Embo-EVAR: A Technique to Prevent Type II Endoleak? A Single-Center Experience.

BACKGROUND: Intraprocedural aneurysm sac embolization (embo-EVAR) during endovascular abdominal aneurysm repair (EVAR) using coils and fibrin glue is a technique for preventing type II endoleak (EII). Our aim is to evaluate feasibility, safety and clinical outcome of this promising approach. MATERIALS AND METHODS: A retrospective clinical case analysis of 72 patients who underwent EVAR during the period 2011-2014. Two groups were compared at 6 and 12 months follow-up with contrast media computed tomography scan and contrast-enhanced ultrasound (CEUS) imaging: consecutively, 36 patients (group A) treated with classic EVAR and 36 patients (group B) treated with embo-EVAR. Coils were released filling better as possible the aneurysm sac; the embolization was completed by injecting fibrin glue. Device and materials used, differential systemic and sac pressures, presence of any endoleak, and complication were registered. RESULTS: In our experience, we had 100% technical success without surgical conversion. Embo-EVAR was performed, after endograft deployment, in group B patients, all with ratio of Δ-pressures (obtained from Δ-sac pressure/Δ-differential pressure) > 0.16. No early or late complications occurred and mortality was nil. Follow-up was performed with computed tomography-angiography and CEUS at 6 and 12 months. We observed 9 type II and 1 type Ia endoleak in group A and 2 type II and 1 type Ib endoleaks in group B. Mean radiation exposure time was 30.3 min in group A and 43.3 min in group B. EVAR procedure average cost was 9,000 €. The average cost of sac embolization was 1,500€. CONCLUSIONS: Although a randomized study is necessary, embo-EVAR may be a valid approach to prevent type II endoleaks and further complications. Mild costs and exposure-dose increase could be accepted to avoid reinterventions, and in our experience, it could be routinely performed with excellent results.

The Italian Registry of Endovascular Treatment in Acute Stroke: rationale, design and baseline features of patients.

Endovascular treatment (ET) showed to be safe in acute stroke, but its superiority over intravenous thrombolysis is debated. As ET is rapidly evolving, it is not clear which role it may deserve in the future of stoke treatments. Based on an observational design, a treatment registry allows to study a broad range of patients, turning into a powerful tool for patients' selection. We report the methodology and a descriptive analysis of patients from a national registry of ET for stroke. The Italian Registry of Endovascular Treatment in Acute Stroke is a multicenter, observational registry running in Italy from 2010. All patients treated with ET in the participating centers were consecutively recorded. Safety measures were symptomatic intracranial hemorrhage, procedural adverse events and death rate. Efficacy measures were arterial recanalization and 3-month good functional outcome. From 2008 to 2012, 960 patients were treated in 25 centers. Median age was 67 years, male gender 57 %. Median baseline NIHSS was 17. The most frequent occlusion site was Middle cerebral artery (46.9 %). Intra-arterial thrombolytics were used in 165 (17.9 %) patients, in 531 (57.5 %) thrombectomy was employed, and 228 (24.7 %) patients received both treatments. Baseline features of this cohort are in line with data from large clinical series and recent trials. This registry allows to collect data from a real practice scenario and to highlight time trends in treatment modalities. It can address unsolved safety and efficacy issues on ET of stroke, providing a useful tool for the planning of new trials.

Epidemiology of stroke in northern Italy: the Cerebrovascular Aosta Registry, 2004-2008.

