Damage Control Interventional Radiology in Liver Trauma: A Comprehensive Review.

The liver is the second most common solid organ injured in blunt and penetrating abdominal trauma. Non-operative management (NOM) has become the standard of care for liver injuries in stable patients, where transarterial embolization (TAE) represents the main treatment, increasing success rates and avoiding invasive surgical procedures. In hemodynamically (HD) unstable patients, operative management (OM) is the standard of care. To date, there are no consensus guidelines about the endovascular treatment of patients with HD instability or in ones that responded to initial infusion therapy. A review of the literature was performed for published papers addressing the outcome of using TAE as the primary treatment for HD unstable/transient responder trauma liver patients with hemorrhagic vascular lesions, both as a single treatment and in combination with surgical treatment, focusing additionally on the different definitions used in the literature of unstable and transient responder patients. Our review demonstrated a good outcome in HD unstable/transient responder liver trauma patients treated with TAE but there still remains much debate about the definition of unstable and transient responder patients.

Value of multidetector computed tomography angiography in severe non-variceal upper gastrointestinal bleeding: a retrospective study in a referral bleeding unit.

BACKGROUND: Non-variceal upper gastrointestinal bleeding is a common gastroenterological emergency associated with significant morbidity and mortality. Upper gastrointestinal endoscopy is currently recommended as the gold standard modality for both diagnosis and treatment. As historically played a limited role in the diagnosis of acute non-variceal upper gastrointestinal bleeding, multidetector-row computed tomography angiography is emerging as a promising tool in the diagnosis of non-variceal upper gastrointestinal bleeding, especially for severe cases. However, to date, evidence concerning the role of multidetector-row computed tomography angiography in the non-variceal upper gastrointestinal bleeding diagnosis is still lacking. AIM: The purpose of this study was to retrospectively investigate the diagnostic performance of emergent multidetector-row computed tomography angiography performed prior to any diagnostic modality or following urgent upper endoscopy to identify the status, the site, and the underlying etiology of severe non-variceal upper gastrointestinal bleeding. METHODS: Institutional databases were reviewed in order to identify severe acute non-variceal upper gastrointestinal bleeding patients who were admitted to our bleeding unit and were referred for emergent multidetector-row computed tomography angiography prior to any hemostatic treatment (< 3 h) or following (< 3 h) endoscopy, between December 2019 and October 2022. The study aim was to evaluate the diagnostic performance of multidetector-row computed tomography angiography to detect the status, the site, and the etiology of severe non-variceal upper gastrointestinal bleeding with endoscopy, digital subtraction angiography, surgery, pathology, or a combination of them as reference standards. RESULTS: A total of 68 patients (38 men, median age 69 years [range 25-96]) were enrolled. The overall multidetector-row computed tomography angiography sensitivity, specificity, and accuracy to diagnose bleeding status were 77.8% (95% CI: 65.5-87.3), 40% (95% CI: 5.3-85.3), and 75% (95% CI: 63.0-84.7), respectively. Finally, the overall multidetector-row computed tomography angiography sensitivity to identify the bleeding site and the bleeding etiology were 92.4% (95% CI: 83.2-97.5) and 79% (95% CI: 66.8-88.3), respectively. CONCLUSION: Although esophagogastroduodenoscopy is the mainstay in the diagnosis and treatment of most non-variceal upper gastrointestinal bleeding cases, multidetector-row computed tomography angiography seems to be a feasible and effective modality in detecting the site, the status, and the etiology of severe acute non-variceal upper gastrointestinal bleeding. It may play a crucial role in the management of selected cases of non-variceal upper gastrointestinal bleeding, especially those clinically severe and/or secondary to rare and extraordinary rare sources, effectively guiding timing and type of treatment. However, further large prospective studies are needed to clarify the role of multidetector-row computed tomography angiography in the diagnostic process of acute non-variceal upper gastrointestinal bleeding.

Pseudoaneurysms embolization with glue via percutaneous direct puncture: a multicenter experience on 54 patients.

