[Endovascular treatment for recurrent carotid stenosis]. / Il trattamento endovascolare della restenosi carotidea.

PURPOSE: Surgery of recurrent carotid stenosis (RCS) has higher complication rates than primary carotid endoarterectomy (CEA). Percutaneous transluminal angioplasty (PTA) and stent placement were evaluated retrospectively with a view to proposing then as alternative procedures for RCS. METHODS: In the last 10 years, 19 patients underwent 20 endovascular procedures for RCS at our Department. The mean interval between CEA and PTA was 21 months (range 4-96): 14 patients had PTA within 2 years, 3 patients within 2 and 3 years,and 2 after 3 years. The mean degree of stenosis was 92% (range 80-95%). PTA was performed by balloon catheters (size 4-7 mm) without using cerebral protection device; one self-expanding stent was used to treat RCS after PTA. All patients underwent physical examination and carotid color-coded Doppler sonography in autumn 1999 RESULTS: The procedure was technically successful, with residual stenosis lower than 50%, in 17 of 19 patients; 10 patients showed residual stenosis lower than 30%. Carotid PTA was stopped due to transient neurological deficit in one case. One RCS proved uncompliant even though high-pressure balloon catheters were used. The mean follow-up period in 16 patients was 37.4 months (range 3-99 months). Carotid restenosis after PTA developed in 3 patients, respectively after 29,18 and 7 months. In the last case RCS was successfully treated by stent placement (Wallstent). The primary patency rate was 81%, the secondary patency rate was 88% and the late clinical success rate was of 94%. CONCLUSIONS: In selected cases, PTA without the use of cerebral protection devices and stent placement proved to be a safe and effective alternative treatment for early RCS. When an atherosclerotic lesion is suspected surgery or endovascular treatment with cerebral protection devices are recommended.

Identification of the etiology of primary aldosteronism with adrenal vein sampling in patients with equivocal computed tomography and magnetic resonance findings: results in 104 consecutive cases.

The objectives of this study were to investigate the usefulness of adrenal vein sampling in identifying the etiology of primary aldosteronism (PA) in patients with equivocal CT and MR findings. Between 1990 and 1999, 104 referred hypertensive patients (45 women and 59 men, aged 49.6 +/- 11.6 yr) were diagnosed to have PA with inconclusive computed tomography scan and magnetic resonance results, based on established criteria. Adrenal vein sampling (AVS) for measurement of plasma aldosterone (A) and cortisol (C) levels was performed in all. Selectivity of AVS was assessed by the ratio between C levels in each adrenal vein and in the infrarenal inferior vena cava plasma (C(side)/C(IVC)). A receiver operator characteristics analysis was carried out to establish 1) the best AVS-derived index, 2) the degree of selectivity that could provide an accurate diagnosis, and 3) whether a correct diagnosis could be made from a unilaterally selective AVS. An aldosterone-producing adenoma (average diameter, 12.2 +/- 0.08 mm) was eventually diagnosed in 41 patients (39.4%) and was excluded in the rest. Adrenal vein rupture leading to partial adrenal loss occurred in 1 patient (0.9% complication rate). By assuming a cut-off value of C(side)/C(IVC) > or = 1.1, AVS was selective in 85.7% and 94.1% of cases on the right and left sides, respectively, and bilaterally in 80.6% of cases. Of all AVS-derived indexes, the A/C of one over the A/C contralateral side [(A/C)(side)/(A/C)(contralateral side)] furnished the best diagnostic accuracy. With a bilaterally selective AVS, a value of (A/C)(side)/(A/C)(contralateral side) > or = 2 provided a conclusive etiological diagnosis of PA in 79.7% of cases. At variance, no accurate diagnosis could be made from unilaterally selective AVS. AVS was feasible and safe in most PA patients with inconclusive computed tomography and magnetic resonance scans. When bilaterally selective (i.e. C(side)/C(IVC) > or = 1.1) a ratio of (A/C)(side)/(A/C)(control) > or = 2 provided the best compromise of sensitivity and false positive rate for lateralization of the etiology of PA.

Rectal cancer: CT local staging with histopathologic correlation.

