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.

Complex central venous catheter for dialysis: interventional radiology experience in insertion and management of their complications.

BACKGROUND: CVCs are defined 'complex' when they are inserted through non-conventional accesses or positioned in non-usual sites or substituted by IR endovascular procedures. We report our experience in using diagnostic and interventional radiology techniques for complex CVC insertion and management; we recommend some precautions and techniques that could lead to long-term availability of central venous access and to avoid non-conventional sites CVC insertion. METHODS: We retrospectively evaluated 617 patients, between January 2010 and December 2019, (mean age 71 ± 13; male 448/617), treated in our department for insertion of tunnelled CVC for haemodialysis. RESULTS: Among 617 patients, 241 cases (39%) are considered 'complex' because they required either a PTA with or without stenting to restore/maintain venous access or had an unusual positioning site or required unconventional access. A direct correlation between CT angiography and PTA (r = 0.95; p-value <0.001) and an inverse correlation between CT angiography and unconventional 'rescue' access (r = -0.92; p-value <0.001) were found. CONCLUSIONS: Precise pre-operative planning of treatment in a multidisciplinary setting and diagnostic and interventional radiology procedures knowledge allows reducing complex catheterisms in haemodialysis patient.

Prognostic risk factors for loss of patency after femoropopliteal bailout stenting with dual-component stent: results from the TIGRIS Italian Multicenter Registry.

PURPOSE: To identify the risk factors associated with patency loss after bailout stenting with third-generation hybrid heparin-bonded nitinol stent of the femoropopliteal segment. METHODS: Prospective, multicenter, single-arm registry including 156 patients (50 females, mean age 72 ± 11 years) subjected, from February 2017 to December 2018, to provisional stenting with Gore Tigris vascular stent of the distal superficial femoral artery, with or without involvement of the popliteal artery, in 9 different centers. The 194 lesions, with Rutherford score ≥ 3, were stented in case of recoil, dissection or residual stenosis not responding to percutaneous trans-luminal angioplasty (PTA). The follow-up (FU) was performed with clinical evaluation and duplex ultrasound (DUS) at 1, 6 and 12 months. RESULTS: The primary patency rate was 99(95%CI 98-100)% at 1 month, 86(80-92)% at 6 months and 81(74-88)% at-12 months. After patency loss, 13/23 (56.5%) patients were re-treated, yielding a primary assisted patency of 91(86-96)% at 6 months and 88(82-94)% at 12 months and a secondary patency of 94(90-98)% at 6 months and 90(84-95)% at 12 months. Rutherford score ≥ 4 (p = 0.03) and previous severe treatments (p = 0.01) were identified as risk factors for early patency loss during FU. The involvement of the popliteal artery was not an independent risk factor for loss of patency. CONCLUSIONS: The bailout stenting of the femoropopliteal segment with third-generation nitinol stents is a safe and effective option in case of recoil, dissection or residual stenosis not responding to PTA. Critical limb ischemia and history of previous major treatment at the same level are significant prognostic factors for patency loss during FU.

Asynchronous Bilateral Ureteric-Arterial Fistula: Diagnosis and Treatment.

A 48-year-old woman submitted to anterior exenteration plus ileal-cutaneous conduit for metastatic cervical cancer during the change of the ureteral stent showed massive bleeding in the left ureter. A selective intra-arterial angiography showed a fistula between the ureter and the left common iliac artery that the interventional radiologist quickly repaired by inserting a vascular endoprosthesis. Six months later, gross hematuria secondary to right ureter-iliac fistula occurred again and a second endoprosthesis was inserted. Asynchronous bilateral ureteric stent-related vascular fistula is an uncommon scenario, but it should be suspected in the presence of hematuria following ureteral stent replacement.

Gynecological Malignancies: Bail-Out Interventional Radiology Treatments.

