Artificial intelligence and radiomics enhance the positive predictive value of digital chest tomosynthesis for lung cancer detection within SOS clinical trial.

OBJECTIVE: To enhance the positive predictive value (PPV) of chest digital tomosynthesis (DTS) in the lung cancer detection with the analysis of radiomics features. METHOD: The investigation was carried out within the SOS clinical trial (NCT03645018) for lung cancer screening with DTS. Lung nodules were identified by visual analysis and then classified using the diameter and the radiological aspect of the nodule following lung-RADS. Haralick texture features were extracted from the segmented nodules. Both semantic variables and radiomics features were used to build a predictive model using logistic regression on a subset of variables selected with backward feature selection and using two machine learning: a Random Forest and a neural network with the whole subset of variables. The methods were applied to a train set and validated on a test set where diagnostic accuracy metrics were calculated. RESULTS: Binary visual analysis had a good sensitivity (0.95) but a low PPV (0.14). Lung-RADS classification increased the PPV (0.19) but with an unacceptable low sensitivity (0.65). Logistic regression showed a mildly increased PPV (0.29) but a lower sensitivity (0.20). Random Forest demonstrated a moderate PPV (0.40) but with a low sensitivity (0.30). Neural network demonstrated to be the best predictor with a high PPV (0.95) and a high sensitivity (0.90). CONCLUSIONS: The neural network demonstrated the best PPV. The use of visual analysis along with neural network could help radiologists to reduce the number of false positive in DTS. KEY POINTS: • We investigated several approaches to enhance the positive predictive value of chest digital tomosynthesis in the lung cancer detection. • Neural network demonstrated to be the best predictor with a nearly perfect PPV. • Neural network could help radiologists to reduce the number of false positive in DTS.

Adrenal Incidentalomas are Tied to Increased Risk of Diabetes: Findings from a Prospective Study.

CONTEXT: The frequency of adrenal incidentalomas and their association with comorbid conditions have been assessed mostly in retrospective studies that may be prone to ascertainment bias. OBJECTIVE: The objective of this work is to evaluate the frequency of adrenal incidentalomas and their associated comorbid conditions. DESIGN: A prospective cohort study was conducted. SETTING: This study took place at a radiology department at a public hospital. PARTICIPANTS: Unselected outpatients who underwent an abdominal computed tomography (CT) from January 2017 to June 2018. Patients with known or suspected adrenal disease or malignancy were excluded. EXPOSURE: All abdominal CT scans were evaluated by an experienced radiologist. Hormonal workup including a 1-mg dexamethasone suppression test was performed in patients bearing adrenal incidentalomas. MAIN OUTCOME AND MEASURE: Frequency of adrenal incidentalomas in abdominal CT of unselected patients; frequency of comorbid conditions, and hormonal workup in patients bearing adrenal incidentalomas. RESULTS: We recruited 601 patients, and in 7.3% of them an adrenal tumor was found serendipitously. The patients bearing an adrenal incidentaloma had higher body mass index (P = .009) and waist circumference (P = .004) and were more frequently diabetic (P = .0038). At multivariable regression analysis, diabetes was significantly associated with the presence of adrenal incidentalomas (P = .003). Autonomous cortisol secretion was observed in 50% of patients who did not suppress cortisol less than 50 nmol/L after 1 mg dexamethasone. CONCLUSIONS: The frequency of adrenal incidentalomas is higher than previously reported. Moreover, adrenal incidentalomas are tied to increased risk of type 2 diabetes. This finding is free from ascertainment bias because patients with adrenal incidentalomas were drawn from a prospective cohort with the same risk of diabetes as the background population.

Tailored intraoperative localization of non-palpable pulmonary lesions for thoracoscopic wedge resection using hybrid room technology.

