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.

Severe metrorrhagia in patients with advanced gynecologic cancer: endovascular treatment benefits in acute and chronic setting.

PURPOSE: Interventional radiology plays an established role in the management of many conditions of the female reproductive tract. Since in benign gynecological and obstetric pathologies, as myomas and postpartum hemorrhages, uterine arteries embolization has been already evaluated, this manuscript aims to report on a single-center experience concerning the endovascular management of metrorrhagia caused by gynecological malignancies. MATERIALS AND METHODS: Single-center retrospective analysis of thirty patients affected by gynecologic cancer treated with endovascular embolization between January 2016 and December 2018 for acute or chronic metrorrhagia. RESULTS: All patients were in advanced oncological stage (III or IV) with loco-regional spread of the tumor or invasion of pelvic structures, with a poor performance status. They were not suitable for surgery. On initial CT angiography, contrast media extravasation was confirmed in two patients (6.6%), while on DSA examination, tumor stain was displayed in 28 patients (93.4%). In two patients (6.6%) a pseudoaneurysm was reported. CONCLUSIONS: Endovascular treatment of metrorrhagia in oncologic patients could be a valid therapeutic alternative, especially when in elderly patients with poor clinical conditions not suitable for surgery. A bilateral and superselective embolization using non-resorbable embolic agents should be performed, except for those cases in which there is infiltration of major vessels causing pseudoaneurysms or fistulas that require embolization.

Successful endovascular embolization of a giant splenic artery pseudoaneurysm secondary to a huge pancreatic pseudocyst with concomitant spleen invasion.

Pseudoaneurysms of the pancreatic and peripancreatic arteries is a well-known complication of chronic or necrotizing pancreatitis due to proteolytic enzymatic digestion of the arterial wall. A major part of peripancreatic pseudoaneurysms involve the splenic artery, but any peripancreatic artery may be involved and bleed. They are potentially life threatening for patients, due to spontaneous intraperitoneal rupture, rupture and fistulization into the surrounding organs, or fistulization into the pancreatic duct. Small ones are usually asymptomatic and are often diagnosed incidentally, while giant (> 5 cm) aneurysms and pseudoaneurysms are symptomatic and may be detected as a pulsatile mass in the upper-left quadrant or epigastrium. Imaging plays a key role in the identification of splenic artery aneurysms and pseudoaneurysms, while angiography still represents the gold standard for the diagnosis, although nowadays it plays a prominent role in treatment. Treatment of splenic artery pseudoaneurysms is mandatory because of the high probability of rupture, with a mortality rate of up to 90%. The gold standard treatment is represented by surgery, with a mortality rate between 16% and 50%. In recent years the endovascular approach has proven to be an effective alternative treatment for splenic artery pseudoaneurysms, and it is currently the method of choice. In this article, we present the case of a ant pseudoaneurysm of the splenic artery due to huge pseudocysts in a young alcoholic patient with recurrent and chronic pancreatitis, complicated by fistulization and invasion of spleen parenchyma and arteriovenous fistula.

Embolization of high-flow priapism: technical aspects and clinical outcome from a single-center experience.

PURPOSE: High-flow priapism is an incomplete and painless persistent erection caused by trauma. Its diagnosis is performed thanks to clinic and imaging evaluation with detection of fistula/pseudoaneurysm in the cavernous tissue. This paper aims to retrospectively assess the efficacy and safety of superselective arterial embolization in patients with high-flow priapism. MATERIALS AND METHODS: From January 2008 to March 2017, nine patients with high-flow priapism have been treated in a single center with embolization. The main etiology was trauma in eight subjects. The patients were evaluated with laboratory examinations and clinical and imaging findings (color Doppler ultrasonography and angiography). The mean follow-up time after embolization was 24 months. RESULTS: Eleven procedures were performed in nine patients: two of them required a second treatment session because of recurrence after 1-2 weeks. Embolic agents were microcoils, microparticles (300-500 µm) and Spongostan. Restoration of erectile function was monitored by clinical and color Doppler evaluation during follow-up. CONCLUSIONS: Superselective embolization should be the procedure of choice in patients affected by high-flow priapism; this technique appears to be successful in preserving erectile function. The choice of the embolic agent is crucial, and it should be tailored for each patient.

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.

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.

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.

A Pictorial Review of the Role of Imaging in the Detection, Management, Histopathological Correlations, and Complications of COVID-19 Pneumonia.

Imaging plays an important role in the detection of coronavirus (COVID-19) pneumonia in both managing the disease and evaluating the complications. Imaging with chest computed tomography (CT) can also have a potential predictive and prognostic role in COVID-19 patient outcomes. The aim of this pictorial review is to describe the role of imaging with chest X-ray (CXR), lung ultrasound (LUS), and CT in the diagnosis and management of COVID-19 pneumonia, the current indications, the scores proposed for each modality, the advantages/limitations of each modality and their role in detecting complications, and the histopathological correlations.

Iliopsoas bursitis: The role of diagnostic imaging in detection, differential diagnosis and treatment.

Iliopsoas bursitis is characterized by distension of the iliopsoas muscle bursa due to synovial fluid and/or hypertrophic synovium. Hip disease is usually associated with it, however, isolated bursitis is also present. Clinically Diagnosing iliopsoas bursitis can be difficult, and imaging is usually required to differentiate iliopsoas bursitis from other inguinal masses such as lymphadenopathy, hernias, and tumors. We present the case of a 45-year-old athletic patient who underwent diagnostic examination for recurrent right hip pain and a recent development (last 3 months) of a bulky right inguinal mass.

Successful endovascular treatment of a spontaneous bleeding accessory spleen: A case report.

Accessory spleens are often encountered in radiologic studies and they are not usually associated with symptoms. They could arise from autotransplantation of splenic tissue after splenic trauma or splenectomy (splenosis) [1]. In this case we describe a woman treated for splenectomy 20 years before and subsequently for adhesions, that suffered sudden left upper abdominal quadrant pain, weakness, and pale color. Contrast-enhanced computed tomography revealed free spilling in the abdomen and venous bleeding of a big accessory spleen; thus the patient underwent transcatheter arterial embolization with coils. Due to the 2 previous surgical operations in the splenic loggia, endovascular treatment compared to "open surgery" was the best choice in this case because of determined less complications, a shorter period of hospitalization, and a reduction of health cost.