EVALUATION OF AN ACTIVE PERSONAL DOSIMETRY SYSTEM IN INTERVENTIONAL RADIOLOGY AND NEURORADIOLOGY: PRELIMINARY RESULTS.

Active personal dosimeters (APD) supply real-time data on radiation dose rates and equivalent doses, enabling reduction of operator exposure to radiation in diagnostic and surgical procedures. Data from the use of the Raysafe i2 APD system in an angiography room are reported. Preliminary characterisation of the APD system was first carried out in terms of angular dependence and of Hp(10) response during the simulation of five typical surgical protocols. Reference measurements, simultaneously obtained from TLDs, were used to obtain a correction factor. APD data for patients and for primary and secondary operators were then recorded over 52 surgical procedures. The correlation between kerma air product (KAP) and reference point air kerma (Kar) and operator dose as a function of position with respect to the source of radiation is reported. The data indicate that the APD system could help operators to optimise behaviours and use of room protection to effectively minimise radiation dose.

Autologous CD133+ cells augment the effect of portal embolization.

AIM: The standard to treat liver tumors is a resection. When the future liver remnant (FLRV) is below 30% (healthy livers) or 40% (cirrhotic livers or previous chemotherapy), surgery carries the risk of severe complications. Portal vein embolization (PVE) gained a worldwide diffusion as a tool to augment the FLRV. Cell therapies are recent players at the frontiers of medicine. This study presents a clinical experience to evaluate the synergistic effect of combined PVE and autologous CD133+ cells coadministration. METHODS: Sixteen patients have been enrolled in the study up today. Inclusion criteria were: primary or metastatic liver malignancy with a FLRV<30% or 40%. A baseline volumetric CT-scan was obtained. CD34+ were mobilized to the blood stream by G-CSF administration and collected by immunomagnetic separation. Simultaneously with PVE, cells were administered to the non occluded liver segments. Follow-up CT scans were taken at 30th post treatment day. RESULTS: The patients (N.=6) showed an increased volume gain (Mann-Whitney test P<0.001, two sided) compared to a set of cases whose treatment was PVE only (N.=10). DISCUSSION: The use of autologous stem cells as an augmenter of liver regeneration has a clinical potential to improve the resectability of liver tumors.

OEM-TACE: a new therapeutic approach in unresectable intrahepatic cholangiocarcinoma.

Intrahepatic cholangiocarcinoma (ICC) is a rare life-threatening disease, whose only treatment with potential for cure is surgical resection. However, only 27% of patients at most are suitable for surgery when first diagnosed. For patients with unresectable disease, therapeutic options are chemotherapy or chemoradiation. We evaluated the feasibility and safety of oxaliplatin-eluting microspheres transarterial chemoembolization (OEM-TACE) associated with chemotherapy (ChT) in patients affected by unresectable ICC. Between December 2005 and May 2008 we treated nine patients (six female and three male) with unresectable ICC. All patients had undergone OEM-TACE associated with chemotherapy with oxaliplatin and gemcitabine. A retrospective comparison was carried out with a historical group of 11 patients treated with ChT only, estimating the prevalence of adverse effects and the median survival of the two groups. A total of 30 TACEs were performed during the observational time (ranging from one to seven procedures per patient). OEM-TACEs were followed by few adverse effects (AEs), without G4 AEs, according to CTACAE 3.0. According to RECIST criteria, 44% (4/9) of patients achieved partial responses and 56% (5/9) stabilization of disease. Overall survival analysis in the two groups showed a significantly increased survival in patients treated with ChT and OEM-TACE, with respect to those treated with ChT (30 vs. 12.7 months; p=0.004). In conclusion, in our experience OEM-TACE associated with ChT in the treatment of advanced unresectable ICC is a safe and feasible treatment causing no major adverse events. Although RECIST criteria can underestimate the rate of responses in patients treated with locoregional therapies, we achieved very encouraging results. A randomized multicentric trial is warranted to assess the actual superiority of OEM-TACE associated with ChT compared to conventional chemotherapy.

Non-randomized, prospective, multi-centre evaluation of the ABSOLUTE .035 peripheral self-expanding stent system for occluded or stenotic superficial femoral or proximal popliteal arteries (ASSESS Trial): acute and 30-day results.

