Two-dimensional perfusion angiography permits direct visualization of redistribution of flow in hepatocellular carcinoma during b-TACE.

OBJECTIVES: To demonstrate in vivo redistribution of the blood flow towards HCC's lesions by utilizing two-dimensional perfusion angiography in b-TACE procedures. MATERIAL AND METHODS: In total, 30 patients with 35 HCC nodules treated in the period between January 2019 and November 2021. For each patient, a post-processing software leading to a two-dimensional perfusion angiography was applied on each angiography performed via balloon microcatheter, before and after inflation. On the colour map obtained, reflecting the evolution of contrast intensity change over time, five regions of interests (ROIs) were assessed: one on the tumour (ROI-t), two in the immediate peritumoural healthy liver parenchyma (ROI-ihl) and two in the peripheral healthy liver parenchyma (ROI-phl). The results have been interpreted with a novel in silico model that simulates the hemodynamics of the hepatic arterial system. RESULTS: Among the ROIs drawn inside the same segment of target lesion, the time-to-peak of the ROI-t and of the ROI-ihl have a significantly higher mean value when the balloon was inflated compared with the ROIs obtained with deflated balloon (10.33 ± 3.66 s vs 8.87 ± 2.60 s (p = 0.015) for ROI-t; 10.50 ± 3.65 s vs 9.23 ± 2.70 s (p = 0.047) for ROI-ihl). The in silico model prediction time-to-peak delays when balloon was inflated, match with those observed in vivo. The numerical flow analysis shows how time-to-peak delays are caused by the obstruction of the balloon-occluded artery and the opening of intra-hepatic collateral. CONCLUSION: The measurements identify predictively the flow redistribution in the hepatic arteries during b-TACE, supporting a proper positioning of the balloon microcatheter.

Cone-Beam CT-Guided Transarterial Tagging of Endophytic Renal Tumors with Indocyanine Green for Robot-Assisted Partial Nephrectomy.

PURPOSE: To evaluate the safety, efficacy, and clinical impact of preoperative cone-beam computed tomography (CT)-guided selective embolization of endophytic renal tumors with the fluorescent dye indocyanine green (ICG) and ethiodized oil in patients undergoing robot-assisted partial nephrectomy (RAPN) using near-infrared fluorescence imaging (NIR-FI). MATERIALS AND METHODS: Patients with renal endophytic tumors eligible for RAPN and transarterial embolization with ICG and ethiodized oil were prospectively enrolled. Technical success was defined as the completion of the embolization procedure. Radiographic success, defined as ethiodized oil accumulation in the nodule, was classified as poor, moderate, good, or optimal on the basis of postembolization cone-beam CT. Surgical visibility of the tumors during RAPN with the use of NIR-FI was classified as follows: (a) not visible, (b) visible with poorly defined margins, and (c) visible with well-defined margins. RESULTS: Forty-one patients underwent preoperative selective embolization. Technical success was 100%. Ethiodized oil accumulation on cone-beam CT was poor in 2 (4.9%), moderate in 6 (14.6%), good in 25 (61.0%), and optimal in 8 (19.5%) of 41 patients. During RAPN with NIR-FI, tumors were visible with well-defined margins in 26 (63.4%), visible with blurred margins in 14 (34.1%), and not visible in 1 (2.4%) of 41 cases. There were no adverse events following endovascular embolization. CONCLUSIONS: Preoperative transarterial superselective embolization of endophytic renal tumors with ICG and ethodized oil in patients undergoing RAPN is safe and effective, allowing accurate intraoperative visualization and resection of endophytic tumors.

Role of CT and MR imaging in the assessment of suspected spondylodiscitis and planning of needle biopsy.

