Multimodal approach to the endovascular treatment of embolisation or exclusion of the renal arteries and their distal and/or polar branches: personal experience.

PURPOSE: This study reviews our experience over the last 10 years with procedures of embolisation and/or exclusion of the renal arteries, their parenchymal branches and the polar arteries [renal artery embolisation (RAE)]. MATERIALS AND METHODS: Twenty-seven patients (19 men and eight women; age range 37-93 years; mean 74 years) underwent RAE. The indications were: symptomatic gross haematuria in nine patients (33.3%) (tumour-related in seven and iatrogenic in two), symptomatic inoperable renal tumour in five (18.5%), large subcapsular or perirenal haematoma in three (11.1%) and aneurysm of the main renal artery in two (7.4%). Eight patients (29.6%) scheduled for endovascular aneurysm repair (EVAR) of the abdominal aorta underwent prophylactic embolisation of the renal polar branch arising from the aneurysmal sac or the subrenal aortic neck to prevent the possible revascularisation of the sac. Different embolisation agents were used: coils (17 cases), embolisation particles (14 cases), glue (one case), coated stent (two cases) and mechanical occlusion devices (two cases). In 11 cases, two to three different embolisation agents were used together. RESULTS: Technical success was achieved in 26/27 patients (96.3%); in one case, embolisation of a polar artery arising from the aneurysmal sac was not possible. One case of gross haematuria recurred 13 months after the procedure and was re-treated with success. There were no cases of major or minor complications. CONCLUSIONS: RAE is an effective and minimally invasive procedure in the treatment of neoplastic/iatrogenic symptomatic gross haematuria and in the palliative treatment of inoperable renal tumours. One possible new indication is the prophylactic exclusion of the polar artery arising from the neck or the sac of an abdominal aortic aneurysm in patients who are candidates for EVAR. In our experience, we observed very low morbidity and a short hospital stay. This procedure requires the availability of various materials for performing embolisation and experience in their use.

64-Slice CT urography: optimisation of radiation dose.

PURPOSE: This study assessed means by which to optimise 64-slice computed tomography urography (CTU) in evaluating the urinary tract, with a view to obtaining the best trade-off between image quality and radiation dose. MATERIALS AND METHODS: Image quality was analysed in terms of spatial and contrast resolution on several scans of a phantom performed with automatic dose modulation and different reconstruction kernels and accepted noise level. Data were compared with the radiation dose values recorded for 52 patients who underwent CTU examination. RESULTS: Radiation dose and image quality differed considerably depending on the reconstruction parameters, even though a higher dose did not always imply better image definition. Data obtained in the phantom were consistent with those obtained in patients. Depending on the clinical problem, the radiation dose varied from 6.2 to 17.6 mSv. CONCLUSIONS: CTU cannot be considered a standard examination: the scan parameters need to be adapted to the image quality required for the specific clinical problem.

64-Slice CT urography: 30 months of clinical experience.

PURPOSE: This study sought to assess the diagnostic accuracy of 64-slice computed tomography urography (CTU) in evaluation of the urinary tract. MATERIALS AND METHODS: A total of 322 CTU procedures were carried out in 317 consecutive patients (mean age 64.4 years). The findings were compared with previous and subsequent patient workup considering both laboratory and imaging studies, such as urine cytology, abdominal ultrasound and CT, cystoscopy, retrograde pyelography, surgery and pathology. RESULTS: Out of 322 CTU examinations, 169 showed significant urinary tract changes, whereas 153 revealed no urinary disease, in good agreement with the follow-up. In particular, in bladder evaluation, for which we have a direct comparison with cystoscopy in 125 patients, we calculated a CTU sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy of 85%, 94%, 92%, 89% and 90%, respectively. CONCLUSIONS: CTU was accurate for urinary tract evaluation, but it cannot replace cystoscopy in patients in whom a malignant bladder disease is suspected.

Comparison between 64-row CT angiography and digital subtraction angiography in the study of lower extremities: personal experience.

