Andrea Giorgianni

Comparative study of jaws with multislice computed tomography and cone-beam computed tomography

PurposeThe aim of this study was to compare the dosimetric and diagnostic performance of multislice computed tomography (MSCT) and cone-beam computed tomography (CBCT) in the study of the dental arches.Materials and methodsEffective dose and dose to the main organs of the head and neck were evaluated by means of thermoluminescent dosimeters (TLDs) placed in an Alderson Rando anthropomorphic phantom and using a standard CBCT protocol and an optimised MSCT protocol. Five patients with occlusal plane ranging from 54 cm to 59 cm who needed close follow-up (range 1–3 months) underwent both examinations. Image quality obtained with CBCT and MSCT was evaluated.ResultsEffective dose and dose to the main organs of the head and neck were higher for MSCT than for CBCT. Image quality of CBCT was judged to be equivalent to that of MSCT for visualising teeth and bone but inferior for visualising soft tissues. Beam-hardening artefacts due to dental-care material and implants were weaker at CBCT than at MSCT.ConclusionsWhen panoramic radiography is not sufficient in the study of the teeth and jaw bones, CBCT can provide identical information to MSCT, with a considerable dose reduction. MSCT is, however, indicated when evaluation of soft tissue is required.RiassuntoObiettivoScopo di questo lavoro è confrontare le performances dosimetriche e diagnostiche di tomografia computerizzata multidetettore (TCMD) e tomografia computerizzata a fascio conico (TCFC) nello studio delle arcate dentarie.Materiali e metodiSi è provveduto alla misurazione della dose alle strutture di capo e collo e della dose efficace con dosimetri a termoluminescenza (TLD) posti in un fantoccio antropomorfo Alderson Rando utilizzando un protocollo TCFC ed uno TCMD ottimizzato. Sono stati esaminati 5 pazienti, con circonferenza al piano occlusale entro un range prestabilito (54–59 cm) e che avevano necessità di effettuare controlli ravvicinati nel tempo (range 1-3 mesi), con entrambi i sistemi TC ed è stata valutata la qualità delle immagini ottenute.RisultatiLa dose efficace agli organi è superiore per la TCMD rispetto alla TCFC. La qualità delle immagini della TCFC è stata giudicata sovrapponibile alla TCMD nello studio dei denti e dell’osso, inferiore nella valutazione dei tessuti molli. Artefatti da indurimento del fascio dovuti alla presenza di materiale medicamentoso e protesico incidono negativamente sulla qualità dell’immagine maggiormente nel caso della TCMD rispetto alla TCFC.ConclusioniLo studio delle strutture ossee può essere effettuato, se la radiografia ortopanoramica non è sufficiente, mediante TCFC, che fornisce informazioni sovrapponibili a quelle della TCMD con notevole risparmio di dose; la TCMD è indicata qualora sia necessario valutare anche i tessuti molli.

Popliteal artery pseudoaneurysm after a revision of total knee arthroplasty: endovascular treatment with a stent graft

Injury to the popliteal artery during total knee arthroplasty is a very rare but dangerous complication. Several mechanisms are capable of generating a direct trauma to the vessel, like posterior retractor and oscillating saw. We report a case of popliteal artery pseudoaneurysm in a 52-year-old woman that occurred during revision of total knee arthroplasty, requiring emergency repair by means of percutaneous endovascular covered stenting.

Endovascular Treatment of Femoropopliteal Aneurysms: A Five-Year Experience

PurposeTo assess the effectiveness of endovascular treatment of femoropopliteal aneurysms (FPAs).MethodsIn the last 5 years, we have treated 17 FPAs (diameter 21–75 cm, mean 38.4 cm; length 27–100 cm, mean 72.5 cm) in 15 patients (age 57–80 years, mean 70.9 years). The diagnosis was obtained by color Doppler ultrasound (CDU) and the procedure was planned by CT angiography (CTA) and preprocedural angiography. Eight FPAs were excluded with only one stent-graft; in 8 patients, two stent-grafts were positioned; and in 1 patient, three stent-grafts were used. In 14 cases we used a Wallgraft endoprosthesis, in 2 cases a Hemobahn, and in 1 case an Excluder contralateral leg. The patients were followed up with CDU and occasionally with CTA.ResultsImmediate technical success was obtained in 17 of 17 cases (100%). One patient died during the first year. During a mean follow-up of 26.9 months (range 3–60 months) we observed 6 of 16 (38%) stent-graft occlusions (3 of which were recanalized with locoregional thrombolysis and 3 with mechanical thrombectomy). Two stent-grafts were patent at 12 and 24 months. Four patients experienced subsequent occlusions and recanalizations until corrected by surgical bypass (1 at 14 months, 2 at 18 months, and 1 at 36 months). Therefore the primary patency was 63% and assisted patency was 73%.ConclusionThe endovascular approach is a minimally invasive treatment option for FPAs. Moreover endovascular stent-grafting does not necessarily preclude conventional surgical repair, but it can delay it. Longer follow-up will be needed to determine the long-term patency rate.