PURPOSE: Our aim was to assess the role of computed tomography (CT) or magnetic resonance imaging (MRI) in the assessment of spondylodiscitis, identifying the best target structures for biopsy to increase the likelihood of positive cultures. MATERIALS AND METHODS: This study was approved by our Institutional Review Board, and requirement for specific consent form was waived. In this retrospective single Institution study, we evaluated clinical and imaging records of 60 patients who underwent spine biopsy for suspected spondylodiscitis from January 2016 to May 2021. CT and MRI sensitivity and inter-reader agreement were assessed according to the phase of spondylodiscitis, defined as acute, subacute or chronic. Inter-reader agreement for the diagnosis and identification of spondylodiscitis phase was assessed using K statistics. Univariate logistic regression analysis was performed to assess any relationship between MRI/CT findings, spondylodiscitis phase and positive cultures. RESULTS: Sixty patients (48 males) with mean age 59, 2 ± 29 were enrolled in this study. MRI showed higher sensitivity (96% vs 65% of CT) in the diagnosis and good inter-reader agreement (k = 0.8) in the identification of the acute and subacute phase of spondylodiscitis, and moderate inter-reader agreement (k = 0.7) and lower sensitivity (80% vs 95% of CT) for the chronic phase. Univariate analysis showed as MRI-specific findings such as extensive hyperintensity of vertebral body and/or disc on Short Tau Inversion Recovery-T2w images, paravertebral collections, preserved or augmented disc height and presence of a vertebral fractures were mainly found in the acute/subacute phase and was a predictor for positive cultures (p < 0.05). CONCLUSION: MRI and CT are both able to identify the different phases of spondylodiscitis, although MRI is more sensitive in the acute phase. Findings such as extensive hyperintensity of the disc/vertebral body, fractures and paravertebral collections, represent the main targets for biopsy related to a positive culture.

Balloon occluded TACE (B-TACE) vs DEM-TACE for HCC: a single center retrospective case control study.

BACKGROUND: To compare oncological results and safety profile of balloon micro-catheter trans-arterial chemoembolization (b-TACE) and drug-eluting-microsphere (DEM-TACE) in patients with hepatocellular-carcinoma (HCC). METHODS: This is a case-control, retrospective, single-center study. Between January-2015/March-2019, 149 patients (131 males [87.9%]) with 226 HCC were treated, 22 patients (35 HCC; 19 [86.4%] males) with b-TACE and 127 with DEM-TACE (191 HCC, 112 [88.2%] males). Embolization protocol was standardized (sequential 100 ± 25 and 200 ± 25 µm microspheres). Results were evaluated by modified-response-evaluation-criteria-in-solid-tumor [mRECIST] at 1, 3-6 and 9-12 months and time to recurrence after complete response [TTR] at 1 years. Cox's regression weighted with tumor dimensions was performed. Adverse events (AEs) were recorded. RESULTS: mRECIST oncological response at all time points (1, 3-6 and 9-12 months) for both treatments were similar, with the exception of Objective response rate at 9-12 months. Objective response at 1 and 3-6 months between b-TACE vs DEM-TACE [23/35 (65.7%) vs 119/191 (62.3%), 21/29 (72.4%) vs 78/136 (57.4%) (p > 0.05), respectively]. On the contrary, at 9-12 months, it was significantly higher in b-TACE subgroup than DEM-TACE (15/19 [78.9%] vs 48/89 [53.9%], p = 0.05). TTR for complete response at 1 year had a better trend for b-TACE vs DEM-TACE (278.0 days [196.0-342.0] vs 219.0 days [161.0-238.0], OR 0.68 [0.4-1.0], p = 0.10). The use of balloon micro-catheter reduced the relative risk of the event of recurrence by 0.63 [CI95% 0.38-1.04]; p = 0.07). No significant differences were found in AEs rate. CONCLUSION: b-TACE showed a trend of better oncological response over DEM-TACE with and longer TTR with a similar adverse events rate, in patients presenting with larger tumors.

Prognostic risk factors for loss of patency after femoropopliteal bailout stenting with dual-component stent: results from the TIGRIS Italian Multicenter Registry.

