Evaluation of the Relationships Between Computed Tomography Features, Pathological Findings, and Prognostic Risk Assessment in Gastrointestinal Stromal Tumors.

OBJECTIVES: The aim of this study was to correlate computed tomography (CT) findings with pathology in gastrointestinal stromal tumors (GISTs). METHODS: A retrospective evaluation of CT images of 44 patients with GISTs was performed. Computed tomography findings analyzed were location, size, margins, degree and pattern of contrast enhancement, angiogenesis, necrosis, signs of invasion, peritoneal effusion, peritoneal implants, surface ulceration, and calcifications.Associations between CT features and mitotic rate, Miettinen classes of risk, lesions size, and among CT features were investigated. χ Test and Fisher test were performed. RESULTS: Mitotic rate was associated with margins (P = 0.016) and with adjacent organ invasion (P = 0.043). Pattern of contrast enhancement (P = 0.002), angiogenesis (P = 0.006), necrosis (P = 0.006), invasion of adjacent organs (P = 0.011), and margins (P = 0.006) were associated with classes of risk. Several associations (P < 0.05) between lesion size and CT features and among all the investigated CT features were found. CONCLUSIONS: Computed tomography features could reflect GIST biology being associated with the mitotic rate and with classes of risk.

The role of contrast enhanced computed tomography in the diagnosis of necrotizing fasciitis and comparison with the laboratory risk indicator for necrotizing fasciitis (LRINEC).

PURPOSE: To evaluate the diagnostic efficacy of contrast enhanced computed tomography (CECT) in emergency departments for diagnosis of necrotizing fasciitis (NF) and for differential diagnosis of other musculoskeletal infections; to correlate radiological findings with the laboratory risk indicator for necrotizing fasciitis (LRINEC). MATERIALS AND METHODS: 7 radiological parameters to be analysed on CECT scans were established, exams of 36 patients with proven diagnosis of NF (n 12) and other musculoskeletal infections (n 24) were retrospectively reviewed; LRINEC score was calculated. Fisher's test and Spearman's and Kendall's coefficients of rank correlations were performed. RESULTS: Two parameters were found to be strongly associated with the diagnosis of NF: involvement of the fascia (Spearman's ρ of 0.888, p < 0.001) and lack of fascial enhancement (Spearman's ρ of 0.672, p < 0.001). LRINEC score did not show strong association with the presence of fasciitis NF (Spearman's ρ of 0.490, p = 0.0024). CONCLUSION: Computed tomography (CT) parameters, which are significantly associated with the diagnosis of NF, are the involvement of the fascia and its lack of enhancement; LRINEC score could be high (>5) also in other musculoskeletal infections. Final diagnosis of necrosis among the fascia is surgical. Presence of gas is not a specific sign of necrotizing fasciitis being present in other musculoskeletal infections. CT could easily discriminate NF from other musculoskeletal infections, adds an important value to clinical and laboratory tests in diagnosis of NF in an emergency context when magnetic resonance imaging, which is superior to CT in this discernment, could not be performed.

The Clinical and Radiological Examination of Acute Intimate Partner Violence Injuries: A Retrospective Analysis of an Italian Cohort of Women.

BACKGROUND: Intimate partner violence (IPV) is the most frequent type of violence against women. We compared clinical and radiological IPV characteristics to stranger assault (SA). METHODS: We retrospectively identified 123 women with IPV from court reports and matched them to 124 SA. Clinical and radiological characteristics were evaluated by testing their sensitivity, specificity, positive and negative predictive value for IPV, and the strength of their association with IPV. RESULTS: IPV women referred with more delay to the emergency department (ED), had more ED accesses, and showed more mismatch between reports to the triage and disclosures to the ED physician. They also displayed more head, neck, and face injuries, and new-plus-old fractures. CONCLUSION: The identification of specific features may help ED physicians to suspect IPV.

Radiological contrast media in the breastfeeding woman: a position paper of the Italian Society of Radiology (SIRM), the Italian Society of Paediatrics (SIP), the Italian Society of Neonatology (SIN) and the Task Force on Breastfeeding, Ministry of Health, Italy.