AIM: The aim of the paper was to investigate the performance of the ABSOLUTE .035 Peripheral Self-Expanding Stent System in preventing restenosis of superficial femoral or proximal popliteal arteries. Due to a lack of large controlled trials proving its long-term durability femoropopliteal artery stenting is still a matter of debate. In this paper we report the study design, the acute and short-term results of a prospective European registry on the treatment of TASC B and C femoropopliteal lesions with the use of the ABSOLUTE stent. METHODS: This prospective, non-randomized, multi-centre study enrolled 122 patients with symptomatic peripheral occlusive disease at 14 sites in Europe. Patients were included with obstructed femoropopliteal arteries. Key inclusion criteria were de novo lesions > or = 4.0 mm and < or = 7.0 mm in diameter, and > or = 40 mm and < or = 200 mm in length. Single target vessel treatment had to be performed with a maximum of three stents. RESULTS: Mean target lesion length was 108 +/- 44 mm (range 22.2 to 200 mm) and mean reference vessel diameter 4.6 +/- 0.8 mm by quantitative angiography; 71% of the lesions analyzable by quantitative angiography (QA) had total occlusions. A total of 227 stents were implanted, 224 of which were deployed successfully (98.7%). Mean percentage of diameter stenosis was reduced from 90.9 +/- 15.5 % (range 41.3 to 100) to 19.0 +/- 8.4% (range 2.3 to 41.5). Device and procedural success were 83.6% each whereas technical success reached 100%. Sixteen lesions had a > or = 30% residual stenosis post-procedure, 6 of them (37.5%) rated as being calcified. Eleven patients experienced major complications (9.1%) and 6 patients experienced minor complications (5%) within 30 days. Duplex ultrasound based 1-month restenosis rate was 9.3%. Target lesion revascularization (TLR) and target vessel revascularization (TVR) rates were 0.8% and 1.7%, respectively and amputation rate was 0.8%. Mean ankle-brachial index (ABI) at rest and after exercise increased significantly from baseline to 30 days follow-up by 0.63 +/- 0.20 to 0.94 +/- 0.17 and from 0.44 +/- 0.23 to 0.85 +/- 0.21, respectively (P<0.001 each). CONCLUSION: The treatment of TASC B and C femoro-popliteal lesions with use of the ABSOLUTE stent is safe and feasible. Short-term follow-up documents persistent improvement of hemodynamics. The 6- and 12-month data have to be awaited for further conclusions:

A study on maximum skin dose in cerebral embolization procedures.

BACKGROUND AND PURPOSE: It is essential to measure the skin dose of radiation received by patients during interventional neuroradiologic procedures performed under fluoroscopic guidance, such as embolization of cerebral aneurysms, which is regarded as a high-dose interventional radiology procedure. In this study, we report a method for evaluating maximum skin dose (MSD), an ideal marker of radiation-induced effects, based on an innovative use of radiochromic films. MATERIALS AND METHODS: Forty-eight procedures were studied in 42 patients undergoing embolization of cerebral aneurysms. Fluoroscopic and digital dose-area product (DAP), fluoroscopy time, and total number of acquired images were recorded for all procedures. The MSD was measured using Gafchromic XR type R films. RESULTS: The MSD was measured in one group of 21 procedures. The coefficient (kappa) of the interpolation line between the skin dose and the DAP (kappa = 0.0029 cm(-2)) was determined. An approximate value of MSD from the DAP for the remaining 27 procedures was estimated by means of an interpolation line. The mean MSD was found to be 1.16 Gy (range, 0.23-3.20 Gy). CONCLUSION: The use of radiochromic XR type R films was shown to be an effective method for measuring MSD. These films have the advantage of supplying information on both the maximum dose and the distribution of the dose: this satisfies the most stringent interpretation of Food and Drug Administration, American College of Radiology, and international recommendations for recording skin dose.

Double stenting procedure and coil embolization in a patient with carotid stenosis and incidental ipsilateral intracranial aneurysm. A case report and dosimetric evaluation.