BACKGROUND: Many surgical options, eventually combined with neoadjuvant therapy, are available for the treatment of rectal cancer. Preoperative staging is essential to plan the correct treatment. Our aim was to evaluate the diagnostic accuracy of computed tomography (CT) in the local staging of rectal cancer. METHODS: Between February 1995 and May 2000, 105 patients (65 male, 40 female; mean age = 58, range = 36-88 years) after preoperative locoregional CT staging underwent rectal resection for rectal cancer. In all patients, radiologic T and N staging was verified with pathologic examination of excised specimens. Patients were examined after air insufflation of the ampulla, during intravenous contrast injection; analysis of the rectoanal region was performed with thin (3-5 mm) contiguous slices. For T staging, Tis-T2, T3, and T4 groups were considered. For N staging, two groups of patients were considered: in 52 patients, N+ stage was attributed to all visible lymph nodes; in the other 53 patients, only lymph nodes >5 mm were recorded as N+. RESULTS: Pathologic examination showed 61 T1-T2, 40 T3, and four T4 tumors; CT examination correctly identified 50 T1-T2 (81.9%), 33 T3 (82.5%), and three T4 (75%) lesions. With regard to N stage, pathologic examination in the first group (52 patients) showed only 11 cases of lymph node involvement. CT examination detected all 11 true-positive lymph nodes but overestimated 30 false-positive cases. In the second group (53 patients), pathology showed 26 cases of nodal involvement: CT examination identified 23 true-positive, 19 true-negative, eight false-positive, and three false-negative lymph nodes. CONCLUSION: CT correctly staged 86 (82%) of 105 lesions. Overestimation occurred in T2 patients (11 of 61, 18%) and underestimation in T3 patients (seven of 33, 21%), in accordance with other reports dealing with superior accuracy of endorectal ultrasonography in local staging of early disease. Conversely, the criterion we suggest for evaluating metastatic perirectal lymph nodes (diameter > 5 mm) provided 79.2% diagnostic accuracy, 88.5% sensitivity, and 86.5% negative predictive value. This can be useful in those patients in whom prompt surgery, soon after radiochemotherapy in the case of nodal involvement, may likely be curative. With further improvement with spiral CT in local staging and nodal involvement, a larger number of transanal curative resections can be predicted.

Arterioportal fistulas in patients with liver cirrhosis: usefulness of color Doppler US for screening.

PURPOSE: To evaluate the usefulness of routine ultrasonographic (US) evaluation of the hepatic arterial resistive and pulsatility indexes and of the direction of portal venous blood flow for the diagnosis of intrahepatic arterioportal fistulas (APFs) in patients with liver cirrhosis. MATERIALS AND METHODS: In all patients with cirrhosis examined at one center over 4 years, the resistive (RI) and the pulsatility (PI) indexes in the right and left branches of the hepatic artery were evaluated with Doppler US. An APF was suspected when an RI decrease of at least 20% and a PI decrease of at least 30% were present in one hepatic lobe relative to values in the other lobe and portal blood flow in the lobe with the decreased values was reversed. The RI and PI in patients with an APF were compared with those in 75 patients with cirrhosis and without APFs at angiography. RESULTS: Seven patients with an APF were identified. APFs suspected at Doppler US were always confirmed with angiography. The percent differences +/- SD in the RI and the PI between the two intrahepatic branches of the hepatic artery in patients with versus in patients without an APF were as follows: RI, 35% +/- 6 (range, 27%-42%) versus 5% +/- 4 (range, 0%-15%) (P: <.001); PI, 50% +/- 5 (range, 41%-58%) versus 11% +/- 7 (range, 0%-26%) (P: <.001). CONCLUSION: The intrahepatic arterial resistive and pulsatility indexes and the direction of portal blood flow should be evaluated in routine screening for APFs in patients with liver cirrhosis.

Course of renal function in type 2 diabetic patients with abnormalities of albumin excretion rate.