BACKGROUND: This retrospective multicentric study aims to report on technical safety and effectiveness of pseudoaneurysms embolization with glue (N-butyl cyanoacrylate) adopting a percutaneous direct puncture approach. RESULTS: Fifty-four patients data were collected from five centers. All patients at the time of treatment presented with unruptured PAs and were hemodynamically stable. True aneurysms and lesions treated with embolics other than glue were excluded. Pseudoaneurysms diagnosis was based on CT and anamnestic data; initial investigation with digital-subtracted arteriography was acquired in all cases; then, percutaneous embolizations were performed in the angio-suite (ultrasound, fluoroscopy, ConeBeam CT guidance) or in CT. Technical success was considered as complete pseudoaneurysm embolization at final imaging with sole percutaneous strategy, without need for additional endovascular embolization. Clinical success was intended as pseudoaneurysm resolution within one week follow-up with stabilization or restored clinical conditions. Pseudoaneurysms origins were traumatic (57.4%), inflammatory (24.1%) or spontaneous (18.5%); 39 patients (72.2%) were symptomatic, presenting with pain and/or pulsatile mass. Mean lesions diameter was 19.3 mm (range: 7-30); pseudoaneurysms were located in abdomen (48.1%), limbs (42.6%) and thorax (9.3%). Coagulation function was impaired in 16.6% and 48.1% was under antiplatelets/anticoagulation therapy. In 16.6% the percutaneous approach followed previous treatments failure. The image-guidance modality for percutaneous puncture was most often ultrasound combined with fluoroscopy (38%). Clinical success was obtained in all patients while technical success occurred in 94.4% because 3 patients required an additional endovascular embolization. Complications were registered in 14.8%, all of low grade without clinical sequelae neither prolonged recovery (7 non target embolizations, 1 post-embolization syndrome). CONCLUSIONS: In this study, pseudoaneurysms embolization with glue via percutaneous direct puncture was safe and effective with a low rate of minor complications.

Combined DSA- and US-guided management of acute bleeding: effectiveness of percutaneous glue embolization in six cases.

AIMS: This study aims to report on safety and effectiveness of glue embolization of acute hemorrhages performed by US-guided percutaneous direct puncture, in patients where the standard endovascular approach is technically unfavourable. METHODS: In this single center retrospective analysis, patients affected by traumatic or non traumatic acute hemorrhages were treated with glue embolization technically performed by US-guided direct puncture. Patients suffered from active bleeding detected at contrast-enhanced Computer Tomography and confirmed at Digital Subtracted Arteriography, with concomitant hemoglobin drop and blood pressure reduction. Six patients were reviewed; hemorrhages occurred in liver parenchima (1), gallbladder (1) and lower limbs (4). Bleedings etiologies were post-traumatic (5) and inflammatory (1); four had extraluminal blushes while 2 were pseudoaneurysms. In five cases (4 limbs and 1 hepatic bleedings) the direct-puncture approach was adopted because of technically unfavourable vascular anatomy for superselective embolization; in one case (cystic artery pseudoaneurysm), an endovascular embolization would entail a high risk of gallbladder ischemia because of its terminal arterial supply. Technical success was defined disappearance of bleeding signs at last arteriography; clinical success was considered stabilization and/or improvement of hemoglobin values and arterial pressure without additional interventions. RESULTS: Both technical and clinical successes were obtained in 100% of the cases without major complications. No needle occlusion occurred during glue injection. CONCLUSIONS: In this study percutaneous US-guided embolization by direct puncture was a safe and effective approach to manage acute bleedings; it could be considered as an alternative in patients with unfavourable vascular anatomy for the standard catheter-directed endovascular embolization.

Guidelines on the diagnosis, treatment and management of visceral and renal arteries aneurysms: a joint assessment by the Italian Societies of Vascular and Endovascular Surgery (SICVE) and Medical and Interventional Radiology (SIRM).

The objective of these Guidelines is to provide recommendations for the classification, indication, treatment and management of patients suffering from aneurysmal pathology of the visceral and renal arteries. The methodology applied was the GRADE-SIGN version, and followed the instructions of the AGREE quality of reporting checklist. Clinical questions, structured according to the PICO (Population, Intervention, Comparator, Outcome) model, were formulated, and systematic literature reviews were carried out according to them. Selected articles were evaluated through specific methodological checklists. Considered Judgments were compiled for each clinical question in which the characteristics of the body of available evidence were evaluated in order to establish recommendations. Overall, 79 clinical practice recommendations were proposed. Indications for treatment and therapeutic options were discussed for each arterial district, as well as follow-up and medical management, in both candidate patients for conservative therapy and patients who underwent treatment. The recommendations provided by these guidelines simplify and improve decision-making processes and diagnostic-therapeutic pathways of patients with visceral and renal arteries aneurysms. Their widespread use is recommended.