OBJECTIVES: Breastfeeding is a well-recognised investment in the health of the mother-infant dyad. Nevertheless, many professionals still advise breastfeeding mothers to temporarily discontinue breastfeeding after contrast media imaging. Therefore, we performed this review to provide health professionals with basic knowledge and skills for appropriate use of contrast media. METHODS: A joint working group of the Italian Society of Radiology (SIRM), Italian Society of Paediatrics (SIP), Italian Society of Neonatology (SIN) and Task Force on Breastfeeding, Ministry of Health, Italy prepared a review of the relevant medical literature on the safety profile of contrast media for the nursing infant/child. RESULTS: Breastfeeding is safe for the nursing infant of any post-conceptional age after administration of the majority of radiological contrast media to the mother; only gadolinium-based agents considered at high risk of nephrogenic systemic fibrosis (gadopentetate dimeglumine, gadodiamide, gadoversetamide) should be avoided in the breastfeeding woman as a precaution; there is no need to temporarily discontinue breastfeeding or to express and discard breast milk following the administration of contrast media assessed as compatible with breastfeeding. CONCLUSIONS: Breastfeeding women should receive unambiguous professional advice and clear encouragement to continue breastfeeding after imaging with the compatible contrast media. KEY POINTS: • Breastfeeding is a well-known investment in the health of the mother-infant dyad. • Breastfeeding is safe after administration of contrast media to the mother. • There is no need to temporarily discontinue breastfeeding following administration of contrast media.

Gadoxetic acid-enhanced MRI for hepatocellular carcinoma and hypointense nodule observed in the hepatobiliary phase.

PURPOSE: The aim of our study was to evaluate the diagnostic accuracy of gadoxetic acid-enhanced magnetic resonance (MR) imaging both in the detection of hepatocellular carcinoma (HCC) and precancerous lesions and in the assessment of their evolution. MATERIALS AND METHODS: A retrospective study was undertaken on 56 patients with chronic liver disease and suspected liver lesions. We evaluated the number, size and signal intensity of the nodules on dynamic and hepatobiliary MR images. Follow-up studies were carried out every 3 months. Statistical analysis was performed using the Fisher's exact test. RESULTS: A total of 120 nodules were identified in 41 patients. Of these, 92/120 nodules (76.6%; mean diameter 18.4 mm) showed the typical HCC vascular pattern: 90/92 nodules appeared hypointense and 2/92 were hyperintense on hepatobiliary phase images. An additional 28/120 hypointense, nonhypervascular nodules (23.3%; mean diameter 11 mm) were detected on hepatobiliary phase images, 15 of which showed hypointensity also on the equilibrium phase images. During the 3- to 12-month follow-up, 14/28 nodules (mean diameter 13.3 mm) developed the typical vascular pattern of HCC. CONCLUSIONS: Gadoxetic acid-enhanced MR imaging is useful for detecting HCC as well as hypovascular nodules with potential progression to HCC. Lesions measuring more than 10 mm in diameter are at higher risk of developing into HCC (p = 0.0128).

Dual energy CT (DECT) of the liver: conventional versus virtual unenhanced images.

OBJECTIVE: To compare image quality and noise of conventional unenhanced (CU) and virtual unenhanced (VU) images in patients who underwent hepatic dual energy computed tomography (DECT) and to assess potential radiation dose reduction. MATERIALS AND METHODS: Forty consecutive patients were studied. Mean CU and VU image quality and noise were analyzed by two blinded radiologists using a five-point grade scale. The effective radiation dose of a triple-phase protocol (CU, arterial and DE portal phases) were compared with that of a dual-phase protocol (arterial and DE portal phases). RESULTS: No significant difference in mean image quality was observed between VU (3.92 ± 0.85) and CU images (4.20 ± 0.72). A significant difference in mean image noise was observed between VU and CU (P < 0.01). The dose reduction achieved by omitting the unenhanced acquisition was 30.47 ± 7.07% (P < 0.01). In 6 patients, a complete VU liver image was not obtained. CONCLUSIONS: VU images can be obtained with similar image quality as CU. This approach favors a reduction in patient's radiation exposure. Nevertheless, a complete abdominal DECT is possible only in patients with a low body mass index, due technical limitations of the present DECT systems.

A large porocarcinoma of perineal region: MR findings and review of the literature.

We present the case of a 54-year-old woman affected by a large perineal region eccrine porocarcinoma, with a wide local invasion. We discuss the clinical presentation and the imaging findings and review the literature.

Cosa Nostra and the Camorra: Assessment of personality, alexithymic traits, and attachment styles.

