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PURPOSE: To report procedural data and outcomes of a novel image guidance technique, CT renal arteriography (CTRA), performed to target and ablate small intraparenchymal renal tumors. MATERIALS AND METHODS: We retrospectively analyzed data of 2 patients undergoing CTRA-guided ablation for 3 renal intraparenchymal tumors, from February to March 2023. We previously evaluated tumor visibility with US/CEUS, and in all cases conspicuity was poor, whereas contrast-enhanced CT (CECT) clearly depicted all hypervascular nodules. Our primary endpoint was CTRA-guidance feasibility for renal ablation, defined as the precise probe deployment inside the target tumor. The secondary endpoint was CTRA-guided ablation technical success, intended as the inclusion of the whole tumor inside the necrotic volume, with 5 mm safety margins. RENAL scores, complications, procedural time, dose length product (DLP), serum creatinine variation and hospital stay length were also recorded. RESULTS: A confident deployment of the probe tip inside the nodule was accomplished in all 3 cases, with a 100% of correct targeting. We observed immediate technical success after all 3 ablations. The 3 nodules had a RENAL score <7 points, and we encountered no complications due to line placement or ablation. The average time from preablative to postablative CTRA was 54 min (50-58min), with a DLP of 3632mGy*cm (2807-4458mGy*cm). Serum creatinine didn't show a significant variation after the procedures; both patients were hospitalized for 2 days. CONCLUSION: Preliminary data showed that CTRA-guidance might provide unique advantages over conventional CECT-guidance to assist the ablation of small renal intraparenchymal tumor not visualized on US/CEUS.
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Ablação por Cateter , Neoplasias Renais , Humanos , Creatinina , Estudos Retrospectivos , Ultrassonografia de Intervenção , Neoplasias Renais/diagnóstico por imagem , Neoplasias Renais/cirurgia , Neoplasias Renais/patologia , Tomografia Computadorizada por Raios X , Angiografia , Ablação por Cateter/métodos , Resultado do TratamentoRESUMO
PURPOSE: To evaluate the clinical outcome of US-guided percutaneous thrombin injection in the treatment of non-femoral artery pseudoaneurysms (NFAP). MATERIALS AND METHODS: Among all pseudoaneurysms treated in our institution, we retrospectively collected NFAP embolized with percutaneous thrombin injections from January 1, 2015, to December 31, 2021. The embolization was prompted for an ongoing antiaggregating/anticoagulation therapy, NFAP optimal US visibility, or high surgery-related risks. Causes, location, size and neck of NFAP, complications, number of repeated treatments, clinical success and patients clinical conditions at discharge were annotated. The endpoint for clinical success was the resolution of NFAP at postprocedural imaging, with no resort to surgery. RESULTS: Eight consecutive patients (5 females, median age 73 years, range 46-84) underwent 16 procedures. Arterial damage was due to catheterization (3), CVC mispositioning (2), trauma, hemorrhagic diathesis and endoprosthesis endoleak. We treated humeral (2), subclavian (2), thyrocervical, anterior tibial, radial and pancreaticoduodenal arteries. Median pseudoaneurysm size was 530 mm2 (range 32-2400 mm2), with a thin (7/8) or non-visible (1/8) neck. No complications occurred. Clinical success was obtained in 7/8 patients (88%), with a single treatment in 4, multiple in 3 cases (4 embolizations, 3 and 2, respectively). One patient underwent surgical suture after the second failed attempt of percutaneous embolization. Seven patients were discharged in good clinical conditions; one died during hospitalization, due to the worsening of the underlying cardiac disease. CONCLUSIONS: Percutaneous US-guided thrombin injection to treat NFAP is feasible in selected cases, with rare complications. Clinical success is often reached, also by repeated injections.
