Left radial vs right femoral: comparison between arterial accesses in c-TACE procedures in terms of operator radiations exposure and patient comfort.

PURPOSE: This multicenter prospective study aims to compare transradial access versus transfemoral access in conventional transarterial chemoembolization (c-TACE) procedures, focusing on operators radiations exposure, patients comfort, technical success and vascular access complications. MATERIALS AND METHODS: Patients were affected by hepatocellularcarcinoma (HCC) in intermediate stage or previous stages unfit for ablation and/or surgery; they were randomized into two groups according to arterial access site (Group F: right femoral access in standard position; Group R: radial access with left arm abduced 90°). Overall fluoroscopy time was recorded. Eight thermoluminescence dosimeters were positioned immediately before each procedure to monitor radiation doses. Technical success was intended as complete HCC nodules lipiodolization at final plain cone-beam CT. RESULTS: Group F included 23 patients, while group R 19. Mean fluoroscopy time was lower in group F but difference was not statistically significant (p-value > 0.05). In terms of operators radiations exposure, no significant differences were found (p-value > 0.05). Technical success was obtained in 81.5% in group F and 84.8% in group R, without significant differences (p-value > 0.05). Patients discomfort was significantly (p-value < 0.05) higher in group F. Concerning minor complications, no statistical differences were appreciated (p-value > 0.05); no major complications occurred. CONCLUSIONS: In this study, no statistical differences were observed in terms of operators radiations exposure, fluoroscopy time and technical success during c-TACE performed with left radial access compared to right femoral access; patients comfort was significantly better with radial access. These data should lead interventional radiologists to favor radial access in c-TACE interventions.

Pelvic ring fractures with concomitant large hematomas: diagnostic investigation with arteriography and eventual embolization in 157 trauma patients, with or without contrast extravasation at emergency CT.

PURPOSE: This study aims to evaluate the diagnostic value of pelvic arteriography in patients with pelvic ring fractures and associated large hematomas, in both cases of positive or negative findings of contrast agent extravasation at emergency CT; in those patients with positive DSA subsequently treated with embolization, correlations with clinical-radiological parameters were investigated. MATERIALS AND METHODS: In this single-center retrospective study, patients with acute blunt pelvic trauma showing at CT pelvic ring fractures with associated large (> 3 cm) hematoma, with or without signs of arterial bleeding, were investigated with DSA. Technical success was considered radiographic bleeding control with disappearance of angiographic bleeding; clinical success was defined as clinical bleeding control hemodynamically stable, before applying other surgical maneuvers. Pelvic ring fractures were evaluated according to Tile classification system. RESULTS: One hundred and fifty-seven patients, mean age 54years, were analyzed. 70.7% had polytrauma; 14.6% patients assumed antiplatelets and/or anticoagulation therapy. False-negative and false-positive rates at CT were 29.6% and 27.1%, respectively. Polytrauma and B3/C1 Tile pattern fractures were significantly associated with bleeding signs at DSA. Seventy-two patients required embolization: 52.8% showed direct signs of DSA bleeding; among these, technical and clinical successes were 88.8% and 81.9%, respectively. CONCLUSIONS: In this study, patients with pelvic ring fractures and concomitant hematomas > 3 cm, with or without contrast extravasation at CT, have been examined in depth with DSA focusing on both direct and indirect angiographic signs of bleeding, finding polytrauma and Tile fracture patterns B3/C1 predictive factors for arterial hemorrhage detection at DSA despite negative CT findings.

Primary non-parasitic splenic cyst: US- and fluoroscopy-guided percutaneous management by alcohol sclerosis on six patients.

PURPOSE: This manuscript aims to report on a retrospective analysis of six patients treated with combined US- and fluoroscopic-guided percutaneous alcohol sclerosis for primary non-parasitic splenic cysts. METHODS: In this retrospective analysis, three females and three males affected by primary non-parasitic splenic cysts were included. All except one were symptomatic. Preoperative cyst diameter was in mean 113 mm (range: 67-210 mm). Ethanol 96% was adopted as sclerosant agent; the amount of ethanol injected corresponded to the 20%-30% of the cystic volume. US follow-up was planned at 2/4 weeks; MR follow-up was conducted almost at 6 months after the last treatment session. Technical success was considered as cyst disappearance or reduction of the maximum diameter <50 mm; clinical success, in those symptomatic cases, was considered as symptoms resolution or marked improvement. RESULTS: Eleven procedures had been performed: one in three patients, three in two patients and two in one patient. Technical success was 83.3%; clinical success was 80%. Only one patient, with a preoperative cystic diameter of 210 mm and despite three treatment sessions, had an increase in the cystic size and did not report symptoms improvement. CONCLUSIONS: In this sample, US-guided percutaneous alcohol sclerosis was a safe and effective spleen preserving option to treat primary non-parasitic splenic cysts.