PURPOSE: To identify the risk factors associated with patency loss after bailout stenting with third-generation hybrid heparin-bonded nitinol stent of the femoropopliteal segment. METHODS: Prospective, multicenter, single-arm registry including 156 patients (50 females, mean age 72 ± 11 years) subjected, from February 2017 to December 2018, to provisional stenting with Gore Tigris vascular stent of the distal superficial femoral artery, with or without involvement of the popliteal artery, in 9 different centers. The 194 lesions, with Rutherford score ≥ 3, were stented in case of recoil, dissection or residual stenosis not responding to percutaneous trans-luminal angioplasty (PTA). The follow-up (FU) was performed with clinical evaluation and duplex ultrasound (DUS) at 1, 6 and 12 months. RESULTS: The primary patency rate was 99(95%CI 98-100)% at 1 month, 86(80-92)% at 6 months and 81(74-88)% at-12 months. After patency loss, 13/23 (56.5%) patients were re-treated, yielding a primary assisted patency of 91(86-96)% at 6 months and 88(82-94)% at 12 months and a secondary patency of 94(90-98)% at 6 months and 90(84-95)% at 12 months. Rutherford score ≥ 4 (p = 0.03) and previous severe treatments (p = 0.01) were identified as risk factors for early patency loss during FU. The involvement of the popliteal artery was not an independent risk factor for loss of patency. CONCLUSIONS: The bailout stenting of the femoropopliteal segment with third-generation nitinol stents is a safe and effective option in case of recoil, dissection or residual stenosis not responding to PTA. Critical limb ischemia and history of previous major treatment at the same level are significant prognostic factors for patency loss during FU.

Polyethylene Glycol Epirubicin-Loaded Transcatheter Arterial Chemoembolization Procedures Utilizing a Combined Approach with 100 and 200 µm Microspheres: A Promising Alternative to Current Standards.

PURPOSE: To report clinical effectiveness, toxicity profile, and prognostic factors of combined 100 µm ± 25 and 200 µm ± 50 epirubicin-loaded polyethylene glycol (PEG) microsphere drug-eluting embolic transcatheter arterial chemoembolization protocol in patients with hepatocellular carcinoma. MATERIALS AND METHODS: In this prospective, single-center, single-arm study with 18 months of follow-up, 36 consecutive patients (mean age 69.9 y ± 10.8; 26 men, 10 women; 54 naïve lesions) were treated. Embolization was initiated with 100 µm ± 25 microspheres, and if stasis (10 heart beats) was not achieved, 200 µm ± 50 microspheres were administered. Each syringe (2 mL) of PEG microsphere was loaded with 50 mg of epirubicin. Results were evaluated using Modified Response Evaluation Criteria In Solid Tumors with multidetector computed tomography/magnetic resonance imaging at 1, 3-6, 9-12, and 15-18 months. Toxicity profile was assessed by laboratory testing before and after the procedure. Complications were recorded. Postembolization syndrome (PES) was defined as onset of fever/nausea/pain after the procedure. Patient/lesion characteristics and treatment results were correlated with predicted outcome using regression analysis. Child-Pugh score was A in 86.1% of patients (31/36) and B in 13.9% (5/36). RESULTS: In 10 of 21 lesions, < 2 cm in diameter (47.5%) stasis was achieved with 100 µm ± 25 microspheres only, whereas all other lesions required adjunctive treatment with 200 µm ± 50 microspheres. Reported adverse events were grade 1 acute liver bile duct injury (3/39 cases, 7.7%) and PES (grade 2; 3/39 cases, 7.7%). Complete response (CR) at 1, 3-6, 9-12, and 15-18 months was 61.1%, 65.5%, 63.63%, and 62.5%. Objective response (CR + partial response) at 1, 3-6, 9-12, and 15-18 months was 83.3%, 65.85%, 63.63%, and 62.5%. No single factor (laboratory testing, etiology, patient status, hepatic status, tumor characteristics, administration protocol) predicted outcomes except for albumin level at baseline for CR (P < .05, odds ratio = 1.09). CONCLUSIONS: The combined microsphere sizing strategy was technically feasible and yielded promising results in terms of effectiveness and toxicity.

Sequential dual-phase cone-beam CT is able to intra-procedurally predict the one-month treatment outcome of multi-focal HCC, in course of degradable starch microsphere TACE.

