and the patient’s history of syphilis, aneurysm of the ascending aorta was considered as a possible diagnosis. We postulated
that
the
nonenhanced
part
of the
aneurysm
represented
a thrombus within the aneurysm. On angiograms of the aortic root, the aneurysm appeared to be localized at the base of the innominate artery.
Because
the
patient
had
chronic
respiratory
insufficiency,
surgery was not considered. Three months later, MR imaging was performed to study features of the aneurysm and to determine if the size of the mality was increasing. A Philips T5 imager (0.5 T), cardiac and a rnultislice spin-echo sequence with a TE of 1 5 msec effective
TR
of
461
msec
were
aneurysm
2 cm in diameter
innominate
artery
suggesting
the
Aneurysms of
(Fig.
used.
(1].
showed
an
void
was
present
of choice for imaging aneurysm or buckling of this vessel. Angiography should be limited to those cases in which the MR findings are equivocal and further differentiation of an aneurysm from buckling of the
innominate
artery
is needed.
Syphilis
Martin
artery is the
are rare and account most
common
for 3%
etiologic
De Wever
factor
Heerlen,
from
an
aneurysm
of
the
tortuosity of the innominate artery often occur in hypertensive females.
innominate
artery.
Buckling
scans,
we
aneurysms.
When
that
CT
plays
the aneurysm
University
and
mass
think
Hospital
Netherlands
Maastricht,
Hospital
Snoop
Maastricht
The Netherlands
are more frequent entities and These entities may also simulate
in the upper mediastinum [2, 3J. Unlike aneurysms, which may rupture, resulting in death, buckling of the innominate artery is a benign condition [3]. Because of difficulties in differentiating an aneurysm from buckling of the innominate artery on axial CT a right-sided
The
Gabriel
11 1. The diagnosis was not initially considered after CT because it was difficult to differentiate an aneurysm localized in the ascending
aorta
Goei K. T. Tjwa
Reginald
in the aneurysm,
of thrombus.
of the innominate
all aneurysms
images
at the right side of the origin of the
1 B). No flow
presence
Oblique
the MR abnorgating, and an
Fig. 1.-Luetic aneurysm of innominate artery mimicking a mediastinal mass. A, Radiograph shows lesion (arrow) in right side of mediastinum that appeared to be localized in anterior mediastinum on lateral radiograph (not shown). B, Oblique cardiac-gated Ti-weighted spin-echo MR image shows aneurysm (arrow) at origin of innominate artery (arrowhead). Note absence of flow void in aneurysm, indicating formation of thrombus.
a minor
role
in the
imaging
of these
is completely filled with thrombus, the diagnosis may be missed even with CT [4]. MR imaging is noninvasive and can show the longitudinal course of the innominate artery. Consequently, it seems to be the technique
REFERENCES
1 , Gay BB Jr, Walker FJ. Aneurysm of the innominate artery: review of clinical and radiologic findings in 18 cases. Radiology 1953:60:804-813 2. Christensen EE, Landay MJ, Dietz GW, Brinley G. Buckling of the innominate artery simulating a right apical lung mass. AJR 1978:131:119-123 3, Green RA. Enlargement of the innominate and subclavian arteries simulating a mediastinal
4, Tadavarthy
neoplasm.
Am Rev Tuberc
1959:79:790-798
SM, Castaneda-Zuniga WR, Klugman J. Ben Shachar J, Amplatz K. Syphilitic aneurysms of the innominate artery. Radiology 1981: 139:31 -34
1344
LETTERS
December
AJR:159,
1992
A New Technique for Retrieving Catheter Fragments in the Pulmonary Artery A new loop-snare pulmonary
artery
Downloaded from www.ajronline.org by 60.248.135.99 on 10/25/15 from IP address 60.248.135.99. Copyright ARRS. For personal use only; all rights reserved
of a 5-French
system
has
Berman
for retrieving
catheter
devised (Fig.
been
angiographic
1). The
balloon
fragments
system
in the
is composed
catheter
and
a 0.01 8-in.
(0.46 mm) guidewire 260 cm long (Hanako Medical, Chiyoda, Japan). The catheter originally had two sets of three small side holes at the tip; the walls between two
holes
the distal two holes of one set and the proximal
of another
set were
removed,
yielding
two
large
holes,
one
for each set of side holes. A loop snare was formed, with the guidewire inserting through the two large holes. This system, balloon into
catheter
the
with
pulmonary
the wire
loop-snare
had a catheter
had previously An attempt Intravascular
been
made
Retriever
accidentally
into
the
be safely
method
fragment
and
easily
pulmonary
cut
fragment
to retrieve
Set
was
used
in the left pulmonary
had an IV catheter
had
was
can
the
advanced
artery.
The newly devised girl who
loop,
B
long
(Cook,
in the
it by using Bloomington,
in a 6-year-old artery. She
vena
inferior
an 8-French IN).
