Domenico Lumia

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.

Endovascular treatment of steno-occlusions of the infrarenal abdominal aorta.

Purpose.Our aim is to report our experience in the endovascular treatment of steno-occlusions of the infrarenal abdominal aorta.Materials and methods.We selected 19 patients (mean age 66.3 years, range 45–80): five with complete occlusion of the infrarenal aorta and both common iliac arteries (CIAs), four of which were associated with occlusion of the external iliac arteries (EIAs); three with complete occlusion and three with severe stenosis of the distal aorta with occlusion or stenosis of the CIAs and EIAs; and eight with focal severe stenosis of the infrarenal aorta. All patients were treated with direct stenting.Results.Immediate technical success was 94.7% (18/19 cases). We observed two cases of distal embolism treated with thrombolysis, one case of mild renal failure and one case of transient angina abdominis. During the follow-up (mean 19.6 months; range 6–48), 2/18 (11.1%) occlusions of an iliac stent occurred 1 and 3 months after the procedure (treated with local intra-arterial thrombolysis). The primary patency rate was 88.8% and the secondary patency rate was 100%.Conclusions.Direct stenting is a feasible and safe option for the treatment of infrarenal abdominal aortic steno-occlusions, especially in patients at high surgical risk, with good early and late clinical results.

Endovascular Treatment of Anastomotic Pseudoaneurysms after Aorto-iliac Surgical Reconstruction

PurposeTo assess the effectiveness of endovascular treatment of anastomotic pseudoaneurysms (APAs) following aorto-iliac surgical reconstruction.MaterialsWe retrospectively evaluated 21 men who, between July 2000 and March 2006, were observed with 30 APAs, 13 to the proximal anastomosis and 17 to the distal anastomosis. The patients had had previous aorto-iliac reconstructive surgery with a bypass due to aneurysm (15/21) or obstructive disease (6/21). The following devices were used: 12 bifurcated endoprostheses, 2 aorto-monoiliac, 4 aortic extenders, 1 stent-graft leg, and 2 covered stents. Follow-up was performed with CT angiography at 1, 3, and 6 months after the procedure and yearly thereafter.ResultsImmediate technical success was 100%. No periprocedural complications occurred. Four patients died during follow-up from causes not related to APA, and 1 (treated for prosthetic-enteric fistula) from sepsis 3 months after the procedure. During a mean follow-up of 19.7 months (range 1–72 months), 2 of 21 occlusions of stent-graft legs occurred 3 and 24 months after the procedure (treated with thrombolysis and percutaneous transluminal angioplasty and femorofemoral bypass, respectively) and 1 type I endoleak. Primary clinical success rate was 81% and secondary clinical success was 91%.ConclusionEndovascular treatment is a valid alternative to open surgery and can be proposed as the treatment of choice for APAs, especially in patients who are a high surgical risk. Further studies with larger series and longer follow-up are necessary to confirm the long-term effectiveness of this approach.

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.

Multislice computed tomography with colon water distension (MSCT-c) in the study of intestinal and ureteral endometriosis

This study evaluates retrospectively the accuracy and reproducibility of multislice computed tomography with colon water distension (MSCT-c) in diagnosing bowel (BE) and ureteral (UE) endometriosis. Sixty-four patients underwent MSCT-c and videolaparoscopic surgery. Two radiologists reviewed MSCT-c examinations: sensitivity and specificity were calculated, considering histological exam as reference standard. In the BE cases, the degree of bowel wall infiltration was also assessed. Sensitivity and specificity for both readers were 100% and 97.6% for BE and 72.2% and 100% for UE; the interobserver agreement was excellent. The degree of bowel wall involvement was correctly defined in 90.9% of cases. MSCT-c is an accurate and reproducible technique but-considering the age of the patients-delivers a nonnegligible radiation dose.

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.

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.