Pelvic ring fractures with concomitant large hematomas: diagnostic investigation with arteriography and eventual embolization in 157 trauma patients, with or without contrast extravasation at emergency CT.

PURPOSE: This study aims to evaluate the diagnostic value of pelvic arteriography in patients with pelvic ring fractures and associated large hematomas, in both cases of positive or negative findings of contrast agent extravasation at emergency CT; in those patients with positive DSA subsequently treated with embolization, correlations with clinical-radiological parameters were investigated. MATERIALS AND METHODS: In this single-center retrospective study, patients with acute blunt pelvic trauma showing at CT pelvic ring fractures with associated large (> 3 cm) hematoma, with or without signs of arterial bleeding, were investigated with DSA. Technical success was considered radiographic bleeding control with disappearance of angiographic bleeding; clinical success was defined as clinical bleeding control hemodynamically stable, before applying other surgical maneuvers. Pelvic ring fractures were evaluated according to Tile classification system. RESULTS: One hundred and fifty-seven patients, mean age 54years, were analyzed. 70.7% had polytrauma; 14.6% patients assumed antiplatelets and/or anticoagulation therapy. False-negative and false-positive rates at CT were 29.6% and 27.1%, respectively. Polytrauma and B3/C1 Tile pattern fractures were significantly associated with bleeding signs at DSA. Seventy-two patients required embolization: 52.8% showed direct signs of DSA bleeding; among these, technical and clinical successes were 88.8% and 81.9%, respectively. CONCLUSIONS: In this study, patients with pelvic ring fractures and concomitant hematomas > 3 cm, with or without contrast extravasation at CT, have been examined in depth with DSA focusing on both direct and indirect angiographic signs of bleeding, finding polytrauma and Tile fracture patterns B3/C1 predictive factors for arterial hemorrhage detection at DSA despite negative CT findings.

Effectiveness and Safety of Different Vascular Closure Devices: Multicentre Prospective Observational study.

AIM: The aim of this prospective, multicentre, observational study was to compare the efficacy and safety of balloon-based and non-balloon-based vascular closure devices (VCDs). MATERIALS AND METHODS: From March 2021 to May 2022, 2373 participants from 10 different centres were enrolled. Among them, 1672 patients with 5-7 Fr accesses were selected. Successful haemostasis, failure and safety were evaluated. Successful haemostasis was defined as the possibility to obtain complete haemostasis with the use of VCDs, without any complication. Failure management was defined as the need of manual compression. Safety was defined as the rate of complications. Cases of haematomas/pseudoaneurysms (PSA) and artero-venous fistula (AVF) were collected. RESULTS: VCDs mechanism of action is statistically significant associated with the outcome. Non-balloon-based VCDs demonstrated a statistically significant better outcome: successful haemostasis was obtained in 96.5% vs. 85.9%, of cases when compared to balloon occluders (p < 0.001). The incidence of AVF was statistically more frequent using non-balloon occluders devices (1.57% vs 0%, p: 0.007). No significant statistical difference was found in comparing haematoma and PSA occurrence. Thrombocytopenia, coagulation deficit, BMI, diabetes mellitus and anti-coagulation were demonstrated to be independent predictors of failure management. CONCLUSION: Our study suggests a better outcome with the same complication rate, except that for AVF incidence for non-balloon collagen plug device if compared to balloon occluders vascular closure devices.

Percutaneous Embolization of Biliary Leaks: Initial Experience with Extravascular Application of a PTFE-Covered Microplug.