INTRODUCTION: VATS wedge resection can require conversion to thoracotomy when pulmonary lesions cannot be identified. Hybrid operating rooms (HORs) provide real-time image acquisition capabilities allowing the intraoperative placement of markers to facilitate the removal of non-palpable nodules during VATS. OBJECTIVES: To present our workflow based on the alternative use of two different markers according to the location of the lung lesion and report our initial results. METHODS: All consecutive patients with non-palpable lesions requiring VATS wedge resection underwent localization of the targets in HOR. Lesions were considered non-palpable if they were small (<1 cm), deep (>1 cm from surface), subsolid, or located within a dystrophic area. Anesthetized patients were placed in lateral decubitus. Cone-beam CT (CBCT) was performed, and the needle trajectory was planned using Syngo iGuide Needle Guidance. Metal hook-wire or coil was placed, according to our workflow, close to the lesion and their position was verified by CBCT or fluoroscopy. RESULTS: Eleven VATS wedge resections were performed in 10 patients with 12 non-palpable lesions. The localization was performed with seven hook-wires and four coils in 30 minutes (range 17-56 minutes). The median estimated total effective dose was 11.6 mSv (range 1.9-24.7 mSv). Eleven lesions were removed by VATS, and one deep nodule required a thoracotomy. No complications were observed. CONCLUSIONS: Our experience confirms that HOR is suitable for simultaneous localization and VATS resection of 'difficult' pulmonary lesions. A versatile approach, using different devices, seems advisable for the removal of targets in every clinical scenario, reducing the VATS conversion rate.

Comparison of digital tomosynthesis and computed tomography for lung nodule detection in SOS screening program.

PURPOSE: To compare the lung nodules' detection of digital tomosynthesis (DTS) and computed tomography (CT) in the context of the SOS (Studio OSservazionale) prospective screening program for lung cancer detection. MATERIALS AND METHODS: One hundred and thirty-two of the 1843 subjects enrolled in the SOS study underwent CT because non-calcified nodules with diameters larger than 5 mm and/or multiple nodules were present in DTS. Two expert radiologists reviewed the exams classifying the nodules based on their radiological appearance and their dimension. LUNG-RADS classification was applied to compare receiver operator characteristics curve between CT and DTS with respect to final diagnosis. CT was used as gold standard. RESULTS: DTS and CT detected 208 and 179 nodules in the 132 subjects, respectively. Of these 208 nodules, 189 (91%) were solid, partially solid, and ground glass opacity. CT confirmed 140/189 (74%) of these nodules but found 4 nodules that were not detected by DTS. DTS and CT were concordant in 62% of the cases applying the 5-point LUNG-RADS scale. The concordance rose to 86% on a suspicious/non-suspicious binary scale. The areas under the curve in receiver operator characteristics were 0.89 (95% CI 0.83-0.94) and 0.80 (95% CI 0.72-0.89) for CT and DTS, respectively. The mean effective dose was 0.09 ± 0.04 mSv for DTS and 4.90 ± 1.20 mSv for CT. CONCLUSIONS: The use of a common classification for nodule detection in DTS and CT helps in comparing the two technologies. DTS detected and correctly classified 74% of the nodules seen by CT but lost 4 nodules identified by CT. Concordance between DTS and CT rose to 86% of the nodules when considering LUNG-RADS on a binary scale.

Consensus conference on TIPS management: Techniques, indications, contraindications.

The trans jugular intrahepatic Porto systemic shunt (TIPS) is no longer viewed as a salvage therapy or a bridge to liver transplantation and is currently indicated for a number of conditions related to portal hypertension with positive results in survival. Moreover, the availability of self-expandable polytetrafluoroethylene (PTFE)-covered endoprostheses has dramatically improved the long-term patency of TIPS. However, since the last updated International guidelines have been published (year 2009) new evidence have come, which have open the field to new indications and solved areas of uncertainty. On this basis, the Italian Association of the Study of the Liver (AISF), the Italian College of Interventional Radiology-Italian Society of Medical Radiology (ICIR-SIRM), and the Italian Society of Anesthesia, Analgesia and Intensive Care (SIAARTI) promoted a Consensus Conference on TIPS. Under the auspices of the three scientific societies, the consensus process started with the review of the literature by a scientific board of experts and ended with a formal consensus meeting in Bergamo on June 4th and 5th, 2015. The final statements presented here were graded according to quality of evidence and strength of recommendations and were approved by an independent jury. By highlighting strengths and weaknesses of current indications to TIPS, the recommendations of AISF-ICIR-SIRM-SIAARTI may represent the starting point for further studies.

