Emergency endovascular treatment of a ruptured internal iliac artery aneurysm long after abdominal aortic aneurysm surgical repair.

The purpose of this report is to describe the endovascular exclusion of an internal iliac artery (IIA) aneurysm in emergency setting, long after abdominal aortic aneurysm surgical repair. An 85-year-old male presented with a contained rupture of a huge IIA aneurysm, ten years after aortoiliac bifurcated grafting. Because of poor clinical conditions an emergency endovascular treatment was planned. A stent-graft was positioned from the proximal right branch of the bifurcated surgical prosthesis to the distal external iliac artery, covering the hypogastric aneurysm neck. One month after the procedure, CT scan demonstrated the complete exclusion of the aneurysm. Endovascular treatment of IIA aneurysms is an excellent option to reduce perioperative morbidity and mortality in high risk patients, particularly in an emergency setting.

[Angiography with spiral computerized tomography in the study of aneurysms of the visceral arteries. Techniques and results]. / Angiografia con Tomografia Computerizzata spirale nello studio degli aneurismi delle arterie viscerali. Tecnica e risultati.

INTRODUCTION: The aneurysms of visceral vessels are characterized by few or no symptoms and the diagnosis is often occasional. We investigated the usefulness of CT angiography in the diagnosis and preoperative assessment of this condition. MATERIALS AND METHODS: From January 1993 to March 1998, twenty-five patients (aged 32-69 years) with 28 aneurysms underwent CT angiography before and after contrast agent injection to study lesion number, site, size, neck, intraluminal thrombosis and wall calcifications. Data from axial images were postprocessed on an external work-station to obtain CT angiograms. CT angiography findings were analyzed with a double blinded method by 2 radiologists comparing CT angiography with digital subtraction angiography images and evaluating the information obtained from Multiplanar (MPR), Maximum Intensity Projection (MIP) and Shaded Surface Display (SSD) reconstructions. Surgical findings were available for 10 patients. RESULTS: There was complete agreement between CT angiography and digital subtraction angiography in the identification of all lesions; the correlation rate was 94.42% for lesion location, 89.28% for lesion size, 85.71% for detection of endoluminal thrombosis and 82.14% for identification of wall calcifications. Axial and MPR images were useful in the assessment of ali parameters, while MIP images accurately demonstrated wall calcifications and the lesion relationships with adjacent structures. No additional information was obtained from SSD reconstructions. CONCLUSIONS: In our experience CT angiography can replace digital subtraction angiography in the diagnosis and preoperative work-up of visceral vessels aneurysms. CT angiography was superior to digital angiography in the evaluation of the lesion exact dimensions in cases with large thrombotic component and diffuse wall calcifications.

[An introduction to fast and ultrafast sequences in magnetic resonance]. / Introduzione alle sequenze veloci ed ultraveloci in risonanza magnetica.

The main limitations of magnetic resonance imaging (MRI) are due to the long acquisition time needed for data sampling. Fast and ultrafast sequences, thanks to progress in hardware and software technology, allow the acquisition times to be dramatically reduced. Such improvements will definitely increase MR capabilities and make MRI a fast and dynamic technique no longer depending on patients' cooperation and limited by patients' conditions--e.g., trauma, pediatric, or claustrophobic patients--or even by the anatomic features of the region of interest. The latest experimental studies are aimed at increasing the clinical applications and the perspectives of clinical MRI and at such ambitious goals as MR-fluoroscopy, interventional MRI, total body examination in less than one minute and functional MRI. In this paper the technical principles and the main indications of this new kind of sequences are reported, with a special emphasis on Gradient-Echo (GE), Turbo Spin-Echo (turbo SE) or Fast Spin-Echo (fast SE), Turbo FLASH and Echo Planar (EP) sequence. A smaller flip angle (FA) and the substitution of the 180 degrees RF pulse with a gradient reversal are the main differences of GE from SE sequences. From GE sequences, several fast sequences are derived, such as angiographic and turbo FLASH sequences. The latter, thanks to 180 degrees preinversion RF pulse, using idoneous inversion times (IT), provide flexible contrast. Turbo SE sequences, which are directly derived from conventional SE sequence, allow the acquisition time to be markedly shortened, by acquiring several Fourier lines of K-space for each TR. The repetition of several 180 degrees pulses following the excitatory 90 degrees RF pulse does the trick through the creation of multiple echoes for a single TR. EP sequences are the fastest ones currently available: with them, an image can be acquired in 30-100 ms. However, the limited availability of the relative hardware and the need of both quality implementation and the definition of clinical indications are major obstacles to the widespread use of these sequences. The SE T2-weighted sequence, the main responsible for the long examination time, will be replaced soon. Further implementation of these sequences will make MRI a fast, flexible and adaptable method to any exam and patient disability.