The Mafia (Cosa Nostra) and the Camorra are criminal organizations deeply rooted in an immoral familyism in which group interests are protected to the detriment of the individual. The aim of this study was to investigate the presence of personality disorders, alexithymic traits and specific attachment styles in a sample of members belonging to these two different organized crime groups. We carried out two studies adopting two different perspectives. In the first study, we recruited 20 participants (10 members of Cosa Nostra and 10 members of the Camorra) who were serving time in the Augusta (Sicily) prison for crimes they had committed as members of the two Mafia-type organizations. The age of the Cosa Nostra members ranged from 28 to 62 years (M = 47.40, SD = 10.25); the age of the Camorra members ranged from 45 to 68 (M = 55.30, SD = 7.06). We tested personality profiles, attachment styles, alexithymia, and psychopathy and compared the results between the two groups. In this study while we did not find significant differences between the two groups, we were able to identify some discrepancies in a few of the variables analysed. In the second study, we used the Structured Interview of Personality Organization (STIPO) to analyse the personality organization of 10 of 20 participants (5 members of Cosa Nostra and 5 members of Camorra). Analysing the results at the STIPO we found a significant presence of borderline personality organization in both groups. As regards attachment style, we found that Camorra-members' scores high (75°) on the Discomfort with Closeness (related to Avoidant Attachment Style) and Relationship as Secondary factors of the Attachment Style Questionnaire. The Data collected in our study were not sufficient to identify a specific personality disorder or a specific serious psychological condition in the two groups of participants. Nonetheless, thanks to use of the STIPO we were able to determine that in the sample analysed there was not one subject with a psychotic personality organization; we did however find the presence of borderline personality organization and neurotic personality organization in some of the subjects.

Non-Hypervascular Hypointense Nodules at Gadoxetic Acid MRI: Hepatocellular Carcinoma Risk Assessment with Emphasis on the Role of Diffusion-Weighted Imaging.

INTRODUCTION AND AIM: In cirrhotic patients, the characterization of hypovascular nodules, hypointense on hepatobiliary phase gadoxetic acid disodium-enhanced magnetic resonance images (Gd-EOB-DTPA-enhanced MRI), is essential to look for the proper approach strategy. Our objective was to evaluate the imaging features and risk assessment of hypovascular nodules, hypointense on Gd-EOB-DTPA-enhanced MRI, focusing on the diagnostic value of diffusion-weighted imaging (DWI). MATERIAL AND METHODS: This prospective study includes 35 patients with 50 hypovascular hypointense nodules. Signal intensity on T2-weighted images and DWI, vascular pattern on dynamic contrast-enhanced MRI and on hepatobiliary phase, and volume doubling time were analyzed for each nodule as well as patient's clinical features. Univariate and multivariate analyses were made to determine the variables associated with the development of hypervascular pattern. RESULTS: On 24 months follow-up period, 40% of the hypointense nodules (mean size 14 mm ± 6.1) became hypervascular hepatocellular carcinoma (HCC) with 6 and 12 months cumulative risk of 45 and 55%. Nine/12 (75%, mean size 15.50 mm ± 7.2) that appeared hyperintense in DWI at first exam show malignant transformation (p value = 0.007). Univariate and multivariate analyses identified hyperintensity at initial DWI (OR 6.49; 95% CI 1.28-32.80; p value = 0.009) and size ≥10 mm (OR 6.22; 95% CI 1.57-24.63; p value = 0.024) as independent factors with the development of HCC. CONCLUSION: In conclusion, hypovascular lesions ≥10 mm and those hyperintense in DWI were associated with progression to hypervascular HCC. A close follow-up or histological characterization is recommended to improve patients outcome and to develop effective treatment.

Magnetic resonance enterography in Crohn's disease: new simple proposal to assess disease activity.

PURPOSE: The aim is to determine the accuracy of magnetic resonance enterography (MRE) in evaluating Crohn's disease (CD) activity. MATERIALS AND METHODS: Seventy-seven patients with CD underwent MRE. The primary analysis was to determine associations between MRE findings, Harvey-Bradshaw Index, and C-reactive protein (CRP), then we have created a new MRE score that it was also correlated with clinical and laboratory data. RESULTS: MRE score for CD significantly correlates with CRP (P=.003). Significant associations were found between degree of contrast enhancement and CRP (P=.002) and between comb sign and CRP (P=.001). CONCLUSIONS: These results make MRE an important instrument for evaluation of CD activity.

Detection of axillary lymph node metastases in breast cancer with Tc-99m tetrofosmin scintigraphy.