Interventional radiology presents nowadays a relevant role in the management of gynecological malignancies, especially in advanced stages where conventional surgery may be contraindicated. Progression to multiorgan failure may be related to cancer disease extension or, more acutely, to concomitant infections, bleedings or thromboembolic complications. Infiltration of adjacent organs, as ureters and biliary ducts, ascites and pelvic collections often occur in advanced stages: considering the clinical fragility of these patients, percutaneous procedures are frequently applied. Regarding hemorrhagic complications, bleeding may occur into the tumor itself, due to cancer tissue erosion and vessels infiltration, or may be related to iatrogenic vascular lesions consequent to surgery, mini-invasive procedures and chemoradiotherapy; embolization represents a bail-out treatment in both acute and chronic scenarios. Aim of this paper is to review interventional radiology procedures in patients affected by gynecological malignancies in advanced stages not suitable for surgery.

Treatment of juxta-anastomotic stenoses for failing distal radiocephalic arteriovenous fistulas: Drug-coated balloons versus angioplasty.

The aim of our study is to report the results of two types (type A, type B) paclitaxel drug-coated balloon compared with standard percutaneous transluminal angioplasty in the treatment of juxta-anastomotic stenoses of mature but failing distal radiocephalic hemodialysis arteriovenous fistulas. Two groups of 26 and 44 patients treated with two different drug-coated balloon are compared with a control group of 86 treated with standard percutaneous transluminal angioplasty. A color Doppler ultrasound was performed to evaluate stenosis and for treatment planning. We assess primary patency, defined as the absence of dysfunction of the arteriovenous fistulas, patent lesion or residual stenosis < 30% and no need for further reintervention of target lesion. Primary patency and secondary patency are evaluated after 12 months with color Doppler ultrasound for the whole arteriovenous fistulas, defined as absolute (absolute primary patency, absolute secondary patency) and target lesion. Postprocedural technical and clinical success was 100%. After 12 months, absolute primary patency is 81.8% for type A, 84.1% type B, and 54.7% for standard percutaneous transluminal angioplasty; target lesion primary patency is 92% type A, 86.4% type B, and 62.8% standard percutaneous transluminal angioplasty; absolute secondary patency is 95.4% type A, 95.5% type B, and 80.7% standard percutaneous transluminal angioplasty; target lesion secondary patency is 100% type A, 97.7% type B, and 80.7% standard percutaneous transluminal angioplasty. All the patients treated with drug-coated balloon (type A + type B) have an absolute primary patency of 83.3%, a target lesion primary patency of 87.9%, an absolute secondary patency of 95.5%, and a target lesion secondary patency of 98.4%. Our study confirms that the use of drug-coated balloon, indiscriminately among different brands, improves primary patency with statistically significant difference in comparison with standard percutaneous transluminal angioplasty and decreases reintervention of target lesion in juxta-anastomotic stenoses of failing distal arteriovenous fistulas maintaining the radiocephalic fistula as long as possible.

Predictive and Prognostic Value of Early Disease Progression by PET Evaluation in Advanced Non-Small Cell Lung Cancer.

OBJECTIVE: To assess the predictive and prognostic value of progressive metabolic disease (PMD) by the use of early 18Fluorodeoxyglucose positron emission tomography (18FDG-PET) in patients with clinical stage IV non-small cell lung cancer (NSCLC) treated with first-line chemotherapy. METHODS: An 18FDG-PET performed following the first cycle of chemotherapy (PET-1) was compared with a pretreatment 18FDG-PET (PET-0) and a computed tomography (CT) scan after the third cycle (CT-3). The primary endpoint was the positive predictive value (PPV) of PMD. Secondary endpoints included the prognostic value of PMD. RESULTS: Eleven of 38 patients (29%) had a PMD by PET-1, and 15 (39%), including all patients with a PMD, experienced a progressive disease by CT-3. The PPV of PMD was 100% according to both the European Organization for Research and Treatment of Cancer (EORTC) criteria and the PET Response Criteria In Solid Tumors (PERCIST) (p value for both, <0.0001). Patients with a PMD by PET-1 had a median overall survival of 7.0 months versus 14.0 months for those without a PMD (p = 0.04, according to the EORTC criteria). CONCLUSIONS: Early 18FDG-PET assessment deserves further investigation for the identification of NSCLC patients who do not benefit from first-line chemotherapy.