Lung cancer detection with digital chest tomosynthesis: first round results from the SOS observational study.

OBJECTIVE: Baseline results of the Studio OSservazionale (SOS), observational study, a single-arm observational study of digital chest tomosynthesis for lung cancer detection in an at-risk population demonstrated a detection rate of lung cancer comparable to that of studies that used low dose CT scan (LDCT). We present the results of the first round. METHODS: Totally 1,703 out of 1,843 (92%) subjects who had a baseline digital chest tomosynthesis underwent a first round reevaluation after 1 year. RESULTS: At first round chest digital tomosynthesis, 13 (0.7%) subjects had an indeterminate nodule larger than 5 mm and underwent low-dose CT scan for nodule confirmation. PET/CT study was obtained in 10 (0.5%) subjects and 2 subjects had a low-dose CT follow up. Surgery, either video-assisted thoracoscopic or open surgery for indeterminate pulmonary nodules was performed in 10 (0.2%) subjects. A lung cancer was diagnosed and resected in five patients. The lung cancer detection rate at first round was 0.3% (5/1,703). CONCLUSIONS: The detection rate of lung cancer at first round for tomosynthesis is comparable to rates reported for CT. In addition, results of first round digital chest tomosynthesis confirm chest tomosynthesis as a possible first-line lung cancer-screening tool.

Prostatic artery embolization in benign prostatic hyperplasia: preliminary results in 13 patients.

AIM: The aim of the paper is to report the clinical outcome after prostatic artery embolisation (PAE) in 13 consecutive patients with benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS). MATERIALS AND METHODS: From May 2012 to October 2013, we performed PAE in 13 consecutive patients (mean age 75.9 years) with BPH and LUTS and refractory to medical therapy; seven patients had an indwelling bladder catheter. Clinical follow-up (mean follow-up time 244 days) was performed using the international prostate symptoms score (IPSS), quality of life (QoL), the international index of erectile function (IIEF), blood prostatic specific antigen (PSA) testing and transrectal prostatic ultrasound (US) scan with volume and weight calculation at 3, 6 and 12 months. Pre-procedural CT angiography (CTA) was done for vascular mapping. Embolisation was performed using Embosphere (300-500 micron). Technical success was defined when selective prostatic arterial embolisation was completed in at least one pelvic side. Clinical success was defined when symptoms and quality of life were improved. RESULTS: PAE was technically successful in 12/13 patients (92%). In one patient, PAE was not performed because of tortuosity and atherosclerosis of iliac arteries. PAE was completed bilaterally in 9/13 (75%) patients and unilaterally in three (27%). All patients removed the bladder catheter from 4 days to 4 weeks after PAE. We obtained a reduction in IPSS (mean, 17.1 points), an increase in IIEF (mean, 2.6 points), an improvement in Qol (mean, 2.6 points) and a volume reduction (mean, 28%) at 12 months. CONCLUSIONS: Consistent with the literature, our experience showed the feasibility, safety and efficacy of PAE in the management of patients with LUTS related to BPH. PAE may play an important role in patients in whom medical therapy has failed, who are not candidates for surgery or transurethral prostatic resection (TURP) or refuse any surgical treatment. Larger case series and comparative studies with standard TURP can confirm the validity of the technique.

Trends in utilization of transarterial treatments for hepatocellular carcinoma: results of a survey by the Italian Society of Interventional Radiology.