The most important prognostic factor in breast (B) cancer (C) is axillary (A) lymph (L) node (N) status, and virtually all patients with BC undergo ALN dissection to assess N involvement. The aim of this study was to evaluate the accuracy of planar and tomographic Tc-99m tetrofosmin scintigraphy in the detection of ALN involvement in BC. A group of 85 female patients (age range: 31-82 years) with 87 BCs were studied before surgery. Three planar images, right and left prone lateral and supine anterior thoracic views, and 360 degrees supine thoracic single photon emission tomography (SPET) were acquired after Tc-99m tetrofosmin injection (740 MBq i.v.). ALN status was evaluated by histological exam after A dissection: metastatic ALN involvement was proved in 31 out of 87 cases. Sensitivity was 87.1% (27/31) for SPET and 61.3% (19/31) for planar images (p<0.01); specificity was 92.9% (52/56) and 94.6% (53/56), respectively, with a global accuracy of 90.8% (79/87) for SPET and 82.8% (72/87) for planar imaging (p<0.05). Sensitivity rose from 75% in non-palpable Ns to 94.7% in palpable ones for SPET, and from 41.7 to 73.7% for planar scans. SPET was positive in 17/18 (94.4%) patients with >3 metastatic Ns and in 10/13 (76.9%) with < or = 3 involved Ns, whereas planar images were positive in 14/18 (77.8%) and in 5/13 (38.5%) cases, respectively. In conclusion, our findings indicate that Tc-99m tetrofosmin scintigraphy is useful in the presurgical detection of ALN metastases in BC, with SPET more accurate than conventional planar images, thus suggesting its more frequent use in scintimammography; moreover, the total number of histologically involved Ns can affect the scintigraphic results.

Histologic assessment of biliary obstruction with different percutaneous endoluminal techniques.

BACKGROUND: Despite the sophisticated cross sectional image techniques currently available, a number of biliary stenosis or obstructions remain of an uncertain nature. In these pathological conditions, an "intrinsic" parietal alteration is the cause of biliary obstruction and it is very difficult to differentiate benign from malignant lesions using cross-sectional imaging procedures alone. We evaluated the efficacy of different endoluminal techniques to achieve a definitive pathological diagnosis in these situations. METHODS: Eighty patients underwent brushing, and or biopsy of the biliary tree through an existing transhepatic biliary drainage route. A subcoort of 12 patients needed balloon-dilatation of the bile duct and the material covering the balloon surface was also sent for pathological examination (balloon surface sampling). Pathological results were compared with surgical findings or with long-term clinical and instrumental follow-ups. Success rates, sensitivity, specificity, accuracy, confidential intervals, positive predictive value and negative predictive value of the three percutaneous techniques in differentiating benign from malignant disease were assessed.The agreement coefficient of biopsy and brushing with final diagnosis was calculated using the Cohen's "K" value. RESULTS: Fifty-six patients had malignant strictures confirmed by surgery, histology, and by clinical follow-ups. Success rates of brushing, balloon surface sampling, and biopsy were 90.7, 100, and 100%, respectively. The comparative efficacy of brushing, balloon-surface sampling, and biopsy resulted as follows: sensitivity of 47.8, 87.5, and 92.1%, respectively; specificity of 100% for all the techniques; accuracy of 69.2, 91.7 and 93.6%, Positive Predictive Value of 100% for all the procedures and Negative Predictive Value of 55, 80, and 75%, respectively. CONCLUSIONS: Percutaneous endoluminal biopsy is more accurate and sensitive than percutaneous bile duct brushing in the detection of malignant diseases (p < 0.01).

Percutaneous vertebroplasty for pain management in patients with multiple myeloma: is radiofrequency ablation necessary?

PURPOSE: This study was designed to investigate the added role of radiofrequency ablation (RFA) to vertebroplasty on the pain management of patients with multiple myeloma (MM). METHODS: Thirty-six patients (51-82 years) with vertebral localization of MM were randomly divided into two groups: 18 patients (group A) who underwent RFA and then vertebroplasty, and 18 patients (group B) who underwent only vertebroplasty. Primary endpoints were technical success and pain relief score rate measured by the visual analogue pain scores (VAS) and Roland-Morris Questionnaire (RMQ); secondary endpoint was the amount of administered analgesia. Survival and complications were compared. RESULTS: Technical success was 100 % in both groups. The VAS score (at 24 h and 6 weeks postprocedure) decreased in equal manner for both groups from a mean of 9.1-3.4 and 2.0 for group A and from a mean of 9.3-3.0 and 2.3 for group B; RMQ mean score was 19.8 for group A and 19.9 for group B and decreased to a mean of 9.6 and 8.2 for group A and 9.5 and 8.7 for group B. The amount of medication was equally decreased in the two groups. No statistically significant difference was noted. No major complication occurred and two patients died from other causes. CONCLUSIONS: The use of percutaneous vertebroplasty alone appears to be effective for the pain management of the patients with vertebral involvement of multiple myeloma. The use of RFA that includes cost and time does not offer any clear added benefit on the midterm pain management of such patients.

