Topographical Variations between Splenic Flexure and Spleen: A Study with CT Image-Based Reconstruction.

INTRODUCTION: An issue that is seldom seen in the literature relates the detailed relationship of the splenic flexure (SF) and the spleen-both carefully examined-with a prospective approach in patients undergoing computer tomography (CT) scan. MATERIALS AND METHODS: SF localization has been searched and examined in 120 consecutive CT scans. Several different variables (age, gender, BMI, indication of CT scan, etc.) have been considered. In cooperation with the Radiology Division, we brought to completion a dedicated topographic outline, with the purpose of providing a detailed classification for SF localization. RESULTS: The SF lies, in 52% of cases, in what we called the inferior (I) position, below the spleen. Other categories of our classification were anterior (A) and posterior (P) positions, which were found respectively in 42% and 8% of analyzed cases. Considering all the variables given, we did not find any significant statistical correlation (p > 0.05). CONCLUSIONS: This study was carried out to classify types of SF in terms of its positional relationship with the spleen. We investigated 120 CT scans and classified the SF into three types, according to its localization: inferior (I), anterior (A), and posterior (P) types. A better understanding of the anatomic variability in SF may be useful for minimizing complications and performing an accurate surgical dissection.

Breast reconstruction by tissue expansion: What is the integrity of the chest wall?

BACKGROUND: Both tissue expanders and implants are commonly used during breast reconstructions. These devices are the preferred choice of many plastic surgeons around the world during breast reconstruction due to their technical ease of use, low comorbidity and safety. However, several issues such as the integrity of the chest wall during and after tissue expansion remain unclear. Here we present a longitudinal study that shows deformities of the chest wall caused by the use of tissue expanders. PATIENTS AND METHODS: A prospective longitudinal study of the chest wall in 36 patients who underwent immediate two-stage expander-to-implant reconstruction from 2010 to 2013 was conducted to evaluate the possible causes of chest wall deformity. Computed tomography (CT) scans of the chest walls were taken before the second-stage reconstruction and after 1 year. Chest wall deformities (graded from I, no deformities, to V, costal fracture) were evaluated with CT scans. RESULTS: This study examined 36 breast reconstructions. Chest wall deformities were observed by a CT scan before the second-stage reconstruction. There were eight patients with grade I scores, 14 with grade II, 10 with grade III and four with grade IV. No cases of costal fracture (grade V) were observed. At the 1-year follow-up after the TE/implant change, 22 patients had the same degree of chest wall deformity. Ten patients showed an improvement and four a higher-grade deformity. CONCLUSION: Chest wall deformities commonly occur after tissue expander/implant reconstruction. However, the size of the expander, reconstruction timing and filling volume are not correlated with deformity development.

Comparison of cone-beam CT-guided and CT fluoroscopy-guided transthoracic needle biopsy of lung nodules.

PURPOSE: To compare the diagnostic performance of cone-beam CT (CBCT)-guided and CT fluoroscopy (fluoro-CT)-guided technique for transthoracic needle biopsy (TNB) of lung nodules. METHODS: The hospital records of 319 consecutive patients undergoing 324 TNBs of lung nodules in a single radiology unit in 2009-2013 were retrospectively evaluated. The newly introduced CBCT technology was used to biopsy 123 nodules; 201 nodules were biopsied by conventional fluoro-CT-guided technique. We assessed the performance of the two biopsy systems for diagnosis of malignancy and the radiation exposure. RESULTS: Nodules biopsied by CBCT-guided and by fluoro-CT-guided technique had similar characteristics: size, 20 ± 6.5 mm (mean ± standard deviation) vs. 20 ± 6.8 mm (p = 0.845); depth from pleura, 15 ± 15 mm vs. 15 ± 16 mm (p = 0.595); malignant, 60% vs. 66% (p = 0.378). After a learning period, the newly introduced CBCT-guided biopsy system and the conventional fluoro-CT-guided system showed similar sensitivity (95% and 92%), specificity (100% and 100%), accuracy for diagnosis of malignancy (96% and 94%), and delivered non-significantly different median effective doses [11.1 mSv (95 % CI 8.9-16.0) vs. 14.5 mSv (95% CI 9.5-18.1); p = 0.330]. CONCLUSION: The CBCT-guided and fluoro-CT-guided systems for lung nodule biopsy are similar in terms of diagnostic performance and effective dose, and may be alternatively used to optimize the available technological resources. KEY POINTS: • CBCT-guided and fluoro-CT-guided lung nodule biopsy provided high and similar diagnostic accuracy. • Effective dose from CBCT-guided and fluoro-CT-guided lung nodule biopsy was similar. • To optimize resources, CBCT-guided lung nodule biopsy may be an alternative to fluoro-CT-guided.