Our aim was to prospectively ascertain the incidence of first-ever stroke and ischaemic stroke subtypes, mortality, functional outcome and recurrence in northern Italy. We identified all possible cases of stroke (1st January 2004 and 31st December 2008). Multiple overlapping sources were used. Standard definitions for incident cases, pathological types and infarction subtypes were used. Patient characteristics were identified and analysed, case-fatality was ascertained from administrative databases, and outcome was assessed in all surviving patients by modified Rankin Scale. We identified 1,326 incident strokes. The pathological diagnosis was confirmed in 94% of cases. The incidence of first-ever stroke was 80.2 per 100,000 (95% CI 73-87) when adjusted to world population. The incidence of embolic stroke was significantly greater in women than in men (p < 0.001) whereas the incidence of atherothrombotic stroke was significantly greater in men than in women (p < 0.001). The case-fatality of incident strokes was 9.5% at 7 day, 16.1% at 28 day, and 29.9% at 1 year. Case-fatality of ischaemic stroke was lower than that of other pathological types (p < 0.0001). Hypertension was the most important risk factor, and atrial fibrillation was the most common in embolic stroke. Increasing age, female gender and embolic stroke subtypes were associated with an adverse outcome. Data on stroke incidence and case-fatality were similar to those of other high-income countries. However, differences were found in the distribution of risk factors and prognosis across the stroke types and ischaemic stroke subtypes. Gender differences in long-term functional outcomes were significant.

Treatment of juxtarenal aortic aneurysm with the Multilayer stent.

PURPOSE: To report the use of a new type of uncovered stent to treat aortic aneurysms. CASE REPORT: Under compassionate use, an 81-year-old man with multiple comorbidities and an expanding 63-mm juxtarenal abdominal aortic aneurysm was treated with a 28×100-mm Multilayer flow-modulating stent. Immediately, the blood flow velocity inside the aneurysm sac appeared reduced on fluoroscopy. All aortic branches covered by the stent (celiac trunk, superior mesenteric artery, and renal arteries) remained patent. Serial computed tomography at up to 12 months has shown excellent stent and visceral artery patency and progressive reduction in the sac diameter (58 mm) and volume (84.9 cm(3) to 82.8 cm(3)). CONCLUSION: This case shows that the use of an uncovered multilayer stent reduces the flow in the aneurysm but preserves perfusion of the branch arteries, which is impossible with covered stents.

Interventional radiology at a single institution over 9 years: a comprehensive evaluation of procedures and an estimation of collective effective dose.

PURPOSE: To investigate the exposure parameters, effective dose, frequency, and collective dose for interventional radiology (IR) procedures performed at a single institution during a 9-year period. MATERIALS AND METHODS: According to the anatomic region imaged, seven diagnostic and 16 therapeutic IR procedures performed between 2002 and 2010 were retrospectively investigated with regard to exposure setting parameters and frequency. Dose-area products (DAPs), cumulative doses (CDs), and irradiation time values were analyzed on a sample of 1,100 examinations. DAP distributions (median, mean, and percentiles) were adjunctively determined by using bootstrap resampling in PCXMC software to estimate patient effective dose. Data provided by the Radiological Information System allowed collective effective and per-capita doses to obtained. RESULTS: The exposure parameters showed widespread variability. The median DAP values for pelvic arteriography and pelvic arterial angioplasty/stent placement were 10,015 and 19,424 cGy·cm(2), respectively. For the 23 procedures studied, the estimated average per-procedure effective dose ranged from 0.34 to 104.9 mSv. The pelvis (37%) was the region most often imaged in diagnostic procedures, and angioplasty/stent treatment of vessels was the most frequently performed therapeutic procedure (44%). During the study period, IR procedures increased in frequency (+137%), with a consequent increase in the per-capita dose (0.172 to 0.461 mSv) and collective dose (21 to 58 man-Sv/y). CONCLUSIONS: A comprehensive Monte Carlo-aided analysis, which allowed evaluation of contributions in terms of per-procedure and collective doses to the population for the practice of IR, showed a significant growth rate during the study period.

Criteria and scheduling of quality control of B-mode and doppler ultrasonography equipment.

Periodic quality control (QC) for ultrasound scanners checks their overall performance, reducing the risk of inaccurate diagnoses. Data from routine annual QC activity were analyzed to optimize the scheduling and the criteria of further QC programs. Among all the ultrasound scanners (68 transducers) in use at the Regional Medical Department of the Aosta Valley, which are currently tested, 48.6% showed problems, mainly (35.3%) related to defects detectable by physical and mechanical inspection. Nearly two-thirds of these problems impacted QC parameters. Failures were significantly related to the workload and to the "technological level" of the equipment. QC scheduling should therefore include a daily/weekly physical inspection in addition to a more complete, objective and software algorithms-based test, the frequency of which should be tailored on the basis of the equipment characteristics. © 2012 Wiley Periodicals, Inc. J Clin Ultrasound, 2012.