A lethal complication after transarterial chemoembolization with drug-eluting beads for hepatocellular carcinoma.

Background. The current standard of care for patients with large or multinodular noninvasive hepatocellular carcinoma is conventional transarterial chemoembolization (TACE). TACE may also be performed with drug-eluting beads, but serious complications of this procedure have been reported. Methods. Aim of this report is to present a patient affected by multifocal HCC who underwent TACE with drug-eluting bead (DEB-TACE). Results. Following the procedure the patient developed a hepatic abscess and biliobronchial fistula resulting in adult respiratory distress syndrome and death. Conclusion. We speculate that DEB-TACE has a prolonged effect on the tumor and the surrounding liver, resulting in progressive enlargement of the necrotic area. This activity that can extend to the surrounding healthy hepatic tissues may continue indefinitely.

Drug-eluting balloon for the treatment of failing hemodialytic radiocephalic arteriovenous fistulas: our experience in the treatment of juxta-anastomotic stenoses.

PURPOSE: The purpose of this article is to report our experience with drug-eluting balloons for the treatment of juxta-anastomotic stenoses of failing radiocephalic hemodialytic arteriovenous shunt and to evaluate the primary and secondary patency (PP and SP). METHODS: After approval by the local hospital's Ethical and Scientific Review Board, 26 consecutive patients with juxta-anastomotic stenosis of radiocephalic hemodialytic shunt were treated with angioplasty with drug-eluting balloon. The main objective was to evaluate PP defined, in accordance with the Kidney Disease Outcomes Quality Initiative recommendation, as the absence of dysfunction of the vascular access, patent lesion or residual stenosis <30% and no need for further reintervention of the target lesion (TL). PP and SP at 6, 12 and 24 months were evaluated, with echo color doppler and phlebography, for both arteriovenous fistulae, defined as absolute, and TL. RESULTS: Immediate postprocedural technical and clinical success was 100% for all the patients; we had only one technical failure in repeated treatments. At 6 months the absolute and TL PP was 96.1%; at 12 months the absolute PP was 81.8%, TL PP 90.9%, absolute SP 95.4%, TL SP 100%; at 24 months the absolute and TL PP was 57.8%; absolute and TL SP 94.7%; only one arteriovenous fistula was lost during the period. CONCLUSIONS: The use of drug-eluting balloons, after standard angioplasty, improves primary patency and decreases reinterventions of TL in juxta-anastomotic stenoses of failing native dialytic arteriovenous shunts.

Management of severe blunt renal trauma in adult patients: a 10-year retrospective review from an emergency hospital.

UNLABELLED: What's known on the subject? and What does the study add? Immediate surgery for major renal truma has led to a high rate of nephrectomy in comparison with an expectant management. We reviewed our case material on the management of severe blunt renal trauma in adults with emphasis on conservative management. Only shattered kidneys and pedicle avulsion required immediate surgery. OBJECTIVE: To review retrospectively the management of major blunt renal truma in adult patients admitted to our level I trauma centre. PATIENTS AND METHODS: Among 1460 blunt abdominal trauma cases collected from January 2001 to December 2010, 221 (15%) affected the kidneys. All patients, except seven who needed immediate laparotomy, underwent a computed tomography scan to stage the injuries. Renal injuries were graded according to the American Association for the Surgery of Trauma Grading System; grade 4 and 5 injuries were subclassified based on vascular or parenchymal injury. RESULTS: Only 45/221 patients (20%) suffered major blunt renal trauma (21 grade 3, 18 grade 4 and six grade 5); 43% of the patients had associated lesions and 77% had gross haematuria. Nephrectomy rates were 9% for grade 3, 22% for grade 4 and 83% for grade 5 with an exploration rate of 26% for major renal trauma. CONCLUSIONS: Conservative management of grade 3-5 blunt renal trauma in haemodynamically stable patients yields more favourable results with high renal salvage rate. Grade 5 injuries still result in a nephrectomy rate of more than 80%. The absence of data on long-term outcomes and a potential inclusion bias due to the retrospective nature of the data represent major limitations of this review.