Role of low dose CT angiography in the follow-up after endovascular aneurysm repair of abdominal aorta.

BACKGROUND: Computed tomography angiography (CTA) is the most employed modality in the follow-up after endovascular aneurysm repair (EVAR) of abdominal aorta (AA); repeated standard controls expose patients to a high cumulative radiation dose (RD). PURPOSE: To compare image quality and RD between 100 kV and 120 kV protocols in the same group of patients, previously treated with EVAR. MATERIAL AND METHODS: Thirty patients, who had performed a previous CTA at 120 kV, underwent a low dose CTA with the same 64-detector machine. Images were evaluated qualitatively and quantitatively. The influence of body mass index (BMI), considering three groups of patients (normal weight, overweight, and obese) was also assessed. RD values (volume CT dose index and effective dose) were calculated. RESULTS: The mean qualitative score at 100 kV was worse than that at 120 kV, but the difference was not statistically significant and in all cases the image quality was satisfactory. At 100 kV the vessels mean attenuation value was significantly higher; signal-to-noise ratio significantly lower; contrast-to-noise ratio lower, but the difference was not significant. Regarding BMI, the difference in the qualitative score was significant in the obese group, but not in the other two groups; of the quantitative parameters only the signal-to-noise ratio presented a significant difference in the obese group. The average CTDIvol was reduced by 22% and the mean effective dose by 36% with the 100 kV protocol compared to the 120 kV protocol. Both differences were significant. CONCLUSION: The 100 kV protocol allowed a consistent RD reduction, maintaining a satisfactory image quality in all patients.

Usefulness and safety of biliary percutaneous transluminal forceps biopsy (PTFB): our experience.

AIM: To evaluate the usefulness and safety of percutaneous transluminal forceps biopsy in patients suspected of having a malignant biliary obstruction. MATERIAL AND METHODS: Forty consecutive patients (21 men and 19 women; mean age, 71.9 years) underwent forceps biopsy through percutaneous transhepatic biliary access performed to drain bile. Lesions involved the common bile duct (n 8), common hepatic duct (n 18), hilum (n 6), ampullary segment of the common bile duct (n 8) and were biopsied with 7-F biopsy forceps. Final diagnosis was confirmed with pathologic findings at surgery, or clinical and radiologic follow-up. RESULTS: Twenty-one of 40 biopsies resulted in correct diagnosis of malignancy. Thirteen biopsy diagnosis were proved to be true-negative. There were six false-negative and no false-positive diagnoses. Sensitivity, specificity and accuracy in aspecific biliary obstructions were 85%, 100% and 88,7% respectively. Sensitivity of biopsy in malignancies was higher than in benign obstructions (100% vs 68,4%, CI = 95%). Sensitivity was lower in the hilum tract and in the common bile duct than in other sites (CI = 95%). No major complications related to biopsy procedures occurred. CONCLUSIONS: Percutaneous transluminal forceps biopsy is a safe procedure, easy to perform through a transhepatic biliary drainage tract, providing high accuracy in the diagnosis of malignant biliary obstructions.

Microwave ablation of lung tumours: single-centre preliminary experience.

