D. Laganà

Percutaneous imaging-guided ablation therapies in the treatment of symptomatic bone metastases: preliminary experience

PurposeThe treatment of pain in bone metastases is currently multidisciplinary. Among the various therapies, local radiotherapy is the gold standard for pain palliation from single metastasis, even though the maximum benefit is obtained between 12 and 20 weeks from initiation. In carefully selected patients, several ablation therapies achieve this objective in 4 weeks. The purpose of this study was to assess the technical success, effectiveness and possible complications of percutaneous ablation therapies in patients with symptomatic bone metastases.Materials and methodsFrom November 2003 to May 2008, ten ablation treatments were performed in ten patients with acute pain from metastatic bone lesions. Patient selection and choice of the most appropriate ablation treatment was made based on lesion characteristics. Three patients were treated with radiofrequency, one with plasma-mediated radiofrequency, two with plasma-mediated radiofrequency and cementoplasty, three with radiofrequency and cementoplasty and one with microwave.ResultsAssessments were based not only on imaging but also on the visual analogue scale (VAS) score for determining pain and on changes in morphine-equivalent doses. In both cases, 3-month follow-up showed a statistically significant reduction of pain. In no case did local complications occur either during or after treatment. Only one patient treated with radiofrequency (1/9, 11%) developed low-grade fever and general malaise during the 6 days following the procedure, compatible with a post-radiofrequency syndrome, which was treated with acetaminophen (paracetamol) only and resolved on day 7.ConclusionsPercutaneous ablation therapies represent a safe and valuable alternative for treating localised pain from single bone metastasis, providing rapid (4-week) relief of symptoms and a significant reduction in morphine doses. This contributes to improving the quality of life of patients with metastatic disease.RiassuntoObiettiviIl trattamento del dolore nelle metastasi ossee è attualmente multidisciplinare. Tra le varie terapie, la radioterapia locale è il gold-standard nella palliazione del dolore da metastasi singola, anche se il massimo beneficio si ottiene tra le 12 e le 20 settimane dall’inizio della terapia. In pazienti accuratamente selezionati, varie terapie ablative raggiungono quest’obiettivo in 4 settimane. Scopo di questo lavoro è valutare il successo tecnico, l’efficacia e le eventuali complicanze delle terapie ablative percutanee in pazienti affetti da metastasi ossee sintomatiche.Materiali e metodiDa novembre 2003 a maggio 2008 sono stati effettuati 10 trattamenti in 10 pazienti con dolore acuto da lesioni metastatiche ossee. La selezione dei pazienti e la scelta del trattamento ablativo più idoneo è stata fatta sulla base delle caratteristiche della lesione. Tre pazienti sono stati trattati con radiofrequenza, 1 con radiofrequenza plasma-mediata, 2 con radiofrequenza plasma mediata e cementoplastica, 3 con radiofrequenza e cementoplastica, 1 con microonde.RisultatiLa valutazione è stata effettuata non solo con imaging, ma anche con una VAS score (visual analoge scale) per la determinazione del dolore e con la variazione delle dose equivalenti di morfina. In entrambi i casi la riduzione è stata statisticamente significativa. In nessun caso si sono verificate complicanze locali sia durante che dopo il trattamento. Solamente in un paziente trattato con radiofrequenza (1/9, 11%) abbiamo riscontrato nei 6 giorni successivi al trattamento insorgenza di febbricola e malessere generale compatibile con la “sindrome post-radiofrequenza”, risoltasi poi al settimo giorno e trattata solo con acetaminofene (paracetamolo).ConclusioniLe tecniche ablative percutanee rappresentano una sicura e valida alternativa al trattamento del dolore localizzato da metastasi ossee singole, apportando in breve tempo (4 settimane) un miglioramento della sintomatologia e una sensibile riduzione delle dosi di morfina. Ciò concorre a migliorare la qualità della vita in pazienti affetti da malattia metastatica.