PHIL® (precipitating hydrophobic injectable liquid): retrospective multicenter experience on 178 patients in peripheral embolizations.

PURPOSE: This study aims to analyze safety and effectiveness of PHIL® (Microvention, CA-USA) in peripheral endovascular embolization procedures, both in elective and emergent scenarios. MATERIALS AND METHODS: This is a multicenter retrospective study, involving 178 patients from five interventional radiology departments from January 2017 to December 2021. Patients treated by an endovascular embolization with PHIL® were included; different PHIL® viscosities were adopted. Exclusion criteria were: neuroradiological endovascular interventions, other cohesive liquid embolics adopted during the same procedure, follow-up < 30 days. Technical success was intended as definitive target vessel occlusion without the need for other embolics after PHIL® injection. Clinical success was considered as restoration of hemodynamic status in case of emergent embolization and improvement of clinical conditions in case of elective procedures, without additional interventions at 30 days. RESULTS: Sixty-four women and 114 men, mean age 62 years (range 6-91), were evaluated. Sixty-three patients were in elective scenarios (AVMs, type-II endoleaks, tumors, varices, aneurysms, varicoceles) and 115 were in emergent settings (hemorrhage, pseudoaneurysms, hemoptysis, priapism); 190 procedures were performed in 178 patients. Overall technical and clinical success rates were 94.7% and 92.1%, respectively. The complications rate was 7.4% (6 grade-I, 7 grade-III, 1 grade-IV). PHIL®-25 was the more adopted viscosity; totally, 311 vials were injected (rate: 1.64 vial/procedure). CONCLUSION: In this series, PHIL® proved to be a safe and effective liquid embolic in peripheral embolizations, both in elective and emergent scenarios. The pre-filled syringe preparation allowed operators to use it even when unplanned at beginning of the intervention.

Endovascular treatment of cesarean scar pregnancy: a retrospective multicentric study.

PURPOSE: To assess the role of Uterine Artery Embolization (UAE) to treat cesarean scar pregnancy (CSP) using different embolic materials, focusing on its clinical and technical success rates; the association of UAE with methotrexate (MTX) and/or dilatation & curettage (D&C) was evaluated also. MATERIALS AND METHODS: A retrospective analysis 33 patients (mean age 35 years) affected by CSP and treated with UAE from March 2012 to 2020 was performed. Dynamic levels of serum ß-HCG have been collected until they decreased to normal values after procedures. For the statistical analysis the sample was divided into 2 groups: UAE versus UAE + MTX. RESULTS: The gestational sac age ranged between 5 and 13 weeks (mean 7 weeks). According to operator's preference, 11 patients (33.33%) were treated with sponge injection, 2 patients (6.06%) with a combination of sponge and microsphere the remaining 20 patients (60.60%) with microspheres alone. No major complications occurred after UAE and D&C, neither side effects related to the MTX administration. Technical and clinical success rates were 97% and 85%, respectively. Mean percentage of ß-HCG reduction was 90% (range - 99.92 to + 7.98%). Statistical analysis with linear regression shows a R2 value of 0.9624 in UAE group while a R2 value of 0.9440 in UAE + MTX group with statistical significance (p < 0.0001). No significative differences were found between the two groups about clinical success rate and embolic material adopted. CONCLUSION: In this series UAE has been found to be safe and effective for the treatment of CSP.

A cross-sectional study evaluating hospitalization rates for chronic limb-threatening ischemia during the COVID-19 outbreak in Campania, Italy.