PURPOSE: This study was designed to provide an overview of the practice of locoregional treatments for HCC by the Italian centers of Interventional Radiology (IR) with particular reference to transarterial modalities. METHODS: A questionnaire of 11 questions on locoregional treatment of HCC was e-mailed to 134 Italian IR centers. RESULTS: The response rate was 64.9% (87/135 centers). Of 8,959 procedures in 2011, 67% were transarterial treatments, 31% percutaneous ablations, and 2% Y90-radioembolizations. Regarding (chemo)embolization, approximately 59% of procedures were performed in the intermediate stage, 28% in the early stage, and 12.8% in the advanced stage. TACE techniques varied greatly; approximately 52% of procedures were performed with drug-eluting particles and 32% with lipiodol, drug, and reabsorbable particles. In selected cases, 53 of 78 (68%) centers combine chemoembolization and ablation, whereas 28 centers (35.9%) combine Sorafenib and chemoembolization. In 2011, 13 of 78 (16.7%) responding centers performed Y90-radioembolization, with approximately 52% of procedures performed in the advanced stage and 46% in the intermediate stage. Approximately 62% of Y90-radioembolizations were performed using resin spheres and 38% using glass spheres. CONCLUSIONS: With almost 9,000 procedures performed each year, locoregional treatments of HCC, most of all transarterial (chemo)embolizations, represent a major part of daily clinical practice in many Italian IR centers. The high variability in responses regarding transarterial treatments for HCC patients highlights the need for solid scientific evidence allowing better definition of clinical indications and standardization of technical approaches.

Hepatic brucelloma.

We present a case of hepatic abscess caused by Brucella melitensis (or hepatic brucelloma) diagnosed in a 59-year-old man 33 years after an episode of acute brucellosis that had completely resolved. Recovery from symptoms and a decrease in lesion size seen on radiological assessment were achieved through prolonged combined antibiotic therapy, without the need for surgery. Hepatic brucelloma is a rare complication of brucellosis, which is the most common zoonosis globally, mainly occurring in specific endemic areas and causing a range of clinical manifestations. In this Grand Round, we review the clinical manifestations, diagnostic approach (through laboratory, radiology, and histology findings), differential diagnosis, treatment, and prognosis of hepatic brucelloma.

Treatment of visceral aneurysm using multilayer stent: two-year follow-up results in five consecutive patients.

PURPOSE: The present study was performed to analyze the midterm results (five consecutive patients, 2-year follow-up) of the endovascular management of visceral artery aneurysms using the Cardiatis Multilayer Flow Modulator (CMFM) (Cardiatis, Isnes, Belgium), a self-expandable stent. MATERIALS AND METHODS: From August 2009 to January 2011, we implanted five CMFMs in five patients (all men; mean age 73 years) to treat two common hepatic artery aneurysms, one celiac trunk aneurysm, one splenic artery aneurysm, and one superior mesenteric artery aneurysm (diameter 25-81 mm). The primary end point was technical success. The secondary end point was stent patency, absence of aneurysm rupture or reperfusion, and shrinking of the sac at 6-, 12-, and 24-month follow-up using computed tomography angiography. Follow-up ranged from 24 to 48 months (mean 31.2). RESULTS: Technical success was achieved in all patients. Complete exclusion of the aneurysm with sac shrinking was achieved in two patients. Two stents became occluded at 6- and 24-month follow-up, respectively; both patients were asymptomatic and were not retreated. One patient developed sac reperfusion due to incomplete aneurysm exclusion. CONCLUSION: Long-term results in a wider population are needed to validate the effectiveness of the CMFM.

Epidemiology, clinical-treatment patterns and outcome in 256 hepatocellular carcinoma cases.