Volumetric analysis of the aneurysmal sac with computed tomography in the follow-up of abdominal aortic aneurysms after endovascular treatment

PurposeOur aim was to assess the usefulness of volumetric analysis for the follow-up of abdominal aortic aneurysms after endovascular repair (EVAR) and operator independence of the method.Materials and methodsWe retrospectively evaluated 99 computed tomography (CT) exams of 33 patients. Two blinded operators assessed the volume before treatment and after EVAR at 1–3 and 12–24 months. Friedman’s statistical test was used to assess the reproducibility of the method. The time required for postprocessing by the two operators was compared.ResultsOne patient was excluded. Twenty-one patients showed no endoleak: 12/21 showed a volume reduction at both follow-up scans (9.7% and 19.5%, respectively); 8/21 showed an early volume increase (9.8%) with a late reduction (10.5%); 1/21 patient showed a volume increase at both follow-up scans (endotension). Eleven patients had an endoleak (one type I, nine type II and one type III); 4/9 type II endoleaks showed a volume reduction at both post-EVAR scans (8.5% and 19.5%). All other cases showed a volume increase after EVAR (type II 15.4%/16.8%, type I 24.1%/9.1%, type III 8%/10.7%). The Friedman statistical test assessed operator independence with p < 0.001. Mean difference between the two operators was 0.9% (0–4.3%).ConclusionsCT volume analysis is an accurate and reproducible modality for the follow-up of abdominal aortic aneurysms after EVAR. At early follow-up, contrast-enhanced CT remains mandatory to identify small endoleaks. For later follow-up, volumetric analysis would eliminate the need for contrast material in asymptomatic patients with stable or decreasing aneurysm volume.RiassuntoObiettivoScopo del presente lavoro è stato valutare l’utilità clinica dell’analisi volumetrica nel follow-up dei pazienti sottoposti a trattamento endovascolare per aneurisma dell’aorta addominale (EVAR) e stabilire l’indipendenza dall’operatore del metodo.Materiali e metodiSono state valutate retrospettivamente 99 tomografie computererizzate (TC) di 33 pazienti. Due operatori in cieco hanno calcolato il volume prima e dopo EVAR a 1–3 e 12–24 mesi. È stato utilizzato il test statistico di Friedman per provare la riproducibilità del metodo. È stato inoltre confrontato il tempo necessario ai due operatori per il post-processing.RisultatiUn paziente è stato escluso. In 21 pazienti non è stata osservata la presenza di endoleak: 12/21 presentavano una riduzione del volume ad entrambi i controlli (9,7%/19,5% rispettivamente); 8/21 presentavano un incremento iniziale (9,8%) con una riduzione tardiva (10,5%); in 1/21 il volume era incrementato ad entrambi i controlli (endotension). È stato osservato un endoleak in 11 pazienti (1/11 tipo I, 9/11 tipo II e 1/11 tipo III); 4/9 endoleak tipo II presentavano una riduzione volumetrica ad entrambi i controlli dopo EVAR (8,5%/19,5%). In tutti gli altri casi si è osservato un incremento volumetrico post-EVAR (tipo II 15,4%/16,8%, tipo I 24,1%/9,1%, tipo III 8%/10,7%). Il test statistico di Friedman ha dimostrato l’indipendenza dall’operatore con p<0,001. Lo scarto medio tra i due operatori è stato di 0,9% (0%–4,3%).ConclusioniIl calcolo del volume alla TC è un metodo accurato e riproducibile per il follow-up degli aneurismi dell’aorta addominale dopo EVAR. Al controllo precoce, l’impiego del mezzo di contrasto (MdC) rimane indispensabile per identificare la presenza di piccoli endoleak. Per i controlli successivi, l’analisi volumetrica consente di eliminare l’uso del MdC nei pazienti asintomatici con volume dell’aneurisma stabile o ridotto.

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.