The expansion of coronavirus disease 2019 (COVID-19) prompted measures of disease containment by the Italian government with a national lockdown on March 9, 2020. The purpose of this study is to evaluate the rate of hospitalization and mode of in-hospital treatment of patients with chronic limb-threatening ischemia (CLTI) before and during lockdown in the Campania region of Italy. The study population includes all patients with CLTI hospitalized in Campania over a 10-week period: 5 weeks before and 5 weeks during lockdown (n = 453). Patients were treated medically and/or underwent urgent revascularization and/or major amputation of the lower extremities. Mean age was 69.2 ± 10.6 years and 27.6% of the patients were women. During hospitalization, 21.9% of patients were treated medically, 78.1% underwent revascularization, and 17.4% required amputations. In the weeks during the lockdown, a reduced rate of hospitalization for CLTI was observed compared with the weeks before lockdown (25 vs 74/100,000 inhabitants/year; incidence rate ratio: 0.34, 95% CI 0.32-0.37). This effect persisted to the end of the study period. An increased amputation rate in the weeks during lockdown was observed (29.3% vs 13.4%; p < 0.001). This study reports a reduced rate of CLTI-related hospitalization and an increased in-hospital amputation rate during lockdown in Campania. Ensuring appropriate treatment for patients with CLTI should be prioritized, even during disease containment measures due to the COVID-19 pandemic or other similar conditions.

Severe metrorrhagia in patients with advanced gynecologic cancer: endovascular treatment benefits in acute and chronic setting.

PURPOSE: Interventional radiology plays an established role in the management of many conditions of the female reproductive tract. Since in benign gynecological and obstetric pathologies, as myomas and postpartum hemorrhages, uterine arteries embolization has been already evaluated, this manuscript aims to report on a single-center experience concerning the endovascular management of metrorrhagia caused by gynecological malignancies. MATERIALS AND METHODS: Single-center retrospective analysis of thirty patients affected by gynecologic cancer treated with endovascular embolization between January 2016 and December 2018 for acute or chronic metrorrhagia. RESULTS: All patients were in advanced oncological stage (III or IV) with loco-regional spread of the tumor or invasion of pelvic structures, with a poor performance status. They were not suitable for surgery. On initial CT angiography, contrast media extravasation was confirmed in two patients (6.6%), while on DSA examination, tumor stain was displayed in 28 patients (93.4%). In two patients (6.6%) a pseudoaneurysm was reported. CONCLUSIONS: Endovascular treatment of metrorrhagia in oncologic patients could be a valid therapeutic alternative, especially when in elderly patients with poor clinical conditions not suitable for surgery. A bilateral and superselective embolization using non-resorbable embolic agents should be performed, except for those cases in which there is infiltration of major vessels causing pseudoaneurysms or fistulas that require embolization.

Embolization of peripheral arteriovenous malformations and fistulas with precipitating hydrophobic injectable liquid (PHIL®).

PURPOSE: This paper reports on the preliminary experience of a single center in the embolization of peripheral AVMs and fistulas with precipitating hydrophobic injectable liquid (PHIL®), focusing on technical aspects and short-term clinical outcomes. MATERIALS AND METHODS: Seven males and five females were included in this study, mean age 42.16 years. For ten of them, it was the first embolization treatment; two had been previously treated with Onyx® embolization. PHIL® was injected with a transarterial approach without other embolics during the same procedure. Lesions were localized in small bowel (1), colon (1), head face (5), forefoot (1), uterus (1) and thorax (3); all were symptomatic. After 30-day clinical follow-up, a contrast-enhanced CT or MR was acquired at 3 months from intervention to detect eventual lesion residual. RESULTS: After a single embolization procedure, complete technical success was obtained in 50%, while clinical improvement without additional therapies was appreciable in all patients. No technical failure occurred; in two cases, a small amount of PHIL® proximally refluxed in nontarget vessels without clinical effects. No tattooing effects of superficial lesions neither artifacts at CT and cone-beam CT controls were evident. CONCLUSIONS: PHIL® seems to be a safe and effective liquid embolic agent for the treatment of peripheral AVMs and fistulas; although a direct comparison between PHIL and Onyx was not performed, PHIL might present the advantages of reduced artifacts at postprocedural CT scan and no need for shaking time preparation, but it is more expensive due to lower volume of product for each package and slightly less radiopaque at fluoroscopy.

Successful endovascular embolization of a giant splenic artery pseudoaneurysm secondary to a huge pancreatic pseudocyst with concomitant spleen invasion.

