Initial experience with percutaneous biopsies of bone lesions using XperGuide cone-beam CT (CBCT): technical note.

PURPOSE: This paper describes our preliminary experience with percutaneous bone biopsy under XperGuide conebeam computed tomography (CBCT) guidance. MATERIALS AND METHODS: Seventeen patients (11 men and 6 women; mean age 57.8; range 17-81) with 17 bone lesions underwent biopsy with XperGuide CBCT (Philips Medical System, Best, The Netherlands). The mean diameter of the lesions was 2.32 cm (range 1-8 cm). Technical success (defined as the correct positioning of the needle within the lesion), diagnostic accuracy, sensitivity and specificity were evaluated. Complication rate was also recorded. RESULTS: The technical success rate was 100%. In 15 patients, a sample of adequate material for histopathological analysis to yield a definitive diagnosis was obtained; in two patients, the sample was inadequate for a definitive diagnosis. In one of these two cases, the lesion was closely followed up for 1 year, during which it remained stable in size, and as a result, it was considered a false positive; the other was considered a false negative. Diagnostic accuracy, sensitivity and specificity were 94.12%, 90.91% and 100%, respectively. No major complications were recorded; only one patient had slight bleeding, with a consequent small haematoma, which reabsorbed in about 15 days. CONCLUSIONS: Bone biopsy under XperGuide CBCT guidance can be considered accurate as a result of the combination of real-time needle orientation and spatial resolution of CT fluoroscopy. Moreover, our results are encouraging in terms of complication rate, diagnostic accuracy, sensitivity, specificity and reduction of CT workload.

Percutaneous cholecystostomy as the sole treatment in critically ill and elderly patients.

PURPOSE: This study was done to investigate the effectiveness and clinical outcome of percutaneous cholecystostomy (PC) of treating acute cholecystitis in critical ill and elderly patients. MATERIALS AND METHODS: In the last 3 years, PC was performed on 30 elderly and critically ill patients (17 men, 13 women; mean age 78.6, range 57-97 years) with acute cholecystitis and comorbid diseases. RESULTS: Technical success was 30/30 (100%). Clinical effectiveness was 30/30 (100%), with statistically significant reductions in while blood cell (WBC) count, C-reactive protein (CRP) and fever. Mean WBC upon admission (19.87×10(3)±1.61×10(3) /µl), axillary temperature (38.2±0.11 °C), and CRP (248.7±4.76 mg/l) values were significantly decreased in the 72 h following PC [12.9×10(3) ± 1.05×10(3)/µl (p≤0.0001), 37 ± 0.04 °C (p≤0.0001), 113.5 ± 3 mg/l (p≤0.0001), respectively]. Clinical and ultrasonographic (US) signs of acute cholecystitis decreased in all patients. There were no major complications or procedure-related deaths, and the morbidity rate was low (3/30; 10%). CONCLUSIONS: PC appears to be a fast, easy and effective treatment for the acute phase of cholecystitis in elderly and critically ill patients. Procedure-related morbidity and mortality rates are very low compared with surgery. Conservative treatment for patients who are not eligible for surgery is acceptable.

Complications of microwave and radiofrequency lung ablation: personal experience and review of the literature.

PURPOSE: Complications correlated with percutaneous radiofrequency ablation (RFA) and microwave ablation (MWA) of lung tumours were retrospectively reviewed to compare them with data from the literature and to assess risk factors related with the procedures. MATERIALS AND METHODS: From January 2003 to January 2009, 29 patients (36 lung lesions) were treated with RFA; from January 2007 to January 2009, 16 patients (17 lung lesions) were treated with MWA. Complications recorded at our institution are reported following the Society of Interventional Radiology guidelines. A systematic review of the literature was performed. RESULTS: Any major complication of RFA or MWA was recorded. In agreement with the literature, pneumothorax was the most frequent complication, even though the incidence in our series was lower than reported in the literature (3.5% vs. 4.3-18%). Other complications of RFA were pleural effusion and subcutaneous emphysema. No massive haemorrhages, haemoptysis, abscesses, pneumonia, infections or tumour seeding were recorded in our series. The most common complication of MWA was pneumothorax (25% vs. 39% reported in the literature). Pleural effusion was a common reaction, but therapeutic drainage was never required. CONCLUSIONS: Pneumothorax is the most common complication of both techniques. RFA and MWA are both excellent choices in terms of safety and tolerance.

