Alberto Rebonato

Endovascular Exclusion of Visceral Artery Aneurysms with Stent-Grafts: Technique and Long-Term Follow-up

This paper describes four cases of visceral artery aneurysms (VAAs) successfully treated with endovascular stent-grafts and discusses the endovascular approach to VAAs and the long-term results. Four balloon expandable stent-grafts were used to treat three splenic artery aneurysms and one bleeding common hepatic artery pseudoaneurysm. The percutaneous access site and the materials were chosen on the basis of CT angiography findings. In all cases the aneurysms were successfully excluded. In one case a splenic infarction occurred, with nonrelevant clinical findings. At 16- to 24-month follow-up three patients had patent stents and complete exclusion and shrinkage of the aneurysms. One patient died due to pancreatitis and sepsis, 16 days after successful stenting and exclusion of a bleeding pseudoaneurysm. We conclude that endovascular treatment using covered stent-grafts is a valid therapeutic option for VAAs. Multislice CT preoperative study helps in planning stent-graft positioning.

A New Device for Vascular Embolization: Report on Case of Two Pulmonary Arteriovenous Fistulas Embolization Using the Amplatzer Vascular Plug

A pulmonary arteriovenous fistula (PAVF) is a rare vascular malformation commonly treated by embolization with coils or balloons to prevent the risk of several serious complications such as cerebral embolism and brain abscess. A 32-year-old female with two PAVFs and neurological ischemic manifestations has been successfully treated by transcatheter embolization of both fistulas using a new device (Amplatzer Vascular Plug). This self-expanding cylindrical nitinol mesh cage with high radial strength allows a chance of relocation until properly positioned. It is preferred to coils or balloons because a large caliber of feeding artery implied high risk of uncontrollable distal embolization. There appear to be no reports in the literature concerning use of this device, which could represent a useful innovative tool in embolotherapies, especially in large vascular areas.

Late Migration of a Covered Stent into the Stomach after Repair of a Splenic Artery Pseudoaneurysm.

We would like to report our experience of a rather rare complication that occurred in a 76-year old patient tree years after endovascular repair of a splenic artery pseudoaneurysm with a covered stent. Three years after stent insertion, the patient complained of mild abdominal pain and melena; it was revealed endoscopically that the covered stent has eroded the stomach wall and migrated into the stomach. The splenic artery is the most common location among the spectrum of potential presentation sites of visceral arteries aneurysms and pseudoaneurysms. Endovascular treatment with the use of coils or stents is the first option due to lower morbidity and mortality than open surgery. Endovascular repair may also lead to complications and patients need to be followed up in order to confirm aneurysm sealing, and exclude late complication. Minor stent graft migration may occur in the long term, however extra vascular migration is extremely rare.

Preoperative Serum Markers Prognostic Evaluation in Colon Cancer Patients

Aim: Demonstrate that preoperative tumor markers are prognostic factor in colon rectal cancer and their high levels are correlated with bad prognosis.Methods: We retrospectively analyzed two hundred and thirty-one patients affected by colorectal cancer who underwent radical surgery between January 2012 and August 2016 from a prospectively collected database. The study group consisted of 224 patients: 132 men and 92 women. Demographic details, surgical procedure, histopathologic diagnosis, and survival data were prospectively collected and retrospectively reviewed for this study. Normal cut off values for Carcinoembryonic antigen (CEA) and Carbohydrate Antigen 19.9 (CA 19.9) were respectively 5 ng/ml and 35 UI/ml. A P-value<0.05 was deemed to be statistically significant.Results: Tumor location was 94 times on ascending colon (42%), 13 on transverse colon (5.8%), 77 on descending colon (34.4%) and 40 on rectum (17.8%). All tumors were histologically diagnosed as adenocarcinoma of the colon-rectum and staged according to the TNM staging system. Preoperative serum CEA level was significantly associated only with T stage and serum albumin level; whereas there were no statistically significant differences between preoperative serum CA19.9 and patients’ clinical pathologic characteristics. Overall survival (OS) and disease-free survival (DFS) showed a statistically significant difference in the two groups of patients who are dichotomized according to the normal cut-off value of CEA and Ca 19.9. At the multivariate analysis both preoperative CEA and Ca 19.9 resulted as independent prognostic factor for survival with a p<0.05.Conclusion: These two tumor markers could have a role as prognostic factors leading to a stricter postsurgical follow up in those patients with elevated preoperative values.Core tip: Preoprative measurement of Cea and Ca19.9 is a cheap and routine exam. Their role could help to identify patients with poor prognosis in the preoperative period and to strictly follow up them in the post-surgical setting.