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Falso Aneurisma , Trombina , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Pessoa de Meia-Idade , Falso Aneurisma/diagnóstico por imagem , Falso Aneurisma/tratamento farmacológico , Artéria Femoral/diagnóstico por imagem , Estudos Retrospectivos , Trombina/uso terapêutico , Resultado do Tratamento , Ultrassonografia de Intervenção/efeitos adversos , MasculinoRESUMO
OBJECTIVES: Temporal muscle thickness (TMT) is a surrogate marker of sarcopenia, correlated with survival expectancy in patients suffering from brain metastases and recurrent or treated glioblastoma. We evaluated the prognostic relevance of TMT measured on brain MRIs acquired at diagnosis in patients affected by glioblastoma. METHODS: We retrospectively enrolled 51 patients in our Institution affected by methylated MGMT promoter, IDH1-2 wild-type glioblastoma, who underwent complete surgical resection and subsequent radiotherapy with concomitant and maintenance temozolomide, from January 1, 2015, to April 30, 2017. The last clinical/radiological follow-up date was set to September 3, 2019. TMT was measured bilaterally on reformatted post-contrast 3D MPRAGE images, acquired on our 3-T scanner no more than 2 days before surgery. The median, 25th, and 75th percentile TMT values were identified and population was subdivided accordingly; afterwards, statistical analyses were performed to verify the association among overall survival (OS) and TMT, sex, age, and ECOG performance status. RESULTS: In our cohort, the median OS was 20 months (range 3-51). Patients with a TMT ≥ 8.4 mm (median value) did not show a statistically significant increase in OS (Cox regression model: HR 1.34, 95% CI 0.68-2.63, p = 0.403). Similarly, patients with a TMT ≥ 9.85 mm (fourth quartile) did not differ in OS compared to those with TMT ≤ 7 mm (first quartile). The statistical analyses confirmed a significant association among TMT and sex (p = 0.0186), but none for age (p = 0.642) and performance status (p = 0.3982). CONCLUSIONS: In our homogeneous cohort of patients with glioblastoma at diagnosis, TMT was not associated with prognosis, age, or ECOG performance status. KEY POINTS: ⢠Temporal muscle thickness (TMT) is a surrogate marker of sarcopenia and has been correlated with survival expectancy in patients suffering from brain metastases and recurrent or treated glioblastoma. ⢠We appraised the correlation among TMT and survival, sex, age at surgery, and performance status, measured on brain MRIs of patients affected by glioblastoma at diagnosis. ⢠TMT did not show any significant correlation with prognosis, age at surgery, or performance status, and its usefulness might be restricted only to patients with brain metastases and recurrent or treated glioblastoma.
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Neoplasias Encefálicas , Glioblastoma , Sarcopenia , Neoplasias Encefálicas/complicações , Neoplasias Encefálicas/diagnóstico por imagem , Neoplasias Encefálicas/genética , Metilação de DNA , Metilases de Modificação do DNA , Enzimas Reparadoras do DNA , Glioblastoma/complicações , Glioblastoma/diagnóstico por imagem , Glioblastoma/genética , Humanos , Prognóstico , Estudos Retrospectivos , Sarcopenia/complicações , Sarcopenia/diagnóstico por imagem , Sarcopenia/patologia , Músculo Temporal/patologiaRESUMO
OBJECTIVES: To compare the outcome of US-guided percutaneous irrigation of calcific tendinopathy (US-PICT) of the rotator cuff in patients with or without previous external shockwave therapy (ESWT). METHODS: We analyzed all patients treated with US-PICT from March 1, 2016, to October 1, 2019, with shoulder pain refractory to conservative management for rotator cuff calcific tendinopathy, diagnosed with ultrasound. Each patient was examined using the Constant-Murley Score (CMS) questionnaire (score 0-100) before and after treatment. We tested CMS differences using the Mann-Whitney U (Wilcoxon rank-sum) test in the two groups. US-PICT was performed placing two or multiple 14G needles, according to the calcification size, inserted under US guidance to create a circuit of irrigation in the calcified tendon. NaCl solution at 38 °C was then injected from the entry needle in a variable amount to hydrate and fragment the calcification, finally allowing for its expulsion through the exit needle. All patients also received an intrabursal steroid injection. RESULTS: From 2016 to 2019, 72 US-PICT treatments were performed on 70 patients (females = 46; males = 26) with a mean age of 49.7 years (SD = 8.7. Thirty-three (47%) underwent previous ESWT, while thirty-seven (53%) had no previous treatments. No treatment-related complications were observed. Follow-up was averagely 14.4 months (median = 11.6, SD = 11.9, range 1-45); 37 patients had a follow-up shorter than 12 months (1-11.6); 35 patients were visited after more than 1 year (12.2-45.6, Table W). Before treatment, the mean CMS was 35 (SD = 21); after treatment, it reached 75.4, with an average CMS improvement of 40.3 points (SD = 23.7, p < 0.001). The comparison of improvement between the ESWT and non-ESWT group yielded no significant difference (p = 0.3). CONCLUSIONS: US-PICT of the rotator cuff is an effective procedure to reduce shoulder pain and increase mobility in patients with calcific tendinopathy, both in short- and long-term time intervals. Previous unsuccessful ESWT does not affect the outcome of US-PICT.