PURPOSE: This paper describes the initial experience with a PTFE-covered microplug to perform extravascular embolizations in patients with iatrogenic biliary leaks. MATERIALS AND METHODS: A retrospective multicenter analysis has been conducted on seven patients. All were symptomatic for abdominal pain and had an abdominal drainage adjacent to the supposed site of leakage. The biliary output of the drainage was monitored daily. Biliary leak etiology was iatrogenic: four after laparoscopic cholecistectomy for gallstones, one after explorative laparotomy for pancreas head adenocarcinoma with concomitant cholecistectomy for gallstones, and two after long-standing internal-external right biliary drainage for cholangiocarcinoma. In four cases leakage sourced from cystic duct stump, in one from an aberrant bile duct and in two from bilio-cutaneous fistula. Technical success was considered leak resolution at the last cholangiography. Clinical success was defined improvement in the clinical conditions together with progressive resolution of the biliary output from the abdominal drainage until removal. RESULTS: Technical and clinical successes were 100%. A 5 mm microplug was adopted in five cases of post-cholecistectomy leaks. A 3 mm microplug and a 9 mm microplug were deployed in the two cases of peripheral leaks related to bilio-cutaneous fistulas. In three patients additional embolics (coils in two cases; spongel slurry in one case) were required. Minor complications occurred in three patients. CONCLUSION: This initial experience on seven patients with iatrogenic biliary leaks demonstrated that percutaneous transhepatic PTFE-covered microplug embolization is technically feasible and clinically effective to achieve leak resolution. Future researches with larger samples are needed to confirm these findings.

The Role of CT-Angiography in the Acute Gastrointestinal Bleeding: A Pictorial Essay of Active and Obscure Findings.

Gastrointestinal bleeding is a potentially life-threatening abdominal emergency that remains a common cause of hospitalisation. Although 80-85% of cases of gastrointestinal bleeding resolve spontaneously, it can result in massive haemorrhage and death. The presentation of gastrointestinal bleeding can range from asymptomatic or mildly ill patients requiring only conservative treatments to severely ill patients requiring immediate intervention. Identifying the source of the bleeding can be difficult due to the wide range of potential causes, the length of the gastrointestinal tract and the intermittent nature of the bleeding. The diagnostic and therapeutic approach is fully dependent on the nature of the bleeding and the patient's haemodynamic status. Radiologists should be aware of the appropriate uses of computed tomography angiography and other imaging modalities in patients with acute gastrointestinal bleeding, as well as the semiotics of bleeding and diagnostic pitfalls in order to appropriately diagnose and manage these patients. The learning objective of this review is to illustrate the computed tomography angiography technique, including the potential role of dual-energy computed tomography angiography, also highlighting the tips and tricks to identify the most common and uncommon features of acute gastrointestinal bleeding and its obscure form.

Massive bleeding from gastric submucosal arterial collaterals secondary to splenic artery thrombosis: A case report.

BACKGROUND: Gastric submucosal arterial collaterals (GSAC) secondary to splenic artery occlusion is an extraordinary rare and potentially life-threatening cause of acute upper gastrointestinal bleeding. Here, we report a case of massive bleeding from GSAC successfully treated by means of a multidisciplinary minimally invasive approach. CASE SUMMARY: A 60-year-old non-cirrhotic gentleman with a history of arterial hypertension was admitted due to hematemesis. Emergent esophagogastroduodenoscopy revealed pulsating and tortuous varicose shaped submucosal vessels in the gastric fundus along with a small erosion overlying one of the vessels. In order to characterize the fundic lesion, pre-operative emergent computed tomography-angiography was performed showing splenic artery thrombosis (SAT) and tortuous arterial structures arising from the left gastric artery and the left gastroepiploic artery in the gastric fundus. GSAC was successfully treated by means of a minimally invasive step-up approach consisting in endoscopic clipping followed by transcatheter arterial embolization (TAE). CONCLUSION: This was a previously unreported case of bleeding GSAC secondary to SAT successfully managed by means of a multidisciplinary minimally invasive approach consisting in endoscopic clipping for the luminal bleeding control followed by elective TAE for the definitive treatment.

PHIL® (precipitating hydrophobic injectable liquid): retrospective multicenter experience on 178 patients in peripheral embolizations.