Pseudoaneurysms of the pancreatic and peripancreatic arteries is a well-known complication of chronic or necrotizing pancreatitis due to proteolytic enzymatic digestion of the arterial wall. A major part of peripancreatic pseudoaneurysms involve the splenic artery, but any peripancreatic artery may be involved and bleed. They are potentially life threatening for patients, due to spontaneous intraperitoneal rupture, rupture and fistulization into the surrounding organs, or fistulization into the pancreatic duct. Small ones are usually asymptomatic and are often diagnosed incidentally, while giant (> 5 cm) aneurysms and pseudoaneurysms are symptomatic and may be detected as a pulsatile mass in the upper-left quadrant or epigastrium. Imaging plays a key role in the identification of splenic artery aneurysms and pseudoaneurysms, while angiography still represents the gold standard for the diagnosis, although nowadays it plays a prominent role in treatment. Treatment of splenic artery pseudoaneurysms is mandatory because of the high probability of rupture, with a mortality rate of up to 90%. The gold standard treatment is represented by surgery, with a mortality rate between 16% and 50%. In recent years the endovascular approach has proven to be an effective alternative treatment for splenic artery pseudoaneurysms, and it is currently the method of choice. In this article, we present the case of a ant pseudoaneurysm of the splenic artery due to huge pseudocysts in a young alcoholic patient with recurrent and chronic pancreatitis, complicated by fistulization and invasion of spleen parenchyma and arteriovenous fistula.

Emborrhoid in patients with portal hypertension and chronic hemorrhoidal bleeding: preliminary results in five cases with a new coiling release fashion "Spaghetti technique".

PURPOSE: This manuscript reports on a preliminary experience concerning emborrhoid in patients affected by cirrhotic portal hypertension; furthermore, a novel customized technique of coils release, named "Spaghetti technique," is described. MATERIALS AND METHODS: Five patients with chronic anemia due to internal hemorrhoidal bleeding and cirrhotic portal hypertension were treated. Clinics and hemoglobin values were evaluated to objectively assess clinical conditions up to 3 months follow-up. Embolizations were performed with fibered coils, oversized, released stretched and not packed. RESULTS: Technical success, intended as occlusion of all superior hemorrhoidal artery branches, was 100%. In two patients, inferior hemorrhoidal arteries were embolized too. No patients reported major or minor complications. At 3-month follow-up, clinical improvement was obtained in four of the five patients; hemoglobin values improved or remained stable in the whole sample. CONCLUSIONS: Based on this limited experience, emborrhoid seems to be safe and effective at 3-month follow-up to improve symptoms in patients with cirrhotic portal hypertension and chronic anemia due to hemorroidal bleeding; the stretched fashion to release oversized coils provides effective embolization.

Embolization of high-flow priapism: technical aspects and clinical outcome from a single-center experience.

PURPOSE: High-flow priapism is an incomplete and painless persistent erection caused by trauma. Its diagnosis is performed thanks to clinic and imaging evaluation with detection of fistula/pseudoaneurysm in the cavernous tissue. This paper aims to retrospectively assess the efficacy and safety of superselective arterial embolization in patients with high-flow priapism. MATERIALS AND METHODS: From January 2008 to March 2017, nine patients with high-flow priapism have been treated in a single center with embolization. The main etiology was trauma in eight subjects. The patients were evaluated with laboratory examinations and clinical and imaging findings (color Doppler ultrasonography and angiography). The mean follow-up time after embolization was 24 months. RESULTS: Eleven procedures were performed in nine patients: two of them required a second treatment session because of recurrence after 1-2 weeks. Embolic agents were microcoils, microparticles (300-500 µm) and Spongostan. Restoration of erectile function was monitored by clinical and color Doppler evaluation during follow-up. CONCLUSIONS: Superselective embolization should be the procedure of choice in patients affected by high-flow priapism; this technique appears to be successful in preserving erectile function. The choice of the embolic agent is crucial, and it should be tailored for each patient.

Endovascular Treatment of Peripheral Vascular Blowout Syndrome in End-Stage Malignancies.

BACKGROUND: Vascular blowout syndrome (VBOS) is a life-threatening condition secondary to direct tumor encasement or invasion in advanced stage malignancies. Endovascular management can be used as an alternative to surgical treatment in this fragile patient population, providing a minimally invasive measure both acutely and prophylactically. METHODS: Three patients with peripheral VBOS secondary to advanced stage malignancies underwent successful endovascular treatment. Technical success was obtained in all patients with nonsignificant perioperative complications. RESULTS: Endovascular management controlled immediate life-threatening hemorrhage and enabled these high-risk patients to undergo other adjunctive therapeutic modalities. CONCLUSIONS: Endovascular treatment can offer a safe and effective palliative measure of peripheral VBOS secondary to neoplastic erosion in patients with advanced stage malignancies.