Percutaneous Treatment of Traumatic Upper-extremity Arterial Injuries: A Single-center Experience

PURPOSEnTo assess the feasibility and effectiveness of emergency percutaneous treatment of traumatic injuries of upper-extremity arteries.nnnMATERIALS AND METHODSnBetween January 2000 and December 2007, 11 patients (mean age, 49.9 years) with traumatic injuries of upper-extremity arteries were observed: three had pseudoaneurysms, four had dissections, three had transections, and one had mural hematoma. Lesions involved the axillary (n = 6), subclavian (n = 3), or brachial artery (n = 2). Pseudoaneurysms and transections were treated with stent grafts, (n = 6) and dissections and mural hematomas were treated with bare stents (n = 2) or angioplasty (n = 3). Follow-up (mean, 45.1 months; range, 12-84 months) was performed with color Doppler ultrasonography at 1, 3, 6, and 12 months and then, yearly.nnnRESULTSnImmediate technical success was obtained in all cases. No major complications occurred; there was one asymptomatic occlusion of the interosseous artery and one case of incomplete thrombosis of the radial artery (with recanalization after 1 month with systemic medical therapy). During a mean follow-up of 45.1 months, one stent-graft occlusion occurred, which was treated with intraarterial pharmacologic thrombolysis (urokinase 60,000 IU/h for 12 hours). Overall primary clinical success rate was 95.2% and secondary clinical success rate was 100%.nnnCONCLUSIONSnPercutaneous treatment is a feasible and safe tool for injuries of upper-extremity arteries because it can provide a fast and definitive termination of bleeding or a resolution of acute ischemia. This approach, with its low invasiveness, can be proposed as first-line treatment in patients with traumatic lesions of upper-extremity arteries.

Treatment of secondary hyperparathyroidism with ultrasonographically guided percutaneous radiofrequency thermoablation.

We present a case of a 63-year-old woman with a recurrent secondary hyperparathyroidism hyperplasia with absolute contraindication for surgery, treated in 2 sessions with percutaneous ultrasonographically guided radiofrequency tissue ablation. The complete pathologic tissue ablation was confirmed by contrast-enhanced ultrasonography performed before and after the treatment and by clinical and laboratory follow-up. Furthermore in work progress, the percutaneous ultrasonographically guided radiofrequency tissue ablation can be considered a feasible and effective nonsurgical alternative treatment for symptomatic secondary hyperparathyroidism in high-risk patients.

Ultrasound-Guided Radiofrequency Thermal Ablation of Uterine Fibroids: Medium-Term Follow-Up

Previous studies have shown that radiofrequency thermal ablation (RFA) of uterine fibroids through a percutaneous ultrasound (US)-guided procedure is an effective and safe minimally invasive treatment, with encouraging short-term results. The aim of this study was to assess the results in terms of volume reduction and clinical symptoms improvement in the midterm follow-up of fibroids with a diameter of up to 8xa0cm. Eleven premenopausal females affected by symptomatic fibroids underwent percutaneous US-guided RFA. Symptom severity and reduction in volume were evaluated at 1, 3, 6, 9, and 12xa0months. The mean symptom score (SSS) before the procedure was 50.30 (range 31.8–67.30), and the average quality of life (QOL) score value was 62 (range 37.20–86.00). The mean basal diameter was 5.5xa0cm (range 4.4–8) and the mean volume was 101.5xa0cm3 (range 44.58–278xa0cm3). The mean follow-up was 9xa0months (range 3–12xa0months). The mean SSS value at the end of the follow-up was 13.38 (range 0–67.1) and the QOL 90.4 (range 43.8–100). At follow-up the mean diameter was 3.0xa0cm (range 1.20–4.5xa0cm), and the mean volume was 18xa0cm3 (range 0.90–47.6xa0cm3). In 10 of 11 patients we obtained total or partial regression of symptoms. In one case the clinical manifestations persisted and it was thus considered unsuccessful. In conclusion, US-guided percutaneous RFA is a safe and effective treatment even for fibroids up to 8xa0cm.

