Percutaneous biliary interventions through the gallbladder and the cystic duct: What radiologists need to know.

Percutaneous cholecystostomy is an established drainage procedure for the management of high-risk patients with acute cholecystitis. However, percutaneous image-guided access to the gallbladder may not be limited to the simple placement of a drain, but may also be used as an alternative approach to the biliary tree through the catheterization of the cystic duct, for a variety of other more complicated conditions. Percutaneous transcholecystic interventions may be performed in both malignant and benign disease. In the case of malignant jaundice, the transcholecystic route may be used when the liver parenchyma is occupied by metastatic lesions and transhepatic access is not possible. In benign conditions, access through the gallbladder may offer a solution if the biliary tree is not dilated. The transcholecystic access may then be route of insertion of large sheaths, internal drainage catheters, lithotripsy devices, stone retrieval baskets, and stents. The purpose of this review is to illustrate the techniques and to discuss the indications, complications, and technical difficulties of this alternative access to the biliary tree.

Integrated treatment of secondary hepatolithiasis. Case report.

Hepatolithiasis is defined as the occurrence of stones proximal to the biliary confluence and represents a prevalent disease in South East Asia being uncommon in Western countries. Biliary sepsis, hepatic abscesses and cholangiocarcinoma are considered potential complications. The Authors describe a case of a 68 years male patient affected by a left massive intrahepatic lithiasis secondary to common duct stones and associated to acute pancreatitis. The patient refused surgery and was submitted to a conservative transhepatic percutaneous treatment. After a complete removal of intrahepatic stones and a positioning of external internal biliary drainage (14F), a laparoscopic cholecistectomy was performed. The MRI control showed a complete resolution of the intrahepatic lithiasis. Conservative transhepatic percutaneous approach to hepatolithiasis represents a safe and effective treatment allowing good medium-long term results. Surgery is recommended in case of severe hepatic fibrosis or atrophy, suspected cholangiocarcinoma or multiple strictures with biliary distorsion. Integrated therapeutical protocols in referral multidisciplinary centers-offers the best long term results.

Gross hematuria of uncommon origin: the nutcracker syndrome.

Left renal vein hypertension, also called "nutcracker phenomenon" or "nutcracker syndrome," is a rare vascular abnormality responsible for gross hematuria. The phenomenon is attributable to the idiopathic decrease in the angle between the aorta and the superior mesenteric artery with consequent compression of the left renal vein. The entrapment of the left renal vein is not easily detectable by ordinary diagnostic procedures. We report two cases of gross hematuria (persistent in one patient and recurrent in the other) caused by "nutcracker phenomenon." In both cases, no remarkable findings were obtained from medical history, urinary red blood cells morphology, repeated urinalysis, pyelography, cystoscopy, or ureteroscopy. Left renal vein dilation in one case was found with a computed tomography (CT) scan performed on the venous tree of left kidney. The diagnosis of "nutcracker phenomenon" was confirmed by renal venography with measurement of pressure gradient between left renal vein and inferior vena cava in both cases. In one case, the diagnosis was complicated by the presence of Mycobacterium tuberculosis in urine. The "nutcracker phenomenon" is probably more common than thought. Early diagnosis is important to avoid unnecessary diagnostic procedures and complications such as the thrombosis of the left renal vein. Many procedures are available to correct the compression of the left renal vein entrapped between the aorta and the superior mesenteric artery: Gortex graft vein interposition, nephropexy, stenting, and kidney autotransplantation. After surgery, gross hematuria ceases in almost all patients.

Percutaneous computed tomography-guided ethanol injection in aldosterone-producing adrenocortical adenoma.