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Calcinose/terapia , Lesões do Manguito Rotador/terapia , Dor de Ombro/terapia , Irrigação Terapêutica/métodos , Ultrassonografia de Intervenção/métodos , Terapia Combinada , Feminino , Ondas de Choque de Alta Energia , Humanos , Injeções Intra-Articulares , Masculino , Pessoa de Meia-Idade , Esteroides/uso terapêutico , Inquéritos e QuestionáriosRESUMO
OBJECTIVE: Lombardy (Italy) was the epicentre of the COVID-19 pandemic in March 2020. The healthcare system suffered from a shortage of ICU beds and oxygenation support devices. In our Institution, most patients received chest CT at admission, only interpreted visually. Given the proven value of quantitative CT analysis (QCT) in the setting of ARDS, we tested QCT as an outcome predictor for COVID-19. METHODS: We performed a single-centre retrospective study on COVID-19 patients hospitalised from January 25, 2020, to April 28, 2020, who received CT at admission prompted by respiratory symptoms such as dyspnea or desaturation. QCT was performed using a semi-automated method (3D Slicer). Lungs were divided by Hounsfield unit intervals. Compromised lung (%CL) volume was the sum of poorly and non-aerated volumes (- 500, 100 HU). We collected patient's clinical data including oxygenation support throughout hospitalisation. RESULTS: Two hundred twenty-two patients (163 males, median age 66, IQR 54-6) were included; 75% received oxygenation support (20% intubation rate). Compromised lung volume was the most accurate outcome predictor (logistic regression, p < 0.001). %CL values in the 6-23% range increased risk of oxygenation support; values above 23% were at risk for intubation. %CL showed a negative correlation with PaO2/FiO2 ratio (p < 0.001) and was a risk factor for in-hospital mortality (p < 0.001). CONCLUSIONS: QCT provides new metrics of COVID-19. The compromised lung volume is accurate in predicting the need for oxygenation support and intubation and is a significant risk factor for in-hospital death. QCT may serve as a tool for the triaging process of COVID-19. KEY POINTS: ⢠Quantitative computer-aided analysis of chest CT (QCT) provides new metrics of COVID-19. ⢠The compromised lung volume measured in the - 500, 100 HU interval predicts oxygenation support and intubation and is a risk factor for in-hospital death. ⢠Compromised lung values in the 6-23% range prompt oxygenation therapy; values above 23% increase the need for intubation.
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Betacoronavirus , Infecções por Coronavirus/diagnóstico , Intubação Intratraqueal/métodos , Pulmão/diagnóstico por imagem , Oxigenoterapia/métodos , Pneumonia Viral/diagnóstico , Tomografia Computadorizada por Raios X/métodos , COVID-19 , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/terapia , Feminino , Mortalidade Hospitalar , Hospitalização , Humanos , Itália/epidemiologia , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/epidemiologia , Pneumonia Viral/terapia , Prognóstico , Estudos Retrospectivos , SARS-CoV-2RESUMO
PURPOSE: To evaluate safety and efficacy of CT hepatic arteriography compared with conventional CT fluoroscopy guidance in percutaneous radiofrequency (RF) and microwave (MW) ablation to treat colorectal liver metastases (CRLM). MATERIALS AND METHODS: This single-center comparative, retrospective study analyzed data of 108 patients treated with 156 percutaneous ablation procedures (42 CT fluoroscopy guidance [25 RF ablation, 17 MW ablation]; 114 CT hepatic arteriography guidance [18 RF ablation, 96 MW ablation]) for 260 CRLM between January 2009 and May 2019. Local tumor progression-free survival (LTPFS) was assessed using univariate and multivariate Cox proportional hazard regression analyses. LTPFS and overall survival (OS) were estimated using the Kaplan-Meier method. RESULTS: There were no complications related to the transarterial catheter procedure. CT hepatic arteriography proved superior to CT fluoroscopy regarding 2-year LTPFS (18/202 [8.9%] vs 19/58 [32.8%]; P < .001, respectively). CT hepatic arteriography versus CT fluoroscopy (hazard ratio = 0.28; 95% confidence interval, 0.15-0.54; P < .001) and MW ablation versus RF ablation (hazard ratio = 0.52; 95% confidence interval, 0.24-1.12; P = .094) were positive predictors for longer LTPFS. Multivariate analysis revealed that CT hepatic arteriography versus CT fluoroscopy (hazard ratio = 0.41; 95% confidence interval, 0.19-0.90; P = .025) was associated with a significantly superior LTPFS. OS was similar between the 2 cohorts (P = .3). CONCLUSIONS: While adding procedure time and marginal patient burden, transcatheter CT hepatic arteriography-guided ablation was associated with increased local disease control and superior LTPFS compared with conventional CT fluoroscopy. CT hepatic arteriography represents a safe and valid alternative to CT fluoroscopy, as it reduces the number of repeat ablations required without adding risk or detrimental effect on survival.