The
cava. Dotter
fragment
in two.
One of the two pieces was carried away
artery.
The
newly
devised
loop
snare
was
ad-
vanced into the left pulmonary artery with the balloon inflated, and the tip of the catheter was placed in the artery smoothly and safely. We retrieved the fragment in 1 mm (Fig. 2). Many nonsurgical techniques in the pulmonary artery have
for the retrieval been reported
of catheter fragments [1-3]. They can be
classified into three groups according to the instruments used: loop snare, grasping forceps, and basket retriever. Our new retrieval system is a loop-snare system, but it has some advantages over the
D
C Fig. 2.-A-D,
retrieval
Schematic
drawing catheter
system to remove
shows procedure for using loop-snare fragment from left pulmonary artery.
techniques. Our system is safer, easier, and more reliable than stiff-tipped catheters from the point of view of handling. Because of the balloon at the tip of the catheter, even an inexperi-
conventional
enced
operator
pulmonary than
can
artery
the usual
advance
with
ones
little
the
tip with
difficulty.
because
The
the modified
the
snare
snare side
loop holes
loop
into
the
left
is easier
to open
are large
enough
to accommodate the wire. Furthermore, this system can be made easily from catheters available in any cardiovascular laboratory and is not
expensive.
Masayuki Kiyohiko
Zuguchi Sakamoto
Yoshihiro Takai and colleagues Tohoku
C
University
Sendai
980, Japan
REFERENCES
1 . Uflacker
R, Lima 5, Melicher AC. Intravascular foreign bodies: percutaneous retrieval. Radiology 1986:160:731-735 2. Tanaka M, lyomasa Y. Nonsurgical technique for removal of catheter fragments from the pulmonary artery. Cathet Cardiovasc Diagn 1983:9:
109-112 3, Yedlicka JW, Cerlson JJE, Amplatz DWK, Castaneda-Zuniga WR. Intravascular foreign body removal. In: Wilfrido AC, Tadavarthy SM, eds. Interventiona! radiology, 2nd ed. Baltimore: Williams & Wilkins, 1992: 705-716
H D
Fig.
E
1.-Schematic
F
drawing of procedure for making angiographic balloon catheter
snare device from Berman
modified loopand long thin
guidewire. A, Anglographic balloon catheter. Arrow indicates side hole. B-D, Walls are removed between distal two small side holes on one side and between proximal two on other side, yielding two large side holes, one on each side of catheter. Asterisk = knife, arrowhead = balloon. E and F, Loop snare is formed by inserting long guidewire (open arrow) through two large side holes.
Percutaneous Hepatocellular Recently, bleeding
Chung
hepatocellular
intratumoral
injection
first case
of control
graphically
guided
Ethanol Injection Carcinoma et al. [1]
reported
carcinoma of alcohol
of bleeding percutaneous
in Bleeding
findings who
during
were
laparotomy.
hepatocellular injection
in three
patients
successfully We
carcinoma
of alcohol.
treated describe
with by the
by sono-
AJR:159,
December
Fig. 1.-Sonogram
shows
perito-
Atypical
neal fluid collection (arrowhead) and hyperechogenic tumor nodule (arrow) injected with absolute alcohol in woman with bleeding hepatocellular carcinoma.
Downloaded from www.ajronline.org by 60.248.135.99 on 10/25/15 from IP address 60.248.135.99. Copyright ARRS. For personal use only; all rights reserved
1345
LETTERS
1992
Choledochal
In his review proposes
abdominal
tenderness.
Blood
on pediatric
devised
by
biliary
Alonso-Lej
sonography et al. [2]
[1], for
HaIler
classifying
cysts into three major types: type 1 , concentric dilatation of the common bile duct; type 2, diverticular outpouching of the common bile duct; and type 3, choledochocele. In a previous article in the AJR, Savader et al. [3] proposed a scheme outlined by Todani et al. (cited in [4]) that classifies choledochal cysts into five types and subtypes as follows: type 1 A, cystic dilatation of the common bile duct; type 1 B, focal, segmental, dilatation of the common bile duct; type 1C, fusiform choledochal dilatation; type 2, true choledochal choledochal
and extrahepatic
3, choledochocele; type 4A, multiple intrahepatic cysts; type 4B, multiple extrahepatic cysts; type 5,
Caroli’s
We recently
diverticulum;
A 60-year-old woman with because of sudden abdominal
article
a scheme
Cyst
alcoholic cirrhosis pain and anemia. pressure
and
pulse
was hospitalized She had diffuse rate
were
type
disease.
choledochal
normal.
cyst
that
does
treated not
a patient
conform
to any
who
had an unusual
of these
types.
Relevant laboratory results were as follows: hemoglobin, 6.8 g/dI (68 g/l); hematocrit, 14.2% (0.14); prothrombin time, 52% of control; total serum bilirubin, 52 MmoI/l; serum alkaline phosphatase, 267 lU/I (normal,