The additional value of the arterial phase in the CT assessment of liver vascular injuries after high-energy blunt trauma.

PURPOSE: In the literature, no consensus exists about which CT protocol is to be adopted in patients who underwent high-energy blunt trauma. The aim of the study is to evaluate the additional value of the arterial phase in the CT assessment of vascular injuries of the liver. METHODS: Admission CT examinations for patients with traumatic injury of the liver due to high-energy blunt trauma, performed between 2011 and 2017 in two major trauma centres, were retrospectively reviewed. Images were analysed for presence or absence of liver parenchymal injury, intrahepatic contained vascular injuries and active bleeding in the arterial and portal venous phase of the CT study. RESULTS: Two hundred twelve patients have been identified. Parenchymal injuries were detected as isolated in 90.6% of cases, whereas they were associated with vascular injuries in 9.4% of cases: contained vascular injuries in 3.3% and active bleeding in 6.1%. Out of all parenchymal injuries detected on the CT portal venous phase, 90.5% were also detectable in the arterial phases (p < 0.0001). All of the contained vascular injuries were visible in the CT arterial phase, whereas they were detectable in 28.5% of cases also during the venous phase (p = 0.02). All 13 cases of active bleeding were detected on the CT venous phase, and 76.9% of these cases were also revealed in the arterial phase, thus confirming their arterial origin (p = 0.22). CONCLUSION: The addiction of the arterial phase to the venous phase in the CT assessment of patients who underwent high-energy blunt trauma allows an accurate identification and characterization of traumatic vascular injuries, so distinguishing between patients suitable for conservative management and those requiring interventional or surgical treatment.

Transarterial embolization of peripheral high-flow arteriovenous malformation with ethylene vinyl alcohol copolymer (Onyx®): single-center 10-year experience.

PURPOSE: High-flow arteriovenous malformations (AVMs) are complex vascular lesions for which transcatheter embolization is considered as first-choice treatment nowadays. Multiple embolizing agents have been described, and among them, Onyx® seems to be promising; this is a liquid embolic agent, originally applied in neurointerventional radiology and recently adopted also in peripheral embolizations. The aim of this study is to report on a 10-year experience of transarterial embolization of peripheral high-flow AVM with Onyx® in terms of technical and clinical outcomes. MATERIALS AND METHODS: Retrospective analysis was conducted on patients affected by high-flow AVM and treated electively by transarterial embolization with Onyx®. Data collection included: preinterventional clinical radiological evaluations, procedural data and post-procedural clinical radiological assessment. Technical and clinical success was evaluated; follow-up was conducted 30 days after the last treatment session and yearly in case of success. RESULTS: Sixteen patients have been included, totally 38 embolizing procedures. Additional embolizing agents were required in 5 patients. Technical success was obtained in 11 patients; at 30-day follow-up, 15 patients showed improvements in symptoms, even those with incomplete embolization; however, after almost 1 year from treatment accomplishment, 7 patients showed relapse of symptoms and presented radiological signs of AVM recurrence. No clinically relevant complications occurred. CONCLUSIONS: In this series, in accordance with previous but limited published data, Onyx® appeared safe and technically effective to embolize high-flow peripheral AVM with transarterial approach. Clinical radiological follow-up is mandatory because new feeder recruitment has to be expected; patients should be informed of the concrete possibility of multiple treatment sessions.

Percutaneous management of bone metastases: state of the art, interventional strategies and joint position statement of the Italian College of MSK Radiology (ICoMSKR) and the Italian College of Interventional Radiology (ICIR).

Interventional radiology provides local management of bone metastases (BM) with a palliative intent in most cases, or with a curative intent in selected patients. Its role has rapidly expanded in the last decade, offering new treatment solutions often in combination with surgery, radiation therapy and medical treatments. The aim of the present paper is to increase awareness, acceptance and adoption of interventional radiology procedures for the treatment of BM; and to present the joint position of the Italian College of Musculoskeletal Radiology and the Italian College of Interventional Radiology.

The role of interventional radiology in the treatment of lower limb vascular injuries after orthopaedic surgery.