Image-guided percutaneous treatment of abdominal-pelvic abscesses: a 5-year experience

PurposeThis study was undertaken to evaluate the efficacy of image-guided percutaneous drainage in treating abdominal and pelvic abscesses.Materials and methodsFrom August 2001 to August 2006, 95 patients (49 men and 46 women; mean age 61 years, range 25–92) with 107 abscesses underwent image-guided percutaneous drainage. Thirty-one abscesses were retroperitoneal (9 peripancreatic, 17 perirenal, 5 pararenal), 37 intraperitoneal (2 in communication with the small bowel), 8 intrahepatic (2 in communication with the extrahepatic biliary system and 2 with the intrahepatic biliary system), 4 perisplenic and 27 pelvic (4 in communication with the large bowel). Seventy-one of 107 procedures were performed with ultrasonographic (US) guidance and 36/107 with computed tomography (CT) guidance. All procedures were carried out with 8-to 14-Fr pigtail drainage catheters.ResultsImmediate technical success was achieved in 107/107 fluid collections. No major complications occurred. In 98/107 abscesses, we obtained progressive shrinkage of the collection (>50%) with consequent clinical success. In 9/107 cases, percutaneous drainage was unable to resolve the fluid collection. There were 12 cases of catheter displacement and six of obstruction.ConclusionsPercutaneous drainage is feasible and effective in treating abdominal and pelvic abscesses. It may be considered both as a preparatory step for surgery and a valuable alternative to open surgery. Failure of the procedure does not, however, preclude a subsequent surgical operation.RiassuntoObiettivoValutare la fattibilità del drenaggio percutaneo imaging-guidato nel trattamento degli ascessi addomino-pelvici.Materiali e metodiDall’agosto 2001 all’agosto 2006, 95 pazienti (49 uomini e 46 donne, età media 61 anni, range 25–92) portatori di 107 raccolte sono stati sottoposti a drenaggio percutaneo imaging guidato. Trentuno raccolte erano retroperitoneali (9 peripancreatiche, 17 perirenali, 5 pararenali), 37 intraperitoneali (2 comunicanti con l’intestino tenue), 8 intra-epatiche (2 in comunicazione con il sistema biliare extraepatico e 2 con il sistema biliare intraepatico), 4 peri-spleniche e 27 pelviche (6 comunicanti con l’intestino crasso). Settantuno/107 procedure sono state realizzate sotto guida ecografica, 36/107 sotto guida TC utilizzando drenaggi percutanei di calibro variabile tra 8–14 Fr.RisultatiIl successo tecnico immediato è stato ottenuto in 107/107 raccolte. Non si sono verificate complicanze maggiori. In 98/107 raccolte il drenaggio percutaneo ha realizzato una progressiva riduzione dimensionale (>50%) con successivo successo clinico. In 9/107 raccolte, il drenaggio percutaneo si è dimostrato inefficace. Si sono verificati 12/107 sposizionamenti e 6/107 ostruzioni del catetere.ConclusioniLa procedura percutanea si è dimostrata tecnicamente fattibile ed efficace nel trattamento delle raccolte addominali e pelviche proponendosi in parte come tecnica propedeutica, in prevalenza come valida pancrealternativa alla chirurgia tradizionale che peraltro non viene preclusa in caso di insuccesso.

Bleeding from peristomal varices in a cirrhotic patient with ileal conduit: treatment with transjugular intrahepatic portocaval shunt (TIPS)

We report an unusual case of a 71-year-old man with liver cirrhosis who presented recurred bleedings from the stoma of the ileal conduit after radical cystoprostatectomy. The haemorrhages could not be treated by local measures, and a transjugular intrahepatic portocaval shunt was performed, displacing an endoprosthesis and a self-expandable stent. We highlight the role of TIPS to treat recurrent bleedings from the stoma in cirrhotic patients with ileal conduit and portal hypertension.