Palliative treatment of neoplastic strictures by self-expanding nitinol Strecker stent.

The purpose of this study was to evaluate technical and clinical results of self-expanding esophageal stent implanted in patients with malignant esophageal strictures and clinically significant dysphagia. From June 1992 to September 1994, 27 patients with inoperable tumors of the esophagus or gastric cardiac were treated by placement of 37 self-expanding nitinol stents. Water-soluble contrast and endoscopy studies were performed after the procedure and during the follow-up period. Successful stenting of the stricture was achieved in 27 patients. The mean dysphagia grade dropped from 2.3 to 1 (SD +/- 0.54) immediately after the procedure. After the insertion of the stent, 16 patients died in a period of time ranging from 0 to 13 months (mean 5.6 months), whereas at the end of the study 11 patients were alive 4-15 months after the procedure (mean 8.3 months). No major complications were observed. The results of this study are encouraging because esophageal stent placement was technically easy and clinically effective.

[The stenotic-occlusive anatomy and pathology of the renal arteries. Their evaluation by magnetic resonance angiography]. / Anatomia e patologia steno-occlusiva delle arterie renali. Valutazione con angiografia a risonanza magnetica.

Magnetic resonance angiography of the renal arteries was performed in 10 healthy subjects, 10 patients with renal artery stenosis and 2 patients with accessory renal artery (1 unilateral, 1 bilateral). All patients selected among 35 subjects with suspected renovascular hypertension had previously undergone digital subtraction angiography. Four patients were studied before and after percutaneous transluminal angioplasty. MRA was performed with time-of-flight technique, with 2D and 3D FISP and 2D FLASH gradient-echo sequences. Digital subtraction angiography demonstrated stenoses ranging 40% to 90% in 10 cases, 7 unilateral (1 transplanted kidney) and 3 bilateral. RA correctly depicted > 90% stenoses in 5 cases, between 50% and 90% stenoses in 2 cases and < 50% in 2 cases. Four stenoses were not properly graded (3 over-graded and 1 not visualized because distal to ostium). Diagnostic accuracy was 71% for unilateral stenoses and 66% for bilateral stenoses (overall accuracy 69.2%).

[Percutaneous transluminal renal angioplasty of the solitary kidney]. / L'angioplastica percutanea transluminale renale nel monorene.

We report on our experience with percutaneous transluminal angioplasty (PTA) of the renal artery in solitary kidney patients. PTA was performed on 31 subjects (mean age: 52 years): 7 had a solitary kidney because of nephrectomy and 24 had a solitary functioning kidney. Patients were selected with clinical and laboratory examinations first and then with angiography. PTA was employed to treat renal artery stenoses 60%-95% of the whole arterial lumen. The procedure has been considered technically successful in 29 cases, with 77%-33% reduction of the mean amount of stenosis. As to the clinical evaluation of the results, blood pressure and creatinine values variations were considered. Of the 25 patients on follow-up, 13 appeared to be treated (52%), 8 improved (32%) and 4 unchanged (18%). On the whole, we observed 5 complications (2 hematomas at the approach site, 1 intimal dissection and 2 segmental infarcts), with a 23.4% rate comparable with PTA complications in non-solitary kidney patients. The good revascularization, the reduction in blood pressure values, the very small percentage of complications point to PTA of the renal artery as the procedure of choice in solitary kidney patients.

[Interventional radiology in the treatment of acute and chronic mesenteric ischemia]. / La radiologia interventistica nel trattamento dell'ischemia mesenterica acuta e cronica.