Reply to: Ethylene Vinyl Alcohol Copolymer as First Hemostatic Liquid Embolic Agent for Non-variceal Upper Gastrointestinal Bleeding Patients: Pros and Cons

Dear Editor, It was a great pleasure to read in CVIR the comment of Loffroy et al. [1] on the previously published article from our group on the use of Onyx for the treatment non-variceal upper gastrointestinal bleeding [2]. Firstly, we would like to thank the authors of the meticulous literature overview on the topic and to mention that we highly appreciate their commentary as recognized experts on the area. We believe that the whole IR and Neuro-IR community is aware of the physical properties of Onyx as an embolic agent since its introduction in the 1990s; therefore, we did not consider necessary describing that in our manuscript [3]. We take on board some of the constructive criticism on the use of the mentioned liquid embolic, and we would like to reply on the raised issues. Firstly, we think that we are all aware that the use of DMSO can lead to severe vascular spasm when used in large quantities and of course we agree that the injection rate should be slow. In our practice, we tend to aspirate approximately 0.5 ml with a dedicated syringe, according to the dead space offered by the microcatheter used, and inject with a rate of approximately 0.5 ml/min and never experienced any problems. We believe that the 0.2 ml that the authors suggest is applied to microcatheters with very limited dead space. Secondly, the whole injection process lasts between 2 to 5 min and we struggle to define this as ‘‘time-consuming,’’ given that the patients have been intermittently bleeding for days in some cases. We are pleased to hear that the authors of the letter would prefer to use glue as a quicker solution but we believe for the majority of IRs this is considered as less controlled than Onyx. On that note, we need to mention that reflux may more likely occur with use of glue than with the use of Onyx at least in our opinion. We also need to agree that DMSO is indeed volatile and is excreted via respiration and sweat and that the ward has to be advised about this effect, but this is a standard process done by our nurses during the handover. This effect clearly will not influence our clinical decision in choosing an embolic agent. We also have to agree with the last point raised. It is not only DMSO injection but also Onyx injection may lead to minor reactions that follow it’s infusion: The most commonly reported side effect is a burning sensation as a result of an exothermic reaction that is generated from the contact between Onyx and blood, especially when it is injected rapidly; this is a minor issue, but it should not be underestimated because is an indication of temporary interruption of the embolization procedure. In our series, even due to the critical clinical condition of the patients, deep sedation or general anesthesia was performed in all cases. Furthermore, we need to mention that our paper is enhancing the use of liquid embolics for the use of upper gastrointestinal bleeding. There is also another disadvantage of Onyx that the authors of the letter did not mention but we believe is worth mentioning at this stage and this is the required ‘‘activation time’’ of Onyx. It is important to & Miltiadis E. Krokidis mkrokidis@hotmail.com

Endovascular treatment of recurrent erectile dysfunction due to venous occlusive disease.