Suprarenal inferior vena cava filter implantation.

PURPOSE: This study evaluated the feasibility, safety, and efficacy of the suprarenal implantation of a retrievable filter in patients with renal cell carcinoma (RCC) and renal vein thrombosis (RVT) [extending or not extending to the inferior vena cava (IVC)] undergoing surgery. MATERIALS AND METHODS: Between March 2005 and May 2010, 13 patients (eight men and five women; mean age 67.08 years, range 38-95) with RCC and RVT associated or not with IVC thrombosis underwent implantation of a retrievable suprarenal IVC filter. All patients underwent computed tomography angiography (CTA), which documented RVT and in some cases its extension to the IVC. The level of IVC involvement by the neoplastic thrombus was evaluated on the basis of the Oto classification. Cavography was performed before and after filter implantation. Surgical resection of RCC was performed in all patients. A CTA scan was performed 1 week before filter removal. RESULTS: The procedure had 100% feasibility. All filters were correctly deployed in the suprarenal tract of the IVC. There was no evidence of peri-or postprocedural complications. All patients were monitored for clinical symptoms of pulmonary embolism (PE). There was no evidence of PE in the 30 days after the procedure. All suprarenal IVC filters were removed from 30 to 60 days after surgery. CONCLUSIONS: Implantation of a temporary suprarenal IVC filter is an additional and feasible procedure that can prevent immediate and perioperative PE.

Upper urinary tract biopsy: an old device for a new approach.

PURPOSE: The authors sought to evaluate the feasibility, diagnostic accuracy and safety of urological biopsy performed using a flexible alligator forceps. MATERIALS AND METHODS: Twenty-seven patients with suspected urothelial malignancy underwent retrograde biopsy using a 7-F biopsy forceps (Cordis, Miami, FL, USA). Mild sedation was guaranteed by an anaesthesiologist. The final diagnosis was confirmed by cytohistological data and subsequently by pathology findings at surgery. Lesions with benign histopathology were closely monitored for at least 12 months. RESULTS: The technical success rate was 92.6%. The high diagnostic accuracy was related to the positive correspondence between histological outcomes and surgical results or follow-up observations. As regards sample site, the procedure was less successful in calyceal lesions than in lesions located in the upper urinary tract, with a technical success of 71.43%. Twenty patients had asymptomatic haematuria in the early hours after the procedure; ten of them had mild dysuria. No one require medication, and no major complications occurred. CONCLUSIONS: Urological forceps biopsy is a safe and easy procedure. It provides a relatively high level of accuracy in the diagnosis of lesions of the upper urinary tract.

Endovascular treatment of ruptured abdominal aortic aneurysms: aorto-uni-iliac or bifurcated endograft?

PURPOSE: This study evaluated the safety and technical and clinical success rates of positioning endovascular endografts (EG) in ruptured abdominal aneurysms. MATERIALS AND METHODS: Patients with a ruptured abdominal aortic aneurysm confirmed by contrast-enhanced computed tomography angiography (CTA) were eligible for the analysis. Of 67 patients, 42 (62.7%) were treated with EG. Thirteen patients (30.9%) received an aorto-uni-iliac EG (group A) and 29 a bifurcated EG (group B). Patients were divided for comparative analysis according to the configuration of the EG implanted. RESULTS: The primary technical success rate was 100%; the primary clinical success rate was 95% (40/42). There were two intraoperative deaths (4.7%) related to intractable shock. No patient required conversion to open repair. Overall, 12 patients (28.5%) died within 30 days. The in-hospital death rate was 30.9% (13/42). Hospital mortality rate was statistically higher in group A; the type of EG and intensive care unit admission were the only independent predictors of hospital mortality. CONCLUSIONS: In our experience, a higher mortality rate was observed for the aorto-uni-iliac configuration; shock at admission was confirmed as the most important factor for postoperative survival.

Radiofrequency ablation for single lung tumours not suitable for surgery: seven years' experience.