Hepatic radiofrequency under CT-fluoroscopy guidance

PurposeThis study was done to assess the effectiveness and advantages of computed tomography (CT) fluoroscopy as a guide for locating and treating lesions that are not amenable to ultrasound (US) guidance, and to evaluate the CT signs of immediate technical success and the short-term results.Materials and methodsOver the past year, we selected 14 patients (four women and ten men; mean age 73, range 61–83 years) out of 103 candidates for hepatic radiofrequency ablation (RFA). The 14 lesions comprised seven residual tumours after combined embolisation and US-guided RFA of a large hepatocellular carcinoma (HCC), which were indistinguishable from necrosis or surrounding healthy parenchyma; two HCC nodules in locations that were inaccessible by US; five metastases (two from renal carcinoma, two from colorectal adenocarcinoma and one from lung carcinoma), of which one could not be distinguished from the surrounding healthy parenchyma on US and four were inaccessible by US. Lesion diameters were between 1.4 and 3.5 cm. The procedures were performed in the CT room with anaesthesiological assistance using a coaxial LeVeen needle electrode (14 gauge, 2-to 4-cm array diameter). Immediate technical success was evaluated by multidetector CT (MDCT), and follow-up was carried out with MDCT at 3 and 6 months and yearly thereafter.ResultsImmediate technical success was obtained in 13/14 patients; one case required further placement of the electrode due to incomplete ablation of a hypervascular lesion. In 2/3 metastatic lesions with portal vein supply, there were no recurrences at 3 and 6 months; in 1/3, we observed disease progression, with the appearance of additional nodules at 6 months. The two metastases with arterial supply showed no signs of recurrence at 3 months; one case developed a recurrence along the ablation margin, with the appearance of satellite nodules at 6 months. In two HCC nodules, there was immediate technical success and no recurrence at 3 and 6 months. Of the seven residual tumours of HCC, all treated with immediate technical success, we observed disease progression, with the appearance of satellite nodules at 3 months in one case, at 6 months in another and at 12 months in another; 3/7 patients were free of disease at 12-month follow-up; 1/7 died 5 months later due to causes unrelated to the procedure.ConclusionsCT fluoroscopy is overcoming the limitations of CT in locating and treating lesions with different hepatic vascularisation and those unamenable to US; furthermore, it reduces the length of the procedure, thanks to the faster and more accurate placement of the needle electrode. MDCT proved to be a reliable method in the assessment of immediate and short-term results of RFA.RiassuntoObiettivoValutare l’efficacia e i vantaggi della guida fluoro-TC nel localizzare e trattare lesioni non raggiungibili o non fattibili con guida ecografica e valutarne i segni TC di successo tecnico immediato e a breve distanza di tempo.Materiali e metodiNell’ultimo anno abbiamo selezionato 14/103 pazienti (4 femmine e 10 maschi) candidati a un trattamento di radiofrequenza (RF) epatica, età media 73 anni (range 61–83) portatori di 14 lesioni epatiche: 7 residui di grosso HCC, esito di terapia combinata mediante embolizzazione e RF eco-guidata non distinguibili dalla necrosi o dal parenchima epatico sano circostante; 2 noduli di HCC non raggiungibili con guida ecografica per sede; 5 metastasi (2 da carcinoma del rene, 2 da adenocarcinoma del colon-retto e 1 da carcinoma del polmone), di cui 1 non distinguibile dal parenchima sano circostante all’ecografia e 4 non raggiungibili per sede. Le lesioni presentavano diametro compreso tra 1,4 e 3,5 cm. Le procedure sono state espletate in sala TC in assistenza anestesiologica con ago elettrodo di LeVeen coassiale (14 gauge, diametro apertura uncini da 2 a 4 cm). Il successo tecnico immediato è stato valutato con TC multistrato (TCMS) post-procedura; il follow-up è stato espletato mediante TCMS a 3, 6 mesi e successivamente annualmente.RisultatiÈ stato ottenuto successo tecnico immediato in 13/14 pazienti; in 1 caso e stata necessaria un’infissione ulteriore per parziale ablazione di lesione ipervascolarizzata. Nelle 3 lesioni metastatiche a prevalente vascolarizzazione veno-portale si è documentato successo tecnico immediato e assenza di recidiva a 3 e 6 mesi in 3 casi; un paziente ha sviluppato a 6 mesi una progressione di malattia per comparsa di altre lesioni ripetitive. Le 2 metastasi a prevalente vascolarizzazione arteriosa, non hanno evidenziato a 3 mesi segni TC di recidiva; a 6 mesi in 1 caso si è documentata una recidiva lungo il margine di ablazione e comparsa di microlesioni satelliti. I 2 noduli di HCC trattati hanno ottenuto entrambi successo tecnico immediato e assenza di recidiva a 3 e 6 mesi dal trattamento. Dei 7 residui di HCC, tutti trattati con successo tecnico immediato, 1/7 ha avuto ripresa di malattia per comparsa di noduli satelliti a 3 mesi, 1/7 a 6 mesi e 1/7 a 12 mesi; 3/7 sono liberi da malattia al followup a 12 mesi; 1 è deceduto prima dei 6 mesi per cause non correlate alla procedura.ConclusioniLa guida fluoro-TC ha attualmente superato i limiti della TC nel localizzare e trattare lesioni a differente vascolarizzazione epatica e quelle non fattibili sotto guida ecografica; inoltre ha ridotto i tempi di procedura per il più veloce ed accurato posizionamento dell’ago-elettrodo. La TCMS si è dimostrata metodica affidabile nella valutazione dei risultati della RF immediati e a breve distanza.