Volumetric analysis of the aneurysmal sac with computed tomography in the follow-up of abdominal aortic aneurysms after endovascular treatment.

PURPOSE: Our aim was to assess the usefulness of volumetric analysis for the follow-up of abdominal aortic aneurysms after endovascular repair (EVAR) and operator independence of the method. MATERIALS AND METHODS: We retrospectively evaluated 99 computed tomography (CT) exams of 33 patients. Two blinded operators assessed the volume before treatment and after EVAR at 1-3 and 12-24 months. Friedman's statistical test was used to assess the reproducibility of the method. The time required for postprocessing by the two operators was compared. RESULTS: One patient was excluded. Twenty-one patients showed no endoleak: 12/21 showed a volume reduction at both follow-up scans (9.7% and 19.5%, respectively); 8/21 showed an early volume increase (9.8%) with a late reduction (10.5%); 1/21 patient showed a volume increase at both follow-up scans (endotension). Eleven patients had an endoleak (one type I, nine type II and one type III); 4/9 type II endoleaks showed a volume reduction at both post-EVAR scans (8.5% and 19.5%). All other cases showed a volume increase after EVAR (type II 15.4%/16.8%, type I 24.1%/9.1%, type III 8%/10.7%). The Friedman statistical test assessed operator independence with p < 0.001. Mean difference between the two operators was 0.9% (0-4.3%). CONCLUSIONS: CT volume analysis is an accurate and reproducible modality for the follow-up of abdominal aortic aneurysms after EVAR. At early follow-up, contrast-enhanced CT remains mandatory to identify small endoleaks. For later follow-up, volumetric analysis would eliminate the need for contrast material in asymptomatic patients with stable or decreasing aneurysm volume.

A case of gastroduodenal artery aneurysm in a HIV-positive patient treated by combined percutaneous thrombin injection and endovascular coil embolization.

First described in 1989, HIV-related aneurysms have been rarely reported. Considered atypical if compared to classic atherosclerotic diseases, they show no preferred location and frequently involve young patients with no other risk factors for atherosclerosis but with an impaired immune system. They are probably related to an auto-immune damage inside the aortic wall associated with a necrotizing perivasculitis. Visceral artery aneurysms are rare and life-threatening diseases; the superior mesenteric and gastro-duodenal and pancreatic vessels are rarely involved. The advantages related to the endovascular approach to these aneurysms seems to be even more effective in immuno-impaired patients (i.e. HIV+). We report a case of a young patient affected by a HIV-related gastroduodenal artery aneurysm which was treated with a combined percutaneous and endovascular approach.

Imaging-guided percutaneous radiofrequency ablation of adrenal metastases: preliminary results at a single institution with a single device.

The aim of this study was to show the feasibility, safety, imaging appearance, and short-term efficacy of image-guided percutaneous radiofrequency ablation (RFA) of adrenal metastases (AM). Seven imaging-guided percutaneous RFA treatments were performed in six patients (two men and four women; mean age, 67.2 years; range, 55-74 years) with six AM who were referred to our institution from 2003 to 2006. One patient was treated twice for recurrence after first treatment. The average diameter of the treated AM was 29 mm (range, 15-40 mm). In all patients, the diagnosis was obtained with CT current protocols in use at our institution and confirmed by pathology with an image-guided biopsy. No major complications occurred. In one patient shortly after initiation of the procedure, severe hypertension was noted; another patient developed post-RFA syndrome. In five of six lesions, there was no residual enhancement of the treated tumor. In one patient CT examination showed areas of residual enhancement of the tumor after treatment. Our preliminary results suggest that imaging-guided percutaneous RFA is effective for local control of AM, without major complications and with a low morbidity rate related to the procedure. Long-term follow-up will need to be performed and appropriate patient selection criteria will need to be determined in future randomized trials.

Combined treatment of ablative therapy with percutaneous radiofrequency and cementoplasty of a symptomatic metastatic lesion of the acetabulum.

We report the case of a symptomatic metastatic lesion of the acetabulum from colon adenocarcinoma in an 82-year-old woman patient treated by a combined approach of thermal ablation with percutaneous radiofrequency and cementoplasty. We obtained an immediate technical success with a good control of pain without any complications at a 6-month clinical follow-up.

Colonic stenting for malignant disease: review of literature.

Colonic stents potentially offer effective palliation for patients with bowel obstruction attributable to incurable malignancy, and a "bridge to surgery" for those in whom emergency surgery would necessitate a stoma. Literature search of the Medline, Scopus and Cochrane Library was performed to identify comparative studies reporting outcomes on colonic stenting and surgery for large bowel obstruction; and to identify the use of stents as a "bridge to the elective surgery". Colorectal stenting can be considered a safe and effective procedure with a low mortality and morbidity for both preoperative and palliative decompression of colonic obstruction.

The impact of perioperative blood transfusion on clinical outcomes in colorectal surgery.