AIM: To analyze the epidemiology, clinical characteristics, treatment patterns and outcome in hepatocellular carcinoma (HCC) patients. METHODS: We analyzed clinical, pathological and therapeutic data from 256 consecutive patients, examined at S. Croce Hospital in Cuneo-Piedmont, with a diagnosis of HCC between 30(th) June 2000 and 1(st) July 2010. We analyzed the hospital imaging database and examined all medical records, including the diagnosis code for HCC (155.0 according to the ICD-9M classification system), both for inpatients and outpatients, and discovered 576 relevant clinical records. After the exclusion of reports relating to multiple admissions for the same patient, we identified 282 HCC patients. Moreover, from this HCC series, we excluded 26 patients: 1 patient because of an alternative final diagnosis, 8 patients because of a lack of complete clinical data in the medical record and 17 patients because they were admitted to different health care facilities, leaving 256 HCC patients. To highlight possible changes in HCC patterns over the ten-year period, we split the population into two five-year groups, according to the diagnosis period: 30(th) June 2000-30(th) June 2005 and 1(st) July 2005-1(st) July 2010. Patients underwent a 6-mo follow up. RESULTS: Two hundred and fifty-six HCC patients were included (male/female 182/74; mean age 70 years), 133 in the first period and 123 in the second. Hepatitis C virus (HCV) infection was the most common HCC risk factor (54.1% in the first period, 50.4% in the second; P = 0.63); in the first period, 21.8% of patients were alcoholics and 15.5% were alcoholics in the second period (P > 0.05); the non-viral/non-alcoholic etiology rate was 3.7% in the first period and 20.3% in the second period (P < 0.001). Child class A patients increased significantly in the second period (P < 0.001). Adjusting for age, gender and etiology, there was a significant increase in HCC surveillance during the second period (P = 0.01). Differences between the two periods were seen in tumor parameters: there was an increase in the number of unifocal HCC patients, from 53 to 69 (P = 0.01), as well as an increase in the number of cases where the HCC was < 3 cm [from 22 to 37 (P = 0.01)]. The combined incidence of stage Barcelona Clinic Liver Cancer 0 (very-early) and A (early) HCC was 46 (34.6%) between 2000-2005, increasing to 62 (50.4%) between 2005-2010 (P = 0.01). Of the patients, 62.4% underwent specific treatment in the first group, which increased to 90.2% in the second group (P < 0.001). Diagnosis period (P < 0.01), Barcelona-Clinic Liver Cancer stage (P < 0.01) and treatment per se (P < 0.05) were predictors of better prognosis; surveillance was not related to survival (P = 0.20). CONCLUSION: This study showed that, between 2000-2005 and 2005-2010, the number of HCV-related HCC decreased, non-viral/non alcoholic etiologies increased and of surveillance programs were more frequently applied.

Lung cancer detection with digital chest tomosynthesis: baseline results from the observational study SOS.

INTRODUCTION: Observational studies consistently support strategies for early cancer diagnosis and treatment. Owing to its high prevalence, mortality rate, and easily identifiable at-risk population groups, lung cancer seems ideal for early detection programs. We present the baseline results of the SOS study, a single-arm observational study of digital chest tomosynthesis for lung cancer detection in an at-risk population. METHODS: Accrual of study participants started in December 2010 and ended in December 2011. Participants considered eligible were smokers or former smokers aged 45 to 75 years, with a smoking history of at least 20 pack-years, without malignancy in the 5 years before the start of the study. A tomosynthesis examination was performed at baseline and another the year after. RESULTS: Of the 1919 candidates assessed, 1843 (96%) were enrolled into the study: the mean age was 61 years (range, 48-73 years); 1419 (77%) were current smokers. The most prevalent comorbidities were hypertension, chronic obstructive pulmonary disease, and cardiovascular diseases. A total of 1843 tomosynthesis studies were obtained. Pulmonary abnormalities were detected in 268 subjects (14.5%). First-line basal computed tomography (CT) was subsequently carried out in 132 subjects (7.2%), 68 (4.9%) of which were referred for follow-up CT. Positron-emission tomography/CT was performed on 27 individuals (1.46%), and lung cancer was detected in 18 (0.98%) of them. CONCLUSION: The detection rate of noncalcified lung nodules for tomosynthesis was comparable with rates reported for CT. A small subgroup underwent low-dosage CT and entered a follow-up program. Overall, lung cancer was detected in approximately 1% of cases. Digital chest tomosynthesis holds promise as a first-line lung cancer screening tool.

Natural history and outcome of hepatic vascular malformations in a large cohort of patients with hereditary hemorrhagic teleangiectasia.