The feasibility, safety and effectiveness of percutaneous computed tomography-guided ethanol injection (PEI-CT) was investigated in a patient affected by aldosterone-producing adenoma (APA). A 42-year-old male patient with typical features of hyperaldosteronism presented a solitary left adrenal adenoma measuring 2 cm, with a normal contralateral gland, evidenced by both CT scan and adrenal [75Se-19]-nor-cholesterol scintigraphy. After normalization of potassium plasma levels, 4 ml of sterile 95% ethanol with 0.5 ml of 80% iothalamate sodium was injected. The procedure was completed in about 30 min. No severe pain or local complication was noted. Five hours after PEI, a fourfold and a twofold increase in aldosterone and cortisol plasma levels were observed, respectively. After 11 days on a normal sodium and potassium diet, normal potassium plasma levels and reduced aldosterone plasma levels were present, with reappearance of an aldosterone postural response. Plasma renin activity and aldosterone plasma levels normalized 1 month later, with reappearance also of a plasma renin activity postural response and maintenance of normal potassium plasma levels even on a high sodium and normal potassium diet. The patient has remained hypertensive, although lower antihypertensive drug dosages have been employed. After 17 months, normal biochemical, hormonal and morphological findings were still present. Thus, we suggest PEI-CT as a further alternative approach to surgery in the management of carefully selected patients with APA.

Percutaneous splenic artery occlusion for portal hypertension. A new mechanical technique for hypersplenism.

We studied 16 patients with hypersplenism, splenomegaly, and moderate nonbleeding portal hypertension with the purpose of discovering a hyperdynamic component associated with splenomegaly. We treated the patients' splenic hyperdynamic component and hypersplenism with a splenectomy. We measured wedge hepatic vein pressure (WHVP) before and after superior mesenteric artery occlusion by a balloon catheter, and after splenic artery (SA) occlusion by a balloon catheter. In 11 patients, following SA temporary occlusion an average WHVP reduction of 10.4 cm saline was obtained, and SA occlusion by Gianturco's coils was performed to obtain a gradual and segmentary occlusion. No colliquative phenomena were observed, and a stable decrease of WHVP with a marked improvement of peripheral cytopenia was obtained.

Stop-flow technique for loco-regional delivery of high dose chemotherapy in the treatment of advanced pelvic cancers.

AIM: To verify the rationale of a pelvic stop-flow technique for the perfusion of high-doses of mitomycin C and anthacyclines in patients with inoperable, recurrent pelvic cancer. METHODS: The stop-flow technique was realized by using percutaneous double-balloon arterial-venous catheters that selectively isolate the pelvic vascular section and a perfusion provided by an extracorporeal pump for 20 min. Ten patients (pts) with unresectable pelvic recurrence from colon-rectal cancer were treated with a combination of Mitomycin C (MMC, 20 mg/sqm) plus doxorubicin (DOXO, 75 mg/sqm; 8pts) or epirubicin (EPI, 75 mg/sqm; 2pts) infused into the isolated pelvic compartment. Blood samples were collected from the extracorporeal vascular flow and from peripheral plasma, and analysed for drug quantitation. RESULTS: During the procedure, there were no technical or hemodynamic complications, and no deaths occurred during surgery or in the postoperative period. MMC and DOXO peak levels measured in the extracorporeal system which irrotates the tumor area, were on average 21.6 (range: 4.3-44.3, MMC) and 17.2 (range: 1.8-48.4, DOXO) times higher than those observed in the peripheral blood. Similarly; the area under concentration (AUC) versus time curves measured in the pelvic compartment during stop-flow perfusion were 19.9 (range: 3.8-45.0, MMC) and 13.4 (range: 1.2-26.6, DOXO) times higher than the corresponding value in peripheral circulation. The drug percentage eliminated in the ultra filtrate was only 7.7% (MMC) and 0.9% (DOXO), and the plasmatic AUC(0-24) were similar to those observed with iv bolus of equivalent drug doses. Minimal systemic and local toxicities were observed. One complete pathological and 2 partial responses were observed; pain remission in 8/10 patients. median survival was 12 months (8-31). CONCLUSION: The endo-arterial administration into the local vasculature produces high pelvic-systemic concentration gradients during the stop-flow perfusion with limited local and systemic toxicity. The encouraging clinical results suggest further evaluation.

An unusual case of ascites.

A 76-year-old woman with abdominal pain and diarrhoea developed ascites that did not respond to treatment. There were no signs of liver damage. Abdominal ultrasonography with colour Doppler revealed an arterial-like flow in the enlarged splenic vein. Using selective mesenteric arteriography, we were able to diagnose a shunt between the inferior mesenteric artery and the inferior mesenteric vein. This is an unusual case of ascites due to prehepatic portal hypertension secondary to an extrahepatic arterioportal fistula.