of the internal pudendal veins without the possibility of embolizing the external pudendal vein, the periprostatic venous plexus, and the DDV. In fact, many papers were published referring to the embolization techniques of the deep dorsal vein and the related efferents (internal and external pudendal veins and the periprostatic venous plexus).8,9 At our institution, we developed a minimally invasive technique with an anterograde approach of the DDV under US-guided puncture.10 Subsequently, we performed the selective catheterization and embolization under fluoroscopic guidance of the periprostatic plexus and both the internal and external pudendal veins, using N-butyl-2-cyanoacrylate (NBCA). We are convinced that this approach Dear Editor, We have read with great interest the excellent review by Kim et al.1 which reports the tools available in interventional radiology (IR) to face the frustrating problem of impotence. The social and psychological implication of this pathology drove the effort of scientific medicine searching for a solution for centuries.2 As known, the etiology of vasculogenic Erectile Dysfunction (ED) is complex and multifactorial providing either arterial or venous dysfunction, and the precise interplay of all physiologic mechanisms involved is not completely understood. Vasculogenic ED offers the opportunity to exploit modern IR techniques restoring compromised arterial inflow in case of artery insufficiency or reducing venous outflow in case of veno-occlusive dysfunction (VOD). The paper exhaustively reports the state-of-the art on this topic discussing endovascular embolization techniques and the inherent limitations. The ZEN (Zotarolimus-Eluting Peripheral Stent System for the Treatment of Erectile Dysfunction in Males with Suboptimal Response to PDE5 Inhibitors) trial well represents a modern option to treat the inadequate arterial inflow to corpora cavernosa.3 However, normal pelvic vascular anatomy and the correlation between the pelvic arterial disease and the ED are still not clear, and further studies are necessary to better define the role of pudendal stenting.1 The physiology of VOD was demonstrated in the 1970s;4 patients suffering of ED due to VOD, usually have damage to the corporeal smooth musculature or the tunica albuginea, or both, which results in impairments of vascular dilation. Hence, penis veins were the subject of medical and nonmedical therapies for centuries as the “penile ring” system could prove.5 Concerning the VOD and the penis deep dorsal vein (DDV), the option of surgical ligation, although developed some decades ago, was improved in the last years with encouraging outcomes.6 Kim et al.1 clearly underline the role of the embolization techniques and their limitations dealing with VOD. The authors report the work of Aschenbach et al.7 which obtained an 88.8% clinical success rate after endovascular internal pudendal vein embolization therapy with histoacryl-lipiodol using a trans-femoral approach. The retrograde approach of the technique requires a bilateral selective catheterization LETTER TO THE EDITOR

Sacrum colon-rectal cancer metastasis: microwave ablation for palliative pain treatment

Local treatment of bone metastasis (BM) remains controversial in colon-rectum carcinoma for pain control. A patient developed a sacrum BM 4years after a left colectomy for an adenocarcinoma. Metastasis was treated in one session of CT-guided microwave ablation showing good pain control immediately after and on follow-up at four months.

Feasibility and Value of Radiographic Union Score Hip Fracture after Treatment with Intramedullary Nail of Stable Hip Fractures

Introduction: Given the importance of fracture healing on patient outcome in clinical practice, it is critical to assess fracture healing. Aim: The aim of this study was to evaluate the feasibility of the Radiographic Union Score Hip fracture after treatment with intramedullary nail of stable hip fractures. Patients and Methods: We retrospectively collected the data from the clinical records of our institution of the 47 patientswho had undergone intertrochanteric hip fracture treatment using an intramedullary nail. Pain visual analogic score (VAS) was collected the same day that X-rays were taken. Plain hip X-rays were performed, in two radiographic views, at 40 and 90 days after the surgical procedure. The correlation between the RUSH and VAS score was evaluated. Results: Mean RUSH and VAS scores showed a strong statistical improvement between the 40 and 90 day follow-ups. RUSH value at 40 days fitted an inverse linear regression with VAS, p-value of 0.0063 and r2 of 0.15. At 90 days the regression between RUSH and VAS scores was not significant. Conclusion: RUSH could be proposed as an objective system to evaluate union in hip fractures treated with intramedullary nail.