Community-based study of stroke incidence in the Valley of Aosta, Italy. CARe-cerebrovascular Aosta Registry: years 2004-2005.

The purpose of our study was to determine the incidence of stroke, case-fatality rate and disability at 1 year in the Valley of Aosta (Italy) in the years 2004 and 2005. All suspected strokes occurring between January 1, 2004, and December 31, 2005, in the resident population of the Valley of Aosta were identified according to the WHO criteria for stroke and included in a stroke registry (Cerebrovascular Aosta Registry, CARe) after revision by a clinical panel. Multiple overlapping sources were used to ascertain the cases. In the study period, 553 incident strokes were registered. A CT scan was performed in 94.2% of cases. The crude annual incidence rate was 223 (95% CI 197-249) per 100,000 inhabitants. After age and sex adjustment to the 'European' population, the stroke incidence rate was 126 (95% CI 106-146). In the 1-year follow-up, only a small number of patients with a first-ever stroke in their life time suffered a new event. Compared with the previous study performed in our region (Valley of Aosta) in 1989, a marked decline in the incidence rate was seen after adjustment to the 'European' population, and the 28-day case-fatality rate declined dramatically between 1989 and 2004-2005.

The contribution of interventional cardiology procedures to the population radiation dose in a 'health-care level I' representative region.

This study evaluates per-procedure, collective and per capita effective dose to the population by interventional cardiology (IC) procedures performed during 2002-11 at the main hospital of Aosta Valley Region that can be considered as representative of the health-care level I countries, as defined by the UNSCEAR, based on its socio-demographic characteristics. IC procedures investigated were often multiple procedures in patients older than 60 y. The median extreme dose-area product values of 300 and 22 908 cGycm(2) were found for standard pacemaker implantation and coronary angioplasty, respectively, while the relative mean per-procedure effective dose ranged from 0.7 to 47 mSv. A 3-fold increase in frequency has been observed together with a correlated increase in the delivered per capita dose (0.05-0.27 mSv y(-1)) and the collective dose (5.8-35 man Sv y(-1)). Doses increased particularly from 2008 onwards mainly because of the introduction of coronary angioplasty procedures in the authors' institution. IC practice contributed remarkably in terms of effective dose to the population, delivering ∼10% of the total dose by medical ionising radiation examination categories.

TomoDirect: an efficient means to deliver radiation at static angles with tomotherapy.

AIMS AND BACKGROUND: The TomoTherapy Hi-Art II system is able to deliver dynamic intensity-modulated radiation therapy within a helical geometry providing robust conformality and modulation, abrupt dose falloff, and reliable accuracy. A new upgrade named TomoDirect was introduced recently, allowing delivery of radiation at discrete angles with a fixed gantry. We present our preliminary clinical experience with TomoDirect. METHODS: Three specific clinical contexts were chosen for the implementation of TomoDirect, namely palliation of bone metastasis pain (BP), whole brain radiation therapy for intracranial secondary lesions (WBRT), and adjuvant whole breast radiation therapy after conservative surgery for early stage breast cancer (AWBRT). After appropriate positioning, planning CT, contouring, and plan generation, all patients were treated with the TomoDirect upgrade of the TomoTherapy Hi-Art II system with different doses and fractionation according to clinical decision-making. RESULTS: Between May and December 2010, 41 patients were treated with TomoDirect. Eighteen patients were treated for BP (mainly vertebral metastases) with a predominant posterior field arrangement. Seven patients were treated for WBRT (multiple brain lesions) with a parallel-opposed latero-lateral approach and 16 patients were treated for conventionally fractionated AWBRT mainly with a 2-field tangential approach. Radiation treatments were generally well tolerated and the acute toxicity was mild. CONCLUSIONS: While helical tomotherapy allows the delivery of very sophisticated treatment plans, in certain anatomical sites and clinical contexts where the number of beam directions is constrained and supposed not to affect plan quality, TomoDirect might be an efficient means to deliver radiation at static angles with consistent dosimetric and clinical results.