Interventional radiology in iatrogenic ureteral leaks: case series and literature review.

Iatrogenic ureteral injuries are a dramatic complication in medical practice. Nowadays there are no universal guidelines for their management. The aim of our study was to evaluate the feasibility of the percutaneous treatment in restoring ureteral integrity in 19 patients that came to our attention. In each case retrograde stenting failed and patients were candidates for re-surgery. Our strategy consists of two phases. The first step is the nephrostomy that allows an external urinary diversion putting dry the damaged ureteral segment. The second step is the anterograde ureteral double-J stenting that keeps near the two stumps promoting the healing of the injured tract. In complete sections, when both retrograde and anterograde stenting singularly failed, we performed a rendez-vous technique with a combined radiological trans-nephrostomic access and urological cystoscopic approach to realign and catheterize the ureteral stumps. In patients with Bricker urinary diversion, peri-anastomotic leaks were treated by positioning a multi-hole pig-tail catheter with the inner end in the renal pelvis and the distal portion outgoing from the cutaneous stoma. Subsequent pyelographic controls demonstrated the resolution of the ureteral leak in all patients and none required a surgical re-intervention. Nephrostomies were removed and ureteral stents were regularly changed. We conclude that interventional uro-radiology may offer a valid conservative option in iatrogenic urinary injuries.

"Trap technique": A new multimodal approach for the treatment of intracardiac foreign body retrieval.

In medical practice, the retrieval of intravascular foreign bodies (IFBs) represents a challenge and often requires a multidisciplinary approach. We report a case of a 65-year-old male patient with a metallic guide wire extended from the right subclavian artery to the left ventricle. An interventional radiology team employed the "trap technique", with a combination of a retrieval device and angiographic catheters, which results crucial in this case. Proper device management and imaging assessment are essentil to the successful retrieval of IFBs. Further research is warranted to refine IFB retrieval techniques and evaluate long-term outcomes.

Endovascular treatment of pulmonary artery aneurysm: Single case experience.

A peripheral pulmonary artery aneurysm (PAA) is a dilatation involving all 3-vessel wall layers (the intima, media, and adventitia) of a distal pulmonary artery. It represents a rare but potentially life-threatening condition. There are only some reviews of transcatheter embolization of unruptured idiopathic peripheral PAAs. Association with cardiac diseases, infections, vascular anomalies, pulmonary hypertension, and vasculitis has been noted. We report a case of a 38-year-old woman, with a history of third-degree atrioventricular (AV) block, treated with pacemaker placement, who presented a PAA in the left pulmonary lobe. Transcatheter coil embolization was performed, using a triple coaxial catheter system (a 6F outer, a 5F intermediate, and a 2.4F inner catheter) to prevent rupture and the aneurysm was successfully embolized. Although there is no consensus on the treatment for unruptured idiopathic peripheral PAAs, transcatheter embolization may be a promising treatment option.

Stenting of the superior vena cava and right pulmonary artery in a woman with a mediastinal mass and acute respiratory distress syndrome (ARDS).

We report the case of a woman with a mass in the anterior and middle mediastinum (a non-small-cell lung carcinoma), determining significant compression of both superior vena cava and right pulmonary artery. The patient developed acute respiratory distress syndrome , necessitating intubation and admission to the Intensive Care Unit . Radiotherapy sessions to reduce the mass effect were attempted, without significant clinical improvement. Due to the persistence of severe hypoxemia, stenting of the superior vena cava and the right pulmonary artery was performed, the latter resulting in a significant improvement of the arterial blood gas parameters, allowing extubation of the patient. In our opinion, stenting of the superior vena cava and the pulmonary artery (or its branches) is an effective and safe treatment; it should be considered in similar cases, especially if other - less invasive - treatments fail.

Oncology and complications.

