Radiological stent placement of post sleeve gastrectomy leak: efficacy, imaging features and post-procedure complications.

Laparoscopic sleeve gastrectomy (SG) is the most commonly performed bariatric procedure. The primary and insidious early post-SG complication is the gastric leak (GL). In literature, there are many studies describing the endoscopic stent placement as treatment of GL and few studies about stent placement performed by interventional radiology under fluoroscopic guide. Our aims were to describe the radiological stent placement technique, to compare endoscopic and radiological stent placement, to illustrate normal diagnostic features and summarise the incidence of complications after stent placement, removal, and their imaging features. This was a single centre retrospective study of 595 patients who underwent SG between 2011 and 2019. Inclusion criteria: patients who developed GL after SG and treated with gastro-oesophageal stent placement by endoscopy or interventional radiology; availability of medical history and imaging studies; follow-up time after stent removal (1 year). The rates of technical success, clinical success and complications after stent placement and removal were collected and compared between the two methods of stent positioning. A total of 17/595 (2.8%) patients developed a radiologically diagnosed GL after SG. The type II-III GLs (15/17) were treated with endoscopic or radiological stent placement. 9/15 (60%/Group A) patients underwent gastro-oesophageal stenting by interventional radiology and 6/15 (40%/Group B) were treated with endoscopic stent placement. The technical and clinical success rate was 100% for both groups. Stent migration occurred in 22% and 27% for Group A and B respectively. Post-extraction stenosis was the main late complication, occurring in 22% in Group A and 0% in Group B. Gastro-esophageal stent placement performed by interventional radiologists is a valid "mini-invasive" treatment for GL. This procedure is not inferior to endoscopic positioning regarding efficacy, periprocedural and postprocedural complication rate. It's necessary to be familiar with radiological findings after stent placement and removal. Computed tomography (CT) scan is the main radiological technique to identify stent placement complications. Upper gastrointestinal (UGI) series are the first radiological procedures used to detect late complications after stent removal.

Clinically Suspected Segmental Arterial Mediolysis of the Splanchnic Arteries: A Report of 2 Rare Cases.

BACKGROUND Segmental arterial mediolysis (SAM) is an uncommon vascular pathology characterized by arteriopathy, mainly of medium-sized abdominal splanchnic vessels, without an atherosclerotic, inflammatory, infectious, or autoimmune underlying etiology. Segmental arterial mediolysis is clinically heterogeneous and symptoms may be completely nonspecific. The knowledge of radiological features of segmental arterial mediolysis and the exclusion of other pathologies should direct early diagnosis and refer patients for correct treatment. CASE REPORT In the last 2 years, we treated 2 different adult patients (an 89-year-old woman and a 52-year-old man) with spontaneous visceral bleeding, admitted to the Emergency Department due to acute onset of abdominal pain, anemia, and computed tomographic angiography (CTA) evidence of aneurysmatic, and stenotic alterations of splanchnic arteries. Based on clinical, laboratory, and radiological features, segmental arterial mediolysis was suspected. These 2 patients were referred to our Interventional Radiology Department and treated with super-selective transcatheter arterial embolization (TAE), performed by a minimally invasive approach, allowing an immediate clinical improvement with regression of symptoms and avoiding major surgical treatment. CONCLUSIONS In patients with clinical, laboratory, and radiological signs of acute and/or chronic abdominal bleeding and radiological findings suggesting segmental arterial mediolysis, mini-invasive endovascular treatment is a safe, extremely reliable, and secure procedure and appears to be the first-choice treatment when available. Since abdominal bleeding could have fatal consequences in these patients, timely diagnosis and endovascular therapy are essential to treat visceral vascular alterations due to segmental arterial mediolysis.

Distal radial artery: The last extreme rescue arterial access for interventional radiologists?