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Técnicas de Ablação , Neoplasias Colorretais/patologia , Angiografia por Tomografia Computadorizada , Neoplasias Hepáticas/cirurgia , Radiografia Intervencionista , Técnicas de Ablação/efeitos adversos , Técnicas de Ablação/mortalidade , Idoso , Neoplasias Colorretais/mortalidade , Angiografia por Tomografia Computadorizada/efeitos adversos , Angiografia por Tomografia Computadorizada/mortalidade , Feminino , Fluoroscopia , Humanos , Neoplasias Hepáticas/diagnóstico por imagem , Neoplasias Hepáticas/mortalidade , Neoplasias Hepáticas/secundário , Masculino , Pessoa de Meia-Idade , Países Baixos , Duração da Cirurgia , Intervalo Livre de Progressão , Radiografia Intervencionista/efeitos adversos , Radiografia Intervencionista/mortalidade , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Fatores de TempoRESUMO
PURPOSE: To assess the use of optimized radiofrequency (RF) to achieve larger, spherical ablation volumes with short application duration for hepatocellular carcinoma (HCC). MATERIALS AND METHODS: Twenty-two patients (M:F = 17:5, median age 69.6 year, range 63-88) with 28 HCCs due to HCV + liver cirrhosis underwent RFA. 20/28 (71.4%) were tumors ≤3cm diameter, and 8/28 (28.6%) ranged from 3.2 to 4.2 cm. RF was applied using up to 2500mA via an optimized pulsing algorithm with real-time ultrasound monitoring to detect hyperechogenic changes. Single insertions of an internally cooled electrode were performed using exposed tips of 2 or 3 cm for 13 HCCs and 4 cm for 15 HCCs. All patients were followed-up for a minimum of 5 years with contrast-enhanced computed tomography (CECT). RESULTS: Technical success was achieved without adverse events in all cases. The mean ablation time was 8.5 ± 2.6 min. In 21/28 (75%), ablation duration ranged from 3 to 9 min, with 12 min duration applied in only 7/28 (25%). Mean coagulation diameters were 2.4 ± 0.14, 3.3 ± 0.62, and 4.4 ± 1.0, for 2, 3 and 4 cm electrodes, respectively (p < 0.01). The sphericity index was 74.9 ± 12.8 for 4 cm electrodes and 81.9 ± 8.0 for shorter electrodes (p = 0.091). At 5-year follow-up, no tumor ≤3 cm had recurrence and only 2/8 (25%) >3 cm tumors developed local progression. One patient had multifocal disease with no local progression. CONCLUSION: Efficient delivery of RF energy can considerably decrease the ablation time in many instances while achieving larger, relatively spherical, and reproducible areas of ablation with extremely low rates of local tumor progression and adverse events.
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Carcinoma Hepatocelular , Ablação por Cateter , Neoplasias Hepáticas , Ablação por Radiofrequência , Idoso , Algoritmos , Carcinoma Hepatocelular/diagnóstico por imagem , Carcinoma Hepatocelular/cirurgia , Eletrodos , Humanos , Neoplasias Hepáticas/diagnóstico por imagem , Neoplasias Hepáticas/cirurgia , Recidiva Local de Neoplasia , Resultado do TratamentoRESUMO
PURPOSE: To retrospectively evaluate the accuracy of a novel software platform for assessing completeness of percutaneous thermal ablations. MATERIALS & METHODS: Ninety hepatocellular carcinomas (HCCs) in 50 patients receiving percutaneous ultrasound-guided microwave ablation (MWA) that resulted in apparent technical success at 24-h post-ablation computed tomography (CT) and with ≥1-year imaging follow-up were randomly selected from a 320 HCC ablation database (2010-2016). Using a novel volumetric registration software, pre-ablation CT volumes of the HCCs without and with the addition of a 5 mm safety margin, and corresponding post-ablation necrosis volumes were segmented, co-registered and overlapped. These were compared to visual side-by-side inspection of axial images. RESULTS: At 1-year follow-up, CT showed absence of local tumor progression (LTP) in 69/90 (76.7%) cases and LTP in 21/90 (23.3%). For HCCs classified by the software as "incomplete tumor treatments", LTP developed in 13/17 (76.5%) and all 13 (100%) of these LTPs occurred exactly where residual non-ablated tumor was identified by retrospective software analysis. HCCs classified as "complete ablation with <100% 5 mm ablative margins" had LTP in 8/49 (16.3%), while none of 24 HCCs with "complete ablation including 100% 5 mm ablative margins" had LTP. Differences in LTP between both partially ablated HCCs vs completely ablated HCCs, and ablated HCCs with <100% vs with 100% 5 mm margins were statistically significant (p < .0001 and p = .036, respectively). Thus, 13/21 (61.9%) incomplete tumor treatments could have been detected immediately, were the software available at the time of ablation. CONCLUSIONS: A novel software platform for volumetric assessment of ablation completeness may increase the detection of incompletely ablated tumors, thereby holding the potential to avoid subsequent recurrences.