We describe a case of incidental detection of an intracranial left ICA wide-necked aneurysm during digital subtraction angiography performed to assess a sub-occlusive and calcified stenosis in the extracranial portion of the same artery. Angioplasty and stenting of ICA stenosis, plus intracranial stent deployment across the aneurysm neck was performed during the same procedure. Aneurysm coil embolization was postponed to a further session one month later. The radiation dose and irradiated areas were also evaluated during endovascular procedures.

Successful treatment of TIPS-induced hepatic failure with an hourglass stent-graft: a simple new technique for reducing shunt flow.

A simple new technique for creating an hourglass reducing stent-graft by means of targeted balloon expansion of each end of a commercially available device is presented. A 67-year-old man with progressive hepatic failure after TIPS creation was treated. A 48-mm-long Jostent stent-graft was placed inside the TIPS through a 10-F introducer and fully expanded only at the proximal and distal ends, resulting in an hourglass shape. Immediate increase of portal pressure was achieved, followed by complete clinical recovery. Advantages of covered versus bare reducing stents are discussed.

Percutaneous radiofrequency ablation of small hepatocellular carcinoma: long-term results.

The aim of this study was to evaluate the effectiveness and the safety of percutaneous radiofrequency (RF) thermal ablation of hepatocellular carcinoma (HCC) in 88 patients with a long follow-up, and to compare conventional electrodes and expandable electrodes. Eighty-eight patients with 101 hepatocellular carcinoma nodules (< or = 3.5 cm in diameter) underwent RF thermal ablation by means of either conventional electrodes or an expandable electrode. Therapeutic efficacy was evaluated with dynamic contrast CT, serum alpha-feto protein level, US examination at the end of the treatment, and during follow-up. Complete necrosis was obtained in all tumor nodules in a mean number of 3.3 sessions (tumor treated by conventional electrodes) or 1.5 sessions (tumor treated by expandable electrode). The mean follow-up was 34 months; overall survival rate was 33% at 5 years. Disease-free survival at 5 years was 3%; local recurrence rate was 29% in patients treated with conventional electrodes; 14% in patients treated with the expandable electrode. Two major complications and 14 minor complications were observed. Radiofrequency thermal ablation in small HCC is very effective with a low percentage of major complications. The use of an expandable electrode substantially reduced the number of treatment sessions but did not modify the overall survival rate and the disease-free survival rate.

Percutaneous radio-frequency thermal ablation of nonresectable hepatocellular carcinoma after occlusion of tumor blood supply.

PURPOSE: To evaluate the usefulness of percutaneous radio-frequency (RF) thermal ablation of nonresectable hepatocellular carcinoma (HCC) after occlusion of the tumor arterial supply. MATERIALS AND METHODS: Sixty-two patients with cirrhosis and biopsy-proved HCC underwent RF ablation after interruption of the tumor arterial supply by means of occlusion of either the hepatic artery with a balloon catheter (40 patients) or the feeding arteries with gelatin sponge particles (22 patients). RESULTS: After a single RF procedure in 56 patients and after two procedures in six patients, spiral computed tomography (CT) demonstrated a nonenhancing area corresponding in shape to the previously identified HCC, which was suggestive of complete necrosis. No major complications occurred. Two patients subsequently underwent surgical resection; the remaining 60 patients were followed up with spiral CT. During a mean follow-up of 12.1 months, 11 HCC nodules showed areas of local progression; 49 were identified as nonenhancing areas with a 40%-75% reduction in maximum diameter. The 1-year estimate of failure risk was 19% for local recurrence and 45% for overall intrahepatic recurrence. The estimated 1-year survival was 87%. Histopathologic analysis of one autopsy and two surgical specimens revealed more than 90% necrosis in one specimen and 100% necrosis in two. CONCLUSION: HCC nodules 3.5-8.5 cm in diameter can be ablated in one or two RF sessions after occlusion of the tumor arterial supply.

Percutaneous radiofrequency thermal ablation combined with transcatheter arterial embolization in the treatment of large hepatocellular carcinoma.

