Andrea Ianniello

Indications for the use of the Amplatzer vascular plug in interventional radiology

PurposeThis study was undertaken to assess the indications and effectiveness of the Amplatzer vascular plug (AVP) system in interventional radiology.Materials and methodsOver the past year, we selected 12 patients (seven men and five women; mean age 65.8 years, range 45–82) for the occlusion of five internal iliac arteries (in three aortoiliac aneurysms, one internal iliac aneurysm and one isolated common iliac artery aneurysm), two common iliac arteries (in two ruptured abdominal aortic aneurysms), two subclavian arteries (in aortic arch aneurysms) and three splenic artery aneurysms. We used 15 AVPs (splenic artery aneurysms were excluded, with one AVP in the feeding vessel and one in the draining vessel).ResultsWe achieved immediate technical success in 12/12 cases. No rupture or dissection of the treated arteries occurred. During the follow-up (mean 4.6 months, range 3–6) computed tomography (CT) angiography and/or contrast-enhanced ultrasound demonstrated complete artery occlusion and aneurysm exclusion.ConclusionsEase and speed of use combined with precise, controlled delivery justify the growing use of the AVP in interventional radiology. No doubt, the system’s versatility will extend its indications, and larger studies with longer follow-up periods will validate the results achieved so far.RiassuntoObiettivoValutare le possibili indicazioni e l’efficacia del sistema Vascular Plug Amplatzer (VPA) in radiologia interventistica.Materiali e metodiNell’ultimo anno abbiamo selezionato 12 pazienti (7 maschi e 5 femmine), (età media 65,8 anni, range 45–82) per l’occlusione di: 5 arterie ipogastriche (in 3 aneurismi aorto-iliaci, 1 aneurisma dell’arteria ipogastrica e 1 aneurisma isolato dell’arteria iliaca comune), 2 arterie iliache comuni (in aneurismi dell’aorta addominale rotti), 2 arterie succlavie (in aneurismi dell’arco aortico) e di 3 aneurismi dell’arteria splenica. Sono stati utilizzati 15 VPA (gli aneurismi splenici sono stati esclusi mediante 2 VPA a monte e a valle).RisultatiÈ stato ottenuto successo tecnico immediato 12/12 casi. Non si sono verificate complicanze maggiori quali rottura, perforazione o dissezione del vaso trattato. Durante il follow-up (medio 4,6 mesi, range 3–6) il controllo con angio-TC e/o ecografia con MdC ha dimostrato la completa occlusione dei vasi trattati e l’esclusione degli aneurismi.ConclusioniLa rapidità e semplicità di utilizzo e il preciso e controllato rilascio dell’AVP, con immediato successo tecnico, ne giustificano la divulgazione in radiologia interventistica. La versatilità del dispositivo ne amplierà sicuramente le indicazioni con risultati avvalorati da pubblicazioni ulteriori e studi numericamente più ampi e con follow-up più protratto.

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.

Percutaneous radiofrequency thermal ablation of renal cell carcinoma: Is it possible a day-hospital treatment?

