Anna Maria Ierardi

Initial experience with percutaneous biopsies of bone lesions using XperGuide cone-beam CT (CBCT): technical note

PurposeThis paper describes our preliminary experience with percutaneous bone biopsy under XperGuide conebeam computed tomography (CBCT) guidance.Materials and methodsSeventeen patients (11 men and 6 women; mean age 57.8; range 17–81) with 17 bone lesions underwent biopsy with XperGuide CBCT (Philips Medical System, Best, The Netherlands). The mean diameter of the lesions was 2.32 cm (range 1–8 cm). Technical success (defined as the correct positioning of the needle within the lesion), diagnostic accuracy, sensitivity and specificity were evaluated. Complication rate was also recorded.ResultsThe technical success rate was 100%. In 15 patients, a sample of adequate material for histopathological analysis to yield a definitive diagnosis was obtained; in two patients, the sample was inadequate for a definitive diagnosis. In one of these two cases, the lesion was closely followed up for 1 year, during which it remained stable in size, and as a result, it was considered a false positive; the other was considered a false negative. Diagnostic accuracy, sensitivity and specificity were 94.12%, 90.91% and 100%, respectively. No major complications were recorded; only one patient had slight bleeding, with a consequent small haematoma, which reabsorbed in about 15 days.ConclusionsBone biopsy under XperGuide CBCT guidance can be considered accurate as a result of the combination of real-time needle orientation and spatial resolution of CT fluoroscopy. Moreover, our results are encouraging in terms of complication rate, diagnostic accuracy, sensitivity, specificity and reduction of CT workload.RiassuntoObiettivoScopo del lavoro è descrivere la nostra esperienza preliminare delle biopsie ossee percutanee eseguite sotto guida XperGuide cone-beam (CBCT).Materiali e metodiDiciassette pazienti (11 maschi e 6 femmine; età media 57,8 anni, range 17–81) con 17 lesioni ossee sono stati sottoposti a biopsia percutanea con guida XperGuide CBCT. Il diametro medio delle lesioni era di 2,32 cm (range 1–8 cm). Sono stati valutati il successo tecnico (definito come il corretto posizionamento dell’ago all’interno della lesione), l’accuratezza diagnostica, la sensibilità e la specificità. è stata inoltre riportata la percentuale di complicanze.RisultatiIl successo tecnico è stato del 100%. In 15 pazienti, è stato ottenuto un campione di materiale adeguato per l’esame isto-patologico e per giungere ad una diagnosi definitiva; in 2 pazienti il campione è risultato inadeguato per giungere ad una diagnosi. In uno dei 2 casi, la lesione è stata seguita per un periodo di follow-up di 1 anno, durante il quale le sue dimensioni sono rimaste stabili; pertanto questa è stata considerata un falso positivo. L’altra è stata considerata un falso negativo. Accuratezza diagnostica, sensibilità e specificità erano rispettivamente del 94,12%, 90,91% e 100%. Non è stata registrata nessuna complicanza maggiore; solo un paziente ha presentato un lieve sanguinamento con un conseguente piccolo ematoma, assorbitosi spontaneamente in circa 15 giorni.ConclusioniLa biopsia ossea sotto guida XperGuide CBCT può essere considerata accurata grazie alla combinazione tra la possibilità di orientamento nello spazio real-time dell’ago e la risoluzione spaziale della fluoro-tomografia computerizzata (TC). Inoltre, i nostri risultati sono incoraggianti in termini di percentuale di complicanze, accuratezza diagnostica, sensibilità, specificità e non ultimo, riduzione del carico di lavoro del servizio TC.

Understanding venous malformations of the head and neck: a comprehensive insight

Venous malformations (VMs) are congenital vascular malformations. They are very often misnamed and thus incorrectly managed. The aim of the present paper is to provide the reader with the most updated literature available and to offer a detailed description of each single aspect of this disease. In detail, the paper discusses the epidemiology, the embryological origins and the physiopathology of VMs. Then, the clinical features of sporadic, inherited and syndromic VMs are discussed. The instrumental diagnosis is presented, and the role of US, CT, MRI and phlebography is pointed out. Differential diagnoses with other vascular malformations and tumors are described. The clinical session ends with the staging of VMs relying on MRI and rheological features. All aspects of treatment are described: conservative measures, medical treatment, sclerotherapy, laser and surgery are thoroughly discussed. A section is reserved to bony VMs. Their clinical aspects and the appropriate treatment are presented.