Venae comitantes as a potential vascular resource to create native arteriovenous fistulae.

PURPOSE: The arteriovenous fistula (AVF) represents the gold standard for hemodialysis (HD) vascular access. In some critical cases, use of the deep venous circle may represent an alternative approach and venae comitantes could be employed for this purpose. METHODS: Sixty patients with chronic renal failure in which the deep venous circle was used to create an AVF were identified; of the 48 who had a direct anastomosis between the brachial artery and vena comitans, 42 had a long-term follow-up (mean follow-up 59 weeks), while six were lost to follow-up. RESULTS: Immediate success (patency and palpable thrill) was achieved in 88% of cases (primary and early failure 12%). Primary accessibility rate was 62%, while 11 patients required a second surgical approach to make the vein accessible to needling. Secondary accessibility rate of 71% was due to surgical revisions. In the 80-week observation period, the complication rate was 10% with irreversible loss of the AVF in all these cases. Cumulative patency was 71% at the 80th week. Including all 42 patients, technical and functional success rate, defined as vein accessibility to needling and chance of an adequate HD treatment, was 62%. CONCLUSIONS: AVF employing venae comitantes may represent a suitable alternative in the absence of other vascular accesses for HD.

Atypical placement of hemodialysis catheters in patients with complete and irreversible obstruction of central venous vessels.

PURPOSE: This article describes the approach to atypical placement of central venous catheters (CVC) in dialysis patients with complete untreatable obstruction of central venous vessels. METHODS: Five patients with complete obstruction of central venous vessels underwent CT venography and digital venous angiography. After ultrasound-guided and radioscopic-assisted cannulation of the internal jugular vein, permanent CVCs were placed in atypical locations: in two patients a preliminary venous angioplasty was performed to facilitate the catheter positioning in a mediastinal enlarged collateral vein and in a persistent left superior vena cava; in three patients the CVC was placed in the azygos vein, enlarged because of the obstruction of the superior vena cava. RESULTS: In all cases, we achieved satisfactory morphological and functional immediate results. Hemodialysis (HD) was carried out long term in all patients except one who presented a non-functioning CVC after 4 months. In one case the catheter, still functioning well after 9 months, was removed due to kidney transplantation. The CVC in the left superior vena cava was replaced with a longer one after 12 months, and it is still functioning well 3 months after replacement. The patency of the other two catheters has to date been kept for 9 and 18 months. CONCLUSIONS: The placement of CVC for HD in atypical sites can be considered a viable option in extreme cases; adequate imaging support is paramount in order to facilitate the procedure and to avoid complications.

Simultaneous transarterial and portal embolization for unresectable tumors of the liver.

Hepatic portal vein embolization and transcatheter arterial chemoembolization are well-defined procedures respectively introduced to increase the future remnant liver and to avoid tumor progression before a scheduled hepatectomy. If used alone, both this approaches do not always improve surgical outcome, sometimes resulting in drop out from definitive surgery because of progression of disease. Since the late 1980s, sequential approach with TACE and PVE has been introduced as a preoperative treatment in order to: prevent tumor progression during the weeks intervening before operation; strengthen the effects of PVE by embolizing possible arterio-portal shunts; improve the FRL volumetric increase through the acceleration of hepatocytes proliferation. The risk of liver parenchymal necrosis, related to the double occlusion of blood supply, is usually avoided by maintaining an interval of weeks between the two procedures (PVE performed 2-3 weeks after TACE and surgery performed 4-6 weeks after PVE), but during this period the tumor may grow, nullifying the results obtained. We herein report a literary review and our initial experience with one patient affected by hepatocellular carcinoma involving the whole right liver, treated with TACE and right PVE, both performed in the same session. Although this technique still needs validation after the treatment of a wider number of patients, it seems to be feasible and effective.

