Role of multidetector-row CT in assessing the source of arterial haemorrhage in patients with pelvic vascular trauma. Comparison with angiography.

PURPOSE: We investigated the role of multidetector-row computed tomography (MDCT) in identifying active bleeding and its source in polytrauma patients with pelvic vascular injuries with or without associated fractures of the pelvis. MATERIALS AND METHODS: From January 2003 to December 2007, 28 patients (19 men and nine women, age range 16-80 years) with acute symptoms from blunt pelvic trauma and a drop in haematocrit underwent MDCT and angiography. Conventional radiography of the pelvis was performed in all patients at the time of admission to the emergency department. MDCT was performed with a four-row unit in 15 patients and a 16-row unit in the remaining 13 patients. The study included whole-body CT to identify craniocerebral, vertebral, thoracic, abdominal and pelvic injuries. CT was performed before and after rapid infusion (4-5 ml/s) of intravenous contrast material (120 ml) using a power injector. A triphasic contrast-enhanced study was performed in all patients. MDCT images were transferred to a workstation to assess pelvic fracture, site of haematoma and active extravasation of contrast material, visibility of possible vascular injuries and associated traumatic lesions. At angiography, an abdominal and pelvic aortogram was obtained in all cases before selective catheterisation of the internal iliac arteries and superselective catheterisation of their branches for embolisation purposes. Results related to identifying the source of bleeding at MDCT were compared with sites of bleeding or vascular injury identified by selective pelvic angiography. The sensitivity and positive predictive value (PPV) of MDCT were determined. RESULTS: MDCT allowed us to identify pelvic bleeding in 21/28 patients (75%), with most cases being detected in the delayed contrast-enhanced phase (13/21 cases, 61.9%). Injured arteries were identified on MDCT in 12/21 cases (57%): the obturator artery (n=9), internal iliac artery (n=6), internal pudendal artery (n=6) and superior gluteal artery (n=5) were most frequently injured. In 8/21 patients (28.6%), more than one artery was injured. Among the 12 patients in whom MDCT showed the presence of pelvic haemorrhage, there was agreement between MDCT and angiography in ten cases. Angiography confirmed the site of bleeding detected on MDCT and identified a second arterial haemorrhage in one patient. There was no agreement between MDCT and angiography in the last patient. MDCT showed a sensitivity of 42.85% and a PPV of 100% in identifying the injured arteries. CONCLUSIONS: Arterial haemorrhage is one of the most serious problems associated with pelvic fracture, and it remains the leading cause of death attributable to such fractures. MDCT provides diagnostic information regarding the presence of small pelvic fractures and, thanks to the contrast-enhanced angiographic technique, it is capable of identifying pelvic bleeding, with the demonstration in some cases of it source. The presence of contrast material extravasation is an indicator of injury to a specific artery passing through the region of the pelvis where the extravasation is noted on MDCT. Urgent angiography and subsequent transcatheter embolisation are the most effective methods for controlling ongoing arterial bleeding in pelvic injuries.

Successful endovascular treatment of a recurrent giant celiac artery aneurysm.

Visceral artery aneurysms are very rare and aneurysms of the celiac trunk are the rarest ones: they are in most cases asymptomatic and their detection is frequently incidental. In this article we report the case of a man affected by severe abdominal pain with a huge aneurysm of the celiac trunk, first successfully treated with coil embolization, but, after 10 months, another endovascular embolization was required for deployment of the metallic coils previously released, ahead into the fund of the sac with recanalization of the aneurysm. A second endovascular treatment was performed with other coils and Amplatzer-Plug. The high risk of rupture makes treatment of such aneurysms mandatory and surgery is still considered the gold standard therapy of VAA, but, due to its high morbidity and mortality risks, in the last years, it has been widely replaced by endovascular embolization. An effective endovascular embolization requires not only the complete filling of the aneurysmal sac, but also the complete vascular exclusion of its in-flow and out-flow tracts, to reduce the risk of its anterograde or retrograde reperfusion.

A Touchless system for image visualization during surgery: preliminary experience in clinical settings.

Today clinicians may access large medical datasets, but very few systems have been designed to allow a practical and efficient exploration of data directly in critical medical environments such as operating rooms (OR). This work aims to assess during tests in laboratory and clinical settings a Surgery Touchless System (STS). This system allows clinicians to interact with medical images by using two different approaches: a gesture recognition and a voice recognition based system. These two methods are based on the use of a Microsoft Kinect and of a selective microphone, respectively. The STS allows navigating in a specifically designed interface, to perform several tasks, among others, to manipulate biomedical images. In this article, we assessed both the recognitions approaches in laboratory with 5 users. In addition, the STS was tested using only the voice-based recognition approach in clinical settings. The assessment was performed during three procedures by two interventionalradiologists. The five volunteers and the 2 radiologists filled two questionnaires to assess the system. The system usability was positively evaluated in laboratory tests. From clinical trials emerged that the STS was considered safe and useful by both the radiologists: they used the system an averaged number of times of 10 and 15 for patients, and found the system useful. These promising results allow considering this system useful for providing information not otherwise accessible and limiting the impact of human error during the operation. Future work will be focused on the use of the STS on a high number and different types of procedure.

Total or partial percutaneous renal ablation in the treatment of renovascular hypertension: radiological and clinical aspects.

