Endovascular Treatment of Visceral Artery Pseudoaneurysms in Patients with Chronic Pancreatitis: Our Single-Center Experience.

BACKGROUND: To analyze our experience in endovascular treatment as first-line approach for severe and acute hemorrhage in patients with chronic pancreatitis. METHODS: From 2010 to 2016 at our institution, 12 males (mean age 66 years) with bleeding pseudoaneurysms (PSAs) underwent urgent visceral angiography and endovascular treatment. All patients had chronic pancreatitis. True visceral artery aneurysms and PSAs arising after surgery were excluded from the study. RESULTS: Pancreatitis was caused by alcohol abuse in 9 (9/12, 75%) patients and biliary lithiasis in 3 (3/12, 25%). Involved arteries were gastroduodenal (5/12, 50%), splenic (2/12, 16%), common hepatic (2/12, 16%), middle colic (1/12, 9%), and celiac trunk (1/12, 9%). All patients underwent computed tomography angiography (CTA) scan and visceral angiography followed by endovascular treatment using different devices. Technical success rate was 100%. Bleeding was stopped in all patients, and no one required reembolization. No major complications occurred. There were 2 complications associated with the endovascular procedure: in one case, a coil migration and in another case, in-stent restenosis at 6 months. Follow-up included CTA performed during hospitalization and at 6 months after the procedure. CONCLUSIONS: Our experience confirms the role of CTA and visceral angiography as diagnostic and therapeutic tool, respectively.

Celiac Trunk Mycotic Aneurysm: Diagnosis and Treatment of a Post-infective Endocarditis Complication.

Pseudoaneurysms could be the dynamic evolution of an infectious break in the arterial wall; in the post-antibiotic era they are uncommon complication following infective endocarditis (IE) and are associated with high rates of morbidity and mortality especially for patients in whom a prompt diagnosis and therapeutic strategy are not performed. In this report, we describe a case of pseudoaneurysm of the celiac trunk developed as a complication of IE. Endovascular treatment is our first-line approach.

Magnetic Resonance Assessment of Peritoneal Carcinomatosis: Is There a True Benefit From Diffusion-Weighted Imaging?

PURPOSE: To assess the added value of diffusion weighted imaging (DWI) with intermediate (500 s/mm2) and high (1000 s/mm2) b values when combined to conventional contrast-enhanced magnetic resonance imaging (MRI) in identifying peritoneal neoplastic involvement. METHODS: Twenty-four patients with peritoneal carcinomatosis from gastrointestinal or gynecological tumors were retrospectively evaluated. All patients underwent peritonectomy with hyperthermic intraoperative chemotherapy and 1.5 T MRI including DWI with 500 s/mm2 and 1000 s/mm2 b values within 1 month from surgery. Images were independently reviewed by 2 radiologists with different experience in abdominal MRI in 3 separate reading sessions, the first including conventional MR images alone (T2-weighted, T1-weighted pre- and post gadolinium injection), the second conventional MRI and DWI with a b value of 500 s/mm2 (b 500-DWI), and the third conventional MRI and DWI with a b value of 1000 s/mm2 (b 1000-DWI). Apparent diffusion coefficient maps were included in the DWI analyses. Peritoneal dissemination was assessed in 9 anatomical sites, including right and left subphrenic space, paracolic gutters, small bowel mesentery, greater omentum, gastric-bowel serosa, free peritoneal surfaces, rectosigmoid-colon mesentery, and pelvis. The presence or absence of peritoneal dissemination for each patient and for each site was scored using a 5-point confidence scale. Sensitivity, specificity, and area under the curve (AUC) for identifying per-site peritoneal implants were calculated for each reader at each reading session. Interobserver agreement was evaluated using kappa statistics. RESULTS: For both readers, the sensitivity and AUC values resulting from combined interpretation of conventional MRI and DWI (both b500-DWI and b1000-DWI) were significantly higher than those of conventional MRI alone (P < 0.001). The added value of DWI was greater for the less experienced reader (sensitivity 0.55, specificity 0.73, AUC 0.64 on conventional MRI; sensitivity 0.75, specificity 0.72, AUC 0.74 on b500-DWI; sensitivity 0.87, specificity 0.72, AUC 0.80 on b1000-DWI) than for the more experienced reader (sensitivity 0.63, specificity 0.75, AUC 0.70 on conventional MRI; sensitivity 0.76, specificity 0.77, AUC 0.77 on b500-DWI; sensitivity 0.85, specificity 0.72, AUC 0.79 on b1000-DWI), although the differences between the 2 observers were not statistically significant. Interobserver agreement resulted to be fair (κ = 0.30) when dealing with conventional MRI alone. The addition of b500-DWI and b1000-DWI to conventional MRI allowed to reach a substantial agreement (κ = 0.75). CONCLUSIONS: The combined interpretation of high b value DWI and conventional MRI provides increased sensitivity and diagnostic performance in detection of peritoneal carcinomatosis in oncologic patients.