OBJECTIVE: To evaluate the prognostic value of sequential dual-phase CBCT (DP-CBCT) imaging performed during degradable starch microsphere TACE (DSM-TACE) session in predicting the HCC's response to treatment, evaluate with modify response evaluation criteria in solid tumours (mRECIST) at 1-month multi-detector CT (MDCT) follow-up. MATERIALS AND METHODS: Between January and May 2018, 24 patients (68.5 ± 8.5 year [45-85]) with HCC lesions (n = 96 [average 4/patient]) were prospectively enrolled. Imaging assessment included: pre-procedural MDCT, intra-procedural DP-CBCT performed before first and second DSM-TACEs and 1-month follow-up MDCT. Lesions' attenuation/pseudo-attenuation was defined as average value measured on ROIs (HU for MDCT; arbitrary unit called HU* for CBCT). Lesions' attenuation modification was correlated with the post-procedural mRECIST criteria at 1-month MDCT. RESULTS: Eighty-two DSM-TACEs were performed. Lesion's attenuation values were: pre-procedural MDCT arterial phase (AP) 107.00 HU (CI 95% 100.00-115.49), venous phase (VP) 85.00 HU (CI 95% 81.13-91.74); and lesion's pseudo-attenuation were: first CBCT-AP 305.00 HU* (CI 95% 259.77-354.04), CBCT-VP 155.00 HU* (CI 95% 135.00-163.34). For second CBCT were: -AP 210.00 HU* (CI 95% 179.47-228.58), -VP 141.00 HU* (CI 95% 125.47-158.11); and for post-procedural MDCT were: -AP 95.00 HU (CI 95% 81.35-102.00), -VP 83.00 HU (CI 95% 78.00-88.00). ROC curve analysis showed that a higher difference pseudo-attenuation between first and second DP-CBCTs is related to treatment response. The optimal cut-off value of the difference between first and second CBCT-APs to predict complete response, objective response (complete + partial response) and overall disease control (objective response + stable disease) were > 206 HU* (sensitivity 80.0%, specificity 81.7%), > 72 HU* (sensitivity 79.5%, specificity 83.0%) and > - 7 HU* (sensitivity 91.6%, specificity 65.4%), respectively. CONCLUSIONS: DP-CBCT can predict intra-procedurally, by assessing lesion pseudo-attenuation modification, the DSM-TACE 1-month treatment outcome.

A Steerable Sheath to Deploy Hypogastric Bridging Stent by Contralateral Femoral Approach in an Iliac Branch Procedure after Endovascular Aneurysm Repair.

Aneurysmal degeneration of distal landing zones after endovascular aneurysm repair (EVAR) can be a potential cause of late failure of this technique. Aneurysmal degeneration of common iliac arteries increases the risk of rupture of the iliac aneurysm itself as well as of the abdominal aortic aneurysm owing to aneurysm's reperfusion as a type Ib endoleak. Reoperation consists in plugging and covering the internal iliac artery (IIA), by extension into the external iliac artery, or preservation of antegrade flow in IIA by iliac branch devices (IBDs) or sandwich technique. The management of common iliac aneurysms after EVAR with the purpose of preserving antegrade flow into IIA generally requires a brachial or axillary access. However, this approach may be theoretically associated with local or systemic complications. We report a case of IBD implantation after EVAR, using a steerable sheath for IIA bridging stent deployment via contralateral femoral approach.

Minimally invasive treatment of gastric leak after sleeve gastrectomy.

PURPOSE: Obesity is a leading problem in Western countries, and laparoscopic sleeve gastrectomy (SG) is the most commonly used procedure for the surgical management of morbid obesity. SG is recognised as one of the safest and most effective bariatric procedures but it is limited by a rate of gastric leaks (GL) ranging from 1.4% to 20%. No international consensus exists about the treatment of GL. This paper reports our experience with the noninvasive management of GL. MATERIALS AND METHODS: From July 2004 to December 2010, 16 patients with GL after SG were referred to our unit. All patients underwent contrast radiography (Gastrografin) and computed tomography (CT) examination. On the basis of the radiographic findings, patients were divided into those eligible for drainage and those not eligible. RESULTS: Twelve patients (75%) were eligible for percutaneous drainage. Of these, seven patients (44%) were successfully treated with percutaneous drainage alone, whereas five patients (31%) required placement of a covered stent due to incomplete resolution of the collection. After 1009.8±456.7 days of follow-up, one patient died from a cardiovascular event and two patients required a bilio-pancreatic-digestive bypass (BPD-BP). Twelve patients (75%) were in an excellent state of health with significant reduction of their body mass index (BMI). CONCLUSIONS: Our experience confirms the value of an algorithm based on patient eligibility for percutaneous drainage in the treatment of GL. The patient's general condition and in particular the presence of sepsis supports the value of this approach in preference to the conventional surgical approach.