[Multislice computed tomographic angiography in the assessment of central veins for endovascular treatment planning: comparison with phlebography]. / Angio-TC MS nello studio dei vasi venosi centrali per la pianificazione del trattamento endovascolare: studio comparativo con la flebografia.

The dysfunction of a vascular access for hemodialysis and its loss may depend on drainage difficulties of the superficial or deep venation due to hemodynamically significant stenosis or obstruction of a central vein, which generally involve the innominate-subclavian veins or superior vena cava. These alterations are often neglected due to their central and deep location; when there is hemodynamic compensation, they may remain asymptomatic. For these reasons every suspect clinical sign for central vein stenosis (gross arm syndrome or venous hypertension in an arteriovenous fistula) must not be ignored, as timely intervention is essential for functional recovery of the vessel and for the protection of the arteriovenous fistula. The modern imaging techniques ensure thorough diagnostic assessment, while the possibilities of endovascular treatment with interventional radiology allow, in a large proportion of cases, optimal minimally invasive treatment, but above all the recovery of venation in a hemodialyzed patient. We report our experience with multislice computed tomographic angiography (MS-CTA) and reconstruction software for treatment planning of central vein stenosis or obstruction. Forty-nine patients were studied with MS-CTA (GE 16). Images were acquired in the venous phase (120-180 seconds after contrast medium injection) followed by digital vascular reconstruction (AutoBone for bone removal, vessel analysis for caliber and length measurements, thin and curved MIP, MPR). Within a week control phlebography was performed. The venous tree was divided into seven segments and analyzed in a double-blind fashion with a distinction between patent segments, 50-70% stenosis, >70% stenosis, occlusion, and collateral vascular beds. There was excellent correspondence in all the examined segments for patency, >70% stenosis, and occlusion, with high sensitivity (98%), specificity (99.3%), and diagnostic accuracy (99.1%). The binomial test demonstrated a highly significant concordance (alpha=0.99) for all patients and in all vascular segments with the exception of 70% stenoses, in which MS-CTA gave a slight overestimate. In the central venous district, color Doppler ultrasonography may not be as effective as for the peripheral study of arteriovenous fistulae, and second-level imaging techniques such as MS-CTA are more useful. We suggest that endovascular treatment must be preceded by MS-CTA. This examination shows the lesions that may benefit from endovascular treatment and recognizes ''uncrossable'' lesions, ie, the ones that will not benefit from treatment. Moreover, it allows accurate planning of endovascular treatment by showing the lesion type (stenosis or obstruction), the position and extension of the involved vessels, the vessel caliber above and below the lesion, and the possible presence of a collateral vascular bed. MS-CTA with dedicated reconstruction software, if correctly performed and accurately reconstructed, is a precious tool for diagnosis and treatment planning.

Liver metastases from lung cancer: is surgical resection justified?

Resection of the liver for metastatic lesions has largely been done for secondary colorectal or neuroendocrine tumors, and there is little information of its value for other lesions. Recent improvements in hepatic surgery have made resection of metastases a safe procedure and it should certainly be considered whenever there is an isolated lesion. We report the case of a successful resection of an isolated secondary hepatic lesion from a lung primary tumor, which was resected approximately 4 years beforehand. A review of the literature demonstrates that although early reports of similar procedures were not favorable, more recent reports reinforce the value of an aggressive approach in favorable cases.

Magma ascent and the pressurization of Mount Etna's volcanic system.

After a period of deflation during the 1991-1993 flank eruption, Mount Etna underwent a rapid inflation. Seismicity and ground deformation show that since 1994, a huge volume of magma intruded beneath the volcano, producing from 1998 onward a series of eruptions at the summit and on the flank of the volcano. The last of these, started on 27 October 2002, is still in progress and can be considered one of the most explosive eruptions of the volcano in recent times. Here we show how geodetic data and seismic deformation, between 1994 and 2001, indicate a radial compression around an axial intrusion, consistent with a repressurization of Mount Etna's plumbing system at a depth of 6 to 15 kilometers, which triggered most of the seismicity and provoked the dilatation of the volcano and the recent explosive eruptive activity.