Transradial artery approach as primary access for transcatheter diagnosis and intervention is associated with lower risk of bleeding and major vascular complications, improved patient comfort and shorter time to hemostasis and ambulation than femoral one. Patient's adequate hand collateral perfusion, assessed by the Barbeau test, must be depicted prior to transradial artery approach in order to assess any absolute contraindication (D waveform). We describe the distal transradial artery approach, recently proposed for coronary interventions, used in emergency to embolize an intestinal bleeding in an 84-year-old woman and a left pectoralis major muscle bleeding in an 83-year-old woman, both with high risk of bleeding for femoral approach and contraindication for transradial artery approach (Barbeau D waveform).

Varicocele, conventional laparoscopic ligation versus occluding balloon embolization.

INTRODUCTION: Varicocele is a relatively complex pathology that affects the pampiniform plexus of veins in the spermatic cord. Modern treatment involves both urological/surgical and interventional procedures. Our objective is to compare outcomes of conventional laparoscopic ligation (LL) and occluding balloon embolization (OBE) a percutaneous interventional procedure. MATERIALS AND METHODS: We treated retrospectively a total of 98 patients, divided in two cohorts; arm A with 48 and arm B with 50 patients. Arm A patients underwent LL, while arm B ones were treated in interventional radiology suite, via OBE method. No comorbidities were reported, especially scrotal ones. Hence, all patients have been asked to respect 3 and 6 months' follow-up, clinical examination and ultrasonography were performed. Age range of the entire sample: 15-45 years old, with average of 28 years. The study involved two European centers. We performed a comparative analysis (Fisher's test) of intra-operative time, hospitalization and patient's postoperative recovery time. RESULTS AND LIMITATIONS: Outcomes have been in line with the recent literature ones, allowing the occluding balloon embolization a small advantage for quicker operative average time, hospitalization needed and full recovery to normal activities for the patient. Main limitation was the unfeasibility of cost-effectiveness analysis due to national differences, limited sample and lack of complete semen analysis pre- and postoperative. CONCLUSION: Both OBE and LL are safe and effective procedures in the treatment of varicocele, conceding OBE a slight advantage in terms of hospital stay and full recovery to normal activity of patients.

Early post-procedural patients compliance and VAS after UAE through transradial versus transfemoral approach: preliminary results.

PURPOSE: The aim of our study is to verify VAS and patient compliance in the immediate post-procedural time, in patients undergoing UAE through radial approach versus femoral procedure. METHODS: Between January and September 2017, 30 consecutive patients (age range 28-47, average 32 years) were enrolled for the study. UAE was performed by two interventional radiologists with more than 10 years of experience and more than 100 cases of UAE done. Patients were divided into two groups: transfemoral approach (group a, n = 15 patients) and transradial approach (group b, n = 15 patients). After procedure, patients were questioned about the compliance using the questionnaire at 24 h and VAS rating at 6, 12, 18 and 24 h. RESULTS: The average of VAS in group b was lower than in group a in each evaluation at 6 h (p < 0.20), 12 h (p < 0.07), 18 h (p < 0.02) and 24 h (p < 0.22) on the basis of Mann-Whitney U test, however, without a clear scientific evidence. Also the compliance score at 24 h had better results in the group b (average 14.0, range 13.0-16.0) in comparison with group a (average 18.0, range 17.0-21.4) (p < 0.001). CONCLUSION: Transradial approach improves the compliance and VAS of patients undergone to UAE.

Feasibility of percutaneous cryoablation of vertebral metastases under local anaesthesia in ASAIII patients.

PURPOSE: spine metastases are common concern from several primary neoplasms, modern management include percutaneous techniques such as ablation and cementoplasty. This research aims to evaluate the treatment under local anaesthesia in high-risk patients (ASA III). METHODS AND MATERIAL: from January 2013 up to September 2016 we treated via percutaneous cryoablation 11 advanced oncological patients classified as ASA III, then retrospectively a review of their clinical history has been performed. Interventions were managed under local anaesthesia, injecting low doses of bupivacaine 2,5mg/ml (from10 to 30ml). Cryoprobes of 17G were introduced under CT guidance. VAS scores were evaluated pre, intra and post operative up to the 3rd month and further, statistical analyses were obtained using T student test. RESULTS: thirteen spinal metastases were cryoablated in 11 patients (6W, 5M; mean age of 53 years, range 52-81). Tumour location was: sacrum (n=6), lumbar spine (n=3), thoracic spine (n=2). The average VAS value during the procedure was 5,27 (standard deviation 0,90). There were statistically significant decreases in the median numeric VAS scale score at 1-week, 1-month, and 3-month time points (P<.001 for all). Technical success was achieved in all cases. Among patients with neurological deficit, some clinical improvement was assessed. CONCLUSION: cryoablation with or without subsequent cement injection can be safely performed with local anaesthesia for pain relief also in patients with high ASA score with higher risk of complications, in the absence of any other suitable treatment.