Radiologic revascularization procedures--i.e., percutaneous transluminal angioplasty (PTA) and fibrinolysis--are a valuable alternative to surgery in the treatment of stenoses and occlusions of the visceral vessels, that is the celiac tripod and the superior and inferior mesenteric arteries. We treated 32 patients, 10 of them with acute mesenteric ischemia and 22 with chronic mesenteric ischemia and clinical signs of angina abdominis. Grüntzig or pre-shaped Cobra or Simmons balloons were employed (diameter: 5-7 mm, with variable length) when PTA was performed. Urokinase or rtPA was employed for fibrinolysis. In 3 cases acute mesenteric ischemia was not occlusive and could be successfully treated with papaverine infusion. In 7 cases, acute mesenteric ischemia was occlusive: in 5 of these patients it was successfully treated by PTA and/or fibrinolysis. Our results were positive in 80% of the cases, with remission of clinical signs in 4 of 5 patients treated for acute mesenteric ischemia. In 22 patients with chronic mesenteric ischemia, 26 stenotic occlusions were observed at angiography and 22 were treated with PTA, which was technically successful in 21 instances (early success rate: 85-95%). At 24 months, 10% of restenosis was observed. In our experience, PTA of the visceral district, possibly preceded by loco-regional infusion of fibrinolytic drugs, can be widely applied and yields excellent therapeutic results.

[Treatment of intrahepatic arteriovenous fistula after biopsy. Results in 5 chemoembolization candidates with hepatocarcinoma]. / Trattamento delle fistole artero venose intraepatiche post bioptiche. Risultati in 5 pazienti con epatocarcinoma candidati a chemioembolizzazione.

We report our experience in the treatment of post-bioptic intrahepatic arterioportal fistulas (HAPF) in 5 patients with hepatocellular carcinoma (HCC) treated February, 1993, to May, 1995. In this retrospective study, we reviewed the imaging findings and clinical records of 3 men and 2 women (age range: 49-71 years) with HCC previously diagnosed with US, CT and biopsy. HAPF was detected by angiography (DSA) performed before chemoembolization (TACE). All HAPFs were referrable to biopsy (14-gauge Thru-Cut needle) and were treated with platinum coils positioned through coaxial catheters. TACE was performed immediately after or within a week of HAPF embolization. Therapeutic response after TACE was assessed on the basis of clinical and CT findings, while HAPF embolization success was assessed on the basis of DSA and color Doppler US findings. Reembolization was required in two patients--7 maneuvers in all in 5 patients. Complete HAPF occlusion was demonstrated in 4 patients during color Doppler follow-up and immediately after and at 13 and 24 months (in 2 patients) at DSA. Two of 5 patients died, one because of liver failure after 15 months' follow-up and the other because of complications related to liver transplantation at 11 months' follow-up. Of the extant 3 patients, one underwent liver transplantation and was followed-up for 25 months, while the other two are alive after 24 and 13 months, respectively. Our experience demonstrates that HAPF embolization in HCC patients is really useful for hemodynamic redistribution before TACE and to avoid further HAPF progression.

[Assessment of "occasional" atherosclerotic lesions identified with computerized tomography. Analysis of tomodensitrometric findings and identification of "risk" groups in 1,500 patients]. / Valutazione delle lesioni aterosclerotiche "occasionali" nella Tomografia Computerizzata. Analisi dei reperti tomodensitometrici e individuazione di gruppi "a rischio" in 1500 pazienti.

Atherosclerosis is a disease with a chronic-progressive course. We report on the statistic prevalence of vascular lesions in 1,500 asymptomatic patients with vascular diseases examined with Computed Tomography (CT) for different reasons. The aortoiliac arterial district was involved in 934/1,500 patients (62.3%), with simple or calcified plaques, thrombosis or dilatations. We investigated the involvement of other arterial vessels (47%) whenever feasible (57.7% of cases). The aorta was thrombosed in 107 patients (2.8%) and the thrombus associated with a calcification and a dilated vessel in 45 of them (42.1%). The aorta or the iliac arteries were enlarged in 62 patients (4.1%) and arterial diameter exceeded 4 cm in 20 patients (1.3%). Finally, the statistical significance was analyzed considering risk factors-i.e., smoking, arterial hypertension, diabetes and hypolipoproteinemia. All the patients with 2 or more risk factors had positive CT findings; the prevalence was 75% in cigarette smokers, 83% in hypertensive, 81.3% in dislipidemic and 93.5% in diabetic patients. These data demonstrate that, in agreement with international literature reports, it is possible to single out the groups of patients that, because of their age, risk factors and sex, should be considered for color Doppler screening programs and the selected cases to be submitted to CT.