Heterogeneity in renal structure has been described in type 2 diabetic patients with both microalbuminuria and proteinuria; in fact, only a subset of type 2 diabetic patients have the typical diabetic glomerulopathy. However, it is currently unknown whether abnormalities in albumin excretion rate (AER) have a different renal prognostic value depending on the underlying renal structure. Aims of this study were: 1) to study the course of renal function in type 2 diabetic patients with altered AER; 2) to evaluate the relationship between the course of glomerular filtration rate (GFR) and renal structure; and 3) to evaluate the relationship between the course of GFR and baseline AER levels, metabolic control, and blood pressure levels during a follow-up period of 4 years. A total of 108 type 2 diabetic patients, 74 with microalbuminuria (MA) and 34 with proteinuria (P), were recruited into a prospective study that encompassed: 1) a baseline kidney biopsy with morphometric measurements of glomerular parameters; 2) intensified antihypertensive treatment for an average 4-year period (blood pressure target <140/90 mmHg); and 3) determinations of GFR at baseline and every 6 months. Mean (+/- SD) GFR significantly decreased from baseline in both MA (-1.3+/-9.4 [95% CI -3.51 to +0.86], P < 0.05) and P (-3.0+/-13.0 ml x min(-1) x 1.73 m(-2) per year [-7.71 to +1.61], P < 0.01). However, the changes in GFR were quite heterogeneous. Thus, on the basis of percent GFR change per year from baseline (delta%GFR), both MA and P patients were defined as progressors or nonprogressors when they were below or above the median, respectively. Baseline parameters of glomerular structure had a strong influence on the course of GFR. Indeed, the odds ratios of being progressors significantly increased across the quartiles of baseline glomerular basement membrane (GBM) width and mesangial fractional volume [Vv(mes/glom)], being 2.71 and 2.85 higher, respectively, in the fourth quartile than in the first quartile (P < 0.01 for both). Conversely, nonprogressors outnumbered progressors in the first quartile of GBM width (odds ratio: 2.14, P < 0.05) and in the first quartile of Vv(mes/glom) (odds ratio: 2.28, P < 0.01). Baseline albumin excretion rate (AER) did not influence delta%GFR; in fact, the number of progressors did not increase across quartiles of baseline AER among either MA or P. Similarly, mean blood pressure levels during follow-up (and intensified antihypertensive therapy) did not affect the course of GFR: the number of progressors and nonprogressors did not change across quartiles of mean blood pressure. In contrast, HbA1c during follow-up had an impact on delta%GFR: the odds ratio for being a progressor increased across quartiles of HbA1c, particularly for the highest quartile (HbA1c >9.0%). In conclusion, the course of renal function is heterogeneous in type 2 diabetic patients with microalbuminuria or proteinuria. In fact, a subset of patients has a rapid decline in GFR over a 4-year follow-up period; these patients have more advanced diabetic glomerulopathy and worse metabolic control than the remaining patients, whose GFR remains stable. These two cohorts are otherwise undistinguishable as regards the degree of AER at baseline and tight blood pressure control. Kidney biopsy has an important prognostic role in these patients. Thus, tight blood pressure control, when not associated with satisfactory glycemic control, is unable to prevent rapid GFR decline in type 2 diabetic patients with typical diabetic glomerulopathy.

Transcatheter arterial chemoembolization for hepatocellular carcinoma in patients with Child's grade A or B cirrhosis: a multivariate analysis of prognostic factors.

We evaluated factors affecting long-term survival after transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) complicating cirrhosis. One hundred eighty-two patients with Child's class A or B cirrhosis and an HCC, not amenable to surgery or percutaneous ethanol injection, underwent 346 TACEs (mean 1.9) with epirubicin, iodized oil, and gelatin sponge. Many prognostic factors were subjected to univariate analysis and thereafter, when significant, to the Cox's hazard proportional model. Finally, the significant indices in the Cox's model were used to estimate the accuracy of the probability of death with computation of the area under the receiving operative characteristic (ROC) curve. The cumulative survival rates at 1, 2, 3, and 5 years were 0.83, 0.52, 0.40, and 0.16, respectively. According to Cox's model, the factors associated with significantly worse survival were the presence of ascites (p = 0.0027), elevated bilirubin levels (p = 0.0163), elevated alpha-fetoprotein (alphaFP) values (p = 0.0067), a tumor greater than 5 cm in diameter (p = 0.0001), and the absence of a tumor capsule-like rim (p = 0.0278). According to these parameters, the accuracy of the probability of death estimated with ROC analysis was 0.63. Minor and major complications occurred in 82 patients (45%) and caused death in 2 patients. Long-term prognosis after TACE for HCCs in patients with Child's class A or B cirrhosis depends on the presence of ascites, the bilirubin level, the alphaFP value, the diameter of the tumor, and the presence of a tumor capsule-like rim. However, when considered altogether, these variables are poor predictors to evaluate survival, and other factors should be investigated to identify subjects more responsive to TACE. Complications occur in a high percentage of patients, but they do not affect long-term prognosis.