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Ablação por Cateter/métodos , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , SoftwareRESUMO
BACKGROUND: The aim of this study is to report the results of transarterial embolization (TAE) in the setting of postoperative bleeding after hip surgery. METHODS: We retrospectively evaluated 40 patients (male:female = 15:25, median age = 68 years) who underwent TAE from 2006 to 2016: 77.5% underwent total hip arthroplasty, 20% open reduction internal fixation, and 2.5% external fixation. Preangiographic multidetector computed tomography angiography was performed in 20 (49%) cases, and 9 of them showed arterial extravasation. Twenty-seven TAEs were performed within a week from surgery; active bleeding was seen in 33 (80.5%) angiograms. Gelatin sponge, microparticles, coils, n-butyl cyanoacrylate, and combinations of them were used as embolic materials. RESULTS: Bleeding was controlled in all cases. The most frequently embolized arteries were branches of the deep femoral artery (n = 17). Permanent embolization agents (microparticles, coils, n-2-butyl-cyanoacrylate) were used in 88% of cases; temporary agents (gelfoam) in 12%. One procedure was complicated by arterial dissection. Hospital discharge averaged 20 days post-TAE (median = 17, range = 3-104). One-month survival rate was 97.5%. One patient died of ischemic bowel perforation. CONCLUSION: TAE is safe and effective in stopping the bleeding of the hip region and should be performed early, to avoid irreversible ischemic damage. Multidetector computed tomography angiography can be used to confirm doubtful evidence of ongoing bleeding. Several embolic materials can be used, each one offering different advantages. Low complication and mortality rates were observed. TAE seems to be the ideal first-line intervention when postoperative bleeding of the operated hip is detected.
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Artroplastia de Quadril/efeitos adversos , Embolização Terapêutica/estatística & dados numéricos , Hemorragia Pós-Operatória/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Angiografia , Embolização Terapêutica/métodos , Embucrilato , Feminino , Esponja de Gelatina Absorvível , Humanos , Masculino , Pessoa de Meia-Idade , Hemorragia Pós-Operatória/etiologia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
PURPOSE: To evaluate technical and clinical outcomes of intraoperative (laparoscopic/laparotomic) microwave ablation on HCC. MATERIALS AND METHODS: This is a retrospective single-center study evaluating consecutive patients treated for very early/early-stage HCC with intraoperative microwave ablation from 1 July 2017 to 30 June 2023. In these patients, a percutaneous US-guided approach was excluded due to the nodule's suboptimal visibility or harmful location and liver resection for a deep position or adherences. Data about the clinical stage, surgical approach, liver pathology and nodules characteristics, technical success, complications, and follow-up were collected. Technical success was intended as the absence of locoregional persistence at follow-up CT/MRI controls. RESULTS: A total of 36 cirrhotic patients (M:F = 30:6, median age 67 years) were enrolled; 18/36 (50%) had a single nodule, 13/36 (36%) had two, 4/36 had three (11%), and 1/36 had four (3%). Among the patients, 24 (67%) were treated with laparoscopy, and 12/36 (33%) with a laparotomic approach. Sixty HCCs of 16.5 mm (6-50 mm) were treated for 7 min (2-30 min) with 100 W of power. A total of 55 nodules (92%) were treated successfully and showed no residual enhancement at the first postoperative follow-up; the other 5/60 (8%) underwent chemo/radioembolization. There was one complication (3%): a biliary fistula treated with percutaneous drainage and glue embolization. The average hospital stay was 3.5 days (1-51 days), and patients were followed up on average for 238 days (13-1792 days). During follow-up, 5/36 patients (14%) underwent liver transplantation, 1/36 (2%) died during hospitalization and 1 after discharge. CONCLUSIONS: Laparoscopic/laparotomic intraoperative HCC MW ablation is feasible in patients unsuitable for percutaneous approach or hepatic resection, with rare complications and with good technical and clinical outcomes.