PURPOSE: To evaluate whether the combination of hepatic segmental transcatheter arterial embolization (TAE) with percutaneous radiofrequency (RF) ablation can increase the volume of coagulation necrosis to treat patients with large hepatocellular carcinoma (HCC). METHOD: Fourteen patients with cirrhosis and HCC whose greatest diameter ranged from 3.8 to 6.8 cm (mean, 5.2 cm) underwent segmental TAE followed within 3 days by RF interstitial thermal ablation with an expandable needle electrode inserted into the tumour under sonographic guidance, after local anesthesia. We made one or more needle electrode insertions depending on tumor shape. Posttreatment necrosis was evaluated by ultrasonography, dynamic computed tomography (CT) and alpha-fetoprotein dosage in all cases, repeated every three to four months. RESULTS: Tumor ablation was obtained in one session in 11 (78%) patients (with one needle electrode insertion in 8 patients), in two sessions in 1, in three sessions in 2. In a mean follow-up of 13.2 months (range 6-23) two patients died from unrelated causes; one patient showed multinodular HCC 6 months after the treatment; 4 patients developed new lesions, treated by a new course of RF ablation (3 cases) or by surgery (1 case); therefore 11/12 patients still in follow-up were disease-free. No fatal complications were observed. One month after the treatment, fluid collection at the site of the ablated tumor was observed in one patient which was percutaneously drained. CONCLUSIONS: Percutaneous RF thermal ablation performed after TAE effectively treated HCCs larger than tumors suitable for segmental TAE or RF application alone; the result was achieved in two thirds of the cases in a single session with only one needle electrode insertion.

Relationship between the shape and size of radiofrequency induced thermal lesions and hepatic vascularization.

AIMS AND BACKGROUND: The aim of this study was to evaluate the relationship between hepatic vascularisation and the final size and shape of radiofrequency (RF) induced thermal lesions. METHODS: Series of four RF thermal lesions were created in explanted calf livers and in pig livers maintaining the following experimental conditions throughout the procedure: normal hepatic perfusion, occlusion of the hepatic artery, occlusion of the portal vein, occlusion of both hepatic artery and portal vein (Pringle maneuver) and subtotal occlusion of the hepatic veins. A 14G expandable needle electrode was used to make the thermal lesions. Each lesion was created applying predetermined temperatures ranging between 95 and 115 degrees C and an exposure time of 20 minutes. RESULTS: Occlusion of the hepatic artery during the RF procedure resulted in moderate and not significant increases in thermal lesion diameter compared with those obtained in normally perfused liver (3.0 +/- 0.4 cm vs 3.0 +/- 0.2 cm), while occlusion of the portal vein resulted in larger lesion diameters (3.5 +/- 0.3 cm). In both these cases the diameters of the thermal lesions were smaller than those obtained in explanted calf liver (4.0 +/- 0.3 cm) and their shape showed peripheral irregularities. Thermal lesions larger than those seen in normally perfused liver and equaling those observed in explanted calf liver were created both during the Pringle maneuver (4.0 +/- 0.2 cm) and after subtotal occlusion of the hepatic veins (4.0 +/- 0.3 cm). In both these cases the thermal lesions were regular in shape. CONCLUSIONS: Occlusion of the blood flow during the RF procedure avoids heat loss by convection, resulting in the creation of larger thermal lesions than those obtained in normally vascularized liver using the same electrode, temperatures and exposure time. This technique could therefore be employed in humans to destroy large hepatic tumor nodules.

Percutaneous treatment of small hepatic tumors by an expandable RF needle electrode.

OBJECTIVE: The aim of this study was to evaluate the usefulness of expandable RF needle electrodes in the treatment of hepatic cancer. SUBJECTS AND METHODS: Thirty-seven patients, 23 of whom had 26 hepatocellular carcinoma nodules and 14 of whom had 19 hepatic metastatic nodules, underwent treatment by RF interstitial thermal ablation with expandable needle electrodes. Forty-five tumor nodules were treated in 64 RF interstitial thermal ablation sessions with 83 needle electrode insertions. The mean diameter of the tumor nodules was 2.5 cm (range, 1.1-3.5 cm). Immediate posttreatment tumor necrosis was evaluated by dynamic CT in all cases. Two patients with hepatocellular carcinoma and three patients with metastases underwent surgical resection 20-60 days after RF treatment. The remaining 32 patients were followed up clinically. RESULTS: The mean number of RF interstitial thermal ablation sessions to complete tumor nodule treatment was 1.4. Mean number of needle electrode insertions was 1.8. No complications were observed. Posttreatment dynamic CT showed a completely nonenhancing area in the site of the treated tumor in 44 of 45 cases. The remaining patient with metastatic disease had persistent enhancing tissue. Histology showed complete necrosis in four treated tumor nodules and residual viable cancer in one. Twenty-one patients with hepatocellular carcinoma were followed up for 6-19 months (mean, 10 months). Of these patients, six showed recurrences and 15 remained apparently disease-free. Two patients died, one from advanced cancer and one from other causes. Eleven patients with hepatic metastases were followed up for 7-20 months (mean, 12 months). Of these patients, nine showed recurrent disease and only two remained apparently disease-free. Two patients died from disseminated disease. CONCLUSION: RF interstitial thermal ablation of hepatic tumor by expandable needle electrodes is a safe and effective technique. Local ablation of tumors not exceeding 3.5 cm in diameter is achieved in a short time without complications.