BACKGROUND: Hereditary hemorrhagic telangiectasia is a genetic disease characterized by teleangiectasias involving virtually every organ. There are limited data in the literature regarding the natural history of liver vascular malformations in hemorrhagic telangiectasia and their associated morbidity and mortality. AIM: This prospective cohort study sought to assess the outcome of liver involvement in hereditary hemorrhagic telangiectasia patients. METHODS: We analyzed 16 years of surveillance data from a tertiary hereditary hemorrhagic telangiectasia referral center in Italy. We considered for inclusion in this study 502 consecutive Italian patients at risk of hereditary hemorrhagic telangiectasia who presented at the hereditary hemorrhagic telangiectasia referral center and underwent a multidisciplinary screening protocol for the diagnosis of hereditary hemorrhagic telangiectasia. Of the 502 individuals assessed in the center, 154 had hepatic vascular malformations and were the subject of the study; 198 patients with hereditary hemorrhagic telangiectasia and without hepatic vascular malformations were the controls. Additionally, we report the response to treatment of patients with complicated hepatic vascular malformations. RESULTS: The 154 patients were included and followed for a median period of 44 months (range 12-181); of these, eight (5.2%) died from VM-related complications and 39 (25.3%) experienced complications. The average incidence rates of death and complications were 1.1 and 3.6 per 100 person-years, respectively. The median overall survival and event-free survival after diagnosis were 175 and 90 months, respectively. The rate of complete response to therapy was 63%. CONCLUSIONS: This study shows that substantial morbidity and mortality are associated with liver vascular malformations in hereditary hemorrhagic telangiectasia patients.

Radiofrequency thermal ablation of small tumors in transplanted kidneys: an evolving nephron-sparing option.

Small tumors in transplanted kidneys are rarely detected during follow-up. With surgical treatment, it is sometimes challenging to preserve the graft and its function. Image-guided ablation techniques have been recently reported as effective in treating these tumors. Herein three cases of radiofrequency (RF) thermal ablation in transplanted kidneys are reviewed and compared with cases in the literature. There were no major complications seen, the mean change in serum creatinine level was no greater than 0.1 mg/dL, and complete ablation was sustained on imaging studies at 3, 18, and 62 months follow-up. RF ablation can be considered a safe, function-preserving, and effective evolving therapeutic option for small tumors in transplanted kidneys.

Transarterial chemoembolization for hepatocellular carcinoma with drug-eluting microspheres: preliminary results from an Italian multicentre study.

The purpose of this article is to present the early results of a multicentre trial using HepaSphere microspheres loaded with chemotherapeutic agents for transarterial chemoembolization (TACE) in patients with unresectable hepatocellular carcinoma. From December 2005 to March 2007, 50 patients (36 male and 14 female, mean age 68.4 years) were treated by selective TACE using HepaSphere microspheres loaded with doxorubicin or epirubicin. The diameter of the treated lesions ranged from 20 to 100 mm (mean 42.5; maximum of 4 tumor nodules). Tumor response was evaluated by computed axial tomography according to the World Health Organization criteria as modified by the European Association for the Study of Liver Diseases. All of the procedures were technically successful, and there were no major complications. At 1-month follow-up, complete tumor response was observed in 24 of 50 (48%), partial response in 18 of 50 (36%), and stable disease in 8 of 50 (16%) patients, and there were no cases of disease progression. At 6-month follow-up (31 of 50 patients), complete tumor response was obtained in 16 of 31 (51.6%), partial response in 8 of 31 (25.8%), and progressive disease in 7 of 31 (22.6%) patients. Within the initial 9-month follow-up, TACE with HepaSphere was successfully repeated twice in 3 patients, whereas 3 patients underwent the procedure 3 times. Our initial multicentre experience demonstrates that TACE using HepaSphere is feasible, is well tolerated, has a low complication rate, and is associated with promising tumor response. When complete tumor response in not achieved, additional treatments can be performed without difficulties. Longer follow-up on larger series is mandatory to confirm these preliminary results.

Correlation between delayed-enhancement magnetic resonance and nitrate myocardial Tc-99m tetrofosmin scintigraphy in myocardial infarction: a case report.

INTRODUCTION: Delayed-enhancement magnetic resonance imaging (DE-MRI) has been recently proposed as an alternative tool in identifying myocardial viability and transmural distribution of necrosis in the myocardium. CASE PRESENTATION: We describe a case of a 71-year-old man admitted for ischemic-like chest pain in which DE-MRI and post-nitrate 99mTc-tetrofosmin myocardial scintigraphy equally contributed to the diagnosis of previous lateral myocardial infarction. CONCLUSION: In this patient with coronary artery disease, the absence of uptake of tracer at myocardial scintigraphy appeared to be closely correlated to DE-MRI data. Cardiologists can use SPECT or DE-MRI to obtain similar information about myocardial viability.