Scleroembolization for treatment of hypertension caused by intrarenal arterial fibrodysplasia.

This paper reports a 13-year-old girl with severe hypertension due to fibrodysplasia of intrarenal arterial branches in the upper pole of the left kidney. Scleroembolization of the abnormal vascular region was carried out by injecting, via a transcutaneous catheter, an 80% solution of sodium iothalamate in ethanol, followed by a suspension of Gore-Tex particles in the same solution, which resulted in complete and persistent normalization of blood pressure.

Total or partial percutaneous renal ablation in the treatment of renovascular hypertension: radiological and clinical aspects.

In 15 patients with renovascular hypertension, considered unsuitable for angioplasty or surgery, percutaneous renal ablation was performed by injection of ethanol into the renal vasculature. Partial or complete renal ablation was confirmed by follow-up intravenous pyelography or arteriography. Patients were followed-up for a mean of 24.8 months after therapy and blood pressure was improved in all patients with five being cured. This study shows that percutaneous renal ablation is a useful and successful method of therapy for renal hypertension, and that it should be considered in patients unsuitable for surgery or angioplasty.

Treatment of carotid-cavernous fistula by trans-venous anterior (trans-orbital) approach. Case report and review of previous report.

A case is reported of successful occlusion of a dural carotid-cavernous fistula (type D) by means of a transvenous anterior approach. Through the left angular vein, the distal superior ophthalmic vein (SOV) and the cavernous sinus were cannulated and three Gianturco coils were delivered close to the fistulous communications. Obliteration of the carotid-cavernous communication was achieved sparing the internal carotid artery and its branches. The major advantage of entering the sinus from the venous route is to preclude any damage to the artery, distal migration of the detachable balloon or of thrombi, intracavernous pseudoaneurysm formation. The trans-orbital approach may be considered chiefly when the openings are in the antero inferior compartment and the SOV is enlarged. Its applications, quite sporadic until now, probably will become more popular, mainly in treating D type fistulas, thanks to the good results achieved and to its safety.

Dorsolumbosacral phlebography.

Two variations on the currently most commonly used technical method for phlebography are described. The first variation involves an original method for visualizing the dorsolumbosacral epidural plexus via the retrograde route from the azygos vein. If necessary this can be associated with catheterization and simultaneous injection into an ascending lumbar vein or into a lateral sacral vein. This method permits exploration from T7 to S1 and provides phlebograms of excellent quality, owing to the reduction in the flow caused by countercurrent injection. The second variation involves visualizing the epidural venous plexus by means of double percutaneous transfemoral catheterization of the hypogastric veins, using balloon catheters. This method is performed easily and rapidly. Preferential flow is obtained via the epidural plexus, and there is less diversion of the contrast medium through anastomoses and less filling of the vena cava. The specific indications for these methods are described. The availability of alternative methods beyond the traditional one renders epidural phlebography more reliable and more manageable, and it ensures certainty of diagnosis.

Phlebography of the cavernous and intercavernous sinuses.

The study of pituitary diseases is described, with visualization of the cavernous and intercavernous sinuses accomplished through percutaneous, transfemoral catheterization, using special methods to ensure its reliability. The most characteristic normal and pathological findings are described. The value of this method and the indications for its use in diagnosis are discussed. The possibility of combining morphological investigations with regional functional studies of pituitary hormones by selective blood sampling is suggested. This technical development opens new prospects for the future and further broadens the indications for use of this procedure.

Late innominate vein thrombosis. Unusual complication following sternal closure.

An unusual complication of the median sternotomy is reported. A 37-year-old male experienced a left innominate vein thrombosis 20 months after surgery. The combined treatment consisting of local infusion with Urokinase, surgical removal of the wire and balloon catheter dilatation, was completely successful.

[Hemorrhage of esophageal varices: conservative or emergency treatment?]. / Le emorragie da varici esofagee: trattamento conservativo o intervento d'urgenza?

The emergency treatment of bleeding esophageal varices still remain a very difficult problem. In this report results obtained with conservative and operative procedures will be compared. In particular 32 patients underwent transhepatic occlusion of the gastric vessels feeding varices, and 8 patients (total experience 27 cases) to emergency esophageal transection with the EEA stapler instrument. The conclusion is that both methods represent useful alternatives, in selected cases, rather than being antagonists.