Hepatic vascular malformations in hereditary hemorrhagic telangiectasia: Doppler sonographic screening in a large family.

BACKGROUND/AIMS: The prevalence of hepatic vascular malformations in hereditary hemorrhagic telangiectasia has been estimated in the literature on clinical criteria, thus giving unreliable data. In our study the presence of hepatic vascular malformations in hereditary hemorrhagic telangiectasia was evaluated in a large Italian family by using Doppler sonography findings were compared to computed tomography and angiography results. Clinical features were related to the severity of hepatic vascular malformations. METHODS: Seventy-three relatives were checked for the presence of signs of hereditary hemorrhagic telangiectasia. Abdominal Doppler ultrasonography was performed in all of them. Every subject with a positive Doppler ultrasonography for hepatic vascular malformations underwent abdominal computed tomography and celiac angiography. RESULTS: Forty family members proved to be affected by hereditary hemorrhagic telangiectasia. Of these, hepatic vascular malformations were evidenced by Doppler ultrasonography in 13 females. Doppler ultrasongraphy demonstrated minimal hepatic vascular abnormalities in three subjects, moderate in three, and severe in seven. Doppler study was diagnostic for arteriovenous shunt with hepatic veins in seven cases and with portal vein in two. Computed tomography failed to demonstrate hepatic vascular malformations in two cases, while angiography confirmed the Doppler sonographic findings in all cases. Cholestasis was present in subjects with moderate and severe hepatic vascular malformations. CONCLUSIONS: Doppler sonography is the ideal imaging technique to screen hereditary hemorrhagic telangiectasia affected families for hepatic vascular malformations. These malformations do not appear to be age-dependent, but sex-dependent. Cholestasis is the main clinical sign, and it seems to correlate with the severity of hepatic vascular derangement.

Percutaneous RF interstitial thermal ablation in the treatment of hepatic cancer.

OBJECTIVE: The aim of this study was to evaluate the usefulness of RF interstitial thermal ablation for treating hepatic cancer. SUBJECTS AND METHODS: Fifty patients, 39 who had 41 hepatocellular carcinoma nodules and 11 who had 13 hepatic metastatic nodules, underwent RF interstitial thermal ablation. In all but one, a thermal necrosis volume greater than the tumoral nodule volume was created to obtain total tumor destruction. One large tumor was treated for debulking purposes. RESULTS: Hepatocellular carcinoma nodule destruction was achieved in a mean of 3.3 sessions of RF interstitial thermal ablation. During a mean follow-up of 22.6 months (range, 3-66 months), 16 (41%) of 39 patients had recurrences; two (5%) of these patients showed local recurrences and the remaining 14 (36%) had new lesions. Nine of these 16 patients underwent further RF interstitial thermal ablation that proved effective. RF interstitial thermal ablation was also successfully repeated in four patients who had a second recurrence. With RF interstitial thermal ablation, we treated 54 hepatocellular carcinoma nodules in 39 patients. Eleven (28%) of the 39 patients died: five from hepatic failure due to advanced cancer and six from causes other than cancer. Autopsy was performed on three patients who died from causes other than cancer, one had had two new courses of RF interstitial thermal ablation for two new lesions. Gross examination failed to detect two treated tumor nodules; histologic examination of three other treated tumor nodules showed total necrosis in two nodules and a 3-mm focus of viable cancer cells in the other nodule. Cumulative survival curves showed the median survival time to be 44 months. The survival rate for the first year was 0.94, 0.86 for the second year, 0.68 for the third year, and 0.40 for the fourth and fifth years. In the patients treated for metastatic nodules, posttreatment imaging studies showed necrosis that varied from 80% to 100% in all cases. Pathologic studies performed on two patients who underwent surgery after RF interstitial thermal ablation showed 100% necrosis in one case and 80% necrosis in the other. CONCLUSION: RF interstitial thermal ablation is a useful percutaneous treatment for hepatic cancer.