In 15 patients with renovascular hypertension, considered unsuitable for angioplasty or surgery, percutaneous renal ablation was performed by injection of ethanol into the renal vasculature. Partial or complete renal ablation was confirmed by follow-up intravenous pyelography or arteriography. Patients were followed-up for a mean of 24.8 months after therapy and blood pressure was improved in all patients with five being cured. This study shows that percutaneous renal ablation is a useful and successful method of therapy for renal hypertension, and that it should be considered in patients unsuitable for surgery or angioplasty.

Percutaneous cholecystectomy in the human: a technical note.

A new procedure--percutaneous ablation of the gallbladder--is reported in 2 patients. In this technique, ethanol is injected into the gallbladder and bucrylate is injected into the cystic duct to produce necrosis of the gallbladder.

Silicone biliary stents.

Large silicone stents (9-28 French) were placed in the biliary tree of 173 patients over a 3-year period. Their use markedly reduced the incidence of catheter occlusion and sepsis. Only three cases of cholangitis and one case each of excessive bleeding and pleural effusion occurred. No skin irritation or pancreatitis occurred. The large bore of the catheter and the use of biocompatible material improved the safety and efficacy of biliary drainage.

[Cholangiocarcinoma of the main biliary tract. Judging its resectability by imaging procedures]. / Il colangiocarcinoma della via biliare principale. Giudizio di resecabilità con procedure di imaging.

Eighteen patients with main biliary tract cholangiocarcinomas and no spread to the gallbladder and to the papilla of Vater underwent a combined US, ERCP/PTC and CT study. Angiography was performed on a selected group of 12 patients. We divided the infiltrating, polypoid or stenosing lesions in three groups: upper portion tumors, involving the confluence and the common hepatic duct (8 patients); middle portion tumors, originating from the common bile duct between the confluence of the cystic duct and the upper duodenal profile (6 patients); and finally lower third tumors, originating from the common bile duct between the upper rim of the duodenum and the papilla of Vater (4 patients). According to ERCP and/or PTC, US, CT and angiographic findings, only 9 of 18 cholangiocarcinomas were judged as resectable. The authors stress the need to optimize the use of imaging methods: US can locate the biliary obstruction; ERCP and/or PTC can show the tumor and its spread out of the duct, and finally angiography can exclude or confirm the vascular involvement of the hepatic hilum.

Treatment of massive hemorrhage after renal biopsy with percutaneous arterial obliteration.

Severe perirenal hemorrhage is a major, although rare, postbiopsy complication. We report a case of a 48-year-old man with a postbiopsy massive bleeding from a ramification of the renal artery supplying the lower pole of the left kidney. Treatment consisted of complete obliteration of the bleeding vessel by helding a percutaneous catether in wedge position during a renal arteriographyc study. Our case shows that percutaneous arterial obliteration is a successful procedure in treating postbiopsy renal hemorrhage, representing an effective alternative to surgical therapy.

[A comparative multicenter study of the efficacy of single- and double-lumen catheter drainage]. / Studio comparativo multicentrico sull'efficacia del drenaggio dei cateteri a singolo e doppio lume.

Our study was aimed at comparing the therapeutic efficiency of single and double lumen catheters in the drainage of abdominal fluid collections. We report the results of in vitro and in vivo studies carried out to assess the usefulness of each catheter type based on its therapeutic results. In the in vitro study the aspiration efficacy of the catheters was tested in a simulated cavity. In the in vivo study 188 patients with 206 fluid collections in the abdomen were examined; the patients had been treated percutaneously with single or double lumen catheters, randomly. In each patient we studied drainage efficiency related to aspiration efficacy, the time the catheter rested in the cavity, patient's discomfort and finally the cost of both the device and hospitalization. Some patients underwent surgery for specific reasons, but nevertheless their clinical conditions were absolutely improved thanks to percutaneous drainage. The results of this study yield useful clinical data to choose the most suitable catheter for the percutaneous treatment of abdominal fluid collections. Single lumen catheters work better than double lumen ones, the latter being also more expensive. Hospitalization time is also reduced when single lumen catheters are used.

Treatment of severe renovascular hypertension by percutaneous transluminal renal angioplasty in patients with solitary functioning kidney. Effects on blood pressure and renal function.

In this study the effects of percutaneous transluminal renal angioplasty on blood pressure and renal function were studied in 9 hypertensive patients with stenosis of the main artery of a solitary functioning kidney. The outcome of the percutaneous dilatation of the renal artery stenosis, and the effects on blood pressure and renal function were evaluated for a mean period of 16.4 +/- 2.13 (SE) months (ranging from 3 to 65 months). A successful dilatation of the renal artery stenosis was shown in all the patients by the aortography performed 1 h after the procedure. At the discharge (7.8 +/- 0.9 days after dilatation), blood pressure was 'cured' in 2 patients and 'improved' in the remaining patients; renal function was improved in all patients who had reduced renal function. At the last follow-up, no restenosis was found in patients who repeated the follow-up angiography; blood pressure was 'cured' in 3 patients and 'improved' in 6 patients, and renal function appeared steadly improved. In contrast with other reports, our results demonstrate that percutaneous renal angioplasty is a safe and effective procedure and should be attempted before considering surgical intervention in patients with artery stenosis of a solitary functioning kidney.