TIPS with expanded polytetrafluoroethylene-covered stent: results of an Italian multicenter study.

OBJECTIVE: Our objective is to describe the results of a multicenter prospective trial on the safety and efficacy of transjugular intrahepatic portosystemic shunts (TIPS) using the Viatorr stent-graft. SUBJECTS AND METHODS: From 2001 to 2003, 114 patients (75 men and 39 women; mean age, 59.3 years) with portal hypertension underwent TIPS with the Viatorr stent-graft. Indications for treatment were variceal bleeding (n = 49, 43.0%), refractory ascites (n = 52, 45.6%), hypertensive gastropathy (n = 10, 8.8%), Budd-Chiari syndrome (n = 1, 0.9%), and hepatorenal syndrome (n = 2, 1.7%). Eight patients (7.0%) had Child-Pugh class A cirrhosis; 60 (52.6%), Child-Pugh class B; and 46 (40.4%), Child-Pugh class C. Patients were monitored by color Doppler sonography and phlebography. RESULTS: The procedure was successful in 113 (99.1%) of 114 patients; in one patient, creation of the track was not feasible. The mean portosystemic pressure gradient decreased from 21.8 to 8.7 mm Hg. Three minor immediate complications (2.6%) occurred (two cases of self-limiting hemoperitoneum and one extrahepatic portal puncture requiring covered stenting). At a mean follow-up of 11.9 months, the overall mortality rate was 31.0% (35/113), with a 30-day mortality rate of 8.8% (10/113). Mortality was significantly higher in patients in Child-Pugh class C with refractory ascites and with post-procedural encephalopathy. Cumulative primary patency rates were 91.9%, 79.9%, and 75.9% at 6, 12, and 24 months' follow-up, respectively. Restenosis occurred in 15 patients (13.3%) within the stent (n = 8, 53.3%) or at the ends of the portal (n = 1, 6.7%) or hepatic (n = 6, 40%) veins and was solved by percutaneous transluminal angioplasty (n = 11), stenting (n = 3), or parallel TIPS (n = 1). The secondary patency rate was 98.2%. Post-procedural encephalopathy occurred in 27 patients (23.9%). CONCLUSION: The Viatorr stent-graft is safe and effective in TIPS creation, with high primary patency rates. Covering the entire track up to the inferior vena cava can increase patency.

Surgical treatment of an aneurysm originating from a Kommerell's diverticulum in the right-sided aortic arch with retroesophageal component.

We report the case of a 41-year-old man presenting with a large Kommerell's diverticulum aneurysm in the right-sided aortic arch with retroesophageal component and moderate thoracic aortic dilation. Surgical treatment was performed through left thoracotomy and consisted of aneurysmectomy, closure of the distal aortic arch defect and aorta-left subclavian artery bypass. After 2 years computed tomography showed no modifications in the thoracic aortic morphology and the patency of the graft to the subclavian artery.

High prevalence of hepatic focal nodular hyperplasia in subjects with hereditary hemorrhagic telangiectasia.

A vascular pathogenesis of hepatic focal nodular hyperplasia (FNH) has been suggested; this study was aimed to evaluate in families with hereditary hemorrhagic telangiectasia (HHT) the prevalence of FNH, relating it to presence and stage of hepatic vascular malformations (VMs). Fifty-two HHT families underwent a screening program including abdominal Doppler sonography (US) searching for hepatic VMs; we classified them as minimal, moderate and severe, depending on the number and degree of abnormalities found by Doppler US. Presence of focal liver lesions was recorded. Diagnosis of FNH was made if at least two examinations, whether color Doppler US, liver scintigraphy, dynamic computed tomography (CT) or magnetic resonance (MR), showed suggestive findings. FNH was found in five out of 274 subjects (1.8%). All five were affected by HHT. Thus, percentage related to the group of affected patients increased to 2.9; 4/5 presented severe liver VMs. Female-to-male ratio was 4:1. FNH was single in three cases; tumor size ranged between 20 and 90 mm. During follow-up, no lesion showed a reduction in size, three showed an increase. Prevalence of FNH in patients with HHT is far greater than that reported in the general population; Doppler US role in its diagnosis and follow-up is highlighted.