MDCT evaluation of the cardiac venous system

PurposeThis study was undertaken to evaluate the usefulness of electrocardiographically (ECG)-gated multidetector-row computed tomography (MDCT) for the assessment of the coronary venous system and detection of its anatomical variants, in order to identify those suitable for lead placement in cardiac resynchronisation therapy (CRT).Materials and methodsWe retrospectively examined the coronary MDCT studies of 89 patients (73 males, 16 females, average age 62.5 years, range 31–79) referred for suspected coronary artery disease. The cardiac venous system was assessed in all patients using three-dimensional (3D) postprocessing on a dedicated Vitrea workstation (five patients were excluded from the analysis).ResultsThe coronary sinus, the great cardiac vein, the anterior interventricular vein and the middle cardiac vein were visualised in all cases. The lateral cardiac vein was visualised in 56/84 patients (67%) and the posterior cardiac vein in 63/84 patients (75%), never both missing. Along the postero-lateral wall of the left ventricle, only one branch was present in 44 cases, two branches in 21 cases and three or more branches in 19/84 cases (22%). Evaluation of the maximum diameter revealed that the lateral vein was dominant over the posterior vein in 20/40 cases. The small cardiac vein was visualised in 11/84 cases.ConclusionsMDCT provides good depiction of the cardiac venous system, enabling the study of the vessel course and the identification of anatomical variants. Hence, this imaging technique could be proposed for the preoperative planning of CRT in selected patients.RiassuntoObiettivoScopo del nostro lavoro è valutare l’utilità della tomografia computerizzata multistrato (TCMS) nell’individuazione delle varianti anatomiche del sistema venoso coronarico al fine di riconoscere quelle ritenute più idonee per l’impianto dell’elettrocatetere necessario per la terapia di resincronizzazione cardiaca (CRT).Materiali e metodiSono stati valutati retrospettivamente 89 pazienti consecutivi (73 maschi e 16 femmine, età media 62,5 anni, range di età 31–79), sottoposti ad angio—TCMS per sospetta patologia coronarica. Abbiamo valutato il sistema venoso coronarico in tutti i pazienti utilizzando una workstation dedicata Vitrea per il postprocessing 3D (5 pazienti sono stati esclusi).RisultatiIl seno coronarico, la grande vena cardiaca, la vena interventricolare anteriore e la vena cardiaca media sono state visualizzate in tutti i pazienti. La vena cardiaca laterale è stata visualizzata in 56/84 casi (67%), mentre la vena cardiaca posteriore in 63/84 casi (75%); in nessun caso mancavano entrambe. Complessivamente in prossimità della parete postero-laterale del ventricolo sinistro è stato possibile visualizzare un solo ramo in 44 casi, due rami in 21 casi, tre o più rami in 19 casi. Nei pazienti che presentavano due rami per la parete posterolaterale del ventricolo sinistro, valutando il calibro massimo della vena, la vena laterale è stata considerata dominante sulla posteriore in 20/40 casi. La piccola vena cardiaca è risultata visualizzabile in 11/84 casi.ConclusioniLa TCMS permette una buona visualizzazione delle vene coronariche, consentendo lo studio del decorso vasale e l’identificazione delle varianti anatomiche. Pertanto, questa tecnica di imaging potrebbe essere proposta nel planning dei pazienti da sottoporre alla CRT.

Fluoroscopically guided retrograde replacement of ureteral stents

PurposeWe assessed the feasibility of fluoroscopically guided transurethral replacement of ureteral stents as an alternative to cystoscopy.Materials and methodsOver the last year, we replaced 27 double-J ureteral stents in 20 patients (10 men and 10 women; mean age 67.7 years, range 43–83); 15/20 patients had a native kidney, 3/20 had a transplanted kidney and 2/20 had a ureteroileal conduit. The procedures were performed in the angiography suite with the patient under sedation. All stents were grasped with a gooseneck snare under fluoroscopic control, and the distal end was withdrawn just outside the urethra; then a wire was advanced through the stent lumen and positioned in the renal pelvis. The stent was then removed and replaced with a new double-J stent.ResultsThe procedures were successful in 26/27 cases. We observed 7 cases of mild haematuria that resolved spontaneously. During follow-up (1–16 months, mean 6.7), stent obstruction occurred in 4 cases, requiring an additional retrograde replacement.ConclusionsTransurethral fluoroscopically guided retrograde replacement of dysfunctioning ureteral stents is an effective and safe alternative to cystoscopy.RiassuntoObiettivoValutare la fattibilità della sostituzione transuretrale con guida fluoroscopica degli stent ureterali, come alternativa alla cistoscopia.Materiali e metodiNel corso dell’ultimo anno abbiamo sostituito 27 stent ureterali in 20 pazienti (10 maschi e 10 femmine; età media 67,7 anni, range 43–83); 15/20 in reni nativi; 3/20 in pazienti portatori di trapianto renale e 2/20 in pazienti con uretero-ileo-cutaneostomia. Le procedure sono state espletate in sala angiografica in sedazione. Tutti gli stent sono stati agganciati per via transuretrale utilizzando un catetere “gooseneck”; l’estremo distale dello stent è stato quindi retratto al di fuori del meato uretrale. Successivamente è stato introdotto un filo guida attraverso lo stent posizionandolo nella pelvi renale. Quindi lo stent è stato rimosso e sostituito con un nuovo stent 8F doppio J.RisultatiLa procedura è riuscita tecnicamente in 26/27 casi. Abbiamo osservato 7 casi di ematuria moderata, a risoluzione spontanea. Durante il follow-up (1–16 mesi, medio 6,7) abbiamo osservato 4 occlusioni di stent, sostituiti sempre per via retrograda con guida fluooscopica.ConclusioniLa procedura è una sicura ed efficace alternativa alla cistoscopia per la sostituzione retrograda degli stent ureterali non funzionanti.