Percutaneous ilio-caval thrombectomy with the Amplatz device: preliminary results.

The Amplatz Thrombectomy Device (ATD) is a percutaneous, rotational thrombectomy catheter, capable of recirculating and homogenizing the thrombus in order to obtain mechanical clot dissolution. The authors present their experience with mechanical thrombectomy with the ATD in eight cases of ilio-caval thrombosis. Under temporary caval filter protection, the ATD was introduced through the right transjugular approach (in one patient this was used in combination with the right femoral approach) and activated for a time ranging from 90 to 180 s. Complete clearing of thrombotic material in the treated venous segments was achieved in six cases (75 %), partial success was obtained in one case (12.5 %) and failure occurred in one patient (12.5 %). One patient developed a recurrence of venous iliac thrombosis 1 week after the procedure and postphlebitic syndrome 6 months after the first episode of deep venous thrombosis, and one patient died from acute myocardial infarction, unrelated to thrombectomy session, after 3 days. A negative clinical and radiological follow-up at 3, 6, 12 and 24 months was obtained in the remaining six patients. If a fresh free-floating ilio-caval clot must be removed immediately, the ATD can be effective under temporary filter protection.

[Interventional radiology of the digestive system]. / La radiologia interventistica nell'apparato digerente.

The authors report on the use of interventional radiology modalities in the treatment of some gastrointestinal diseases (intussusception, stenosis, hemorrhage, etc). The results are compared with literature data relative to both interventional radiology and conventional therapeutic procedures. In our series, hydrostatic reduction of ileocolic intussusception was successful in 60% of cases. Transluminal dilatation with a balloon catheter was attempted in 108 patients with alimentary tract stenosis and was successful in 93. Hemorrhage and ischemia can be treated by means of transcatheter therapy (vasopressin, embolization) and percutaneous angioplasty. Percutaneous gastrostomy appears to be an effective alternative to surgical gastrostomy. Tapeworm infections can be cured by intraduodenal injection of "Gastrografin" (Schering). The success achieved in the different applications is such as to suggest a wider use of interventional radiology procedures, for they offer a more favorable cost/benefit ratio and often yield better results than conventional techniques.

[Bi- and tridimensional reconstruction with spiral computerized tomography in esophageal neoplasms. Preliminary clinical applications]. / Ricostruzioni bi e tridimensionali con Tomografia Computerizzata spirale nelle neoplasie dell'esofago. Applicazioni cliniche preliminari.

Spiral CT allows rapid data acquisition in an entire anatomical region during a single breath-hold and permits to obtain 2D and 3D reconstructions with good diagnostic accuracy. We investigated the capabilities of spiral CT reconstructions in demonstrating esophageal cancers. Spiral CT was performed in 10 patients with esophageal cancers and in 3 patients who underwent endoprostheses placement with surgical or interventional procedures. Bidimensional (MPR, CPR, MIP) and three-dimensional reconstructions with Shaded Surface Display (SSD) were obtained at the end of each exam. In the analysis of the results, CT reconstructions were compared with previous barium esophagography. Some of the main semiologic patterns were considered: tumor visualization, longitudinal extent of the neoplasm and its relationships with adjacent structures. MPRs were obtained in 9 patients and allowed to visualize the esophageal lumen with a filling defect, the neoplastic mass and its longitudinal and extraluminal extent. SSD reconstructions was obtained in 7 patients and allowed a good assessment of longitudinal neoplasm extent in 6 patients. Neoplastic mass visualization and extraluminal tumor extent were difficult to assess in all cases. MIP reconstructions were obtained in all patients and demonstrated longitudinal neoplasm extent with good accuracy. Neo-plastic tissue was visualized only indirectly through the filling defect of the esophageal lumen. MIP allowed to define, in 5 patients, the relationships of the neoplasms with adjacent vascular structures after the intravenous administration of contrast agent. In conclusion, we consider that Spiral CT reconstructions can be useful for a more accurate staging of esophageal cancers.