Carotid artery stenting: influence of experience and cerebrovascular risk factors on outcome

AIM To evaluate technical success, complications and the influence of the learning curve on outcome in carotid artery stenting (CAS) performed in patients not suitable for surgery. PATIENTS AND METHODS One hundred and nine procedures of protected carotid stenting in 103 high risk patients were performed. All patients presented at least one factor that potentially increased the surgical risk of carotid endoarterectomy (CEA), according to SAPPHIRE criteria. Neurologic complications were quantified by the National Institutes of Health Stroke Scale (NIHSS) and were evaluated by median Rankin Scale (mRS). To evaluate the influence of experience of the operator to perform CAS, we retrospectively analyzed periprocedural and neurological complications of the first 50 procedures compared with that of the following 59 interventions. RESULTS Technical success rate was 98%. Neurological periprocedural complications were revealed in 4.5% of patients. In-hospital and 30-days neurological complications rate was 7.6 and 2.6% respectively. Periprocedural neurological complications rate was lower in the last procedures performed, according to a higher confidence of the operators. CONCLUSIONS CAS may be performed as an alternative of CEA for the treatment of severe carotid obstructive disease in patients not suitable for surgery. The learning curve positively influence complications rate.

The role of ethylene–vinyl alcohol copolymer in association with other embolic agents for the percutaneous and endovascular treatment of type Ia endoleak

AimTo evaluate safety, technical and clinical success of embolization of type Ia endoleak (T1a EL) using ethylene–vinyl alcohol copolymer as embolic agent alone or in combination with other materials.Materials and methodsFive patients presented T1a EL after endovascular repair of aortic aneurysms (EVAR) with radiological evidence of expanding sac size; in particular, three had contained rupture. In one patient, proximal cuff insertion was previously performed, in three patients proximal cuff was urgently inserted but T1a EL persisted; one patient, previously treated with Ovation Abdominal Stent Graft System, was directly proposed for endovascular treatment. In all cases, endovascular embolization was successfully performed and the transfemoral approach was always chosen; in one case it failed and translumbar approach by direct puncture of the sac was required. Used embolization agents were glue, ethylene–vinyl alcohol copolymer (Onyx) and coils in three cases, n-butyl cyanoacrylate and Onyx in one case, Onyx and coils in the last case.ResultsTechnical success rate was 100% as well as clinical success. No major or minor complication, including non-target embolization, was registered. Clinical success was 100% until today and the sac diameter remained stable in four patients and decreased in one.ConclusionsOnyx may be considered a suitable embolic agent in the treatment of patients with type Ia endoleaks after EVAR, after failure of conventional treatments such as prolonged balloon inflation of the aortic neck or deployment of large bare stent.

Percutaneous management of bone metastases: state of the art, interventional strategies and joint position statement of the Italian College of MSK Radiology (ICoMSKR) and the Italian College of Interventional Radiology (ICIR)

Interventional radiology provides local management of bone metastases (BM) with a palliative intent in most cases, or with a curative intent in selected patients. Its role has rapidly expanded in the last decade, offering new treatment solutions often in combination with surgery, radiation therapy and medical treatments. The aim of the present paper is to increase awareness, acceptance and adoption of interventional radiology procedures for the treatment of BM; and to present the joint position of the Italian College of Musculoskeletal Radiology and the Italian College of Interventional Radiology.

Vascular Emergencies of the Retroperitoneum: Recent Advances in MDCT and Interventional Radiology

Vascular emergencies of the retroperitoneum can arise from traumatic or nontraumatic arterial or venous injuries. Advances in interventional radiology technique have permitted less invasive alternative treatments to surgery for the management of aortic and inferior vena cava acute injuries. In this chapter, the MDCT findings of large-vessel vascular emergencies within the retroperitoneum are discussed, with correlative interventional findings and treatment.