Endovenous laser ablation of spermatic vein for the treatment of varicocele.

INTRODUCTION: Varicocele is a relatively complex pathology of the scrotum veins', known to be one of the easiest to treat. Modern treatment involves both surgical (open, laparoscopic and microsurgery) and interventional approach (either with coils and/or sclerosant injection). Our aim is to demonstrate the feasibility and the reliability of endovenous laser ablation (EVLA) of the spermatic vein for the treatment of varicocele. MATERIALS AND METHODS: We consecutively and prospectively treated 11 patients (age range 24-45 years old, mean 31y) with left varicocele, phlebografically classified as Bahren type I and with indication for percutaneous treatment. Clinical success was evaluated by color doppler ultrasound (CDUS) one week, one months and three months after the procedures. We also evaluated the pain feeling for 48 h after the procedure on the basis of the visual analogue score (VAS) obtained through telephonic interview. RESULTS: Technical success was achieved in all cases. In all cases varicocele disappeared at CDUS at 1 and three months with reflux abolition. Two cases of small vein laceration were noted without sequelae, no other complication has been described. All patients reported improvements either regarding symptoms and/or spermiographic parameters. CONCLUSIONS: In our experience, EVLA of spermatic vein is a feasible and safe treatment in patients with Bahren type I varicocele. The key advantage of this technique is the adoption of a standardized protocol, which remains one of the main problems in gaining scientific evidence in case of coil or sclerosant embolisation (type and number of coils, amount of sclerosant agent etc).

Left spermatic vein retrograde sclerosis: comparison between sclerosant agent injection through a diagnostic catheter versus through an occluding balloon catheter.

PURPOSE: The aim of this study was to compare the technical success between left spermatic vein (LSV) scleroembolisation achieved with the injection of sclerosant through a diagnostic catheter and through an occluding balloon (OB), in the treatment of male varicocele. MATERIALS AND METHODS: From January 2012 to September 2013, we prospectively enrolled 100 patients with left varicocele and an indication for LSV scleroembolisation related to symptoms or spermiogram anomalies; patients were randomised to two groups (we wrote a list of 100 lines assigned casually with A or B and each patient was consecutively allocated to group A or B on the basis of this list). Patients in group A underwent injection of the sclerosing agent through an angiographic diagnostic catheter (free catheter technique) and patients in group B through an OB catheter (OB technique). In cases of incomplete occlusion of the LSV, the procedure was completed with coils. Total occlusion of the LSV at post-treatment phlebography during a Valsalva manoeuvre before any coil embolisation was considered a technical success. The rate of complications was also evaluated. The Fischer's test was used for statistical analysis. RESULTS: We evaluated a total of 90 patients because five patients for each group were not included in the statistical analysis owing to technical problems or complications. In group A we had a technical success of 75.6 versus 93.4 % in group B, and the difference was statistically significant (P = 0.003); in particular, we had to complete the embolisation with insertion of coils in 11 cases (24.4 %) in group A, and in three cases in group B (6.6 %). In group A, LSV rupture occurred in four cases (8 %) so the procedure was completed by sclerosant injection through the OB located distally to the lesion. These patients were not considered for evaluation. In another case, a high flow shunt towards the inferior vena cava was detected, so the patient underwent OB injection to stop the flow to the shunt, and was not included for statistical evaluation. In group B, vein rupture with contrast leakage was noted in six cases (12 %); nonetheless, all the procedures were completed because the OB was positioned distally to the vessel tear, obviating any retrograde leakage of sclerosant. In group B, in five cases (10 %), we were unable to advance the OB though the LSV ostium so the procedures were completed with the diagnostic catheter and not considered for statistical evaluation. CONCLUSION: On the basis of our data, the embolisation of the LSV obtained by injecting the sclerosant through an OB rather than through a diagnostic catheter seems to be more effective in achieving total vein embolisation, as well as allowing a controlled injection of sclerosant even in cases of vein rupture.