Prehepatic portal hypertension: experience with 88 cases.

Although prehepatic portal hypertension (PHPH) is less common than intrahepatic portal hypertension, it gives rise to more serious diagnostic and therapeutic problems than the latter. From their experience of 88 cases, the authors feel that it is necessary for a correct approach to PHPH to derive a classification useful throughout the clinical course of these patients. They distinguish PHPH due to extrinsic obstruction from PHPH due to intrinsic obstruction, and subdivide these two classes according to etiologic, pathologic and hemodynamic criteria. A series of principles has been developed, in answer to the problems related to each of these classes, as an aid in the prevention of portal hypertension relapse.

Visceral artery aneurysms secondary to collateral circulation.

OBJECTIVE: To evaluate dilatation of visceral arteries secondary to anomalies and collateral circulation. DESIGN: Case report. SETTING: Department of Vascular Surgery, University Hospital. PATIENTS: Two patients with secondary visceral aneurysms were reported. First patient (case 1) had a mid-aortic dysplastic syndrome with multiple aneurysms of the celiac trunk and right renal artery. Other patient (- case 2) presented an inferior pancreaticoduodenal artery aneurysm associated with proximal common hepatic artery occlusion. INTERVENTIONS: The case 1 was submitted to aortic and left renal artery angioplasty (PTFEE), while in the case 2 the resection of aneurysm was performed. RESULTS: Both patients had complete resolution of symptoms and are alive today. CONCLUSIONS: Clinical observations confirmed the development of visceral artery aneurysms secondary to arterial hypertension and collateral circulation.

[Compression of the celiac tripod by the arcuate ligament of the diaphragm]. / Compressione del tripode celiaco da parte del legamento arcuato del diaframma.

A case of external compression of the coeliac trunk on the part of the lateral arcuate ligament is reported. A brief account of the questions still posed by Dunbar's syndrome is followed by the assertion that dynamic, not static, aortography must be performed since it is in itself sufficient to clinch the diagnosis. It is suggested that pain is not an expression of reduced arterial flow, but of compression of the coeliac plexus, with the results that surgical management must associate adventitiectomy with section of the arcuate ligament. This will ensure displacement of the plexus, and prevent possible postoperative periarterial fibrosis from causing the reappearance of pain by involving the nerve fibres.

[Fistula following emergency total colectomy: an efficient method of treatment]. / Fistola dopo colectomia totale in urgenza: un metodo efficace di trattamento.

A personal case of enterocutaneous fistula secondary to total emergency colectomy is reported with particular emphasis on an effective form of radiological management, based on the percutaneous sclerosing of the fistulous tract using absolute ethanol and a hyperosmotic contrast medium (Angioconray 80%). By this approach a rapid closure of the fistulous tract was obtained. Moreover the procedure was easy to perform, well tolerated by the patient and devoid of untoward side effects.

[Gastrointestinal angiodysplasia. Clinical, endoscopic, angiographic and histologic study]. / Angiodisplasia gastrointestinale. Studio clinico, endoscopico, angiografico ed istologico.

The authors report 10 cases of gastrointestinal bleeding angiodysplasia (4 male and 6 female). The surgical treatment was normally provided and the main clinical features, were observed by radiological, endoscopic and pathological findings. Angiodysplasia was observed in the colon (4 cases), in the small intestine (3 cases) and in the stomach (3 cases). Common symptoms (bleeding and sideropenic anaemia), where possible associated with endoscopic and angiographic study, permitted to determine diagnosis and lesion's extension. Pathological findings showed that vascular dilatation wasn't present only in the mucosa and in the submucosa, as in the amartomatous congenital forms, but was present in all intestinal wall, as in the secondary forms, more frequent.

[Splenoportography: still important technic. New prospects (author's transl)]. / Splénoportographie: une technique toujours actuelle. Nouvelles perspectives.

Splenoportography still plays today an important role among angiographic examinations used in the study of portal hypertension. The authors arrived at these conclusions after studying the results obtained in more than 500 examinations carried out. In the text, they give a few details of the technic used to improve the photographic result and to reduce the risk of the examination.