A Low Daily Intake of Simple Sugars in the Diet Is Associated with Improved Liver Function in Cirrhotic Liver Transplant Candidates.

(1) Background: We investigated, for the first time, whether dietary simple sugar intake affects MELD score changes over time in a cohort of cirrhotic liver transplant candidates. (2) Methods: the MELD score, dietary habits using a 3-day food diary, and visceral adipose tissue index (VATI) measured with CT scan were assessed in 80 consecutive outpatient cirrhotic patients at baseline, after counseling to follow current nutritional guidelines. The MELD score was reassessed after six months and the DELTA-MELD was calculated as the MELD at the second assessment minus the MELD at baseline. (3) Results: Compared with the baseline, the MELD score of cirrhotic patients at the end of the study was decreased, stable, or increased in 36%, 8% and 56% of patients, respectively. In separate multiple linear regression models, DELTA-MELD was positively and independently correlated with the daily intake of simple sugars expressed in g/kg body weight (p = 0.01) or as a percentage of total caloric intake (p = 0.0004) and with the number of daily portions of fruit, added sugar, jam, and honey (p = 0.003). These associations were present almost exclusively in patients with VATI above the median value. (4) Conclusions: In cirrhotic patients with high amounts of visceral adipose tissue the consumption of simple sugars and fructose should be limited to improve their clinical outcome.

Carotid artery stenting: analysis of a 12-year single-center experience.

PURPOSE: To analyze a 12-year experience performing carotid artery stenting (CAS) with cerebral protection. METHODS: In accord with NASCET criteria, 672 patients underwent CAS at our hospital between November 1999 and September 2011 for de novo or postsurgical restenosis; among these, 636 patients (474 men; mean age 68 ± 6.8 years, range 63-85) had a minimum 6-month follow-up, which qualified them for this analysis. The majority of patients (381, 59.9%) were symptomatic; 47 patients had staged bilateral CAS procedures (total of 683 procedures). A cerebral protection device was used in 94.7%. Patients underwent duplex ultrasound and clinical evaluation during follow-up. Neurological adverse events were correlated with plaque morphology, patient age >80 years, learning curve, and spasm. RESULTS: Technical success was achieved in all cases. Neurological events [3 (0.4%) major strokes, 8 (1.2%) minor strokes, and 11 (1.6%) transient ischemia attacks] occurred in 22 (3.2%) of the 683 cases within 30 days of the procedure (no events in follow-up). These involved 5 (2.0%) of the 255 asymptomatic patients and 17 (4.5%) of the 381 symptomatic patients (p=0.001). Neurological events proved to be higher in patients >80 years (6.4% vs. 2.7% of patients <80 years, p<0.05) and in those with complex plaque morphology (6.1% vs. 1.0% in stable plaques, p<0.001). After a mean follow-up of 76 ± 32.4 months, 478 (70%) patients were alive, with a 30-day mortality of 1.9% (none due to stroke). In-stent stenosis occurred in 9 (1.3%) stents and was resolved with angioplasty or re-stenting. The primary patency rate was 98.7%. CONCLUSION: CAS is a valid technique for the treatment of carotid occlusive disease, with a very low rate of in-stent stenosis. Neurological complications were correlated with complex plaque morphology, which makes accurate pretreatment evaluation of the lesion mandatory if good CAS outcomes are to be achieved.

Lower limb multilevel treatment with drug-eluting balloons: 6-month results from the DEBELLUM randomized trial.