PURPOSE The aim of this study is to evaluate the feasibility of the procedure in day-hospital and discuss prognostic factors, efficacy and complications of percutaneous radiofrequency ablation in the treatment of renal cell carcinoma. MATERIALS AND METHODS Between January 2003 and August 2008, 26 patients (mean age 79, range 70-87 years, 15 men and 11 women) affected by 27 kidney tumoral lesions, 25 RCC and two renal oncocitome (one patient was affected by two RCC), undergo 29 treatments of RFA (three patients underwent two treatments due to residual tumor at the CT performed 1 month after the first treatment). Three out of 26 patients had only one kidney due to progressed nephrectomy because of RCC; three/26 patients were carriers of oncological comorbidity while four/26 patients were carriers of medical comorbidity. The remaining 16/26 patients refused the surgical option. The lesions had a diameter between 1 and 4 cm (average diameter 2.4 cm). Seventeen of the 27 lesions were exophytic, five/27 parenchymal, three/27 was central while two/27 was mixed. All the lesions had been characterized either by CT or MRI. On the basis of the same investigation the feasibility of the radiofrequency procedure was verified. For all the procedures the RF type 3000 radiofrequency generator system was used together with the LeVeen ago-electrode. Twenty-one lesions out of 27 were treated under ultrasound guidance while six/27 lesions under the CT guide. After the procedure a US control was performed to exclude early complications and the same day the patients were discharged from hospital: the procedure was performed in day-hospital. RESULTS The technical success of the procedure was obtained in all cases (100%). After the procedure, 18 patients, without complications and comorbidity, were discharged from hospital the same day, seven patients with comorbidity were kept under observation for one night while one patient was hospitalized. The primary success of the treatment, rated with CT or MRI after 1 month, was obtained in 25/27 of the cases. In two/27 lesion, an incomplete ablation was obtained; for this reason these patients underwent a second treatment and after 6 month of a regular follow-up, no more neoplastic tissue was identified. During the follow-up there were no signs of disease in any patients. No major peri-procedural complications were recorded; only one patient had to be assisted for the appearance of a peri renal liquid (urinoma) and a thin pneumothorax layer that resolved completely in few days after the procedure. CONCLUSIONS Preliminary results with RFA of RCC are promising. Radiofrequency thermal ablation could prove to be a useful treatment for patients who are unsuitable for surgery; in this study we demonstrate the feasibility of the treatment in day-hospital for selected patients.

Radiofrequency thermal ablation for pain control in patients with single painful bone metastasis from hepatocellular carcinoma

OBJECTIVE The aim of this study was to assess the safety and the efficacy of radiofrequency thermal ablation (RFA) for pain relief and analgesics use reduction in two patients with painful bone metastases from hepatocellular carcinoma (HCC). MATERIALS AND METHODS Two patients with lytic metastases from HCC located at the left superior ileo-pubic branch and at the middle arch of VII rib, performed RFA displacing a LeVeen Needle (3.5 and 4.0 cm diameter) under US (ultrasonography) and fluoroscopic guidance. Two methods were used to determine the response of both patients: the first method was to measure patients worst pain with a Brief Pain Inventory (BPI) 1 day after the procedure, every week for 1 month, and thereafter at week 8 and 12 (total follow-up 3 months); the second method was to evaluate patients analgesics use recorded at week 1, 4, 8 and 12. Analgesic medication use was translated into a morphine-equivalent dose. RESULTS The RFA were well tolerated by the patients who did not develop any complication. Both patients obtained substantial reduction of pain, which decreased from a mean score of 8 to approximately 2 in 4 weeks. In both patients we observed a reduction in the use of morphine dose-equivalent after a peak at week 1. CT (computed tomography) imaging, performed at 1 month after RFA, demonstrated that both procedures were technically successful and safe because consistent necrosis and no evidence for complications were observed. CONCLUSION RFA provides a potential alternative method for palliation of painful osteolytic metastases from HCC; the procedure is safe, and the pain relief is substantial.

Endovascular Treatment of a Ruptured Pulmonary Artery Aneurysm in a Patient with Behçet's Disease Using the Amplatzer Vascular Plug 4

A pulmonary artery aneurysm is a common manifestation and the leading cause of mortality in Behçets disease. We describe a case of spontaneous rupture of a pulmonary artery aneurysm that, due to the inadequacy of medical therapy and the disadvantages of surgery, became the ideal candidate for endovascular management and was successfully performed by using the Amplatzer Vascular Plug 4.