The use of microwaves ablation in the treatment of epiphyseal osteoid osteomas.

OBJECTIVE: This study was designed to demonstrate the feasibility and the reliability of microwave ablation (MWA) of epiphyseal osteoid osteomas (OO). MATERIALS AND METHODS: From February to November 2012, 7 patients (4 males and 3 females; age range 16-30 years) with epiphyseal OOs were treated with MWA. The treatment was performed with 16 G antennas with a power of 20 W for 2 min. The OOs were approached by using coaxial needles inserted with hammer or with automatic drill. All patients underwent spinal anaesthesia, with posttreatment 6-8 h observation before discharging. We treated epiphyseal OOs placed away from nervous and vascular nontarget structures, located in: femoral head (n = 2), femoral lesser trochanter (n = 2), femoral neck (n = 2), and proximal tibial epiphysis (n = 1). CT was used to visualize the nidus and to insert the needle for thermal ablation and for postprocedure control. Technical success was considered the positioning of the antenna in the nidus, while the efficacy of treatment was clinically evaluated as the complete remission of pain after the procedure by using the visual analogue score (VAS). Follow-up was performed by using VAS score 1 day, 1 week, and 1, 3, and 6 months after the procedure, whereas MRI examination was performed immediately after the procedure, at 1 month, and in any case of recurrence. Complications were also recorded. RESULTS: All patients experienced resolution of the symptomatology (VAS = 0) in ~1 week until the last follow-up, with residual VAS < 2 points occurring only from 1 to 7 days after the procedure. No intraprocedural complication was noted, whereas one patient had back pain for 2 months after the procedure, likely due to spinal analgesic injection. CONCLUSIONS: In our experience, MWA can be safely performed with excellent results without complications in selected cases of epiphyseal OOs; however, the clinical significance of this report is limited because there were only few patients included in this study. Thus, these data must be confirmed by further and larger studies.

Vertebroplasty in multiple myeloma with osteolysis or fracture of the posterior vertebral wall. Usefulness of a delayed cement injection.

AIM: The goal of this study was to specifically address the incidence of dorsal leakage when performing vertebroplasty in patients with posterior wall osteolysis or fracture, by using a delayed injection of cement with the aim of increasing its viscosity. MATERIALS AND METHODS: We prospectively reviewed the records of 24 patients (13 women, 11 men; age range 42-67 years; mean age 54.7) with diagnosis of multiple myeloma (MM) who underwent 34 vertebroplasties between January 2007 and January 2010 for painful osteolytic localization of MM with dorsal cortical osteolysis or fracture. All vertebroplasties were performed with an 8 min delay, which was half of the allotted injecting time given for the chosen cement. In 11 cases there were fractures involving the posterior wall, in 1 case with dorsal fragment dislocation, and in 33 cases there was dorsal cortical osteolysis. All of the patients showed no response to standard treatments such as radiotherapy, chemotherapy, and analgesic treatments. RESULTS: Technical success was achieved in all cases. In 20 patients, we treated only one high-risk vertebral lesion, in six patients we treated two segments, and in one patient we treated three segments. All patients experienced improvement in symptoms after the procedure as demonstrated by improved visual analogue scores (VAS) and performance status (PS) and decreased doses of analgesic. There was a dorsal leakage in 2/34 (5.8%) treated vertebral bodies in which an epidural space tumor extension was also diagnosed, without increasing neurological symptoms after the intervention. CONCLUSION: From these results vertebroplasty with delayed injection of cement is safe and effective in the treatment of vertebral localization of myeloma with osteolysis or fracture of the posterior vertebral wall.