Magnetic resonance cholangiopancreatography with secretin stimulation in the diagnosis of intraductal papillary mucinous neoplasm: a paradigmatic case report.

Context. One of the characteristic findings of intraductal papillary mucinous neoplasms (IPMN) is the presence of a direct communication between the lesion and the ductal pancreatic system and when magnetic resonance cholangiopancreatography (MRCP) shows uncertain findings, it is useful to perform a MRCP after secretin stimulation (MRCP-S) which provides a better visualization of the ductal system. Case Report. We present a case of 51-year-old man in whom, during a CT follow-up for a renal tumour, was found a cystic lesion of the pancreas. To better evaluate the lesion and its suspected communication with the pancreatic system, MR with gadolinium and MRCP and MRCP-S were performed. With the MRCP and MRI it was not possible to identify a clear communication between the cystic lesion and the ductal system. MRCP-S showed an increase in signal intensity of the lesion and its communication with the ductal system, allowing us to classify the cystic lesion as a main duct in intraductal papillary mucinous neoplasm. The patient underwent a surgical duodenal pancreatectomy. The histological result of the specimen confirmed the diagnosis of adenocarcinoma IPMN. Conclusion. In this case MRCP-S has allowed a clearer identification of the cystic lesion allowing a correct diagnosis and treatment.

Accuracy of high-resolution MRI with lumen distention in rectal cancer staging and circumferential margin involvement prediction.

OBJECTIVE: To evaluate the accuracy of magnetic resonance imaging (MRI) with lumen distention for rectal cancer staging and circumferential resection margin (CRM) involvement prediction. MATERIALS AND METHODS: Seventy-three patients with primary rectal cancer underwent high-resolution MRI with a phased-array coil performed using 60-80 mL room air rectal distention, 1-3 weeks before surgery. MRI results were compared to postoperative histopathological findings. The overall MRI T staging accuracy was calculated. CRM involvement prediction and the N staging, the accuracy, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were assessed for each T stage. The agreement between MRI and histological results was assessed using weighted-kappa statistics. RESULTS: The overall MRI accuracy for T staging was 93.6% (k = 0.85). The accuracy, sensitivity, specificity, PPV and NPV for each T stage were as follows: 91.8%, 86.2%, 95.5%, 92.6% and 91.3% for the group ≤ T2; 90.4%, 94.6%, 86.1%, 87.5% and 94% for T3; 98,6%, 85.7%, 100%, 100% and 98.5% for T4, respectively. The predictive CRM accuracy was 94.5% (k = 0.86); the sensitivity, specificity, PPV and NPV were 89.5%, 96.3%, 89.5%, and 96.3% respectively. The N staging accuracy was 68.49% (k = 0.4). CONCLUSION: MRI performed with rectal lumen distention has proved to be an effective technique both for rectal cancer staging and involved CRM predicting.

Reconstruction of the superior vena cava by biologic conduit: assessment of long-term patency by magnetic resonance imaging.

BACKGROUND: To assess the long-term patency of the biologic prosthetic conduit used for reconstruction of the superior vena cava (SVC) by magnetic resonance imaging (MRI). METHODS: Patients undergoing oncologic resection and reconstruction of the SVC by a bovine pericardial prosthesis (January 2003 to April 2010) have been studied after 1 year (if surviving) by MRI for the assessment of the conduit long-term patency. Results were compared with those of a control group of patients with normal SVC. Blood flow and area of lumen section at 3 different levels (proximal, middle, distal) were analyzed. RESULTS: Sixteen consecutive patients surviving after 1 year from surgery out of 17 (9 lung cancer, 8 mediastinal malignancy) undergoing SVC reconstruction were included. One patient died postoperatively and was not included. Sixteen patients with similar demographic characteristics were studied in the control group. Mean blood flow was 18.4±3.5 mL/sec (range 14.3 to 25.7) in patients with reconstructed SVC and 20.8±4.1 mL/sec (range 15.3 to 27.7) in the control group. Mean area of the conduit lumen section was 2.2±0.6 cm2 (range 1.6 to 3.6) at proximal level, 2.9±1.3 cm2 at middle level (range 1.3 to 5.7), and 2.1±0.9 cm2 (range 0.5 to 4) at distal level in the reconstructed group, and 2.6±0.7 cm2 (range 1.8 to 4.2), 2.7±0.7 cm2 (range 1.9 to 4.3), and 2.4±0.3 cm2 (range 1.8 to 3.1), respectively, at proximal, middle, and distal levels in the control group. Differences between the 2 groups were not significant (p>0.05). CONCLUSIONS: The MRI assessment in terms of blood flow and area of lumen section at 3 different levels confirms that bovine pericardial conduit used for SVC replacement shows an optimal patency over the long term.