Congenital absence of the portal vein associated with focal nodular hyperplasia of the liver and cystic dysplasia of the kidney.

Congenital absence of portal vein is a rare malformation. To date, 16 cases have been reported--all in association with other anomalies, i.e. benign or malignant hepatic neoplasms in 6 cases and cardiac malformations in 12. This case report described a girl with congenital absence of portal vein, focal nodular hyperplasia of the liver and cystic kidney dysplasia. Angiography showed the splenic vein and superior mesenteric vein joining to form a common trunk that entered the inferior vena cava directly above the liver. A review of the other cases in the literature is provided and the clinical aspects of our patient are discussed.

[Long-term results of chemoembolization for hepatocarcinoma]. / Risultati a lungo termine della chemioembolizzazione nell'epatocarcinoma.

We reviewed the long-term results of transcatheter arterial chemoembolization in the treatment of inoperable hepatocellular carcinoma (HCC) complicating cirrhosis; the survival analysis was used to assess the clinical efficacy of the procedure. Several chemoembolization protocols are discussed because no standard treatment exists. Literature data show cumulative survival rates after chemoembolization for an HCC to range 60% to 80% at one year and 40% to 50% at two years; comparative studies, although contradictory, show a trend of chemoembolization to prolong survival in patients with inoperable carcinoma. The main prognostic factors are tumor size and extent, liver function impairment, the grade of Lipiodol tumor uptake, and the tumor response to therapy. The complication rates of chemoembolization vary largely in the literature, mainly because of the different standards used to define adverse events. Chemoembolization morbility rate is usually high, ranging 20% to 55%, but most complications are generally well treated with conservative management. The mortality rate is usually very low and well acceptable for a palliative anticancer therapy. In conclusion, chemoembolization is clinically effective in prolonging survival in cirrhotic patients with HCC; the lack of any reliable alternative therapy makes chemoembolization play a major role in the treatment of HCC when surgery or percutaneous ethanol injection are unfeasible.

Short-term effects of transcatheter arterial chemoembolisation on metabolic activity of the liver of cirrhotic patients with hepatocellular carcinoma.

BACKGROUND: Transcatheter arterial chemoembolisation, a procedure for the treatment of hepatocellular carcinoma, provokes a pronounced but transient increase in hepatic cytolysis parameters. A definite evaluation of the impairment of liver function after this treatment, performed by adequate techniques, is still lacking. AIMS: To assess and quantify the impairment of liver metabolic activity after arterial chemoembolisation in patients with cirrhosis. The variations of hepatic vein pressure gradient provoked by this procedure were evaluated. PATIENTS: 15 patients with cirrhosis (Child's class A and B) and hepatocellular carcinoma. METHODS: 17 transcatheter arterial chemoembolisations with epirubicin, iodised oil, and gelfoam were performed; liver function was assessed before, the following day, and after seven days measuring galactose elimination capacity; aminopyrine breath test was also performed in six patients before the procedure and seven days after. In 10 patients intrinsic hepatic clearance of indocyanine green and hepatic vein pressure gradient were measured by hepatic vein catheterisation before and 30 minutes after chemoembolisation. RESULTS: Intrinsic hepatic clearance of indocyanine green decreased significantly from (mean (SEM)) 355 (140) ml/min to 277 (98) ml/min after the procedure (p = 0.0007). Galactose elimination capacity did not show significant changes, being 4.00 (0.90) mg/min/kg body weight at baseline, 4.20 (0.90) mg/min/kg body weight after one day, and 3.95 (0.87) mg/min/kg body weight seven days after chemoembolisation. Aminopyrine breath test was 2.31 (1.09)% and remained unchanged after treatment, being 2.39 (2.04)% at day 7. Baseline hepatic vein pressure gradient was 17.0 (5.5) mm Hg, and 14.4 (3.7) mm Hg 30 minutes after chemoembolisation (p = 0.09). CONCLUSIONS: A single transcatheter chemoembolisation in cirrhotic patients was detected by galactose elimination capacity and aminopyrine breath test one and seven days after the procedure. Therefore it can be considered a safe therapeutic tool for hepatocellular carcinoma in Child's class A and B cirrhotic patients.

[The preoperative chemoembolization of hepatocarcinoma due to cirrhosis]. / La chemioembolizzazione preoperatoria dell'epatocarcinoma su cirrosi.