Prevalence and Clinical Relevance of Extracardiac Findings in Cardiovascular Magnetic Resonance Imaging.

PURPOSE: To assess the prevalence of extracardiac findings (ECF) during cardiovascular magnetic resonance (CMR) examinations and their downstream effect on clinical management. MATERIALS AND METHODS: We retrospectively identified 500 consecutive patients. Trans-axial balanced steady-state free precession nongated images acquired from the upper thorax to the upper abdomen were evaluated independently by 2 radiologists. ECF were classified as nonsignificant (benign, with no need for further investigation), significant (mandatory to be reported/monitored), and major (clinically remarkable pathology, mandatory to be reported/investigated/treated). Fifteen-month clinical follow-up information was collected through hospital records. RESULTS: Of 500 patients, 108 (21.6%) showed a total of 153 ECF: 59 (11.8% of the entire study population; 38.5% of all ECF) nonsignificant, 76 (15.2%; 49.7%) significant, and 18 (3.6%; 11.8%) major ECF. The most frequent ECF were pleural effusion, hepatic cyst, renal cyst, and ascending aorta dilatation. Of 94 significant and major ECF, 46 were previously unknown and more common in older patients. Newly diagnosed major ECF (n=11, 2.2% of the entire study population, and 7.2% of all ECF)-including 5 tumors (1% of study population)-were confirmed by downstream evaluations and required specific treatment. Patients with major ECF were significantly older than patients without with major ECF. Newly diagnosed clinically significant and major ECF prompted downstream diagnostic tests in 44% and 100% of cases, respectively. CONCLUSIONS: The detection of significant and major ECF is common during CMR reporting. The knowledge and the correct identification of most frequent ECF enable earlier diagnoses and faster treatment initiation of unknown extracardiac pathologies in patients referred to CMR imaging.

Embolization of Bleeding Pulmonary Arterial Pseudoaneurysm in a Woman With Infective Endocarditis.

Pulmonary arterial pseudoaneurysm is a rare but life-threatening complication of infective endocarditis. This report describes a case of bleeding pulmonary arterial pseudoaneurysm in a young, drug-addicted woman with tricuspid annuloplasty after infective endocarditis that was promptly identified by computed tomography pulmonary angiography and successfully treated using coil embolization. Perfusion scintigraphy at 30 days confirmed the safety of endovascular treatment.

Performance of diffusion-weighted magnetic resonance imaging at 3.0T for early assessment of tumor response in locally advanced rectal cancer treated with preoperative chemoradiation therapy.

PURPOSE: The purpose of the article is to determine whether changes in apparent diffusion coefficient (ADC) values of locally advanced rectal cancer (LARC) obtained 2 weeks after the beginning of chemoradiation therapy (CRT) allow to predict treatment response and whether correlate with tumor histopathologic response. METHODS: Forty-three patients receiving CRT for LARC and 3.0T magnetic resonance imaging with diffusion-weighted sequences before treatment, 2 weeks during, and 8 weeks post the completion of CRT were included. ADC values were calculated at each time point and percentage of ADC changes at 2 weeks (ΔADC during) and 8 weeks (ΔADC post) were assessed. Data were correlated to surgical results and histopathologic tumor regression grade (TRG), according to Mandard's classification. ADC values and ΔADCs of complete responders (CR; TRG1) and non-complete responders (non-CR; TRG 2-5) were compared. Receiver-operating characteristic curve (ROC) analysis was used to assess diagnostic accuracy of ΔADC for differentiating CR from non-CR. The correlation with TRG was investigated using Spearman's rank test. RESULTS: ΔADC during and ΔADC post were significantly higher in CR (33.9% and 57%, respectively) compared to non-CR (13.5% and 2.2%, respectively) group (p = 0.006 and p < 0.001, respectively). ROC analysis revealed the following diagnostic performances: ΔADC during: AUC 0.78 (0.08), p = 0.004, cut-off 20.6% (sensitivity 75% and specificity 76.5%); ΔADC post: AUC 0.94 (0.04), p ≤ 0.001, cut-off 22% (sensitivity 95% and specificity 82.4%). Significant moderate and good negative correlation was found between ΔADC during and ΔADC post and TRG (r = - 0.418, p = 0.007; r = - 694, p ≤ 0.001, respectively). CONCLUSION: ΔADC at 2 weeks after the beginning of CRT is a reliable tool to early assess treatment response.

Rectal cancer MRI: protocols, signs and future perspectives radiologists should consider in everyday clinical practice.

