Intra-arterial hepatic chemotherapy: management of liver tumors by percutaneous port-a-cath positioning.

In the past, intrahepatic arterial locoregional chemotherapy was performed by surgical approach via gastroduodenal artery; early use of percutaneously placed arterial port was complicated by clotting and bleeding in 50% of pts. More recently, permanent catheters were positioned percutaneously in GDA by Japanese group and fixed to the artery by means of bucrylate in order to reduce dislocation. We present the technique and the preliminary results of percutaneous implantation of intraarterial catheters connected to a subcutaneous infusion reservoir for prolonged regional chemotherapy of hepatic tumors. Two hundred patients underwent to percutaneous arterial port implant, for loco-regional chemotherapy for liver primary or metastatic tumors. Catheter dislodgments were observed in 14,5%, but in 90% the catheters could be reinserted. No case of catheter related mortality was registered. Percutaneous positioning of arterial port is a safe and effective technique to deliver loco-regional treatment for hepatic tumors. Complication rates are similar to the surgical series and to other percutaneous interventional radiological reports. This percutaneous approach in the hands of a skilled team allows intra-arterial infusion in a wide percentage of pts, improving the accuracy of clinical trials by a faster and optimal balanced comparison between systemic and arterial arm.

[Vascular access in hemodialysis. Surveillance and role of percutaneous transluminal angioplasty]. / Accessi vascolari in emodialisi. Sorveglianza e ruolo dell'angioplastica percutanea transluminale.

The function of vascular shunts in hemodialysis plays a vital role for the efficiency and effectiveness of replacement therapy. A study was performed in 147 patients undergoing periodical hemodialysis with distal FAV (no = 86), proximal FAV (no = 33), PTFE grafts (no = 23), Canaud-Tesio catheters (no = 7). A protocol for function evaluation was developed which also included the calculation of overall recirculation (R), that was found to be 10.8 + 7% (using the three blood sample method). In 28/143 patients the monitoring protocol recommended the use of angiography which identified abnormalities in 78% of cases, before the onset of thrombotic phenomena. In particular, surgical radiology was able to resolve 94% of cases in which angiography revealed a stenosis using percutaneous transluminal angioplasty and/or the insertion of one or more stents.

[Role of computerized tomography in percutaneous drainage of acute infected necrotic-hemorrhagic pancreatitis]. / Ruolo della Tomografia Computerizzata e del drenaggio percutaneo nelle pancreatiti acute necrotico-emorragiche infette.

In the last few years, Computed Tomography (CT) has emerged as the most sensitive and reliable imaging technique to diagnose acute pancreatitis (AP). Besides assessing the extent of damage to the pancreas and to periglandular tissue. CT can recognize the major early and late complications of the disease promptly and with extreme accuracy. We investigated the diagnostic capabilities of CT in controlling AP development and tried to assess the role of interventional radiology as a therapeutic support after or instead of surgery in treating the necrotic forms of pancreatitis complicated by sepsis. From 1989 to 1995, acute pancreatitis mostly due to biliary tract disease and alcoholism was diagnosed in 228 patients. Necrotic processes were identified in 105 of them since disease onset; septic complications developed in 57 patients. Surgery was performed in 42 patients, but the result was poor in 11 of them (30%) and CT showed the persistence of some infectious pancreatic exudate which had been drained insufficiently. Since sepsis persisted in these patients, the exudate was aspirated percutaneously after positioning appropriate drainage means guided by abdominal CT. Sepsis resolved completely in 10 patients, while one required subsequent surgery. Percutaneous drainage catheters were positioned in 15 patients as the treatment of choice, under CT and US guidance. Sepsis resolved in 7 cases only (45%), while 3 of the extant patients died and 5 needed surgery. The results of our experience demonstrate the effectiveness of percutaneous drainage under CT guidance. However, this technique should be used after and as a support to surgery, the latter remaining the treatment of choice for infectious necrotic AP. Thus, in our experience, the use of percutaneous aspiration instead of surgery proved to be a less effective tool in curing this condition and its use should therefore be limited to high-risk surgical patients.

[The role of portography with computed tomography in the diagnosis of liver metastases from colorectal neoplasms]. / Il ruolo della portografia con Tomografia Computerizzata nella diagnosi di metastasi epatiche da neoplasie del colon-retto.