PURPOSE: This study was done to review recurrence patterns in patients with lung cancer (primary or secondary) treated with percutaneous image-guided radiofrequency (RF) ablation. MATERIALS AND METHODS: From January 2003 to August 2010, 32 patients (24 with primary non-small-cell lung cancer and eight with metastases) with single lung cancer were treated with RF ablation. Post-treatment imaging results were available for each patient. Follow-up was performed using computed tomography (CT) scans at 1, 3, 6, 12, 18 and 24 months after the procedure and annually thereafter. Patterns of recurrence were classified as local, intrapulmonary, nodal, mixed and distant. We evaluated overall survival after RF ablation and the factors associated with recurrence. RESULTS: Seventeen (53.1%) patients showed no evidence of recurrence at follow-up imaging (range 12-72 months; mean, 32.5 months). Recurrence was seen in 15 (46.9 %) patients (range 6-36 months; mean 14.8 months). Local recurrence (40%) after RF ablation was the most frequent. Median disease-free survival was 20 months. Sex, tumour location, tumour size and tumour stage were not associated with a risk of recurrence. Patient age was related to the risk of recurrence (p<0.05). CONCLUSIONS: Local recurrence is the most common pattern in our series. A more aggressive initial RF ablation might offer improvement in outcomes, but this hypothesis needs to be confirmed by larger studies involving a larger number of patients.

Portomesenteric vein thrombosis following sleeve gastrectomy: Case report focusing on the role of pathogenetic factors.

INTRODUCTION: Sleeve gastrectomy has currently become the most commonly performed bariatric. procedure worldwide according to the last IFSO survey, overtaking gastric bypass with. a share of more than 50% of all primary bariatric-metabolic surgery. Gastric leak, intraluminal bleeding, bleeding from the staple-line and strictures are the most common complications. Portomesenteric vein thrombosis (PMVT)after sleeve gastrectomy is. another complication that has been increasingly reported in case-series in recent.years, although it remains uncommon. In this case report is described an extended portomesenteric vein thrombosis after. sleeve gastrectomy interesting splenic vein too with a favorable course and an. uneventful follow-up. We try to search in this case for pathogenetic factors involved in. this complication. CASE REPORT: A 42-year old man, with a body mass index (BMI) of 45 kg/m2, with a medical history of Obstructive Sleep Apnea Sindrome (OSAS) underwent laparoscopic sleeve gastrectomy. Early postoperative course was uneventful. Six days after discharge he complained abdominal pain and was admitted at the Emergency Department. A CT scan with intravenous contrast showed an occlusion of the portal vein, of the intrahepatic major branches and an extension to the superior mesenteric vein and the splenic vein. The patient received heparin and oral anticoagulation together with intravenous hydration and proton pump inhibitors. Considering the favourable course the patient was discharged after six days with long-term oral anticoagulation therapy. Anticoagulation with acenocumarol was continued for six months after a CT scan showed resolution of the PMVT without cavernoma. He had no recurrence of symptoms. DISCUSSION: Porto-mesenteric thrombosis after sleeve gastrectomy is a rare complication but it has been increasingly reported over the last 10 years along with the extensive use of sleeve gastrectomy. Because PMVT is closely associated with sleeve gastrectomy in comparison with other bariatric procedures, we need to investigate what pathogenetic factors are involved in sleeve gastrectomy. Thrombophylic state, prolonged duration of surgery, high levels of pneumoperitoneum, thermal injury of the gastroepiploic vessels during greater curvature dissection, high intragastric pressure, inadequate antithrombotic prophylaxis and delayed mobilization of the patient after surgery have been reported as pathogenetic factors of portmesenteric vein thrombosis. Most of the cases presented in the literature such as our clinical case resolve with medical therapy, although portal vein thrombus extends into the superior mesenteric vein and the splenic vein. CONCLUSION: Portomesenteric venous thrombosis is a rare but serious complication of bariatric surgery, especially associated with sleeve gastrectomy. Diagnosis is based on CT examination with intravenous contrast, and initial therapy is anticoagulation. Etiologic factors reported in the literature include a long duration of surgery, a high degree of pneumoperitoneum, high intragastric pressure after sleeve gastrectomy and thermal injury to the short gastric vessels and gastroepiploic arcade. Limited operative time, controlled values of pneumoperitoneum, careful dissection with energy device of gastric greater curvature, appropriate prophylaxis with low molecular weight heparin may be useful tools to prevent and limit this complication. Nonetheless we have to search which factors may condition the evolution of an extended PMVT as that described in this case towards resolution or to a further worsening clinical state. Early diagnosis? Correct treatment? Undiscovered patientrelated factors?