Percutaneous radiofrequency interstitial thermal ablation in the treatment of small hepatocellular carcinoma.

PURPOSE: Very few patients affected by hepatocellular carcinoma can undergo surgery, though it is considered the only curative therapy. We evaluated minimally invasive, percutaneous radiofrequency interstitial thermal ablation for treatment of patients with hepatocellular carcinoma who had no surgical prospects. PATIENTS AND METHODS: Twenty-four patients (16 men and 8 women; age range, 53 to 79 years) with 25 hepatocellular carcinoma nodules of not more than 3.0-cm diameter underwent radiofrequency interstitial thermal ablation treatment with the intent to achieve a cure. In each patient, the thermal necrosis volume achieved was about double the tumor volume. RESULTS: At the end of treatment, destruction of the tumor was achieved in all but two cases in which further thermal lesions were needed. During the mean follow-up interval of 24.8 months (range, 6-64), 13 of 24 patients had recurrences, 9 of whom underwent further radiofrequency thermal ablation treatment. Radiofrequency thermal ablation was again repeated in two patients who showed a second recurrence. A total of 36 hepatocellular carcinoma nodules in 24 patients were treated. No complications were observed. Seven patients died: three due to hepatic failure with advanced cancer, three due to heart failure, and one due to pneumonia. Cumulative survival curves indicated that the median survival time was 44 months and survival rate was 0.95 the first year, 0.84 the second year, 0.67 the third year, and 0.45 the fourth and fifth years. CONCLUSIONS: Percutaneous radiofrequency thermal ablation can be considered a useful new treatment for small hepatocellular carcinoma in patients without surgical prospects. It is simple, effective, and safe, and can be repeated in case of recurrence.

Cardiac pacing in unilateral left superior vena cava: evaluation by digital angiography.

In a patient with complete heart block and chronic lymphocytic leukemia a pacemaker lead could not be introduced from either the right or left subclavian vein. Digital subtraction angiography excluded a neoplastic mediastinal mass, demonstrated a unilateral left superior vena cava and defined the best route for lead insertion.

Time-dependent increase of glomerular filtration rate after oral protein load: evidence for diurnal variations in renal response.

Seven healthy male volunteers were studied to test the effect of timing of an oral protein load on renal function. Creatinine clearance (Ccr) was measured during the 4-h period after administration of 72 g of protein in the form of cooked red meat at 1200 hours (lunch protein load, PL) and at 2000 hours (supper PL) the next evening. A low-protein meal in the form of vegetables was given as a control load at 2000 hours on the first day (supper control load, CL) and at 1200 hours on the second day (lunch CL). The 12-h night-time Ccr at fasting was used as the baseline reference value. After the lunch PL, Ccr (mean 127 +/- 6.8 ml/min) was 45% (p less than 0.001) higher than the baseline value (mean 87.9 +/- 5.3 ml/min) and 33% (p less than 0.001) higher than lunch CL (mean 95.8 +/- 5.6 ml/min). After the supper PL, Ccr (mean 106.2 +/- 8.7 ml/min) was 20% (p less than 0.01) higher than the baseline value and 15% (p less than 0.01) higher than the supper CL (mean 93.0 +/- 9.3 ml/min). The differences between baseline and control load values were not statistically significant. In all seven patients, the protein load induced a maximum Ccr value at lunchtime, and Ccr after the lunch PL was 22% higher than Ccr after the supper PL (p less than 0.01). We conclude that in healthy individuals, the Ccr after an oral protein load is correlated to the hour of the day when the study is performed.(ABSTRACT TRUNCATED AT 250 WORDS)