Hybrid treatment of isolated aortic arch aneurysms

PurposeThis study sought to assess the feasibility and effectiveness of hybrid treatment of isolated aortic arch aneurysms.Materials and methodsBetween December 2000 and December 2006, we selected 14 patients affected by 14 isolated aortic arch aneurysms. All patients had involvement of the left subclavian artery, four of the innominate artery and four of the left carotid artery. All patients underwent intentional exclusion of the left subclavian artery and placement of a straight graft; four patients underwent supra-aortic vessel transposition and four underwent carotid-carotid bypass in one case combined with carotid-subclavian bypass. The procedures were planned with multislice computed tomography (MSCT), in some cases associated with virtual endoscopy. The follow-up was performed with MSCT angiography at 1, 3, 6 and 12 months and yearly thereafter.ResultsImmediate technical success was achieved in 100% of cases. There were four ischaemic attacks (three transient ischaemic attacks and one stroke). During follow-up (range 12–48, average 21 months), we observed two type-I endoleaks that were treated by endograft extension, in one case associated with supra-aortic vessel transposition, and two type-II endoleaks that were treated with embolisation.ConclusionsHybrid treatment for aortic arch aneurysms is feasible and provides good short-term results, although it requires accurate planning. Further studies are needed to verify the long-term results.RiassuntoObiettivoScopo di questo lavoro è stato verificare la fattibilità e l’efficacia del trattamento ibrido degli aneurismi isolati dell’arco aortico.Materiali e metodiNel periodo compreso tra dicembre 2000 e dicembre 2006, sono stati selezionati 14 pazienti affetti da 14 aneurismi isolati dell’arco aortico. Tutti coinvolgevano la succlavia sinistra, 4 il tronco anonimo e 3 la carotide sinistra. In tutti i pazienti è stata esclusa intenzionalmente la succlavia sinistra e posizionata un’endoprotesi retta; in 4 pazienti è stata effettuata una trasposizione completa dei tronchi epiaortici mentre in altri 4 pazienti è stato effettuato un by-pass carotidocarotideo, in un caso associato a by-pass carotidosucclavio. Il planning è stato effettuato con angiotomografia computerizzata multi-strato (angio-TCMS), talvolta associata ad endoscopia virtuale. Il follow-up è stato effettuato con angio-TCMS a 1, 3, 6 e 12 mesi, in seguito annualmente.RisultatiAbbiamo ottenuto un successo tecnico immediato nel 100% dei casi. Si sono verificate 4 ischemie cerebrali (3 ischemie cerebrali transitorie e 1 stroke). Durante il follow-up (range 12–48 mesi, medio 21 mesi) abbiamo osservato 2 endoleak di tipo I, trattati con cuffia protesica associata in un caso alla trasposizione dei grossi vasi e 2 endoleak di tipo II, trattati mediante embolizzazione.ConclusioniIl trattamento ibrido degli aneurismi dell’arco è fattibile e garantisce buoni risultati a breve termine, ma richiede un attento planning. Sono necessari ulteriori studi per verificare i risultati a medio e lungo termine.

Plasma-mediated radiofrequency ablation followed by percutaneous cementoplasty under fluoro-CT guidance: a case report

We report a case of a 81-year-old Caucasian man with colorectal carcinoma, treated by surgery in 1998, referred for palliative treatment of a refractory painful caused by osteolytic metastases of 2.5 cm in back-upper ilium spine. Plasma-mediated radiofrequency ablation was performed under conscious sedation, using Fluoroscopic Computer Tomography guidance. After completing the ablation phase of the procedure, a mixture of bone cement and Biotrace sterile barium sulfate was injected into the ablated cavity.Patient was evaluated by using the Brief Pain Inventory and considering pain interference with daily living at day 1 and 3 and week 1, 2, 3, 4 by means of a telephone interview. A post-procedure Computer Tomography scan was performed to examine the distribution of cement deposition few minutes after the procedure. The plasma mediated RFA and cementoplasty were well tolerated by the patient who did not develop any complication.

CT and CT Angiogram in the Diagnosis of Congenital Vascular Malformations

In the setting of pediatric vascular anomalies, multiple imaging modalities can be used to evaluate characteristic of the lesions, such as size, flow velocity, flow direction in relation to the surrounding structures (vessels, muscle, nerve, bone, skin), and lesion content [1].

Imaging of Vascular Malformations

Although clinical history and examination are sufficient to establish the diagnosis of a vascular malformation, imaging is an indispensable part of the full patient workup. Because of limited soft tissue contrast resolution, conventional radiology has little role for the evaluation and diagnosis of congenital vascular malformations. The use of phlebographic techniques is becoming less frequent due to the improvement of other less invasive diagnostic tools like ultrasound and magnetic resonance imaging. Also the historically ubiquitous use of arteriography in the diagnostic imaging workup of vascular malformations has been relegated to a few specific clinical indications, showing an exclusively therapeutic role.