Injuries of the Limbs in Polytrauma: Upper and Lower Limbs

Extremity injuries are the second most common traumatic injuries after head injuries and account until 80% of all cases of vascular trauma. Peripheral injuries are usually not immediately lethal, whether due to penetrating or blunt injuries; nevertheless, a prompt identification of the injuries is crucial for a correct management.

Treatment of venous stenosis in oncologic patients

Symptomatic obstruction related to malignant involvement of large veins may occur in central veins both in the thoracic and pelvic regions, and in the abdominal region of the body. Both cases represent a therapeutic challenge, and endovascular revascularization, consisting of angioplasty and stent placement, is safe and effective. Superior vena cava stenting has become widespread in the management of occlusive venous disease. The percutaneous placement of large expandable metal stents allows rapid restoration of normal blood flow in the majority of patients, thus improving symptoms. Published data on the diagnosis and treatment of symptomatic cancer-related iliocaval obstructions are limited and mainly consist of case reports and small case series. The present review reports the current state of endovascular treatment for both superior vena cava occlusion and iliac compression syndrome in cancer patients.

Type 2 endoleaks in endovascular aortic repair: cone beam CT and automatic vessel detection to guide the embolization:

Background Dual-phase cone beam computed tomography (DP-CBCT) and automatic vessel detection (AVD) software are helpful tools for detecting arteries before planned endovascular interventions. Purpose To evaluate the usefulness of DP-CBCT and AVD software in guiding the trans-arterial embolization (TAE) of challenging T2 lumbar endoleaks (T2-L-EL). Material and Methods Ten patients with T2-L-EL were included in this study. The accuracy of DP-CBCT and the AVD software was defined by the ability to detect the endoleak and arterial feeding vessel, respectively. Technical success was defined as the correct positioning of the microcatheter using AVD software and the successful embolization of the endoleak. Clinical success was defined as the absence of recurrent endoleaks during follow-up and the stability of the sac diameter for persistent endoleaks. The total volume of iodinated contrast medium, overall procedure time, mean procedural radiation dose, and mean fluoroscopy time were recorded. Results The EL was detected by DP-CBCT in all patients. The AVD software identified the feeding arterial branch in all cases. In one patient, the nidus of the endoleak was not reached due to the small caliber of the feeding artery, even though the software had clearly identified the vessel route. The mean contrast volume was 109 mL, the mean overall procedural time was 74.3 min. The mean procedural radiation dose was 140.97 Gy cm2, and the mean fluoroscopy time was 29.8 min. Conclusion The use of DP-CBCT and the AVD software is feasible and may facilitate successful embolization in challenging occult T2-L-EL with complex vasculature.

Preliminary experience with the use of ultra-low profile endografts

PURPOSE We aimed to report a preliminary single-center experience of elective endovascular aortic repair (EVAR) using ultra-low profile (ULP) endografts of 14 F outer diameter. METHODS Data of 67 consecutive patients who underwent EVAR using either Ovation (group A, n=30) or Incraft (group B, n=37) endografts were retrospectively analyzed. RESULTS Aorto-iliac anatomy was significantly different between the two groups, as patients of group A had a greater thrombotic apposition on proximal aortic neck (thrombus thickness: 7.2±1 mm vs. 3.3±1.6 mm, P = 0.042; percentage of the circumference covered by thrombus: 45.2%±10.4% vs. 18.7%±10.6%, P = 0.0003), while patients of group B had a more angulated proximal neck in the coronal axis (35.9°±6.4° vs. 16.7°±5°, P = 0.012). Procedural success was 93.3% and 97.3%, respectively, in groups A and B. One patient in group A required an immediate conversion to open surgery for persistent occlusion of both iliac limbs. Another patient required implantation of a conical endograft with a femoro-femoral right-to-left bypass for occlusion of the contralateral gate during the cannulation. In group B, one intraoperative type Ia endoleak was immediately corrected. Neither deaths nor major adverse events were recorded within 30-days. During a median follow-up of 15.2 months (range, 1-56.7 months) two type Ia endoleaks in group A required open conversion after 12.1 and 40.5 months, respectively. Three patients in group B required a reintervention after 30 days. Neither deaths nor aortic ruptures were recorded during follow-up. CONCLUSION Both ULP endografts showed satisfying early and mid-term results.