Oesophageal GIST: MDCT findings of two cases and review of the literature.

INTRODUCTION: The imaging findings of a gastrointestinal stromal tumour (GIST) have been investigated in various studies; however, the features and the pattern of growth of an oesophageal GIST have been described only in a few reports. We present two cases studied by multidetector computed tomography (MDCT) and we review the literature. METHODS: We describe the diagnostic course and the pattern of presentation at MDCT of two GISTs arising from the oesophageal wall that show two different behaviours and prognosis. We review the literature comparing the features of an oesophageal GIST to the more frequent gastric or intestinal GISTs, evaluating the role of MDCT in the diagnosis and in the follow-up. DISCUSSION AND CONCLUSION: Oesophageal GISTs are uncommon, with less than 5% of all reported cases originating from this site of the GI tract. In our experience, the CT features of the two oesophageal GISTs appeared comparable to the imaging findings of the gastrointestinal stromal tumours of the stomach and of the small bowel, as these neoplasms show signs and a pattern of growth that are fairly characteristic. As reported in literature and appear in our experience, MDCT has an important role in the diagnostic course and in staging the disease even if a definitive diagnosis can be only made with the support of an immunohistochemical examination. In addition, MDCT is extremely useful in monitoring patients surgically or pharmacologically treated in order to evaluate the response to the therapy and the possibility of a progression of the disease.

Role of contrast-enhanced ultrasound in the follow-up of endo-vascular aortic aneurysm repair: an effective and safe surveillance method.

The treatment of Aortic Aneurysm disease is a growing procedure due to increase of life expectancy in Western Countries and relative incidence. In the past ten years we observed a progressive growth of endovascular over open surgery procedures with a related decline in rupture related deaths. Endo Vascular Aortic Repair [EVAR] is a well known technique of treatment of abdominal aortic aneurysms, that has changed the surgical approach to abdominal aortic aneurysms, as it is performed with low perioperative morbility and mortality rate and shorter hospital stay. However although EVAR offers immediate advantages over open surgical repair, it carries the need of close lifelong surveillance due to specific possible complications including rupture, endoleaks, graft migration and enlargement of aneurysm sac size. Contrast Enhanced Computed Tomography [CTA] is actually considered the standard reference in EVAR followup. However CTA carries high costs, radiation exposure and potential renal impairment. In the last five years several studies have been published on the role of Contrast Enhanced UltraSound [CEUS] in EVAR follow-up asserting high accuracy of this evaluation technique with absence of renal impairment, without radiation risk and at low costs. Especially since introduction of second generation Contrast Agents this evaluation technique is gaining popularity in EVAR follow-up surveillance. The diffusion of CEUS investigations by using new generation of contrast medium with appropriate software represents without any doubt an important step in the EVAR surveillance and could open up new strategies in the evaluation of endovascular aortic procedures gaining a fundamental role in EVAR follow-up.

Novel approaches for the surgical treatment of atrial fibrillation: time for a guideline revision?

Atrial fibrillation is a major health problem in Western countries, and is associated with considerable morbidity and resource consumption. Safe and reliable surgical techniques for the termination of this arrhythmia have been developed since the time of the original Cox "maze I" procedure. Novel equipment based on radiofrequency and microwave technologies can be employed to create transmural atrial lesions, even in the context of minimally invasive surgery to the atrioventricular valves via right minithoracotomy. The aim of this paper is to review the recent literature on this approach, and the clinical results in terms of arrhythmia termination and postoperative morbidity. With the aim to substantiate the practice of a simple, yet reliable, surgical ablation during minimally invasive heart valve surgery, we discuss the results of different patterns of atrial lesions having different degrees of surgical complexity. Finally, minimally invasive epicardial ablation for lone atrial fibrillation represents an emerging surgical indication. The results of state-of-the-art transcatheter ablation represent now its benchmark of comparison.