PURPOSE: To report 6-month results of the DEBELLUM (Drug-Eluting Balloon Evaluation for Lower Limb MUltilevel TreatMent) randomized trial to evaluate the efficacy of a drug-eluting balloon (DEB) to reduce restenosis after treatment of multilevel lower limb occlusive disease vs. a conventional angioplasty balloon (AB). METHODS: Between September 2010 and March 2011, 50 consecutive patients (37 men; mean age 66±4 years) with 122 lesions (96 stenoses and 26 occlusions) of the femoropopliteal (92, 75.4%) or below-the-knee (BTK) arteries (30, 24.6%) were enrolled and randomly assigned to the DEB (25 patients with 57 lesions) or AB (25 patients with 65 lesions) group. Twenty patients presented multilevel lesions. Mean lesion length was 7.5±3.5 cm. Thirty-one (62%) of the patients were Fontaine stage IIb, while 19 (38%) were stage III or IV. DEBs or ABs were used for dilation of de novo lesions or for postdilation after primary stenting (superficial femoral artery only). Patients requiring provisional stenting after angioplasty secondary to flow-limiting dissection or residual stenosis >50% were ineligible. Primary endpoint was late lumen loss at 6 months. Secondary endpoints were target lesion revascularization (TLR), amputation, and thrombosis. RESULTS: Late lumen loss was lower in the DEB group (0.5±1.4 vs. 1.6±1.7 mm, p<0.01). TLR was necessary in 6.1% of the DEB group vs. 23.6% of the AB group (p=0.02). Comparing the DEB to AB groups, the thrombosis rates were 3.0% vs. 5.2% (p=0.6), and the amputation rates were 3.0% vs. 7.9% (p=0.36). The binary restenosis rates were 9.1% (3/33 limbs) in the DEB group vs. 28.9% (11/38 limbs) in the control group (p=0.03). The ankle-brachial index improved to a greater degree in the DEB group: 0.87±0.22 vs. 0.70±0.13 (p<0.05). The Fontaine stage improved in both groups but more so in patients treated with DEBs (p=0.04). CONCLUSION: The DEBELLUM trial confirmed the ability of paclitaxel-eluting balloons to reduce restenosis vs. conventional balloons at 6 months after treatment of multilevel (femoropopliteal and BTK) arterial disease in patients affected by claudication and CLI. A lower TLR rate and better clinical outcomes appear to be associated with the use of DEBs regardless of stent placement.

Surgical Resection Is Superior to TACE in the Treatment of HCC in a Well Selected Cohort of BCLC-B Elderly Patients-A Retrospective Observational Study.

Hepatocellular carcinoma (HCC) usually develops in cirrhotic liver, with high recurrence rates. However, considering its increasing detection in non-cirrhotic liver, the choice of treatment assumes particular relevance. This study aimed to investigate outcomes of patients among BCLC stages and enrolled for surgical resection (SR) according to a more complex evaluation, to establish its safety and efficacy. A total of 186 selected HCC patients (median age 73.2 yrs), submitted to SR between January 2005 and January 2021, were retrospectively analyzed. Of which, 166 were staged 0, A, B according to the BCLC system, while 20 with a single large tumor (>5 cm) were classified as stage AB. No perioperative mortality was recorded; complications occurred in 48 (25.80%) patients, and all but two were Clavien−Dindo grade I−II. Median follow-up was 9.2 years. Subsequently, 162 recurrent patients (87,1%) were selected for new treatments. Comparable overall survival rates (OS) were observed at 1, 3, 5, and 10 years in 0, A, B and AB stages (p = 0.2). Eventually, the BCLC-B group was matched to 40 BCLC-B patients treated (2015-2021) with TACE. Significant differences in baseline characteristics (p <0.0001) and in OS were observed at 1 and 3 years (p <0.0001); a significant difference was also observed in oncological outcomes, in terms of the absence, residual, or relapse of disease (p <0.05). Surgery might be a valid treatment in HCC for patients affected by chronic liver disease in a condition of compensation, up to BCLC-B stage. Surgical indication for liver resection in case of HCC should be extensively revised.

Complete transection of the main bile duct: minimally invasive treatment with an endoscopic-radiologic rendezvous.