PURPOSE: This study was undertaken to evaluate the potential of 64-row multislice computed tomography (CT) versus digital subtraction angiography (DSA) in detecting significant lesions of lower-extremity inflow and runoff arteries. MATERIALS AND METHODS: Fifty-three patients underwent 64-row multislice CT and DSA over a mean of 36 days. The vascular tree was divided into 33 segments. Three readers independently reviewed the axial CT scans and multiplanar oblique and two- and three-dimensional reconstructions (maximum intensity projection and volume rendering) images to assess degree of stenosis according to four categories: 1 (0%-49% stenosis); 2 (50%-99% stenosis); 3 (occluded); 4 (not evaluable). In all cases, DSA was performed by arterial catheterisation. RESULTS: In 53 patients, 1,440 segments were evaluated (infrarenal aorta and 16 arterial segments for each leg; 42 bilateral studies, 11 unilateral studies). Compared with DSA, CT angiography yielded 97.2% sensitivity, 97% specificity, 92.5% positive predictive value, 98.9% negative predictive value, 97.1% diagnostic accuracy and 95.4% concordance on the degree of stenosis. CONCLUSIONS: Sixty-four-row multislice CT proved to be helpful in detecting haemodynamically significant lesions in peripheral arterial occlusive disease and improved the results obtained with 4- and 16-slice multidetector CT. In addition, owing to the high spatial resolution and rigorous technique, no variations in the data obtained below the knee were detected, overcoming a limitation of earlier generations of CT scanners.

Renal artery stenosis: comparative evaluation of gadolinium-enhanced MRA and DSA.

PURPOSE: This study was undertaken to evaluate the accuracy of contrast-enhanced magnetic resonance angiography (CE-MRA) in detecting renal artery stenosis using intra-arterial digital subtraction angiography (DSA) as the gold standard. MATERIALS AND METHODS: Thirty-five consecutive patients with possible renovascular hypertension were prospectively studied; 26 of them underwent both MRA and DSA. In these 26 cases, two readers assessed the number of renal arteries, the presence of stenoses and their degree. Results were compared with DSA, and sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy of MRA were determined. Interobserver variability was also calculated. RESULTS: DSA showed 51 main renal arteries (one patient had a single kidney) and six accessory arteries (total number of arteries 57) in the 26 patients considered. Both MRA readers detected all of the 51 main renal arteries and only one accessory vessel. When the presence of stenosis was considered, the readers' results, respectively, were as follows: sensitivity 77% and 72%, specificity 69% and 69%, PPV 86% and 85%, NPV 55% and 50% and diagnostic accuracy 75% and 71%. When the detection of significant stenosis was considered, the results, respectively, were: sensitivity 83% and 83%, specificity 73% and 78%, PPV 60% and 65%, NPV 90% and 91%, and diagnostic accuracy 76% and 80%. Interobserver variation was good when considering stenosis detection (kappa=0.69) and excellent when considering detection of significant stenosis (kappa=0.85). CONCLUSIONS: MRA results do not appear as positive as in the majority of papers in the literature. Multiple reasons can probably be invoked to explain this difference. The mean age of our patients, higher than in many other studies, should be noted and may have accounted for their possible poor cooperation. Moreover, all of the missed significant stenoses were distally located, and therefore, the failure to detect them might be related to the suboptimal spatial resolution of MRA. Nevertheless, MRA showed a high NPV for detecting significant stenoses, a finding of considerable clinical relevance in that it allows patients with normal MRA findings to be spared additional more invasive procedures.

Analysis of different contrast enhancement patterns after microbubble-based contrast agent injection in liver hemangiomas with atypical appearance on baseline scan.

BACKGROUND: We describe different possible enhancement patterns in liver hemangiomas with atypical appearance on baseline ultrasound after microbubble-based contrast agent injection. METHODS: From a series of 253 consecutive lesions that were indeterminate on baseline ultrasound and then scanned after injection of air-filled microbubble contrast agent, 65 focal liver lesions were retrospectively selected on the basis of a diagnosis of liver hemangioma on multiphase contrast-enhanced computed tomography (n = 23), magnetic resonance imaging (n = 27), or histology (n = 15). Each lesion was scanned during arterial phase (30 s after microbubble injection) and late phase (5 min after injection). On-site sonologists performed retrospective assessment of contrast-enhancement patterns by consensus. RESULTS: Centripetal fill-in preceded (n = 50) or not preceded (n = 3) by peripheral nodular/rim-like enhancement was the prevalently observed contrast-enhancement pattern, equivalent to the typical enhancement pattern of liver hemangiomas on contrast-enhanced computed tomography or magnetic resonance imaging. In the remaining lesions, additional enhancement patterns (diffuse contrast enhancement with rapid fill-in and a late hyper-isoechoic appearance, n = 6; peripheral nodular enhancement with a late hypoechoic appearance, n = 3; or persistent heterogeneous and hyperechoic appearance, n = 3) were observed. CONCLUSION: Different contrast-enhancement patterns are possible in atypical liver hemangiomas after microbubble injection. Typical centripetal fill-in is the prevalent pattern and its evidence allows diagnosis.