This collection of cases describes some unusual urological tumors and complications related to urological tumors and their treatment. Case 1: A case of uretero-arterial fistula in a patient with long-term ureteral stenting for ureteral oncological stricture and a second case associated to retroperitoneal fibrosis were described. Abdominal CT, pyelography, cystoscopy were useful to show the origin of the bleeding. Angiography is useful for confirming the diagnosis and for subsequent positioning of an endovascular prosthesis which represents a safe approach with reduced post-procedural complications. Case 2: A case of patient who suffered from interstitial pneumonitis during a cycle of intravesical BCG instillations for urothelial cancer. The patient was hospitalized for more than two weeks in a COVID ward for a suspected of COVID-19 pneumonia, but he did not show any evidence of SARS-CoV-2 infection during his hospital stay. Case 3: A case of a young man with a functional urinary bladder paraganglioma who was successfully managed with complete removal of the tumor, leaving the urinary bladder intact. Case 4: A case of a 61 year old male suffering from muscle invasive bladder cancer who was admitted for a radical cystectomy and on the eighth postoperative day developed microangiopathic hemolytic anemia and thrombocytopenia, which clinically defines thrombotic microangiopathy.

Internal iliac artery aneurysm embolization with direct percutaneous puncture and thrombin injection.

Endoleak it is the most common complication after endovascular abdominal aortic aneurysm repair and it represents the failure of endovascular treatment. In particular type 2 endoleak is associated with retrograde flow in the aneurysm sac from one or more arterial branches. We describe a reperfusion of the aortic aneurysm sac with slow-flow type II endoleak from the right internal iliac artery aneurysm through the posterior door previously closed with coils, and treatment with direct puncture of the internal iliac artery aneurysm with infixion of human thrombin under ultrasound guidance, not previously described in the literature. In this case the direct puncture of the aneurysm sac was the faster and safer way to treat this patient just because the back door was closed by coils and the entry by the iliac graft. Thrombin reduces significantly the presence of artifacts and give to us the exact extension of thrombosis into the aneurysm sac and the echo-guided offers the advantage of being able to monitor the progression of the thrombotic process induced by thrombin injection in real time.

Complications of endourological procedures and their treatment.

Endourological treatment for urinary stones and other obstructive urinary tract diseases is minimally invasive but in some cases it involves serious complications. This collection of cases describes some complications of endourological procedures and how they were treated. Case 1: A case of right ultrasound-guided percutaneous nephrostomy found to be misplaced in the inferior vena cava. The case was safely managed, but it showed that ultrasound guidance alone may be insufficient so it is recommended that percutaneous nephrostomy should be always placed under fluoroscopic control, either alone or in combination with ultrasound guidance. Case 2: A case of renal subcapsular hematoma occurring on retrograde intrarenal surgery at high perfusion pressure. The hematoma was drained under combined ultrasonic and radiological guidance. Post treatment recovery was uneventful. Large stone size, severe ipsilateral hydronephrosis, long operation time, higher hydrostatic pressure of the irrigating solution and low ureteral wall compliance are supposed to be risks factors associated with renal subcapsular formation. Management strategy should be tailored to patient's clinical conditions. In hemodynamically stable patients, large hematoma drainage is recommended to prevent further complications and favours early recovery. Case 3: A case of double J stent fracture discovered one month after the insertion to relieve obstruction from a 1 cm stone in the right proximal ureter. The distal fragment of the stent was removed by cystoscopy while the proximal fragment was removed by semirigid ureteroscopy in two sessions due to fever and extensive calcification. Case 4: A mini-invasive technique for transurethral replacement of completely encrusted urinary stents in female patients. This technique allows the interventional radiologist to replace obstructed urinary stents by avoiding more invasive and traumatic urological procedures with sedation.

Multi-detector row CT scanner angiography in the evaluation of living kidney donors.

Renal vascular anomalies are frequent and are not usually problematic, especially when they have been identified and localised with preoperative imaging; computed tomography angiography is a fast and minimally invasive procedure that may afford accurate visualisation of arterial and venous anatomy. We report on our experience with the utilisation of multi-detector row angiography in the preoperative evaluation of living kidney donors. Nineteen living kidney donors underwent multidetector row scan angiography with 3D post-processing. The subjects were 12 male and 7 female donors with a mean age of 60 years. Renal vascular anomalies were identified in 52.6% of donors. A total of 10 supernumerary arteries were identified. Surgical correlation was available for 19 kidneys (17 left and 2 right). The donated kidneys were selected on the basis of CT scan and renal function. CT scan identified all 29 arteries including 10 double right or left arteries (100% specificity and sensitivity). Dual multi-phase multi-detector row CT angiography is a minimally invasive and highly accurate method for preoperative evaluation of renal donors. It affords comprehensive depiction of the arterial and venous anatomy of the kidney, which is particularly critical for planning and performing the donor nephrectomy, especially via a laparoscopic approach.