BACKGROUND: Complete transection of the common bile duct (CBD) is a dramatic and often extremely difficult-to-repair event after surgery. Abdominal biliary fluid collection or jaundice is the initial symptom, and ERCP is the determinant for diagnosis. OBJECTIVE: To evaluate the safety and efficacy of a combined endoscopic-radiologic technique for the reconstruction of the CBD. DESIGN: Single-center retrospective study. SETTING: Tertiary-care center for biliary surgery. PATIENTS: This study involved 22 patients with complete transection of the CBD after cholecystectomy. INTERVENTION: A guidewire is passed in the subhepatic space through the endoscopic approach. A snare loop is advanced from the percutaneous entry site to catch the free end of the wire and then pulled outside the body: a percutaneous biliary-duodenal (PTBD) drainage is put in place. After a new contralateral PTBD, 4 plastic stents are inserted. The stents are removed endoscopically after 8 to 12 months. MAIN OUTCOME MEASUREMENTS: Success of the rendezvous maneuver, patient recovery, and patient mortality. RESULTS: After a mean follow-up period of 4 years, 16 patients are asymptomatic. Two patients are still under treatment, and 4 patients underwent surgery, as was the surgeon's choice. LIMITATIONS: Single-center, retrospective study with a small population. CONCLUSION: Interruption of the biliary tree does not represent an indication for an often-difficult surgical treatment, because the CBD is often thin in the presence of biliary peritonitis. However, the condition can be treated with a rendezvous technique. Surgery can be performed in elective conditions or completely avoided when conservative therapy is selected.

Retrograde popliteal access in the supine patient for recanalization of the superficial femoral artery: initial results.

PURPOSE: To report an initial experience of superficial femoral artery (SFA) recanalization performed with a dual femoral-popliteal approach in the supine patient. METHODS: From May 2008 to April 2010, 26 patients (16 men; mean age 68 ± 6.3 years) with intermittent claudication and chronic SFA occlusion (mean length 97.4 ± 3.8 mm, range 35-220) underwent percutaneous recanalization from a retrograde popliteal access. The common femoral artery was punctured with an antegrade (n = 9) or retrograde contralateral (n = 17) approach, then with the patient still supine and the knee gently flexed and medially rotated, the popliteal artery was punctured using an 18-G needle under ultrasound (10, 38.4%) or fluoroscopic (16, 61.5%) guidance with a roadmap technique. Once the SFA was recanalized, the procedure was completed with angioplasty and stenting from the femoral approach. At the end of the procedure, hemostasis at the popliteal access was obtained with manual compression (5-10 minutes). RESULTS: Technical success (puncture of the popliteal artery and SFA recanalization) was achieved in all cases. In the majority of patients (24, 91.6%), endoluminal recanalization was possible from the popliteal access; SFA recanalization in the other 2 cases was obtained through the subintimal space. Two small hematomas were found in the popliteal region, but no pseudoaneurysm or arteriovenous fistulas were seen on duplex examinations during a mean 12.5-month follow-up (range 6-28). Twenty (76.9%) SFAs were patent; in-stent restenosis occurred in the remaining 6 (23%). Primary patency was 80.7% at 6 months and 76.9% at 1 year. No stent fracture was observed. CONCLUSION: The retrograde popliteal approach with the patient in the supine position can be considered a "first choice" method for safe and effective SFA recanalization, especially in occlusions located at the distal and mid portion SFA.

Percutaneous spine biopsy under cone beam computed tomography guidance for spondylodiscitis: Time is diagnosis.