PURPOSE: This study was done to evaluate the feasibility, effectiveness and safety of microwave (MW) ablation of lung tumours. MATERIALS AND METHODS: Twenty-four patients underwent percutaneous MW ablation of 26 intraparenchymal pulmonary masses. All patients were judged to be inoperable on the basis of tumour stage, comorbidities, advanced age and/or refusal to undergo surgery. Ablation was performed using a microwave generator (Evident Microwave Ablation System, Covidien Ltd., Dublin). Lesions with a diameter ≤ 3 cm were treated with a single antenna, lesions with a diameter >3 cm were treated by positioning two or more antennae, simultaneously. All patients underwent computed tomography (CT) follow-up with and without contrast administration at 1, 3 and 6 months and then yearly in combination with complete blood and metabolic tests. RESULTS: Technical success was 100 %. No major complications were recorded. Asymptomatic grade-1 pneumothorax was recorded in 9 patients (37.5 %). One case of asymptomatic pleural effusion and one of haemoptysis, not requiring transfusion, were observed. No patients were diagnosed with a post-ablation syndrome. Complete necrosis was observed in 16 of 26 lesions (61.6 %). Partial necrosis was obtained in 30.8 % (8/26 lesions); in one case (3.8 %) a progression of the disease was recorded and in another case (3.8 %) a stability was observed. CONCLUSIONS: Our preliminary experience may be considered in accordance with literature dates, in terms of efficacy and safety.

Use of amplatzer vascular plug to treat a biliary cutaneous fistula.

Several substances have been used in an attempt to sclerose biliary ducts associated with persistent biliary-cutaneous fistula (BCF). The AMPLATZER Vascular Plug (AVP; AGA Medical, USA) system is a recently developed endovascular occlusion device, introduced as an alternative to permanent embolic materials (metallic coils or acrylic glue), in the occlusion of large and medium-calibre arteries and veins. We report a successful use of the AVP to embolize BCF, developed after the removal of an internal-external biliary drainage.

Endovascular treatment in emergency setting of acute arterial injuries after orthopedic surgery.

PURPOSE: To assess the feasibility and effectiveness of emergency endovascular treatment of acute arterial injuries after orthopedic surgery. MATERIALS AND METHODS: Fifteen patients (mean age 68.3 years) with acute arterial injuries after orthopedic surgery were observed, in particular, 5 patients with pseudoaneurysm, 9 patients with active bleeding, and 1 patient with arterial dissection. Transarterial embolization (TAE) and positioning of covered and noncovered stents were the treatments performed. Follow-up after stent implantation (mean 36 months) was performed with color Doppler US (CDU) at 1, 3, 6, and 12 months and yearly thereafter. Plain X-ray was performed to evidence dislodgment or fracture of the graft. A minimum of 12 months' follow-up is available after TAE. RESULTS: Immediate technical success was obtained in all cases. No major complications occurred. Overall clinical success rate was 100%. During mean follow-up, stent-graft occlusions did not occurred. No recurrence and/or consequence of TAE was registered during a minimum follow-up of 12 months. CONCLUSIONS: Percutaneous treatment is a feasible and safe tool for treating arterial injuries because it can provide fast and definitive resolution of the damage. This low-invasiveness approach can be proposed as first-line treatment in patients with acute injuries after orthopedic surgery.

Current role of interventions in metastatic kidney tumors: single center experience.

This study on the treatment of kidney tumor metastases aims to expose our experience in different interventional therapies for renal cell carcinomas metastasis in different organs, broaching their complications and comparing our results with the literature. In the last 5 years, after informed consent, 22 patients with metastatic kidney tumors were enrolled in this retrospective observational study. According to lesion sites, different interventional procedures may be performed: RFA for pancreas, lung, adrenal gland and liver lesions; TAE and RFA for bone lesions and IVC filter positioning for thrombosis of renal vein. There were mainly satisfactory results: complete necrosis of pancreas, lung and adrenal gland metastasis with a technical success rate of 100%; after TAE and RFA of bone lesions, an acceptable blood loss was registered during surgical intervention; no recurrences after liver metastasis ablation were observed in a period of 3 months; positioning of IVC filter was technically correct in 100% of patients; few complications, such as diffuse abdominal pain for pancreas, pneumothorax in the lung RCC metastasis and a post-RFA syndrome for the adrenal. There was a nodular recurrence along the ablation margin in one liver RCC metastasis. Inclusion criteria were relatively strict and only 22 patients were included in this study. The follow-up has been relatively short to date, so we are not certain of the long-term results, though these are comparable to those found in literature. It is possible to conclude that Interventional radiology plays an important role in RCC metastasis treatment, if we have few complications and improved outcomes.