Management and endovascular treatment of symptomatic abdominal aortic aneurysms

Purpose.Our aim is to verify the feasibility and effectiveness of endovascular treatment for symptomatic abdominal aortic aneurysms (AAAs) in urgencies and emergencies.Materials and methods.Over the past 51 months, we treated 38 symptomatic AAAs with endovascular exclusion. In 23 haemodynamically stable patients, computed tomography (CT) angiography was performed before treatment, and AAA exclusion was carried out as an urgent procedure; 15 patients with haemorrhagic shock were examined by ultrasound (US) only in the emergency room whereas the procedure was carried out in emergency and planned using angiography. Time from presentation to treatment was 100 min on average (range: 50–150 min). We used 27 Excluder (Gore) and 11 Zenith (Cook) stentgrafts. The follow-up was performed with CT angiography after 1, 3, 6 and 12 months and yearly thereafter.Results.The immediate technical success rate was 100%, and the perioperative mortality rate was 10.5%. At follow-up completed in 34 patients (range: 1–48 months, mean: 19.2), we observed five endoleaks (14%) (four type 2: two thrombosed spontaneously and two were under observation at the time of writing; one type 3, treated with stent-graft extension) and one occlusion of a stentgraft leg (treated by femorofemoral bypass).Conclusions.Endovascular treatment of AAAs is a good therapeutic alternative even in urgency and emergency conditions where correct planning ensures technical results comparable with those obtained under elective conditions.

Direct primary or secondary percutaneous ureteral stenting: What is the most compliant option in patients with malignant ureteral obstructions?

The objective of this study was to analyze three ureteral stenting techniques in patients with malignant ureteral obstructions, considering the indications, techniques, procedural costs, and complications. In the period between June 2003 and June 2006, 45 patients with bilateral malignant ureteral obstructions were evaluated (24 males, 21 females; average age, 68.3; range, 42–87). All of the patients were treated with ureteral stenting: 30 (mild strictures) with direct stenting (insertion of the stent without predilation), 30 (moderate/severe strictures) with primary stenting (insertion of the stent after predilation in a one-stage procedure), and 30 (mild/moderate/severe strictures with infection) with secondary stenting (insertion of the stent after predilation and 2–3 days after nephrostomy). The incidence of complications and procedural costs were compared by a statistical analysis. The primary technical success rate was 98.89%. We did not observe any major complications. The minor complication rate was 11.1%. The incidence of complications for the various techniques was not statistically significantly. The statistical analysis of costs demonstrated that the average cost of secondary stenting (€637; SD, €115) was significantly higher than that of procedures which involved direct or primary stenting (€560; SD, €108). We conclude that one-step stenting (direct or primary) is a valid option to secondary stenting in correctly selected patients, owing to the fact that when the procedure is performed by expert interventional radiologists there are high technical success rates, low complication rates, and a reduction in costs.

An innovative percutaneous technique for the removal and replacement of dysfunctioning plastic biliary endoprostheses (PBE) in the management of malignant billiary occlusions

Purpose.The purpose of this study was to assess the feasibility and clinical impact of the percutaneous removal and replacement of dysfunctioning plastic biliary endoprostheses (PBE).Materials and methods.Over a period of 24 months, we observed eight patients (age 54–82 years; mean 65) with dysfunctioning PBE. After transhepatic cholangiography and bile duct catheterisation, the endoprostheses were grasped with a gooseneck snare and pushed into the duodenum using a long introducer sheath. Subsequently, we implanted six metallic stents in middle and distal occlusions and four plastic endoprostheses in two patients with proximal occlusion. Clinical and ultrasound followup was performed 1, 3 and 6 months after the procedure and then yearly.Results.The procedure was technically successful in all patients. No major complication occurred. All patients were discharged without biliary drainage catheters. During the follow-up period (mean: 7.1 months), four patients died and two occlusions of metallic stents were treated by implanting a further metallic stent.Conclusions.Percutaneous removal of a dysfunctioning PBE is feasible and allows better quality of life owing to the absence of biliary drainage. Patency of metallic stents is higher than that of PBE. Larger studies are clearly required to validate this approach.