[Percutaneous transluminal angioplasty in the treatment of iliac stenosis. The authors' new guideline for 100 patients]. / L'angioplastica transluminale percutanea nel trattamento delle stenosi iliache. Nuovo orientamento personale negli ultimi 100 pazienti.

This retrospective study was carried out from January, 1990, to September, 1994, after reviewing a series of 100 patients submitted to 143 percutaneous maneuvers (PTA) for aortoiliac revascularization (PTA, PTA and stenting, PTA and bypass). This study was aimed at conforming as much as possible our patients selection criteria and the analysis of the results to the current standards adopted by the major interventional radiology and vascular surgery departments. The Fontaine and the SCVIR classification methods were used for patients selection. Long-term patency was analyzed with clinical and noninvasive diagnostic exams. The results were studied with the Life-table analysis statistical method. The patients were divided into 3 groups: the patients treated only with PTA, those treated with PTA and stenting and finally those submitted to PTA before or after a surgical bypass. The results were analyzed separately. In 95/100 patients the maneuver was technically successful and immediate clinical success was not achieved only in one of them. At the first follow-up we collected data on 87 patients; at 3 years we followed-up 30 patients, but only 5 of them had to be resubmitted to PTA (3 PTA and stenting and 2 PTA alone) because of restenosis. Secondary patency was obtained in 91% and 84% of patients at 1 year and 3 years, respectively. With the Life-table analysis, the cumulative patency rate was 95.44% at 36 months. Few complications were observed (11/100 patients), especially considering that they were classified as "severe" in 3 cases only. To conclude, our results prove PTA to be a highly effective tool in the aortoiliac arteries, whose low mortality and complication rates suggest the use of this percutaneous procedure.

Percutaneous transluminal angioplasty in the treatment of chronic mesenteric ischemia: results and 3 years of follow-up in 23 patients.

BACKGROUND: We evaluated the clinical efficacy of visceral angioplasty in the treatment of chronic mesenteric ischemia. METHODS: Over a 14-year period, we performed percutaneous transluminal angioplasty of 41 occlusive diseases of visceral arteries founded by angiography in 23 patients with chronic mesenteric ischemia. All but one (fibrodysplasic) stenoses were atherosclerotic, and 13 were localized in the ostial tract. Clinical follow-up was evaluated at 2, 6, 12, 24, and 36 months (mean follow-up = 27 months). RESULTS: Angioplasty demonstrated a residual stenosis of 30% or less in 37 procedures, for a technical success rate of 90%. Seventeen of 20 patients had symptom remission after the first treatment, for a short-term clinical success of 77%; two patients needed a reangioplasty after 2 months, and one was referred for aortomesenteric bypass. During a mean follow-up of 27 months (range = 2-36), the clinical success was 88%; 2/15 patients underwent successful repeat angioplasty at 24 and 36 months, for a 100% secondary long-term clinical success. Only two minor complications were encountered. CONCLUSION: Although surgical results are undoubtedly positive, visceral angioplasty is justified in relation to both the high surgical mortality and the low incidence of complications arising from visceral angioplasty.

[Breath-hold gadolinium enhanced tree-dimensional MR angiography: personal experience in the thoracic-abdominal area]. / L'angiografia con Risonanza Magnetica con gadolinio e sequenza tridimensionale gradient-echo apnea. Esperienza personale nel distretto vascolare toraco-addominale.