Gross hematuria caused by a congenital intrarenal arteriovenous malformation: a case report.

INTRODUCTION: We report the case of a woman who presented with gross hematuria and was treated with a percutaneous embolization. CASE PRESENTATION: A 48-year-old Caucasian woman presented with gross hematuria, left flank pain, and clot retention. The patient had no history of renal trauma, hypertension, urolithiasis, or recent medical intervention with percutaneous instrumentation. The patient did not report any bleeding disorder and was not taking any medication. Her systolic and diastolic blood pressure values were normal at presentation. The patient had anemia (8 mg/dL) and tachycardia (110 bpm). She underwent color and spectral Doppler sonography, multi-slice computed tomography, and angiography of the kidneys, which showed a renal arteriovenous malformation pole on top of the left kidney. CONCLUSIONS: The feeding artery of the arteriovenous malformation was selectively embolized with a microcatheter introduced using a right transfemoral approach. By using this technique, we stopped the bleeding, preserved renal parenchymal function, and relieved the patient's symptoms. The hemodynamic effects associated with the abnormality were also corrected.

Percutaneous treatment of traumatic upper-extremity arterial injuries: a single-center experience.

PURPOSE: To assess the feasibility and effectiveness of emergency percutaneous treatment of traumatic injuries of upper-extremity arteries. MATERIALS AND METHODS: Between January 2000 and December 2007, 11 patients (mean age, 49.9 years) with traumatic injuries of upper-extremity arteries were observed: three had pseudoaneurysms, four had dissections, three had transections, and one had mural hematoma. Lesions involved the axillary (n = 6), subclavian (n = 3), or brachial artery (n = 2). Pseudoaneurysms and transections were treated with stent grafts, (n = 6) and dissections and mural hematomas were treated with bare stents (n = 2) or angioplasty (n = 3). Follow-up (mean, 45.1 months; range, 12-84 months) was performed with color Doppler ultrasonography at 1, 3, 6, and 12 months and then, yearly. RESULTS: Immediate technical success was obtained in all cases. No major complications occurred; there was one asymptomatic occlusion of the interosseous artery and one case of incomplete thrombosis of the radial artery (with recanalization after 1 month with systemic medical therapy). During a mean follow-up of 45.1 months, one stent-graft occlusion occurred, which was treated with intraarterial pharmacologic thrombolysis (urokinase 60,000 IU/h for 12 hours). Overall primary clinical success rate was 95.2% and secondary clinical success rate was 100%. CONCLUSIONS: Percutaneous treatment is a feasible and safe tool for injuries of upper-extremity arteries because it can provide a fast and definitive termination of bleeding or a resolution of acute ischemia. This approach, with its low invasiveness, can be proposed as first-line treatment in patients with traumatic lesions of upper-extremity arteries.

Performance assessment of four 64-slice computed tomographic devices for a typical clinical protocol.

OBJECTIVE: To compare the performances of four 64-slice CT devices, as regards radiation dose and image quality. METHODS: Effective dose was measured with thermoluminescent dosimeters in an Alderson Rando phantom (Alderson Research Laboratories, New York, NY). Quantitative image quality was evaluated in a Catphan 600 phantom (The Phantom Laboratory, New York, NY) using 3 parameters (modulation transfer function, contrast-to-noise ratio, and figure of merit). Effective and main organ doses were measured in 40 patients (10 for each CT device), who underwent an abdominal study with the same standard protocol; moreover, in these patients, clinical image quality, using a 5-grade quality score, was assessed. RESULTS: In-phantom measured doses and quantitative image quality showed some differences among the 4 devices. On the contrary, effective and organ doses provided to the patients were similar; no statistically significant differences were found also for clinical image quality. CONCLUSIONS: Some differences were found among the 4 devices from a physical point of view; on the other hand, the patient data were similar.