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Prostate cancer (PC) is the most frequently diagnosed cancer among adult men, and its incidence is increasing worldwide [...].
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PURPOSE: Pediatric liver transplant surgery is burdened by arterial complications whose endovascular treatment is not standardized. We report the outcomes of a cohort of pediatric recipients with hepatic artery complications treated by endoluminal procedures. MATERIALS AND METHODS: From December 2019 to December 2022, consecutive transplanted pediatric patients who underwent endovascular treatment of hepatic artery complications were reviewed. The analysis included: type of complication (occlusion, stenosis, pseudoaneurysm); onset (acute = < 15 days, subacute = 15-90 days, late = > 90 days); endovascular technique (angioplasty, stenting); complications and outcomes. Technical success was defined as the opacification of the hepatic artery at the final angiogram with < 50% residual stenosis and no pseudoaneurysms. Clinical success was defined by graft's and patient's survival. RESULTS: Seventeen patients (8 males; median age 33 months, IQR 9-103) underwent 21 hepatic arteriography procedures for predominantly acute or subacute occlusions (n = 7) or stenosis (n = 11) with concurrent pseudoaneurysms (n = 4). Primary and secondary technical success was achieved in 13/18 and 3/3 procedures, respectively, with overall technical success of 76%. Angioplasty alone was successful in 5/21 procedures; stent-retriever thrombectomy was performed in one occlusion with thrombosis; stenting was required in 9/17 (53%) patients. Clinical success was obtained in 14/17 (82%) patients with hepatic artery patency after a median of 367 days (IQR 114.5-500). Clinical failure occurred in 3 permanent occlusions, with 2 deaths and 1 re-transplantation. Procedure-related complications included minor events in 3/17 (18%) patients and 1/17 (6%) death. CONCLUSION: In liver transplanted children with hepatic artery complications, endovascular treatment may provide clinical success, with stenting often required in acute and subacute conditions. LEVEL OF EVIDENCE: Level 4.
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Falso Aneurisma , Procedimentos Endovasculares , Transplante de Fígado , Masculino , Humanos , Criança , Pré-Escolar , Constrição Patológica , Artéria Hepática/diagnóstico por imagem , Artéria Hepática/cirurgiaRESUMO
PURPOSE: To illustrate diagnostic and interventional imaging for the characterization and treatment of portal vein thrombosis (PVT). INTRODUCTION: The broad spectrum of congenital and acquired PVT manifestations is illustrated, with a focus on the pediatric population; diagnostic and interventional imaging techniques are described. DESCRIPTION: PVT frequently presents as an incidental finding at imaging in the screening for liver diseases or for other unrelated reasons. PVT can be classified based on: extension (intrahepatic, extrahepatic, involving the spleno-mesenteric tract, etc.); degree (partial or complete); onset (acute or chronic); and with or without cavernomatous transformation. This comprehensive review relies on the experience gained from a large series of congenital and acquired PVT in a referral center for pediatric and adult liver transplantation. Diagnostic and interventional imaging techniques are described, including: color-Doppler and contrast-enhanced Ultrasound; CT and MR angiography; retrograde portography; percutaneous transhepatic, transplenic, and transmesenteric portography; transjugular intrahepatic portosystemic shunt creation. Pre- and post-operative imaging assessment of the surgical meso-rex bypass is discussed. The description is enriched with an original series of pictorial imaging findings. CONCLUSION: PVT is a clinical condition associated with significant morbidity and mortality. Diagnostic and interventional imaging plays a crucial role in both conservative and operative management.