PURPOSE: This study aims to analyze safety and effectiveness of PHIL® (Microvention, CA-USA) in peripheral endovascular embolization procedures, both in elective and emergent scenarios. MATERIALS AND METHODS: This is a multicenter retrospective study, involving 178 patients from five interventional radiology departments from January 2017 to December 2021. Patients treated by an endovascular embolization with PHIL® were included; different PHIL® viscosities were adopted. Exclusion criteria were: neuroradiological endovascular interventions, other cohesive liquid embolics adopted during the same procedure, follow-up < 30 days. Technical success was intended as definitive target vessel occlusion without the need for other embolics after PHIL® injection. Clinical success was considered as restoration of hemodynamic status in case of emergent embolization and improvement of clinical conditions in case of elective procedures, without additional interventions at 30 days. RESULTS: Sixty-four women and 114 men, mean age 62 years (range 6-91), were evaluated. Sixty-three patients were in elective scenarios (AVMs, type-II endoleaks, tumors, varices, aneurysms, varicoceles) and 115 were in emergent settings (hemorrhage, pseudoaneurysms, hemoptysis, priapism); 190 procedures were performed in 178 patients. Overall technical and clinical success rates were 94.7% and 92.1%, respectively. The complications rate was 7.4% (6 grade-I, 7 grade-III, 1 grade-IV). PHIL®-25 was the more adopted viscosity; totally, 311 vials were injected (rate: 1.64 vial/procedure). CONCLUSION: In this series, PHIL® proved to be a safe and effective liquid embolic in peripheral embolizations, both in elective and emergent scenarios. The pre-filled syringe preparation allowed operators to use it even when unplanned at beginning of the intervention.

Primary non-parasitic splenic cyst: US- and fluoroscopy-guided percutaneous management by alcohol sclerosis on six patients.

PURPOSE: This manuscript aims to report on a retrospective analysis of six patients treated with combined US- and fluoroscopic-guided percutaneous alcohol sclerosis for primary non-parasitic splenic cysts. METHODS: In this retrospective analysis, three females and three males affected by primary non-parasitic splenic cysts were included. All except one were symptomatic. Preoperative cyst diameter was in mean 113 mm (range: 67-210 mm). Ethanol 96% was adopted as sclerosant agent; the amount of ethanol injected corresponded to the 20%-30% of the cystic volume. US follow-up was planned at 2/4 weeks; MR follow-up was conducted almost at 6 months after the last treatment session. Technical success was considered as cyst disappearance or reduction of the maximum diameter <50 mm; clinical success, in those symptomatic cases, was considered as symptoms resolution or marked improvement. RESULTS: Eleven procedures had been performed: one in three patients, three in two patients and two in one patient. Technical success was 83.3%; clinical success was 80%. Only one patient, with a preoperative cystic diameter of 210 mm and despite three treatment sessions, had an increase in the cystic size and did not report symptoms improvement. CONCLUSIONS: In this sample, US-guided percutaneous alcohol sclerosis was a safe and effective spleen preserving option to treat primary non-parasitic splenic cysts.

Endovascular treatment of cesarean scar pregnancy: a retrospective multicentric study.

PURPOSE: To assess the role of Uterine Artery Embolization (UAE) to treat cesarean scar pregnancy (CSP) using different embolic materials, focusing on its clinical and technical success rates; the association of UAE with methotrexate (MTX) and/or dilatation & curettage (D&C) was evaluated also. MATERIALS AND METHODS: A retrospective analysis 33 patients (mean age 35 years) affected by CSP and treated with UAE from March 2012 to 2020 was performed. Dynamic levels of serum ß-HCG have been collected until they decreased to normal values after procedures. For the statistical analysis the sample was divided into 2 groups: UAE versus UAE + MTX. RESULTS: The gestational sac age ranged between 5 and 13 weeks (mean 7 weeks). According to operator's preference, 11 patients (33.33%) were treated with sponge injection, 2 patients (6.06%) with a combination of sponge and microsphere the remaining 20 patients (60.60%) with microspheres alone. No major complications occurred after UAE and D&C, neither side effects related to the MTX administration. Technical and clinical success rates were 97% and 85%, respectively. Mean percentage of ß-HCG reduction was 90% (range - 99.92 to + 7.98%). Statistical analysis with linear regression shows a R2 value of 0.9624 in UAE group while a R2 value of 0.9440 in UAE + MTX group with statistical significance (p < 0.0001). No significative differences were found between the two groups about clinical success rate and embolic material adopted. CONCLUSION: In this series UAE has been found to be safe and effective for the treatment of CSP.

Guidelines on the management of abdominal aortic aneurysms: updates from the Italian Society of Vascular and Endovascular Surgery (SICVE).