Occlusion of an intraosseous arteriovenous malformation with percutaneous injection of polymethylmethacrylate.

Primary intraosseous arteriovenous malformations are rare. Many minimally invasive procedures can be considered preoperative steps and/or definitive treatment. The case reported regards a young woman with a voluminous arteriovenous extratroncular infiltrating malformation of the humerus. She underwent several treatments, but none of them was completely occlusive. The last treatment consisted of direct percutaneous puncture of the intraosseous alteration and injection of polymethylmethacrylate (PMMA), which is normally used in percutaneous vertebroplasty. We obtained complete occlusion of the humerus lytic lesion. To the best of our knowledge, this represents the first case of intraosseous AVM treated by percutaneous injection of PMMA.

Radiofrequency ablation of intrahepatic cholangiocarcinoma: preliminary experience.

The purpose of this study was to evaluate the safety and efficacy of percutaneous ultrasound (US)-guided radiofrequency ablation (RFA) in patients with intrahepatic cholangiocarcinoma (ICCA) in a small, nonrandomized series. From February 2004 to July 2008, six patients (four men and two women; mean age 69.8 years [range 48 to 83]) with ICCA underwent percutaneous US-guided RFA. Preintervetional transarterial embolization was performed in two cases to decrease heat dispersion during RFA in order to increase the area of ablation. The efficacy of RFA was evaluated using contrast-enhanced dynamic computed tomography (CT) 1 month after treatment and then every 3 months thereafter. Nine RFA sessions were performed for six solid hepatic tumors in six patients. The duration of follow-up ranged from 13 to 21 months (mean 17.5). Posttreatment CT showed total necrosis in four of six tumors after one or two RFA sessions. Residual tumor was observed in two patients with larger tumors (5 and 5.8 cm in diameter). All patients tolerated the procedure, and there with no major complications. Only 1 patient developed post-RFA syndrome (pain, fever, malaise, and leukocytosis), which resolved with oral administration of acetaminophen. Percutaneous RFA is a safe and effective treatment for patients with hepatic tumors: It is ideally suited for those who are not eligible for surgery. Long-term follow-up data regarding local and systemic recurrence and survival are still needed.

Sclerotherapy of peripheral venous malformations: a new technique to prevent serious complications.

Because of its extremely powerful sclerosing effect, in our experience, ethanol can be considered the most efficacious agent in the percutaneous treatment of peripheral venous malformations. To reduce the risk of ethanol reflux into the superficial veins or the central venous system, we developed a simple but very efficacious technique. After the time necessary to obtain the sclerosing effect, we drain the ethanol with the same needle used to inject. The purpose of this article is to describe the technique of sclerotherapy with 96% ethanol for peripheral venous malformations and its effectiveness in reducing the serious complications of alcohol.

Emergency endovascular treatment of sac rupture for type IIIa endoleak in thoracic aortic aneurysm previously excluded with endovascular repair.

Elective endovascular treatment of thoracic aortic pathology has been applied in a variety of conditions. The complications of thoracic aortic stenting are also well recognized. Endoleak after endovascular repair of thoracic aortic aneurysms is the most frequent complication; among them, type III is the least frequent. Endovascular treatment of type III endoleak is generally performed under elective conditions; less frequently, in emergency. We report a successful emergency endovascular management of post-thoracic endovascular repair for thoracic aortic aneurysm rupture due to type IIIa endoleak.

Single-antenna microwave ablation under contrast-enhanced ultrasound guidance for treatment of small renal cell carcinoma: preliminary experience.

The purpose of this study was to determine the safety, effectiveness, and feasibility of microwave ablation (MWA) of small renal cell carcinomas (RCCs) in selected patients. Institutional review board and informed consent were obtained. From December 2007 to January 2009, 12 patients (8 male, 4 female) were enrolled in a treatment group, in which percutaneous MWA of small RCCs was performed under contrast-enhanced ultrasound guidance. The tumors were 1.7-2.9 cm in diameter (mean diameter, 2.0 cm).Therapeutic effects were assessed at follow-up with computed tomography. All patients were followed up for 3-14 months (mean, 6 months) to observe the therapeutic effects and complications (according to SIR classification). Assessment was carried out with CT imaging. No severe complications or unexpected side effects were observed after the MWA procedures. In all cases technical success was achieved. Clinical effectiveness was 100%; none of the patients showed recurrence on imaging. In conclusion, our preliminary results support the use of MWA for the treatment of small renal tumors. This technology can be applied in select patients who are not candidates for surgery, as an alternative to other ablative techniques.