Microwave ablation therapy for treating primary and secondary lung tumours: technical note

PurposeThe purpose of our study was to retrospectively evaluate the feasibility, safety and effectiveness of microwave ablation (MWA) in nine patients with unresectable lung tumour.Materials and methodsTen lesions were treated in ten ablation sessions in nine patients. The treatments were performed with a microwave generator with 45 W and 915 MHz connected to a 14.5-gauge antenna for 10 min. Antenna placement was performed with computed tomography (CT) fluoroscopy guidance or XperGuide. All patients underwent CT follow-up at 1, 3 and 6 months from the procedure.ResultsTechnical success was obtained in all cases; mortality at 30 days was 0%.ConclusionsThis study shows that in selected patients, MWA is a valid alternative to other ablative techniques. Further studies are required to demonstrate the short- and long-term effects of this technique and to make a comparison with other available ablation systems, especially with radiofrequency.RiassuntoObiettivoLo scopo dello studio è stato quello di valutare il successo tecnico, la sicurezza, l’efficacia della metodica del trattamento ablativo mediante microonde (MW) in 9 pazienti affetti da neoplasia polmonare non trattabile chirurgicamente.Materiali e metodiSono state trattate 10 masse polmonari in 10 sessioni d’ablazione in 9 pazienti. È stato utilizzato un sistema ablativo costituito da un generatore di MW a 45 W e 915 MHz connesso ad un antenna 14,5 G, per un tempo di ablazione totale di 10 minuti. Il posizionamento dell’antenna è stato eseguito sotto guida fluoro-tomografia computerizzata (TC) o XperGuide. I pazienti sono stati sottoposti a follow-up mediante TC a 1, 3, 6 mesi dalla procedura.RisultatiSi è ottenuto un successo tecnico in tutti i casi; il tasso di mortalità a 30 giorni è stato dello 0%.ConclusioniQuesto studio dimostra che, in pazienti selezionati, la termoablazione con microonde rappresenta una valida alternativa ad altre tecniche ablative. Sono tuttavia necessari ulteriori studi per confermare a breve e lungo termine l’efficacia di questa metodologia e permettere un confronto con altri sistemi ablativi, in particolare rispetto alla radiofrequenza.

Complications of percutaneous nephrostomy in the treatment of malignant ureteral obstructions: single-centre review.

Purpose.The purpose of this study was to evaluate the incidence and type of complications connected with percutaneous nephrostomy (PCN) deployment by comparing two different techniques.Materials and methods.In the last 3 years, 299 procedures of nephrostomy were performed on 201 patients (93 women, 108 men; mean age 65.7 years, range 32–102 years) at our Institute; all patients were affected by malignancy. In 44 cases (14.72%), patients presented grade IV hydronephrosis and in 255 cases (85.28%) grade II–III hydronephrosis. In 68 patients (23.07%), the procedure was carried out under emergency conditions because of the rapid worsening of renal function. All procedures were carried out in the angiography room, with the patient lying in a prone or prone–oblique position, under ultrasound and fluoroscopic guidance. Access to the pyelocalyceal system (intermediate or lower calices) was performed by using a Seldinger technique in 255/299 cases, or a one–step technique (OST) in 44 procedures when grade 4 hydronephrosis was present. Statistical analysis of results was performed using bilateral tests on proportions as well as χ2 test of independence for contingency tables.Results.We observed no major complications. All in all, the rate of minor complications was 3.01% (9/299 cases): 8/255 (3.13%) cases with the Seldinger technique; 1/44 (2.27%) with OST. We observed 43/299 (14.4%) dislodgements: 32/255 (10.70%) with the Seldinger technique and 11/44 (3,68%) with OST. In 4/299 (1.33%), rupture of the catheter occurred, and in 2/299 (0.67%), kinking occurred (in all cases with OST). From the statistical analysis, we conclude that the examination technique modifies the percentage of complications; in particular, it significantly (p<0.05) influences complications connected with the catheter but not minor complications. In addition, the system of fixing does not affect the percentage of dislodgements.Conclusions.PCN is a method with a high percentage of technical success with low rate of complications thanks to combined use of sonographic and fluoroscopic guidance for the procedure. The OST technique is indicated for a highly remarkable hydronephrosis and in cases where the catheter is only placed for a short period. The Seldinger technique is carried out in patients with grades II and III hydronephrosis and if the disease is predicted to have a long duration.