PURPOSE: This paper focuses on the role of interventional radiology embolisations in a series of patients presenting with iatrogenic vascular injuries of the lower limbs following orthopaedic interventions. MATERIAL AND METHODS: Fourteen patients (mean age: 64 years, range 23-90 years) were retrospectively analysed. Clinical presentation consisted of palpable pulsatile mass, pain, reduced lower limb motion, or visible haematoma; 11 patients had also anaemia (haemoglobin < 7 g/dl). RESULTS: The time between orthopaedic surgery and embolisation ranged between 0 and 67 days (mean: 15 days). Injured arterial vessels were as follows: inferior gluteal artery (2), superficial external pudendal artery (2), deep femoral artery (1), lateral circumflex femoral artery (3), medial circumflex femoral artery (2), articular branch of descending genicular artery (1), perforating femoral arteries (3), posterior tibial recurrent artery (1), and anterior tibial artery (1). The typologies of vascular lesion were: pseudoaneurysm 57%, bleeding with extraluminal contrast agent blush of the terminal arterial segment 36%, and laceration and bleeding with extraluminal contrast agent blush of the arterial main trunk 7%. Embolising agents adopted were microcoils 57%, glue 14%, microplug 7%, particles 14%, and covered stent 7%. In all cases clinical and procedural technical successes were obtained (100%). CONCLUSIONS: For the management of vascular injuries occurring after different orthopaedic interventions of the lower limbs, endovascular embolisations have proven to be safe and effective; orthopaedic surgeons should be aware of the support that interventional radiology could provide in the case of iatrogenic vascular complications.

Safety and effectiveness of transcatheter embolization in the treatment of internal mammary artery injuries.

PURPOSE: Demonstrate the role of endovascular management in the treatment of internal mammary artery (IMA) injuries using transcatheter embolization reviewing our 7-year experience. MATERIALS AND METHODS: Our retrospective analysis of cases consists of a total of 12 patients (8 M and 4 F; mean age 52 years) who underwent angiographic studies and transcatheter embolization for IMA injuries. Causes of vascular injury were divided in high-energy trauma (n = 6), iatrogenic (n = 3) and penetrating injuries (n = 3). Type of trauma, associated injury, imaging findings, treatments and complications were assessed. Imaging findings included active haemorrhage, pseudoaneurysm and focal dissection. RESULTS: Embolization was performed with microcoils in all patients; complete thrombosis was obtained in four patients by additional injection of Spongostan pledgets and in two patients with 300-500 µm particles. The technical success rate was 100%. No patient died as a direct result of vascular injury; one died of myocardial contusion and one for severe multiorgan failure related to high-energy trauma. No major and minor complications were registered. No patient required emergency surgery or subsequent surgical treatment. CONCLUSION: Transcatheter embolization offers an effective, efficient and safe alternative to conventional surgical management of IMA injuries.

Sclerotherapy of peripheral low-flow vascular malformations: technical aspects and mid-term clinical outcome.

PURPOSE: The therapeutical management of low-flow vascular malformations (LFVMs) is challenging because of high recurrence rate; multiple strategies have been proposed. This paper aims to report a single-center experience of direct puncture sclerotherapy of peripheral LFVMs, focusing on technical aspects and clinical outcome in mid-term follow-up. MATERIALS AND METHODS: 16 patients have been treated for peripheral LFVMs (mean age 36.1 years), complaining mild pain, swelling of the region of interest, and cosmetic nuisance. Preprocedural US and MR were acquired; angiography performed only in doubt vascular supply. Standard procedure consisted of direct puncture of the nidus using 20-23 gauge needles under US guidance and injection of up to 15 ml foam of sodium tetradecyl sulphate under fluoroscopic guidance. Clinical and radiological follow-up were assessed at 1, 3, and 6 months. RESULTS: Lesions were localized: 8 in the upper and 5 the in lower limbs, 2 in the cheeks, and 1 in the vaginal labia. All procedures have been technically accomplished (100%). At 6 month follow-up, technical and clinical success were obtained in all cases, while radiological follow-up showed 81.2% (13 patients) complete vessels thrombosis after multiple sclerotherapy sessions. No major complications have been recorded; five patients (31.2%) referred minor complications. CONCLUSIONS: Sclerotherapy via direct puncture of LFVMs is a clinically effective procedure, well tolerated by patients, with reduced costs and mild minor complications rate; interventionalists should always clarify to the patients that multiple sessions would be performed and recurrences are expected at imaging follow-up despite clinical improvement.