PURPOSE: To investigate clinical value and tumor response of preoperative transcatheter arterial chemoembolization for hepatocellular carcinoma (HCC) secondary to cirrhosis. MATERIALS AND METHODS: The clinical, radiologic and histologic findings were reviewed relative to 13 cirrhotic patients operated on for HCC after chemoembolization with an emulsion of Lipiodol UF and epirubucin; additional gel-foam embolization was performed in 12 cases. RESULTS: The mean survival was 24 months. Three patients died within 1 month after surgery; 2 other patients died 10 and 32 months after surgery, respectively. The 2-year recurrence rate was 40%. Tumor size, the grade of iodized oil retention and the embolization technique affected primary tumor necrosis ratio: most of satellite nodules and capsular invasions were persistently viable at histology. CONCLUSIONS: Preoperative chemoembolization neither facilitates, nor contraindicates, HCC surgery. Nevertheless, chemoembolization should always be performed before surgery first to stage the patients with Lipiodol CT and second to administer the first palliation whenever the patient is ineligible for surgery.

Bronchocentric granulomatosis and central diabetes insipidus successfully treated with corticosteroids.

Bronchocentric granulomatosis (BCG) is a rare chronic granulomatous lung disease that leads to destruction of the airway walls. It has been observed in association with various conditions, but never, so far, been reported to involve the central nervous system. We report a case of histologically confirmed pulmonary bronchocentric granulomatosis temporally associated with a partial central diabetes insipidus (CDI). Although the pathological basis of the posterior pituitary gland involvement was not ascertained, the temporal association of bronchocentric granulomatosis and central diabetes insipidus, as well as the fact that corticosteroid treatment provided stable remission of both conditions after a 10 month follow-up, strongly suggest that central diabetes insipidus was aetiologically related to bronchocentric granulomatosis in this patient.

Excess prevalence of supraaortic artery lesions in renovascular hypertension: an arteriographic study.

PURPOSE: High renin or renovascular hypertension (RVH) has been associated with a higher risk of stroke than low-to-normal renin hypertension. Our present purpose was to investigate the angiographic prevalence and distribution of lesions of the supraaortic arteries in a series of consecutive patients with RVH compared with control patients with low-to-normal renin primary hypertension (PH). METHODS: Thirty-two consecutive hypertensives (21 females, 11 males, aged 23-72 years) were investigated by renal and aortic arch digital subtraction arteriography (DSA). None of them had any history or symptoms of cerebrovascular disease. In each, the presence and severity of lesions at 17 different segments of the supraaortic arteries were evaluated and a score for supraaortic lesions was then calculated based on the number and severity of lesions. RVH was diagnosed in 16 patients with renal artery stenoses and normalization of blood pressure after percutaneous transluminal renal angioplasty (PTRA) (n = 12) or surgery (n = 4). The cause of renal artery obstruction was fibrodysplasia in 5 patients (31%) and atherosclerosis in 11 (69%). PH was diagnosed in 16 patients based on a normal renal DSA and exclusion of all other possible causes of hypertension. RESULTS: The RVH and PH groups were similar with respect to age, sex, body mass index, diabetes, smoking habits, serum triglycerides, cholesterol, and blood pressure values, and differed only in plasma renin activity (6.0 +/- 1.7 ng AngI/ml/h in RVH vs. 1.4 +/- 0.3 in PH, mean +/- SEM, p = 0.008). The score for supraaortic arterial lesions was significantly higher in RVH than in PH (181 +/- 32 vs. 17 +/- 9, p = 0.001). This difference was also evident when the five patients with fibrodysplasia were compared with five age- and sex-matched PH patients. The sites most frequently involved were the carotid artery bulb and the internal carotid artery sinus. At each affected site the score was higher for RVH than for PH. CONCLUSION: For the same demographic features and risk profile, RVH was associated with a higher prevalence and severity of supraaortic artery lesions than PH.

Arterial complications of pancreatitis: diagnostic and therapeutic role of radiology.