Plasma-mediated radiofrequency ablation followed by percutaneous cementoplasty under fluoro-CT guidance: a case report.

We report a case of a 81-year-old Caucasian man with colorectal carcinoma, treated by surgery in 1998, referred for palliative treatment of a refractory painful caused by osteolytic metastases of 2.5 cm in back-upper ilium spine. Plasma-mediated radiofrequency ablation was performed under conscious sedation, using Fluoroscopic Computer Tomography guidance. After completing the ablation phase of the procedure, a mixture of bone cement and Biotrace sterile barium sulfate was injected into the ablated cavity.Patient was evaluated by using the Brief Pain Inventory and considering pain interference with daily living at day 1 and 3 and week 1, 2, 3, 4 by means of a telephone interview. A post-procedure Computer Tomography scan was performed to examine the distribution of cement deposition few minutes after the procedure. The plasma mediated RFA and cementoplasty were well tolerated by the patient who did not develop any complication.

Predictive factors for endoleaks after thoracic aortic aneurysm endograft repair.

BACKGROUND: Our prospective investigation aimed to determine and analyze the incidence and the determinants of endoleaks after thoracic stent graft. METHODS: Sixty-one patients affected by thoracic aortic aneurysms were treated between January 2000 and March 2008. The study cohort contained 54 men, with a mean age of 63.6 +/- 17.9 years. The follow-up imaging protocol included chest radiographs and triple-phase computed tomographic angiography performed at 1, 4, and 12 postoperative months and annually thereafter. RESULTS: Median follow-up was 32.4 months (range: 1-96 months). Endoleaks were detected in 9 (14.7%) patients, of which 7 were type 1. Five endoleaks were detected at 30 postoperative days, and the other 4 developed with a mean delay of 12 months. Endovascular or hybrid interventions were used to treat the endoleaks. Secondary technical success rate was 100%. Multivariate analysis demonstrated that the diameter of the aneurysmal aorta (odds ratio 1.75, 95% confidence interval 1.07-2.86) and the coverage of the left subclavian artery (odds ratio 12.05, 95% confidence interval 1.28-113.30) were independently associated with endoleak development. The percentages of patients in whom reinterventions were unnecessary were 94.6% +/- 3.0%, 88.3% +/- 4.5%, and 85.4% +/- 5.2%, at 1, 2, and 5 years, respectively. The actuarial survival estimates at 1, 2, and 5 years were 85.2% +/- 4.6%, 78.1% +/- 5.4%, and 70.6% +/- 6.4%, respectively. CONCLUSIONS: The diameter of the aneurysmal aorta and the position of the landing zone are independent predictors of endoleak occurrence after thoracic stent-graft procedures. A careful follow-up program should be considered in patients in whom these indices are unfavorable, because most of the endoleaks may be successfully and promptly treated by additional endovascular procedures.

Radiofrequency ablation of abdominal wall endometrioma.

Extraperitoneal endometriosis is the presence of ectopic, functional endometrium outside the peritoneal cavity, and its occurrence is exceedingly rare. Diagnostic imaging--including ultrasound, duplex ultrasonography, and magnetic resonance imaging--in the preoperative assessment of patients with suspected abdominal wall endometriosis (AWE) is helpful for detection and accurate determination of the extent of disease. The treatment of choice for AWE is surgical excision. In addition, medical therapies can be used. We present one case of AWE treated with percutaneous radiofrequency ablation under ultrasound guidance. There were no major complications, and the patient's symptoms improved. In selected patients, radiofrequency ablation can be used safely for the treatment of AWE; however, further studies are needed to confirm this hypothesis.