Endovascular treatment of isolated iliac artery aneurysms: 2-year follow-up

PurposeThe aim of this study was to assess the effectiveness of endovascular treatment of isolated iliac artery aneurysms (IAAs).Materials and methodsBetween March 1999 and March 2004, 15 isolated IAAs in 13 patients (mean age: 71.8 years) were selected for endovascular repair by means of a covered stent or stent-graft: 12 were in the common iliac artery (2 with the proximal end 12 mm from the aortic bifurcation and 2 involving the distal hypogastric artery), and three were in the external iliac artery. The preoperative study and the follow-up (at 3, 6 and 12 months and yearly thereafter) were performed by computed tomography (CT) angiography.ResultsPrimary technical success was obtained in all cases, without periprocedural complications. Two patients died within 3 months and were not considered for follow-up. Follow-up (mean duration: 25 months, range: 6–60 months) in the remaining 11 patients, affected by 13 aneurysms, showed aneurysm exclusion in nine cases and progressive shrinkage of the aneurysmal sac in four cases, whereas in the other five, the size of the aneurysm remained unchanged. In a patient with bilateral IAA, bilateral proximal endoleaks were observed after 2 years, and the patient was treated with a bifurcated aortic stent-graft. In another patient with a large aneurysm, a left aortofemoral bypass became necessary after 2 months because of stent-graft dislodgement. In another patient, an endoleak from the hypogastric artery occurred after 2 years but was not treated.ConclusionsEndovascular treatment of isolated IAA is a feasible procedure that is less invasive than surgery and yields excellent short-and midterm results. However, a longer follow-up and larger patient series are needed to verify the long-term efficacy of this form of treatment.RiassuntoObiettivoVerificare l’efficacia del trattamento endovascolare degli aneurismi isolati dell’asse arterioso iliaco (AAI).Materiali e metodiTra marzo 1999 e marzo 2004 sono stati selezionati per l’esclusione endovascolare mediante stent ricoperto o endoprotesi 15 aneurismi isolati dell’AAI in 13 pazienti (età media 71,8 anni): 12 dell’arteria iliaca comune (di cui 2 con estremo prossimale distante 12 mm dalla biforcazione aortica e 2 coinvolgenti distalmente l’arteria ipogastrica) e 3 dell’arteria iliaca esterna. Lo studio pre-operatorio e il follow-up (controlli a 3, 6, 12 mesi e in seguito annualmente) sono stati espletati mediante angio-TC spirale.RisultatiÈ stato documentato il successo tecnico immediato in tutti i pazienti, senza complicanze peri-procedurali. Due pazienti sono deceduti entro 3 mesi e non sono stati considerati ai fini del followup. Il follow-up (durata media 25 mesi, range 6–60 mesi), disponibile nei restanti 11 pazienti, portatori di 13 aneurismi, ha dimostrato l’esclusione dell’aneurisma in 9 casi, con la progressiva riduzione volumetrica della sacca in 4, mentre negli altri 5 la sacca è rimasta immodificata. In un paziente portatore di aneurismi isolati dell’AAI bilaterale si è osservato un endoleak prossimale di entrambi gli aneurismi a 2 anni, trattato pertanto con endoprotesi aortica biforcata; in una paziente con un voluminoso aneurisma si è resa necessaria la conversione in by-pass aorto-femorale sinistro a due mesi di distanza per dislocazione di più endoprotesi embricate; in un paziente, infine, a due anni si è rilevato un endoleak rifornito dall’arteria ipogastrica, che non è stato trattato.ConclusioniL’esclusione endovascolare degli aneurismi isolati dell’AAI è una procedura fattibile, meno invasiva dell’intervento chirurgico, con ottimi risultati a breve e medio termine. È tuttavia necessario un follow-up più protratto e una casistica più numerosa per verificare l’efficacia a lungo termine di questo tipo di trattamento.