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PURPOSE: Cholestasis due to benign biliary strictures is the most common biliary complication after pediatric split liver transplantation (SLT), decreasing graft survival, but consensus about its management lacks. Percutaneous transhepatic cholangiography, bilioplasty and internal-external biliary drainage (IEBD) are standard treatments. The aim of this report is to present the preliminary experience with a new biodegradable biliary stent in the management of post-SLT biliary strictures. MATERIALS AND METHODS: Between September 2020 and April 2021, SLT patients with a single anastomotic benign biliary stricture underwent percutaneous transhepatic implantation of an innovative 10F helical-shaped biodegradable biliary stent, featuring a slow degradation profile, in addition to the standard treatment with bilioplasty and IEBD. The device is unique and the first to be CE-marked for the use in this indication. RESULTS: Six pediatric patients (4 males; median age 8.6 years, interquartile range 3.7 years) underwent percutaneous stent implantation, without complications nor clinical cholestasis during a median follow-up of 271 days (IQR 120.25). Stent dislodgement occurred in one case. CONCLUSION: Preliminary data suggest that implantation of a new biodegradable biliary stent may be considered in the management of post-SLT cholestasis in pediatric patients. Some technical tips are useful during implantation. This device may prolong biliary drainage, potentially relieving the discomfort of long-term IEBD.
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Colestase , Transplante de Fígado , Criança , Pré-Escolar , Colestase/diagnóstico por imagem , Colestase/etiologia , Colestase/cirurgia , Constrição Patológica/cirurgia , Drenagem/efeitos adversos , Humanos , Transplante de Fígado/efeitos adversos , Masculino , Estudos Retrospectivos , Stents/efeitos adversos , Resultado do TratamentoRESUMO
Background: Over the last two decades, augmented reality (AR) has been used as a visualization tool in many medical fields in order to increase precision, limit the radiation dose, and decrease the variability among operators. Here, we report the first in vivo study of a novel AR system for the guidance of percutaneous interventional oncology procedures. Methods: Eight patients with 15 liver tumors (0.7−3.0 cm, mean 1.56 + 0.55) underwent percutaneous thermal ablations using AR guidance (i.e., the Endosight system). Prior to the intervention, the patients were evaluated with US and CT. The targeted nodules were segmented and three-dimensionally (3D) reconstructed from CT images, and the probe trajectory to the target was defined. The procedures were guided solely by AR, with the position of the probe tip was subsequently confirmed by conventional imaging. The primary endpoints were the targeting accuracy, the system setup time, and targeting time (i.e., from the target visualization to the correct needle insertion). The technical success was also evaluated and validated by co-registration software. Upon completion, the operators were assessed for cybersickness or other symptoms related to the use of AR. Results: Rapid system setup and procedural targeting times were noted (mean 14.3 min; 12.0−17.2 min; 4.3 min, 3.2−5.7 min, mean, respectively). The high targeting accuracy (3.4 mm; 2.6−4.2 mm, mean) was accompanied by technical success in all 15 lesions (i.e., the complete ablation of the tumor and 13/15 lesions with a >90% 5-mm periablational margin). No intra/periprocedural complications or operator cybersickness were observed. Conclusions: AR guidance is highly accurate, and allows for the confident performance of percutaneous thermal ablations.
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Embolization in pediatric patients encompasses a large spectrum of indications, ranging from the elective treatment of congenital diseases of the cardiovascular system to the urgent management of acute hemorrhagic conditions. In particular, the endovascular treatment of central and peripheral vascular malformations and hypervascular tumors represents a wide chapter for both congenital and acquired situations. Thanks to the progressive availability of low-profile endovascular devices and new embolic materials, the mini-invasive approach has gradually overtaken surgery. In this review, the main embolization procedures will be illustrated and discussed, with a focus on clinical indications and expected outcomes. The most recent mini-invasive techniques will be described, with hints on the cutting-edge devices and embolic materials.
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BACKGROUND: Embolisation of the parenchymal tract is a key step after any other transhepatic or transplenic percutaneous portal vein catheterization since eventual venous bleeding is difficult to control and may require surgical management. Different techniques have been proposed to perform tract embolisation. The aim of this study is to compare the safety and efficacy of different techniques of haemostasis of the parenchymal tract. MATERIALS AND METHODS: All the interventional procedures with percutaneous transhepatic or transplenic access to the portal vein (excluding ipsilateral portal vein embolisation) from January 2010 to July 2020, in two tertiary hospitals, were retrospectively analyzed. The following data were evaluated: access site, the technique of embolisation, technical success in terms of immediate thrombosis of the tract, safety and clinical efficacy in terms of the absence of hemorrhagic and thrombotic complications. RESULTS: One-hundred-sixty-one patients underwent 220 percutaneous transhepatic or transplenic portal vein catheterization procedures. The main indications were pancreatic islet transplantation, portal anastomotic stenosis after liver transplantation, and portal vein thrombosis recanalization. As embolic materials gelfoam was used in 105 cases, metallic micro-coils in 54 cases, and cyanoacrylic glue in 44 cases; in 17 cases the parenchymal tract was not embolized. Technical success was 98% without significant difference among groups (p-value = 0.22). Eighteen post-procedural abdominal bleedings occurred, all grade 3 and were managed conservatively; difference among groups was not significant (p-value = 0.25). We detected 12 intrahepatic portal branch thromboses not related to the embolisation technique; only one case of non-target embolisation was documented after liver tract embolisation with glue, without clinical consequences. CONCLUSION: Embolisation of the parenchymal tract after percutaneous portal vein catheterization is technically safe and effective. No significant differences were found between coils, glue, and gelfoam in effectiveness and complications rate. LEVEL OF EVIDENCE: Level 3, Cohort study.