BACKGROUND AND PURPOSE: Percutaneous spine biopsies for spondylodiscitis have been long discussed due to the low microbiologic yield. This retrospective study evaluated factors of cone beam computed tomography-guided spine biopsies that may affect microbiologic yield. METHODS: We retrospectively reviewed percutaneous spine biopsies under cone beam computed tomography for spondylodiscitis performed from January 2015-December 2020. Clinical and technical features such as the time from initial symptoms to biopsy, level biopsied, biopsy needle type/gauge, technical approach, radiation dose, technical success and microbiologic yield were recorded. Pre-procedure magnetic resonance imaging findings were also recorded such as the number of vertebral bodies involved, and disc morphology. Univariate logistic regression analysis and Receiver operating characteristic analysis were performed to assess any relationship between relevant factors and positive cultures. RESULTS: A total of 50 patients underwent cone beam computed tomography-guided biopsies for spondylodiscitis, with resulted positive cultures in 18 patients (36%). The mean time from the initial referral of spinal symptoms to procedure in the positive culture group was the most influential finding for positive cultures (odds ratio 56.3, p < 0.001). Among magnetic resonance imaging findings, thin or degenerated intervertebral disc was a negative factor for positive cultures (odds ratio 0.09, p = 0.006). Univariate analysis showed that percutaneous approach (transpedicular vs posterolateral/interlaminar) needle size (11-13 g vs 16-18G, odds ratio 1.2, p = 0.7) and site of biopsy (disc vs bone vs disc plus endplate) did not significantly affect the microbiologic yield of spine biopsy. CONCLUSION: Percutaneous cone beam computed tomography-guided biopsy for spondylodiscitis is a reliable and safe technique and its microbiologic yield may increase if biopsy is performed within the acute phase of infection.

Hepatic abscess: An uncommon complication after laparoscopic appendectomy.

AIM: Laparoscopic appendectomy is currently the treatment of choice for acute appendicitis in emergency setting. When appendicitis is clinically suspected, an appendicolith can be found in 30% of the patients. Retained or dropped appendicoliths are an uncommon complication that may occur as a consequence of stone expulsion from the appendix, before or during laparoscopic appendectomies. This is very rare with only 30 reported cases of intra-abdominal abscess secondary to an appendicolith in the literature over the past 40 years. The objective of this case report is to illustrate an intrahepatic localization of a dropped appendicolith causing liver abscess. CASE PRESENTATION: A 23-year-old female was admitted to the emergency department of our hospital for an acute appendicitis with coprolite obstructing the lumen and periappendicular effusion. Laparoscopic appendectomy was performed. Persistent liver abscess due to appendicolith was a rare complication treated by percutaneous drainage. The appendicolith was successfully removed from the liver parenchyma by Dormia basket recovery system. DISCUSSION: Treatment options include percutaneous, open, or laparoscopic drainage of the abscess and retrieval of the fecalith, as antibiotics and drainage alone are usually insufficient. CONCLUSION: Only a handful of cases of hepatic abscess formation as a result of dropped appendicoliths have been reported in literature. Our proposal of treatment was the percutaneous approach. There was no need for a surgical procedure to remove the intrahepatic appendicolith. KEY WORDS: Dormia basket, Intrahepatic abscess, Laparoscopic appendectomy, Percutaneous drainage.

Use of Phil Embolic Agent for Bleeding in Non-Neurological Interventions.

OBJECTIVE: To evaluate the safety and efficacy of the Phil liquid embolic agent in non-neurological embolization procedures. M&M: Thirty-five patients with a mean age of 62.5 years underwent percutaneous embolization using Phil for the treatment of visceral arterial bleedings in 20/35 patients (including three gluteal, one bladder, two superior mesenteric, three epigastric, one deep femoral, five internal iliac, four intercostal, and one lingual arteries), splanchnic pseudoaneurysms in 11/35 patients (including three hepatic, five splenic, and three renal arteries), pancreatic bleeding metastasis in 1/35 patient, and gastric bleeding varices in 3/35 patients. Phil is composed of a non-adhesive copolymer dissolved in DMSO (Anhydrous Dimethyl Sulfoxide) with different viscosity. Procedures were performed slowly under continuous fluoroscopic guidance to avoid embolization of non-target vessels. RESULTS: Clinical success was obtained with a single intervention in 34 cases (97.15%), while a repeated procedure was required in one case (2.85%). No technical complications nor non-target embolization occurred. A case of post-embolic syndrome was noted (2.85%) in one patient. DMSO administration-related pain was successfully controlled by medical therapy. CONCLUSION: Phil can be considered a safe and effective embolic agent for the treatment of non-neurologic bleeding.