Magnetic resonance imaging (MRI) allows to non-invasively evaluate rectal cancer staging and to assess the presence of "prognostic signs" such as the distance from the anorectal junction, the mesorectal fascia infiltration and the extramural vascular invasion. Moreover, MRI plays a crucial role in the assessment of treatment response after chemo-radiation therapy, especially considering the growing interest in the new conservative policy (wait and see, minimally invasive surgery). We present a practical overview regarding the state of the art of the MRI protocol, the main signs that radiologists should consider for their reports during their clinical activity and future perspectives. TEACHING POINTS: • MRI protocol for rectal cancer staging and re-staging. • MRI findings that radiologists should consider for reports during everyday clinical activity. • Perspectives regarding the development of latest technologies.

Diagnostic accuracy of biparametric vs multiparametric MRI in clinically significant prostate cancer: Comparison between readers with different experience.

BACKGROUND: MRI plays a crucial role to identify men with a high likelihood of clinically significant prostate cancer who require immediate biopsy. The added value of DCE MRI in combination with T2-weighted imaging and DWI is controversial (risks related to gadolinium administration, duration of MR exam, financial burden, effects on diagnostic performance). A comparison of a biparametric and a standard multiparametric MR imaging protocol, taking into account the different experience of the readers, may help to choose the best MR approach regarding diagnostic performance. PURPOSE: To determine the added value of dynamic contrasted-enhanced imaging (DCE) over T2-weighted imaging (T2-WI) and diffusion weighted imaging (DWI) for the detection of clinically significant prostate cancer, and to evaluate how it affects the diagnostic performance of three readers with different grade of experience in prostate imaging. MATERIALS AND METHODS: Eighty-five patients underwent prostate MR examination at 1.5 T MR scanner performed because of elevated prostate-specific antigen level and/or suspicion of prostate cancer at digital rectal examination. Two MR images sets (Set 1 = biparametric, Set 2 = multiparametric) were retrospectively and independently scored by three radiologists with 7, 3 and 1 years of experience in prostate MR imaging respectively, according to PI-RADS v2. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated by dichotomizing reader scores. Receiver operating characteristic (ROC) analysis was performed and areas under the curve (AUCs) were calculated for each reader and image set. A comparison of ROC curves was performed to test the difference between the areas under the ROC curves among the three readers. RESULTS: There was no significant difference regarding the detection of clinically significant tumor among the three readers between the two image sets. The AUC for the bi-parametric and multi-parametric MR imaging protocol was respectively 0.68-0.72 (Reader 1), 0.72-0.70 (Reader 2) and 0.60-0.54 (Reader 3). ROC curve comparison revealed no statistically significant differences for each protocol among the most experienced (Reader 1) and the other readers (Readers 2-3). CONCLUSION: The diagnostic accuracy of a bi-parametric MR imaging protocol consisting of T2-weighted imaging and DWI is comparable with that of a standard multi-parametric imaging protocol for the detection of clinically significant prostate cancer. The experience of the reader does not significantly modify the diagnostic performance of both MR protocols.

Cutting Balloon Angioplasty (CBA) for the Treatment of Renal Artery Fibromuscular Dysplasia (FMD) in Six Patients: 5-Year Long-Term Results.

PURPOSE: To evaluate long-term outcomes in terms of hypertension control, recurrent stenosis, and reinterventions from patients who underwent cutting balloon angioplasty (CBA) for symptomatic renal artery fibromuscular dysplasia (FMD). MATERIALS AND METHODS: From 2011, six consecutive renal artery FMD women underwent CBA for poorly controlled hypertension, despite antihypertensive therapy. Follow-up consisted of blood pressure monitoring and duplex ultrasonography at 1, 6, and 12 months and thereafter annually for 5 years. RESULTS: All treatments were technically successful. Recurrence of hypertension was found in two patients within 12 months, and reinterventions were performed using CBA. CONCLUSION: Results show the efficacy of CBA for renal artery FMD.

Time-domain analysis of scrotal thermoregulatory impairment in varicocele.

Varicocele is a common male disease defined as the pathological dilatation of the pampiniform plexus and scrotal veins with venous blood reflux. Varicocele usually impairs the scrotal thermoregulation via a hemodynamic alteration, thus inducing an increase in cutaneous temperature. The investigation of altered scrotal thermoregulation by means of thermal infrared imaging has been proved to be useful in the study of the functional thermal impairment. In this study, we use the Control System Theory to analyze the time-domain dynamics of the scrotal thermoregulation in response to a mild cold challenge. Four standard time-domain dynamic parameters of a prototype second order control system (Delay Time, Rise Time, closed poles locations, steady state error) and the static basal temperatures were directly estimated from thermal recovery curves. Thermal infrared imaging data from 31 healthy controls (HCS) and 95 varicocele patients were processed. True-positive predictions, by comparison with standard echo color Doppler findings, higher than 87% were achieved into the proper classification of the disease stage. The proposed approach could help to understand at which specific level the presence of the disease impacts the scrotal thermoregulation, which is also involved into normal spermatogenesis process.