The objective of these Guidelines was to revise and update the previous 2016 Italian Guidelines on Abdominal Aortic Aneurysm Disease, in accordance with the National Guidelines System (SNLG), to guide every practitioner toward the most correct management pathway for this pathology. The methodology applied in this update was the GRADE-SIGN version methodology, following the instructions of the AGREE quality of reporting checklist as well. The first methodological step was the formulation of clinical questions structured according to the PICO (Population, Intervention, Comparison, Outcome) model according to which the Recommendations were issued. Then, systematic reviews of the Literature were carried out for each PICO question or for homogeneous groups of questions, followed by the selection of the articles and the assessment of the methodological quality for each of them using qualitative checklists. Finally, a Considered Judgment form was filled in for each clinical question, in which the features of the evidence as a whole are assessed to establish the transition from the level of evidence to the direction and strength of the recommendations. These guidelines outline the correct management of patients with abdominal aortic aneurysm in terms of screening and surveillance. Medical management and indication for surgery are discussed, as well as preoperative assessment regarding patients' background and surgical risk evaluation. Once the indication for surgery has been established, the options for traditional open and endovascular surgery are described and compared, focusing specifically on patients with ruptured abdominal aortic aneurysms as well. Finally, indications for early and late postoperative follow-up are explained. The most recent evidence in the Literature has been able to confirm and possibly modify the previous recommendations updating them, likewise to propose new recommendations on prospectively relevant topics.

Splenic Artery Pseudoaneurysms: The Role of ce-CT for Diagnosis and Treatment Planning.

Splenic artery pseudoaneurysm (PSA) is a contained vascular wall lesion associated with a high mortality rate, generally related to pancreatitis, trauma, malignancy, iatrogenic injury, and segmental arterial mediolysis. Computed tomography angiography allows us to visualize the vascular anatomy, differentiate a PSA from an aneurysm, and provide adequate information for endovascular/surgical treatment. The present review reports on the main state-of-the-art splenic artery PSA diagnosis, differentiating between the pros and cons of the imaging methods and about the endovascular treatment.

Scrubbing needles: a simple and costless technique to improve needle tip visibility during US-guided liver interventions.

AIMS: To evaluate the echogenicity of a commercially available needle, modified on the tip, by comparing two groups of patients undergoing to percutaneous biliary drainage. METHODS: In this retrospective analysis 16 percutaneous transhepatic biliary drainage (PTBD) procedures performed on 16 oncologic patients were evaluated. Patients were randomly divided into two groups of eight subjects each; in the first group, a standard needle was adopted (group A); in the second group, the needle was manually modified to create a rough surface (group B), by scrubbing the tip with an 11 scalpel blade for 150 s all around its surface. To objectively quantify US needle tip visibility, the contrast-to-noise ratio (CNR) was calculated analyzing B-mode images by positioning region of interests in correspondence of needle tip and liver parenchyma. RESULTS: Needle tip echogenicity was significantly higher in group B where the needle tip was modified compared to control group A (p value = 0.014). CNR, considered to objectively evaluate differences among needle tip echogenicity, was significantly higher in group B with respect to control group A (p value = 0.018). CONCLUSIONS: The proposed method, scrubbing a 22 gauge commercially available needle tip with a scalpel blade, represents an effective technique to improve needle visibility during US-guided punctures of the liver.

Acute upper gastrointestinal bleeding caused by esophageal right bronchial artery fistula: A case report.

BACKGROUND: Fistula between the esophagus and bronchial artery is an extremely rare and potentially life-threatening cause of acute upper gastrointestinal bleeding. Here, we report a case of fistula formation between the esophagus and a nonaneurysmal right bronchial artery (RBA). CASE SUMMARY: An 80-year-old woman with previous left pneumonectomy and recent placement of an uncovered self-expandable metallic stent for esophageal adenocarcinoma was admitted due to hematemesis. Emergent computed tomography showed indirect signs of fistulization between the esophagus and a nonaneurysmal RBA, in the absence of active bleeding. Endoscopy revealed the esophageal stent correctly placed and a moderate amount of red blood within the stomach, in the absence of active bleeding or tumor ingrowth/overgrowth. After prompt multidisciplinary evaluation, a step-up approach was planned. The bleeding was successfully controlled by esophageal restenting followed by RBA embolization. No signs of rebleeding were observed and the patient was discharged home with stable hemoglobin level on postoperative day 7. CONCLUSION: This was a previously unreported case of an esophageal RBA fistula successfully managed by esophageal restenting followed by RBA embolization.