Hypoxic liver perfusion with mitomycin-C for treating multifocal metastases and unresectable primary tumours: a single-centre series of 42 patients.

PURPOSE: The purpose of our study was to retrospectively evaluate the feasibility, toxicity and impact on overall (OS) and disease-free (DFS) survival of intra-arterial liver perfusion with mitomycin-C (MMC) [hypoxic liver perfusion with MMC (HLPM)] in patients with multifocal liver metastases or with unresectable primary liver tumours. MATERIALS AND METHODS: Forty-two patients underwent 56 intra-arterial liver infusions with MMC between June 2001 and May 2009. The patients presented specific characteristics, i.e. they were all refractory to locoregional (LR) and/or systemic treatments. HLPM consists of selective catheterisation of the common hepatic artery, permanent occlusion of the gastroduodenal artery at its origin using metal coils, an inflated balloon catheter placement at the origin of the proper hepatic artery to block blood flow and induce hypoxia for around 10 min, MMC infusion and vascular-bed occlusion through injection of an absorbable haemostatic agent. During the procedure, the patients received anaesthesiological monitoring. Biochemical and morphological responses were evaluated, as were haematological, hepatic and systemic toxicity. RESULTS: Patients were hospitalised for 10 days on average (range 7-15). Side effects were liver toxicity in all cases, acute pancreatitis in one case and liver failure in one case. Computed tomography performed at 30 days documented a partial response (PR) in 29%, stable disease (SD) in 45% and progressive disease (PD) in 26% of patients. The response lasted 4 months on average (range 3-6). Mean overall survival (OS) was 20 months for all patients, reaching 30 months in those with colorectal carcinoma. CONCLUSIONS: The procedure is feasible, and treatmentrelated toxicity and mortality rates are acceptable. It may be considered a palliative treatment option in patients with advanced liver disease in centres with adequately experienced medical teams.

The importance of subcapsular anesthesia in the anesthesiological management for thyroid radiofrequency ablation.

Radiofrequency ablation is a minimally invasive procedure alternative to surgery to treat benign thyroid nodules causing compressive symptoms. Tolerability of this procedure, aimed at treatment of benign conditions, is fundamental. In this study, we evaluated if local anesthesia should be enough to reduce both hospital costs and sedation-related risks for the patient, avoiding deep sedation and presence of the anesthesiologist. From July 2017 to August 2018, 14 consecutive patients (mean age 60.1 years) were treated and divided in two groups: Group A (7 patients) underwent systemic sedoanalgesia (intravenous remifentanil/fentanyl ± intravenous midazolam ± intravenous acetaminophen/nonsteroidal anti-inflammatory drugs) + subcutaneous anesthesia (lidocaine), with anesthesiologist. Group B (7 patients) underwent mild systemic sedoanalgesia (oral solution morphine sulfate + intravenous midazolam + intravenous acetaminophen) + both subcutaneous and subcapsular anesthesia (mepivacaine + bupivacaine), without anesthesiologist. Tolerability, sedation grade (Ramsay scale), total opioid dose, complications, and results at 12 months were analyzed and compared. Mean tolerability was 9.4 in group A and 8.9 in group B (p: 0.786). Mean sedation grade was 3.86 in group A and 2.71 in group B (p: 0.016). Mean total opioid dose was 70.9 mg in group A and 10 mg in group B (p:0.00015). No complications were observed. At 12 months, mean volume reduction was 56.1% in the group A and 60% in the group B. In thyroid radiofrequency ablation, subcapsular anesthesia can decrease both total opioid dose and level of patient's sedation without significant differences in tolerability, allowing to perform ablation without the anesthesiologist.

Septic sacroiliitis: an uncommon septic arthritis.