Hemorrhage from pseudoaneurysm complicating pancreatitis is an infrequent but very severe condition. In most cases, acute, massive gastrointestinal bleeding is typical at onset, and prognosis of these cases is usually poor. Nine cases of arterial lesions secondary to pancreatic inflammation are presented, eight related to chronic pancreatitis and one to acute postoperative pancreatitis. Five patients were evaluated during emergency episodes because of acutely gastrointestinal bleeding (four cases), and pseudocyst acute bleeding (one case). Four patients were selectively evaluated: three had a history of self-limiting gastrointestinal hemorrhage, whereas one had experienced no episodes of gastrointestinal hemorrhage. Angiography was performed in all cases and was always diagnostic, even in the two cases of very small pseudoaneurysms. Transcatheter arterial blockade was attempted in five patients and failed to control the hemorrhage in one acutely bleeding patient because of irreversible shock. Two cases of pancreatic hemorrhage not related to a pseudocyst were effectively and permanently treated by embolization. A case of a pseudoaneurysm associated with a pseudocyst required surgery in addition to embolization for a definite treatment. Nevertheless, when a pseudoaneurysm or a pseudocyst hemorrhages acutely, transcatheter arterial blockade can control the hemorrhage and improve the hemodynamic status of the patient before surgery.

Necrosis of a phaeochromocytoma associated with spontaneous remission of diabetes and hypertension.

The diagnosis of phaeochromocytoma is sometimes difficult since its clinical presentation is quite variable. We report a 52-year-old woman who presented with acute diabetes mellitus and severe hypertension, which spontaneously disappeared. MIBG-scintigraphy and urine and plasma catecholamines were normal. At surgery, a largely necrotic phaeochromocytoma was found. Pathological examination demonstrated extensive avascular necrosis, which had occurred spontaneously without any major symptoms.

Imaging of aldosterone-secreting adenomas: a prospective comparison of computed tomography and magnetic resonance imaging in 27 patients with suspected primary aldosteronism.

We have compared prospectively the sensitivity, specificity and accuracy of CT and MRI in a series of 27 consecutive patients (age 23-76 yrs, 17 females, 10 males) with clinically suspected primary aldosteronism. We found 13 patients with a unilateral aldosterone-producing adenoma (11 on the left and 2 on the right side), 6 with idiopathic hyper-aldosteronism and 8 with primary hypertension, which in two cases was associated with a nonfunctioning adrenal adenoma. The diagnosis of aldosterone-producing adenoma was confirmed at surgery and pathology in all cases. Idiopathic hyper-aldosteronism was diagnosed on the basis of the results of dexamethasone-suppressed adrenal scintigraphy and/or selective adrenal vein sampling. MRI correctly identified all cases of aldosterone-producing adenoma, but gave false positive results in five cases: one had idiopathic hyper-aldosteronism with bilateral nodular hyperplasia and four primary hypertension, which in two patients was associated with a nonfunctioning adrenal adenoma. Therefore, the sensitivity of MRI was 100%, its specificity 64% and overall diagnostic accuracy 81%. In comparison, CT correctly recognized only eight of the 13 patients with aldosterone-producing adenoma and gave false positive results in three primary hypertensives, including the two patients with a nonfunctioning adrenal adenoma. Therefore, its sensitivity, specificity and accuracy were 62, 77 and 69%, respectively. Based on these results, it could be anticipated that about four of every ten patients with aldosterone-producing adenoma would not be correctly diagnosed by CT.(ABSTRACT TRUNCATED AT 250 WORDS)

Palliative treatment of hepatocellular carcinoma with transcatheter arterial embolization.

Thirty-three consecutive patients with previously untreated hepatocellular carcinoma (HCC) and 6 patients with recurrent HCC were treated with transcatheter arterial embolization (TAE). The patients were not eligible for surgical resection or percutaneous ethanol injection. TAE was performed with Lipiodol Ultra-Fluid, epidoxorubicin and Gelfoam, with a mean of 1.7 treatments per patient. CT was performed 15 days after TAE. The mean cumulative survival was 14.2 months in patients with previously untreated HCC. The survival of patients stages Okuda I and II did not differ significantly (p > 0.05); tumor size did not affect survival (p > 0.05). Two patients with recurrent HCC died 7.0 and 9.3 months after the diagnosis of tumor recurrence; the remaining 4 patients are still alive with a maximum follow-up of 22.5 months from the diagnosis of HCC recurrence. Ten complications occurred in 8 patients, and were controlled by medical therapy. Eleven patients died during the study; no death was related to TAE. The series was not randomized, but comparison with the natural history of HCC suggests that TAE is effective as palliative treatment of advanced or recurrent HCC.

[Chemoembolization in the therapy of hepatocarcinoma. A 3-year experience]. / La chemioembolizzazione nella terapia dell'epatocarcinoma. Esperienza di 3 anni.