Colorectal cancer is the second-leading cause of cancer-related death in the US. The prognosis of advanced colorectal cancer remains poor in spite of the advances obtained in recent years with new therapeutic agents, new approaches in surgical procedures and new diagnostic methods. Currently, colorectal cancer is the second most common cancer in Europe both in terms of incidence and mortality. Approximately 90% of all cancer deaths arise from the metastatic dissemination of primary tumors. It is a matter of vital importance whether perioperative blood transfusion promotes tumor recurrence and morbidity. This paper reviews the relevant medical literature published in English language on the theoretical background, methodological problems, results, as well as the possible clinical impact of blood transfusions in colorectal surgery with well-controlled trials. Searches were last update August 2007.

Post-radiofrequency ablation syndrome after percutaneous radiofrequency of abdominal tumours: one centre experience and review of published works.

The aim of this study was to evaluate prospectively post-radiofrequency ablation (RFA) syndrome and to determine its effect on the quality of life in the 15 days after percutaneous RFA treatment. We carried out an internal review board-approved prospective study of the delayed symptoms that occurred after 71 consecutive RFA sessions in 53 patients (12 women and 41 men; age range 45-83 years; mean age 71.6 years) with 45 primary liver tumours, 34 liver metastases, 3 renal cell carcinoma (RCC), 2 residual lesions from RCC after nephrectomy and 1 pancreatic metastases from RCC. Postablation symptoms occurred in 17 of 53 (32%) patients. Six of 17 patients developed low-grade fever (from 37.5 to 38.5 degrees C). Other symptoms included delayed pain (9/17), nausea (7/17), vomiting (3/17), malaise (3/17) and myalgia (1). Postablation syndrome is a common phenomenon after RFA of solid abdominal tumours. Not only in our study but also in the previous ones the occurrence is observed in approximately one-third patients. Patients should be informed that these symptoms are self-limiting after RFA and most patients should be able to resume near-complete preprocedural levels of activity within 10 days after the procedure.

Endovascular treatment of isolated iliac artery aneurysms: 2-year follow-up.

PURPOSE: The aim of this study was to assess the effectiveness of endovascular treatment of isolated iliac artery aneurysms (IAAs). MATERIALS AND METHODS: Between March 1999 and March 2004, 15 isolated IAAs in 13 patients (mean age: 71.8 years) were selected for endovascular repair by means of a covered stent or stent-graft: 12 were in the common iliac artery (2 with the proximal end 12 mm from the aortic bifurcation and 2 involving the distal hypogastric artery), and three were in the external iliac artery. The preoperative study and the follow-up (at 3, 6 and 12 months and yearly thereafter) were performed by computed tomography (CT) angiography. RESULTS: Primary technical success was obtained in all cases, without periprocedural complications. Two patients died within 3 months and were not considered for follow-up. Follow-up (mean duration: 25 months, range: 6-60 months) in the remaining 11 patients, affected by 13 aneurysms, showed aneurysm exclusion in nine cases and progressive shrinkage of the aneurysmal sac in four cases, whereas in the other five, the size of the aneurysm remained unchanged. In a patient with bilateral IAA, bilateral proximal endoleaks were observed after 2 years, and the patient was treated with a bifurcated aortic stent-graft. In another patient with a large aneurysm, a left aortofemoral bypass became necessary after 2 months because of stent-graft dislodgement. In another patient, an endoleak from the hypogastric artery occurred after 2 years but was not treated. CONCLUSIONS: Endovascular treatment of isolated IAA is a feasible procedure that is less invasive than surgery and yields excellent short-and midterm results. However, a longer follow-up and larger patient series are needed to verify the long-term efficacy of this form of treatment.

Fluoroscopically guided retrograde replacement of ureteral stents.

PURPOSE: We assessed the feasibility of fluoroscopically guided transurethral replacement of ureteral stents as an alternative to cystoscopy. MATERIALS AND METHODS: Over the last year, we replaced 27 double-J ureteral stents in 20 patients (10 men and 10 women; mean age 67.7 years, range 43-83); 15/20 patients had a native kidney, 3/20 had a transplanted kidney and 2/20 had a ureteroileal conduit. The procedures were performed in the angiography suite with the patient under sedation. All stents were grasped with a gooseneck snare under fluoroscopic control, and the distal end was withdrawn just outside the urethra; then a wire was advanced through the stent lumen and positioned in the renal pelvis. The stent was then removed and replaced with a new double-J stent. RESULTS: The procedures were successful in 26/27 cases. We observed 7 cases of mild haematuria that resolved spontaneously. During follow-up (1-16 months, mean 6.7), stent obstruction occurred in 4 cases, requiring an additional retrograde replacement. CONCLUSIONS: Transurethral fluoroscopically guided retrograde replacement of dysfunctioning ureteral stents is an effective and safe alternative to cystoscopy.

Complications of percutaneous nephrostomy in the treatment of malignant ureteral obstructions: single-centre review.