Gross hematuria caused by a congenital intrarenal arteriovenous malformation: a case report.

IntroductionWe report the case of a woman who presented with gross hematuria and was treated with a percutaneous embolization.Case presentationA 48-year-old Caucasian woman presented with gross hematuria, left flank pain, and clot retention. The patient had no history of renal trauma, hypertension, urolithiasis, or recent medical intervention with percutaneous instrumentation. The patient did not report any bleeding disorder and was not taking any medication. Her systolic and diastolic blood pressure values were normal at presentation. The patient had anemia (8 mg/dL) and tachycardia (110 bpm). She underwent color and spectral Doppler sonography, multi-slice computed tomography, and angiography of the kidneys, which showed a renal arteriovenous malformation pole on top of the left kidney.ConclusionsThe feeding artery of the arteriovenous malformation was selectively embolized with a microcatheter introduced using a right transfemoral approach. By using this technique, we stopped the bleeding, preserved renal parenchymal function, and relieved the patients symptoms. The hemodynamic effects associated with the abnormality were also corrected.

Cutting Balloon angioplasty for the treatment of haemodyalisis vascular accesses: midterm results.

Purpose.The purpose of this study was to assess the effectiveness of Cutting Balloon angioplasty in the treatment of stenoses in haemodialysis arteriovenous accesses. Materials and methods.Over the past 2 years, we have observed 80 patients with stenotic haemodialysis accesses; 24 of these (mean age 66.4 years, range 50–81) with 26 stenoses of 24 accesses (21 Cimino–Brescia fistulas and 3 dialysis loops) were selected for Cutting Balloon angioplasty. In 11 cases, the Cutting Balloon device was used after failure to dilate the access with a high–pressure balloon whereas in 15 cases (10 focal stenoses and 5 restenoses), it was used as a first choice. Two Cutting Balloon devices had a diameter of 8 mm, two of 7 mm, 11 of 6 mm, eight of 5 mm and one of 4 mm. The follow–up was performed by colour Doppler ultrasound (CDUS) and clinical assessment at 1, 3, 6, 12, 18 and 24 months.Results.In all patients, postprocedure angiography demonstrated immediate technical success. No periprocedural complications occurred. Follow–up examinations (range 3–24 months, mean 18.2 months) demonstrated patency of the vascular access and its good functioning during dialysis in 23/24 cases (95%). Only in one case did we observe a haemodynamically significant restenosis, which was treated again with Cutting Balloon angioplasty.Conclusions.Cutting Balloon angioplasty is safe and effective in the treatment of haemodialysis access stenosis, especially in cases of severe stenosis, with low restenosis rate both in the short and medium term.

Urgent endovascular ligature of a ruptured splenic artery pseudoaneurysm in a patient with acute pancreatitis: a case report

IntroductionWe report on the successful endovascular treatment of a ruptured splenic artery pseudoaneurysm. Our patient had acute pancreatitis superimposed on chronic calcific pancreatitis and chronic renal impairment. Contrast-enhanced ultrasonography was used to assess post-embolization results.Case presentationOur patient was a 67-year-old white Caucasian man with recurrent pancreatitis. Computed tomography angiography showed a pancreatic pseudocyst with a ruptured pseudoaneurysm, which was successfully embolized using an endovascular percutaneous approach. At six months, persistent renal failure led to contrast-enhanced ultrasonography. This confirmed the absence of turbulent blood flow and extravasation of contrast medium in the pseudocyst.ConclusionOur experience with this case leads us to support the role of interventional radiology as a first-line treatment tool. Contrast-enhanced ultrasonography can be used to follow-up embolization procedures in patients with impaired renal function.