PURPOSE: To investigate different clinical applications of gadolinium-enhanced MR angiography (Gd MRA) using three-dimensional breath-hold GE sequences, without bolus time calculation, in patients with vascular diseases. MATERIAL AND METHODS: Forty-seven patients were examined (49 studies in all). Eleven of them had an abdominal aortic aneurysm, 6 surgical bypass, 7 renal artery stenosis, 3 aortoiliac Wallstent, 7 aortic stent-graft; 11 patients had a suspected condition in the thoracic aorta and pulmonary arteries, 1 had subclavian artery stenosis and 1 suspected axillary artery compression. All patients were submitted to breath-hold Gd MRA, after 30-40 mL Gd, with a 1.5 T magnet (Gyroscan ACS-NT, Philips, The Netherlands) and a standard body coil. The GE sequences were acquired with TR = 8.8, TE = 2.7, FA = 60 degrees, matrix = 163 x 512, with 28 seconds acquisition time. Digital subtraction angiography and intraoperative findings were the reference standards to evaluate the results. RESULTS: Thoracopulmonary district: metastatic compression of axillary vessels was found in 1 breast cancer patient; the true and the false lumens and the intimal flap were identified in 2 patients with chronic aortic dissection (Stanford A), and graft patency and complete resolution of the aortic dissection was seen in the patient operated on for acute aortic dissection (Stanford A). The thrombus, lumen, extent and diameter were studied in 2 patients with thoracic aortic aneurysms. Subclavian artery stenosis was demonstrated in 1 patient, which was treated with transluminal angioplasty and stenting. The other 6 patients had normal findings. Abdominal aortic aneurysms (AAA): as for disease extent, breath-hold Gd MRA had 100% sensitivity and specificity compared with surgical findings. Juxtarenal aneurysm extent, which had been missed at DSA, was detected in 1 patient and then confirmed at surgery. Stenosis: comparing DSA and MRA findings in the whole series of patients we had 97.4% agreement (155/159 arteries), that is 76.4% (13/17) arteries) considering only stenoses > 50%. Breath-hold Gd MRA sensitivity and specificity were 100 and 87.5%, respectively, in our 28 stenoses. Bypass, aortoiliac stent, vascular endograft: patency was demonstrated in all the 6 surgical bypass patients, and there was agreement with color Doppler findings in 5 of 6. Breath-hold Gd MRA seems to have no possible applications in the follow-up of percutaneously implanted iliac stents, but we had excellent findings about patency and position of nichel-titanium endografts used for AAA treatment. CONCLUSIONS: We optimized breath-hold 3D MRA without bolus transit time calculation and with high-dose Gd in different clinical vascular conditions. In our opinion, 3D GE sequences can replace DSA in selected cases, providing a fast, accurate and noninvasive examination.

[Magnetic resonance angiography in the study of abdominal neoplasms. Preliminary experience]. / L'angiografia con risonanza magnetica nello studio delle neoplasie addominali. Esperienza preliminare.

This study was designed to evaluate MRA imaging as a potential non-invasive method to study vascular infiltration in patients with abdominal neoplasms. Forty-three patients with abdominal tumors proven by CT and/or MRI were examined with MRA and subsequently with angiography. Of 15 cases of liver tumor, MRA allowed poor intratumoral vascularization to be demonstrated in 1 patient only, but it always provided a characteristic sign--i.e., the complete absence of flow in the hepatic segments infiltrated by the tumor and the evidence of pericapsular neovascularization. In 8 cases portal vein involvement was observed (4 cases of compression/dislocation, 2 cases of infiltration and 2 of thrombosis). In all cases MRA allowed the relationship between tumor and venous structures to be evaluated. It also demonstrated collateral vessel formations in 8 patients with cancrocirrhosis. Two cases of thrombosis and 3 infiltrations of the vena cava were demonstrated. Neither hepatic artery nor intrahepatic arterial vascularization could be correctly evaluated. Of 10 cases of renal tumors and in 3 of adrenal tumors, renal vein infiltration was seen in 4 cases and compression in 3, with only 1 false-positive finding. In these patients and in those with retroperitoneal masses, MRA provided valuable information on the relationship between tumor and vascular structures and was useful in detecting collateral vessels. In our experience, MRA is to be considered as a complementary technique to be performed after CT or MRI when additional information is needed as to the relationship between tumor and vascular structures. In the preoperative evaluation of abdominal neoplasm, angiography remains the gold standard, in spite of its invasiveness.