PURPOSE: The purpose of this study was to evaluate the incidence and type of complications connected with percutaneous nephrostomy (PCN) deployment by comparing two different techniques. MATERIALS AND METHODS: In the last 3 years, 299 procedures of nephrostomy were performed on 201 patients (93 women, 108 men; mean age 65.7 years, range 32-102 years) at our Institute; all patients were affected by malignancy. In 44 cases (14.72%), patients presented grade IV hydronephrosis and in 255 cases (85.28%) grade II-III hydronephrosis. In 68 patients (23.07%), the procedure was carried out under emergency conditions because of the rapid worsening of renal function. All procedures were carried out in the angiography room, with the patient lying in a prone or prone-oblique position, under ultrasound and fluoroscopic guidance. Access to the pyelocalyceal system (intermediate or lower calices) was performed by using a Seldinger technique in 255/299 cases, or a one-step technique (OST) in 44 procedures when grade 4 hydronephrosis was present. Statistical analysis of results was performed using bilateral tests on proportions as well as chi2 test of independence for contingency tables. RESULTS: We observed no major complications. All in all, the rate of minor complications was 3.01% (9/299 cases): 8/255 (3.13%) cases with the Seldinger technique; 1/44 (2.27%) with OST. We observed 43/299 (14.4%) dislodgements: 32/255 (10.70%) with the Seldinger technique and 11/44 (3,68%) with OST. In 4/299 (1.33%), rupture of the catheter occurred, and in 2/299 (0.67%), kinking occurred (in all cases with OST). From the statistical analysis, we conclude that the examination technique modifies the percentage of complications; in particular, it significantly (p<0.05) influences complications connected with the catheter but not minor complications. In addition, the system of fixing does not affect the percentage of dislodgements. CONCLUSIONS: PCN is a method with a high percentage of technical success with low rate of complications thanks to combined use of sonographic and fluoroscopic guidance for the procedure. The OST technique is indicated for a highly remarkable hydronephrosis and in cases where the catheter is only placed for a short period. The Seldinger technique is carried out in patients with grades II and III hydronephrosis and if the disease is predicted to have a long duration.

Cutting Balloon angioplasty for the treatment of haemodyalisis vascular accesses: midterm results.

PURPOSE: The purpose of this study was to assess the effectiveness of Cutting Balloon angioplasty in the treatment of stenoses in haemodialysis arteriovenous accesses. MATERIALS AND METHODS: Over the past 2 years, we have observed 80 patients with stenotic haemodialysis accesses; 24 of these (mean age 66.4 years, range 50-81) with 26 stenoses of 24 accesses (21 Cimino-Brescia fistulas and 3 dialysis loops) were selected for Cutting Balloon angioplasty. In 11 cases, the Cutting Balloon device was used after failure to dilate the access with a high-pressure balloon whereas in 15 cases (10 focal stenoses and 5 restenoses), it was used as a first choice. Two Cutting Balloon devices had a diameter of 8 mm, two of 7 mm, 11 of 6 mm, eight of 5 mm and one of 4 mm. The follow-up was performed by colour Doppler ultrasound (CDUS) and clinical assessment at 1, 3, 6, 12, 18 and 24 months. RESULTS: In all patients, postprocedure angiography demonstrated immediate technical success. No periprocedural complications occurred. Follow-up examinations (range 3-24 months, mean 18.2 months) demonstrated patency of the vascular access and its good functioning during dialysis in 23/24 cases (95%). Only in one case did we observe a haemodynamically significant restenosis, which was treated again with Cutting Balloon angioplasty. CONCLUSIONS: Cutting Balloon angioplasty is safe and effective in the treatment of haemodialysis access stenosis, especially in cases of severe stenosis, with low restenosis rate both in the short and medium term.

Utility of computed tomography (CT) and of fine needle aspiration biopsy (FNAB) in early diagnosis of fungal pulmonary infections. Study of infections from filamentous fungi in haematologically immunodeficient patients.

PURPOSE: The purpose of this study was to evaluate the sensitivity of percutaneous computed tomography (CT)-guided lung biopsy in the early diagnosis of fungal pulmonary infections. MATERIALS AND METHODS: Between 1997 and 2003, 18 haematologically immunodeficient patients with suspected filamentous fungi infection and negative bronchoalveolar lavage (BAL) underwent percutaneous pulmonary biopsy to diagnose the nature of the infection. In all cases, infection developed during the post-chemotherapy bone marrow aplasia period. RESULTS: Thirteen out of 18 patients had histologic findings positive for fungal infection: 8 Aspergillus and 5 Mucor. In 3 cases, biopsy was not specific, and in one case, the tissue sample was inadequate for a diagnosis; however, clinical course and response to drugs were compatible with fungal infection. In one patient, biopsy was positive for bronchoalveolar carcinoma. The sensitivity of percutaneous CT-guided biopsy was 80% and its positive predictive value was 100%. We only had one pneumothorax as a complication. CONCLUSIONS: Percutaneous CT-guided lung biopsy is an easy, safe and reliable procedure to obtain diagnostic material. Histological discrimination between Aspergillus and Mucor is important in order to plan the correct therapeutic protocols, as Mucor is usually resistant to azoles.