This study was performed to confirm the high sensitivity of CT during arterial portography (CTAP) versus US and dynamic CT in the diagnosis of liver metastases from colorectal cancer. Ninety patients with 108 colorectal cancers underwent US, dynamic CT and CTAP to investigate the presence of liver metastases. US depicted 39 metastases in 26 patients, dynamic CT 46 metastases in 29 patients and CTAP 54 lesions in 34 patients. CTAP detected 8 metastases missed at dynamic CT; 4 of them were < 1 cm in diameter, 3 ranged 1-2 cm and one metastasis > 2 cm in diameter. After preoperative investigations only 7 patients were considered for hepatic resection. At surgery, palpation and intraoperative US of the liver detected two more metastases in the same patients. Our experience, in agreement with recent studies, confirms CTAP as the most sensitive preoperative method in detecting liver metastases and its superiority to be most apparent in lesions < 1 cm in diameter. Therefore, we consider CTAP an essential imaging technique for planning the correct treatment of liver metastases.

[Treatment of superior vena cava syndrome by metal stents. Preliminary experience]. / Trattamento della sindrome della vena cava superiore con stent metallici. Esperienza preliminare.

This study was aimed at verifying the feasibility of stent placement in superior vena cava syndrome (SVCS). From April, 1993, to February 1995, fifteen patients (12 men, 3 women, age range: 48-72 years, average age: 58 years), were treated for malignant stenoses involving superior vena cava in 9 cases, right innominate vein in 3, left innominate vein in 2 and subclavian veins in 1. All patients had been submitted to CT angiography and digital venography to assess side, length and type of the stenosis. In 6 patients locoregional fibrinolysis (with urokinase) was performed. The stenosis was successfully dilated by balloon catheter and the stent was finally removed. Subclavian and innominate veins stenoses were treated with Wallstent, using brachial approach, while stenoses of superior vena cava required transfemoral catheterization for Gianturco-Rosch "Z" stent placement. A control venogram was performed after stenting, with the evaluation of pre/post stent pressure gradient, and later at 1, 3 and 6 months. The stents were positioned in all patients with immediate technical success; no major complications occurred. Two recurrences were successfully resolved. Radiation and/or medical therapy without vascular disobstruction showed worse results in the treatment of superior vena cava syndrome. The percutaneous placement of self-expandable stents should be not only the therapeutic alternative to surgery but the method of choice in these pathologic conditions.

[Transjugular intrahepatic portosystemic shunt (TIPS)]. / Derivazione porto-sistemica intraepatica per via transgiugulare (TIPS).

Transjugular intrahepatic portosystemic (TIPS) is radiological technique that has opened up new therapeutic horizons in the treatment of portal hypertension. Technically, the procedure includes catheterizing of the suprahepatic veins, prevalently right or middle, by means of transjugular access, and the creation of an intrahepatic path with the main portal branch. Later dilatation of the path by angioplasty and the application of a metallic stent at the site of the shunt complete the operation. Personal experience of 43 TIPS in 42 patients with a follow-up of 24 months is reported.

[Treatment of malignant occlusions of bile ducts by one-step technique using metallic endoprostheses. A multicenter study of 50 cases]. / Trattamento delle occlusioni maligne delle vie biliari mediante endoprotesi metalliche con tecnica "one-step". Studio policentrico di 50 casi.

Long-term patency and ease of insertion of self-expandable metallic stents seem to overcome the disadvantages of plastic stents, changing the therapeutic approach to unresectable biliary tree malignancies. Their high cost is the main problem of metallic stents and reducing hospitalization time is a real opportunity to overcome this problem. Self-expandable stents could be the turning point to reduce overall costs. Fifty patients with malignant biliary tree obstruction (Zubrod performance status < 3) were treated with percutaneous placement of 58 Wallstent endoprostheses by the one-step technique. All patients had undergone thorough diagnostic exams - i.e., US, CT, PTC, ERCP with biopsy or brushing. Two major complications occurred in this series: a iatrogenic pseudoaneurysm requiring selective catheterization and embolization with Gianturco coils and a hepatic abscess six months after stent placement. Late stent occlusion occurred in six patients (12%) and was resolved by balloon dilatations. All patients were followed-up with clinical examinations, US and laboratory tests until death; median survival after stent placement was 122 days (range: 70 to 510 days). Average hospitalization time was 7 days with an acceptable cost reduction.