Septic sacroiliitis is an uncommon joint infection and the diagnosis is often delayed. We present the first case of a septic arthritis of the shoulder and of the sacroiliac joint in a woman affected by systemic sclerosis, and we reviewed the medical literature since 1997 to 2008 on septic sacroiliitis with a specific microbiological diagnosis other than Mycobacteria and Brucella species.Evidence shows that antibiotic therapy should be continued until full clinical and radiological resolution is achieved.

Endovascular treatment of a pulmonary artery pseudoaneurysm caused by Swan-Ganz catheter deployment in an anticoagulated patient.

We present a case report of an anticoagulated 78-year old man presenting a pulmonary artery pseudoaneurysm following Swan-Ganz catheter deployment after an aortic valve and aortic root replacement. Diagnosis was established by cone beam CT angiography and catheter angiographyand embolisation was achieved via a combination of plug and glue. This case emphasises the importance of endovascular techniques in the management of iatrogenic pulmonary pseudoaneurysms and shows the benefit of using highly hemostatic polymeric agent in anticoagulated patients to obtain a rapid and effective occlusion.

Clinical experience with Angiojet: a comprehensive review.

The development of various sophisticated mechanical thrombectomy devices and the amassed experience of physicians in minimal invasive therapy produced a paradigm shift in vascular access management toward percutaneous declotting procedures, using pharmaceutical thrombolysis, mechanical thrombectomy, balloon thrombectomy, and a combination of the above techniques. In this setting, in the last years, AngioJet™ (Possis, Minneapolis, MN, USA) rheolytic thrombectomy (RT) showed an increasing use in emergency and election patients. The purpose of this review is to present the current status of percutaneous rheolytic thrombectomy in different fields of applications.

Ethylene-vinyl alcohol polymer trans-arterial embolization in emergency peripheral active bleeding: initial experience.

AIM: The aim of this paper was to evaluate the efficacy, safety, and clinical outcomes of superselective embolization using ethylene-vinyl alcohol copolymer (Onyx Liquid Embolic System; ev3 Neurovascular, Irvine, CA, USA) as the primary treatment in active peripheral emergency arterial bleeding. METHODS: Between January 2014 and June 2014, all patients with active peripheral arterial bleeding who were treated by embolization were retrospectively analyzed. We selected 15 (age 37-91 year old) patients embolized with Onyx, chosen as embolic agent in an intention-to-treat fashion. Multidetector computed tomography was performed in all patients. RESULTS: Active bleeding was detected in all cases. Digital subtraction angiography confirmed CT findings in all cases. The causes of bleeding were traumatic in 8 patients, angiodysplasia in 1 patient, duodenal ulcer in 1, chronic pancreatitis in 1 and unknown in 4 patients. Nine patients were under anticoagulant or antiplatelet therapy. Embolization was possible in all patients. The technical success rate was 100%. The immediate bleeding control rate was 100%. No rebleeding at 30 days occurred (0%). There were no major complications, or deaths attributable to the treatment. No patient needed surgery or new embolization during a mean follow-up period of 5.1 months (range, 4.5-6 months). CONCLUSION: Control of massive active peripheral emergency arterial bleeding using superselective embolization with Onyx is feasible and safe.

Carotid artery stenting: Influence of experience and cerebrovascular risk factors on outcome.

AIM: To evaluate technical success, complications and the influence of the learning curve on outcome in carotid artery stenting (CAS) performed in patients not suitable for surgery. PATIENTS AND METHODS: One hundred and nine procedures of protected carotid stenting in 103 high risk patients were performed. All patients presented at least one factor that potentially increased the surgical risk of carotid endoarterectomy (CEA), according to SAPPHIRE criteria. Neurologic complications were quantified by the National Institutes of Health Stroke Scale (NIHSS) and were evaluated by median Rankin Scale (mRS). To evaluate the influence of experience of the operator to perform CAS, we retrospectively analyzed periprocedural and neurological complications of the first 50 procedures compared with that of the following 59 interventions. RESULTS: Technical success rate was 98%. Neurological periprocedural complications were revealed in 4.5% of patients. In-hospital and 30-days neurological complications rate was 7.6 and 2.6% respectively. Periprocedural neurological complications rate was lower in the last procedures performed, according to a higher confidence of the operators. CONCLUSIONS: CAS may be performed as an alternative of CEA for the treatment of severe carotid obstructive disease in patients not suitable for surgery. The learning curve positively influence complications rate.