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Arterioportal fistulas (APFs) are uncommon vascular abnormalities with a heterogeneous etiology. In pediatric orthotopic liver transplantation (OLT), APFs are frequently iatrogenic, following percutaneous liver interventions. The aim of this study was to report the 10-year experience of a tertiary referral center for pediatric OLT in the interventional radiological (IR) and conservative management of acquired APFs. A retrospective search was performed to retrieve pediatric patients (<18 years old) with a diagnosis of APF at color Doppler ultrasound (CDUS) or computed tomography angiography (CTA) from 2010 to 2020. Criteria for IR treatment were the presence of hemodynamic alterations at CDUS (resistive index <0.5; portal flow reversal) or clinical manifestations (bleeding; portal hypertension). Conservatively managed patients served as a control population. Clinical and imaging follow-up was analyzed. Twenty-three pediatric patients (median age, 4 years; interquartile range = 11 years; 15 males) with 24 APFs were retrieved. Twenty patients were OLT recipients with acquired APFs (16 iatrogenic). Twelve out of twenty-three patients were managed conservatively. The remaining 11 underwent angiography with confirmation of a shunt in 10, who underwent a total of 16 embolization procedures (14 endovascular; 2 transhepatic). Technical success was reached in 12/16 (75%) procedures. Clinical success was achieved in 8/11 (73%) patients; three clinical failures resulted in one death and two OLTs. After a median follow-up time of 42 months (range 1-107), successfully treated patients showed an improvement in hemodynamic parameters at CDUS. Conservatively managed patients showed a stable persistence of the shunts in six cases, spontaneous resolution in four, reduction in one and mild shunt increase in one. In pediatric patients undergoing liver interventions, APFs should be investigated. Although asymptomatic in most cases, IR treatment of APFs should be considered whenever hemodynamic changes are found at CDUS.
RESUMO
PURPOSE: To evaluate the efficacy and safety of percutaneous transhepatic endoscopic holmium laser biliary lithotripsy (PTBL) to treat recurrent cholangitis due to intra/extrahepatic stones, in patients not candidate for traditional endoscopic treatment. MATERIALS AND METHODS: We retrospectively evaluated 28 patients (M:F = 19:9, mean age = 65 years, SD = 14) undergoing 43 PTBL for stone-related recurrent cholangitis from January 1, 2012 to January 31, 2019 in a single academic center. Data collected included demographics, location and number of stones, clinical success after one (primary) or more than one (secondary) PTBL, procedure time, duration of hospital stay, number of retreatments and post-procedural complications. Clinical success was defined as the resolution of cholangitis at 30-day follow-up. RESULTS: PTBL were successful for 23/28 (82%) patients, 16 (57%) with one and 7 (88%) with repeat procedures. The remaining 5 (18%) patients were finally treated with surgery (3, 11%) or further antibiotics (2, 7%). PTBL were performed to treat intrahepatic stones (22 treatments, 51%), extrahepatic (14, 33%), and both intra/extrahepatic (7, 16%). One to three stones were found in 12/43 (28%) PTBL, more than three in 31/43 (72%). Single PTBL was performed in 20/28 (71%) patients, two in 3/28 (11%), three in 3/28 (11%), and four in 2/28 (7%). Median procedure duration was 115 (29-210, 95% CI 101-129) minutes; median hospital stay was 5.5 (2-42) days. The only major complication was the breakage of a guidewire tip, surgically retrieved; minor complications included one aspiration pneumonia and three instances of intrahepatic hemorrhage, treated conservatively. CONCLUSIONS: PTBL was clinically successful in the 82% of patients not candidate for endoscopic treatment, with a low complication rate.