This study was aimed at evaluating the efficacy of chemoembolization (CE) to improve survival in patients with hepatocellular carcinoma (HCC). Our results were compared with the natural history of HCC. Sixty-two consecutive patients with HCC in Okuda's stages I and II underwent CE. Forty-seven patients were treated with CE alone; 9 patients had CE prior to surgery, and 6 patients had it after surgery because of recurrent HCC. One hundred and nine CEs (mean: 1.8 CEs/patient) were performed with Lipiodol UF, epirubicin and gelatin sponge. Actuarial survival was calculated considering Okuda's stage, neoplasm size, and evidence of pseudocapsule. The mean cumulative survival of the 47 patients treated with CE alone was 13.2 months; survival (+/- SE) at 12, 24 and 36 months was 0.75 (+/- 0.07), 0.46 (+/- 0.10) and 0.28 (+/- 0.12). Survival was not affected by Okuda's stage, neoplasm size, evidence of pseudocapsule (p > 0.05). Nevertheless, the patients with early HCC had better prognosis. Eighteen patients (42.9%) died during follow-up, 12 of whom (66.7%) from hepatic failure. The mean survival of patients with recurrence of HCC after surgery was 41 months (range: 24.8-74.9 months) since initial diagnosis of HCC, and 14.8 months (range: 7.1-29.6 months) since diagnosis of recurrence. Two of these patients died from hepatic failure. All the patients who underwent also surgery after CE are still alive (mean survival: 14.7 months). Histologic findings of resected specimens revealed viable neoplastic cells in all cases. Twenty-one major complications (20.2%) occurred in 18 patients (29%); the outcome of complications was favorable in all but one patient who died from sepsis. CE is a reliable and safe treatment for unresectable HCC. Small HCCs should be preferably treated with surgery or, alternatively, with percutaneous alcohol injection.

Cerebral ischemia due to congenital malformations of brachiocephalic arteries--case reports.

Seven cases of congenital anomalies of brachiocephalic arteries are presented; malformations include unilateral absence of the internal carotid artery (ICA) (n = 3), unilateral hypoplasia of the ICA (n = 2), agenesis of the innominate artery (n = 1), and atresia of the subclavian artery (n = 1). All patients but 1 exhibited symptoms of cerebrovascular insufficiency at the time of radiologic investigation; they were not affected by other cardiovascular malformations, except right aortic arch in 2 cases and left cervical arch in another case. Two patients suffering from congenital subclavian steal syndrome underwent surgery to correct the vascular malformations. Embryogenesis and natural history of such malformations are briefly discussed.

[Indications for revascularization procedures in patients with intermittent claudication]. / Indicazioni all'intervento di rivascolarizzazione nei pazienti con claudicatio intermittens.

Patients suffering from arteriosclerotic obliterating disease of the lower limbs that present with symptoms of rest pain, ulcers or more or less severe gangrene are considered as candidates for revascularization operation. Apart from the possible non relevance of individual symptoms, in some instances the revascularization operation is indicated solely on the basis of the angiographic evidence. Ascending thrombosis of the abdominal aorta, double or triple blocks, stenosis of the collateral circulation and, broadly speaking, any other situation that suggests a possible superimposition of an episode of acute ischaemia due to thrombosis in a condition of chronic obliterating arteriopathy are considered as absolute indication for revascularization operation. Patients whose conditions are not listed above are considered as stage II and indication for operation in this case is not absolute but relative or "luxury" since its purpose is only to improve the quality of life. The importance of the symptoms must be considered along with other factors, including the personal, social, working, sporting and psychological needs of the specific individual apart from the absence of general risks related to the patient's condition. The vascular surgeon's expertise is obviously fundamental in exactly evaluating the arteriography and in understanding the precise anatomic picture that varies in every single case: in fact, since the operation is optional and not a necessity, correction of the arterial lesions in only advisable when it is possible to carry out and operation that is broadly risk free and with good short and long term results, with reference to the patient's life expectancy.

Obstructive jaundice in Kawasaki's disease.

We describe a case of Kawasaki's disease in a 10-year-old child who had obstructive jaundice, intrahepatic biliary duct dilatation and gallbladder hydrops. The diagnosis was defined by echography, CT-scan and cholangiography. Immediate relief from symptoms and progressive resolution of jaundice was achieved by percutaneous transhepatic biliary drainage (PTBD). Laparotomy was avoided.